Postoperative Hospital Stay Research Articles

Robot-assisted and laparoscopic partial splenectomy for nonparasitic cysts

21 patients with nonparasitic spleen cysts were operated. Robot-assisted (RA) interventions were applied in 10 cases, laparoscopic--in 11 patients. Men surgery duration was 124 minutes in case of RA-technique and 120 minutes if laparoscopy was used. Blood loss was significantly lower in the group of RA resection (p=0.035). There were no conversions of access in the group of RA-operations while in group of laparoscopy conversion has been required in 1 case. We did not observe complications in case of RA-surgeries. Laparoscopic method was associated with 2 complications (left-sided hydrothorax and fluid accumulation in resection area). Postoperative hospital-stay did not differ in both groups and was 7.1 and 6.4 room-nights in case of RA-interventions and laparoscopy respectively. There were no deaths. Indications for robot-assisted partial splenectomy for nonparasitic cysts include location of mass in upper pole or hilus of spleen, its diameter more than 8 cm, body mass index more than 30 and splenomegaly. Lower pole resection and splenectomy are more advisable using laparoscopic method.

The outcomes of 400 laparoscopic Heller-Dor operations (LHD) for esophageal achalasia

Yano, Fumiaki MD, FACS; Omura, Nobuo; Tsuboi, Kazuto MD; Hoshino, Masato MD; Yamamoto, Se Ryung; Akimoto, Shunsuke MD; Masuda, Takahiro; Nishikawa, Katsunori; Kashiwagi, Hideyuki; Yanaga, Katsuhiko MD, PhD, FACS Author Information

Impact of Intraoperative Fluid Administration on Length of Postoperative Hospital Stay Following Orthognathic Surgery

The purpose of this study was to evaluate whether the volume of intraoperative fluids administered to patients during routine orthognathic surgery is associated with increased length of hospital stay for postoperative convalescence. A retrospective cohort study design was used to identify 168 patients undergoing routine orthognathic surgery at Mayo Clinic from 2010 through 2014. The primary predictor variable was total volume of intravenous fluids administered during orthognathic surgery. The primary outcome variable was the length of hospital stay in hours as measured from the completion of the procedure to patient dismissal from the hospital. Additional covariates were collected including patient demographic data, preoperative American Society of Anesthesiologists (ASA) score, type of intravenous fluid administered, complexity of surgical procedure, and duration of anesthesia. On univariate analysis, total fluid was significantly associated with increased length of stay (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.42 to 2.33; P < .001). After adjustment for surgical complexity and duration of anesthesia on multivariable regression analysis, the association of fluid level with length of hospital stay was no longer statistically significant (OR, 0.86; 95% CI, 0.61 to 1.22; P = .39). Duration of anesthesia remained the only covariate that was significantly associated with increased length of hospital stay in the multivariable regression model (OR, 2.21; 95% CI, 1.56 to 3.13; P < .001). Among surgical complexity, duration of anesthesia, and total volume of intraoperative intravenous fluids administered for routine orthognathic surgery, the duration of anesthesia has the strongest predictive value for patients requiring prolonged hospital stay for postoperative convalescence.

退院準備期間短縮へ向けての大腸ERASプロトコル導入の検討

目的:患者が早期の回復を自覚できる大腸ERASプロトコルを考案し，術後在院日数に及ぼす効果について前向きに検討した．方法:2011年8月から2012年10月に，結腸待機手術を受けた92名を対象とした．早期回復を促す工夫として，ERAS各要素に加え，味等を工夫した低残渣スープ食を周術期に提供した．また，入院時より万歩計を貸与し，活動量を自己管理出来るようにした．本介入開始以前に従来法で管理された55例を対照とした．結果:術後在院日数は5日（従来群8日，p＜0.01），主治医が退院を許可してから実際に退院した日までの退院準備期間は1日（4日，p＜0.01）と有意に短縮した．周術期合併症の発生率に差はなかった．万歩計上の活動量は術後4日目には術前とほぼ同等になった．結語:大腸ERASプロトコルに，患者が術後早期の回復を自覚できる工夫を加えることで，退院準備期間の短縮に寄与した可能性が示唆された．

STAGED HYBRID PROCEDURE FOR MYOCARDIAL REVASCULARISATION IN THE ELDERLY WITH CORONARY ARTERY DISEASE AND HIGH RISK STRATIFICATION

ObjectivesTo summarise the experience of Staged hybrid procedure for Myocardial Revascularisation in the elderly with coronary artery disease and high risk stratification.MethodsBetween August 2008 and December 2011, 10 elderly patients...

