Featured Articles in Apr 2017

Perioperative Risks of Dietary and Herbal Supplements

 

Author list: Ilana Levy, Samuel Attias, Eran Ben-Arye, Lee Goldstein, Ibrahim Matter, Mostafa Somri, Elad Schiff

 

Abstract: 

Background

Patients undergoing surgery often use Dietary and Herbal Supplements (DHS). We explored the risk of DHS–drug interactions in the perioperative setting.

 

Method

In this cross-sectional prospective study, participants hospitalized for surgery completed a questionnaire regarding DHS use. We used pharmacological databases to assess DHS–drug interactions. We then applied univariate and multivariate logistic regression analyses to characterize patients at risk for DHS–drug interactions.

 

Results

Of 526 interviewees, 230 (44%) patients reported DHS use, with 16.5% reporting using DHS that could potentially interact with anesthesia. Twenty-four (10%) patients used DHS that could potentially interact with antithrombotic drugs taken perioperatively. The medical files of three patients included reports of intraoperative bleeding. The patient files of only 11% of DHS users documented DHS use.

 

Conclusion

DHS use poses a significant health risk due to potential interactions. Guidelines should emphasize perioperative management of DHS use.

 

URL: http://rdcu.be/runi


Comparative Validation of Abdominal CT Models that Predict Need for Surgery in Adhesion-Related Small-Bowel Obstruction

 

Author list: Phillip F. Yang, Dean P. Rabinowitz, Shing W. Wong, Maroof A. Khan, Robert C. Gandy

 

Abstract: 

Background

Adhesion-related small-bowel obstruction (ASBO) can be managed without surgery in selected patients. The aim of this study was to validate three previously published computed tomography (CT) models that predict need for surgery.

 

Methods

A retrospective study of patients with ASBO admitted to a tertiary referral hospital between November 2009 and April 2015 was conducted. Data on clinical variables were extracted from medical records. CT signs were assessed by a radiologist who was blinded to whether or not the patients required surgery. Three previously published models were validated by testing their ability to predict need for surgery.

 

Results

The cohort comprised 233 patients with ASBO (mean age 69.7 years, 47.6% male), of whom 73 (31.3%) required surgery. A predictive model using a combination of mesenteric oedema, free intraperitoneal fluid and absence of small-bowel faecalisation had a sensitivity of 38% [95% CI 27–50%], specificity of 88% [81–92%], positive likelihood ratio (LR+) of 3.1 [1.6–5.1] and negative likelihood ratio (LR−) of 0.7 [0.6–0.8]. Only the results of one previously published model (which used a combination of obstipation, free intraperitoneal fluid and high-grade or complete obstruction) could be reproduced. This model had a potentially clinically useful LR+ of 2.9 [1.1–7.4] and LR− of 0.9 [0.8–1.0]. The poor performances of the other two models may be partially explained by measurement bias.

 

Conclusion

The performances of the previously published predictive models in this validation study were varied. Future attempts to develop models should use clearly defined, standardised and reproducible predictors wherever possible.

 

URL: http://rdcu.be/pEKi


Implementation of the World Health Organization Trauma Care Checklist Program in 11 Centers Across Multiple Economic Strata: Effect on Care Process Measures

 

Author list: Angela Lashoher, Eric B. Schneider, Catherine Julliard, Kent Stevens, Elizabeth Colantuoni, William R. Berry, Christina Bloem, Witaya Chadbunchachai, Satish Dharap, Sydney M. Dy, Gerald Dziekan, Russell L. Gruen, Jaymie A. Henry, Christina Huwer, Manjul Joshipura, Edward Kelley, Etienne Krug, Vineet Kumar, Patrick Kyamanywa, Alain Chichom Mefire, Marcos Musafir, Avery B. Nathens, Edouard Ngendahayo, Thai Son Nguyen, Nobhojit Roy, Peter J. Pronovost, Irum Qumar Khan, Junaid Abdul Razzak, Andres M. Rubiano, James A. Turner, Mathew Varghese, Rimma Zakirova

 

Abstract: 

Background

Trauma contributes more than ten percent of the global burden of disease. Initial assessment and resuscitation of trauma patients often requires rapid diagnosis and management of multiple concurrent complex conditions, and errors are common. We investigated whether implementing a trauma care checklist would improve care for injured patients in low-, middle-, and high-income countries.

