Chirurginių ligonių perioperacinis maitinimas: ar jis reikalingas?

Saulius Bradulskis1, Kęstutis Adamonis21 Kauno medicinos universiteto Bendrosios chirurgijos klinika,Josvainių g. 2, LT-3021 Kaunas.2 Kauno medicinos universiteto Gastroenterologijos klinika,Eivenių g. 2, LT-3007 Kaunas.El paštas: [email protected] Įvadas / tikslas Straipsnyje aptariama chirurginių ligonių mitybos nepakankamumo problema. Rezultatai Mitybos nepakankamumas nustatomas nuo 27 iki 50 % šių ligonių. Jis gali būti viena iš svarbiausių pooperacinių komplikacijų, ilgesnio buvimo stacionare pooperaciniu laikotarpiu, papildomų gydymo išlaidų priežastimi. Mitybos korekcija, o ypač maitinimas imuniniais mišiniais, akivaizdžiai padeda spręsti šias problemas. Bereikalingas badavimas prieš operaciją sukelia neigiamų padarinių: sumažėja seilių ir virškinimo trakto sulčių sekrecija, slopinama žarnyno motorika, blogėja kraujo cirkuliacija, padidėja sąlyginai patogeninės žarnų floros virulentiškumas, atrofuojasi gleivinė, padidėja bakterinės translokacijos iš žarnos galimybė, sumažėja antioksidantų, flavonoidų, fitoestrogenų kiekis, slopinamas imunitetas. Badavimas prieš operaciją yra susijęs su pooperaciniu atsparumu insulinui, tiksliau – jo intensyvumu. Prieš operaciją skiriant ligoniui lengvai pasisavinamų angliavandenių, pavyzdžiui, gliukozės, galima sumažinti šio reiškinio intensyvumą pooperaciniu laikotarpiu. Išvados Prieš operaciją ir po jos būtina griežtai laikytis mitybos korekcijos indikacijų, nes kitu atveju ši gydymo procedūra gali būti ne tik nenaudinga, bet ir sukelti komplikaciju, padidinti gydymo išlaidas. Prasminiai žodžiai: perioperacinis laikotarpis, enterinis maitinimas. Perioperative nutrition of surgical patiens: is it necessary? Saulius Bradulskis1, Kęstutis Adamonis2 Background / objective Problems of surgical patients nutrition, pre- and postoperative nutritional problems are discussed. Results Nutrition disorders among surgical patients are frequent – from 50 to 27%. Nutritional disorders may be one of the reasons for complications and long in-hospital stay and additional expenses. Nutritional correction, especially immunonutrition, is beneficial to surgical patients, as it decreases septic complications, in-hospital stay and it helps to save, money. Lack of nutrition has negative consequences: inhibition of digestive tract secretion, motility, splanchnic circulation, increased virulence of pathogenic flora, atrophy of the mucosae, microbial translocation. Data that have become available show that the preoperative administration of carbohydrates to patients undergoing surgery has metabolic benefits postoperatively by reducing postoperative insulin resistance. Conclusions Pre- and postoperative nutritional correction has strong indications, and nonobservance of this indication prolongs in-hospital stay and the preoperative period, as well as increases expenses, and first of all it has no influence on the postoperative complications. Keywords: perioperative period, enteral nutrition

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Ar verta drenuoti pilvaplėvės ertmę atlikus planinę laparoskopinę cholecistektomiją?