Laparoscopy in Combination with Fast Track Multimodal Management is the Best Perioperative Strategy in Patients Undergoing Colonic Surgery

To investigate which perioperative treatment, ie, laparoscopic or open surgery combined with fast track (FT) or standard care, is the optimal approach for patients undergoing segmental resection for colon cancer. Important developments in elective colorectal surgery are the introduction of laparoscopy and implementation of FT care, both focusing on faster recovery. In a 9-center trial, patients eligible for segmental colectomy were randomized to laparoscopic or open colectomy, and to FT or standard care, resulting in 4 treatment groups. Primary outcome was total postoperative hospital stay (THS). Secondary outcomes were postoperative hospital stay (PHS), morbidity, reoperation rate, readmission rate, in-hospital mortality, quality of life at 2 and 4 weeks, patient satisfaction and in-hospital costs. Four hundred patients were required to find a minimum difference of 1 day in hospital stay. Median THS in the laparoscopic/FT group was 5 (interquar-tile range: 4-8) days; open/FT 7 (5-11) days; laparoscopic/standard 6 (4.5-9.5) days, and open/standard 7 (6-13) days (P < 0.001). Median PHS in the laparoscopic/FT group was 5 (4-7) days; open/FT 6 (4.5-10) days; laparoscopic/standard 6 (4-8.5) days and open/standard 7 (6-10.5) days (P < 0.001). Secondary outcomes did not differ significantly among the groups. Regression analysis showed that laparoscopy was the only independent predictive factor to reduce hospital stay and morbidity. Optimal perioperative treatment for patients requiring segmental colectomy for colon cancer is laparoscopic resection embedded in a FT program. If open surgery is applied, it is preferentially done in FT care. This study was registered under NTR222 (www.trialregister.nl).

Surgical Management for the Reduction of Postoperative Hospital Stay following Distal Pancreatectomy

Pancreatic fistula remains a major cause of postoperative morbidity in patients undergoing pancreatectomy and is generally difficult to cure. None of the several surgical techniques and devices available for managing pancreatic remnant have been clinically evaluated. We retrospectively reviewed medical records of 120 consecutive patients who underwent distal pancreatectomy at our institution between October 1992 and September 2009. Furthermore, we divided these cases into 3 periods based on 2 points at which we changed our surgical strategy. One was September 2004, when we introduced a stapling technique for managing remnant pancreas. The other was November 2006, when we started using a closed active drain. We evaluated the incidence of pancreatic fistula, risk factors for its development, and our strategy in the perioperative period. The overall and clinical pancreatic fistula rates gradually decreased but were not significant. The persistent drainage period gradually reduced from 19 days to 8 days (p=0.071) over a time period. Postoperative hospital stay was significantly reduced from 24 days to 14 days (p=0.026). Utilization of a stapling technique and closed active drain significantly reduces postoperative hospital stay.

Postoperative Cardiac Troponin I (cTnI) Level and Its Prognostic Value for Patients Undergoing Mitral Valve Surgery

It has previously been reported that cardiac troponin I (cTnI) is useful in predicting the postoperative course after cardiac surgery, and that elevated serum cTnI levels are associated with increased in-hospital mortality. However, these findings have been reported in heterogeneous groups of cardiac surgical procedures. In the current study, the usefulness of postoperative cTnI measurements for the prediction of patient outcomes in a specific group of cardiac surgical procedures was determined, with the analysis limited to patients undergoing mitral valve surgery. The results of cTnI measurements were compared with postoperative creatine kinase-myocardial band fraction (CK-MB) levels.A total of 24 patients who underwent mitral valve surgery from July 2004 to April 2009 were retrospectively studied. Serum cTnI and CK-MB levels were measured on postoperative day (POD) 0 (immediately after surgery), and on POD 1, 2, and 3. The relationship between serum cTnI and CK-MB levels, cardiopulmonary bypass (CPB) time, aorta cross-clamping (AoC) time, and the length of ICU stay and postoperative hospital stay (POHS) were evaluated.CPB and AoC time influenced postoperative cTnI and CK-MB levels. Values of cTnI on POD 1 and POD 2 were significantly correlated with the length of ICU stay, whereas only the CK-MB level on POD 2 was significantly correlated with the length of ICU stay. In addition, the cTnI levels on POD 1 and POD 2 were significantly correlated with POHS, however, there was no relationship between postoperative CK-MB levels and POHS. Postoperative cTnI measurements are more useful than CK-MB measurements in predicting the postoperative course of a patient following mitral valve surgery.

