RESUMEN
BACKGROUND: Open parastomal hernia repair can be performed using retromuscular synthetic mesh in a keyhole or Sugarbaker configuration. Relative morbidity and durability are unknown. Here, we present perioperative outcomes of a randomized controlled trial comparing these techniques, including 30-day patient-reported outcomes, reoperations, and wound complications in ≤90 days. METHODS: This single-center randomized clinical trial compared open parastomal hernia repair with retromuscular medium-weight polypropylene mesh in the keyhole and Sugarbaker configuration for permanent stomas between April 2019 and April 2022. Adult patients with parastomal hernias requiring open repair with sufficient bowel length for either technique were included. Patient-reported outcomes were collected at 30 days; 90-day outcomes included initial hospital length of stay, readmission, wound morbidity, reoperation, and mesh- or stoma-related complications. RESULTS: A total of 150 patients were randomized (75 keyhole and 75 Sugarbaker). There were no differences in length of stay, readmission, reoperation, recurrence, or wound complications. Twenty-four patients (16%) required procedural intervention for wound morbidity. Ten patients (6.7%) required abdominal reoperation in ≤90 days, 7 (4.7%) for wound morbidity, including 3 partial mesh excisions (1 keyhole compared with 2 Sugarbaker; P = 1). Four mesh-related stoma complications requiring reoperations occurred, including stoma necrosis (n = 1), bowel obstruction (n = 1), parastomal recurrence (n = 1), and mucocutaneous separation (n = 1), all in the Sugarbaker arm (P = .12). Patient-reported outcomes were similar between groups at 30 days. CONCLUSION: Open parastomal hernia repair with retromuscular mesh in the keyhole and Sugarbaker configurations had similar perioperative outcomes. Patients will be followed to determine long-term relative durability, which is critical to understanding each approach's risk-benefit ratio.
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Hernia Ventral , Hernia Incisional , Laparoscopía , Estomas Quirúrgicos , Adulto , Humanos , Herniorrafia/efectos adversos , Mallas Quirúrgicas/efectos adversos , Hernia Incisional/cirugía , Hernia Incisional/complicaciones , Estomas Quirúrgicos/efectos adversos , Colostomía/efectos adversos , Hernia Ventral/etiología , Hernia Ventral/cirugía , Laparoscopía/efectos adversosRESUMEN
OBJECTIVE: We aimed to report long-term clinical and patient-reported outcomes of transversus abdominis release (TAR) with permanent synthetic mesh performed in a high-volume abdominal wall reconstruction practice. SUMMARY BACKGROUND DATA: Despite increasing utilization of TAR in abdominal wall reconstruction, long-term clinical and patient-reported outcomes remain uncertain. METHODS: Prospectively collected registry data from the Cleveland Clinic Center for Abdominal Core Health were analyzed retrospectively. Patients undergoing elective, open VHR with TAR and permanent synthetic mesh implantation between August 2014 and March 2020 with 30-day clinical and ≥1 year clinical or patient-reported outcome follow-up were included. Outcomes included composite hernia recurrence, characterized by patient-reported bulges and recurrent hernias noted on physical exam or imaging, as well as hernia-specific quality of life and pain. RESULTS: A total of 1203 patients were included. Median age was 60 years [interquartile range (IQR): 52-67], median body mass index was 32 kg/m 2 (IQR: 28-36), median hernia width was 15 cm (IQR: 12-19), and 57% of hernias were recurrent. Fascial reapproximation was achieved in 92%. At a median follow-up of 2 years (IQR: 1-4), the overall composite hernia recurrence rate was 26%, with sensitivity analysis yielding best-case and worst-case estimates of 5% and 28%, respectively. Patients experienced improved hernia-specific quality of life and pain regardless of recurrence outcome; however, those who did not recur experienced more substantial improvement. CONCLUSIONS: TAR with permanent synthetic mesh remains a valuable, versatile technique; however, surgeon and patient expectations should be tempered regarding long-term durability. Despite a high rate of recurrence, patients experience measurable improvements in quality of life.
