Featured Articles in May 2017

Laparoscopic Versus Open Cholecystectomy: A Cost–Effectiveness Analysis at Rwanda Military Hospital

 

Author list: Allison Silverstein, Ainhoa Costas-Chavarri, Mussa R. Gakwaya, Joseph Lule, Swagoto Mukhopadhyay, John G. Meara, Mark G. Shrime

 

Abstract: 

Background

Laparoscopic cholecystectomy is first-line treatment for uncomplicated gallstone disease in high-income countries due to benefits such as shorter hospital stays, reduced morbidity, more rapid return to work, and lower mortality as well-being considered cost-effective. However, there persists a lack of uptake in low- and middle-income countries. Thus, there is a need to evaluate laparoscopic cholecystectomy in comparison with an open approach in these settings.

 

Method

A cost–effectiveness analysis was performed to evaluate laparoscopic and open cholecystectomies at Rwanda Military Hospital (RMH), a tertiary care referral hospital in Rwanda. Sensitivity and threshold analyses were performed to determine the robustness of the results.

 

Results

The laparoscopic and open cholecystectomy costs and effectiveness values were $2664.47 with 0.87 quality-adjusted life years (QALYs) and $2058.72 with 0.75 QALYs, respectively. The incremental cost–effectiveness ratio for laparoscopic over open cholecystectomy was $4946.18. Results are sensitive to the initial laparoscopic equipment investment and number of cases performed annually but robust to other parameters. The laparoscopic intervention is more cost-effective with investment costs less than $91,979, greater than 65 cases annually, or at willingness-to-pay (WTP) thresholds greater than $3975/QALY.

 

Conclusion

At RMH, while laparoscopic cholecystectomy may be a more effective approach, it is also more expensive given the low caseload and high investment costs. At commonly accepted WTP thresholds, it is not cost-effective. However, as investment costs decrease and/or case volume increases, the laparoscopic approach may become favorable. Countries and hospitals should aspire to develop innovative, low-cost options in high volume to combat these barriers and provide laparoscopic surgery.

 

URL: http://rdcu.be/qVRC


Laparoscopic Appendectomy: Risk Factors for Postoperative Intraabdominal Abscess

 

Author list: Francisco Schlottmann, Emmanuel E. Sadava, M. E. Pena, Nicolas A. Rotholtz

 

Abstract: 

Background

Laparoscopic appendectomy (LA) has obtained wide acceptance over the last two decades. However, some studies suggest that there is an increased rate of intraabdominal abscess (IAA) when is compared with open appendectomy. Since postoperative IAA is associated with high morbidity, identifying predictive factors of this complication may help to prevent it. The aim of this study was to identify preoperative and intraoperative risk factors for IAA after LA.

  

Methods

From January 2005 to June 2015, all charts of consecutive patients underwent to LA were revised. Demographics, clinical and intraoperative variables were analyzed. Independent risk factors for postoperative IAA were determined by logistic regression analysis.

 

Results

A total of 1300 LA were performed. The mean age was 34.7 (14–94) years. Two hundred and twenty-five patients (17.3%) had complicated appendicitis with perforation and peritonitis. The conversion rate was 2.3% (30 cases). The average hospital stay was 1.6 (0–27) days. There were 30 (2.3%) postoperative IAA. In the multivariate analysis, body mass index (BMI) >30 (p 0.01), leukocytosis >20,000/mm3 (p 0.02), perforated appendicitis (p < 0.001) and operative time >90 min (p 0.04) were associated with the development of postoperative IAA. There was no mortality in the series.

 

Conclusion

Patients with obesity, leukocytosis >20,000/mm3, perforated appendicitis and surgical time longer than 90 min have a higher chance of having a postoperative IAA. A close postoperative follow-up would be necessary in these situations in order to prevent and identify IAA after LA.

 

URL: http://rdcu.be/qVRT


Association Between BMI and Recurrence of Primary Spontaneous Pneumothorax

 

Author list: Juntao Tan, Yang Yang, Jianhong Zhong, Chuantian Zuo, Huamin Tang, Guang Zeng, Jianfeng Zhang, Jianji Guo, Nuo Yang

 

Abstract: 

Background

Whether body mass index (BMI) is a significant risk factor for recurrence of primary spontaneous pneumothorax (PSP) remains controversial. The purpose of this study was to examine whether BMI and other factors are linked to risk of PSP recurrence.

 

Method

A consecutive cohort of 273 patients was retrospectively evaluated. Patients were divided into those who experienced recurrence (n = 81) and those who did not (n = 192), as well as into those who had low BMI (n = 75) and those who had normal or elevated BMI (n = 198). The two pairs of groups were compared in terms of baseline data, and Cox proportional hazards modeling was used to identify predictors of PSP recurrence.

 

Results

Rates of recurrence among all 273 patients were 20.9% at 1 year, 23.8% at 2 years, and 28.7% at 5 years. Univariate analysis identified the following significant predictors of PSP recurrence: height, weight, BMI, size of pneumothorax, and treatment modality. Multivariate analyses identified several risk factors for PSP recurrence: low BMI, pneumothorax size ≥50%, and non-surgical treatment. Kaplan–Meier survival analysis indicated that patients with low BMI showed significantly lower recurrence-free survival than patients with normal or elevated BMI (P < 0.001).

 

Conclusion

Low BMI, pneumothorax size ≥50%, and non-surgical treatment were risk factors for PSP recurrence in our cohort. Low BMI may be a clinically useful predictor of PSP recurrence.

