Laparoscopic Approach in Surgical Staging of Endometrial Cancer

Objective To compare laparoscopy with laparotomy for surgical staging of endometrial cancer. Methods A cohort of women with preoperative diagnosis of endometrial cancer who underwent surgical staging was retrospectively evaluated. The main study end points were: morbidity and mortality, hospital length of stay, perioperative adverse events and recurrence rate. Data analysis was performed with the software SPSS v25 (IBM Corp., Armonk, NY, USA), categorical variables using a Chi-square and Fisher test, and continuous variables using the Student t-test. Results A total of 162 patients were analyzed. One-hundred and thirty eight patients met the inclusion criteria, 41 of whom underwent staging by laparoscopy and 97 by laparotomy. Conversions from laparoscopy to laparotomy happened in 2 patients (4.9%) and were secondary to technical difficulties and poor exposure. Laparoscopy had fewer postoperative adverse events when compared with laparotomy (7.3% vs 23.7%, respectively; p = 0.005), but similar rates of intraoperative complications, despite having a significantly longer operative time (median, 175 vs 130 minutes, respectively; p < 0.001). Hospital stay was significantly lower in laparoscopy versus laparotomy patients (median, 3 vs 7 days, respectively; p < 0.001). No difference in recurrence or mortality rates were observed. Conclusion Laparoscopic surgical staging for endometrial cancer is feasible and safe. Patients have lower postoperative complication rates and shorter hospital stays when compared with the approach by laparotomy.

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2005. Successful Implementation of a Procalcitonin Algorithm Associated with Reduction in Antibiotic Days

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1685 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S672-S673

Author(s):

John B McCoury ◽

Randolph V Fugit ◽

Mary T Bessesen

Keyword(s):

Patient Characteristics ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Categorical Variables ◽

Successful Implementation ◽

Continuous Variables ◽

Chi Square ◽

Clinician Training ◽

Significant Difference ◽

Mortality Table

Abstract Background Randomized controlled trials of procalcitonin (PCT)-based algorithms for antibacterial therapy have been shown to reduce antimicrobial use and improve survival. Translation of PCT algorithms to clinical settings has often been unsuccessful. Methods We implemented a PCT algorithm, supported by focus groups prior to introduction of the PCT test in April 2016 and clinician training on the PCT algorithm for testing and antimicrobial management after test roll-out. The standard PCT algorithm period (SPAP) was defined as October 1, 2017 to March 31, 2018. The antimicrobial stewardship team (AST) initiated an AST-supported PCT algorithm (ASPA) in August 2018. The AST prospectively evaluated patients admitted to ICU for sepsis and ordered PCT per algorithm if the primary medical team had not ordered them. The ASPA period was defined as October 1, 2018–March 31, 2019. The AST conducted concurrent review and feedback for all antibiotic orders during both periods, using PCT result when available. We compared patient characteristics and outcomes between the two periods. The primary outcome was adherence to the PCT algorithm, with subcomponents of appropriate PCT orders and antimicrobial discontinuation. Secondary outcomes were total antibiotic days, excess antibiotic days avoided, ICU and hospital length of stay (LOS), 30-day readmission and mortality. Continuous variables were analyzed with Student t-test. Categorical variables were analyzed with chi-square or Mann–Whitney test, as appropriate. Results There were 35 cases in the SPAP cohort and 57 cases in the ASPA cohort. There were no differences in demographics or infection site (Table 1). Baseline PCT was ordered in 57% of the SPAP cohort and 90% of the ASPA cohort (P = 0.0006) (Table 2). Follow-up PCT was performed in 23% of SPAP and 76% of ASPA (P < 0.0001). Antibiotics were discontinued per algorithm in 2/35 (7%) in the SPAP cohort and 25/57 (44%) in the ASPA cohort (P < 0.0001). Total antibiotic days was 7 (IQR 4–10) in the SPAP cohort and 5 (IQR 2–7) in the ASPA cohort (P = 0.02). There was no significant difference in LOS, ICU LOS, 30-day readmission, or mortality (Table 4). Conclusion A PCT algorithm successfully implemented by an AST was associated with a significant decrease in total antibiotic days. There were no differences in mortality or LOS. Disclosures All authors: No reported disclosures.