 

Method

From 2010 to 2012, the impact of the World Health Organization (WHO) Trauma Care Checklist program was assessed in 11 hospitals using a stepped wedge pre- and post-intervention comparison with randomly assigned intervention start dates. Study sites represented nine countries with diverse economic and geographic contexts. Primary end points were adherence to process of care measures; secondary data on morbidity and mortality were also collected. Multilevel logistic regression models examined differences in measures pre- versus post-intervention, accounting for patient age, gender, injury severity, and center-specific variability.

 

Results

Data were collected on 1641 patients before and 1781 after program implementation. Patient age (mean 34 ± 18 vs. 34 ± 18), sex (21 vs. 22 % female), and the proportion of patients with injury severity scores (ISS) ≥ 25 (10 vs. 10 %) were similar before and after checklist implementation (p > 0.05). Improvement was found for 18 of 19 process measures, including greater odds of having abdominal examination (OR 3.26), chest auscultation (OR 2.68), and distal pulse examination (OR 2.33) (all p < 0.05). These changes were robust to several sensitivity analyses.

 

Conclusion

Implementation of the WHO Trauma Care Checklist was associated with substantial improvements in patient care process measures among a cohort of patients in diverse settings.

 

URL: http://rdcu.be/pEKt


Adrenal Injuries: Historical Facts and Modern Truths

 

Author list: Jody C. DiGiacomo, L. D. George Angus, Edward Coffield

 

Abstract: 

Background

Prior to the advent of whole body computed tomography, injuries of the adrenal gland were almost exclusively identified on postmortem examinations and were associated with severe injury. Recent literature has continued to identify an association between adrenal injuries and high ISS. The purpose of this study was to assess the influence of adrenal trauma on ISS and mortality while controlling for potential confounding factors.

 

Method

A 15-year retrospective review for all adrenal gland injuries from a Level 1 Trauma Center’s Trauma Registry was performed. Based on the characteristics of that patient population, the same Trauma Registry was then queried for case-matched patients, and the two groups compared to assess the influence of adrenal gland injuries on mortality.

 

Results

Seventy-two patients with adrenal injuries were identified and compared to 1026 case-matched patients. The adrenal gland injury was not a contributing factor in any of the study group mortalities. The mean ISS for the adrenal gland injured group was higher than the overall Registry ISS (18.7 vs 10.6) but almost identical to the ISS of patients case matched for abdominal injuries.

 

Conclusions

Case-matched analysis based on multiple clinical variables demonstrates that the ISS of patients with adrenal gland injuries were similar to the ISS of patients with other injuries to the abdominal region and were in fact associated with a 0.02% decrease in mortality.

 

URL: http://rdcu.be/runE


Toward More Efficient Surveillance of Barrett’s Esophagus: Identification and Exclusion of Patients at Low Risk of Cancer

 

Author list: Mats Lindblad, Tim Bright, Ann Schloithe, George C. Mayne, Gang Chen, Jeff Bull, Peter A. Bampton, Robert J. L. Fraser, Piers A. Gatenby, Louisa G. Gordon, David I. Watson

 

Abstract: 

Background

Endoscopic surveillance of Barrett’s esophagus (BE) is probably not cost-effective. A sub-population with BE at increased risk of high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) who could be targeted for cost-effective surveillance was sought.

 

Methods

The outcome for BE surveillance from 2003 to 2012 in a structured program was reviewed. Incidence rates and incidence rate ratios for developing HGD or EAC were calculated. Risk stratification identified individuals who could be considered for exclusion from surveillance. A health-state transition Markov cohort model evaluated the cost-effectiveness of focusing on higher-risk individuals.

