BMJ Surgery Interventions Health Technologies最新文献

Objective: The goal of this study was to explore which enhanced recovery after surgery (ERAS) bundle items were most associated with decreased length of stay after surgery, most likely associated with decreased length of stay after surgery.

Design: A cohort study.

Setting: Large tertiary academic medical centre.

Participants: The study included 1318 women undergoing hysterectomy as part of our ERAS pathway between 1 February 2018 and 30 January 2020 and a matched historical cohort of all hysterectomies performed at our institution between 3 October 2016 and 30 January 2018 (n=1063).

Intervention: The addition of ERAS to perioperative care.This is a cohort study of all patients undergoing hysterectomy at an academic medical centre after ERAS implementation on 1 February 2018. Compliance and outcomes after ERAS roll out were monitored and managed by a centralised team. Descriptive statistics, multivariate regression, interrupted time series analysis were used as indicated.

Main outcome measures: Impact of ERAS process measure adherence on length of stay.

Results: After initiation of ERAS pathway, 1318 women underwent hysterectomy. There were more open surgeries after ERAS implementation, but cohorts were otherwise balanced. The impact of process measure adherence on length of stay varied based on surgical approach (minimally invasive vs open). For open surgery, compliance with intraoperative antiemetics (-30%, 95% CI -18% to 40%) and decreased postoperative fluid administration (-12%, 95% CI -1% to 21%) were significantly associated with reduced length of stay. For minimally invasive surgery, ambulation within 8 hours of surgery was associated with reduced length of stay (-53%, 95% CI -55% to 52%).

Conclusions: While adherence to overall ERAS protocols decreases length of stay, the specific components of the bundle most significantly impacting this outcome remain elusive. Our data identify early ambulation, use of antiemetics and decreasing postoperative fluid administration to be associated with decreased length of stay.

Objective: Secure knots are essential in all areas of surgical, medical and veterinary practice. Our hypothesis was that technique of formation of each layer of a surgical knot was important to its security.

Design: Equal numbers of knots were tied, by each of three groups, using three techniques, for each of four suture materials; a standard flat reef knot (FRK), knots tied under tension (TK) and knots laid without appropriate hand crossing (NHCK). Each knot technique was performed reproducibly, and tested by distraction with increasing force, till each material broke or the knot separated completely.

Setting: Temporary knot tying laboratory.

Materials: The suture materials were, 2/0 polyglactin 910 (Vicryl), 3/0 polydioxanone, 4/0 poliglecaprone 25 (Monocryl) and 1 nylon (Ethilon).

Participants: Three groups comprised, a senior surgeon, a resident surgeon and three medical students.

Outcome measures: Proportion of each knot type that slipped, degree of slippage and length of suture held in loop secured by each knot type.

Results: 20% of FRK tied with all suture materials slipped; all knots tied with the other two techniques, with all materials, slipped, TK (100%) and NHCK (100%). The quantitative degree of slip was significantly less for FRK (mean 6.3%-, 95% CI 2.2% to 10.4%) than for TK (mean 312%, 95% CI 280.0% to 344.0%) and NHCK (mean 113.0%, -95% CI 94.3% to 131.0%).The mean length of suture in loops held within (FRK mean 25.1 mm 95% CI 24.2 to 26.0 mm) was significantly greater than mean lengths held by the other techniques (TK mean 17.0 mm, 95% CI 16.3 to 17.7 mm), (NHCK mean 16.3 mm, 95% CI 15.9 to 16.7 mm). The latter two types of knot may have tightened more than anticipated, in comparison to FRK, with potential undue tissue tension.

Conclusion: Meticulous technique of knot tying is essential for secure knots, appropriate tissue tension and the security of anastomoses and haemostasis effected.

Objectives: We aim to determine what threshold of compressive stress small bowel and colon tissues display evidence of significant tissue trauma during laparoscopic surgery.

