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Mueller TC, Kehl V, Dimpel R, Blankenstein C, Egert-Schwender S, Strudthoff J, Lock JF, Wiegering A, Hadian A, Lang H, Albertsmeier M, Neuberger M, Von Ehrlich-Treuenstätt V, Mihaljevic AL, Knebel P, Pianka F, Braumann C, Uhl W, Bouchard R, Petrova E, Bork U, Distler M, Tachezy M, Izbicki JR, Reissfelder C, Herrle F, Vay C, Knoefel WT, Buia A, Hanisch E, Friess H, Reim D. Intraoperative Wound Irrigation for the Prevention of Surgical Site Infection After Laparotomy: A Randomized Clinical Trial by CHIR-Net. JAMA Surg 2024; 159:484-492. [PMID: 38381428 PMCID: PMC10882507 DOI: 10.1001/jamasurg.2023.7985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/25/2023] [Indexed: 02/22/2024]
Abstract
Importance Surgical site infections frequently occur after open abdominal surgery. Intraoperative wound irrigation as a preventive measure is a common practice worldwide, although evidence supporting this practice is lacking. Objective To evaluate the preventive effect of intraoperative wound irrigation with polyhexanide solution. Design, Setting, and Participants The Intraoperative Wound Irrigation to Prevent Surgical Site Infection After Laparotomy (IOWISI) trial was a multicenter, 3-armed, randomized clinical trial. Patients and outcome assessors were blinded to the intervention. The clinical trial was conducted in 12 university and general hospitals in Germany from September 2017 to December 2021 with 30-day follow-up. Adult patients undergoing laparotomy were eligible for inclusion. The main exclusion criteria were clean laparoscopic procedures and the inability to provide consent. Of 11 700 screened, 689 were included and 557 completed the trial; 689 were included in the intention-to-treat and safety analysis. Interventions Randomization was performed online (3:3:1 allocation) to polyhexanide 0.04%, saline, or no irrigation (control) of the operative wound before closure. Main Outcome and Measures The primary end point was surgical site infection within 30 postoperative days according to the US Centers for Disease Control and Prevention definition. Results Among the 689 patients included, 402 were male and 287 were female. The median (range) age was 65.9 (18.5-94.9) years. Participants were randomized to either wound irrigation with polyhexanide (n = 292), saline (n = 295), or no irrigation (n = 102). The procedures were classified as clean contaminated in 92 cases (8%). The surgical site infection incidence was 11.8% overall (81 of 689), 10.6% in the polyhexanide arm (31 of 292), 12.5% in the saline arm (37 of 295), and 12.8% in the no irrigation arm (13 of 102). Irrigation with polyhexanide was not statistically superior to no irrigation or saline irrigation (hazard ratio [HR], 1.23; 95% CI, 0.64-2.36 vs HR, 1.19; 95% CI, 0.74-1.94; P = .47). The incidence of serious adverse events did not differ among the 3 groups. Conclusions and Relevance In this study, intraoperative wound irrigation with polyhexanide solution did not reduce surgical site infection incidence in clean-contaminated open abdominal surgical procedures compared to saline or no irrigation. More clinical trials are warranted to evaluate the potential benefit in contaminated and septic procedures, including the emergency setting. Trial Registration drks.de Identifier: DRKS00012251.
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Affiliation(s)
- Tara Catharina Mueller
- Department of Surgery, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Victoria Kehl
- Münchner Studienzentrum, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Rebekka Dimpel
- Department of Surgery, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Christiane Blankenstein
- Münchner Studienzentrum, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Silvia Egert-Schwender
- Münchner Studienzentrum, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Judith Strudthoff
- Münchner Studienzentrum, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Johan Friso Lock
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Ali Hadian
- Department of General, Visceral and Transplant Surgery, University Medical Center Mainz, Mainz, Germany
| | - Hauke Lang
- Department of General, Visceral and Transplant Surgery, University Medical Center Mainz, Mainz, Germany
| | - Markus Albertsmeier
- Department of General, Visceral and Transplantation Surgery, Ludwig Maximilians University of Munich, University Hospital, Munich, Germany
| | - Michael Neuberger
- Department of General, Visceral and Transplantation Surgery, Ludwig Maximilians University of Munich, University Hospital, Munich, Germany
| | - Viktor Von Ehrlich-Treuenstätt
- Department of General, Visceral and Transplantation Surgery, Ludwig Maximilians University of Munich, University Hospital, Munich, Germany
| | - André L. Mihaljevic
- Clinical Study Center, Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Phillip Knebel
- Clinical Study Center, Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Frank Pianka
- Clinical Study Center, Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Chris Braumann
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr University Bochum Hospitals, Bochum, Germany
| | - Waldemar Uhl
- Department of General and Visceral Surgery, St. Josef Hospital, Ruhr University Bochum Hospitals, Bochum, Germany
| | - Ralf Bouchard
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Ekaterina Petrova
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Ulrich Bork
