Postoperative complications (PC) are a basic health outcome, but no surgery service in the world records and/or audits the PC associated with all the surgical procedures it performs. Most studies ...that have assessed the cost of PC suffer from poor quality and a lack of transparency and consistency. The payment system in place often rewards the volume of services provided rather than the quality of patients' clinical outcomes. Without a thorough registration of PC, the economic costs involved cannot be determined. An accurate, reliable appraisal would help identify areas for investment in order to reduce the incidence of PC, improve surgical results, and bring down the economic costs. This article describes how to quantify and classify PC using the Clavien-Dindo classification and the comprehensive complication index, discusses the perspectives from which economic evaluations are performed and the minimum postoperative follow-up established, and makes various recommendations. The availability of accurate and impartially audited data on PC will help reduce their incidence and bring down costs. Patients, the health authorities, and society as a whole are sure to benefit.
OBJECTIVE:To validate the Comprehensive Complication Index (CCI) via an assessment of its relation to postoperative costs.
BACKGROUND:The CCI summarizes all the postoperative complications graded by ...the Clavien-Dindo classification (CDC) on a numerical scale. Its relation to hospital costs has not been validated to date.
METHODS:Prospective observational cohort study, including all patients undergoing surgery at a general surgery service during the 1-year study period. All complications graded with the CDC and CCI and related to the initial admission, or until discharge if the patient was readmitted within 90 days of surgery, were included. The surgeries were classified according to their Operative Severity Score (OSS) and in 4 groups of homogeneous surgeries. All postoperative costs were recorded.
RESULTS:In all, 1850 patients were included, of whom 513 presented complications (27.7%). The CDC and the CCI were moderately to strongly correlated with overall postoperative costs (OPCs) in all OSS groups (rs = 0.444–0.810 vs 0.445–0.820; P < 0.001), homogeneous surgeries (rs = 0.364–0.802 vs 0.364–0.813; P < 0.001), prolongation of postoperative stay (rs = 0.802 vs 0.830; P < 0.001), and initial operating room costs (rs = 0.448 vs 0.451; P < 0.001). This correlation was higher in emergency surgery. With higher CDC grades, the OPC tended to increase an upward trend. In the multivariate analysis, CDC, CCI, age, and duration of surgery were all associated with OPC (P < 0.001).
CONCLUSIONS:In our environment, the CCI presented associations with OPC. This demonstration of its economic validity enhances its clinical validity.
Publication in a peer-reviewed journal is the goal of any research project. One of the most important (and possibly the least understood) aspects of the publication process is the choice of a ...suitable journal that is likely to accept your work. Detailed information and tips and tricks to success are given in this editorial.
Review of the treatment of liver hydatid cysts Gomez I Gavara, Concepción; López-Andújar, Rafael; Belda Ibáñez, Tatiana ...
World journal of gastroenterology,
01/2015, Letnik:
21, Številka:
1
Journal Article
Odprti dostop
A review was carried out in Medline,LILACS and the Cochrane Library.Our database search strategy included the following terms: "hydatid ...cyst","liver","management","meta-analysis" and "randomized controlled trial".No language limits were used in the literature search.The latest electronic search date was the 7th of January 2014.Inclusion and exclusion criteria: all relevant studies on the assessment of therapeutic methods for hydatid cysts of the liver were considered for analysis.Information from editorials,letters to publishers,low quality review articles and studies done on animals were excluded from analysis.Additionally,well-structured abstracts from relevant articles were selected and accepted for analysis.Standardized forms were designed for data extraction; two investigators entered the data on patient demographics,methodology,recurrence of HC,mean cyst size and number of cysts per group.Four hundred and fourteen articles were identified using the previously described search strategy.After applying the inclusion and exclusion criteria detailed above,57 articles were selected for final analysis: one meta-analysis,9 randomized clinical trials,5 non-randomized comparative prospective studies,7 non-comparative prospective studies,and 34 retrospective studies(12 comparative and 22 noncomparative).Our results indicate that antihelminthic treatment alone is not the ideal treatment for liver hydatid cysts.More studies in the literature support the effectiveness of radical treatment compared with conservative treatment.Conservative surgery with omentoplasty is effective in preventing postoperative complications.A laparoscopic approach is safe in some situations.Percutaneous drainage with albendazole therapy is a safe and effective alternative treatment for hydatid cysts of the liver.Radical surgery with preand post-operative administration of albendazole is the best treatment option for liver hydatid cysts due to low recurrence and complication rates.
Background We assessed the results of adrenalectomy for solid tumor metastases in 317 patients recruited from 30 European centers. Methods Patients with histologically proven adrenal metastatic ...disease and undergoing complete removal(s) of the affected gland(s) were eligible. Results Non-small cell lung cancer (NSCLC) was the most frequent tumor type followed by colorectal and renal cell carcinoma. Adrenal metastases were synchronous (≤6 months) in 73 (23%) patients and isolated in 213 (67%). The median disease-free interval was 18.5 months. Laparoscopic resection was used in 46% of patients. Surgery was limited to the adrenal gland in 73% of patients and R0 resection was achieved in 86% of cases. The median overall survival was 29 months (95% confidence interval, 24.69–33.30). The survival rates at 1, 2, 3, and 5 years were 80%, 61%, 42%, and 35%, respectively. Patients with renal cancer showed a median survival of 84 months, patients with NSCLC 26 months, and patients with colorectal cancer 29 months ( P = .017). Differences in survival between metachronous and synchronous lesions were also significant (30 vs 23 months; P = .038). Conclusion Surgical removal of adrenal metastasis is associated with long-term survival in selected patients.