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Pared Abdominal , Hernia Ventral , Humanos , Persona de Mediana Edad , Hernia Ventral/cirugía , Estudios Retrospectivos , Mallas Quirúrgicas , Calidad de Vida , Resultado del Tratamiento , Herniorrafia/métodos , Músculos Abdominales/cirugía , Medición de Resultados Informados por el Paciente , Dolor , Recurrencia , Pared Abdominal/cirugíaRESUMEN
BACKGROUND: For small to medium-sized ventral hernias, robotic intraperitoneal onlay mesh (rIPOM) and enhanced-view totally extraperitoneal (eTEP) repair have emerged as acceptable approaches that each takes advantage of robotic instrumentation. We hypothesized that avoiding mesh fixation in a robotic eTEP repair offers an advantage in early postoperative pain compared to rIPOM. METHODS: This is a multi-center, randomized clinical trial for patients with midline ventral hernias ≤ 7 cm, who were randomized to rIPOM or robotic eTEP. The primary outcome was pain (0-10) on the first postoperative day. Secondary outcomes included same-day discharge, length of stay, opioid consumption, quality of life, surgeon workload, and cost. RESULTS: Between November 2019 and November 2021, 100 patients were randomized (49 rIPOM, 51 eTEP) among 5 surgeons. Pain on the first postoperative day [median (IQR): 5 (4-6) vs. 5 (3.5-7), p = 0.66] was similar for rIPOM and eTEP, respectively, a difference maintained following adjustments for surgeon, operative time, baseline pain, and patient co-morbidities (difference 0.28, 95% CI - 0.63 to 1.19, p = 0.56). No differences in pain on the day of surgery, 7, and 30 days after surgery were identified. Same-day discharge, length of stay, opioid consumption, and 30-day quality of life were also comparable, though rIPOM required less surgeon workload (p < 0.001), shorter operative time [107 (86-139) vs. 165 (129-212) min, p < 0.001], and resulted in fewer surgical site occurrences (0 vs. 8, p = 0.004). The total direct costs for rIPOM and eTEP were comparable [$8282 (6979-11835) vs. $8680 (7550-10282), p = 0.52] as the cost savings for eTEP attributable to mesh use [$442 (434-485) vs. $69 (62-76), p = < 0.0001] were offset by increased expenses for operative time [$669 (579-861) vs. $1075 (787-1367), p < 0.0001] and use of more robotic equipment [$760 (615-933) vs. $946 (798-1203), p = 0.001]. CONCLUSION: The avoidance of fixation in a robotic eTEP repair did not reveal a benefit in postoperative pain to offset the shorter operative time and surgeon workload offered by rIPOM.
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Hernia Ventral , Hernia Incisional , Laparoscopía , Procedimientos Quirúrgicos Robotizados , Humanos , Procedimientos Quirúrgicos Robotizados/métodos , Calidad de Vida , Analgésicos Opioides , Mallas Quirúrgicas , Herniorrafia/métodos , Hernia Ventral/cirugía , Dolor Postoperatorio/etiología , Dolor Postoperatorio/prevención & control , Dolor Postoperatorio/cirugía , Laparoscopía/métodos , Hernia Incisional/cirugíaRESUMEN
Importance: Urinary catheters are commonly placed during laparoscopic inguinal hernia repair as a presumed protection against postoperative urinary retention (PUR), one of the most common complications following this operation. Data from randomized clinical trials evaluating the effect of catheters on PUR are lacking. Objective: To investigate the effect of intraoperative catheters on PUR after laparoscopic inguinal hernia repair. Design, Setting, and Participants: This 2-arm registry-based single-blinded randomized clinical trial was conducted at 6 academic and community hospitals in the US from March 2019 to March 2021 with a 30-day follow-up period following surgery. All patients who presented with inguinal hernias were assessed for eligibility, 534 in total. Inclusion criteria were adult patients undergoing laparoscopic, elective, unilateral, or bilateral inguinal hernia repair. Exclusion criteria were inability to tolerate general anesthesia and failure to understand and sign the written consent form. A total of 43 patients were excluded prior to intervention. Interventions: Patients in the treatment arm had placement of a urinary catheter after induction of general anesthesia and removal at the end of procedure. Those in the control arm had no urinary catheter placement. Main Outcomes and Measures: PUR rate. Results: Of the 491 patients enrolled, 241 were randomized to catheter placement, and 250 were randomized to no catheter placement. The median (IQR) age was 61 (51-68) years, and 465 participants (94.7%) were male. Overall, 44 patients (9.1%) developed PUR. There was no difference in the rate of PUR between the catheter and no-catheter groups (23 patients [9.6%] vs 21 patients [8.5%], respectively; P = .79). There were no intraoperative bladder injuries. In the catheter group, there was 1 incident of postoperative urethral trauma in a patient who presented to the emergency department with PUR leading to a suprapubic catheter placement. Conclusions and Relevance: Intraoperative urinary catheters did not reduce the risk of PUR after laparoscopic inguinal hernia repair. While their use did not appear to be associated with a high rate of iatrogenic complications, there may be a low rate of catastrophic complications. In patients who voided urine preoperatively, catheter placement did not appear to confer any advantage and thus their use may be reconsidered. Trial Registration: ClinicalTrials.gov Identifier: NCT03835351.
