Safety and effectiveness of outpatient laparoscopic cholecystectomy in a teaching hospital: a prospective study of 110 consecutive patients

<p>Abstract</p> <p>Background</p> <p>The aim of this study was to evaluate the safety and efficacy of outpatient laparoscopic cholecystectomy (OLC) in a day surgery unit in a teaching hospital. OLC was offered to patients with symptomatic cholelithiasis who met the following established inclusion criteria: ASA (American Society of Anesthesiology) physical status classification class I and II; age: 18 - 70 years; body mass index (BMI) < 30 kg/m²; patient acceptance and cooperation (informed consent); presence of a responsible adult to accompany the patient to his residency; patient residency in Athens. The primary study end-point was to evaluate success rates (patient discharge on the day of surgery), postoperative outcome (complications, re-admissions, morbidity and mortality) and patient satisfaction. A secondary endpoint was to evaluate its safe performance under appropriate supervision by higher surgical trainees (HSTs).</p> <p>Findings</p> <p>110 consecutive patients, predominantly female (71%) and ASA I (89%) with a mean age 40.6 ± 8.1 years underwent an OLC. Surgery was performed by a HST in 90 patients (81.8%). A mean postoperative pain score 3.3 (range 0-6) occurred in the majority of patients and no patient presented postoperative nausea or vomiting. Discharge on the day of surgery occurred in 95 cases (86%), while an overnight admission was required for 15 patients (14%). Re-admission following hospital discharge was necessary for 2 patients (1.8%) on day 2, due to persistent pain in the umbilical trocar site. The overall rate of major (trocar site bleeding) and minor morbidity was 15.5% (17 patients). At 1 week follow-up, 94 patients (85%) were satisfied with their experience undergoing OLC, with no difference between grades of operating surgeons.</p> <p>Conclusions</p> <p>This study confirmed that OLC is clinical effective and can be performed safely in a teaching hospital by supervised HSTs.</p

