Laparoscopic versus open end colostomy closure: a single-center experience.

The aim of this study was to review our experience with laparoscopic end colostomy closure. A retrospective review of a prospectively entered database was performed. Proportions and continuous variables were compared using the Fisher's exact and the Mann-Whitney U tests, respectively. Within the study period, 53 patients underwent closure of end colostomies. The main reasons for the colonic resections were perforated diverticulitis (52.7%) and neoplasms (20.8%). In 28 patients (53%), laparoscopic closure (LC) was attempted. Demographics did not differ between the attempted LC and the primary open closure (OC) group. The conversion rate from an LC to an OC was 50 per cent (14 of 28), mostly as a result of adhesions (71.4%). Hospital length of stay (HLOS) was significantly longer for the OC than with the attempted LC group (15.4 ± 11.9 days vs 11.3 ± 8.5 days, P = 0.046). The overall complication rate was not different between the completed LC and the OC groups (43 vs 56%, P = 0.634). The majority of complications detected (91.1%) were minor and could be treated conservatively. The role of laparoscopy to close end colostomies is questionable, because the conversion rate is high. However, a shorter HLOS can be expected when laparoscopy is successful. To reduce morbidity resulting from prolonged operation times, it is crucial to convert early and pre-emptively if hostile adhesions are found.

Reasons for the persistence of adverse events in the era of safer surgery--a qualitative approach.

OBJECTIVE: We sought to evaluate potential reasons given by board-certified doctors for the persistence of adverse events despite efforts to improve patient safety in Switzerland. SUMMARY BACKGROUND DATA: In recent years, substantial efforts have been made to improve patient safety by introducing surgical safety checklists to standardise surgeries and team procedures. Still, a high number of adverse events remain. METHODS: Clinic directors in operative medicine in Switzerland were asked to answer two questions concerning the reasons for persistence of adverse events, and the advantages and disadvantages of introducing and implementing surgical safety checklists. Of 799 clinic directors, the arguments of 237 (29.7%) were content-analysed using Mayring's content analysis method, resulting in 12 different categories. RESULTS: Potential reasons for the persistence of adverse events were mainly seen as being related to the "individual" (126/237, 53.2%), but directors of high-volume clinics identified factors related to the "group and interactions" significantly more often as a reason (60.2% vs 40.2%; p = 0.003). Surgical safety checklists were thought to have positive effects on the "organisational level" (47/237, 19.8%), the "team level" (37/237, 15.6%) and the "patient level" (40/237, 16.9%), with a "lack of willingness to implement checklists" as the main disadvantage (34/237, 14.3%). CONCLUSION: This qualitative study revealed the individual as the main player in the persistence of adverse events. Working conditions should be optimised to minimise interface problems in the case of cross-covering of patients, to assure support for students, residents and interns, and to reduce strain. Checklists are helpful on an "organisational level" (e.g., financial benefits, quality assurance) and to clarify responsibilities.

Long-term clinical outcomes in patients diagnosed with severe digital ischemia.

QUESTION UNDER STUDY: To investigate the aetiology and long-term clinical outcomes of patients diagnosed with digital ischemia. METHOD: Data of 36 consecutive patients presenting with digital ischemia were collected in July 2000 to June 2001 from a vascular referral centre. Demographic data, aetiology, medication and treatment were abstracted from the medical records. Clinical outcomes were assessed at 5 year follow-up including ulcer healing, digital amputation and mortality. RESULTS: Of the 36 patients, 69.4% were male and the mean age was 55±14 years. In 15 patients (41.7%) a systemic disease was present and of those 53.3% was due to connective tissue disease. Twelve patients (33.3%) had hypothenar hammer syndrome and in 8 patients (22.2%) no apparent cause was found. Whereas 13 patients (36.1%) presented with rest pain or trophic lesions at baseline, no patients presented with these symptoms at follow-up. At follow-up, 18 (62.1%) patients had symptoms on provocation and 5 patients (4 patients with systemic disease and 1 with no apparent cause) had died. Digital amputation was performed in one patient at initial presentation and no digital amputation was performed at follow-up. No ulcer reoccurred and no workers' insurance compensation was applied. Of those with hypothenar hammer syndrome, 80.0% had symptoms on provocation at follow-up. CONCLUSIONS: Among patients with digital ischemia, systemic disease and hypothenar hammer syndrome were the most frequent aetiologies. In patients with hypothenar hammer syndrome the clinical outcome was remarkably benign, although symptoms may persist with provocation, whereas patients with systemic disease have a high mortality rate.