Interfacility transfers in a non-trauma system setting: an assessment of the Greek reality

<p>Abstract</p> <p>Background</p> <p>Quality assessment of any trauma system involves the evaluation of the transferring patterns. This study aims to assess interfacility transfers in the absence of a formal trauma system setting and to estimate the benefits from implementing a more organized structure.</p> <p>Methods</p> <p>The 'Report of the Epidemiology and Management of Trauma in Greece' is a one year project of trauma patient reporting throughout the country. It provided data concerning the patterns of interfacility transfers. We compared the transferred patient group to the non transferred patient group. Information reviewed included patient and injury characteristics, need for an operation, Intensive Care Unit (ICU) admittance and mortality. Analysis employed descriptive statistics and Chi-square test. Interfacility transfers were then assessed according to each health care facility's availability of five requirements; Computed Tomography scanner, ICU, neurosurgeon, orthopedic and vascular surgeon.</p> <p>Results</p> <p>Data on 8,524 patients were analyzed; 86.3% were treated at the same facility, whereas 13.7% were transferred. Transferred patients tended to be younger, male, and more severely injured than non transferred patients. Moreover, they were admitted to ICU more often, had a higher mortality rate but were less operated on compared to non transferred patients. The 34.3% of transfers was from facilities with none of the five requirements, whereas the 12.4% was from those with one requirement. Low level facilities, with up to three requirements transferred 43.2% of their transfer volume to units of equal resources.</p> <p>Conclusion</p> <p>Trauma management in Greece results in a high number of transfers. Patients are frequently transferred between low level facilities. Better coordination could lead to improved outcomes and less cost.</p

Anastomotic leak management after a low anterior resection leading to recurrent abdominal compartment syndrome: a case report and review of the literature

<p>Abstract</p> <p>Introduction</p> <p>Low anterior resection is usually the procedure of choice for rectal cancer, but a series of complications often accompany this procedure. This case report describes successful management of an intricate anastomotic leak after a low anterior resection.</p> <p>Case presentation</p> <p>A 66-year-old Caucasian man was admitted to our hospital and diagnosed with a low rectal adenocarcinoma. He underwent a low anterior resection but subsequently developed fecal peritonitis due to an anastomotic leak. He was operated on again but developed abdominal compartment syndrome, multi-organ failure and sepsis. He was aggressively treated in the intensive care unit and in the operating room. Overall, the patient underwent four laparotomies and stayed in the intensive care unit for 75 days. He was discharged after 3 months of hospitalization.</p> <p>Conclusion</p> <p>Abdominal compartment syndrome may present as a devastating complication of damage control laparotomy. Prompt recognition and goal-directed management are the cornerstones of treatment.</p

The impact of immediate breast reconstruction on the time to delivery of adjuvant therapy: the iBRA-2 study

Background: Immediate breast reconstruction (IBR) is routinely offered to improve quality-of-life for women requiring mastectomy, but there are concerns that more complex surgery may delay adjuvant oncological treatments and compromise long-term outcomes. High-quality evidence is lacking. The iBRA-2 study aimed to investigate the impact of IBR on time to adjuvant therapy. Methods: Consecutive women undergoing mastectomy ± IBR for breast cancer July–December, 2016 were included. Patient demographics, operative, oncological and complication data were collected. Time from last definitive cancer surgery to first adjuvant treatment for patients undergoing mastectomy ± IBR were compared and risk factors associated with delays explored. Results: A total of 2540 patients were recruited from 76 centres; 1008 (39.7%) underwent IBR (implant-only [n = 675, 26.6%]; pedicled flaps [n = 105,4.1%] and free-flaps [n = 228, 8.9%]). Complications requiring re-admission or re-operation were significantly more common in patients undergoing IBR than those receiving mastectomy. Adjuvant chemotherapy or radiotherapy was required by 1235 (48.6%) patients. No clinically significant differences were seen in time to adjuvant therapy between patient groups but major complications irrespective of surgery received were significantly associated with treatment delays. Conclusions: IBR does not result in clinically significant delays to adjuvant therapy, but post-operative complications are associated with treatment delays. Strategies to minimise complications, including careful patient selection, are required to improve outcomes for patients