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Hernia Inguinal , Laparoscopía , Retención Urinaria , Adulto , Anciano , Femenino , Hernia Inguinal/complicaciones , Hernia Inguinal/cirugía , Herniorrafia/métodos , Humanos , Laparoscopía/efectos adversos , Laparoscopía/métodos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/cirugía , Retención Urinaria/etiología , Retención Urinaria/prevención & control , Retención Urinaria/cirugíaRESUMEN
BACKGROUND: Patient-reported outcome measures for parathyroid and thyroid disease (PROMPT) is a 30-question, previously validated, survey assessing symptoms on a scale from 0 to 100. Using PROMPT, we aimed to assess symptom improvement for patients undergoing thyroidectomy and parathyroidectomy. METHODS: Single-center prospective study in which PROMPT was used to assess symptom improvement in patients undergoing parathyroidectomy or thyroidectomy. A postoperative assessment was performed approximately 6 months after surgery and compared to its baseline preoperative assessment. RESULTS: A total of 144 patients completed both assessments (71 parathyroidectomy, 73 thyroidectomy). Parathyroidectomy patients demonstrated significant improvements in all hyperparathyroidism domains (38.2-28.3, p < 0.001) regardless of preoperative calcium and parathyroid hormone levels. Thyroidectomy patients experienced improvement in their compressive symptoms (25.6-16.5, p < 0.001). CONCLUSIONS: PROMPT objectively demonstrates the clinical effectiveness of parathyroidectomy and thyroidectomy in alleviating subjective patient symptoms. PROMPT offers promising use as a standardized metric to assess quality of life improvement within endocrine surgery.
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Calidad de Vida , Glándula Tiroides , Humanos , Glándulas Paratiroides , Paratiroidectomía , Medición de Resultados Informados por el Paciente , Estudios Prospectivos , TiroidectomíaRESUMEN
INTRODUCTION: Collecting accurate operative details remains a limitation of surgical research. Surgeon-entered data in clinical registries offers one solution, but natural language processing (NLP) has emerged as a modality for automating manual chart review (MCR). This study aims to compare the accuracy and efficiency of NLP and MCR with a surgeon-entered, prospective registry data in determining the rate of gross bile spillage (GBS) during cholecystectomy. METHODS: Bile spillage rates were abstracted from an institutional, surgeon-entered clinical registry from July 2018 to January 2019. These rates were compared to those documented in the electronic medical record (EMR) using NLP and MCR to determine the sensitivity, specificity, and efficiency of each approach. RESULTS: Of the 782 registry entries, 191 cases (24.4%) had surgeon-reported bile spillage. MCR identified bile spillage in 121 cases (15.6%); however, bile spillage information was either missing or ambiguous in 454 cases (58.1%). NLP identified 99 cases (12.7%) of bile spillage. Data abstraction times for the registry, NLP, and MCR were 3 min, 5 min, and 12 h, respectively. When compared to the registry, MCR was 45% sensitive and 94% specific, while NLP was 27.2% sensitive and 92% specific for detecting bile spillage. These differences were significant (X2 = 19.446, P = < 0.001). CONCLUSION: Operative details, such as GBS, may not be abstracted by NLP or MCR if not clearly documented in the EMR. Clinical registries capture operative details, but they rely on surgeons to input the data.
