[Optimization of perioperative management in laparoscopic hernioplasty]. / Optimierung des perioperativen Managements am Beispiel der laparoskopischen Leistenbruchoperation.

INTRODUCTION: Although about 150,000-200,000 hernia repair procedures are performed every year in Germany alone, fast-track concepts are mainly ignored for this type of surgery. Therefore, this study was designed to analyze the perioperative management of patients undergoing laparoscopic hernia repair, performed as transabdominal preperitoneal patch hernioplasty (TAPP). Based on these results, the clinical management was optimized in order to shorten the length of stay without affecting the quality of treatment or the complication rate, and the effects of the optimization strategies were reanalyzed. METHODS: With ethics committee approval 249 patients undergoing TAPP procedures were investigated. In the first two study sections, problems of the perioperative management were identified first retrospectively (n=129) and then prospectively (n=60). Based on these results, the clinical management was then redesigned and optimized. A TAPP score was developed including the parameters age, ASA physical status, extent and severity of the procedure and postoperative pain level. Patients were scored 24 h after surgery, and clear-cut criteria were defined for discharge home on the second postoperative day. Furthermore, all patients received 10 mg of sodium picosulfate to avoid postoperative constipation. In the third study section (n=60) the impact of the optimization strategies on length of stay, need for pain medication, complication rate and patient satisfaction (based on the PPP33 questionnaire) was evaluated. RESULTS: Patients were on average approximately 60 years old (range 22-92 years), and demographic data were comparable within the study sections. As a result of the optimization process, 72% of the patients could be discharged home on the second postoperative day whereas previously that had only been possible in 5%. Accordingly, the postoperative length of stay (including the day of surgery) was significantly reduced from 4.2+/-0.6 to 3.3+/-0.6 days. By the administration of sodium picosulfate, 92% of all patients reported defecation on the first day after surgery, whereas previously the majority of patients (60%) had complained of constipation at this time. No serious complications were observed. The number of minor complications was very low in total and neither complication rate nor patient satisfaction was affected by earlier discharge. The second day after surgery was judged to be the ideal time point for discharge by 81% of all patients. CONCLUSIONS: This study demonstrates that the length of stay after laparoscopic hernia repair can be reduced by one day by relatively simple means without affecting patient satisfaction or the complication rate. Most important is the introduction of clear-cut criteria that allow an early decision-making for discharge home. Moreover, many patients complain of constipation after laparoscopic surgery, and this may prolong the length of stay. This problem can be solved completely by the standardized use of sodium picosulfate, administered on the evening after surgery.

Amphetamine derivative related deaths in northern Greece.

Until 1997, only one amphetamine related derivatives (AMPs) fatality had been reported in Greece. Since then, amphetamine (AMP) or AMPs have been found in seven out of 1,500 post-mortem toxicological cases. The cause and manner of death of these seven cases were: 3,4-methylenedioxy-N-methamphetamine (MDMA) and 3,4-methylenedioxy-N-ethylamphetamine (MDEA) poisoning (n = 1), drowning in water (n = 4), cranial injuries caused by a traffic accident (n = 1) and heart failure (n = 1). In the case where the use of AMP or AMPs was considered, the immediate cause of death post-mortem toxicological analysis revealed 2 microg/ml MDMA and 0.7 microg/ml MDEA in blood. MDMA was identified in two cases of drowning (2 microg/ml in blood in the first case and 1.7 microg/g in liver in the second case) and in the traffic accident case (0.4 microg/g in liver). Methamphetamine was detected in two cases of drowning (2.5 microg/ml in blood in the first case and 6 microg/g in liver in the second case). AMP was found in the heart failure case (0.2 microg/g in liver). Alcohol was present, together with AMP or AMPs, in four cases. These findings indicate an increase in the illegal abuse of AMPs in Greece. Because of this, we now routinely screen for AMPs.

Sudden death due to cardiac myxoma.

Primary tumours of the heart are rare, their incidence ranging from 0.0017 to 0.28 per cent in various autopsy series (Colucci and Braunwald, 1992). Thirty per cent of these tumours are cardiac myxomas (McAllister and Fenaglio, 1978). The latter are histologically benign but potentially lethal. Sudden death is reported in 15 per cent of cases and is mainly attributed to massive embolism or mechanical interference to blood flow within the heart by the tumour (Fisher, 1983). This incidence could be due to the absence of clinical manifestations of the disease or to the presence of non-specific or subtle ones that preclude early referral for specialist evaluation (Colucci and Braunwald, 1992). Such a poor prognosis is not altogether justified, however, considering the highly sensitive and accurate diagnostic techniques and the level of surgical treatment which can be offered today (Larsson et al., 1989; Roberts, 1989; Bortolloti et al., 1990; Lyons et al., 1991). We present a case diagnosed at post-mortem of an atrial myxoma which had subtle ante-mortem manifestations. This paper should alert the clinician with regard to the need to be aware of the rather obscure clinical presentation which may accompany this potentially treatable condition.