Functionality of the lower esophageal sphincter after laparoscopic sleeve gastrectomy for morbid obesity

Background: Laparoscopic sleeve gastrectomy (LSG) is a promising procedure forthe treatment of morbid obesity. The stomach is usually transected near the angle ofHis; hence, the lower esophageal sphincter (LES) may be affected withconsequences on postoperative gastroesophageal reflux disease (GERD). Thepurpose of this study was to examine the effect of LSG on the LES and postoperativeGERD.Methods: Severely obese asymptomatic patients submitted to LSG underwentesophageal manometry and GERD evaluation preoperatively and at least 6 weeks postoperatively. Data reviewed included patient demographics, manometricmeasurements, GERD symptoms, and pathology. Statistical analysis was performedby SPSS software.Results: Twelve male and eleven female patients participated in the study. Mean agewas 38.5 ± 10.9 years, and initial body mass index was 47.9 ± 5.1 kg/m2. At follow upexamination, mean excess body mass index loss was 32.3 ± 12.7%. The LES totaland abdominal length increased significantly post-operatively, whereas thecontraction amplitude in the lower esophagus decreased. There was an increase inreflux symptoms postoperatively (p<0.009). The operating surgeon who mostlyapproximated the angle of His resulted in an increased abdominal LES length(p<0.01). The presence of esophageal tissue in the specimen correlated withincreased total GERD score (p<0.05).Conclusions: LSG weakens the contraction amplitude of the lower esophagus, whichmay contribute to postoperative reflux deterioration. It also increases the total and theabdominal length of the LES, especially when the angle of His is mostly approximated. However, if this approximation leads to esophageal tissue excision,reflux is again aggravated. Thus, stapling too close to the angle of His should be donecautiously.Εισαγωγή: Η λαπαροσκοπική επιμήκης γαστρεκτομή (ΛΕΓ) είναι μία υποσχόμενη χειρουργική επέμβαση για τη θεραπεία της νοσογόνου παχυσαρκίας. Ο στόμαχος συνήθως διατέμνεται κοντά στη γωνία του His κι έτσι ο κατώτερος οισοφαγικός σφιγκτήρας (ΚΟΣ) μπορεί να επηρεαστεί, με επιπτώσεις στην μετεγχειρητική γαστροοισοφαγική παλινδρομική νόσο (ΓΟΠΝ). Ο σκοπός αυτής της μελέτης ήταν να διερευνήσει την επίδραση της ΛΕΓ στον ΚΟΣ και στην μετεγχειρητική ΓΟΠΝ. Μέθοδοι: Σοβαρά παχύσαρκοι ασθενείς, χωρίς συμπτώματα ΓΟΠΝ, οι οποίοι θα υποβάλλονταν σε ΛΕΓ, υποβλήθηκαν σε μανομετρία οισοφάγου και αξιολόγηση της παλινδρόμησης τους, προεγχειρητικά και τουλάχιστον έξι εβδομάδες μετά τη χειρουργική επέμβαση. Στα δεδομένα που αναλύθηκαν, περιλαμβάνονταν τα δημογραφικά στοιχεία των ασθενών, οι μανομετρικές μετρήσεις, τα συμπτώματα ΓΟΠΝ και η ιστολογική έκθεση. Η στατιστική ανάλυση πραγματοποιήθηκε με τη χρήση του SPSS software.Αποτελέσματα: 12 άνδρες και 11 γυναίκες συμμετείχαν στη μελέτη. Η μέση ηλικία ήταν 38,5 ± 10,9 έτη κι ο μέσος αρχικός δείκτης μάζας σώματος ήταν 47,9 ± 5,1kg/m2.Στην μετεγχειρητική εξέταση, ο μέσος δείκτης της απώλειας της πλεονάζουσας μάζας σώματος ήταν 32,3 ± 12,7%. Το ολικό και το κοιλιακό μήκος του ΚΟΣ αυξήθηκαν σημαντικά μετεγχειρητικά, ενώ το εύρος των συσπάσεων του κατώτερου οισοφάγου μειώθηκε. Παράλληλα, τα συμπτώματα της παλινδρόμησης αυξήθηκαν σημαντικά μετεγχειρητικά (p<0,009). Το μετεγχειρητικό κοιλιακό μήκος του ΚΟΣ, ήταν πιο αυξημένο στις περιπτώσεις όπου ο χειρουργός προσέγγιζε περισσότερο την γωνία του His κατά τη διατομή (p<0,01). Η παρουσία οισοφαγικού ιστού στο παρασκεύασμα συσχετίζονταν σημαντικά με αυξημένη συνολική βαθμολογία για την παλινδρόμηση(p<0,05).Συμπεράσματα: Η ΛΕΓ μειώνει το εύρος των συσπάσεων στον κατώτερο οισοφάγο,γεγονός που ενδέχεται να συμμετέχει στην επιδείνωση της μετεγχειρητικής παλινδρόμησης. Ταυτόχρονα, η ΛΕΓ αυξάνει το ολικό και το κοιλιακό μήκος του ΚΟΣ,ειδικά όσο περισσότερο προσεγγίζεται η γωνία του His. Παρόλα αυτά, εάν αυτή η προσέγγιση καταλήξει σε εκτομή οισοφαγικού ιστού, η ΓΟΠΝ και πάλι επιδεινώνεται.Επομένως, η διατομή κοντά στη γωνία του His πρέπει να γίνεται με προσοχή