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- National Center for Tumor Diseases, Dresden, Germany: German Cancer Research Center, Heidelberg; Faculty of Medicine and University Hospital Carl Gustav Carus, Technical University of Dresden, Helmholtz Center Dresden-Rossendorf, Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- National Center for Tumor Diseases, Dresden, Germany: German Cancer Research Center, Heidelberg; Faculty of Medicine and University Hospital Carl Gustav Carus, Technical University of Dresden, Helmholtz Center Dresden-Rossendorf, Dresden, Germany
| | - Michael Tachezy
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R. Izbicki
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Reissfelder
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Florian Herrle
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christian Vay
- Department of General, Visceral, Thoracic, and Pediatric Surgery, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Wolfram Trudo Knoefel
- Department of General, Visceral, Thoracic, and Pediatric Surgery, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Alexander Buia
- Asklepios Clinic Langen, Department of General, Visceral and Thoracic Surgery, Langen, Germany
| | - Ernst Hanisch
- Asklepios Clinic Langen, Department of General, Visceral and Thoracic Surgery, Langen, Germany
| | - Helmut Friess
- Department of Surgery, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Daniel Reim
- Department of Surgery, School of Medicine and Health, Technical University of Munich, Munich, Germany
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Buia A, Oguz S, Lehn A, Herrmann E, Hanisch E. Effect of 2D vs. 3D laparoscopy on postoperative complications and operation time in a propensity-score-matched real-world data analysis. Asian J Surg 2023; 46:508-513. [PMID: 35753916 DOI: 10.1016/j.asjsur.2022.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/03/2022] [Accepted: 06/01/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Postoperative complication rates using 3D visualization are rarely reported. The primary aim of our study is to detect a possible advantage of using 3D on postoperative complication rates in a real-world setting. METHOD With a sample size calculation for a medium effect size difference that 3D reduces significantly postoperative complications, data of 287 patients with 3D visualization and 832 with 2D procedure were screened. The groups underwent an exact propensity score-matching to be comparable. Comprehensive complication index (CCI) for every procedure was calculated and Operation Time was determined. RESULTS Including 1078 patients in the study, 213 exact propensity score-matched pairs could finally be established. Concerning overall CCI (3D: 5.70 ± 13.63 vs. 2D: 3.37 ± 9.89; p = 0.076) and operation time (3D: 103.98 ± 93.26 min vs. 2D: 88.60 ±6 9.32 min; p = 0.2569) there was no significant difference between the groups. CONCLUSION Our study shows no advantage of 3D over 2D laparoscopy regarding postoperative complications in a real-world setting, the second endpoint operation time, too, was not influenced by 3D overall.
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Affiliation(s)
- Alexander Buia
- Department of General-, Visceral- and Thoracic Surgery, Asklepios Klinik Langen, Academic Teaching Hospital Goethe-University Frankfurt, Langen, Germany.
| | - Sibel Oguz
- Department of General-, Visceral- and Thoracic Surgery, Asklepios Klinik Langen, Academic Teaching Hospital Goethe-University Frankfurt, Langen, Germany
| | - Annette Lehn
- Institute of Biostatistics and Mathematical Modelling, Department of Medicine, Goethe-University Frankfurt, Frankfurt, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, Department of Medicine, Goethe-University Frankfurt, Frankfurt, Germany
| | - Ernst Hanisch
- Department of General-, Visceral- and Thoracic Surgery, Asklepios Klinik Langen, Academic Teaching Hospital Goethe-University Frankfurt, Langen, Germany
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Piroski V, Müller E, Herrmann E, Hanisch E, Buia A. Reducing Surgical Site Infection by Prophylactic Negative Pressure Wound Therapy in a Cohort of General Surgery Patients. Visc Med 2022; 38:272-281. [PMID: 36160821 PMCID: PMC9421711 DOI: 10.1159/000520464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 10/25/2021] [Indexed: 08/03/2023] Open
Abstract
Background Surgical site infection (SSI) is one of the leading complications in health care. Negative pressure wound therapy (NPWT) is meanwhile widely prophylactically used for preventing SSIs. For evaluating the results of the implantation of this technique, we used the Simon single-arm study design and examine whether NPWT has a prophylactic effect on reducing SSIs in a cohort of general surgery patients. Methods This single-arm, two-stage study includes 81 elective general surgery patients and corresponds to the Simon's design. The sample size calculation was based on a reduction in the superficial SSI rate from 12 to 4% (power 80%, significance level 5%) using a NPWT system. In compliance with Simon's two-Stage design, the study required the recruitment of 34 patients in stage I and 47 patients in stage II. The two-stage design method would be discarded in case of a wound infection in 3 or more patients in stage I or 6 or more patients in stage II. Using the NPWT system in the operating room, a negative pressure wound dressing was applied post-operatively and removed after 7 days. According to the criteria of the Centres for Disease Control and Prevention (CDC), post-operative wound documentation followed on day 7 and 30. Results In stage I, no SSI was apparent. In stage II, 3 patients had SSIs (CDC grade I). Conclusion A prophylactic NPWT can significantly reduce the wound infection rate in elective general surgery.
