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

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 < 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 < 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

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 < 0.05. Doctors showed a significantly better knowledge than students did (p < 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 that their theoretical knowledge is worse as compared with that of doctors. A much more intense professional education is 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 e physicians and the students. Students’ teaching is insufficient consideringMedicinos studentų ir gydytojų žinių apie mitybos korekciją tyrimas Įvadas / tikslasStacionaro pacientų mitybos būklė yra toli gražu ne ideali. Vienas iš būdų ją pagerinti yra personalo teorinių ir praktinių žinių 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 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 gydytojai, o prasčiausiai – bendrosios praktikos gydytojai: teisingų atsakymų mediana atitinkamai 8,5 (6–10) ir 4 (1–6),p < 0,05. Gydytojų žinios yra statistiškai patikimai geresnės nei studentų (p < 0,001).IšvadosApie mitybos nepakankamumo paplitimą žinoma mažai. Stacionaro gydytojų žinios apie mitybos korekciją yra geresnės nei 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 daug intensyvesnis profesinis mokymas.Reikšminiai žodžiai: mitybos korekcija, profesinės žinios, profesinis mokyma

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

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

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

The impact of surgical delay on resectability of colorectal cancer: An international prospective cohort study

AIM: The SARS-CoV-2 pandemic has provided a unique opportunity to explore the impact of surgical delays on cancer resectability. This study aimed to compare resectability for colorectal cancer patients undergoing delayed versus non-delayed surgery. METHODS: This was an international prospective cohort study of consecutive colorectal cancer patients with a decision for curative surgery (January-April 2020). Surgical delay was defined as an operation taking place more than 4 weeks after treatment decision, in a patient who did not receive neoadjuvant therapy. A subgroup analysis explored the effects of delay in elective patients only. The impact of longer delays was explored in a sensitivity analysis. The primary outcome was complete resection, defined as curative resection with an R0 margin. RESULTS: Overall, 5453 patients from 304 hospitals in 47 countries were included, of whom 6.6% (358/5453) did not receive their planned operation. Of the 4304 operated patients without neoadjuvant therapy, 40.5% (1744/4304) were delayed beyond 4 weeks. Delayed patients were more likely to be older, men, more comorbid, have higher body mass index and have rectal cancer and early stage disease. Delayed patients had higher unadjusted rates of complete resection (93.7% vs. 91.9%, P = 0.032) and lower rates of emergency surgery (4.5% vs. 22.5%, P < 0.001). After adjustment, delay was not associated with a lower rate of complete resection (OR 1.18, 95% CI 0.90-1.55, P = 0.224), which was consistent in elective patients only (OR 0.94, 95% CI 0.69-1.27, P = 0.672). Longer delays were not associated with poorer outcomes. CONCLUSION: One in 15 colorectal cancer patients did not receive their planned operation during the first wave of COVID-19. Surgical delay did not appear to compromise resectability, raising the hypothesis that any reduction in long-term survival attributable to delays is likely to be due to micro-metastatic disease

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 <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <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.Peer reviewe

Global economic burden of unmet surgical need for appendicitis

Background: There is a substantial gap in provision of adequate surgical care in many low-and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

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