RESUMEN
AIM: To compare the outcomes between the laparoscopic and open approaches for partial colectomy in elderly patients aged 65 years and over using the American College of Surgeons - National Surgical Quality Improvement Program (ACS NSQIP) database. METHODS: The ACS NSQIP database for the years 2005-2011 was queried for all patients 65 years and above who underwent partial colectomy. 1:1 propensity score matching using the nearest- neighbor method was performed to ensure both groups had similar pre-operative comorbidities. Outcomes including post-operative complications, length of stay and mortality were compared between the laparoscopic and open groups. χ(2) and Fisher's exact test were used for discrete variables and Student's t-test for continuous variables. P < 0.05 was considered significant and odds ratios with 95%CI were reported when applicable. RESULTS: The total number of patients in the ACS NSQIP database of the years 2005-2011 was 1777035. We identified 27604 elderly patients who underwent partial colectomy with complete data sets. 12009 (43%) of the cases were done laparoscopically and 15595 (57%) were done with open. After propensity score matching, there were 11008 patients each in the laparoscopic (LC) and open colectomy (OC) cohorts. The laparoscopic approach had lower post-operative complications (LC 15.2%, OC 23.8%, P < 0.001), shorter length of stay (LC 6.61 d, OC 9.62 d, P < 0.001) and lower mortality (LC 1.6%, OC 2.9%, P < 0.001). CONCLUSION: Even after propensity score matching, elderly patients in the ACS NSQIP database having a laparoscopic partial colectomy had better outcomes than those having open colectomies. In the absence of specific contraindications, elderly patients requiring a partial colectomy should be offered the laparoscopic approach.
Asunto(s)
Colectomía/métodos , Laparoscopía , Factores de Edad , Anciano , Anciano de 80 o más Años , Distribución de Chi-Cuadrado , Colectomía/efectos adversos , Colectomía/mortalidad , Bases de Datos Factuales , Femenino , Humanos , Laparoscopía/efectos adversos , Laparoscopía/mortalidad , Tiempo de Internación , Masculino , Oportunidad Relativa , Complicaciones Posoperatorias , Puntaje de Propensión , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Estados UnidosRESUMEN
Inadequate pain control after ambulatory surgery can lead to unexpected return visits to the hospital. The purpose of this study was to compare patients based on which medications they were prescribed and to see whether this affected the rate of return to the hospital. A retrospective chart review of patients who underwent ambulatory laparoscopic cholecystectomy between January 2009 and December 2013 was performed. Patients were divided into two groups based on the pain medication prescribed after surgery: Opioids and nonopioids. Patients returning to the Emergency room (ER) within seven days were evaluated. If no complication or other diagnosis was identified, the patient was considered to have returned for inadequate pain control. The two groups were statistically compared with each other using Fisher's exact chi-squared test. A total of 749 patients underwent laparoscopic cholecystectomy during the study period: 180 (25.2%) were prescribed opioids, whereas, 560 (74.8%) were prescribed nonopioids. In the nonopioid group, 14 (1.9%) returned to the ER for pain, whereas no patient in the opioid group returned for pain. This difference was statistically significant (P = 0.027). In conclusion, patients who were given opioid pain medications after ambulatory laparoscopic cholecystectomy were less likely to return to the ER for pain. This implied that opioids were better at pain control and helped avoid the costs of unnecessary ER visits. Future research should be aimed at more direct measures of pain control, as well as the role of opioids after inpatient surgery.