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Affiliation(s)
- Vladimir Piroski
- Department of General, Visceral and Thoracic Surgery, Asklepios Klinik Langen, Langen, Germany
| | - Elisa Müller
- Departement of Internal Medicine Goethe-University Frankfurt, Frankfurt, Germany
| | - Eva Herrmann
- Department of Biostatistics and Mathematical Modeling, Goethe-University Frankfurt, Frankfurt, Germany
| | - Ernst Hanisch
- Department of General, Visceral and Thoracic Surgery, Asklepios Klinik Langen, Langen, Germany
| | - Alexander Buia
- Department of General, Visceral and Thoracic Surgery, Asklepios Klinik Langen, Langen, Germany
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Niazi AUR, Jami AA, Shams AZ, Mahmoodi AS, Krapfl E, Falk S, Buia A, Hanisch E. Establishing a breast cancer center in Herat, Afghanistan: an implementation study. Global Health Journal 2021. [DOI: 10.1016/j.glohj.2021.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
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Suna K, Herrmann E, Kröger K, Schmandra T, Müller E, Hanisch E, Buia A. Graduated compression stockings in the prevention of postoperative pulmonary embolism. A propensity-matched retrospective case-control study of 24 273 patients. Ann Med Surg (Lond) 2020; 56:203-210. [PMID: 32670570 PMCID: PMC7338863 DOI: 10.1016/j.amsu.2020.06.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 06/18/2020] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Recommendations for venous thromboembolism and deep venous thrombosis (DVT) prophylaxis using graduated compression stockings (GCS) is historically based and has been critically examined in current publications. Existing guidelines are inconclusive as to recommend the general use of GCS.Patients/Methods: 24 273 in-patients (general surgery and orthopedic patients) undergoing surgery between 2006 and 2016 were included in a retrospectively analysis from a single center. From January 2006 to January 2011 perioperative GCS was employed additionally to drug prophylaxis and from February 2011 to March 2016 patients received drug prophylaxis alone. According to german guidelines all patients received venous thromboembolism prophylaxis with weight-adapted LMWH. Risk stratification (low risk, moderate risk, high risk) was based on the guideline of the American College of Chest Physicians. Data analysis was performed before and after propensity matching (PM). The defined primary endpoint was the incidence of symptomatic or fatal pulmonary embolism (PE). A secondary endpoint was the incidence of deep venous thromboembolism (DVT). RESULTS After risk stratification (low risk n = 16 483; moderate risk n = 4464; high risk n = 3326) a total of 24 273 patient were analyzed. Before to PM the relative risk for the occurrence of a PE or DVT was not increased by abstaining from GCS. After PM two groups of 11 312 patients each, one with and one without GCS application, were formed. When comparing the two groups, the relative risk (RR) for the occurrence of a pulmonary embolism was: Low Risk 0.99 [CI95% 0.998-1.000]; Moderate Risk 0.999 [CI95% 0.95-1.003]; High Risk 0.996 [CI95% 0.992-1.000] (p > 0.05). The incidence of PE in the total group LMWH alone was 0.1% (n = 16). In the total group using LMWH + GCS, the incidence was 0.3% (n = 29). RR after PM was 0.999 [CI95% 0.998-1.00]. CONCLUSION In comparison to prior studies with only small numbers of patients our trial shows in a large group of patients with moderate and high risk developing VTE we can support the view that abstaining from GCS-use does not increase the incidence of symptomatic or fatal PE and symptomatic DVT.
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Affiliation(s)
- Kenan Suna
- Clinic for General, Visceral and Thoracic-Surgery, Asklepios Klinik Langen, Academic Teaching Hospital Goethe-Universität Frankfurt, Röntgenstr 20, Langen, 63225, Germany
| | - Eva Herrmann
- Institute of Biostatistics und Mathematical Modeling, Klinikum und Fachbereich Medizin der Goethe-Universität Frankfurt, Theodor-Stern-Kai 7, Frankfurt Am Main, 60590, Germany
| | - Knut Kröger
- Clinic for Angiology, Helios Klinikum Krefeld, Lutherplatz 40, Krefeld, 47805, Germany
| | - Thomas Schmandra
- Department of Vascular Surgery, Heart and Vascular Clinic, Bad Neustadt, Salzburger Leite 1, Bad Neustadt a. d. Saale, 97616, Germany
| | - Elisa Müller
- Clinic for General, Visceral and Thoracic-Surgery, Asklepios Klinik Langen, Academic Teaching Hospital Goethe-Universität Frankfurt, Röntgenstr 20, Langen, 63225, Germany
| | - Ernst Hanisch
- Clinic for General, Visceral and Thoracic-Surgery, Asklepios Klinik Langen, Academic Teaching Hospital Goethe-Universität Frankfurt, Röntgenstr 20, Langen, 63225, Germany
| | - Alexander Buia
- Clinic for General, Visceral and Thoracic-Surgery, Asklepios Klinik Langen, Academic Teaching Hospital Goethe-Universität Frankfurt, Röntgenstr 20, Langen, 63225, Germany
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Arabacioglu D, Lehn A, Herrmann E, Albers B, Hanisch E, Buia A. Evaluating a Clinical Pathway in Laparoscopic Cholecystectomy: Effective in Reducing Complications? A Propensity Score Matching Analysis. Visc Med 2020; 37:70-76. [PMID: 33718485 DOI: 10.1159/000506718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 02/17/2020] [Indexed: 11/19/2022] Open
Abstract
Background Care pathways are primarily aimed at decreasing length of hospital stay (LOS) and preventing unnecessary costs while maintaining or improving the quality of care. In laparoscopic cholecystectomy, there is insufficient evidence for proving an impact upon postoperative complications. Methods In this retrospective study, logistic regression was used to calculate a propensity score, and, after carrying out 1:1 nearest-neighbor matching, 296 patients were analyzed in both groups with regard to postoperative complications using the Clavien-Dindo classification system as a primary aim. In addition, secondary aims were LOS, compliance to care, and deviation from the care pathway with respect to patient discharge. Relative risk of the primary outcome was calculated and compared with the e-value as sensitivity testing approach. Results Due to the mandatory part of the care pathway, patient record compliance was 100%. Deviation from the care pathway with respect to the planned patient discharge on postoperative day 2 was noted in 16% of the cases. After adjustment for potential factors, the relative risk when comparing Clavien-Dindo complication grades 0 versus 1-4 is 1.64 (95% CI 0.87-3.11), which did not reach significance (p = 0.127). After matching, LOS lasted 3.69 days without and 3.26 days with the care pathway, respectively. Conclusions Against the background of already implemented structured standard operation procedures, a care pathway is not able to reduce postoperative complications. Nevertheless, we consider our clinical pathway a highly valuable tool for the interdisciplinary management of patient hospitalization under the supervision of experienced specialized surgeons.