A Randomized, Clinical Trial to Compare Endoscopic Sphincterotomy and Subsequent Laparoscopic Cholecystectomy with Primary Laparoscopic Bile Duct Exploration During Cholecystectomy in Higher Risk Patients with Choledocholithiasis

Outcomes after endoscopic sphincterotomy (ES) and subsequent laparoscopic cholecystectomy (LC) versus laparoscopic bile duct exploration (LBDE) during LC are comparable in fit patients with choledocholithiasis. This randomized, clinical trial aimed to determine the optimum treatment in patients with higher medical risk. Ninety-one higher risk patients with evidence of bile duct stones were randomized to ES/LC (group A) or LBDE during LC (group B). The primary outcome measure was duct clearance. Secondary outcome measures were complications, number of procedures per patient, conversion, and postoperative hospital stay (POS). Forty-seven patients were randomized to ES/LC and 44 to LBDE. The median age was 74.56 years. On an intention-to-treat basis, duct clearance was achieved in 29 of 47 of group A and 44 of 44 of Group B patients (P < 0.001). Clavien Grade II-V complications occurred in 8 of 47 and 8 of 44 patients (P = 0.884), the median number of procedures was 2 (2-3) and 1 (1-1) (P < 0.001), 2 of 47 and 4 of 44 patients required conversion (P = 0.676), and the median POS was 3 (2-7) and 5 (2-7) days (P = 0.825), respectively. There was no difference between approaches to duct clearance in terms of postoperative stay, complications, or conversion in higher risk patients, but the laparoscopic approach was more effective and efficient and avoided unnecessary procedures.

Intravenous fluid restriction after major abdominal surgery: a randomized blinded clinical trial

BackgroundIntravenous (IV) fluid administration is an essential part of postoperative care. Some studies suggest that a restricted post-operative fluid regime reduces complications and postoperative hospital stay after surgery. We investigated the effects of postoperative fluid restriction in surgical patients undergoing major abdominal surgery.MethodsIn a blinded randomized trial, 62 patients (ASA I-III) undergoing elective major abdominal surgical procedures in a university hospital were allocated either to a restricted (1.5 L/24 h) or a standard postoperative IV fluid regime (2.5 L/24 h). Primary endpoint was length of postoperative hospital stay (PHS). Secondary endpoints included postoperative complications and time to restore gastric functions.ResultsAfter a 1-year inclusion period, an unplanned interim analysis was made because of many protocol violations due to patient deterioration. In the group with the restricted regime we found a significantly increased PHS (12.3 vs. 8.3 days; p = 0.049) and significantly more major complications: 12 in 30 (40%) vs. 5 in 32 (16%) patients (Absolute Risk Increase: 0.24 [95%CI: 0.03 to 0.46], i.e. a number needed to harm of 4 [95%CI: 2–33]). Therefore, the trial was stopped prematurely. Intention to treat analysis showed no differences in time to restore gastric functions between the groups.ConclusionRestricted postoperative IV fluid management, as performed in this trial, in patients undergoing major abdominal surgery appears harmful as it is accompanied by an increased risk of major postoperative complications and a prolonged postoperative hospital stay.Trial registrationCurrent Controlled Trials ISRCTN16719551

Comparison in Terms of Postoperative Morbidity and Hospital Stay between Open Cholecystectomy and Laparoscopic Cholecystectomy

Type of study: Comparative. Aim: To compare the postoperative morbidity in terms of postoperative pain, gait disturbances, wound and respiratory infections along with length of hospital stay in patients undergoing laparoscopic cholecystectomy with those undergoing open surgery for symptomatic gallstone disease to compare the effectivity of minimally invasive surgery with open surgery in reducing postoperative morbidity and thus length of hospital stay. Place and duration of study: Surgical Unit Khyber Teaching Hospital, Peshawar, Pakistan; from July 2006 to December 2006. Materials and methods: This study included a total of 50 patients who underwent either open or laparoscopic cholecystectomy in our unit (SDW KTH). Their clinical data, admission dates and date of surgery were noted. Postoperative progress was followed and requirement of analgesia, nausea, vomiting, febrile morbidity, wound infections and respiratory tract infections, if any were noted. Their date of discharge from hospital was also recorded. Re-admission (if any) for any complication of surgery was noted and further days spent in hospital were recorded. This data was analyzed to see the post-operative morbidity and length of hospital stay in these patients. Results: Out of the 50 patients included in this study, the mean hospital stay for the patients who underwent laparoscopic cholecystectomy was 2.06 days as against 3.93 days for those having open surgery for symptomatic gallstone disease. Also pain (and thus analgesia requirement) and other complications were significantly lower for the patients who had minimally invasive surgery indicating the superiority of laparoscopic technique as regards postoperative hospital stay and morbidity. Conclusion: Minimally invasive surgery is infact very effective in reducing postoperative morbidity and thus hospital stay in patients with gallstones. Although open cholecystectomy is still performed in our hospitals, the time is near when it will be largely replaced by the laparoscopic technique.

