RESUMEN
BACKGROUND: Re-exploration after cardiac surgery remains a relatively frequent complication associated with adverse effects on outcome. We aimed to identify risk factors for re-exploration. METHODS: We retrospectively reviewed 2,403 patients having undergone cardiac surgical procedure between January 2013 and December 2014. Re-exploration was required in 114 patients (4.7%). Patients with oral anticoagulation, infective endocarditis, or a clearly identified bleeding source were excluded. Therefore, 42 patients remained for analysis. A matched cohort was selected for age, sex, ejection fraction, creatinine, and procedure out of the non-re-explored patients. RESULTS: Demographic data were similar in both groups, except for a higher prevalence of diabetes (45 vs. 21%; p = 0.036) in the non-re-explored patients. Surgery was elective in two-thirds and preoperative plasma fibrinogen concentration was lower in patients requiring re-exploration (2.8 ± 0.9 vs. 3.6 ± 0.9 g/L; p = 0.002). During the initial operation, re-explored patients received more packed red blood cells (1.5 ± 3 vs. 0 ± 1 units; p < 0.001), Postoperatively, re-explored patients had higher lactate levels (1.7 ± 1.4 vs. 1.3 ± 0.6 mmol/L, p = 0.044), more chest tube drainage (1,245 ± 948 vs. 685 ± 413 mL; p < 0.001), higher hospital mortality (19 vs. 7%; p = 0.19), and longer intensive care unit (ICU) stays (8 ± 8 vs. 4 ± 7 days; p = 0.010). In addition, more fibrinogen was administrated during the initial surgery. Plasma fibrinogen concentration upon arrival at the ICU was lower in patients requiring re-exploration (2 ± 0.6 vs. 2.7 ± 0.7 g; p < 0.001). Multivariable linear regression analysis identified fibrinogen upon arrival at the ICU as an independent predictor of postoperative bleeding. CONCLUSION: Cardiac surgery patients with low perioperative plasma fibrinogen concentration appear to be more susceptible to bleeding and re-exploration. Re-exploration in this group of patients is associated with increased morbidity and mortality.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/efectos adversos , Fibrinógeno/metabolismo , Hemorragia Posoperatoria/cirugía , Segunda Cirugía , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Procedimientos Quirúrgicos Cardíacos/mortalidad , Regulación hacia Abajo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Hemorragia Posoperatoria/sangre , Hemorragia Posoperatoria/etiología , Hemorragia Posoperatoria/mortalidad , Estudios Retrospectivos , Factores de Riesgo , Segunda Cirugía/efectos adversos , Segunda Cirugía/mortalidadRESUMEN
OBJECTIVES: This multicenter prospective randomized-controlled study was conducted to examine the effectiveness of second-look endoscopy (SLE) implemented after performing endoscopic submucosal dissection (ESD) of gastric neoplasms and to also examine which clinical and endoscopic elements are risk factors for post-ESD bleeding. PATIENTS AND METHODS: Prospective randomized studies were carried out at two tertiary medical centers. Patients were divided into a group that underwent SLE (n=110) and a group that did not undergo SLE (non-SLE, n=110). The patients' clinical characteristics, endoscopic findings, and pathologic outcomes were analyzed after ESD. RESULTS: The post-ESD bleeding rate was 4.1% and no difference was observed between the SLE group and the non-SLE group. There was no difference in age, sex, drug use, comorbidities, endoscopic findings, pathological findings, or ESD procedure time between the SLE group and the non-SLE group. When the 211 patients who showed no post-ESD bleeding and nine patients who showed post-ESD bleeding were compared with each other, there was no difference in whether they underwent SLE, age, drug use, comorbidities, endoscopic findings, or pathological findings. However, the risk of occurrence of post-ESD bleeding was higher when ulcers in lesions were found (odds ratio: 12.54; P=0.03). CONCLUSION: The SLE group and the non-SLE group did not show any significant difference in post-ESD bleeding ratios among gastric neoplasm patients. It was shown that the risk of occurrence for post-ESD bleeding was higher in cases where there were ulcers in lesions than in cases where there was no ulcer in lesions.
