ABSTRACT
The treatment of any causal, procedure-specific and/or concomitant acute pain is an essential quality feature in any surgical subspecialty. An interdisciplinary and interprofessional pain therapy aims for an immediate improvement of the patients' quality of life, a reduction of the risk of postoperative morbidity and mortality in the medium term, prevention of any pain chronification in the long run as well as a reduction of hospitalization and sick leave. The "Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy" exists since 1992. In view of the continuously developing scientific evidence, updated guideline recommendations and interprofessionally designed treatment pathways, these agreements have been adapted to the current requirements and structural conditions of the German healthcare system. Thus, both aforementioned professional associations promote an up to date version of an "Agreement for the Organization of Pain Therapy for Surgical Patients", a precise recommendation and a manual for the acting partners in order to realize the abovementioned goals.
Subject(s)
Anesthesiologists , Pain Management , Pain, Postoperative , Surgeons , Germany , Humans , Pain Management/standards , Pain, Postoperative/drug therapy , Quality of Life , SocietiesABSTRACT
The treatment of any causal, procedure-specific and/or concomitant acute pain is an essential quality feature in any surgical subspecialty. An interdisciplinary and interprofessional pain therapy aims for an immediate improvement of the patients' quality of life, a reduction of the risk of postoperative morbidity and mortality in the medium term, prevention of any pain chronification in the long run as well as a reduction of hospitalization and sick leave. The "Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy" exists since 1992. In view of the continuously developing scientific evidence, updated guideline recommendations and interprofessionally designed treatment pathways, these agreements have been adapted to the current requirements and structural conditions of the German healthcare system. Thus, both aforementioned professional associations promote an up to date version of an "Agreement for the Organization of Pain Therapy for Surgical Patients", a precise recommendation and a manual for the acting partners in order to realize the abovementioned goals.
Subject(s)
Anesthesiology , Pain Management/standards , Pain, Postoperative/therapy , Societies, Medical , Anesthesiologists , Germany , Humans , SurgeonsABSTRACT
BACKGROUND: Dipyrone (metamizole) is widely used for perioperative pain management in countries where it is marketed; however, uncertainty exists concerning the safe use of this drug, specifically considering the rare adverse event of an agranulocytosis. METHODS: As evidence from published studies was lacking, an expert panel developed recommendations for the perioperative use of dipyrone. After a formal, structured consensus process, the recommendations were approved by the involved medical societies. RESULTS: The panel agreed that blood cell counts shall not be standard for short-term perioperative use in patients unless they are at risk for neutropenia. The medical staff shall be aware of the symptoms and course of action when agranulocytosis is suspected. Patients shall be informed about the risks and benefits of dipyrone and about potential alternatives. The expert group concluded that dipyrone has a relatively positive risk-benefit ratio compared to other nonopioid analgesics. The group strongly recommended educating patients about the symptoms of agranulocytosis if they have received dipyrone over several days and/or treatment is to be continued after discharge, because agranulocytosis can occur several days after discontinuation of metamizole. Further recommendations refer to the information of the physician taking over the patient's care after discharge and the avoidance of re-exposure in patients having previously suffered from dipyrone-induced agranulocytosis. CONCLUSION: The group's recommendations shall be communicated in order to raise medical staff's and patients' awareness of the appropriate use of dipyrone in the perioperative period.
Subject(s)
Acute Pain/drug therapy , Agranulocytosis/chemically induced , Analgesics, Non-Narcotic/therapeutic use , Dipyrone/therapeutic use , Perioperative Period , Societies, Medical , Analgesics, Non-Narcotic/adverse effects , Anesthesiology , Dipyrone/adverse effects , Germany , Humans , SwitzerlandABSTRACT
The treatment of any causal, procedure-specific and/or concomitant acute pain is an essential quality feature in any surgical subspecialty. An interdisciplinary and interprofessional pain therapy aims for an immediate improvement of the patients' quality of life, a reduction of the risk of postoperative morbidity and mortality in the medium term, prevention of any pain chronification in the long run as well as a reduction of hospitalization and sick leave. The "Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy" exists since 1992. In view of the continuously developing scientific evidence, updated guideline recommendations and interprofessionally designed treatment pathways, these agreements have been adapted to the current requirements and structural conditions of the German healthcare system. Thus, both aforementioned professional associations promote an up to date version of an "Agreement for the Organization of Pain Therapy for Surgical Patients", a precise recommendation and a manual for the acting partners in order to realize the abovementioned goals.