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Affiliation(s)
- Duygu Arabacioglu
- Department of General, Visceral, and Thoracic Surgery, Asklepios Klinik Langen, Academic Teaching Hospital Goethe University Frankfurt, Langen, Germany
| | - Annette Lehn
- Department of Biostatistics and Mathematical Modeling, Goethe University Frankfurt, Frankfurt, Germany
| | - Eva Herrmann
- Department of Biostatistics and Mathematical Modeling, Goethe University Frankfurt, Frankfurt, Germany
| | - Benjamin Albers
- Department of General, Visceral, and Thoracic Surgery, Asklepios Klinik Langen, Academic Teaching Hospital Goethe University Frankfurt, Langen, Germany
| | - Ernst Hanisch
- Department of General, Visceral, and Thoracic Surgery, Asklepios Klinik Langen, Academic Teaching Hospital Goethe University Frankfurt, Langen, Germany
| | - Alexander Buia
- Department of General, Visceral, and Thoracic Surgery, Asklepios Klinik Langen, Academic Teaching Hospital Goethe University Frankfurt, Langen, Germany
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Buia A, Hopf HB, Herrmann E, Schmandra T, Hanisch E. Septic shock: ECMO beyond ARDS? Introducing the Simon two-stage protocol when randomisation is considered unethical. Scand J Trauma Resusc Emerg Med 2020; 28:22. [PMID: 32183853 PMCID: PMC7077119 DOI: 10.1186/s13049-020-0714-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 03/02/2020] [Indexed: 01/19/2023] Open
Affiliation(s)
- Alexander Buia
- Department of General, Visceral and Thoracic Surgery, Asklepios Klinik Langen, Academic Teaching Hospital Goethe-University Frankfurt, Röntgenstr 20, 63225, Langen, Germany.
| | - Hans-Bernd Hopf
- Department of Anaesthesia and Perioperative Medicine, Asklepios Klinik Langen, Academic Teaching Hospital Goethe-University Frankfurt, Röntgenstr 20, 63225, Langen, Germany
| | - Eva Herrmann
- Department of Biostatistics and Mathematical Modeling, Goethe-University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Thomas Schmandra
- Department of Vascular Surgery, Rhön Klinik Campus Bad Neustadt, Von-Guttenberg-Str. 11, 97616, Bad Neustadt a. d. Saale, Germany
| | - Ernst Hanisch
- Department of General, Visceral and Thoracic Surgery, Asklepios Klinik Langen, Academic Teaching Hospital Goethe-University Frankfurt, Röntgenstr 20, 63225, Langen, Germany
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Krauß M, Heinzel-Gutenbrunner M, Krönung L, Hanisch E, Buia A. Comparing large pore lightweight mesh versus small pore heavyweight mesh in open mesh plug repair of primary and recurrent unilateral inguinal hernia - A questionnaire study for a retrospective analysis of a cohort of elective groin hernia patients using propensity score matching. Int J Surg 2020; 75:93-98. [PMID: 32004716 DOI: 10.1016/j.ijsu.2020.01.130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 01/16/2020] [Accepted: 01/20/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE For surgical treatment of inguinal hernia, large-pore, lightweight mesh has been shown to offer advantages over small-pore, heavyweight options in terms of chronic post-operative inguinal pain, but without the disadvantage of having to deal with an increased recurrence rate. Limited data are available for the mesh plug repair technique. Therefore, the primary aim of this study is to compare large-pore, lightweight mesh versus small-pore, heavyweight mesh for mesh plug repair with regard to chronic pain and recurrences in elective primary unilateral hernias. In addition, we report our experience in repairing recurrent hernias. METHODS Using a modified version of the questionnaire from the Danish Hernia Registry, two groups were surveyed: elective primary unilateral hernias and recurrent unilateral hernias. In both groups small-pore, heavyweight mesh (HWM) and lightweight, large-pore mesh (LWM) were compared with respect to chronic pain and recurrences. Propensity score matching (PS) was carried out on a pool of 1,782 patients. Effect sizes were assessed by using Cohen's d and Cramer's V. RESULTS If the questionnaire item 'lump/swelling' is considered as a surrogate for recurrence (clinically verified in our study), the results in primary hernias after HWM show a 6.0% recurrence rate and 7.3% after LWM (p = 0.487) with a mean follow up of 31,3 months in HWM and 29,2 months in LWM respectively. The questionnaire item 'pain impacting on work/leisure activities' was answered with Yes in 11.5% following HWM and in 10.5% following LWM (p = 0.665). After the evaluation of the overall surgical results, we did not find differences. Comparing primary and recurrent hernia repair we found below small effect size differences with respect to the items of the questionnaire. CONCLUSIONS The use of LWM in repairing elective unilateral primary hernias by the mesh plug technique does not result in less chronic pain and more recurrences when compared with HWM. Recurrent hernias repaired by the mesh plug technique may have same outcomes like in primary hernia repair when considering the magnitude of effect sizes.