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Procesamiento de Lenguaje Natural , Mejoramiento de la Calidad , Registros Electrónicos de Salud , Humanos , Sistema de RegistrosRESUMEN
INTRODUCTION: We investigated short and long-term remission rates after splenectomy in patients with primary and secondary autoimmune hemolytic anemia (AIHA). METHODS: All adults who underwent splenectomy for primary or secondary AIHA at a single center (2004-2018) were retrospectively reviewed. Short-term response was determined at 30-day postoperatively and long-term at one year. Complete response was defined as hemoglobin > 10 g/dL without hemolysis, transfusions, or need for additional medical therapy for > 6 months. RESULTS: Short-term complete response was attained in 22 of 36 patients (61%), partial response in 3 (8%), no response in 11 (31%). The response rate at 1 year was complete in 14/36 (39%), partial in 14 (39%), and 8 non-response (22%). At last available follow-up (median 33.1 months (IQR 19-59), 16/37 patients had experienced a complete response (43%), 14 partial response (38%), 7 non-response (19%). 80% of partial responders with primary AIHA required maintenance therapy compared to 100% with secondary AIHA. CONCLUSION: Splenectomy is associated with short- and long-term improvement in anemia and hemolysis in the majority of patients with AIHA. Immunosuppressants remain important supplemental therapy.
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Anemia Hemolítica Autoinmune , Adulto , Anemia Hemolítica Autoinmune/complicaciones , Anemia Hemolítica Autoinmune/tratamiento farmacológico , Anemia Hemolítica Autoinmune/cirugía , Hemólisis , Humanos , Estudios Retrospectivos , Esplenectomía , Resultado del TratamientoRESUMEN
OBJECTIVE: To study the efficacy of liposomal bupivacaine on postoperative opioid requirement and pain following abdominal wall reconstruction. SUMMARY BACKGROUND DATA: Despite the widespread use of liposomal bupivacaine in transversus abdominis plane block, there is inadequate evidence demonstrating its efficacy in open abdominal wall reconstruction. We hypothesized that liposomal bupivacaine plane block would result in decreased opioid requirements compared with placebo in the first 72 hours after surgery. METHODS: This was a single-center double-blind, placebo-controlled prospective study conducted between July 2018 and November 2019. Adult patients (at least 18 yrs of age) undergoing open, elective, ventral hernia repairs with mesh placed in the retromuscular position were enrolled. Patients were randomized to surgeon-performed transversus abdominis plane block with liposomal bupivacaine, simple bupivacaine, or normal saline (placebo). The main outcome was opioid requirements in the first 72 hours after surgery. Secondary outcomes included total inpatient opioid use, pain scores determined using a 100 mm visual analog scale, length of hospital stay, and patientreported quality of life. RESULTS: Of the 164 patients who were included in the analysis, 57 patients received liposomal bupivacaine, 55 patients received simple bupivacaine, and 52 received placebo. There were no differences in the total opioid used in the first 72 hours after surgery as measured by morphine milligram equivalents when liposomal bupivacaine was compared with simple bupivacaine and placebo (325 ± 225 vs 350 ± 284 vs 310 ± 272, respectively, P = 0.725). Similarly, there were no differences in total inpatient opioid use, pain scores, length of stay, and patient-reported quality of life. CONCLUSIONS: There are no apparent clinical benefits to using liposomal bupivacaine transversus abdominis plane block when compared with simple bupivacaine and placebo for open abdominal wall reconstruction.