Asunto(s)
Disección/métodos , Mucosa Gástrica/cirugía , Gastroscopía , Segunda Cirugía/métodos , Neoplasias Gástricas/cirugía , Anciano , Disección/efectos adversos , Femenino , Mucosa Gástrica/patología , Hemorragia Gastrointestinal/etiología , Gastroscopía/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Hemorragia Posoperatoria/etiología , Estudios Prospectivos , República de Corea , Factores de Riesgo , Segunda Cirugía/efectos adversos , Neoplasias Gástricas/patología , Úlcera Gástrica/patología , Úlcera Gástrica/cirugía , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Although second-look endoscopy is performed within several days after gastric endoscopic submucosal dissection (ESD), there has been no evidence supporting the usefulness of the intervention. We investigated the relationship between delayed bleeding and hemorrhage of mucosal defects after ESD on second-look endoscopy and analyzed risk factors of active bleeding on second-look endoscopy. METHODS: A total of 441 consecutive ESD cases with gastric cancer or adenoma were retrospectively analyzed. Second-look endoscopy was performed in the morning after the day of ESD. Bleeding of mucosal defects on second-look endoscopy was classified according to the Forrest classification, and active bleeding was defined as Forrest Ia or Ib. Delayed bleeding was defined as hematemesis or melena after second-look endoscopy. RESULTS: A total of 406 second-look endoscopies were performed, and delayed bleeding occurred in 11 patients. The incidence rate of delayed bleeding after second-look endoscopy in patients with Forrest Ia or Ib was significantly higher than that in patients with Forrest IIa, IIb or III (7.69 vs. 2.02 %, p < 0.05). Complication of a histological ulcer, large size of the resected specimen and long ESD procedure time were shown to be risk factors for hemorrhage of mucosal defects after ESD on second-look endoscopy by univariate analysis. Multivariate analysis indicated that only large size of the resected specimen was a risk factor. In a specimen size of >35 mm, the odds ratio of active bleeding on second-look endoscopy was 1.9. CONCLUSION: Active bleeding of mucosal defects on second-look endoscopy is a risk factor for delayed bleeding.
Asunto(s)
Adenoma/cirugía , Resección Endoscópica de la Mucosa/efectos adversos , Hemorragia Posoperatoria/etiología , Segunda Cirugía/métodos , Neoplasias Gástricas/cirugía , Adenoma/patología , Anciano , Anciano de 80 o más Años , Resección Endoscópica de la Mucosa/métodos , Femenino , Mucosa Gástrica/patología , Mucosa Gástrica/cirugía , Gastroscopía/efectos adversos , Gastroscopía/métodos , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Segunda Cirugía/efectos adversos , Neoplasias Gástricas/patología , Resultado del TratamientoRESUMEN
AIM: The clinical value of second-look endoscopy (SLE) after endoscopic submucosal dissection (ESD) has been doubted continuously. The aim of this study was to assess the effectiveness of SLE based on the risk of delayed bleeding after ESD. METHODS: A total of 310 lesions of gastric epithelial neoplasms treated by ESD were reviewed. The lesions were divided into two groups based on the risk of post-procedural bleeding estimated by Forrest classification. The high risk of rebleeding group (Forrestâ Ia,â Ib and IIa) required endoscopic treatment, while the low risk of rebleeding group (Forrest IIb, IIc and III) did not. Delayed bleeding after ESD was investigated. RESULTS: Sixty-six lesions were included in the high risk of rebleeding group and 244 lesions in the low risk of rebleeding group. There were no significant differences in delayed bleeding between the high risk group (1/66) and the low risk group (1/244) (P = 0.38). The high risk of rebleeding group tended to be located more often in the mid-third and had higher appearance of flat or depressed shape than the low risk group (P = 0.004 and P = 0.006, respectively). CONCLUSION: SLE with pre-emptive prophylactic endoscopic treatment is still effective in preventing delayed bleeding after ESD.