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Affiliation(s)
- Michael Krauß
- Department of General, Visceral- and Thoracic Surgery, Asklepios Klinik Langen, Academic Teaching Hospital of the Goethe-University Frankfurt, Langen, Germany
| | | | - Lutz Krönung
- Department of General, Visceral- and Thoracic Surgery, Asklepios Klinik Langen, Academic Teaching Hospital of the Goethe-University Frankfurt, Langen, Germany
| | - Ernst Hanisch
- Department of General, Visceral- and Thoracic Surgery, Asklepios Klinik Langen, Academic Teaching Hospital of the Goethe-University Frankfurt, Langen, Germany
| | - Alexander Buia
- Department of General, Visceral- and Thoracic Surgery, Asklepios Klinik Langen, Academic Teaching Hospital of the Goethe-University Frankfurt, Langen, Germany.
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Banjas N, Hopf HB, Hanisch E, Friedrichson B, Fichte J, Buia A. Correction to: ECMO-treatment in patients with acute lung failure, cardiogenic, and septic shock: mortality and ECMO-learning curve over a 6-year period. J Intensive Care 2019; 7:8. [PMID: 30733869 PMCID: PMC6354409 DOI: 10.1186/s40560-019-0362-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 01/18/2019] [Indexed: 11/23/2022] Open
Affiliation(s)
- Norbert Banjas
- 1Department of Visceral and Thoracic Surgery, Asklepios Klinik Langen, Röntgenstr 20, 63220 Langen, Germany
| | - Hans-Bernd Hopf
- 2Department of Anaesthesia and Peri-operative Medicine, Asklepios Klinik Langen, Röntgenstr 20, 63220 Langen, Germany
| | - Ernst Hanisch
- 1Department of Visceral and Thoracic Surgery, Asklepios Klinik Langen, Röntgenstr 20, 63220 Langen, Germany
| | - Benjamin Friedrichson
- 2Department of Anaesthesia and Peri-operative Medicine, Asklepios Klinik Langen, Röntgenstr 20, 63220 Langen, Germany
| | - Julia Fichte
- 2Department of Anaesthesia and Peri-operative Medicine, Asklepios Klinik Langen, Röntgenstr 20, 63220 Langen, Germany
| | - Alexander Buia
- 1Department of Visceral and Thoracic Surgery, Asklepios Klinik Langen, Röntgenstr 20, 63220 Langen, Germany
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Kern M, Buia A, Tonus C, Weigel TF, Dittmar R, Hanisch E, Zapf D. [Psychological stressors, resources and well-being of surgeons in Germany : A cross-sectional study]. Chirurg 2019; 90:576-584. [PMID: 30610261 DOI: 10.1007/s00104-018-0780-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Psychological stress at work is associated with detrimental and health-impairing consequences for employees. OBJECTIVE In this study major stress factors and the resource job control at the workplace of surgeons and facets of mental health were examined and compared to benchmark results of a large reference sample. METHOD Data were collected by a representative online survey among surgeons throughout Germany who were contacted via the Professional Association of German Surgeons. In total 643 surgeons from different organizations and different disciplines completed the questionnaire that was developed using well-validated instruments. RESULTS Time pressure was the most meaningful stress factor for surgeons. Moreover, the results for medical assistants showed adverse stress combinations of high goal uncertainty and low job control as well as high emotional exhaustion and low job satisfaction. In addition, the results indicated that surgeons in single and group practices as well as in outpatient healthcare centers have less stressors and more job resources. CONCLUSION The survey results suggest high levels of burnout risk for German surgeons, especially among medical assistants and medical specialists from large hospitals. In order to maintain a high quality in the surgical disciplines, a concerted effort by all players in the healthcare system is necessary.
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Affiliation(s)
- M Kern
- Abteilung Arbeits- und Organisationspsychologie, Goethe-Universität Frankfurt, PEG, Theodor-W.-Adorno-Platz 6, 63, 60629, Frankfurt am Main, Deutschland.
| | - A Buia
- Klinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Asklepios Klinik Langen, Langen, Deutschland
| | - C Tonus
- Klinik für Allgemein- und Viszeralchirurgie, Asklepios Klinik St. Georg, Hamburg, Deutschland
| | - T F Weigel
- Klinik für Allgemein- und Viszeralchirurgie, Heilig-Geist-Hospital, Bingen, Deutschland
| | - R Dittmar
- Berufsverband der Deutschen Chirurgen, Berlin, Deutschland
| | - E Hanisch
- Klinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Asklepios Klinik Langen, Langen, Deutschland
| | - D Zapf
- Abteilung Arbeits- und Organisationspsychologie, Goethe-Universität Frankfurt, PEG, Theodor-W.-Adorno-Platz 6, 63, 60629, Frankfurt am Main, Deutschland
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Weigel TF, Hanisch E, Hanisch A, Buia A, Müller LP, Messias J, Hessler C. Power of Judgment: The Significance of Kant's Philosophy for the Medical System Today. J Surg Educ 2019; 76:4-8. [PMID: 30111517 DOI: 10.1016/j.jsurg.2018.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 06/17/2018] [Accepted: 07/08/2018] [Indexed: 06/08/2023]
Abstract
The ways of thinking in the manufacturing sciences are increasingly determining the rationality within medicine as a practical or action-based science. This "technological paradigm" infiltrates the field of medicine with the promise of increasing efficiency while simultaneously improving quality at various points in the system. Simple linear causal relationships generally need to be taken into account when manufacturing products. Even complex manufacturing processes can be broken down into the smallest units and, therefore, also be automated. The situation in complex systems such as the human body, however, is completely different. In order for doctors to be able to carry out their actions within this complex system, medicine as a science provides the physician with rules on the means that should be used to decide which remedy should be used, when and how. This judgment of which remedy should be used, when and how, what is known as the indication, is a central medical moment. This requires a power of judgment sharpened by experience. The indication, in turn, essentially determines the course of a disease and thus the quality of the treatment or the quality of result so often referred to these days.
