RESUMEN
STUDY OBJECTIVE: Physicians in France have been asked to change their day-to-day medical practice to reduce overall costs. We examine ways to achieve this goal in thyroid surgery. MATERIAL AND METHODS: We defined and implemented a clinical pathway to optimize the economic viability of thyroid surgery by increasing revenues and lowering expenses. An increase in revenue was achieved by decreasing patient length of stay (LOS) through the use of a fast-track rehabilitation protocol. Expenses were decreased by performing all pre-operative work-up in the out-patient setting and by decreasing costs in the operating room. RESULTS: For 292 consecutive patients who underwent thyroidectomy, the average LOS has been decreased over time to a mean of 2.03 days in 2008; 96% of patients were discharged on the first postoperative day. These results were primarily achieved by using a fast-track rehabilitation clinical pathway, and no increase in postoperative morbidity was noted. Operating time was decreased by 20% through the use of a second surgical assistant and hemostatic scissors but this improvement did not translate into better daily utilization of the operating room. CONCLUSION: The economic profitability of thyroid surgery is improved when mean LOS is reduced to 2 days through a fast-track protocol. Decreasing the duration of hospitalization was more effective than decreasing operative duration in controlling overall costs.
Asunto(s)
Vías Clínicas/economía , Hospitales Públicos/economía , Programas Nacionales de Salud/economía , Neoplasias de la Tiroides/economía , Neoplasias de la Tiroides/cirugía , Nódulo Tiroideo/economía , Nódulo Tiroideo/cirugía , Tiroidectomía/economía , Atención Ambulatoria/economía , Ahorro de Costo/estadística & datos numéricos , Francia , Costos de Hospital/estadística & datos numéricos , Humanos , Tiempo de Internación/economía , Quirófanos/economía , Quirófanos/estadística & datos numéricos , Cuidados Preoperatorios/economía , Sistema de Pago Prospectivo/economía , Estudios de Tiempo y MovimientoRESUMEN
BACKGROUND: Laparoscopy is slowly becoming an established technique for liver resection. This procedure still is limited to centers with experience in both hepatic and laparoscopic surgery. Preliminary reports include mainly minor resections for benign liver conditions and show some advantage in terms of postoperative recovery. The authors report their experience with laparoscopic liver resection, the evolution of the technique, and the results. METHODS: From 1999 to 2006, 70 laparoscopic liver resections were performed using a procedure similar to resection by laparotomy. RESULTS: There were 38 malignant tumors (54%) and 32 benign lesions (46%). The malignant tumors were mainly hepatocellular carcinomas (19 of 24 patients had cirrhosis). The tumor mean size was 3.8 +/- 1.9 cm (range, 2.2-8 cm). There were 19 major hepatectomies, 34 uni- or bisegmentomies, and 17 atypical resections. The operative time was 227 +/- 109 min. Conversion to laparotomy was required for seven patients (10%), mainly for continuous bleeding during transection. Nine patients (13%) required blood transfusion. One patient had both brisk bleeding and gas embolism from a tear in the section line of the right hepatic vein requiring laparoscopic suture. Blood loss and transfusion requirements were significantly lower in recent than in early cases and in resections with prior vascular control than in those without such control. Postoperative complications were experienced by 11 patients (16%), including one bleed from the hepatic stump requiring hemostasis and two subphrenic collections requiring percutaneous drainage. One cirrhotic patient died of liver failure after resection of a partially ruptured tumor. No ascites was observed in other cirrhotic patients. The mean hospital stay was 5.9 days. CONCLUSION: The study results confirm that laparoscopic liver resection, including major hepatectomies, can be safely performed by laparoscopy.
