Featured Articles in Aug 2017

Patient Self-Assessment of Surgical Site Infection is Inaccurate

 

Author list: Vered  Richter, Matan J. Cohen, Shmuel Benenson, Gideon Almogy, Mayer Brezis

 

Abstract: 

Background

Availability of surgical site infection (SSI) surveillance rates challenges clinicians, healthcare administrators and leaders and the public. The purpose of this report is to demonstrate the consequences patient self-assessment strategies have on SSI reporting rates.

 

Methods

We performed SSI surveillance among patients undergoing general surgery procedures, including telephone follow-up 30 days after surgery. Additionally we undertook a separate validation study in which we compared patient self-assessments of SSI with surgeon assessment. Finally, we performed a meta-analysis of similar validation studies of patient self-assessment strategies.

 

Results

There were 22/266 in-hospital SSIs diagnosed (8.3%), and additional 16 cases were detected through the 30-day follow-up. In total, the SSI rate was 16.8% (95% CI 10.1–18.5). In the validation survey, we found patient telephone surveillance to have a sensitivity of 66% (95% CI 40–93%) and a specificity of 90% (95% CI 86–94%). The meta-analysis included five additional studies. The overall sensitivity was 83.3% (95% CI 79–88%), and the overall specificity was 97.4% (95% CI 97–98%). Simulation of the meta-analysis results divulged that when the true infection rate is 1%, reported rates would be 4%; a true rate of 50%, the reported rates would be 43%.

 

Conclusion

Patient self-assessment strategies in order to fulfill 30-day SSI surveillance misestimate SSI rates and lead to an erroneous overall appreciation of inter-institutional variation. Self-assessment strategies overestimate SSIs rate of institutions with high-quality performance and underestimate rates of poor performance. We propose such strategies be abandoned. Alternative strategies of patient follow-up strategies should be evaluated in order to provide valid and reliable information regarding institutional performance in preventing patient harm.

 

URL: http://rdcu.be/tWOn


Does Nissen Fundoplication Provide Lifelong Reflux Control? Symptomatic Outcome After 31–33 Years

 

Author list: P. Neuvonen, J. Sand, M. Matikainen, T. Rantanen

 

Abstract: 

Background

A substantial number of people are suffering from gastroesophageal reflux disease (GERD). The indication for surgical treatment is the failure of medical treatment in patients with objectively verified GERD. The use of PPIs has been noted to increase with the length of follow-up after fundoplication, raising questions concerning the durability of surgical results. The aim of the study was to investigate the results of open Nissen fundoplication (ONF) over a follow-up of more than 31 years.

 

Methods

ONF was performed for 38 consecutive patients. Questionnaires concerning long-term outcome were sent on December 14, 2015, to the 24 patients still living. Long-term symptom evaluation was carried out using the Gastrointestinal Symptom Rating Scale (GSRS), Visick grading, a Visual Analog Scale (VAS), the DeMeester–Johnson reflux scale, and the 15D tool.

 

Results

Seventeen (70.8%) of the 24 patients still living participated in the study. The typical symptoms of GERD had resolved significantly. Dysphagia was graded as none or minimal by 13 (81.3%) patients. The mean 15D score of the patient group was clinically and statistically the same (0.896 vs. 0.899) as that of the age- and sex-standardized general population (p = 0.912). Six (15.8%) patients had used antireflux medication after the operation and 4 of them (10.6%) continuously.

 

Conclusion

Patients in the present study used PPIs less frequently than what has been reported in previous long-term follow-up studies. Our results indicate that successful surgery may provide lifelong relief of GERD symptoms and normalize the health-related quality of life in GERD patients.

 

URL: http://rdcu.be/tWOr


International Variation in Emergency Operation Rates for Acute Diverticulitis: Insights into Healthcare Value

Author list: Michael K. Y. Hong, Anita R. Skandarajah, Rose D. Higgins, Omar D. Faiz, Ian P. Hayes

 

Abstract: 

Background

International comparison of outcomes of surgical diseases has become a global focus because of widespread concern over surgical quality, rising costs and the value of healthcare. Acute diverticulitis is a common disease potentially amenable to optimization of strategies for operative intervention. The aim was to compare the emergency operative intervention rates for acute diverticulitis in USA, England and Australia.

 

Methods

Unplanned admissions for acute diverticulitis were found from an international administrative dataset between 2008 and 2014 for hospitals in USA, England and Australia. The primary outcome measured was emergency operative intervention rate. Secondary outcomes included inpatient mortality and percutaneous drainage rate. Multivariable analysis was performed after development of a weighted comorbidity scoring system.

