Archives of Surgery最新文献

Objective: To evaluate the effect of timing of surgery on the long-term clinical outcome of surgery in chronic pancreatitis (CP).

Design: Cohort study with long-term follow-up.

Setting: Five specialized academic centers.

Patients: Patients with CP treated surgically for pain.

Interventions: Pancreatic resection and drainage procedures for pain relief.

Main outcome measures: Pain relief (pain visual analogue score ≤4), pancreatic function, and quality of life.

Results: We included 266 patients with median follow-up of 62 months (interquartile range, 31-112). Results were presented as odds ratios (ORs)with 95% confidence intervals after correction for bias using bootstrap-corrected analysis. Pain relief was achieved in 149 patients (58%). Surgery within 3 years of symptoms was independently associated with more pain relief (OR, 1.8; 95% CI, 1.0-3.4; P = .03) and less endocrine pancreatic insufficiency (OR, 0.57; 95% CI, 0.33-0.96; P = .04). More pain relief was also observed in patients not taking opioids preoperatively (OR, 2.1; 95% CI, 1.2-4.0; P = .006) and who had 5 or fewer endoscopic treatments prior to surgery (OR, 2.5; 95% CI, 1.1-6.3; P = .04). The probability of achieving pain relief varied between 23% and 75%, depending on these risk factors.

Conclusions: The timing of surgery is an important risk factor for clinical outcome in CP. Surgery may need to be considered at an earlier phase than it is now, preferably within 3 years of symptomatic CP. Likelihood of postoperative pain relief can be calculated on an individual basis using the presented nomogram.

Objective: Venous thromboembolism is associated with substantial morbidity and mortality and is largely preventable. Despite this fact, appropriate prophylaxis is vastly underutilized. To improve compliance with best practice prophylaxis for VTE in hospitalized trauma patients, we implemented a mandatory computerized provider order entry-based clinical decision support tool. The system required completion of checklists of VTE risk factors and contraindications to pharmacologic prophylaxis. With this tool, we were able to determine a patient's risk stratification level and recommend appropriate prophylaxis. To evaluate the effect of our mandatory computerized provider order entry-based clinical decision support tool on compliance with prophylaxis guidelines for venous thromboembolism (VTE) and VTE outcomes among admitted adult trauma patients.

Design: Retrospective cohort study (from January 2007 through December 2010).

Setting: University-based, state-designated level 1 adult trauma center.

Patients: A total of 1599 hospitalized adult trauma patients with a hospital length of stay greater than 1 day.

Main outcome measures: The primary outcome measure was the proportion of patients who were ordered risk-appropriate guideline-suggested VTE prophylaxis. The secondary outcome measure was the proportion of patients with any preventable VTE (defined as VTE in a patient not ordered guideline-appropriate VTE prophylaxis), pulmonary embolism, and/or deep vein thrombosis.

Results: Compliance with guideline-appropriate prophylaxis increased from 66.2% to 84.4% (P < .001). The rate of preventable harm from VTE decreased from 1.0% to 0.17% (P = .04).

Conclusions: Implementation of a mandatory computerized provider order entry-based clinical decision support tool significantly improved compliance with VTE prophylaxis guidelines in hospitalized adult trauma patients. This improved compliance was associated with a significant decrease in the rate of preventable harm, which was defined as VTE events in patients not ordered appropriate prophylaxis.

Hypothesis: Retained surgical sponges are serious medical errors that result in negative patient outcomes. A radiofrequency (RF) mat for the operating room bed has recently been introduced to detect the presence of a retained surgical sponge. The study objectives were to evaluate the sensitivity and specificity of the RF mat for the detection of surgical sponges through the torso of individuals with varying body habitus and to compare the sensitivity of the RF mat with that of the RF wand. We hypothesized that the sensitivity and specificity of the RF technology would be comparable to published findings of the manual sponge count by operating room personnel.

Design: A prospective, crossover, double-blinded study design was used. Participants served as their own controls. SETTING Large Midwestern academic medical center.

Participants: In total, the first phase of the study enrolled 203 participants, including 129 (63.5%) with morbid obesity. One hundred seventeen of 203 participants were also enrolled in the second phase of the study.

Main outcome measures: The study participants reclined in a supine position on top of an RF mat. Four surgical sponges were sequentially placed on top of the torso in locations approximating the abdominal quadrants. The torso was scanned for sponges. In a subset of participants, 4 surgical sponges were sequentially placed underneath the torso, and an RF wand was passed over the abdomen.

Results: Overall, 812 readings were obtained with the RF mat, and 468 readings were obtained with the RF wand. Twelve false-negative readings were obtained with the RF mat, exclusively in participants with super morbid obesity (body mass index [calculated as weight in kilograms divided by height in meters squared] >50.0). Overall, the sensitivity of the RF mat was 98.1%, and the specificity of the RF mat was 100.0%. In the subset of 117 participants in whom the RF wand was also used, the sensitivity and specificity of the wand were each 100.0%.

Conclusions: The sensitivity and specificity of RF device technology are much higher than those of surgical sponge counts or published findings on the use of intraoperative radiographs to identify retained surgical sponges. The RF wand is more sensitive than the RF mat in individuals with morbid obesity.

Objective: To investigate the association between changes in procoagulant/fibrinolytic factors and thrombotic complications following a major hepatectomy. Little information is available regarding the changes in procoagulant/fibrinolytic factors (such as the von Willebrand factor [vWF] and a disintegrin and metalloprotease with a thrombospondin type 1 motif, member 13 [ADAMTS13]), following a major hepatectomy.

Design: Patients who underwent a major hepatectomy from 2010 to 2011 were enrolled. Patients who underwent a pancreatoduodenectomy (PD) during the same period were also observed as controls, for whom operation time and amount of intraoperative blood loss were comparable to those of the patients who underwent a major hepatectomy. Blood samples were prospectively collected to measure various procoagulant/fibrinolytic factors, including vWF and ADAMTS13.

Setting: Nagoya University Hospital, Japan.

Patients: A total of 50 patients who underwent a major hepatectomy and a total of 23 patients who underwent a PD.

Results: The levels of vWF in the patients who underwent a major hepatectomy increased from before the operation to the seventh postoperative day and were significantly higher than those observed in the patients who underwent a PD. The ADAMTS13 activity in the patients who underwent a major hepatectomy gradually decreased throughout the first 14 postoperative days. In contrast, ADAMTS13 activity in the patients who underwent a PD returned to nearly normal levels within 2 weeks. Three patients who underwent a major hepatectomy had clinically significant thrombotic complications within the first 2 weeks after surgery; however, none of the patients who underwent a PD had thrombotic complications. The vWF to ADAMTS13 ratios of the 3 patients who experienced thrombotic complications were extremely high even before the occurrence of complications. No other procoagulant/fibrinolytic factors showed a marked association with thrombotic events. The vWF to ADAMTS13 ratio was significantly correlated with the estimated liver remnant volume (P < .001) but not with other preoperative or intraoperative factors.

Conclusions: The vWF to ADAMTS13 ratio may be a potentially useful marker in predicting thrombotic complications following a major hepatectomy.