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706 Frostbite and Drugs of Abuse: Friend or Foe?

Journal of Burn Care & Research ◽

10.1093/jbcr/iraa024.292 ◽

2020 ◽

Vol 41 (Supplement_1) ◽

pp. S184-S184

Author(s):

Anne L Lambert Wagner ◽

Kiran U Dyamenahalli ◽

Tyler M Smith ◽

Patrick Duffy ◽

Elizabeth J Kovacs ◽

...

Keyword(s):

Length Of Stay ◽

Clinical Outcomes ◽

Drugs Of Abuse ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Homeless Population ◽

Categorical Variables ◽

Burn Patients ◽

Continuous Variables ◽

Exact Test

Abstract Introduction In the literature, the incidence of alcohol and/or drug use among burn patients ranges from 16.4%-69%. Burn patients with positive toxicology (tox) screens on admission are known to have increased rates of morbidity and mortality. To date little has been published on the effects of positive alcohol and/or drug screens on outcomes in the frostbite population. The objective of this study was to investigate the incidence of drugs and alcohol use in admitted patients with severe frostbite and their association with clinical outcomes. Methods A retrospective cohort study was conducted on 141 frostbite patients admitted to a verified burn center from November 2015 to March 2019. Patients were identified using our burn registry and relevant data was obtained through chart reviews. The primary comparison was between patients with and without a positive tox screen on admission, assessing administration of thrombolytics (tPA) and rates of amputation. Contingency analysis for categorical variables was performed using Fisher’s exact test, while the Mann-Whitney U test was used for continuous variables, reporting, two-tailed p values. Results Tox screens were positive in 77.3% (109) of frostbite patients: 52.5% (74) for marijuana and 56.7% (80) for alcohol. Homelessness accounted for 50.4% (71) and 63.1% (89) were tobacco users. Compared to patients with negative tox screens, significantly higher rates of amputation were found in those using marijuana (p=0.016), other drugs of abuse (p=0.008) and tobacco (p=0.0093). Significantly higher limb salvage rates were found in patients presenting with a negative tox screen (p=0.0077). Only tobacco users had a significantly greater length of stay (p=0.02). 36.2% (51) of the patients received tPA with no difference in administration rates between positive and negative tox screened patients. Patients receiving tPA had significantly lower rates of amputation (p=0.02). 51.8% (73) of admitted patients were homeless, with 83.6% (61) testing tox positive. Both increased hospital length of stay (p=< 0.001) and amputation rates (p=0.0004) were observed in the homeless frostbite population. Conclusions Drugs, alcohol and homelessness significantly impact clinical outcomes in frostbite patients. Homelessness, marijuana, tobacco and other drugs of abuse are associated with significantly higher rates of amputation despite receiving tPA at the same rate. Administration of tPA is significant in lowering amputation rates. Applicability of Research to Practice The association between drugs of abuse, homelessness and frostbite highlight the need for increased preventative efforts especially in the homeless population.

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742 Marijuana and Drugs of Abuse: Impact on Clinical Outcomes in Burn Injury

Journal of Burn Care & Research ◽

10.1093/jbcr/iraa024.324 ◽

2020 ◽

Vol 41 (Supplement_1) ◽

pp. S203-S204

Author(s):

Anne L Lambert Wagner ◽

Tyler M Smith ◽

Kiran U Dyamenahalli ◽

Patrick Duffy ◽

Elizabeth J Kovacs ◽

...

Keyword(s):

Length Of Stay ◽

Clinical Outcomes ◽

Drugs Of Abuse ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Categorical Variables ◽