Subject(s)
Anesthesiologists , Pain, Postoperative , Surgeons , Humans , Pain, Postoperative/therapy , Practice Guidelines as Topic , Quality of Life , Societies, MedicalABSTRACT
The treatment of any causal, procedure-specific and/or concomitant acute pain is an essential quality feature in any surgical subspecialty. An interdisciplinary and interprofessional pain therapy aims for an immediate improvement of the patients' quality of life, a reduction of the risk of postoperative morbidity and mortality in the medium term, prevention of any pain chronification in the long run as well as a reduction of hospitalization and sick leave. The "Agreement of the Professional Association of German Anesthesiologists and the Professional Association of German Surgeons for the Organization of Postoperative Pain Therapy" exists since 1992. In view of the continuously developing scientific evidence, updated guideline recommendations and interprofessionally designed treatment pathways, these agreements have been adapted to the current requirements and structural conditions of the German healthcare system. Thus, both aforementioned professional associations promote an up to date version of an "Agreement for the Organization of Pain Therapy for Surgical Patients", a precise recommendation and a manual for the acting partners in order to realize the abovementioned goals.
Subject(s)
Pain, Postoperative/therapy , Clinical Competence , Humans , Monitoring, Physiologic , Pain Management/methods , Patient CareABSTRACT
BACKGROUND: Dipyrone (metamizole) is widely used for perioperative pain management in countries where it is marketed; however, uncertainty exists concerning the safe use of this drug, specifically considering the rare adverse event of an agranulocytosis. METHODS: As evidence from published studies was lacking, an expert panel developed recommendations for the perioperative use of dipyrone. After a formal, structured consensus process, the recommendations were approved by the involved medical societies. RESULTS: The panel agreed that blood cell counts shall not be standard for short-term perioperative use in patients unless they are at risk for neutropenia. The medical staff shall be aware of the symptoms and course of action when agranulocytosis is suspected. Patients shall be informed about the risks and benefits of dipyrone and about potential alternatives. The expert group concluded that dipyrone has a relatively positive risk-benefit ratio compared to other nonopioid analgesics. The group strongly recommended educating patients about the symptoms of agranulocytosis if they have received dipyrone over several days and/or treatment is to be continued after discharge, because agranulocytosis can occur several days after discontinuation of metamizole. Further recommendations refer to the information of the physician taking over the patient's care after discharge and the avoidance of re-exposure in patients having previously suffered from dipyrone-induced agranulocytosis. CONCLUSION: The group's recommendations shall be communicated in order to raise medical staff's and patients' awareness of the appropriate use of dipyrone in the perioperative period.
