RESUMEN
The 9th edition of the American College of Chest Physicians (ACCP) guidelines on antithrombotic therapy and prevention, includes relevant changes compared to previous versions. In the 9th ACCP, leadership of most chapters was given to methodologists who were familiar with the GRADE methodology. All topic panelists underwent a selection process paying particular attention to their financial and intellectual conflicts of interests. In the 9th ACCP guidelines, evidence has been explicitly presented in many evidence profiles and summary of evidence tables. In order to get a more balanced trade-off between desirable and undesirable effects of the alternative prevention and therapeutic interventions, there has been an increased emphasis on clinically relevant events, as opposed to previous surrogate asymptomatic outcomes. In addition, there has been a systematic review and survey on patient values and preferences for thrombotic and bleeding outcomes. As a result of the above changes, the strength of most recommendations has been downgraded compared to previous editions. The main changes regarding prevention on nonorthopedic surgical patients include the adoption of two risk assessment models. The only recommendation that has been upgraded is to extend prophylaxis with low molecular weight heparins (LMWH) for four weeks after abdominal or pelvic cancer surgery. A controversial modification in orthopedic patients is recommendation in favor of the use of aspirin after hip or knee arthroplasty. New oral anticoagulants are recommended, but LMWH are suggested as the preferred option. Extending pharmacological prophylaxis for up to 35days rather than 10-14days is now suggested for patients undergoing major orthopedic surgery.
Asunto(s)
Anticoagulantes/administración & dosificación , Fibrinolíticos/administración & dosificación , Pautas de la Práctica en Medicina/normas , Procedimientos Quirúrgicos Operativos/efectos adversos , Tromboembolia Venosa/prevención & control , Anticoagulantes/efectos adversos , Técnicas de Apoyo para la Decisión , Esquema de Medicación , Medicina Basada en la Evidencia , Fibrinolíticos/efectos adversos , Adhesión a Directriz , Hemorragia/inducido químicamente , Humanos , Selección de Paciente , Guías de Práctica Clínica como Asunto , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Tromboembolia Venosa/etiologíaRESUMEN
PURPOSE: We evaluated the clinical results of different techniques of resection for malignant left-sided colonic obstruction. METHODS: The subjects of this prospective nonrandomized study were 63 consecutive patients who underwent surgery between 1995 and 2000 at a single institution. Patients with nonprimary colonic tumors, lesions located proximally to splenic flexure, peritonitis, perforation, or cecal necrosis were excluded. RESULTS: Segmental colectomy with primary anastomosis (CPA) was performed in 35 patients; with intraoperative colonic irrigation (ICI) in 19, and without ICI in 16. Total or subtotal colectomy (TSC) was performed in 8, and Hartmann's procedure (HP) was performed in 20. There were no differences in age, sex, comorbidity, time of symptoms, preoperative hospital stay, or tumor staging among the groups of patients defined by the different surgical techniques. The overall incidence of postoperative complications was 43%; postoperative mortality, 5%; anastomotic dehiscence, 12%; urgent reoperations, 12%; and readmissions, 5%, without significant differences among the treatment groups. However, the postoperative and total hospital stay were significantly shorter after ICI (P = 0.016 and P = 0.012, respectively). The overall 5-year survival was 42.7%. CONCLUSIONS: We think that segmental colectomy with anastomosis after intraoperative colonic irrigation is the most effective operative treatment for neoplastic left-sided colonic obstructions, considering its safety and cost-effectiveness.