Linas Urbanavičius1, Roman Kartašov2, Juozas Juočas1, Saulius Bradulskis1, Donatas Venskutonis1 1 Lietuvos sveikatos mokslų universiteto Bendrosios chirurgijos klinika,Josvainių g. 2, LT-47144 Kaunas2 Lietuvos sveikatos mokslų universitetas, A. Mickevičiaus g. 9, LT-44307 Kaunas El. paštas: [email protected] TikslasĮvertinti pilvaplėvės ertmės drenavimo teikiamą naudą ir trūkumus atlikus planinę laparoskopinę cholecistektomiją. MetodaiRetrospektyvi 10 metų planinės laparoskopinės cholecitektomijos atvejų analizė. Palyginta operacijos ir gulėjimo ligoninėje trukmė, komplikacijų skaičius ir pobūdis, pakartotinių operacijų reikalingumas pacientų grupėse su ir be pilvaplėvės ertmės dreno. Vertinta drenavimo trukmė, sekrecijos pro dreną kiekis ir pobūdis, pooperacinių komplikacijų ryšys su pilvaplėvės ertmės drenavimu. Dviejų grupių parametriniams duomenims palyginti taikytas Stjudento t kriterijus, neparametrinių duomenų grupėms palyginti – Mano ir Vitnio kriterijus. Kokybinių požymių tarpusavio priklausomumui patikrinti taikytas chi kvadrato kriterijus. Skirtumas laikytas statistiškai reikšmingu, kai p &lt; 0,05. Rezultatai2001–2010 metais atliktos 3196 planinės laparoskopinės cholecistektomijos. Pilvaplėvės ertmė drenuota 895 pacientams (28 %). Operacijos ir gulėjimo ligoninėje trukmė buvo statistiškai reikšmingai ilgesnė, kai buvo drenuojama. Iš viso įvyko 30 chirurginių pooperacinių komplikacijų: 26 – pacientams su drenais ir 4 – be drenų. Pakartotinai operuota 13 pacientų su drenais ir nė vieno – be drenų. Ketvirtadaliui pacientų sekrecijos pro dreną nebuvo, 64 % bendras išsiskyrusio skysčio kiekis neviršijo 100 ml, o 11 % – viršijo. IšvadosDrenavimas atlikus planinę laparoskopinę cholecistektomiją labai pailgina gulėjimo ligoninėje trukmę, nepadeda išvengti pooperacinių komplikacijų ir pakartotinių operacijų. Profilaktinis drenavimas nereikalingas, jeigu operuojant nebuvo komplikacijų. Reikšminiai žodžiai: laparoskopinė cholecistektomija, drenavimas. Is it worth draining the peritoneal cavity after elective laparoscopic cholecystectomy? Linas Urbanavičius1, Roman Kartašov2, Juozas Juočas1, Saulius Bradulskis1, Donatas Venskutonis1 1 Lietuvos sveikatos mokslų universiteto Bendrosios chirurgijos klinika,Josvainių g. 2, LT-47144 Kaunas2 Lietuvos sveikatos mokslų universitetas, A. Mickevičiaus g. 9, LT-44307 Kaunas E-mail: [email protected] PurposeThe purpose of the study was to assess the benefits and drawbacks of the peritoneal cavity drainage after elective laparoscopic cholecystectomy. MethodsA retrospective analysis of elective laparoscopic cholecystectomy cases over 10 years was performed. The duration of surgery, length of in-hospital stay, the number and nature of complications and the need for reoperation were compared in patient groups with and without abdominal cavity drain. The duration of drainage, the amount and type of secretion through the drain were evaluated and the relation between postoperative complications and peritoneal cavity drainage was assessed. For the two-group comparison of parametric data, Student’s t test was applied, and the Mann–Whitney criteria were used for non-parametric data. Chi-square criteria were applied to test the interdependence of qualitative data. The difference was considered statistically significant at p &lt; 0.05. ResultsFrom 2001 to 2010, 3196 elective laparoscopic cholecystectomies were performed. The abdominal cavity was drained in 895 cases (28%). The duration of surgery and the length of in-hospital stay were significantly longer when the peritoneal cavity had been drained. In total, 30 surgical complications were observed: 26 in the drained group and 4 in the non-drained group. In 13 cases with drainage a reoperation was required, and no patient without a drain was reoperated. In a quarter of patients, no secretion through the drain was observed. In 64 percent of the patients, the total amount of secretion did not exceed 100 ml, and in 11 percent of the cases it was more significant. ConclusionsDrainage after elective laparoscopic cholecystectomy significantly increases the length of in-hospital stay and does not prevent postoperative complications and reoperations. Prophylactic drainage is unnecessary, if no complications have occurred during surgery. Keywords: laparoscopic cholecystectomy, drainage

Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study.

BACKGROUND: Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide. METHODS: This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. RESULTS: 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45). CONCLUSION: A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments. TRIAL REGISTRATION: NCT02179112

A survey of medical students’ and doctors’ knowledge of nutritional correction

Background / objectiveThe nutritional state of hospitalized patients is far from ideal. A way to improve it is to develop the personnel’s theoretical and practical background on nutritional correction. Our aim was to survey the level of knowledge among physicians in Lithuanian medical institutions and students of the Lithuanian University of Health Sciences with regard to nutritional insufficiency and its correction.MethodsA random voluntary questionnaire survey was undertaken. The questionnaire was completed by the university and municipal hospital physicians, primary care physicians, residents, 5th–6th year students of the Faculty of Medicine and the 3rd year students of the Faculty of Nursing of the Lithuanian University of Health Sciences. Answers to the questionnaire reflected the theoretical and practical background of the respondents.ResultsOverall, 134 doctors and 67 students or residents anonymously completed the questionnaire with the response rate of 100%. The median of correct answers was 8.5 (6–10) among the university hospital doctors who scored best. Primary care physicians showed the worst knowledge with the median score of 4 (1–6), p &lt; 0.05. Doctors showed a significantly better knowledge than students did (p &lt; 0.001).ConclusionsOverall, there is a poor knowledge with regard to the incidence of malnutrition. Hospital doctors have a better knowledge of nutritional correction than both the primary car&nbsp;that their theoretical knowledge is worse as compared with that of doctors. A much more intense professional education is&nbsp;crucial to improve the nutritional state of patients in the hospitals as well as in the ambulatory practice.Key words: nutritional correction, professional knowledge, professional teaching&nbsp;e physicians and the students. Students’ teaching is insufficient consideringMedicinos studentų ir gydytojų žinių apie&nbsp;mitybos korekciją tyrimas Įvadas / tikslasStacionaro pacientų mitybos būklė yra toli gražu ne ideali. Vienas iš būdų ją pagerinti yra personalo teorinių ir praktinių žinių&nbsp;apie mitybos korekciją gerinimas. Mūsų tyrimo tikslas yra įvertinti Lietuvos gydymo įstaigų gydytojų ir Lietuvos sveikatosmokslų universiteto studentų žinias apie mitybos nepakankamumą ir jo korekciją.MetodaiAtlikta atsitiktinė savanoriška anketinė apklausa. Anketą užpildė universitetinių bei municipalinių ligoninių bendrosios praktikos&nbsp;gydytojai, rezidentai, Lietuvos sveikatos mokslų universiteto medicinos fakulteto V ir VI kurso bei Slaugos fakulteto III kursostudentai. Anketinės apklausos atsakymai atspindi respondentų teorinius ir praktinius pagrindus.Rezultatai134 gydytojai ir 67 studentai ar rezidentai anonimiškai atsakė į visus anketos klausimus. Geriausiai atsakė universitetinių ligoninių&nbsp;gydytojai, o prasčiausiai – bendrosios praktikos gydytojai: teisingų atsakymų mediana atitinkamai 8,5 (6–10) ir 4 (1–6),p &lt; 0,05. Gydytojų žinios yra statistiškai patikimai geresnės nei studentų (p &lt; 0,001).IšvadosApie mitybos nepakankamumo paplitimą žinoma mažai. Stacionaro gydytojų žinios apie mitybos korekciją yra geresnės nei&nbsp;bendrosios praktikos gydytojų ir studentų. Studentai nepakankamai supažindinami su mitybos problemomis – jų teorinėsžinios yra prastesnės nei gydytojų. Norint pagerinti ligonių mitybos būklę ligoninėse ir ambulatorinėje praktikoje, reikalingas&nbsp;daug intensyvesnis profesinis mokymas.Reikšminiai žodžiai: mitybos korekcija, profesinės žinios, profesinis mokyma