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Pared Abdominal , Anestésicos Locales , Músculos Abdominales , Pared Abdominal/cirugía , Adulto , Analgésicos Opioides/uso terapéutico , Bupivacaína , Método Doble Ciego , Humanos , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/prevención & control , Estudios Prospectivos , Calidad de VidaRESUMEN
OBJECTIVE: Calcium and parathyroid hormone (PTH) values are believed to have a linear relationship in patients with primary hyperparathyroidism and correlate with parathyroid gland size, with higher values predicting single-gland disease. In this modern series, these preoperative values were correlated with operative findings to determine their utility in predicting the gland involvement at parathyroid exploration. METHODS: Two thousand consecutive patients who underwent initial surgery for sporadic primary hyperparathyroidism from 2000 to 2014 were reviewed. All patients underwent a 4-gland exploration. Relationships between preoperative calcium and PTH values with the total gland volume of each patient were examined and stratified using the number of involved glands: single adenoma (SA), double adenoma (DA), and hyperplasia (H). RESULTS: There were 1274 (64%) SA, 359 (18%) DA, and 367 (18%) H cases. There was a poor correlation between preoperative calcium and PTH values (R = 0.37) and both poorly correlated with the total gland volume (R < 0.40). Similarly, subgroup analysis using the number of involved glands showed poor correlation. The mean total gland volume was similar among all subgroups (SA = 1.28 cm3, DA = 1.43 cm3, and H = 1.27 cm3; P = .52), implying that individual glands were smaller in multigland disease. SA was found in 271 (53%) of patients with calcium levels of ≤10.5 mg/dL and 122 (78%) with levels of ≥12 mg/dL (P < .001). CONCLUSION: This is the largest series correlating preoperative calcium and PTH values with operative findings of gland size and number of diseased glands. Although a lower calcium value predicts somewhat more multigland disease, the overall poor correlation should make the parathyroid surgeon aware that gland size and multigland disease cannot be predicted by preoperative laboratory testing.
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Calcio , Hiperparatiroidismo Primario , Hormona Paratiroidea/sangre , Calcio/sangre , Humanos , Hiperparatiroidismo Primario/cirugía , Glándulas Paratiroides/diagnóstico por imagen , Glándulas Paratiroides/cirugía , Paratiroidectomía , Estudios RetrospectivosRESUMEN
This article reviews evidence-based techniques for abdominal closure and management strategies when abdominal wall closures fail. In particular, optimal primary fascial closure techniques, the role of prophylactic mesh, considerations for combined hernia repair, closure techniques when the fascia cannot be closed primarily, and management approaches for fascial dehiscence are reviewed.
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Pared Abdominal/cirugía , Técnicas de Cierre de Herida Abdominal/efectos adversos , Dehiscencia de la Herida Operatoria/terapia , Fascia , Humanos , Dehiscencia de la Herida Operatoria/prevención & controlRESUMEN
INTRODUCTION: We present our experience developing and embedding a registry-based module for resident feedback. METHODS: At our institution, entering operative data into the institutional quality collaborative registry is standard practice. In February 2019, a surgical education module was embedded into the registry to capture procedure-specific resident operative assessments. Faculty engagement with the sugical education module was assessed during its first year in existence (February 2019-February 2020). RESULTS: In total, 1074 of 1269 (85%) operative assessments were completed by 27 faculty via the surgical education registry module. Median faculty engagement rate with the module following resident-assisted procedures was 91% [IQR 76%-100%]. Residents received a median of 7 operative assessments [IQR 2-19] over the study period. CONCLUSION: By embedding a surgical education module into an existing surgical quality collaborative registry, procedure-specific operative assessments can be routinely captured.
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Cirugía General , Internado y Residencia , Competencia Clínica , Educación de Postgrado en Medicina , Evaluación Educacional/métodos , Cirugía General/educación , Sistema de RegistrosRESUMEN
BACKGROUND: Opioids are often used to treat pain after traumatic injury, but patient education on safe use of opioids is not standard. To address this gap, we created a video-based opioid education program for patients. We hypothesized that video viewing would lead to a decrease in overall opioid use and morphine equivalent doses (MEDs) on their penultimate hospital day. Our secondary aim was to study barriers to video implementation. METHODS: We performed a prospective pragmatic cluster-randomized pilot study of video education for trauma floor patients. One of two equivalent trauma floors was selected as the intervention group; patients were equally likely to be admitted to either floor. Nursing staff were to show videos to English-speaking or Spanish-literate patients within 1 day of floor arrival, excluding patients with Glasgow Coma Scale score less than 15. Opioid use and MEDs taken on the day before discharge were compared. Intention to treat (ITT) (intervention vs. control) and per-protocol groups (video viewers vs. nonviewers) were compared (α = 0.05). Protocol compliance was also assessed. RESULTS: In intention to treat analysis, there was no difference in percent of patients using opioids or MEDs on the day before discharge. In per-protocol analysis, there was no different in percent of patients using opioids on the day before discharge. However, video viewers still on opioids took significantly fewer MEDs than patients who did not see the video (26 vs. 38, p < 0.05). Protocol compliance was poor; only 46% of the intervention group saw the videos. CONCLUSION: Video-based education did not reduce inpatient opioid consumption, although there may be benefits in specific subgroups. Implementation was hindered by staffing and workflow limitations, and staff bias may have limited the effect of randomization. We must continue to establish effective methods to educate patients about safe pain management and translate these into standard practices. LEVEL OF EVIDENCE: Therapeutic, Level IV.