Postoperative Analgesia and Hospital Stay: A Call for Better Study Design

Postoperative Analgesia and Hospital Stay: A Call for Better Study Design

Postoperative Analgesia and Hospital Stay: A Call for Better Study Design

Postoperative Analgesia and Hospital Stay: A Call for Better Study Design

Management of the rectal stump after emergency sub‐total colectomy: which surgical option is associated with the lowest morbidity?

To identify the preferred surgical management of the rectal stump after emergency subtotal colectomy (ESC) for acute severe colitis by assessing the morbidity associated with each option. Consecutive patients undergoing ESC at a district general hospital between 1999 and 2004 were retrospectively audited for pathology, rectal stump complications and length of postoperative hospital stay (POS). Thirty-seven ESCs were performed, 34 were undertaken for disease refractory to medical treatment, 2 for toxic mega colon and 1 for perforation. Thirty-four cases were for ulcerative colitis, 2 Crohn's colitis and 1 infective colitis. Twenty-seven had an intraperitoneal and 10 a subcutaneously placed closed rectal stump. The median POS for patients with a subcutaneously placed stump was shorter than for those with an intraperitoneal stump, 8 and 15 days, respectively (P = 0.04). Two patients had leakage from an intraperitoneal stump, prolonging POS (33 and 193 days). Three of the subcutaneous stumps leaked causing wound infection but not prolonging the POS (6, 7 and 16 days). Avoiding a second stoma by closing the rectal stump after ESC has been confirmed as acceptable practice by studies over the last 15 years, reporting no overall increase in complications. The location of a closed rectal stump appears to influence the incidence of pelvic sepsis. The lowest pelvic sepsis rate is associated with subcutaneous placement; despite a higher wound infection rate this option appears to be associated with a lower total morbidity reflected in a shorter POS.

Predictors of Duration of Postoperative Hospital Stay in Patients Undergoing Advanced Laparoscopic Surgery

The expansion of the indications for laparoscopic surgery to include high-risk patient, acute and malignant pathology, and more complex procedures may prolong the hospital stay. Cox multiple stepwise regression analysis model was employed to determine independent predictors of prolonged postoperative hospital stay (more than 3 days) following advanced laparoscopic procedures among 10 variables. Some 130 patients had undergone advanced laparoscopic surgical procedures between November 2000 and August 2003. The median postoperative hospital stay was 3 days (interquartile range 2-5), and 81 patients (62.3%) were discharged within 3 days of surgery. The independent predictors of prolonged postoperative hospital stay were ASA score of 3 or 4 (odds ratio [OR] = 4.610, P = 0.0002) and preoperative hospital stay (OR = 0.151 per day, P = 0.001). Independent predictors of duration of preoperative hospital stay were emergency admission to hospital (OR = 9.516, 95% CI 5.770-13.261, P < 0.0001) and an underlying malignant pathology (OR = 7.948, 95% CI 3.623-12.273, P = 0.0004). Advanced laparoscopic surgery is associated with a short postoperative hospital stay in the majority of patients. Prolongation of the postoperative hospital stay (more than 3 days) may be expected if the patient had been in the hospital with an acute or malignant disease for more than 6 days prior to surgery and in patients with high comorbidity. The duration of surgery has no impact on the duration of the postoperative hospital stay.