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

The analgesic action of gabapentin in gynecological procedures

Backgrounds and objective. The aim of the study was to investigate the effect of gabapentin, and the combination of gabapentin and local anaesthetics on the analgesic needs as well as on acute and late pain after abdominal hysterectomy. Methods: In study I sixty patients scheduled for abdominal hysterectomy were randomized to receive orally gabapentin 400 mg 6 hourly or placebo. Treatment started 18 h preoperatively and continued for 5 postoperative days. Pain (visual analogue score) and consumption of morphine for 48 h and of oral paracetamol/codeine was recorded after 2, 4, 8, 24 and 48 h and on days 3-5 postoperatively. After 1 month, patients were interviewed by phone for pain, and analgesic intake after hospital discharge. In study II sixty patients undergoing abdominal hysterectomy were randomly assigned to receive postoperatively gabapentin 400 mg 6 hourly for 7 days plus continuous wound infusion of 0.75% ropivacaine for 30 h or placebo capsules identical to those of gabapentin for 7 days and continuous wound infusion of normal saline for 30 h. Morphine consumption (PCA) for 48 h, paracetamol 500 mg plus codeine 30 mg (Lonalgal® tablets) intake on 3-7 days, visual analogue pain scores (VAS) at rest and after cough during the first 7 postoperative days, the presence and incidence of pain one month later and the need for analgesics at home were recorded. Results: In study I morphine consumption (mean ± SD) was 35 ± 15.7 mg in the control and 28 ± 12.1 mg in the gabapentin group (P = 0.21). Median number (range) of paracetamol 500 mg/codeine 30 mg tablets taken during days 3-5 was 1.0 (0-6) in the control and 2.0 (0-9) in the gabapentin group (P = 0.35). The visual analogue scores at rest and after cough did not differ between the two groups (F = 0.92, df = 1, P = 0.34 and F = 0.56, df = 1, P = 0.46, respectively). One month after surgery, 22/27 (81%) of the control group and 9/25 (36%) of the gabapentin group reported pain in the surgical area (χ² = 11.15, P = 0.002), while 11/27 (41%) of controls and 7/25 (28%) of gabapentin patients consumed analgesics for pain (χ² = 0.93, P = 0.39). The intensity of pain was decreased in the gabapentin group (χ² = 12.6, P = 0.003). In study II the treatment group consumed less cumulative morphine over the first 48 hours (31 ± 13.2 mg versus 50 ± 20.5 mg in the controls, P<0.001) and less Lonalgal® tablets on days 3-7 (z=2.54, P=0.011). The VAS values at rest and after cough did not differ between the groups during the first seven postoperative days. One month postoperatively fewer patients in the treatment group experienced pain due to surgery (17/27, versus 21/24, P=0.045) than in the control group. Conclusions: Gabapentin has no effect on immediate pain after abdominal hysterectomy but decreases pain 1 month postoperatively. Gabapentin and continuous wound infusion with ropivacaine 0.75% decreased the analgesic needs and late pain in patients undergoing abdominal hysterectomy.Σκοπός της μελέτης ήταν να διερευνήσουμε τη δράση της γκαπαπεντίνης και του συνδυασμού γκαμπαπεντίνης και τοπικού αναισθητικού, στον οξύ και τον όψιμο μετεγχειρητικό πόνο, μετά από κοιλιακή υστερεκτομή. Στη μελέτη I, εξήντα ασθενείς προγραμματισμένες για κοιλιακή υστερεκτομή τυχαιοποιήθηκαν να λάβουν από του στόματος γκαμπαπεντίνη 400 mg ανά εξάωρο ή placebo. Η θεραπεία άρχιζε 18 ώρες προεγχειρητικά και συνεχίσθηκε τις πρώτες 5 μετεγχειρητικές ημέρες. Ο πόνος (visual analogue score) και η κατανάλωση της μορφίνης για 48 ώρες και η από του στόματος κατανάλωση της παρακεταμόλης/κωδεΐνης καταγράφονταν μετά από 2, 4, 8, 24 και 48 ώρες και τις ημέρες 3η-5η μετεγχειρητικά. Μετά από ένα μήνα οι ασθενείς απαντούσαν τηλεφωνικά για πόνο και κατανάλωση αναλγητικών μετά την έξοδό τους από το νοσοκομείο. Στη μελέτη II, εξήντα ασθενείς που προγραμματίστηκαν για κοιλιακή υστερεκτομή τυχαία επιλέχθηκαν να λάβουν περιεγχειρητικά γκαμπαπεντίνη 400 mg ανά εξάωρο για επτά ημέρες και συνεχή διήθηση της τομής με 0.75% ροπιβακαΐνη για 30 ώρες ή κάψουλες placebo ίδιες με αυτές της γκαμπαπεντίνης για επτά ημέρες και συνεχή διήθηση της τομής με φυσιολογικό ορό για 30 ώρες. Καταγράφονταν η κατανάλωση μορφίνης με PCA για 48 ώρες, η κατανάλωση δισκίων Lonalgal® (παρακεταμόλη 500 mg με κωδεΐνη 30 mg) την 3η - 7η ημέρα, η οπτική αναλογική κλίμακα του πόνου (VAS) στην ηρεμία και στον βήχα τις επτά πρώτες μετεγχειρητικές ημέρες, η παρουσία και η επίπτωση του πόνου ένα μήνα μετά, και οι ανάγκες σε αναλγητικά στο σπίτι. Τα αποτελέσματα της μελέτης I έδειξαν ότι η κατανάλωση της μορφίνης ήταν 35 ± 15.7 mg στην ομάδα ελέγχου και 28 ± 12.1 mg στην ομάδα της γκαμπαπεντίνης (Ρ = 0.21). Η μέση τιμή των δισκίων Lonalgal® που καταναλώθηκαν από τη 3η -5η ημέρα ήταν 1.0 (0-6) στην ομάδα ελέγχου και 2.0 (0-9) στην ομάδα της γκαμπαπεντίνης (Ρ = 0.35). Η βαθμολογία του πόνου (VAS) στην ηρεμία και στον βήχα δεν διέφερε ανάμεσα στις δύο ομάδες (F = 0.92, df = 1, Ρ = 0.34 and F = 0.56, df = 1, Ρ = 0.46, αντίστοιχα). Ένα μήνα μετά το χειρουργείο, 22/27 (81%) της ομάδας ελέγχου και 9/25 (36%) της ομάδας της γκαμπαπεντίνης ανέφεραν πόνο στην χειρουργική επιφάνεια (χ² = 11.15, Ρ = 0.002), ενώ 11/27 (41%) της ομάδας ελέγχου και 7/25 (28%) της γκαμπαπεντίνης κατανάλωσαν αναλγητικά (χ² = 0.93, Ρ = 0.39). Η ένταση του πόνου ήταν ελαττωμένη στη ομάδα της γκαμπαπεντίνης (χ² = 12.6, Ρ = 0.003). Τα αποτελέσματα της μελέτης II έδειξαν ότι η ομάδα που έλαβε πολυδύναμη αναλγησία κατανάλωσε λιγότερη μορφίνη στο σύνολό της, τις πρώτες 48 ώρες (31 ± 13.2 mg σε σύγκριση με 50 ± 20.5 mg στην ομάδα ελέγχου, Ρ<0.001) και λιγότερα δισκία Lonalgal® από την 3η -7η ημέρα (z=2.54, Ρ=0.011). Οι τιμές VAS στην ηρεμία και στον βήχα δεν διέφεραν ανάμεσα στις ομάδες τις επτά πρώτες μετεγχειρητικές ημέρες. Ένα μήνα μετά το χειρουργείο λιγότερες ασθενείς στην ομάδα της θεραπείας ανέφεραν πόνο που οφειλόταν στην επέμβαση (17/27, vs 21/24, Ρ=0.045) από ότι στην ομάδα ελέγχου. Συμπερασματικά στον οξύ μετεγχειρητικό πόνο δεν βρήκαμε η γκαμπαπεντίνη να έχει επίδραση, μετά από ολική υστερεκτομή, ενώ ο συνδυασμός γκαμπαπεντίνης και τοπικού αναισθητικού ελάττωσε την κατανάλωση αναλγητικών και φαίνεται να έχει δυναμική συνέργεια. Ένα μήνα μετεγχειρητικά η γκαμπαπεντίνη μόνη ή σε συνδυασμό με το τοπικό αναισθητικό ροπιβακαΐνη, ελάττωσε τη συχνότητα του όψιμου πόνου σε ασθενείς που υποβλήθηκαν σε κοιλιακή ολική υστερεκτομή