Subject(s)
Acute Pain , Anesthesiology , Anti-Inflammatory Agents, Non-Steroidal , Dipyrone , Acute Pain/drug therapy , Analgesics , Anti-Inflammatory Agents, Non-Steroidal/therapeutic use , Critical Care , Dipyrone/therapeutic use , HumansABSTRACT
BACKGROUND: Dipyrone (metamizole) is widely used for perioperative pain management in countries where it is marketed; however, uncertainty exists concerning the safe use of this drug, specifically considering the rare adverse event of an agranulocytosis. METHODS: As evidence from published studies was lacking, an expert panel developed recommendations for the perioperative use of dipyrone. After a formal, structured consensus process, the recommendations were approved by the involved medical societies. RESULTS: The panel agreed that blood cell counts shall not be standard for short-term perioperative use in patients unless they are at risk for neutropenia. The medical staff shall be aware of the symptoms and course of action when agranulocytosis is suspected. Patients shall be informed about the risks and benefits of dipyrone and about potential alternatives. The expert group concluded that dipyrone has a relatively positive risk-benefit ratio compared to other nonopioid analgesics. The group strongly recommended educating patients about the symptoms of agranulocytosis if they have received dipyrone over several days and/or treatment is to be continued after discharge, because agranulocytosis can occur several days after discontinuation of metamizole. Further recommendations refer to the information of the physician taking over the patient's care after discharge and the avoidance of re-exposure in patients having previously suffered from dipyrone-induced agranulocytosis. CONCLUSION: The group's recommendations shall be communicated in order to raise medical staff's and patients' awareness of the appropriate use of dipyrone in the perioperative period.
Subject(s)
Agranulocytosis , Dipyrone , Acute Pain/drug therapy , Acute Pain/prevention & control , Agranulocytosis/chemically induced , Agranulocytosis/prevention & control , Analgesics/administration & dosage , Analgesics/adverse effects , Anesthesiology/standards , Association , Critical Care , Dipyrone/administration & dosage , Dipyrone/adverse effects , Humans , Perioperative PeriodABSTRACT
Approximately 20 % of the population are affected by gastroesophageal reflux disease (GERD). The subjective clinical and objective pathological extent of the disease is highly variable and the underlying pathophysiological mechanisms extraordinarily diverse. The importance of hiatus hernia for GERD has been intensively debated for decades. Hiatus hernia was initially considered to be at the center of the pathophysiology but later the function of the lower esophageal sphincter was increasingly considered to be of importance. Currently, additional relevant pathophysiological cofactors are being detected with the continuous improvement in diagnostic methods and used for therapeutic decision-making. Despite standardization of the operative technique and increasing criticism on long-term proton pump inhibitor (PPI) therapy, antireflux surgery still requires a very critical assessment of indications based on a comprehensive diagnostic evaluation.
Subject(s)
Esophageal Sphincter, Lower/physiopathology , Gastroesophageal Reflux/physiopathology , Gastroesophageal Reflux/therapy , Hernia, Hiatal/physiopathology , Hernia, Hiatal/therapy , Algorithms , Diagnosis, Differential , Esophageal Sphincter, Upper/physiopathology , Fundoplication , Gastroesophageal Reflux/diagnosis , Hernia, Hiatal/diagnosis , Humans , Proton Pump Inhibitors/therapeutic useABSTRACT
Pain is no fundamental illness nor should it be a concomitant handicap in any medical treatment. Nevertheless there still is a huge discrepancy between the fundamentally existing medical options of an adequate pain therapy and the actual everyday care of affected patients. An adequate pain therapy in the perioperative or posttraumatic setting represents a basic prerequisite for a rapid recovery and a reduction of any postinterventional risk of morbidity and mortality. An immediate improvement in quality of life secondary to an adequate acute pain therapy increases the chances of an early mobilization, reduces the duration of hospitalization, and thus supports the physical and social rehabilitation of patients. Above that an adequate acute pain therapy will reduce the risk of the development of any chronic pain syndrome as secondary or late effect following operative interventions. These complex interrelations finally also lead to a direct means of cost reduction in the health care system.
