Non-specialized Unit Research Articles

Early outcomes of component separation techniques: an analysis of the Spanish registry of incisional Hernia (EVEREG)

AimTo analyze the outcomes of component separation techniques (CST) to treat incisional hernias (IH) in a large multicenter cohort of patients.MethodsAll IH repair using CST, registered in EVEREG from July 2012 to December 2019, were included. Data on the pre-operative patient characteristics and comorbidities, IH characteristics, surgical technique, complications, and recurrence were collected. Outcomes between anterior (ACS) and posterior component separation (PCS) techniques were compared. Risk factors for complications and recurrences were analyzed.ResultsDuring the study period, 1536 patients underwent CST (45.5% females) with a median age of 64.0 years and median body mass index (BMI) of 29.7 kg/m2. ACS was the most common technique (77.7%). Overall complications were frequent in both ACS and PCS techniques (36.5%), with a higher frequency of wound infection (10.6% vs. 7.0%; P = 0.05) and skin necrosis (4.4% vs. 0.1%; P < 0.0001) with the ACS technique. Main factors leading to major complications were mesh explant (OR 1.72; P = 0.001), previous repair (OR 0.75; P = 0.038), morbid obesity (OR 0.67; P = 0.015), ASA grade (OR 0.62; P < 0.0001), COPD (OR 0.52; P < 0.0001), and longitudinal diameter larger than 10 cm (OR 0.58; P = 0.001). After a minimum follow-up of 6 months (median 15 months; N = 590), 59 (10.0%) recurrences were diagnosed. Operations performed in a non-specialized unit were significantly associated with recurrences (HR 4.903, CI 1.64–14.65; P = 0.004).ConclusionCST is a complex procedure with a high rate of complications. Both ACS and PCS techniques have similar complication and recurrence rates. Operations performed in a specialized unit have better outcomes.

ATYPICAL CLINICAL COURSE OF THE ACUTE MYOCARDIAL INFARCTION: CLINICAL AND ANAMNESTIC CHARACTERISTIC OF PATIENTS, MANAGEMENT AND OUTCOMES (DATA FROM REGISTRY OF ACUTE MYOCARDIAL INFARCTION)

Aim. To study clinical and anamnestic specifics, management and outcomes of acute myocardial infarction (MI) in patients with atypical clinical presentation. Material and methods. Among the Tomsk population, those having had acute MI in 2009-2014 y. were included, registered in the database “Registry of Acute MI” (n=5602), and selected to groups with atypical (n=1319) and common (n=4283) clinical presentation of the MI onset. Statistics was done with software “Statistica 10”. Results. Atypical presentation of MI took place in 23,5% cases. These patients were much older than those with common angina at MI onset; they had more prevalent arterial hypertension, obesity, diabetes. Also, the prevalence of anamnestic MI did not differ between groups, however autopsy revealed more common painless MI. Atypical MI presentation patients sought for medical care in 28 days before the event of MI more frequently than those with typical clinical picture: 36% vs. 26% (p<0,001), but electrocardiography was ordered only for a half of them (54%), that led to misdiagnostics of pre-infarction condition. Every second patient with atypical MI was hospitalized to non-specialized unit, where could not receive high-technology treatment, which hence led to worse outcomes and prognosis. Conclusion. It is necessary to be careful with non-typical MI development possibility in older patients with several comorbidities, and with anamnesis of painless acute MI. Chance of fatal outcome in atypical MI is 10 times higher in this group than in those with typical clinical presentation.

Serious Burn by Sulfuric Acid: Case Report of Particular Therapeutic Strategy in a Non-Specialized ICU at H&#244;pital Principal de Dakar (HPD) S&#233;n&#233;gal

Managing severe burns remains problematic due to the lack of specialized units, but also because of the delay in implementing emergency care. The aim is to show that an adapted strategy, can lead to satisfying management of chemical burns. The authors report retrospectively the case of a patient admitted for chemical burns, and treated in a non-specialized intensive care unit; a 38 years old male, referred for burns by sulfuric acid at his workplace. On admission to H15, the clinic did not reveal any vital organs failure. Burns were localized on two legs and soles of the two feet (18% TBSA). Treatment combined daily dressings with silver sulfadiazine. On day 14, the wound healing associated occlusive gauze dressing, iodine cream application, and mechanical debridement. On day 47, a 5% dermal autograft performed on right foot favored with good attachment grafts. On day 58, the patient was released after complete skin recovery. Then, in a non-specialized burn unit and without early surgery access, our wound healing adapted strategy was successful. In Senegal, chemical burns represent about 2.5% of burn cases. They are often from accidents on occupation job, while generally in Africa chemical burns result from criminal attacks. Patients with severe lesions are admitted in non-specialized environments after an extended time of transfer, and don’t have efficient initial care. This may explain the high morbidity and mortality after burns in our country. The lack of surgical facilities such as skin substitutes, in non-specialized unit on low or median income countries (LMICs), explains this long period of wound healing. The treatment of severe burn in LMICs is hazardous.