Emergency room management of trauma patients in Greece: Preliminary report of a national study

Aim of the study: The aim of this study was to record and to evaluate the epidemiology of trauma in Greece and to assess the quality of management provided for trauma patients in the emergency department in Greek hospitals. Methods: The Hellenic Society of Trauma and Emergency Surgery invited all the official representatives of the society throughout the country to participate in the study. The representatives that responded positively, met with the Board of the society in succeeding meetings to establish the reporting form and the inclusion criteria. Inclusion criteria were defined as trauma patients requiring admission, transfer to a higher level center or arrived dead or died in the emergency department of the reporting hospital. All reports were accumulated by the Hellenic Trauma society, imported in an electronic data base and analyzed. The design of the study was prospective and observational. Results: In total 8862 patients were included in the study in 12 months time. Of them 68.7% (n = 6084) were male, aged 41.8 +/- 20.6 (mean +/- S.D.) and 31.3% were female (n = 2778), aged 52.7 +/- 24.1 (mean +/- S.D.). The mean duration of treatment in the emergency room department was I h and 28 min. Of the total number of patients, 2312 (26.1 %) were initially assessed and managed by a specialist and 6249 (70.5%) were initially assessed and managed by a resident. Conclusions: Data from this study show that there is substantial room for improvement in the patient care in the emergency department following trauma. Further evaluation will be required to identify particular management patterns that can be readily altered. (C) 2008 Elsevier Ireland Ltd. All rights reserved

Interfacility transfers in a non-trauma system setting: an assessment of the Greek reality

Background: Quality assessment of any trauma system involves the evaluation of the transferring patterns. This study aims to assess interfacility transfers in the absence of a formal trauma system setting and to estimate the benefits from implementing a more organized structure. Methods: The ‘Report of the Epidemiology and Management of Trauma in Greece’ is a one year project of trauma patient reporting throughout the country. It provided data concerning the patterns of interfacility transfers. We compared the transferred patient group to the non transferred patient group. Information reviewed included patient and injury characteristics, need for an operation, Intensive Care Unit (ICU) admittance and mortality. Analysis employed descriptive statistics and Chi-square test. Interfacility transfers were then assessed according to each health care facility’s availability of five requirements; Computed Tomography scanner, ICU, neurosurgeon, orthopedic and vascular surgeon. Results: Data on 8,524 patients were analyzed; 86.3% were treated at the same facility, whereas 13.7% were transferred. Transferred patients tended to be younger, male, and more severely injured than non transferred patients. Moreover, they were admitted to ICU more often, had a higher mortality rate but were less operated on compared to non transferred patients. The 34.3% of transfers was from facilities with none of the five requirements, whereas the 12.4% was from those with one requirement. Low level facilities, with up to three requirements transferred 43.2% of their transfer volume to units of equal resources. Conclusion: Trauma management in Greece results in a high number of transfers. Patients are frequently transferred between low level facilities. Better coordination could lead to improved outcomes and less cost