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Analgésicos Opioides/efectos adversos , Analgésicos Opioides/uso terapéutico , Dolor/tratamiento farmacológico , Educación del Paciente como Asunto/métodos , Conocimiento de la Medicación por el Paciente/métodos , Adulto , Anciano , Femenino , Conocimientos, Actitudes y Práctica en Salud , Humanos , Análisis de Intención de Tratar , Modelos Lineales , Masculino , Persona de Mediana Edad , Manejo del Dolor/métodos , Proyectos Piloto , Estudios Prospectivos , Grabación de Cinta de Video , Heridas y Lesiones/complicacionesRESUMEN
BACKGROUND: The hernia sac to abdominal cavity volume ratio (VR) on abdominal CT was described previously as a way to predict which hernias would be less likely to achieve fascial closure. The aim of this study was to test the reliability of the previously described cutoff ratio in predicting fascial closure in a cohort of patients with large ventral hernias. METHODS: Patients who underwent elective, open incisional hernia repair of 18 cm or larger width at a single center were identified. The primary end point of interest was fascial closure for all patients. Secondary outcomes included operative details and abdominal wall-specific quality-of-life metrics. We used VR as a comparison variable and calculated the test characteristics (ie, sensitivity, specificity, and positive and negative predictive values). RESULTS: A total of 438 patients were included, of which 337 (77%) had complete fascial closure and 101 (23%) had incomplete fascial closure. The VR cutoff of 25% had a sensitivity of 76% (95% CI, 71% to 80%), specificity of 64% (95% CI, 54% to 74%), positive predictive value of 88% (95% CI, 83% to 91%), and negative predictive value of 45% (95% CI, 36% to 53%). The incomplete fascial closure group had significantly lower quality of life scores at 1 year (83.3 vs 52.5; p = 0.001), 2 years (85 vs 33.3; p = 0.003), and 3 years (86.7 vs 63.3; p = 0.049). CONCLUSIONS: In our study, the VR cutoff of 25% was sensitive for predicting complete fascial closure for patients with ratios below this threshold. Although there is a higher likelihood of incomplete fascial closure when VR is ≥ 25%, this end point cannot be predicted reliably. Additional studies should be done to study this ratio in conjunction with other hernia-related variables to better predict this important surgical end point.
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Cavidad Abdominal/anatomía & histología , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Hernia Ventral/diagnóstico , Herniorrafia/estadística & datos numéricos , Hernia Incisional/diagnóstico , Anciano , Femenino , Hernia Ventral/patología , Hernia Ventral/psicología , Hernia Ventral/cirugía , Humanos , Hernia Incisional/patología , Hernia Incisional/psicología , Hernia Incisional/cirugía , Masculino , Persona de Mediana Edad , Calidad de Vida , Valores de Referencia , Reproducibilidad de los Resultados , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
BACKGROUND: Missed documentation for critical care time (CCT) for dying patients may represent a missed opportunity for physicians to account for intensive care unit (ICU) services, including end-of-life care. We hypothesized that CCT would be poorly documented for dying trauma patients. METHODS: Adult trauma ICU patients who died between December 2014 and December 2017 were analyzed retrospectively. Critical care time was not calculated for patients with comfort care code status. Critical care time on the day prior to death and day of death was collected. Logistic regression was used to determine factors associated with documented CCT. RESULTS: Of 147 patients, 43% had no CCT on day prior to death and 55% had no CCT on day of death. 82% had a family meeting within 1 day of death. Family meetings were independently associated with documented CCT (OR 3.69, P = .008); palliative care consultation was associated with decreased documented CCT (OR .24, P < .001). CONCLUSIONS: Critical care time is not documented in half of eligible trauma patients who are near death. Conscious (time spent in family meetings and injury acuity) and unconscious factors (anticipated poor outcomes) likely affect documentation.
