Closure methods for laparotomy incisions for preventing incisional hernias and other wound complications (Review)

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BackgroundModern practice guidelines recommend index cholecystectomy (IC) for patients admitted with gallstone pancreatitis (GSP). However, this benchmark has been difficult to widely achieve. Previous work has demonstrated that dedicated acute care surgery (ACS) services can facilitate IC. However, the associated financial costs and economic effectiveness of this intervention are unknown and represent potential barriers to ACS adoption. We investigated the impact of an ACS service at two hospitals before and after implementation on cost effectiveness, patient quality-adjusted life years (QALY) and impact on rates of IC.MethodsAll patients admitted with non-severe GSP to two tertiary care teaching hospitals from January 2008–May 2015 were reviewed. The diagnosis of GSP was confirmed upon review of clinical, biochemical and radiographic criteria. Patients were divided into three time periods based on the presence of ACS (none, at one hospital, at both hospitals). Data were collected regarding demographics, cholecystectomy timing, resource utilization, and associated costs. QALY analyses were performed and incremental cost effectiveness ratios were calculated comparing pre-ACS to post-ACS periods.ResultsIn 435 patients admitted for GSP, IC increased from 16 to 76% after implementing an ACS service at both hospitals. There was a significant reduction in admissions and emergency room visits for GSP after introduction of ACS services (p < 0.001). There was no difference in length of stay or conversion to an open operation. The implementation of the ACS service was associated with a decrease in cost of $1162 per patient undergoing cholecystectomy, representing a 12.6% savings.The time period with both hospitals having established ACS services resulted in a highly favorable cost to quality-adjusted life year ratio (QALY gained and financial costs decreased).ConclusionsACS services facilitate cost-effective management of GSP. The result is improved and timelier patient care with decreased healthcare costs. Hospitals without a dedicated ACS service should strongly consider adopting this model of care.

Objectives: There are long-held concerns that analgesia in patients with acute abdominal pain may obscure the physical examination and lead to missing a diagnosis of appendicitis. Despite evidence to the contrary, analgesia continues to be underutilized and suboptimally dosed in children with acute abdominal pain. The objective of this systematic review and meta-analysis was to determine if opioids provide analgesia without an increase in side effects and appendicitis-related complications.Methods: Trials were identified through electronic searches of MEDLINE (1946MEDLINE ( -2013, EMBASE (1980EMBASE ( -2013, Cochrane Central Register of Controlled Trials (2013), CINAHL (1981CINAHL ( -2013, and Google Scholar (2013). All randomized controlled trials (RCTs) of children aged 0-18 years with acute abdominal pain that compared any opioid analgesic to placebo were included. The methodologic qualities of studies and the overall quality of evidence were evaluated using the Cochrane Collaboration's Risk of Bias tool and the Grading of Recommendations Assessment, Development, and Evaluation system, respectively.Results: Six RCTs met inclusion criteria, and each compared a single-dose parenteral opioid to a placebo, providing data on 342 children aged 5 to 18 years. The pooled mean pre/post difference in selfreported pain scores was 19.61 mm (95% confidence interval [CI] = -1.16 to 40.37 mm) lower in those receiving opioid analgesia. There was no significant increase in the risk of perforation or abscess associated with opioids in cases of appendicitis (relative risk [RR] = 1.03, 95% CI = 0.55 to 1.93). The risk of side effects was significantly greater in patients who received opioids (RR = 6.06, 95% CI = 1.10 to 33.49). Subtherapeutic dosing of opioids was detected in all six trials. Conclusions:The use of opioids in undifferentiated acute abdominal pain in children is associated with no difference in pain scores and an increased risk of mild side effects. However, there is no increased risk of perforation or abscess. The overall quality of evidence is low, suggesting the need for larger, high-quality trials that are powered to detect both serious complications of appendicitis and determine the most efficacious opioid dosing for children.ACADEMIC EMERGENCY MEDICINE 2014;21:1183-1192© 2014 3 Historically, the reluctance among clinicians to provide analgesia to patients with acute abdominal pain 4-6 was thought to be due to concerns of obscuring the diagnosis of appendicitis and delayed management. 7,8 Indeed, pediatric emergentologists have identified disapproval by their surgical colleagues as a barrier to providing analgesia.6 Despite a decade of evidence that opioid analgesia is not associated with an increased risk of diagnostic or management errors, 9,10 this phenomenon continues to be reported. A recent literature review in adults highlighted a lack of therapeutic consensus and an ongoing practice pattern that favors withholding analgesia prior to surgical evaluation.11 Another recent study of children with...

A 42-year-old woman with diabetes mellitus type 2 treated with the sodium-glucose cotransporter-2 inhibitor canagliflozin underwent elective bariatric gastric bypass. The canagliflozin was held for 24 hours preoperatively. She physiologically decompensated on postoperative day 2. Ultimately, she was diagnosed with euglycemic diabetic ketoacidosis that required intensive care management. This diagnosis was challenging to make as the patient never became hyperglycemic. We use this case to discuss the pharmacology and potential risk of perioperative sodium glucose cotransporter-2 inhibitor administration and to advocate for revision of current guidelines regarding the perioperative management of these agents.

We describe our technique using the combination of a recent surgical technique (ALPPS) and an anomalous vascular anatomy to push the current limits of liver resectability. The approach allowed the resection of the three hepatic veins and preserved a peripheral segment 6 as the only future liver remnant, having an inferior hepatic vein as its outflow.

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IntroductionAcute care surgical services provide timely comprehensive emergency general surgical care while optimizing the use of limited resources. At our institution, 50% of the daily dedicated operating room (OR) time allocated to the Acute Care Emergency Surgery Service (ACCESS) came from previous elective general surgery OR time. We assessed the impact of this change in resource allocation on wait-times for elective general surgery cancer cases.MethodsWe retrospectively reviewed adult patients who underwent elective cancer surgeries in the pre-ACCESS (September 2009 to June 2010) and post-ACCESS (September 2010 to June 2011) eras. Wait-times, calculated as the time between booking and actual dates of surgery, were compared within assigned priority classifications. Categorical and continuous variables were compared using chi-square and Mann–Whitney U tests respectively.ResultsA total of 732 cases (367 pre-ACCESS and 365 post-ACCESS) were identified, with no difference in median wait-times (25 versus 23 days) between the eras. However, significantly fewer cases exceeded wait-time targets in the post-ACCESS era (p <0.0001). There was a significant change (p = 0.027) in the composition of cancer cases, with fewer breast cancer operations (22% versus 28%), and more colorectal (41% versus 32%) and hepatobiliary cancer cases (5% versus 2%) in the post-ACCESS era.ConclusionThese results suggest that shifting OR resources towards emergency surgery does not affect the timeliness of surgical cancer care. This study may encourage more centres to adopt acute care surgical services alongside their elective or subspecialty practices.