 

Results

During 2067 person-years of follow-up of 640 patients, 17 individuals progressed to HGD or EAC (annual IR 0.8%). Individuals with columnar-lined esophagus (CLE) ≥2 cm had an annual IR of 1.2% and >8-fold increased relative risk of HGD or EAC, compared to CLE <2 cm [IR—0.14% (IRR 8.6, 95% CIs 4.5–12.8)]. Limiting the surveillance cohort after the first endoscopy to individuals with CLE ≥2 cm, or dysplasia, followed by a further restriction after the second endoscopy—exclusion of patients without intestinal metaplasia—removed 296 (46%) patients, and 767 (37%) person-years from surveillance. Limiting surveillance to the remaining individuals reduced the incremental cost-effectiveness ratio from US$60,858 to US$33,807 per quality-adjusted life year (QALY). Further restrictions were tested but failed to improve cost-effectiveness.

Conclusions

Based on stratification of risk, the number of patients requiring surveillance can be reduced by at least a third. At a willingness-to-pay threshold of US$50,000 per QALY, surveillance of higher-risk individuals becomes cost-effective.

 

URL: http://rdcu.be/runU


Chylous Ascites Management After Pancreatic Surgery

 

Author list: Nicolas Tabchouri, Eric Frampas, Frederic Marques, Claire Blanchard, Adam Jirka, Nicolas Regenet

 

Abstract: 

Background

Postoperative chylous ascites (CA) following pancreatic surgery is uncommon. If left untreated, it leads to malnutrition, immunodeficiency and increased postoperative morbidity and mortality. The aim of this study was to seek out risk factors associated with CA onset and conservative treatment (CT) failure in order to determine better management of CA following pancreatic resection.

 

Methods

All consecutive patients who underwent pancreatic surgery between 2004 and 2014 were reviewed retrospectively. Main demographic, clinical and pathological data were searched for CA risk factors. Patients with CA successfully treated with CT alone were compared to those requiring additional bipedal lymphangiography (BPLAG) in order to seek out risk factors associated with CT failure.

 

Results

Fifteen patients (2.4 %) developed CA after pancreatic surgery. Para-aortic lymph node sampling and early enteral feeding were found to be independent risk factors for postoperative CA (OR 6.36, p = 0.024 and OR 12.18, p = 0.02, respectively). CT was successful in ten patients, and five patients required additional BPLAG to achieve CA resolution. Statistical analysis revealed no significant risk factors for CT failure, including total lymph node count (p = 0.196), para-aortic lymph node sampling (p = 0.661) or maximum chyle loss per day (p = 0.758).

 

Conclusion

Owing to postoperative CA rarity, there is no consensus in treatment. Early on, CT should be attempted in all patients with CA. BPLAG is a safe and efficient procedure that should be discussed earlier in the step-up therapeutic management.

 

URL: http://rdcu.be/pEKS


Enhanced Recovery After Surgery Programs Improve Patient Outcomes and Recovery: A Meta-analysis

 

Author list: Christine S. M. Lau, Ronald S. Chamberlain

 

Abstract: 

Background

Enhanced recovery after surgery (ERAS) programs have been developed to improve patient outcomes, accelerate recovery after surgery, and reduce healthcare costs. ERAS programs are a multimodal approach, with interventions during all stages of care. This meta-analysis examines the impact of ERAS programs on patient outcomes and recovery. 

 

Methods

A comprehensive search of all published randomized control trials (RCTs) assessing the use of ERAS programs in surgical patients was conducted. Outcomes analyzed were length of stay (LOS), overall mortality, 30-day readmission rates, total costs, total complications, time to first flatus, and time to first bowel movement.

 

Results

Forty-two RCTs involving 5241 patients were analyzed. ERAS programs significantly reduced LOS, total complications, and total costs across all types of surgeries (p < 0.001). Return of gastrointestinal (GI) function was also significantly improved, as measured by earlier time to first flatus and time to first bowel movement, p < 0.001. There was no overall difference in mortality or 30-day readmission rates; however, 30-day readmission rates after upper GI surgeries nearly doubled with the use of ERAS programs (RR = 1.922; p = 0.019).

 

Conclusions

ERAS programs are associated with a significant reduction in LOS, total complications, total costs, as well as earlier return of GI function. Overall mortality and readmission rates remained similar, but there was a significant increase in 30-day readmission rates after upper GI surgeries. ERAS programs are effective and a valuable part in improving patient outcomes and accelerating recovery after surgery.

 

URL: http://rdcu.be/pELc


 

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