Colloid Preload versus Crystalloid Co-Load in the Setting of Norepinephrine Infusion during Cesarean Section: Time and Type of Administered Fluids Do Not Matter

Background and Goal of Study: Spinal anesthesia for cesarean section is frequently associated with a high incidence of hypotension, which may bring about untoward effects for both the mother and fetus. Recently, norepinephrine has emerged as a promising alternative in maintaining blood pressure in the obstetric setting. Fluid administration is another technique still widely used to prevent maternal hypotension. The optimal fluid strategy to prevent maternal hypotension has not been elucidated yet. It has been recently suggested that the main strategy in the prevention and management of hypotension should be the combination of vasoconstrictive medications and fluid administration. The aim of this randomized study was to compare the incidence of maternal hypotension in parturients receiving either colloid preload or crystalloid co-load in the setting of prophylactic norepinephrine infusion during elective cesarean section under combined spinal–epidural anesthesia. Materials and Methods: After ethics committee approval, 102 parturients with full-term singleton pregnancies were randomly allocated to either 6% hydroxyethyl starch 130/0.4 5 mL/kg before the onset of spinal anesthesia (colloid preload group) or Ringer’s lactate solution 10 mL/kg concurrent with the subarachnoid injection (crystalloid co-load group). In both groups, norepinephrine 4 μg/min starting simultaneously with the administration of the subarachnoid solution was also administered. The primary outcome of the study was the incidence of maternal hypotension, defined as systolic arterial pressure (SAP) Results: Data analysis was performed on 100 parturients: 51 in the colloid preload group and 49 in the crystalloid co-load group. No significant differences were demonstrated between the colloid preload group and the crystalloid co-load group in the incidence of hypotension (13.7% vs. 16.3%, p = 0.933) or the incidence of severe hypotension (0% vs. 4%, p = 0.238). The median (range) ephedrine dose was 0 (0–15) mg in the colloid preload group and 0 (0–10) mg in the crystalloid co-load group (p = 0.807). The incidence of bradycardia, reactive hypertension, requirement for modification of vasopressor infusion, time to the first occurrence of hypotension, and maternal hemodynamics did not differ between the two groups. There were no significant differences in other maternal side effects or neonatal outcomes between groups. Conclusions: The incidence of hypotension with a norepinephrine preventive infusion is low and comparable with both colloid preload and crystalloid co-load. Both fluid-loading techniques are appropriate in women undergoing cesarean delivery. It appears that the optimal regimen for prevention of maternal hypotension is a combined strategy of a prophylactic vasopressor such as norepinephrine and fluids

Maximal Effort Cytoreduction in Epithelial Ovarian Cancer: Perioperative Complications and Survival Outcomes from a Retrospective Cohort

Background: Rates of maximal effort cytoreductive surgery in ovarian cancer patients increase gradually the last decade. The purpose of the present study is to evaluate factors that contribute to survival and morbidity outcomes in this group of patients. Methods: We retrospectively reviewed patient records of epithelial ovarian cancer patients with an intermediate and high Mayo Clinic surgical complexity score, operated between January 2010 and December 2018. Results: Overall, 107 patients were enrolled in the present study with a median age of 62 years (23–84) and a follow-up of 32 months (2–156). Thirteen Clavien-Dindo grade IIIa complications were documented in 10 patients (9.3%). Of all the investigated factors, only stage IVb (p = 0.027) and interval debulking surgery (p = 0.042) affected overall survival rates. Overall survival outcomes of patients operated on a primary setting started to differentiate compared to those that received neo-adjuvant chemotherapy after the 4th postoperative year. Conclusions: Maximal effort cytoreductive procedures should be considered feasible in the modern surgical era, as they are accompanied by acceptable rates of perioperative morbidity. Hence, every effort should be made to perform them in the primary setting, rather than following neoadjuvant chemotherapy as current evidence favor increased survival rates of patients that will likely surpass an interval of observation of more than 4 years