OBJECTIVE:Using clinical outcomes, to validate the comprehensive complication index (CCI) as a measure of postoperative morbidity in all patients undergoing surgery at a general surgery department.
...BACKGROUND:The Clavien-Dindo classification (CDC) is the most widely used system to assess postoperative morbidity. The CCI is a numerical scale based on the CDC. Once validated, it could be used universally to establish and compare the real postoperative complications of each surgical procedure.
METHODS:Observational prospective cohort study. All patients who underwent surgery during the 1-year study period were included. All the complications graded with the CDC and related to the initial admission, or until discharge if the patient was readmitted within 90 days of surgery, were included. Surgical procedures were classified according to the operative severity score (OSS) as minor, moderate, major, or major+. The clinical validation of the CCI was performed by assessing its correlation with 4 different clinical outcomes.
RESULTS:A total of 1850 patients were included513 (27.7%) presented complications and 101 (5.46%) were readmitted. In the multivariate analysis, the CCI and CDC were associated with postoperative stay, prolongation of postoperative stay, readmission, and disability in all OSS groups (P < 0.001). The CCI was superior to the CDC in all models except for prolongation of stay for OSS moderate and major+.
CONCLUSIONS:The CCI can be applied in all the procedures carried out at general surgery departments. It is able to determine the morbidity and allows the comparison of the outcomes at different services.
OBJECTIVE:To provide evidence-based recommendations for the management of exocrine pancreatic insufficiency (EPI) after pancreatic surgery.
BACKGROUND:EPI is a common complication after pancreatic ...surgery but there is certain confusion about its frequency, optimal methods of diagnosis, and when and how to treat these patients.
METHODS:Eighteen multidisciplinary reviewers performed a systematic review on 10 predefined questions following the GRADE methodology. Six external expert referees reviewed the retrieved information. Members from Spanish Association of Pancreatology were invited to suggest modifications and voted for the quantification of agreement.
RESULTS:These guidelines analyze the definition of EPI after pancreatic surgery, (one question), its frequency after specific techniques and underlying disease (four questions), its clinical consequences (one question), diagnosis (one question), when and how to treat postsurgical EPI (two questions) and its impact on the quality of life (one question). Eleven statements answering those 10 questions were providedone (9.1%) was rated as a strong recommendation according to GRADE, three (27.3%) as moderate and seven (63.6%) as weak. All statements had strong agreement.
CONCLUSIONS:EPI is a frequent but under-recognized complication of pancreatic surgery. These guidelines provide evidence-based recommendations for the definition, diagnosis, and management of EPI after pancreatic surgery.
Introduction
Enhanced recovery after surgery (ERAS) has been shown to facilitate discharge, decrease length of stay, improve outcomes and reduce costs. We used this concept to design a comprehensive ...fast-track pathway (OR-to-discharge) before starting our liver transplant activity and then applied this protocol prospectively to every patient undergoing liver transplantation at our institution, monitoring the results periodically. We now report our first six years results.
Patients and methods
Prospective cohort study of all the liver transplants performed at our institution for the first six years. Balanced general anesthesia, fluid restriction, thromboelastometry, inferior vena cava preservation and temporary portocaval shunt were strategies common to all cases. Standard immunosuppression administered included steroids, tacrolimus (delayed in the setting of renal impairment, with basiliximab induction added) and mycophenolate mofetil. Tacrolimus dosing was adjusted using a Bayesian estimation methodology. Oral intake and ambulation were started early.
Results
A total of 240 transplants were performed in 236 patients (191♂/45♀) over 74 months, mean age 56.3±9.6 years, raw MELD score 15.5±7.7. Predominant etiologies were alcohol (
n
= 136) and HCV (
n
= 82), with hepatocellular carcinoma present in 129 (54.7%). Nine patients received combined liver and kidney transplants. The mean operating time was 315±64 min with cold ischemia times of 279±88 min. Thirty-one patients (13.1%) were transfused in the OR (2.4±1.2 units of PRBC). Extubation was immediate (< 30 min) in all but four patients. Median ICU length of stay was 12.7 hours, and median post-transplant hospital stay was 4 days (2-76) with 30 patients (13.8%) going home by day 2, 87 (39.9%) by day 3, and 133 (61%) by day 4, defining our fast-track group. Thirty-day-readmission rate (34.9%) was significantly lower (28.6% vs. 44.7%
p
=0.015) in the fast-track group. Patient survival was 86.8% at 1 year and 78.6% at five years.
Conclusion
Fast-Tracking of Liver Transplant patients is feasible and can be applied as the standard of care
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