Design: This study included 10 small bowel and 10 colon samples from patients undergoing routine gastrointestinal surgery. Each sample was compressed with pressures ranging from 100 kPa to 600 kPa. Two pathologists who were blinded to all study conditions, performed a histological analysis of the tissues. Experimentation: November 2018-February 2019. Analysis: March 2019-May 2020.

Setting: An inner-city trauma and ambulatory hospital with a 40-bed inpatient general surgery unit with a diverse patient population.

Participants: Patients were eligible if their surgery procured healthy tissue margins for experimentation (a convenience sample). 26 patient samples were procured; 6 samples were unusable. 10 colon and 10 small bowel samples were tested for a total of 120 experimental cases. No patients withdrew their consent.

Interventions: A novel device was created to induce compressive "grasps" to simulate those of a laparoscopic grasper. Experimentation was performed ex-vivo, in-vitro. Grasp conditions of 0-600 kPa for a duration of 10 s were used.

Results: Small bowel (10), M:F was 7:3, average age was 54.3 years. Colon (10), M:F was 1:1, average age was 65.2 years. All 20 patients experienced a significant difference (p<0.05) in serosal thickness post-compression at both 500 and 600 kPa for both tissue types. A logistic regression analysis with a sensitivity of 100% and a specificity of 84.6% on a test set of data predicts a safety threshold of 329-330 kPa.

Conclusions: A threshold was discovered that corresponded to both significant serosal thickness change and a positive histological trauma score rating. This "force limit" could be used in novel sensorized laparoscopic tools to avoid intraoperative tissue injury.

Objectives: COVIDTrach is a UK multicentre prospective cohort study project that aims to evaluate the outcomes of tracheostomy in patients with COVID-19 receiving mechanical ventilation and record the incidence of SARS-CoV-2 infection among healthcare workers involved in the procedure.

Design: Data on patient demographic, clinical history and outcomes were entered prospectively and updated over time via an online database (REDCap). Clinical variables were compared with outcomes, with logistic regression used to develop a model for mortality. Participants recorded whether any operators tested positive for SARS-CoV-2 within 2 weeks of the procedure.

Setting: UK National Health Service departments involved in treating patients with COVID-19 receiving mechanical ventilation.

Participants: The cohort comprised 1605 tracheostomy cases from 126 UK hospitals collected between 6 April and 26 August 2020.

Main outcome measures: Mortality following tracheostomy, successful wean from mechanical ventilation and length of time from tracheostomy to wean, discharge from hospital, complications from tracheostomy, reported SARS-CoV-2 infection among operators.

Results: The median time from intubation to tracheostomy was 15 days (IQR 11, 21). 285 (18%) patients died following the procedure. 1229 (93%) of the survivors had been successfully weaned from mechanical ventilation at censoring and 1049 (81%) had been discharged from hospital. Age, inspired oxygen concentration, positive end-expiratory pressure setting, fever, number of days of ventilation before tracheostomy, C reactive protein and the use of anticoagulation and inotropic support independently predicted mortality. Six reports were received of operators testing positive for SARS-CoV-2 within 2 weeks of the procedure.

Conclusions: Tracheostomy appears to be safe in mechanically ventilated patients with COVID-19 and to operators performing the procedure and we identified clinical parameters that are predictive of mortality.

Trial registration number: The study is registered with ClinicalTrials.Gov (NCT04572438).

Objectives: To evaluate functional outcomes following Aquablation in various prostate volume and anatomical subgroups.

Design: A meta-analysis with individual patient data undergoing Aquablation therapy from four prospective, global, clinical studies that have been conducted with Aquablation; WATER, WATER II, FRANCAIS WATER and OPEN WATER.

Setting: Australia, Canada, Lebanon, Germany, New Zealand, UK and the USA.

Participants: 425 men with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) with 1-year follow-up.

Interventions: Aquablation therapy is an ultrasound guided, robotically executed waterjet ablative procedure for the prostate.

Main outcome measures: The analyses focus International Prostate Symptom Score (IPSS), uroflowmetry, postoperative Incontinence Severity Index (ISI) and surgical retreatment.

