Consequences and predisposing factors of self-discharge against medical advice in plastic and hand surgery.

PURPOSE: Therapeutic success of surgical interventions is significantly affected by patients' adherence. Patient autonomy can lead to unreasonable behavior. We analyzed the consequences and predisposing factors of patient self-discharge in a plastic and hand surgery cohort. STUDY DESIGN AND SETTING: Data was collected retrospectively in a case-control study with n = 73 patients who had self-discharged in a 10-year time period and n = 130 controls (discharge by the surgeon). Data was collected through the hospital information systems and a particular questionnaire. Statistical analyses were performed via chi-squared test and logistic regression analyses. RESULTS: Patients who self-discharged against medical advice had a significantly higher complication rate (p = 0.045) and a higher number of revision operations (p < 0.001). They were more often dissatisfied with the primary inpatient treatment (p < 0.05). Secondly, they lived more often in shared households (p = 0.002; OR 5.387 (1.734-16.732)) or had to take care of their children at home (p = 0.006; OR 1.481 (1.280-1.741)). There was a significantly lower pain score (NAS) on time of self-discharge (p = 0.002) as well as 24 h after self-discharge (p < 0.001) in self-discharged patients. CONCLUSION: Self-discharge was associated with predisposing factors and poorer outcomes. Patient autonomy can lead to health-compromising behavior and patients should be counseled accordingly.

Prospective randomized controlled trial on comparison of standard CO2 pressure pneumoperitoneum insufflator versus AirSeal®.

BACKGROUND: AirSeal® is a valve-free insufflation system that enables a stable pneumoperitoneum with continuous smoke evacuation and CO2 recirculation during laparoscopic surgery. Comparative evidence on the use of AirSeal® and standard CO2 insufflator in laparoscopic general surgery procedures is scarce. The aim of this study was to compare surgical outcomes between AirSeal® and standard CO2 insufflators in patients undergoing the most frequently performed laparoscopic procedures. METHODS: One hundred and ninety-eight patients undergoing elective laparoscopic cholecystectomy, colorectal surgery and hernia repair were randomized to either AirSeal® (group A) or standard pressure CO2 insufflator (group S). The primary endpoints were operative time and level of postoperative shoulder tip pain (Visual Analog Scale). Secondary outcomes included Clavien-Dindo grade complications, surgical side effect and length of hospital stay. RESULTS: Patients were randomized to either group A (n = 101) or group S (n = 97) and were analyzed by intention-to-treat. There was no significant difference in mean operative time between the groups (median [IQR]; 71 min [56-94] in group A vs. 69 min [52-93] in group S; p = 0.434). Shoulder tip pain levels were significantly lower in group S (VAS 0 [0-3] in group S vs. 2 [0-4] in group A; p = 0.001). There was no significant difference in complications, surgical side effects (subcutaneous emphysema was not observed in any group) and length of hospital stay. CONCLUSION: This randomized controlled trial showed that using the AirSeal® system did not reduce operative time and was associated with a higher postoperative shoulder tip pain compared to standard CO2 insufflator for short elective surgeries. ClinicalTrials.gov (NCT01740011).