Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

BACKGROUND: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. METHODS: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. FINDINGS: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96-1·28). INTERPRETATION: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. FUNDING: National Institute for Health Research Health Services and Delivery Research Programme

Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

Background: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. Methods: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. Findings: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96–1·28). Interpretation: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. Funding: National Institute for Health Research Health Services and Delivery Research Programme

Unicystic ameloblastoma mimicking a dentigerous cyst: short case report

Observation: This case reports an unusual morphology and localisation of ameloblastoma that imitates a dentigerous cyst on an inclused mandibular canine. Comments: Ameloblastoma is a local odontogenic benign tumour which often relapse. It is usually described in its polycystic form in the posterior mandibular part

Thrombasthénie de Glanzmann et avulsions dentaires : à propos d’un cas

Introduction : La thrombasthénie de Glanzmann est une maladie congénitale rare et sévère de l’hémostase primaire. Elle se caractérise par un défaut d’agrégation plaquettaire pouvant entraîner des hémorragies majeures. Elle se transmet sous le mode autosomique récessif. Les patients atteints nécessitent une prise en charge multidisciplinaire lors d’un acte chirurgical. Observation : Il s’agissait d’une femme de 20 ans adressée pour avulsion de 18, 28 et 48 enclavée avec des épisodes de péricoronarites récidivants. Elle présentait une thrombasthénie de Glanzmann depuis l’enfance. Elle rapportait deux épisodes hémorragiques sévères depuis le diagnostic. Le bilan d’hémostase préopératoire a rapporté une Hb à 11 g/dL, des plaquettes à 380 000 g/L, un TCA et un TQ/TP normaux mais un PFA fortement allongé (>100 secondes). Après avis de l’hématologue, le protocole suivant a été adopté : hospitalisation traditionnelle (48 h), choix d’une anesthésie générale avec intubation naso-trachéale, perfusion IV de rFVIIa (Novoseven®) 30 minutes avant l’acte chirurgical puis 2 heures après, 3 grammes d’acide tranexamique (Exacyl®) IV puis per os et en bain de bouche. L’hémostase chirurgicale a associé des sutures à l’utilisation d’oxycellulose (Surgicel®) et de colle de fibrine (Tissucol®) dans les alvéoles et sur les sutures. Les avulsions se sont déroulées sans accident hémorragique per- et postopératoire. Discussion : La thromboasthénie de Glanzmann fait partie des thrombopathies affectant l’agrégation plaquettaire et il en existe deux types. Le diagnostic de certitude repose sur des examens biologiques et une étude génétique. En cas de chirurgie programmée, le médecin référent doit établir un protocole personnalisé en fonction du risque hémorragique du patient. Les traitements hémostatiques par voie générale à disposition sont les transfusions de concentrés plaquettaires ou de facteur VII activé recombinant (Novoseven®). Si le patient présente une allo- ou une iso-immunisation liée aux transfusions plaquettaires, l’utilisation de rFVIIa est recommandée. Conclusion : Le rôle du chirurgien oral est crucial dans la prise en charge de ces patients. Outre la procédure de substitution hématologique, l’efficacité de l’hémostase chirurgicale est conditionnée par une bonne gestion des risques de saignement per- et postopératoire