Asunto(s)
Hepatectomía/métodos , Laparoscopía/métodos , Neoplasias Hepáticas/patología , Neoplasias Hepáticas/cirugía , Adulto , Anciano , Biopsia con Aguja , Estudios de Cohortes , Femenino , Francia , Hepatectomía/efectos adversos , Hepatectomía/estadística & datos numéricos , Humanos , Inmunohistoquímica , Incidencia , Complicaciones Intraoperatorias/epidemiología , Laparoscopía/efectos adversos , Laparoscopía/estadística & datos numéricos , Laparotomía/estadística & datos numéricos , Tiempo de Internación , Pruebas de Función Hepática , Neoplasias Hepáticas/mortalidad , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Dolor Postoperatorio/epidemiología , Probabilidad , Pronóstico , Estudios Retrospectivos , Medición de Riesgo , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
OBJECTIVE: In elective large bowel surgery the incidence of general complications with standard perioperative care is up to 27%. Hospital discharge occurs 10 to 15 days after a conventional or laparoscopic colonic resection. The aim of a fast track management is to reduce the number of general complications and the length of hospital stay. MATERIAL AND METHODS: We prospectively evaluated a multimodal protocol in our service utilizing a combined thoracic epidural analgesia, an early mobilization and oral nutrition to accelerate postoperative recovery after elective colonic surgery. RESULTS: One hundred thirty-two consecutive patients aged an average of 66 years (range 22-88) were operated by laparotomy (n =71) or laparoscopy (n =61) and treated with the fast track rehabilitation protocol. Surgical complications occurred in 15 patients (11 %), four of these had an anastomotique leakage (3%). General complications occurred in 11 patients (8 %), the mortality was 1 %. The median length of hospital stay was four days (range 3-77) and 14 patients (11%) had to be readmitted. CONCLUSION: Application of a fast track rehabilitation protocol lowered the number of general complications and reduced the duration of hospital stay in our study.
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Colectomía/rehabilitación , Enfermedades del Colon/cirugía , Complicaciones Posoperatorias/prevención & control , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Laparoscopía , Laparotomía , Tiempo de Internación , Masculino , Persona de Mediana Edad , Estado Nutricional , Cuidados Posoperatorios , Estudios Prospectivos , Factores de TiempoRESUMEN
BACKGROUND: Despite the growing clinical use of the percutaneous dilatational tracheostomy data concerning their first line application are still lacking. METHODS: Retrospective analysis of the intra- and postinterventional morbidity of a modified dilatational tracheostomy in a surgical intensive care unit of a German university hospital over a 2-year period. RESULTS: A total of 107 elective dilatational tracheostomies were performed in 105 patients. There were no intraoperative complications. 2 accidental decannulations occurred in the postoperative period. One conventional tracheostomy had to be performed secondary. Stoma side bleeding or clinical relevant infection had not been observed. After definite decannulation wound closure was spontaneous in all patients. CONCLUSIONS: The first line application of the dilatational tracheostomy has a low morbidity.
Asunto(s)
Traqueostomía/métodos , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Traqueostomía/efectos adversos , Traqueostomía/mortalidadRESUMEN
OBJECTIVE: The synthetic implant meshes in clinical use for the treatment of abdominal hernias are generally made of polyester in France and of polypropylene in Germany. Serving as an implant material for the replacement of the cruciate ligament, the Trevira is another polymer of polyester in clinical use with excellent results. This animal trial was performed to ascertain whether it offers any advantages over polypropylene for abdominal incisional hernia repair. MATERIAL AND METHODS: [corrected] In 12 pigs 10 x 10 cm of the abdominal wall preserving the peritoneum was resected and subsequently implanted a 15 x 15 cm synthetic mesh of polyethylene terephthalate (Trevira) in half of them and of polypropylene (Prolene) in the other half using a sublay technique. After two and six month the implant size was measured and the extend of the foreign body reaction determined by the microscopically presence of foreign body giant cells. RESULTS: No significant differences concerning the implant size were shown between the two groups at any of the time periods. The acute inflammatory reaction observed was significantly higher at the polypropylene than at the polyethylene terephthalate implant (number of giant cells after 2 month: Prolene 2.2 +/-0.4, Trevira: 0.8 +/-0.2, after six month: Prolene: 4.6 +/-1.3, Trevira: 1.1 +/-0.5). In contrast to the polyethylene terephthalate all polypropylene samples showed calcification areas after six month. CONCLUSION: In this animal trial Trevira mesh showed a high biocompatibility with a low foreign body reaction. It appears to be a promising new implant for the treatment of hernia.
