PurposeThe aim of this study was to provide a systematic overview on both laparoscopic and conventional Hartmann reversal. Furthermore, the Hartmann procedure is reevaluated in the light of new emerging alternatives.MethodsMedline, Ovid, EMBASE, and Cochrane database were searched for studies reporting on outcomes after Hartmann reversal.ResultsThirty-five studies were included in this review of which 30 were retrospective. A total of 6,249 patients with a mean age of 60 years underwent Hartmann reversal. Two thirds of patients were classified as American Society of Anesthesiologists (ASA) I–II. The mean reversal rate after a Hartmann procedure was 44%, and mean time interval between Hartmann procedure and Hartmann reversal was 7.5 months. The most frequent reported reasons for renouncing Hartmann reversal were high ASA classification and patients’ refusal. The overall morbidity rate ranged from 3% to 50% (mean 16.3%) and mortality rate from 0% to 7.1% (mean 1%). Patients treated laparoscopically had a shorter hospital stay (6.9 vs. 10.7 days) and appeared to have lower mean morbidity rates compared to conventional surgery (12.2% vs. 20.3%).ConclusionHartmann reversal carries a high risk on perioperative morbidity and mortality. The mean reversal rate is considerably low (44%). Laparoscopic reversal compares favorably to conventional; however, high level evidence is needed to determine whether it is superior.
There is no evidence that suggests that, compared with aprotinin, alternative antifibrinolytics such as tranexamic acid were less effective in reducing blood loss in major pediatric surgery.
Introduction:Advances in perinatal medicine have contributed to significantly improved survival of newborns. While some infants die despite extensive medical treatment, a larger proportion dies following medical decision-making (MDM). International guidelines about end-of-life (EOL) MDM for neonates unify in their recommendation for shared decision-making (SDM) between doctors and parents. Yet, we do not know to what extent SDM is realized in neonatal practice.ObjectiveWe aim at examining to which extent SDM is implemented in the NICU setting.MethodsBy means of Qualitative Content Analysis, audio-recorded conversations between neonatologists and parents were analyzed. We used a framework by de Vos that was used to analyze similar conversations on the PICU.ResultsIn total we analyzed 17 conversations with 23 parents of 12 NICU patients. SDM was adopted only to a small extent in neonatal EOL-MDM conversations. The extent of sharing decreased considerably over the stages of SDM. The neonatologists suggested finding a decision together with parents, while at the same time seeking parents' agreement for the intended decision to forgo life-sustaining treatment.ConclusionsSince SDM was only realized to a small extent in the NICU under study, we propose evaluating how parents in this unit experience the EOL-MDM process and whether they feel their involvement in the process acceptable and beneficial. If parents evaluate their involvement in the current approach beneficial, the need for implementation of SDM to the full extent, as suggested in the guidelines, may need to be critically re-assessed.
Background: Guidelines recommend shared decision making (SDM) between neonatologists and parents when a decision has to be made about the continuation of life-sustaining treatment (LST). In a previous study, we found that neonatologists and parents at a German Level-III Neonatal Intensive Care Unit performed SDM to a variable but overall small extent. However, we do not know whether parents in Germany prefer an extent of more or sharing. Methods: We performed a qualitative interview study with parents who participated in our first study. We analyzed the semi-structured interviews with qualitative content analysis according to Kuckartz. Results: The participation in medical decision making (MDM) varied across cases. Overall, neonatologists and parents conducted SDM in most cases only to a small extent. All parents appreciated their experience independent of how much they were involved in MDM. The parents who experienced a small extent of sharing were glad that they were protected by neonatologists from having to decide, shielding them from a conflict of interest. The parents who experienced a large extent of sharing especially valued that they were able to fulfil their parental duties even if that meant partaking in a decision to forgo LST. Discussion: Other studies have also found a variety of possibilities for parents to partake in end-of-life decision making (EOL-DM). Our results suggest that parents do not have a uniform preference for one specific decision-making approach, but rather different parents appreciate their individual experience regardless of the model for DM. Conclusion: SDM is apparently not a one-size-fits-all approach. Instead, neonatologists and parents have to adapt the decision-making process to the parents’ individual needs and preferences for autonomy and protection. Therefore, SDM should not be prescribed as a uniform standard in medico-ethical guidelines, but rather as a flexible guidance for DM for critically ill patients in neonatology.
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