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Affiliation(s)
- T F Weigel
- Department of General- and Visceral Surgery, Heilig-Geist-Hospital, Bingen, Germany.
| | - E Hanisch
- Department of Visceral- and Thoracic Surgery, Asklepios Klinik, Langen, Germany
| | - A Hanisch
- KfW Development Bank, Frankfurt, Germany
| | - A Buia
- Department of Visceral- and Thoracic Surgery, Asklepios Klinik, Langen, Germany
| | - L P Müller
- Department of Trauma and Orthopaedic Surgery, University of Cologne, Cologne, Germany
| | - J Messias
- Department of General- and Visceral Surgery, Heilig-Geist-Hospital, Bingen, Germany
| | - C Hessler
- Department of General- and Visceral Surgery, Heilig-Geist-Hospital, Bingen, Germany
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Banjas N, Hopf HB, Hanisch E, Friedrichson B, Fichte J, Buia A. ECMO-treatment in patients with acute lung failure, cardiogenic, and septic shock: mortality and ECMO-learning curve over a 6-year period. J Intensive Care 2018; 6:84. [PMID: 30598825 PMCID: PMC6299557 DOI: 10.1186/s40560-018-0352-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 12/03/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Based on promising results over the past 10 years, the method of extracorporeal membrane oxygenation (ECMO) has developed from being used as a 'rescue therapy' to become an accepted treatment option for patients with acute lung failure (ARDS). Subsequently, the indication was extended also to patients suffering from cardiogenic and septic shock. Our aim was to evaluate hospital mortality and associated prognostic variables in patients with lung failure, cardiogenic, and septic shock undergoing ECMO. Furthermore, a cumulative sum (CUSUM) analysis was used to assess the learning curve of ECMO-treatment in our department. METHODS We retrospectively analysed the data of 131 patients undergoing ECMO treatment in the intensive care unit of the Asklepios Hospital of Langen over the time period from April 2011 to July 2016. We categorised the patients into three groups: lung failure (n = 54); cardiogenic shock (n = 58); and septic shock (n = 19). The primary outcome variable was hospital mortality along with identification of prognostic variables on mortality before initiating ECMO using logistic regression. Second outcome variable was the learning curve of our department in patients with ECMO. RESULTS 6-year hospital mortality was 54% in patients with lung failure, 59% in patients with cardiogenic shock, and 58% in patients with septic shock.The CUSUM analysis revealed a typical learning curve with a point of inflection in the year 2014. Patients treated before 2014 had a worse outcome (p = 0.04 whole cohort; p = 0.03 for lung failure). Furthermore, less than 20 treatments per year respectively treatment before 2014 were associated negatively with hospital mortality of lung failure patients showing an odds ratio of 4.04, as well as in the entire cohort with an odds ratio of 3.19. CONCLUSION For the first time, a steep ECMO-learning curve using the CUSUM tool has been described. Obviously, the experience with ECMO has to be taken into account when defining the role of ECMO in ARDS, cardiogenic, and septic shock.
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Affiliation(s)
- Norbert Banjas
- Department of Visceral and Thoracic Surgery, Asklepios Klinik Langen, Röntgenstr 20, 63220 Langen, Germany
| | - Hans-Bernd Hopf
- Department of Anaesthesia and Peri-operative Medicine, Asklepios Klinik Langen, Röntgenstr 20, 63220 Langen, Germany
| | - Ernst Hanisch
- Department of Visceral and Thoracic Surgery, Asklepios Klinik Langen, Röntgenstr 20, 63220 Langen, Germany
| | - Benjamin Friedrichson
- Department of Anaesthesia and Peri-operative Medicine, Asklepios Klinik Langen, Röntgenstr 20, 63220 Langen, Germany
| | - Julia Fichte
- Department of Anaesthesia and Peri-operative Medicine, Asklepios Klinik Langen, Röntgenstr 20, 63220 Langen, Germany
| | - Alexander Buia
- Department of Visceral and Thoracic Surgery, Asklepios Klinik Langen, Röntgenstr 20, 63220 Langen, Germany
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Blythe J, Herrmann E, Faust D, Falk S, Edwards-Lehr T, Stockhausen F, Hanisch E, Buia A. Acute cholecystitis - a cohort study in a real-world clinical setting (REWO study, NCT02796443). Pragmat Obs Res 2018; 9:69-75. [PMID: 30498388 PMCID: PMC6207389 DOI: 10.2147/por.s169255] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background For decades, the optimal timing of surgery for acute cholecystitis has been controversial. Recent meta-analyses and population-based studies favor early surgery. One recent large randomized trial has demonstrated that a delayed approach increases morbidity and cost compared to early surgery within 24 hours of hospital admission. Since cases of severe cholecystitis were excluded from this trial, we argue that these results do not reflect real-world clinical situations. From our point of view, these results were in contrast to the clinical experience with our patients; so, we decided to analyze critically all our patients with the null hypothesis that the patients treated with a delayed cholecystectomy after an acute cholecystitis have a similar or even better outcome than those treated with an early operative approach. Patients and methods We retrospectively analyzed clinical data from all patients with cholecystectomies in the period between January 2006 and September 2015. A total of 1,723 patients were categorized into four groups: early (n=138): urgent surgery of patients with acute cholecystitis within the first 72 hours of the onset of symptoms; intermediate (n=297): surgery of patients with acute cholecystitis within an average of 10 days after the onset of symptoms; delayed (n=427): initial non-surgical treatment of acute cholecystitis with surgery performed within 6-12 weeks of the onset of symptoms; and elective (n=868): cholecystectomy within a symptom-free interval of choice in patients with symptomatic cholecystolithiasis without signs of acute cholecystitis. Results In a real-world scenario, early/intermediate cholecystectomy in acute cholecystitis was associated with a significant increase in morbidity and mortality (Clavien-Dindo score) compared to a delayed approach with surgery performed 6-12 weeks after the onset of symptoms. The adjusted linear rank statistics showed a decrease in the complication score with values of 2.29 in the early group, 0.48 in the intermediate group, -0.26 in the delayed group and -2.12 in the elective group. The results translate into a continuous decrease of the complication score from early over intermediate and delayed to the elective group. Conclusion These results demonstrate that delayed cholecystectomy can be performed safely. In cases with severe cholecystitis, early and/or intermediate approaches still have a relatively high risk of morbidity and mortality.