Asunto(s)
Procedimientos Quirúrgicos Ambulatorios/métodos , Analgésicos no Narcóticos/administración & dosificación , Analgésicos Opioides/administración & dosificación , Colecistectomía Laparoscópica/métodos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Dolor Postoperatorio/tratamiento farmacológico , Readmisión del Paciente/estadística & datos numéricos , Adulto , Procedimientos Quirúrgicos Ambulatorios/efectos adversos , Distribución de Chi-Cuadrado , Colecistectomía Laparoscópica/efectos adversos , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Dolor Postoperatorio/diagnóstico , Estudios Retrospectivos , Medición de Riesgo , Resultado del TratamientoRESUMEN
Kink of the transplant renal artery is a rare yet correctable cause of early graft dysfunction. We describe a 35-year-old male patient with end-stage renal disease who underwent live, related renal transplantation with end-to-side anastomosis of the graft vessels with the external iliac vessels. He had oliguria and uncontrolled hypertension in the post-operative course and was found to have a parvus tardus waveform on Doppler ultrasound and an acute angled kink of the renal artery on angiography. After failure of initial attempts at per cutaneous transluminal renal angioplasty, the patient was re-explored and the graft renal artery was anastomosed with the internal iliac artery. The patient had a steady recovery and was discharged with a good renal function. A kinking of the renal artery should be excluded when early graft dysfunction is associated with a parvus tardus waveform.
Asunto(s)
Trasplante de Riñón/efectos adversos , Disfunción Primaria del Injerto/etiología , Obstrucción de la Arteria Renal/complicaciones , Arteria Renal/patología , Arteria Renal/trasplante , Adulto , Anastomosis Quirúrgica , Humanos , Imagen por Resonancia Magnética , Masculino , Obstrucción de la Arteria Renal/diagnóstico por imagen , Obstrucción de la Arteria Renal/etiología , Ultrasonografía DopplerRESUMEN
Kidney donation from hypertensive donors is now an accepted norm in live related kidney transplantation. The use of hypertensive donors with renal artery stenosis due to atherosclerosis and fibromuscular dysplasia is still debated. The prime concern is about the deleterious effect of hypertension on the donor and the risk of recurrence of such lesions in the solitary kidney. Even as the response of atherosclerotic renal artery stenosis to revascularisation is unpredictable, there is an improvement in blood pressure following revascularisation of kidneys with fibro-muscular dysplasia. The first use of such kidney donors was reported in 1984 and, since then, there have been a few reports of successful use of kidneys from donors with renal artery stenosis. We report here two interesting cases of successful transplantation of kidneys from live related kidney donors with hypertension due to renal artery stenosis who became normotensive with good graft function in the recipient. We conclude that moderately hypertensive donors with renal artery stenosis are fit to donate.
Asunto(s)
Selección de Donante , Hipertensión Renovascular/diagnóstico , Trasplante de Riñón , Donadores Vivos , Nefrectomía , Obstrucción de la Arteria Renal/diagnóstico , Anciano , Angiografía de Substracción Digital , Antihipertensivos/uso terapéutico , Femenino , Humanos , Hipertensión Renovascular/diagnóstico por imagen , Hipertensión Renovascular/tratamiento farmacológico , Hipertensión Renovascular/etiología , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Obstrucción de la Arteria Renal/complicaciones , Obstrucción de la Arteria Renal/diagnóstico por imagen , Obstrucción de la Arteria Renal/tratamiento farmacológico , Resultado del TratamientoRESUMEN
True mycotic aneurysms are extremely rare cerebrovascular lesions with a dismal prognosis. They mostly follow fungal meningitis or septicaemia and herald their presence with the development of subarachnoid haemorrhage. The authors report an extremely rare occurrence of bilateral anterior cerebral artery aneurysms caused by mucormycosis. The infection was diagnosed after investigation of prolonged fever following transsphenoidal surgery. The aneurysm was diagnosed after a subarachnoid haemorrhage and the patient finally died. The present case highlights an atypical presentation of fungal infection that can perplex the best of clinicians and thus delay diagnosis. As subarachnoid haemorrhage due to true mycotic aneurysmal rupture is uniformly associated with a fatal outcome, the authors speculate that a high index of suspicion should be maintained when a neurosurgical patient is predisposed to fungal infection. This approach, combined with the empirical institution of antifungal drugs, provides the only chance of survival.