Featured Articles in Feb 2017

Ethical and Surgical Dilemmas in Patients with Neglected Surgical Diseases Visiting a Field Hospital in a Zone of Recent Disaster

 

Author list: Guy Lin, Tal Marom, David Dagan, Ofer Merin

 

Abstract: 

Background

The massive typhoon Haiyan (Yolanda) ripped across the central Philippines on November 8, 2013, and damaged infrastructure including hospitals. The Israeli Defense Forces field hospital was directed by the Philippine authorities to Bogo City in the northern part of the island of Cebu, to assist the damaged local hospital. Hundreds of patients with neglected diseases sought for medical treatment which was merely out of reach for them. Our ethical dilemmas were whether to intervene, when the treatment we could offer was not the best possible.

 

Method

Each patient had an electronic medical record that included diagnosis, management and aftercare instructions. We retrospectively reviewed all charts of patients.

 

Results

Over 200 patients presented with neglected chronic diseases (tuberculosis, goiter, hypertension and diabetes). We limited our intervention to extreme values of glucose and blood pressure. We had started anti-tuberculosis medications, hoping that the patients will have an option to continue treatment. We examined 85 patients with a presumed diagnosis of malignancy. Without histopathology and advanced imaging modality, we performed palliative operations on three patients. Eighteen patients presented with inguinal hernia. We performed pure tissue repair on seven patients with large symptomatic hernias. We examined 12 children with cleft lip/palate and transferred two of them to Israel. We operated on one child with bilateral club feet. Out of 37 patients with pterygium, our ophthalmologist repaired the nine patients with the most severe vision disturbance.

 

Conclusion

Medical delegations to disaster areas should prepare a plan and appropriate measures to deal with non-urgent diseases.

 

URL: http://rdcu.be/oDBV


Long-Term Mortality in Patients Operated for Perforated Peptic Ulcer: Factors Limiting Longevity are Dominated by Older Age, Comorbidity Burden and Severe Postoperative Complications

 

Author list: K. Thorsen, J.A. Soreide, K. Soreide

 

Abstract: 

Background

Perforated peptic ulcer (PPU) is a surgical emergency associated with high short-term mortality. However, studies on long-term outcomes are scarce. Our aim was to investigate long-term survival after surgery for PPU.

 

Methods

A population-based, consecutive cohort of patients who underwent surgery for PPU between 2001 and 2014 was reviewed, and the long-term mortality was assessed. Survival was investigated by univariate analysis (log-rank test) and displayed using Kaplan–Meier survival curves. Multivariable analysis of risk factors for long-term mortality was assessed by Cox proportional hazards regression and reported as hazard ratio (HR) with 95 % confidence intervals (CI).

 

Results

A total of 234 patients were available for the calculation of ninety-day, one-year and two-year mortality, and the results showed rates of 19.2 % (45/234), 22.6 % (53/234) and 24.8 % (58/234), respectively. At the end of follow-up, a total of 109 of the 234 patients (46.6 %) had died. Excluding 37 (15.2 %) patients who died within 30 days of surgery, 197 patients had long-term follow-up (median 57 months, range 1–168) of which 36 % (71/197) died during the follow-up period. In multivariable analyses, age >60 years (HR 3.95, 95 % CI 1.81–8.65), active cancer (HR 3.49, 95 % CI 1.73–7.04), hypoalbuminemia (HR 1.65, 95 % CI 0.99–2.73), pulmonary disease (HR 2.06, 95 % CI 1.14–3.71), cardiovascular disease (HR 1.67, 95 % CI 1.01–2.79) and severe postoperative complications (HR 1.76, 95 % CI 1.07–2.89) during the initial stay for PPU were all independently associated with an increased risk of long-term mortality. Cause of long-term mortality was most frequently (18 of 71; 25 %) attributed to new onset sepsis and/or multiorgan failure.

 

Conclusion

The long-term mortality after surgery for PPU is high. One in every three patients died during follow-up. Older age, comorbidity and severe postoperative complications were risk factors for long-term mortality.