Asunto(s)
Disección/métodos , Gastrectomía/métodos , Gastroscopía/métodos , Técnicas Hemostáticas , Hemorragia Posoperatoria/prevención & control , Segunda Cirugía/métodos , Neoplasias Gástricas/cirugía , Anciano , Disección/efectos adversos , Femenino , Gastrectomía/efectos adversos , Gastroscopía/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Hemorragia Posoperatoria/etiología , Estudios Retrospectivos , Factores de Riesgo , Segunda Cirugía/efectos adversos , Neoplasias Gástricas/patología , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: The standard of care for colorectal peritoneal carcinomatosis is evolving from chemotherapy to cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with disease limited to the peritoneum. Peritoneal carcinomatosis from colorectal cancer treated with chemotherapy alone results in median survival of 5 to 13 months, whereas CRS with HIPEC for early peritoneal carcinomatosis from colorectal cancer resulted in median survival of 48-63 months and 5 year survival of 51%.Completeness of cytoreduction and limited disease are associated with longer survival, yet early peritoneal carcinomatosis is undetectable by conventional imaging. Exploratory laparotomy can successfully identify early disease, but this approach can only be justified in patients with high risk of peritoneal carcinomatosis. Historical data indicates that patients presenting with synchronous peritoneal carcinomatosis, ovarian metastases, perforated primary tumor, and emergency presentation with bleeding or obstructing lesions are at high risk of peritoneal carcinomatosis. Approximately 55% of these patient populations will develop peritoneal carcinomatosis. We hypothesize that performing a mandatory second look laparotomy with CRS and HIPEC for patients who are at high risk for developing peritoneal carcinomatosis from colorectal cancer will lead to improved survival as compared to patients who receive standard of care with routine surveillance. METHODS/DESIGN: This study is a prospective randomized trial designed to answer the question whether mandatory second look surgery with CRS and HIPEC will prolong overall survival compared to the standard of care in patients who are at high risk for developing peritoneal carcinomatosis from colorectal cancer (CRC). Patients with CRC at high risk for developing peritoneal carcinomatosis who underwent curative surgery and subsequently received standard of care adjuvant chemotherapy will be evaluated. The patients who remain without evidence of disease by imaging, physical examination, and tumor markers for 12 months after the primary operation will be randomized to mandatory second look surgery or standard-of-care surveillance. At laparotomy, CRS and HIPEC will be performed with intraperitoneal oxaliplatin with concurrent systemic 5-fluorouracil and leucovorin. Up to 100 patients will be enrolled to allow for 35 evaluable patients in each arm; accrual is expected to last 5 years. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT01095523.