Subject(s)
Acute Pain/therapy , Pain Management/methods , Pain, Postoperative/therapy , Wounds and Injuries/therapy , Acute Pain/classification , Chronic Pain/classification , Chronic Pain/therapy , Ethics, Medical , Germany , Guideline Adherence , Humans , Pain Management/ethics , Pain, Postoperative/classification , Palliative Care/ethics , Palliative Care/methodsABSTRACT
BACKGROUND: Early function diagnostics and problem-oriented management are basic requirements in cases of functional problems and complications following antireflux surgery for gastroesophageal reflux disease (GERD). HISTORY, DIAGNOSTICS, AND THERAPEUTIC MANAGEMENT: A detailed history with a focus on the development of symptoms before and after the initial antireflux operation are fundamental prerequisites for a good diagnostic work-up. The data of preoperative function tests should always be reconsidered when re-evaluating a patient and be compared to the current findings. Thus, an analysis of the indications of any previous antireflux operation and an analysis of potential new or aggravated functional defects are essential. The general criteria indicating an operative procedure in gastroesophageal reflux disease do not change following such operation. Beyond these, symptomatic functional disorders caused by an antireflux operation may represent a new indication for an operative revision. INDICATION FOR RE-OPERATION: In the case of a symptomatic reflux recurrence, three essential criteria indicate an operative procedure: (i)âa progressive type of GERD (proven functional defects, hiatal hernia, presence of typical reflux symptoms, necessity of increasing PPI dosage), (ii)ânon acid-dependent symptoms in spite of adequate medication (aspiration, volume reflux, pulmonary symptoms) and (iii)âan alternative to medical therapy (preference, dependence, side effects, quality of life). In addition to these, symptomatic mechanical problems are important additional criteria for a redo procedure: the dissolution of the fundoplication wrap, the telescope-like slippage of the fundoplication around the proximal stomach ("slipped Nissen"), a paraesophageal herniation, and the transhiatal migration of an intact fundoplication. Finally, the rather seldom occurring wrong construction of the fundoplication and a not detected primary motility disorder (e.âg., achalasia) are indications for redo surgery in most cases. CONCLUSION: The decision for any redo surgery following antireflux operations should always be based on a sound balance between symptomatic impairment and objective findings in functional disorders. This analysis allows for a responsible decision process since any redo surgery holds the risk of a lower success rate than the initial operation.
Subject(s)
Fundoplication , Gastroesophageal Reflux/diagnosis , Gastroesophageal Reflux/surgery , Hernia, Hiatal/diagnosis , Hernia, Hiatal/surgery , Laparoscopy/methods , Postoperative Complications/diagnosis , Postoperative Complications/surgery , Humans , Recurrence , Reoperation , Risk FactorsABSTRACT
The introduction of the DRG (diagnosis-related groups) system as basis for reimbursement in the German health-care system has led to a mentality of quality orientation and verification of therapeutic results. An immediate result was the formation of medical "centres" on rather different levels and consequently the inauguration of institutions, authorities, and organisations to review these centres. Finally, a range of certifications was installed in order to stratify the rather diverse aims of different centres. This review critically evaluates the current situation in the field of general and abdominal surgery in Germany.
Subject(s)
General Surgery/organization & administration , General Surgery/trends , Specialties, Surgical/organization & administration , Specialties, Surgical/trends , Surgicenters/organization & administration , Surgicenters/trends , Viscera/surgery , Certification , Cost-Benefit Analysis/trends , Diagnosis-Related Groups/economics , Diagnosis-Related Groups/trends , Forecasting , General Surgery/economics , Germany , Health Services Needs and Demand/economics , Health Services Needs and Demand/organization & administration , Health Services Needs and Demand/trends , Humans , National Health Programs/economics , National Health Programs/trends , Quality Assurance, Health Care/economics , Quality Assurance, Health Care/trends , Quality Indicators, Health Care/economics , Quality Indicators, Health Care/trends , Reimbursement Mechanisms/economics , Reimbursement Mechanisms/trends , Societies, Medical , Specialties, Surgical/economics , Surgicenters/economicsABSTRACT
BACKGROUND: Reflux recurrence is the most common long-term complication of fundoplication. Its frequency was independent from the type of fundoplication in randomized studies. Results for different techniques of laparoscopic antireflux surgery were retrospectively evaluated after 10 years. METHODS: From 1992 to 1997, 120 patients had primary laparoscopic fundoplication with a "tailored approach" (type of wrap chosen according to esophageal peristalsis): 88 received a Nissen, 22 an anterior, and 10 a Toupet fundoplication. Follow-up of 87% of the patients included disease-related questions and the gastrointestinal quality-of-life index (GIQLI). RESULTS: Of the patients, 89% would select surgery again. Heartburn was reported by 30% of the patients. Regurgitations were noted from 15% of patients after a Nissen, 44% after anterior fundoplication, and 10% after a Toupet (p = 0.04). Twenty-eight percent were on acid-suppressive drugs again. Following Nissen fundoplication, proton pump inhibitors were less frequently used (p = 0.01) and on postoperative pH-metry reflux recurrence rate was lower (p = 0.04). The GIQLI was 110 +/- 24 without significant differences for the type of fundoplication. DISCUSSION: Ten years after laparoscopic fundoplication, overall outcome is good. A quarter of the patients are on acid-suppressive drugs. Nissen fundoplication appears to control reflux better than a partial fundoplication.