Published Data ◽

Complication Rates ◽

Burn Patients ◽

Wound Infections

Abstract Introduction Alcohol has been shown to increase hospital length of stay, complications and mortality in burn patients in studies examining its effects over the past 25 years. In contrast, there is a scarcity of published data on the effects of marijuana and other drugs of abuse in the burn population. The primary aim of this study is to evaluate the clinical outcomes of marijuana use on burn patients in comparison to other drugs of abuse including alcohol. Methods A retrospective cohort study was conducted on 875 burn patients admitted to a verified burn center from July 2015 to July 2019. Patients were identified from our burn registry and additional data was obtained from chart reviews. The primary comparison was between patients with and without a positive toxicology (tox) screens on admission. Contingency analysis for categorical variables was performed using Fisher’s exact test, while the Mann-Whitney U test was used to compare continuous variables, reporting two-tailed p values. Results Results of admission tox screens on all burn admissions were positive in 48% (423) of patients for drugs of abuse including: marijuana 41% (358), alcohol 16% (141), and stimulants 15% (134). Tox screens positive for alcohol were significant for increased: hospital length of stay (LOS) (p=0.0121), ICU LOS (p=0.0166), ventilator days (p=0.0324), number of operations (p=0.0341), and complication rates (p=0.0005). Patients with positive drug, but negative alcohol screens showed significant increases in: hospital LOS (p=0.029), hospital complications (p=0.0251), and wound infections (p=0.04). Patients testing positive for marijuana approached significance for an increased hospital LOS (p=0.0756) and was significant for increased wound infections (p=0.0476). Looking at median ages: tox positive patients (35) were significantly younger (p=< 0.0001) than negative (49). The median age for patients testing positive for marijuana (35) was significantly younger (p=< 0.0001) than those that testing negative (47). Median age regarding alcohol tox screens was insignificant. Looking at significance in median TBSA, significance was found between tox positive (4.3%) and tox negative (3.5%) patients (p=0.004). TBSA was insignificant in the other groups. Conclusions Almost half of all admitted burn patients tested positive for alcohol and other drugs of abuse. As in previous studies, patients testing positive for alcohol continue to have a more complicated hospital course and longer hospital and ICU LOS. Marijuana, positive in 41% of all burn admissions, showed significance in increased wound infections and a slight trend towards an increased hospital stay. Applicability of Research to Practice The association between burns and drugs of abuse including alcohol indicates the need for increased preventative and educational efforts especially in patients suffering from alcohol abuse/dependence and younger patients.

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Technical approach and outcomes of failed infrarenal endovascular aneurysm repairs rescued with fenestrated and branched endografts

CVIR Endovascular ◽

10.1186/s42155-019-0075-z ◽

2019 ◽

Vol 2 (1) ◽

Cited By ~ 1

Author(s):

Jesse Manunga ◽

Larissa I. Stanberry ◽

Peter Alden ◽

Jason Alexander ◽

Nedaa Skeik ◽

...

Keyword(s):

Adverse Events ◽

Stent Graft ◽

Graft Patency ◽

Hospital Length ◽

Aortic Aneurysms ◽

Hospital Length Of Stay ◽

Type I ◽

Technical Success ◽

Vessel Patency ◽

Major Adverse Events

Abstract Background Endovascular rescue of failed infrarenal repair (EVAR) has emerged as an attractive option to stent graft explantation. The procedure, however, is underutilized due to limited devices accessibility and the challenges associated with their implantation in this patient population. The purpose of this study was to report our outcomes and discuss our approach to rescuing previously failed infrarenal endovascular aneurysm repairs (EVAR) with fenestrated/branched endografts (f/b-EVAR). Methods A retrospective analysis of prospectively collected data of consecutive patients with failed EVAR rescued with f/b-EVAR at our institution from November 2013 to March 2019 was conducted. The study primary end point was technical success; defined as the implantation of the device with no type I a/b or type III endoleak or conversion to open repair. Secondary endpoints included major adverse events (MAEs), graft patency and reintervention rates. Results During this time, 202 patients with complex aortic aneurysms were treated with f/b-EVAR. Of these, 19 patients (Male: 17, mean age 79 ± 7 years) underwent repair for failed EVAR. The median time from failed repair to f/b-EVAR was 48 (30, 60) months. Treatment failure was attributed to stent graft migration in 9 (47.4%) patients, disease progression in 5 (26.3%), short initial neck in 3 (15.8%) and unable to be determined in 2 (10.5%). Three patients were treated urgently with surgeon modified stent graft. Technical success was achieved in 18 patients (95%), including two who had undergone emergent repair for rupture. Seventy-two targeted vessels (97.3%) were successfully incorporated. Sixteen (84.2%) patients required a thoracoabdominal repair to achieve a durable seal. Major adverse events (MAEs) occurred in 3 patients (15.7%) including paralysis and death in one (5.3%), compartment syndrome and temporary dialysis in another and laparotomy with snorkeling of one renal and bypass of the other in the third patient. Median (IQR) hospital length of stay was 3 (2, 4) days. Late reintervention, primary target vessel patency and primary assisted patency rates were 5.3%, 98.6% and 100%, respectively. Conclusion Implantation of f/b-EVAR in patients with failed previous EVAR is a challenging undertaking that can be performed safely with a high technical success and low reintervention rates.