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Cuidados Críticos/normas , Documentación/normas , Cuidado Terminal/normas , Heridas y Lesiones/mortalidad , Heridas y Lesiones/terapia , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
BACKGROUND: Preoperative localization studies are essential for parathyroid re-exploration. When noninvasive studies do not regionalize the abnormal parathyroid gland, selective parathyroid venous sampling may be employed. We studied the utility of parathyroid venous sampling in reoperative parathyroid surgery and the factors that may affect parathyroid venous sampling results. METHODS: Patients with hyperparathyroidism and previous cervical surgery undergoing evaluation for reoperative parathyroidectomy over a 20-year period were identified. Patients with indeterminate or negative noninvasive studies underwent parathyroid venous sampling. Parathyroid hormone values were mapped with a ≥2-fold increase above peripheral signifying positive parathyroid venous sampling. These results were correlated with reoperative findings. RESULTS: Parathyroid venous sampling was positive in 113 of 140 (81%). Re-exploration occurred in 75 (66%). Parathyroid venous sampling correctly detected the region of abnormal glands in 58 (77%). With 1 gradient, 1 abnormal gland was found in 81%. With multiple gradients, 1 abnormal gland was found in 78%, most often at the site with the largest gradient. Eighty percent of patients who underwent reoperative parathyroidectomy were biochemically cured. CONCLUSION: Parathyroid venous sampling can guide parathyroid re-exploration when noninvasive localizing studies are indeterminate. Expectation of 1 versus multiple remaining glands was key in interpreting the results.
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Hiperparatiroidismo/cirugía , Glándulas Paratiroides/diagnóstico por imagen , Paratiroidectomía/métodos , Radiografía Intervencional/métodos , Reoperación/métodos , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Hiperparatiroidismo/sangre , Hiperparatiroidismo/diagnóstico , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Glándulas Paratiroides/irrigación sanguínea , Glándulas Paratiroides/cirugía , Hormona Paratiroidea/sangre , Cintigrafía , Recurrencia , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Venas , Adulto JovenRESUMEN
BACKGROUND: Randomized controlled trials (RCTs) are the gold standard to establish evidence for surgical practice but can be hindered by high costs, complexity, and time requirements. Recently, observational registries have been leveraged as platforms for clinical trials to address these limitations, though few registry-based surgical RCTs have been conducted. Here, we present our group's approach to surgical registry-based RCTs and early results. MATERIALS AND METHODS: To facilitate these trials, we focused on registry integration into surgeons' workflows, routine collection of patient-reported outcomes at clinic visits, and pragmatic trial design featuring broad inclusion criteria and standard of care follow-up. These features maximize generalizability and facilitate follow-up by minimizing visits and tests outside of normal practice. RESULTS: Since 2017, our group has completed enrollment in 4 registry-based RCTs with another 5 trials ongoing. Of these, 4 trials have been multicenter. Over 1000 patients have been enrolled in these studies, with follow-up rates of 90% or greater. Most of these trials are on track to complete enrollment in approximately 2 y from their start date. Beyond salary support, resource utilization is low. None of our trials has been terminated due to lack of resources or futility. CONCLUSIONS: Registry-based RCTs allow for efficient conduct of pragmatic surgical trials. Thoughtful study design, registry integration into surgeons' routines, and a team culture embracing research are paramount. We believe registry-based trials are the future of affordable, high-level, prospective surgical research.