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Hernia Ventral/cirugía , Mallas Quirúrgicas , Animales , Materiales Biocompatibles , Calcinosis , Reacción a Cuerpo Extraño , Hernia Ventral/veterinaria , Poliésteres , Porcinos , Resultado del TratamientoRESUMEN
We report the case of a successfully resected hemorrhagic Dieulafoy's vascular malformation using a transgastric laparoscopic approach. A 37-year-old man was admitted for hematemesis and anemia. Emergency endoscopy revealed active hemorrhage from a submucosal vascular malformation in the posterior gastric wall. Dieulafoy's disease was suspected. It was initially treated by repeated endoscopy. Due to recurrent bleeding, on day 3 the patient was scheduled for surgery. The laparoscopic treatment consisted of an anterior gastrotomy, followed by extirpation and resection of the lesion after evaluation of the gastro-esophageal junction. There was no need for intraoperative endoscopy. To our knowledge, this is the first description of the application of a transgastric laparoscopic approach for the management of a hemorrhagic Dieulafoy's vascular malformation.
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Hemorragia Gastrointestinal/etiología , Laparoscopía/métodos , Escleroterapia/métodos , Estómago/irrigación sanguínea , Adulto , Arterias/anomalías , Transfusión Sanguínea , Terapia Combinada , Enbucrilato/uso terapéutico , Epinefrina/uso terapéutico , Hemorragia Gastrointestinal/cirugía , Hemorragia Gastrointestinal/terapia , Gastroscopía , Hematemesis/etiología , Humanos , Masculino , Soluciones Esclerosantes/uso terapéutico , Estómago/cirugía , Vasoconstrictores/uso terapéuticoRESUMEN
The use of mesh in incisional hernia repair has reduced the rate of hernia recurrence. Laparoscopic placement of mesh is a promising alternative to the classical open approach. Recent studies involving large numbers of patients have shown the laparoscopic approach to be feasible in 95% of cases; the incidence of postoperative complications was low and hernia recurrence occurred in 3-5% at three years. Several retrospective studies and one randomized study comparing open versus laparascopic ventral hernia repair suggest that the laparoscopic repair yields better results (fewer postoperative complications and lower recurrence rate) than the classical open approach.
Asunto(s)
Hernia Ventral/cirugía , Laparoscopía , Humanos , Laparoscopía/métodosRESUMEN
BACKGROUND: Increased lipid peroxidation is believed to stimulate liver metastasis in pancreatic cancer. However, the effect of the laparoscopic biopsy of pancreatic lymph nodes on liver metastasis is still unknown. We hypothesized that the effects of a pneumoperitoneum with carbon dioxide (CO2) increase lipid peroxidation and stimulate liver metastasis. METHODS: Ductal pancreatic adenocarcinoma was induced in Syrian hamsters (n = 30) by weekly subcutaneous injections of N-nitrosobis-2-oxopropylamine (BOP) for 12 weeks. In group 1, a laparotomy and biopsy of pancreatic lymph nodes was performed. Groups 2 and 3 underwent laparoscopic biopsy with either CO2 or helium. In the 5th postoperative week, the hamsters were killed and the incidence of liver metastasis was analyzed histopathologically. We then made determinations of the level of lipid peroxidation (thiobarbituric acid-reactive substances [TBARS])as well as the activity of glutathionperoxidase (GSH-PX) and superoxidismutase (SOD) in pancreatic carcinoma and liver metastases of the animals. RESULTS: The incidence of liver metastasis was higher in the CO2 group (60%) than in the helium (30%) and laparotomy groups (20%) (p < 0.05). The concentration of TBARS was greater in pancreatic carcinoma and intrametastatic hepatic tissue than in extratumorous pancreatic and extrametastastic hepatic tissue in all groups. Extrametastatic hepatic concentration of TBARS was higher in the CO2 group (19.4 +/- 0.88 nmol/mg protein) than the laparotomy (10.66 +/- 0.95 nmol/mg protein) and helium groups (10.79 +/- 0.58 nmol/mg protein). GSH-PX and SOD activity was significantly lower in pancreatic carcinoma tissue and intrametastatic hepatic tissue than in extratumorous pancreatic and extrametastatic hepatic tissue. However, in the CO2 group (1.24 +/- 0.48 107 U/mg protein), extrametastatic GSH-PX activity was lower than in the laparotomy (1.73 +/- 0.4 107 U/mg protein) and helium groups (1.63 +/- 0.28 107 U/mg protein). CONCLUSION: After laparoscopic biopsy of pancreatic lymph nodes in the CO2 group, lipid peroxidation was increased and GSH-PX activity was decreased in extrametastatic hepatic tissue compared to the intrametastatic sections. This mechanism may be responsible for the increased liver metastasis in the CO2 group.