Subject(s)
Fundoplication/methods , Gastroesophageal Reflux/surgery , Laparoscopy/methods , Quality of Life , Adult , Case-Control Studies , Female , Follow-Up Studies , Fundoplication/adverse effects , Gastric Acidity Determination , Gastroesophageal Reflux/diagnosis , Humans , Laparoscopy/adverse effects , Length of Stay , Male , Middle Aged , Pain, Postoperative/physiopathology , Postoperative Care/methods , Preoperative Care/methods , Probability , Retrospective Studies , Risk Assessment , Severity of Illness Index , Statistics, Nonparametric , Treatment OutcomeABSTRACT
BACKGROUND: Reflux recurrence is the most common long-term complication following fundoplication. Results for different techniques of laparoscopic antireflux surgery were retrospectively compared after 10 years. METHODS: From 1992 to 1997, the 120 patients studied had laparoscopic fundoplication with 'tailored' approaches: 88 Nissen, 22 anterior, and ten Toupet fundoplications. Follow-up of 87% of these patients included disease-related questions and the gastrointestinal quality of life index (GIQLI). RESULTS: Of the patients, 89% would select surgery again. Regurgitations after fundoplication were noted from 15% of patients after Nissen, 44% after anterior, and 10% after Toupet types (P=0.04). Twenty-eight percent were on acid suppression therapy. Proton pump inhibitors were used less frequently following Nissen fundoplication (P=0.01). The GIQLI score was 110+/-24 without significant differences for type of fundoplication. DISCUSSION: Overall results are satisfactory after 10 years of experience with fundoplication. Total fundoplication appears to control reflux better than partial fundoplication.
Subject(s)
Fundoplication/methods , Gastroesophageal Reflux/surgery , Laparoscopy/methods , Postoperative Complications/prevention & control , Aged , Female , Follow-Up Studies , Gastroesophageal Reflux/etiology , Gastroesophageal Reflux/prevention & control , Humans , Male , Middle Aged , Patient Satisfaction , Postoperative Complications/etiology , Secondary PreventionSubject(s)
Endoscopy , Esophagoscopy , Gastroesophageal Reflux/surgery , Gastroscopy , Animals , Esophagoscopy/methods , Gastroscopy/methods , HumansABSTRACT
It was the aim of this study to analyze whether a shorter measuring period would render the same diagnostic information on esophageal motility as a circadian measuring period in ambulatory esophageal manometry. In an investigation on normal volunteers (n = 10), patients with gastroesophageal reflux disease without esophageal motility disorders (n = 13), and patients with esophageal motility disorders (n = 14), a comparison was performed between a 5-hr and a 24-hr motility study. An analysis was performed on inter- and intraindividual reproducibility of time periods, prandial phases, and motility sequences (Wilcoxon and Spearman test). There was no significant difference between the two analyzed measuring periods in all three groups with regard to the diagnostic information on esophageal motility in 44 of 45 comparisons for intraindividual variability. A measuring period restricted to 5 hr offers the same diagnostic information on esophageal peristaltic activity as a 24-hr motility study.