Asunto(s)
Adenocarcinoma/terapia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Quimioterapia del Cáncer por Perfusión Regional , Neoplasias Colorrectales/terapia , Hipertermia Inducida , Laparotomía , Neoplasias Peritoneales/terapia , Segunda Cirugía , Adenocarcinoma/mortalidad , Adenocarcinoma/secundario , Protocolos de Quimioterapia Combinada Antineoplásica/efectos adversos , Quimioterapia Adyuvante , Neoplasias Colorrectales/mortalidad , Neoplasias Colorrectales/patología , Supervivencia sin Enfermedad , Fluorouracilo/administración & dosificación , Humanos , Hipertermia Inducida/efectos adversos , Laparotomía/efectos adversos , Leucovorina/administración & dosificación , Compuestos Organoplatinos/administración & dosificación , Oxaliplatino , Neoplasias Peritoneales/mortalidad , Neoplasias Peritoneales/secundario , Estudios Prospectivos , Medición de Riesgo , Factores de Riesgo , Tamaño de la Muestra , Segunda Cirugía/efectos adversos , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Surgical management of advanced-stage ovarian cancer (ASOC) can require diaphragmatic surgery (DS) to achieve complete cytoreduction. The aim of this study was to evaluate modalities and morbidities of DS at the time of initial surgery (INS) and interval debulking surgery (IDS; performed after neoadjuvant chemotherapy). STUDY DESIGN: Retrospective review of patients undergoing (unilateral or bilateral) DS at the time of INS or IDS for ASOC. RESULTS: Between 2005 and 2008, 63 patients were studied. Treatment of the diaphragm was unilateral in 31 patients and bilateral in 32 patients. DS was performed respectively at the time of INS in 22 patients (35%) and IDS in 41 (65%) patients. Complete cytoreductive surgery was achieved in 95% (21 of 22 in the INS group and 39 of 41 in the IDS group). Surgical procedures used during DS were (in the INS and IDS groups, respectively) stripping in 14 (64%) and 16 (39%), coagulation in 2 (9%) and 10 (24%), and both procedures in 6 (27%) and 15 (37%). An intraoperative chest tube was placed in 14% of patients in each group. Postoperative chest complications requiring treatment occurred in 6 cases: pulmonary embolism (3 cases), symptomatic pleural effusion requiring chest drainage (1 case), and pneumothorax necessitating chest drainage (2 cases). CONCLUSIONS: Rate of overall morbidity related to DS was not statistically different in patients undergoing INS and IDS. Surgical treatment of this upper part of the abdomen is key to achieving complete cytoreductive surgery in ASOC.
Asunto(s)
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Diafragma/patología , Diafragma/cirugía , Neoplasias Ováricas/patología , Neoplasias Ováricas/cirugía , Ovariectomía , Neoplasias Peritoneales/cirugía , Segunda Cirugía , Absceso Abdominal/etiología , Adulto , Anciano , Biomarcadores de Tumor/sangre , Antígeno Ca-125/sangre , Quimioterapia Adyuvante , Tubos Torácicos/efectos adversos , Competencia Clínica , Fístula del Sistema Digestivo/etiología , Femenino , Hematoma/etiología , Humanos , Persona de Mediana Edad , Terapia Neoadyuvante/métodos , Estadificación de Neoplasias , Neoplasias Ováricas/tratamiento farmacológico , Ovariectomía/efectos adversos , Grupo de Atención al Paciente , Neoplasias Peritoneales/secundario , Derrame Pleural/etiología , Neumotórax/etiología , Valor Predictivo de las Pruebas , Pronóstico , Embolia Pulmonar/etiología , Reoperación/efectos adversos , Reoperación/métodos , Estudios Retrospectivos , Segunda Cirugía/efectos adversos , Segunda Cirugía/métodos , Dehiscencia de la Herida Operatoria/etiologíaAsunto(s)
Glucanos/administración & dosificación , Glucosa/administración & dosificación , Laparoscopía/efectos adversos , Adherencias Tisulares/tratamiento farmacológico , Adherencias Tisulares/prevención & control , Adulto , Dextranos/uso terapéutico , Femenino , Procedimientos Quirúrgicos Ginecológicos/efectos adversos , Humanos , Complicaciones Posoperatorias/tratamiento farmacológico , Complicaciones Posoperatorias/prevención & control , Segunda Cirugía/efectos adversosRESUMEN
OBJECTIVE: To evaluate the efficacy and safety of Adept (4% icodextrin solution) in reducing adhesions after laparoscopic gynecological surgery involving adhesiolysis. DESIGN: Multicenter, prospective, randomized, double-blind study comparing Adept with lactated Ringer's solution (LRS). PATIENT(S): Four hundred two patients randomized intraoperatively to Adept (n = 203) or LRS (n = 199) returned for second laparoscopy within 4-8 weeks. Incidence, severity, and extent of adhesions were determined on both occasions. MAIN OUTCOME MEASURE(S): The primary efficacy measure defined by the Food and Drug Administration was the number of patients achieving clinical success with adhesion treatment. Other measures included incidence and American Fertility Society (AFS) scores. RESULT(S): Significantly more Adept patients achieved clinical success than did LRS patients (49% vs. 38%). In infertility patients, Adept demonstrated particular clinical success compared with LRS (55% vs. 33%). This was reflected in the number of patients with a reduced AFS score (53% vs. 30%) and in fewer patients with a moderate/severe AFS category score (43% vs. 14%). Safety was comparable in both groups. Most events were related to the surgery, with an increase in transient labial edema in the Adept group. CONCLUSION(S): This is the first randomized, double-blind trial of an adhesion reduction agent. It demonstrated that Adept is a safe and effective adhesion reduction agent in laparoscopy.