Clinical Experience with Biliopancreatic Diversion for the Treatment of Obesity

Background: Biliopancreatic diversion (BPD), by ad hoc stomach(AHS-BPD) or ad hoc stomach ad hoc alimentary limb(AHS-AHAL-BPD), has been accepted as an effective surgicaltreatment for morbid obesity. Patients and Methods: FromJanuary 1, 1992 to December 31, 2003, 136 patients (F/M 117/19, mean age 40.2 (range 20-61) years) underwent AHSAHAL-BPD. Mean preoperative body weight was 136.4 (91-236) kg, with a mean body mass index of 49.1 (38-75). Threeof these patients were converted from a previous verticalbanded gastroplasty to AHS-BPD (1 patient with stomach preservation).The last 4 patients underwent video-assisted BPD(representing an initial laparoscopic BPD experience that ispresently in progress). After at least 36 months of follow-up,10 patients underwent abdominal dermolipectomy (8 patientsduring incisional hernia repair, 1 patient in combination withthigh dermolipectomy). Results: Mean postoperative hospitalstay was 12 (8-30) days. Follow-up is currently in progress inall patients. Weight loss of initial overweight was 75% in124 patients with 24-month follow-up, with excellent long-termweight maintenance. Protein deficiency was the main specificcomplication, which was encountered in 6 patients (4.4%).Conclusions: Our clinical experience supports the effectivenessand safety of AHS-AHAL-BPD, despite some criticism.This procedure seems to be suitable for patients with severeobesity and elevated BMI who poorly tolerate food intake restriction,but accept a long-term follow-up. Careful preoperativeclinical assessment and selection of patients reliable forlong-term follow-up (especially for dietary regimen in the firstpostoperative months), are the keys of success with BPD interms of weight loss and reduction of specific complications.

Effect of Hyperglycemia on the Length of Postoperative Hospital Stay

Background: Diabetes mellitus is the most common endocrinopathy encountered in the perioperative period and has long been assumed to increase perioperative risk. However, when diabetes mellitus was segregated from old age and the complications of it, it was questioned that diabetes mellitus itself increased perioperative risk. In this study, we investigated the influence of hyperglycemia on the length of postoperative hospital stay. Methods: We studied 100 patients undergone intra-abdominal operations with general anesthesia. These patients were divided into the hyperglycemic group (n = 20) with postoperative blood glucose level higher than 10 mM and the non-hyperglycemic group (n = 80) with glucose level lower than 10 mM and we investigated the length of postoperative hospital stay, serum electrolyte, serum chemistry, arterial blood gas values, and base excess by unmeasured anions. We also divided these patients into the diabetic patients group (n = 15) and the non-diabetic patients group (n = 85) and compared the same variables. Results: The length of postoperative hospital stay was significantly prolonged in the hyperglycemic group ( days) compared with the non-hyperglycemic group ( days), and the cumulative postoperative hospital stay curves based on Kaplan-Meier method also showed significant difference between the two groups. When we compared the length of postoperative hospital stay between the diabetic and the non-diabetic patients, there was no significant difference. Conclusions: This study demonstrated that hyperglycemia prolonged the length of postoperative hospital stay. This finding suggests that the patient´s glucose level should be monitored and controlled within an adequate range perioperatively.

POSTERIOR ENDOSCOPIC DISCECTOMY USING ENDOSCOPIC LUMBAR DISCECTOMY SYSTEM (ELDS)

Characteristics of endoscopic lumbar discectomy system (ELDS) developed in Japan were introduced, and the first 50 cases were clinically evaluated. Patients included: 4 cases of double disc herniationat two levels; 1 cranially and 3 caudally migrated discs; 3 spinal canal stenosis; 1 synovial cyst; and 3 persistent ring apophysis. In 4 central disc herniation cases, 1 case was approached bilaterally and other 3 cases unilaterally. Using a step-dilator system, targeting inter-laminar space was exposed and a tubular retractor either of 16 or 18 mm diameter was inserted through the paravertebral muscle. A 30° endoscope of 3 mm diameter was installed to a tubular retractor. Partial laminectomy and resection of ligamentum flavum were performed using microsurgical instruments, followed by medial retraction of the symptomatic nerve root and incision of the herniated disc. Average surgery time was 119 minutes and estimated blood loss was 49.1 gm. Patients left their bed at 1.9 days post-operative and average hospital-stay was 11.5 days. Recovery ratio of the Japanese Orthopedic Association (JOA) score was 80.7%. Average visual analog pain scale at the first day post-operative was 2.9 cm and CRP at the 7th day was 0.4 mg/dl. Adjacent two-level discectomy was possible with one midline skin incision. Coexistence of severe lumbar spinal canal stenosis was most technically demanding pathology. ELDS provided brightened and magnified surgery field. This can be an effective assistant for minimally invasive lumbar disc surgery.

On the Effect on Antimicrobial use and Postoperative Hospital Stay of Prophylactic Treatment with Doxycycline in Colorectal Surgery

On the Effect on Antimicrobial use and Postoperative Hospital Stay of Prophylactic Treatment with Doxycycline in Colorectal Surgery