Subject(s)
Esophageal Motility Disorders/physiopathology , Esophagus/physiopathology , Adult , Aged , Circadian Rhythm , Female , Gastroesophageal Reflux/physiopathology , Humans , Male , Manometry , Middle Aged , Peristalsis , Time FactorsABSTRACT
Columnar-lined epithelium with specialized intestinal metaplasia of the esophagus (i.e., Barrett's esophagus) is a premalignant condition caused by chronic gastroesophageal reflux disease. Progression of intestinal metaplasia may be avoided by antireflux surgery, whereas regeneration of esophageal mucosa could be achieved by endoscopic argon plasma coagulation (EAPC). The aim of this prospective study was to show the early results of a combination of EAPC and antireflux surgery. Thirty patients with Barrett's esophagus were treated between August 1996 and December 1999. Regeneration of esophageal mucosa was achieved with several sessions of EAPC under general anesthesia. All patients were receiving a double dose of proton pump inhibitors. Endoscopic follow-up was performed 6 to 8 weeks after the last session. Antireflux surgery (Nissen [n = 26] or Toupet [n = 4] fundoplication) followed complete regeneration of the squamous epithelium in the esophagus. One year after laparoscopic fundoplication and EAPC follow-up with endoscopy and quadrant biopsies of the esophagus, 24-hour pH monitoring and esophageal manometry were performed. All 30 patients showed complete regeneration of the squamous epithelium after a median of two sessions (range 1 to 7) of EAPC. Twenty-two patients underwent 1-year follow-up studies. All showed endoscopically an intact fundic wrap. Recurrence of a 1 cm segment of Barrett's epithelium without dysplasia was present in two patients, both of whom had recurrent acid reflux due to failure of their antireflux procedure. Our results indicate that the combination of EAPC and antireflux surgery is an effective treatment option in patients with Barrett's esophagus with gastroesophageal reflux disease. Long-term follow-up of this therapy is necessary to evaluate its effect on cancer risk in Barrett's esophagus.
Subject(s)
Barrett Esophagus/surgery , Electrocoagulation/methods , Esophagoscopy/methods , Fundoplication/methods , Gastroesophageal Reflux/surgery , Laparoscopy/methods , Adult , Aged , Argon , Barrett Esophagus/etiology , Barrett Esophagus/pathology , Biopsy , Combined Modality Therapy , Disease Progression , Female , Gastroesophageal Reflux/complications , Gastroesophageal Reflux/diagnosis , Humans , Male , Middle Aged , Pilot Projects , Prospective Studies , Recurrence , Risk Factors , Treatment OutcomeABSTRACT
In a prospective study of 188 patients with morbid obesity, the time-dependent changes in the quality of life of individual patients were analyzed following laparoscopic gastric banding (LGB). These 188 patients (148 females and 40 males; age 19 to 59 years; body mass index 33 to 72 kg/m(2)) underwent evaluation of the LGB according to a strict protocol that included psychological testing using standardized instruments, detailed medical evaluation, upper gastrointestinal function studies, and evaluation of quality of life using the Gastrointestinal Quality of Life Index (GIQLI). Following this evaluation, 73 patients (57 females and 16 males; age 37 years [range 19 to 59 years]; body mass index 48 kg/m(2) [range 37 to 72 kg/m(2)]) underwent LGB and were followed up for 2 years focusing on weight loss, postoperative morbidity, weight-related comorbidity, and quality of life. The results demonstrate that LGB is well able to allow for a significant loss of excess weight and a significant improvement in patients' quality of life, both after a rather short period of time after surgery and at a continuous rate throughout the follow-up. The price for this success that was found in approximately 90% of patients is a complication rate of 38%; 85% of these patients, almost one third of all patients, must undergo some type of revision surgery. However, once the complications are resolved, these patients achieve the same level of weight loss and improvement in quality of life as patients with an uncomplicated postoperative course.