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Affiliation(s)
- Jennifer Blythe
- Department of Internal Medicine, Bürgerhospital Frankfurt, Frankfurt, Germany
| | - Eva Herrmann
- Institute for Biostatistics and Mathematical Modelling, University Hospital Goethe University, Frankfurt, Germany
| | - Dominik Faust
- Department of Gastroenterology, Hepatology and Infectious Disease, Asklepios Klinik Langen, Langen, Germany
| | - Stephan Falk
- OptiPath Pathology Associates Frankfurt, Frankfurt, Germany
| | - Tina Edwards-Lehr
- Department of Visceral and Thoracic Surgery, Asklepios Klinik Langen, Langen, Germany,
| | | | - Ernst Hanisch
- Department of Visceral and Thoracic Surgery, Asklepios Klinik Langen, Langen, Germany,
| | - Alexander Buia
- Department of Visceral and Thoracic Surgery, Asklepios Klinik Langen, Langen, Germany,
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Abstract
BACKGROUND The 3D laparoscopy is currently under intensive discussion. At the moment the majority of newly acquired laparoscopy systems include the 3D technique. New 4K systems, which will be offered in combination with 3D, are complicating the decision-making when buying new laparoscopic systems. The aim of the article is to show the advantages and possible limitations of 3D laparoscopy. Furthermore, the position of 3D laparoscopy in the current video market is evaluated. MATERIAL AND METHODS This study was based on an up to date literature search in PubMed. Concerning the question whether the 3D is replacing the 2D laparoscopy, observations from the industry and a personal evaluation were included in the analysis. RESULTS The current studies show clear advantages of 3D laparoscopy concerning operation time, efficiency and workload. A major proportion of the studies were conducted on simulation trainers; however, some clinical trials also confirmed these results. The learning curve in laparoscopic surgery is clearly improved with the 3D technique and 3D also seems be useful for operations by experts. The limitation is that not every surgeon can see three dimensionally. Furthermore, the set-up in the operation room needs to be optimized so that a 3D system can be successfully implemented with the nursing staff and side effects, such as exhaustion, dizziness or headache can be prevented. CONCLUSION The choice of video system will depend on the personal interest of the surgeon and the ability to see 3D. It can be assumed that the majority of the systems will include 3D laparoscopy but 2D laparoscopy will not be completely replaced. A dynamic development of 3D in association with 4K and robotics can be expected.
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Affiliation(s)
- A Buia
- Klinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Asklepios Kliniken Langen, Röntgenstr. 20, 63225, Langen, Deutschland
| | - S Farkas
- Klinik für Allgemein- und Viszeralchirurgie, St. Josefs-Hospital Wiesbaden, Beethovenstraße 20, 65189, Wiesbaden, Deutschland.
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Hellinger A, Wotzlaw F, Fackeldey V, Pistorius G, Zdichavsky M, Jünemann R, Buia A. Development of an open prospective observational multicentre cohort study to determine the impact of standardization of laparoscopic intraperitoneal onlay mesh repair (IPOM) for incisional hernia on clinical outcome and quality of life (LIPOM-Trial). Contemp Clin Trials Commun 2016; 4:118-123. [PMID: 29736474 PMCID: PMC5935894 DOI: 10.1016/j.conctc.2016.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Revised: 07/05/2016] [Accepted: 08/09/2016] [Indexed: 11/26/2022] Open
Abstract
Background Incisional hernias are one of the most frequent complications in abdominal surgery. Laparoscopic repair has been widely used since its first description but has not been standardized. A panel of hernia experts with expertise on the subject “incisional hernia” was established to review existing literature and define a standard approach to laparoscopic IPOM-repair for incisional hernia. All involved surgeons agreed to perform further IPOM-repairs of incisional hernia according to the protocol. Methods/design This article summarizes the development of an open prospective observational multicentre cohort study to analyse the impact of a standardization of laparoscopic IPOM-repair for incisional hernia on clinical outcome and quality of life (health care research study). Discussion Our literature search found that there is a lack of standardization in the surgical approach to incisional hernia and the use of medical devices. The possibility of different surgical techniques, various meshes and a variety of mesh fixation techniques means that the results on outcome after incisional hernia repair are often not comparable between different studies. We believe there is a need for standardization of the surgical procedure and the use of medical devices in order to make the results more comparable and eliminate confounding factors in interpreting the results of surgical hernia repair. This approach, in our view, will also illustrate the influence of the operative technique on the general quality of surgical treatment of incisional hernias better than a “highly selective” study and will indicate the “reality” of surgical treatment not only in specialist centres. Trial registration The LIPOM-trial is registered at www.clinicaltrials.gov, with identifier: NCT02089958.