Biomarker assessment of tobacco smoking exposure and risk of dementia death: pooling of individual-participant data from 14 cohort studies

BACKGROUND: While there is a suggestion that self-reported tobacco smoking may be a risk factor for dementia, to date, it has not been possible to explore the thresholds at which this exposure elevates risk. Accordingly, our aim was to relate cotinine, a biomarker of tobacco smoking, to risk of dementia death. METHODS: We pooled 14 prospective cohort studies that held data on cotinine (plasma or saliva), covariates and death records. RESULTS: In the 33 032 study members (17 107 women) with salivary cotinine data, a mean duration of 8.3 years of follow-up gave rise to 135 deaths ascribed to dementia; while in 15 130 study members (7995 women) with plasma cotinine data, there were 119 dementia deaths during 14.3 years of mortality surveillance. After multiple adjustment, both plasma cotinine (per 1 SD higher cotinine; 95% CI 1.29; (1.05 to 1.59)) and salivary cotinine (1.10 (0.89 to 1.36)) were positively related to dementia risk, with stronger effects apparent for plasma. CONCLUSION: Our finding that plasma cotinine was related to an elevated risk of dementia death warrants testing in studies with measures of disease onset as opposed to just mortality

Deep versus Moderate Neuromuscular Blockade in Gynecologic Laparoscopic Operations: Randomized Controlled Trial

Background: To investigate whether deep neuromuscular blockade (NMB) improves surgical conditions and postoperative pain compared to moderate block, in patients undergoing gynecologic laparoscopic surgery. Methods: A single blind, randomized, controlled trial was undertaken with laparoscopic gynecologic surgical patients, who were randomly assigned to one of the following two groups: patients in the first group received deep NMB (PTC 0-1) and in the other, moderate NMB (TOF 0-1). Primary outcomes included assessing the surgical conditions using a four-grade scale, ranging from 0 (extremely poor) to 3 (optimal), and patients’ postoperative pain was evaluated with a five-grade Likert scale and the analgesic consumption. Results: 144 patients were analyzed as follows: 73 patients received deep NMB and 71 moderate NMB. Mean surgical field scores were comparable between the two groups (2.44 for moderate vs. 2.68 for deep NMB). Regarding postoperative pain scores, the patients in the deep NMB experienced significantly less pain than in the group of moderate NMB (0.79 vs. 1.58, p p = 0.007). From the secondary endpoints, an interesting finding of the study was that patients on deep NMB had significantly fewer incidents of subcutaneous emphysema. Conclusions: Our data show that, during the performance of gynecologic laparoscopic surgery, deep NMB offers no advantage of operating filed conditions compared with moderate NMB. Patients may benefit from the deep block as it may reduce postoperative pain

Deep versus Moderate Neuromuscular Blockade in Gynecologic Laparoscopic Operations: Randomized Controlled Trial

Background: To investigate whether deep neuromuscular blockade (NMB) improves surgical conditions and postoperative pain compared to moderate block, in patients undergoing gynecologic laparoscopic surgery. Methods: A single blind, randomized, controlled trial was undertaken with laparoscopic gynecologic surgical patients, who were randomly assigned to one of the following two groups: patients in the first group received deep NMB (PTC 0-1) and in the other, moderate NMB (TOF 0-1). Primary outcomes included assessing the surgical conditions using a four-grade scale, ranging from 0 (extremely poor) to 3 (optimal), and patients&rsquo; postoperative pain was evaluated with a five-grade Likert scale and the analgesic consumption. Results: 144 patients were analyzed as follows: 73 patients received deep NMB and 71 moderate NMB. Mean surgical field scores were comparable between the two groups (2.44 for moderate vs. 2.68 for deep NMB). Regarding postoperative pain scores, the patients in the deep NMB experienced significantly less pain than in the group of moderate NMB (0.79 vs. 1.58, p &lt; 0.001). Moreover, when the consumption of analgesic drugs was compared, the moderate NMB group needed more extra opioid analgesia than the deep NMB group (18.3% vs. 4.1%, p = 0.007). From the secondary endpoints, an interesting finding of the study was that patients on deep NMB had significantly fewer incidents of subcutaneous emphysema. Conclusions: Our data show that, during the performance of gynecologic laparoscopic surgery, deep NMB offers no advantage of operating filed conditions compared with moderate NMB. Patients may benefit from the deep block as it may reduce postoperative pain