Association of mechanical bowel preparation with oral antibiotics and anastomotic leak following left sided colorectal resection:an international, multi-centre, prospective audit

Introduction: The optimal bowel preparation strategy to minimise the risk of anastomotic leak is yet to be determined. This study aimed to determine whether oral antibiotics combined with mechanical bowel preparation (MBP+Abx) was associated with a reduced risk of anastomotic leak when compared to mechanical bowel preparation alone (MBP) or no bowel preparation (NBP). Methods: A pre-planned analysis of the European Society of Coloproctology (ESCP) 2017 Left Sided Colorectal Resection audit was performed. Patients undergoing elective left sided colonic or rectal resection with primary anastomosis between 1 January 2017 and 15 March 2017 by any operative approach were included. The primary outcome measure was anastomotic leak. Results: Of 3676 patients across 343 centres in 47 countries, 618 (16.8%) received MBP+ABx, 1945 MBP (52.9%) and 1099 patients NBP (29.9%). Patients undergoing MBP+ABx had the lowest overall rate of anastomotic leak (6.1%, 9.2%, 8.7% respectively) in unadjusted analysis. After case-mix adjustment using a mixed-effects multivariable regression model, MBP+Abx was associated with a lower risk of anastomotic leak (OR 0.52, 0.30–0.92, P&nbsp;=&nbsp;0.02) but MBP was not (OR 0.92, 0.63–1.36, P&nbsp;=&nbsp;0.69) compared to NBP. Conclusion: This non-randomised study adds ‘real-world’, contemporaneous, and prospective evidence of the beneficial effects of combined mechanical bowel preparation and oral antibiotics in the prevention of anastomotic leak following left sided colorectal resection across diverse settings. We have also demonstrated limited uptake of this strategy in current international colorectal practice

Pooled analysis of who surgical safety checklist use and mortality after emergency laparotomy

Background: The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods: In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results: Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89⋅6 per cent) compared with that in countries with a middle (753 of 1242, 60⋅6 per cent; odds ratio (OR) 0⋅17, 95 per cent c.i. 0⋅14 to 0⋅21, P &lt; 0⋅001) or low (363 of 860, 42⋅2 percent; OR 0⋅08, 0⋅07 to 0⋅10, P &lt; 0⋅001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference −9⋅4 (95 per cent c.i. −11⋅9 to −6⋅9) per cent; P &lt; 0⋅001), but the relationship was reversed in low-HDI countries (+12⋅1 (+7⋅0 to +17⋅3) per cent; P &lt; 0⋅001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0⋅60, 0⋅50 to 0⋅73; P &lt; 0⋅001). The greatest absolute benefit was seen for emergency surgery in low-and middle-HDI countries. Conclusion: Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries

Elective cancer surgery in COVID-19-free surgical pathways during the SARS-CoV-2 pandemic: An international, multicenter, comparative cohort study

PURPOSE As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19–free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19–free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19–free surgical pathways. Patients who underwent surgery within COVID-19–free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19–free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score–matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19–free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION Within available resources, dedicated COVID-19–free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks

Outcomes from elective colorectal cancer surgery during the SARS-CoV-2 pandemic

This study aimed to describe the change in surgical practice and the impact of SARS-CoV-2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS-CoV-2 pandemic

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background: Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods: The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results: A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P &lt; 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion: Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)