 

URL: http://rdcu.be/oDBY


Improvement of Postoperative Pain Control Processes and Outcomes in Veterans of a Surgical Intensive Care Unit

 

Author list: Melissa S. D’Andrea, P. Marco Fisichella

 

Abstract: 

Background

Postoperative pain remains undertreated in critically ill patients. We hypothesized that the adequacy of pain control in our Surgical Intensive Care Unit (SICU) was above the reported average of 71 % in the literature and that the introduction of the critical care pain observation tool (CPOT) could improve it. We used a Lean Six Sigma methodology to improve our processes and quantify our improvement.

 

Method

We retrospectively review 713 consecutive veterans admitted to our SICU. Between December 2014 and February 2015, postoperative pain was assessed every 2 h and rated “acceptable,” “unacceptable,” or “unable to assess”. Between March 2015 and October 2015, postoperative pain was assessed with CPOT. Concurrently, we implemented a postoperative pain education program and documented this activity in the electronic medical record.

 

Results

The baseline adequacy of pain control was 78 %, which improved to 99 % after the introduction of CPOT. We concurrently achieved a 100 % median documentation of postoperative pain education in the electronic medical record. The introduction of CPOT improved the process σ from 2.3 to 3.8. The process of documenting pain education achieved a process σ of 3.1.

 

Conclusion

The proportion of veterans with acceptable pain control in our SICU is higher than that reported in the literature and the application of a Six Sigma methodology that involved the introduction of the CPOT has allowed us to improve the perception of pain control and comply with the newest regulatory directives.

 

URL: http://rdcu.be/oDB4


Surgery-Related Muscle Loss and Its Association with Postoperative Complications After Major Hepatectomy with Extrahepatic Bile Duct Resection

 

Author list: Hidehiko Otsuji, Yukihiro Yokoyama, Tomoki Igami, Gen Sugawara, Takashi Mizuno, Junpei Yamaguchi, Masato Nagino

 

Abstract: 

Background

Several studies have reported that preoperative sarcopenia negatively impacts postoperative outcomes. Meanwhile, changes in skeletal muscle mass during the acute phase after surgery and their association with postoperative complications are unknown.

 

Method

This study included 254 patients who underwent major hepatectomies with extrahepatic bile duct resections. Total psoas muscle area (TPA) was measured using abdominal computed tomography images obtained before and 1 week after surgery. The percent change in TPA after surgery was calculated. Patients were stratified by sex-specific tertiles according to the extent of muscle mass change by percentage. Surgery-related muscle loss (SML) was defined as the lowest tertile of percent change in TPA.

 

Results

Male patients with a percent change of TPA lower than −5.0 % (n = 54) and female patients with that lower than −2.6 % (n = 31) were included in the lowest tertile and were categorized into a group with SML. The incidence rates of major complications, pancreatic fistula, infectious complications, and mortality were all significantly higher in the group with SML than in the group without SML. By multivariate analyses, SML was identified as an independent factor associated with major complications (odds ratio 3.21; 95 % confidential interval 1.82–5.76, p < 0.001).

 

Conclusions

SML is significantly associated with postoperative morbidity and mortality in patients who underwent major hepatectomies with extrahepatic bile duct resections.

 

URL: http://rdcu.be/oDCc


Treatment-Based Three-Dimensional Classification and Management of Anorectal Infections

 

Author list: A. E. Ortega, K. G. Cologne, J. Shin, S. W. Lee, G. T. Ault

 

Abstract: 

This article provides a current overview on clinical anatomy, pathophysiology, workup and surgical management of anorectal abscesses. Based on the three-dimensional nature of anorectal abscesses, a novel treatment-based classification is proposed. It examines the basis of a philosophic shift from simple drainage to concomitant definitive treatment of abscesses and their underlying primary fistulous trajectories. Complications are discussed specifically in this context.

 

Conclusions

The time-honored precept of “first do no harm” remains operant in the treatment of anorectal infections. However, definitive surgical management should be considered when prevention of recurrent infections or complex fistulas is an achievable end-point. Treatment-based classification and management of these pleomorphic infections facilitates this goal. An individualized surgical approach in corono-axial and sagittal subclassifications is summarized in Table 3. Patients should be counseled regarding the possibility of minor incontinence. It may result from simple drainage as well as definitive treatment.