 

URL: http://rdcu.be/qVR2


Diagnosis and Treatment of 26 Cases of Abdominal Cocoon

 

Author list: Sheng Li, Jun-Jiang Wang, Wei-xian Hu, Mou-Cheng Zhang, Xian-Yan Liu, Yong Li, Guan-Fu Cai, Sen-Lin Liu, Xue-Qing Yao

 

Abstract: 

Background

Abdominal cocoon (AC) is a rare abdominal disease with nonspecific clinical features, and it is difficult to be diagnosed before operation and hard to be treated in clinical practice. The aim of this study is to investigate the diagnosis and treatment of AC.rior 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

The clinical manifestations, findings during surgery, treatments, and follow-up results of 26 cases of AC were retrospectively studied from January 2001 to January 2015.

 

Results

All of 26 cases were diagnosed as AC definitely by laparotomy or laparoscopic surgery. Their clinical findings were various, with 7 intestines obstructed with bezoars and 4 intestines perforated by spiny material. Based on the existence of the second enterocoelia, all cases were categorized into 2 types: type I is absent of second enterocoelia (18 cases, 69.23%), while type II shows second enterocoelia (8 cases, 30.77%). Twenty cases (12 were type I and 8 were type II) underwent membrane excision and careful enterodialysis to release the small intestine entirely or partially, while the other 6 cases (all were type I) did not. In addition, all patients were treated with medical treatment and healthy diet and lifestyle. Finally, most of the patients recovered smoothly.

 

Conclusions

AC can be categorized into two types; surgery is recommended for type II and part of type I with severe complications, but sometimes conservative therapy might be appropriate for type I. Laparoscopic surgery plays an important role in the diagnosis and treatment of AC. Furthermore, favorite health education, healthy diet and lifestyle are of significance in patients’ recovery.

 

URL: http://rdcu.be/qVSD


The Effects of Intravenous Lidocaine Infusions on the Quality of Recovery and Chronic Pain After Robotic Thyroidectomy: A Randomized, Double-Blinded, Controlled Study

 

Author list: Kwan Woong Choi, Kee-Hyun Nam, Jeong-Rim Lee, Woong Young Chung, Sang-Wook Kang, Young Eun Joe, Jae Hoon Lee

 

Abstract: 

Background

The effect of the systemic lidocaine on postoperative recovery has not been definitively investigated despite its analgesic efficacy after surgery. The aim of this randomized, double-blinded, controlled study was to evaluate the effect of intravenously administered lidocaine on the quality of recovery and on acute and chronic postoperative pain after robot-assisted thyroidectomy.

 

Methods

Ninety patients who were undergoing robotic thyroidectomy were randomly assigned to the lidocaine or the control groups. The patients received 2 mg/kg of lidocaine followed by continuous infusions of 3 mg/kg/h of lidocaine (Group L) or the same volume of 0.9% normal saline (Group C) intravenously during anesthesia. The acute pain profiles and the quality of recovery, which was assessed using the quality of recovery-40 questionnaire (QoR-40), were evaluated for 2 days postoperatively. Chronic postsurgical pain (CPSP) and sensory disturbances at the surgical sites were evaluated 3 months after surgery.

 

Results

The QoR-40 and pain scores that were assessed during the 2 days that followed surgery were largely comparable between the groups. However, CPSP was more prevalent in the Group C than in the Group L (16/43 vs. 6/41; p = 0.025). The tactile sensory score 3 months after the operation was significantly greater in the Group L than in the Group C (7 vs. 5; p = 0.001).

 

Conclusions

Systemic lidocaine administration was associated with reductions in CPSP and sensory impairment after robot-assisted thyroidectomy although it was not able to reduce acute postsurgical pain or improve the quality of recovery.

 

URL: http://rdcu.be/qVSK


Effect of Remote Ischaemic Preconditioning on Liver Injury in Patients Undergoing Major Hepatectomy for Colorectal Liver Metastasis: A Pilot Randomised Controlled Feasibility Trial

 

Author list: Sanjeev Kanoria, Francis P. Robertson, Naimish N. Mehta, Giuseppe Fusai, Dinesh Sharma, Brian R. Davidson

 

Abstract: 

Background

Liver resection produces excellent long-term survival for patients with colorectal liver metastases but is associated with significant morbidity and mortality from ischaemia reperfusion injury (IRI). Remote ischaemic preconditioning (RIPC) can reduce the effect of IRI. This pilot randomised controlled trial evaluated RIPC in patients undergoing major hepatectomy at the Royal Free Hospital, London.

 

Methods

Sixteen patients were randomised to RIPC or sham control. RIPC was induced through three 10-min cycles of alternate ischaemia and reperfusion to the leg. At baseline and immediately post-resection, transaminases and indocyanine green (ICG) clearance were measured.

 

Results

The RIPC group had lower ALT and AST levels immediately post-resection (ALT: 43% lower 497 ± 165 vs 889 ± 170 IU/L; p = 0.019 AST: 54% lower 408 ± 166 vs 836 ± 167 IU/L; p = 0.001) and at 24 h (ALT: 41% lower 412 ± 144 vs 698 ± 137 IU/L; p = 0.026 AST: 50% lower 316 ± 116 vs 668 ± 115 IU/L; p = 0.02). ICG clearance was reduced in controls versus RIPC immediately after resection (ICG-PDR: 11.1 ± 1.1 vs 16.5 ± 1.4%/min; p = 0.035).

 

Conclusion

This pilot study shows that RIPC has potential to reduce liver injury following hepatectomy justifying a prospective RCT powered to demonstrate clinical benefits.

 

URL: http://rdcu.be/qVTT


 

BACK