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Key Words
- ASA, American Society of Anesthesiologists
- CCS, Carolina Comfort Scale
- CDC, Center for Disease Control and Prevention
- Clinical outcome
- DSMB, Data safety Management Board
- EHS, European Hernia Society
- HP, Hernia Panel
- IDEAL, Idea Development, Exploration, Assessment, Long-term Follow-up
- IPOM, Intraperitoneal onlay mesh augmentation
- LIPOM, Laparoscopic intraperitoneal onlay mesh augmentation
- LIPOM-Trial
- Laparoscopic incisional hernia repair
- NRS, Numerical Rating Scale
- Prospective observational multicentre cohort trial
- Quality of life
- TM, Trade mark
- W, Width
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Affiliation(s)
- A Hellinger
- Department of General and Visceral Surgery, Klinikum Fulda, Universitätsmedizin Marburg - Campus Fulda, Fulda, Germany
| | - F Wotzlaw
- Department of General and Visceral Surgery, Klinikum Fulda, Universitätsmedizin Marburg - Campus Fulda, Fulda, Germany
| | - V Fackeldey
- Department of General, Vascular and Visceral Surgery, Klinik Kitzinger Land, Kitzingen, Germany
| | - G Pistorius
- Department of General, Thoracic and Visceral Surgery, Sozialstiftung Bamberg, Bamberg, Germany
| | - M Zdichavsky
- Department of General, Visceral and Transplantation Surgery, University of Tübingen, Tübingen, Germany
| | - R Jünemann
- StatConsult, Gesellschaft für klinische und Versorgungsforschung mbH, Magdeburg, Germany
| | - A Buia
- Department of General and Visceral Surgery, St. Elisabethen-Krankenhaus, Frankfurt a. M., Germany
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Abstract
AIM: To review current applications of the laparoscopic surgery while highlighting the standard procedures across different fields.
METHODS: A comprehensive search was undertaken using the PubMed Advanced Search Builder. A total of 321 articles were found in this search. The following criteria had to be met for the publication to be selected: Review article, randomized controlled trials, or meta-analyses discussing the subject of laparoscopic surgery. In addition, publications were hand-searched in the Cochrane database and the high-impact journals. A total of 82 of the findings were included according to matching the inclusion criteria. Overall, 403 full-text articles were reviewed. Of these, 218 were excluded due to not matching the inclusion criteria.
RESULTS: A total of 185 relevant articles were identified matching the search criteria for an overview of the current literature on the laparoscopic surgery. Articles covered the period from the first laparoscopic application through its tremendous advancement over the last several years. Overall, the biggest advantage of the procedure has been minimizing trauma to the abdominal wall compared with open surgery. In the case of cholecystectomy, fundoplication, and adrenalectomy, the procedure has become the gold standard without being proven as a superior technique over the open surgery in randomized controlled trials. Faster recovery, reduced hospital stay, and a quicker return to normal activities are the most evident advantages of the laparoscopic surgery. Positive outcomes, efficiency, a lower rate of wound infections, and reduction in the perioperative morbidity of minimally invasive procedures have been shown in most indications.
CONCLUSION: Improvements in surgical training and developments in instruments, imaging, and surgical techniques have greatly increased safety and feasibility of the laparoscopic surgical procedures.
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Malvasi A, Tinelli A, Buia A, De Luca GF. Possible long-term teratogenic effect of isotretinoin in pregnancy. Eur Rev Med Pharmacol Sci 2009; 13:393-396. [PMID: 19961047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The isotretinoin, a 13-cis-retinoic acid, has revolutionized the management of severe treatment-resistant acne and it has been widely used for a range of dermatological conditions, in 90% of the time in young women between 13 and 45 years of age. This agent has severe teratogenic effects, as serious craniofacial, cardiovascular, thymic and central nervous system malformations. The baseline population risk of malformations is 3-5%, but it increases to almost 30% in women exposed to isotretinoin during the first trimester of pregnancy. Generally, patients in treatment with isotretinoin avoid eventual pregnancy during assumption and, after its stopping, fertility and foetal development are normal once circulating isotretinoin levels return to normal. There are no known deleterious effects on male fertility and on long-term teratogenic effect of isotretinoin. In this report, we suppose the possibility to develop a foetal malformations after a long-term wash out from isotretinoin therapy. A 32 year-old healthy nullipara pregnant woman, with an uneventful past gynaecological history, was admitted in Hospital, with a severe depressive syndrome in a 18 weeks malformed pregnancy for thoraco-omphalopagus conjoined twins. She only assumed isotretinoin, at dose of 1 mg/kg a day, for a severe and scarring acne for 7 months. After 3 months of pharmacological wash out, patient become pregnant and manifested this severe malformation. Woman interrupted gestation, by labour induction.
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Affiliation(s)
- A Malvasi
- Department of Obstetrics and Gynaecology, Santa Maria Hospital, Bari, Italy
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