 

URL: http://rdcu.be/oDCf


Handcrafted Vacuum-Assisted Device for Skin Ulcers Treatment Versus Traditional Therapy, Randomized Controlled Trial

 

Author list: Israel Gonzalez Gonzalez, Medina Andrade Luis Angel, Maria Valeria Jimenez Baez, Brenda Ruiz Flores, Maria de los Angeles Martinez Ferretiz, Stepphany Vanestty Woolf, Israel Lopez, Luis Sandoval-Jurado, Fany Guadalupe Pat-Espadas, Alan Alejandro Reyes Cruz, Arsenio Torres Delgado

 

Abstract: 

Background

Chronic lower limb ulcers constitute a public health problem, with important socioeconomic implications and high attention cost. This trial evaluates handcrafted vacuum-assisted therapy versus traditional treatment effectiveness for lower limbs ulcers.

 

Methods

It was a prospective randomized clinical trial conducted over 144 patients with lower limbs ulcers. Patients were randomized into two groups of 72 patients: Experimental group were treated with debridement, cure and a handcrafted vacuum-assisted device that was changed every 72 h. Control group was treated with debridement and cure with soap every 24 h. Ulcers were evaluated every 72 h and on 10th day. The presence of systemic inflammatory response, pain, granulation tissue and viability for discharge was registered and analyzed .

 

Results

After exclusion of 18 patients, 126 were included, 65.1% were men with an average of 58 years. Sole region ulcer by diabetic foot was the more frequent in both groups (73%). Leukocytes count, systemic inflammatory response and pain were significantly lower in experimental group (p < 0.05). Discharge criteria and granulation tissue were present earlier in experimental group (p < 0.05).

 

Conclusion

Handcrafted vacuum-assisted system is a feasible and safe method to treat chronic ulcers. This system would benefit patients favoring earlier infection control, faster granulation tissue appearance and earlier discharge.

 

URL: http://rdcu.be/oDCl


Effects of Topical Atorvastatin (2 %) on Posthemorrhoidectomy Pain and Wound Healing: A Randomized Double-Blind Placebo-Controlled Clinical Trial

 

Author list: Shahram Ala, Mina Alvandipour, Majid Saeedi, Maliheh Hamidian, Afshin Shiva, Nasrin Rahmani, Fatemeh Faramarzi

 

Abstract: 

Background

Atorvastatin is a 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase inhibitor widely used in treatment of hypercholesterolemia and prevention of coronary heart disease and has various pleiotropic effects. In this study, the efficacy of atorvastatin emulgel (2 %) in reducing postoperative pain at rest, pain during defecation and analgesic requirement after open hemorrhoidectomy was investigated.

 

Methods

A total of 66 patients with third- and fourth-degree hemorrhoids undergoing open hemorrhoidectomy were included in this prospective, double-blind, randomized controlled trial. The patients were randomly assigned to either atorvastatin emulgel or placebo immediately after surgery and then every 12 h for 14 days. The primary outcomes were intensity of pain at rest and during defecation, measured with a visual analog scale, and the analgesic requirement, measured by amount of pethidine and acetaminophen consumption, and percent of wound healing.

 

Results

There was no significant difference in the average postoperative pain scores in the first 48 h (P12h = 1, P24h = 0.128 and P48h = 0.079) after the surgery between the two groups, but at the week 1 the pain scores during defecation were considerably lower in the atorvastatin group than in placebo group (P = 0.004), which also was the same at the week 2 (P = 0.03). There was no significant difference in the average pethidine and acetaminophen (mg) administration at 12 h and 24 h between the two groups after surgery. Regarding the data about wound healing, at the week two the healing was much better in the treatment group than it was in control group and the difference was statistically significant (P = 0.04).

 

Conclusions

Compared with placebo, atorvastatin emulgel reduced postoperative pain at rest and on defecation and could improve the healing process after open hemorrhoidectomy.

 

URL: http://rdcu.be/oDDF


 

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