 

Results

There were 15,150 unplanned admissions for acute diverticulitis. The emergency operative intervention rates were 16, 13 and 10% for USA, England and Australia. The percutaneous drainage rate was highest in USA at 10%, while the mortality rate was highest in England at 2.8%. The propensity for emergency operative intervention was higher in USA (OR 1.45, p < 0.001) and England (OR 1.49, p < 0.001) than in Australia. The risk of 7-day mortality was higher in England than in Australia (OR 2.79, p < 0.001). Percutaneous drainage was associated with reduced 7-day mortality risk.

 

Conclusion

Australia has a lower propensity for emergency operative intervention, while England has a greater risk of mortality for acute diverticulitis. International variations raise the issue of healthcare value in terms of differing resource use and outcomes.

 

URL: http://rdcu.be/tWOz


A Novel Scoring System for Diagnosing Acute Mesenteric Ischemia in the Emergency Ward

 

Author list: Zhen Wang, Jun-Qiang Chen, Jin-lu Liu, Lei Tian

 

Abstract: 

Background

Early diagnosis of acute mesenteric ischemia (AMI) based on clinical judgment has been proved to be too difficult. Therefore, it is important for identifying clinical parameters that can differentiate AMI from other acute abdomen upon presentation.

 

Methods

We analyzed a database of 106 consecutive patients admitted to the emergency ward for suspected AMI in whom diagnosis of AMI was confirmed by laparotomy, CT angiography or mesenteric angiography. The patients’ demographics, previous history, clinical signs, results of laboratory investigations and ultrasonography were collected. Diagnostic cutoff value of quantitative indexes was derived from the receiver operating curve. Multivariate logistic regression was used to identify risk factors for AMI and formulated these risk factors into a scoring system.

 

Results

A total of 45 patients (42.5%) were confirmed to have AMI. Compared with other acute abdomen, AMI had significantly increased level of white blood cell (Odds ratio (OR) 16.11, 95% confidence interval (CI) 1.10–235.34), red cell distribution width (OR 27.65, 95% CI 1.53–501.02), mean platelet volume (OR 16.06, 95% CI 1.48–174.50) and D-dimer (OR 42.91, 95% CI 2.56–718.09). A diagnostic score was calculated by adding points assigned to the four parameters, and a cutoff score of four best identified patients with AMI, with sensitivity, specificity, positive and negative predictive values of 97.8, 91.8, 89.8 and 98.2%, respectively.

 

Conclusions

This scoring system based on easily available parameters could be used as a useful tool for differentiating AMI from other acute abdomen in the emergency ward. Prospective studies with large sample remain needed for validating the results.

 

URL: http://rdcu.be/tWOF


Enhanced Recovery After Surgery (ERAS®) in Individuals with Diabetes: A Systematic Review

 

Author list: Zaina Albalawi, Michael Laffin, Leah Gramlich, Peter Senior, Finlay A. McAlister

 

Abstract: 

Background

Prevalence of diabetes in surgical patients is 10–40%. It is well recognized that they have higher rates of complications, and longer stays in hospital compared to patients without diabetes. Enhanced recovery after surgery (ERAS) is an evidence-based multimodal surgical care pathway that improves postoperative complications and length of stay in patients without diabetes. This review evaluates the evidence on whether individuals with diabetes would benefit from ERAS implementation.

 

Methods

MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL) and EMBASE searched with no language restrictions applied. Conference proceedings and bibliographies were reviewed. Experts in the field were contacted, and www.clinicaltrials.gov searched for ongoing trials.

 

 

 

Results

The electronic search yielded 437 references. After removing duplicates, 376 were screened for eligibility. Conference proceedings and bibliographies identified additional references. Searching www.clinicaltrials.gov yielded 59 references. Contacting experts in the field identified no further studies. Fourteen full articles were assessed and subsequently excluded for the following reasons: used an intervention other than ERAS®, did not include patients with diabetes, or used an uncontrolled observational design.

 

Conclusions

To date, the effects of ERAS® on patients with diabetes have not been rigorously evaluated. This review highlights the lack of evidence in this area and provides guidance on design for future studies.