Results: 425 men with prostates ranging in size from 20 to 150 mL underwent Aquablation therapy. The outcomes from the seven questions in the IPSS questionnaire were grouped by the following; prostates <100 mL, prostates ≥100 mL, prostate anatomy with an obstructive median lobe identifed by imaging, and prostate anatomy without an obstructive median lobe. Regardless of subgroup, all outcomes are consistent and demonstrate a significant improvement from baseline. Specifically, improvements in frequency, urgency and nocturia demonstrated bladder function improvement. Patients entering treatment with severe incontinence, ISI score >4, and regardless of prostate size, showed a reduction in incontinence during patient follow-up. Surgical retreatment due to BPH symptoms occurred in 0.7% (95% CI 0.1%-2.0%).

Conclusions: Across a variety of prostate anatomies, Aquablation therapy showed remarkable functional improvements following the index procedure. Additionally, men with moderate to severe LUTS/BPH and overactive bladder resulting in urge incontinence showed a reduction in incontinence symptoms postprocedure.

Objectives –: Partial gland ablation (PGA) therapy is an emerging treatment modality that targets specific areas of biopsy proven prostate cancer (PCa) to minimize treatment-related morbidity by sparing benign prostate. This qualitative study aims to explore and characterize perceptions and attitudes toward PGA in men with very-low-risk, low-risk, and favorable intermediate-risk PCa on active surveillance (AS).

Design –: 92 men diagnosed with very-low-risk, low-risk, and favorable intermediate-risk PCa on AS were invited to participate in semi-structured telephone interviews on PGA.

Setting –: Single tertiary care center located in New York City.

Participants –: 20 men with very-low-risk, low-risk, and favorable intermediate-risk PCa on AS participated in the interviews.

Main outcome measures –: Emerging themes on perceptions and attitudes toward PGA were developed from transcripts inductively coded and analyzed under standardized methodology.

Results –: Four themes were derived from twenty interviews that represent the primary considerations in treatment decision-making: (1) the feeling of psychological safety associated with low-risk disease; (2) preference for minimally invasive treatments; (3) the central role of the physician; (4) and the pursuit of treatment options that align with disease severity. Eleven men (55%) expressed interest in pursuing PGA only if their cancer were to progress, while 9 men (45%) expressed interest at the current moment.

Conclusions –: Though an emerging treatment modality, patients were broadly accepting of PGA for PCa with men primarily debating the risks versus benefits of proactively treating low-risk disease. Additional research on men's preferences and attitudes toward PGA will further guide counseling and shared decision-making for PGA.

Objectives: This study aimed to identify a threshold in annual surgeon volume associated with increased risk of revision (for any cause) and deep infection requiring surgery following primary elective total knee arthroplasty (TKA).

Design: A propensity score matched cohort study.

Setting: Ontario, Canada.

Participants: 169 713 persons who received a primary TKA between 2002 and 2016, with 3-year postoperative follow-up.

Main outcome measures: Revision arthroplasty (for any cause), and the occurrence of deep surgical infection requiring surgery.

Results: Based on restricted cubic spline analysis, the threshold for increased probability of revision and deep infection requiring surgery was <70 cases/year. After matching of 51 658 TKA recipients from surgeons performing <70 cases/year to TKA recipients from surgeons with greater than 70 cases/year, patients in the former group had a higher rate of revision (for any cause, 2.23% (95% Confidence Interval (CI) 1.39 to 3.07) vs 1.70% (95% CI 0.85 to 2.55); Hazard Ratio (HR) 1.33, 95% CI 1.21 to 1.47, p<0.0001) and deep infection requiring surgery (1.29% (95% CI 0.44 to 2.14) vs 1.09% (95% CI 0.24 to 1.94); HR 1.33, 95% CI 1.17 to 1.51, p<0.0001).

Conclusions: For primary TKA recipients, cases performed by surgeons who had performed fewer than 70 TKAs in the year prior to the index TKA were at 31% increased relative risk of revision (for any cause), and 18% increased relative risk for deep surgical infection requiring surgery, at 3-year follow-up.