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Ensayos Clínicos Controlados Aleatorios como Asunto , Sistema de Registros , Procedimientos Quirúrgicos Operativos , HumanosRESUMEN
BACKGROUND: Little data exist to inform discharge opioid prescribing for patients undergoing abdominal wall reconstruction. The aim of this study was to evaluate postoperative, patient-reported opioid use after abdominal wall reconstruction. We hypothesized that the majority of patients undergoing open abdominal wall reconstruction would require between 16 and 30 opioid tablets after discharge. METHODS: Postoperative, patient-reported opioid use was collected prospectively for all patients undergoing elective, open abdominal wall reconstruction at a single high-volume center. All opioid medications were converted to an equivalent number of 5 mg oxycodone tablets. The primary outcome was the total number of opioid tablets taken within 30 days of hospital discharge after abdominal wall reconstruction. RESULTS: Ninety-eight patients were included. Median hernia width was 15 cm (interquartile range 12-19), 42% were recurrences, and all underwent transversus abdominis release. At the 30-day follow-up visit, 24% reported no postdischarge opioid use, and 76% reported taking 15 tablets or fewer. Of the 23 patients who used no opioids on the day before discharge, 16 (70%) reported taking no opioids after discharge. CONCLUSION: Most patients reported taking fewer opioid tablets than prescribed and fewer than our hypothesis within 30 days of abdominal wall reconstruction. Opioid use on the day before discharge may allow for prognostication of outpatient opioid requirements to prevent overprescribing.
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Pared Abdominal/cirugía , Analgésicos Opioides/administración & dosificación , Herniorrafia/efectos adversos , Dolor Postoperatorio/tratamiento farmacológico , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Dolor Postoperatorio/etiologíaRESUMEN
INTRODUCTION: With increasing frequency, patients with idiopathic splenomegaly are referred to surgeons for splenectomy. We evaluated the diagnostic utility of splenectomy and feasibility of a minimally invasive approach in the face of idiopathic splenomegaly. METHODS: We retrospectively reviewed 68 patients who underwent splenectomy for idiopathic splenomegaly. The primary endpoint was the rate of definitive diagnosis based on final surgical pathology of the removed spleen. RESULTS: Preoperative workup included a bone marrow biopsy and peripheral blood smear in 93% and 100% of patients, respectively, with none having lymphadenopathy warranting biopsy. Splenectomy provided a definitive diagnosis for 44 (64.7%) patients. Of these, 34 (50%) patients had an underlying malignancy, of which more than half were splenic marginal zone lymphoma. There were 33 (48.5%) laparoscopic, 23 (33.8%) open, 10 (14.7%) laparoscopic converted to open, and two (2.9%) laparoscopic hand-assist cases. Conversion to open was due to splenic size [median craniocaudal length 21.8 cm (cm)] in eight and staple line bleeding at the splenic hilum in two patients. Overall, the laparoscopic approach was completed in patients with a smaller splenic size compared to open (median craniocaudal length 15.2 vs. 26.0 cm, p < 0.0001). The open group had one (1.5%) intra-operative mortality due to uncontrollable hemorrhage. Thirty-day complication rates were similar for laparoscopic and open approaches (p = 0.10). CONCLUSION: Splenectomy is an effective diagnostic modality in determining a pathologic cause for splenomegaly in this patient population. Laparoscopic splenectomy can be performed safely in appropriate cases with craniocaudal splenic size having the largest influence on surgical approach.
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Laparoscopía/métodos , Esplenectomía/métodos , Esplenomegalia/cirugía , Adulto , Anciano , Biopsia , Femenino , Humanos , Laparoscopía/efectos adversos , Linfadenopatía/patología , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Bazo/patología , Esplenectomía/efectos adversos , Esplenomegalia/patologíaRESUMEN
BACKGROUND: Geriatric patients, age ≥65, frequently require no operation and only short observation after injury; yet many are prescribed opioids. We reviewed geriatric opioid prescriptions following a statewide outpatient prescribing limit. METHODS: Discharge and 30-day pain prescriptions were collected for geriatric patients managed without operation and with stays less than two midnights from May and June of 2015 through 2018. Patients were compared pre- and post-limit and with a non-geriatric cohort aged 18-64. Fall risk was also assessed. RESULTS: We included 218 geriatric patients, 57 post-limit. Patients received fewer discharge prescriptions and lower doses following the limit. However, this trend preceded the limit. Geriatric patients received fewer opioid prescriptions but higher doses than non-geriatric patients. Fall risk was not associated with reduced prescription frequency or doses. CONCLUSIONS: Opioid prescribing has decreased for geriatric patients with minor injuries. However, surgeons have not reduced dosage based on age or fall risk.