Asunto(s)
Glucanos/administración & dosificación , Glucosa/administración & dosificación , Laparoscopía/efectos adversos , Adherencias Tisulares/tratamiento farmacológico , Adulto , Método Doble Ciego , Femenino , Glucanos/química , Glucosa/química , Procedimientos Quirúrgicos Ginecológicos/efectos adversos , Humanos , Icodextrina , Complicaciones Posoperatorias/tratamiento farmacológico , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Segunda Cirugía/efectos adversos , Adherencias Tisulares/etiología , Adherencias Tisulares/prevención & controlRESUMEN
Despite the best medical and endoscopic efforts, some patients with nonvariceal upper gastrointestinal bleeding suffer recurrences. Because high risk stigmata (visible vessels, active bleeders and adherent clots) often persist despite apparently successful initial hemostasis and have a variable natural history, it would seem reasonable to at least consider a routine second look endoscopy. However, a review of the literature revealed six randomized trials that, in aggregate, do not support such a strategy. In fact, a second look does not appear to be effective and is associated with an increased number of procedures, treatment sessions and possibly retreatment-related complications. In addition, the cointerventions in these trials are already out of date and the potential absolute risk reductions are low when a second look is used with intravenous proton pump inhibitors and/or the application of endoscopic hemoclips or combination endoscopic therapy. Finally, the Forrest classification may provide dangerously misleading estimates of prognosis because it is being used out of context. This review critically analyzes routine second look endoscopy.
Asunto(s)
Endoscopía Gastrointestinal , Segunda Cirugía , Costos y Análisis de Costo , Endoscopía Gastrointestinal/efectos adversos , Endoscopía Gastrointestinal/economía , Hemorragia Gastrointestinal/cirugía , Humanos , Inhibidores de la Bomba de Protones , Ensayos Clínicos Controlados Aleatorios como Asunto , Recurrencia , Medición de Riesgo , Segunda Cirugía/efectos adversos , Segunda Cirugía/economía , Resultado del Tratamiento , Tracto Gastrointestinal Superior/cirugíaRESUMEN
The most commonly used techniques for percutaneous endoscopic gastrostomy (PEG) require two passes of the gastroscope. The aim of this study was to clarify whether the second per oral gastroscopy can be replaced by passing a laryngo-fiberscope through the previously inserted PEG feeding tube. Twelve patients with head and neck cancer undergoing "pull through" PEG procedures were included in this prospective study. Instead of the second per oral pass of the gastro-intestinal fiberscope, a laryngo-fiberscope was passed through the inserted feeding tube to assess the correct position of the PEG internal disc. To gain more deflection to the tip of the instrument a string was led through the instrument channel and was brought back to the hand of the examiner outside the instrument. Pulling the string provided a bigger angulation to the end of the scope and thus a good view. In all twelve patients the "trans tubal" endoscopy was successful and provided a good second look to judge the position PEG internal disc. The procedure caused no inconvenience for the patient. "Trans tubal" endoscopy is a simple, safe and painless procedure to assess the position of the PEG feeding tube without having to pass the gastro-intestinal fiberscope a second time.