 

URL: http://rdcu.be/tWO0


Optimization of Chest Tube Management to Expedite Rehabilitation of Lung Cancer Patients After Video-Assisted Thoracic Surgery: A Meta-Analysis and Systematic Review

 

Author list: Bo Deng, Kai Qian, Jing-Hai Zhou, Qun-You Tan, Ru-Wen Wang

 

Abstract: 

Background

The aim of this meta-analysis and systematic review of published evidence was to optimize chest tube management for fast-track rehabilitation of lung cancer patients after video-assisted thoracic surgery (VATS).

 

Methods

The PubMed, Web of Science, and EMBASE databases were searched to identify all studies that addressed the issue of chest tube management after VATS for lung cancer. Finally, 35 articles were included for analysis, i.e., 29 randomized controlled trials and 6 clinical trials.

 

Results

After synthesis of the published evidence, the following protocol for chest tube drainage was formulated: (1) after VATS lung wedge resection, chest tube drainage can be omitted in selected cases; (2) normally, one 28Fr chest tube (or 19Fr Blake drain) is placed; (3) the use of a digital monitoring system is recommended; (4) in case of increasing pneumothorax or severe air leakage supported by digital recording system, the tube should be placed with active suction; and (5) the chest tube can be removed within 48 h postoperatively when air leakage is resolved and fluid drainage is <400 mL/day.

 

Conclusions

Further multicenter studies are warranted based on the variations of body sizes among different ethnicities.

 

URL: http://rdcu.be/tWO3


Is An Ostomy Rod Useful for Bridging the Retraction During the Creation of a Loop Ileostomy? A Randomized Control Trial

 

Author list: P. Motoi Uchino, Hiroki Ikeuchi, Toshihiro Bando, Teruhiro Chohno, Hirofumi Sasaki, Yuki Horio

 

Abstract: 

Background

A loop ileostomy is generally created during restorative proctocolectomy (RPC) for treating ulcerative colitis (UC), and an ostomy rod is often used to prevent stoma retraction. However, its usefulness or harmfulness has not been proven. We performed a prospective randomized control study to investigate the non-inferiority of ostomy creation without a rod to prevent stoma retraction.

Methods

Patients with UC who underwent RPC were enrolled and randomly divided into groups either with or without ostomy rod use. Incidences of stoma retraction and dermatitis were compared.

 

Results

Of the 320 patients in the study groups, 308 qualified for the intention-to-treat (ITT) analysis, and 257 were included in the per-protocol (PP) analysis. Ostomy retraction was recognized in 6 patients, 3 with a rod and 3 without. The difference with rod use (95% confidence interval) was 0.1 (−2.9 to 3.1)% in the PP analysis and 0.0 (−2.2 to 2.2)% in the ITT analysis. There were no significant differences in stoma retraction regardless of whether an ostomy rod was used in either analysis. Dermatitis was more common in patients with rod use (84/154) than in those without (40/154) (p < 0.01).

 

Conclusions

Although median body mass indices were extremely low (20 kg/m2), an ostomy rod is not routinely needed as it may increase the risk of dermatitis. However, results in obese patients may differ from those shown here, which should be clarified via further studies.

 

URL: http://rdcu.be/tWPi


Laparoscopic Repair of Duodenal Atresia: Systematic Review and Meta-Analysis

 

Author list: Anastasia Mentessidou, Amulya K. Saxena

 

Abstract: 

Background

To investigate the outcome of laparoscopic repair of duodenal atresia (LRDA) in relation to different approaches with regard to suture material and anastomosis technique. To identify evidence for the safety and efficacy of LRDA compared with the conventional open repair.

 

Methods

Systematic search was performed for all studies on LRDA, excluding case reports, and all comparative studies between LRDA and open repair. Chi-square was used to assess associations between complications or conversions rates and different LRDA approaches (suture material, suturing technique). Meta-analysis was employed to compare LRDA and open repair.

 

Results

The complications and conversions rates of LRDA were not affected by the different suture materials (Silk, Vicryl, PDS; p = 0.51) or suturing technique (interrupted, continuous; p = 0.46). The meta-analysis did not show significant differences between LRDA and open repair in overall complications rate (p = 0.88), time to feeds (p = 0.12) and hospitalization time (p = 0.28), although it revealed longer operative time with LRDA (p < 0.0001).

 

Conclusions

LRDA shows comparable safety and efficacy with the open repair, although it is associated with significantly longer operative time. There is no evidence that the type of the suture material or anastomotic technique affects the outcome of LRDA.

 

URL: http://rdcu.be/tWPt

 


 

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