Abdominal aortic aneurysm and the challenges of management in a developing country: A review of three cases

There is an increase in the incidence of abdominal aortic aneurysm (AAA) over the last six decades, probably as a result of higher longevity and lifestyle changes witnessed in the years following World War II. Though earlier studies mainly from Southern Africa suggest abdominal aortic aneurysms as uncommon amongst black Africans, recent reports from Africa emphasized an increasing incidence of vascular diseases and its sequelae including AAA. There are, however, few documented case reports of AAA in our environment over the years suggesting the rarity of this disease. We report the management and outcome of three different types of infrarenal AAA with synthetic graft in a General Surgery Unit over a four-year period between 2001 and 2005. Follow-up evaluation confirmed a successful outcome in two patients. Abdominal aortic aneurysms may be occurring more frequently than reported in our environment and its management, using basic evaluation techniques, can be successfully achieved with reasonable outcome when performed in a non-specialized unit by General Surgeons in institutions with limited resources. Contrary to the popularly held view of rarity of AAA, the disease may be increasing in incidence amongst black African. Its evaluation and treatment is also feasible with the availability of reconstructive graft in a non-specialized surgical unit.

Long-term results of tailored D2 lymph node dissection after R0 surgery for gastric cancer

Implementation of extended lymph node dissection for gastric cancer in western non-specialized centers through tailoring its extent upon disease stage and patient comorbidities was suggested as a wise policy to reduce morbidity and mortality rates, albeit with a potential for undertreatment in elderly and/or comorbid patients. Current definition of R(0) resection for gastric cancer lacks consideration of treatment-related variables such as extended lymph node dissection. Few studies to date have tried to fill this gap in such a clinical context. A retrospective evaluation of factors influencing long-term results after R(0) surgery was done in a prospective series of a non-specialized western surgical unit during the implementation of D(2) lymphadenectomy. Univariate and multivariate analysis of 22 variables were performed on a prospective database of 233 consecutive R(0) resections performed by ten different surgeons in 10 years. Endpoint was disease-free survival calculated at 5 and at 10 years. Disease-free survival rates were independently influenced by age, American Society of Anesthesiologists (ASA) status and lymph node ratio. Subset analysis of the status at censor stratified for age and ASA status failed to identify any significant difference in disease recurrence rates. Lymph node ratio was the only treatment-related independent prognostic factor for long-term results after R(0) surgery for gastric cancer in the setting of a non-specialized western unit, where the extent of lymph node dissection needs to be tailored on the presence of comorbidities (ASA status).

The long term results of open antireflux surgery in a community-based health care center.

There is no previous study concerning long term results of open Nissen fundoplication performed by general surgeons in a nonspecialized unit. Of 45 consecutive patients in a general provincial center, 39 were available for follow-up after a mean period of 78 months. All patients were interviewed using a standard questionnaire, and 35 of them consented to undergo endoscopy. Of the patients, 85% had no or only mild reflux symptoms. The figures for dysphagia, flatulence, and bloating were 31%, 67%, and 46%, respectively. Endoscopy showed defective fundic wrap in 37% of the patients and erosive esophagitis in 29%. Five patients (13%) with recurrent esophagitis were referred for H2-blocker or omeprazole medication, and five others (13%) were scheduled for repeat antireflux surgery. The results were somewhat worse in regard to prevalence of defective fundic wrap and recurrent esophagitis than in other reports, which were from specialized units.

The long term results of open antireflux surgery in a community-based health care center

OBJECTIVE: There is no previous study concerning long term results of open Nissen fundoplication performed by general surgeons in a nonspecialized unit. METHODS: Of 45 consecutive patients in a general provincial center, 39 were available for follow-up after a mean period of 78 months. All patients were interviewed using a standard questionnaire, and 35 of them consented to undergo endoscopy. RESULTS: Of the patients, 85% had no or only mild reflux symptoms. The figures for dysphagia, flatulence, and bloating were 31%, 67%, and 46%, respectively. Endoscopy showed defective fundic wrap in 37% of the patients and erosive esophagitis in 29%. Five patients (13%) with recurrent esophagitis were referred for H2-blocker or omeprazole medication, and five others (13%) were scheduled for repeat antireflux surgery. CONCLUSIONS: The results were somewhat worse in regard to prevalence of defective fundic wrap and recurrent esophagitis than in other reports, which were from specialized units.

Recurrent laryngeal nerve palsy in thyroid gland surgery related to operations and nerves at risk.

Recurrent laryngeal nerve palsy is rare, but it is the most common complication in thyroid gland surgery. Depending on whether the measurement of the rate of occurrence is based on the number of operations or on the number of nerves at risk, the rate may vary widely. The elapsed time from the operation to when the palsy is considered permanent has also differed among various studies. In a ten-year series of 514 thyroid gland operations at a county hospital, all patients with a postoperative palsy were examined six months to ten years after the operation. After a primary operation almost 50% of the palsies were temporary, reducing the permanent palsy rate to 5.8% based on the number of operations, or 3.6% based on the number of nerves at risk. With more extensive surgery, the rate increased. This series illustrates the importance of the method by which the recurrent laryngeal nerve palsy rate is defined and calculated. The rates also show that the complication rate may be kept at a low level even in a nonspecialized unit.