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Laparoscopy in Liver Transplantation: The Future Has Arrived

HPB Surgery ◽

10.1155/2012/148387 ◽

2012 ◽

Vol 2012 ◽

pp. 1-7 ◽

Cited By ~ 3

Author(s):

Quirino Lai ◽

Rafael S. Pinheiro ◽

Giovanni B. Levi Sandri ◽

Gabriele Spoletini ◽

Fabio Melandro ◽

...

Keyword(s):

Liver Transplantation ◽

Scientific Progress ◽

Laparoscopic Approach ◽

Standard Of Care ◽

Radical Change ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Therapeutic Laparoscopy ◽

Stage Disease ◽

End Stage

In the last two decades, laparoscopy has revolutionized the field of surgery. Many procedures previously performed with an open access are now routinely carried out with the laparoscopic approach. Several advantages are associated with laparoscopic surgery compared to open procedures: reduced pain due to smaller incisions and hemorrhaging, shorter hospital length of stay, and a lower incidence of wound infections. Liver transplantation (LT) brought a radical change in life expectancy of patients with hepatic end-stage disease. Today, LT represents the standard of care for more than fifty hepatic pathologies, with excellent results in terms of survival. Surely, with laparoscopy and LT being one of the most continuously evolving challenges in medicine, their recent combination has represented an astonishing scientific progress. The intent of the present paper is to underline the current role of diagnostic and therapeutic laparoscopy in patients waiting for LT, in the living donor LT and in LT recipients.

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Outcomes of Tube Thoracostomies Performed by Advanced Practice Providers vs Trauma Surgeons

American Journal of Critical Care ◽

10.4037/ajcc2008.17.4.357 ◽

2008 ◽

Vol 17 (4) ◽

pp. 357-363 ◽

Cited By ~ 18

Author(s):

Laura C. Bevis ◽

Gina M. Berg-Copas ◽

Bruce W. Thomas ◽

Donald G. Vasquez ◽

Ruth Wetta-Hall ◽

...

Keyword(s):

Nurse Practitioners ◽

Insertion Site ◽

Physician Assistants ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Complication Rates ◽

Advanced Practice ◽

Trauma Centers ◽

Significant Difference ◽

Trauma Surgeons

Background The role of advanced registered nurse practitioners and physician assistants in emergency departments, trauma centers, and critical care is becoming more widely accepted. These personnel, collectively known as advanced practice providers, expand physicians’ capabilities and are being increasingly recruited to provide care and perform invasive procedures that were previously performed exclusively by physicians. Objectives To determine whether the quality of tube thoracostomies performed by advanced practice providers is comparable to that performed by trauma surgeons and to ascertain whether the complication rates attributable to tube thoracostomies differ on the basis of who performed the procedure. Methods Retrospective blinded reviews of patients’ charts and radiographs were conducted to determine differences in quality indicators, complications, and outcomes of tube thoracostomies by practitioner type: trauma surgeons vs advanced practice providers. Results Differences between practitioner type in insertion complications, complications requiring additional interventions, hospital length of stay, and morbidity were not significant. The only significant difference was a complication related to placement of the tube: when the tube extended caudad, toward the feet, from the insertion site. Interrater reliability ranged from good to very good. Conclusions Use of advanced practice providers provides consistent and quality tube thoracostomies. Employment of these practitioners may be a safe and reasonable solution for staffing trauma centers.

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Laparoscopic versus Open End Colostomy Closure: A Single-center Experience

The American Surgeon ◽

10.1177/000313481408000417 ◽

2014 ◽

Vol 80 (4) ◽

pp. 361-365 ◽

Cited By ~ 5

Author(s):

Peter Studer ◽

Beat SchnüRiger ◽

Melika Umer ◽

Dino KröLl ◽

Daniel Inderbitzin ◽

...

Keyword(s):

Conversion Rate ◽

Hospital Length ◽

Colostomy Closure ◽

Hospital Length Of Stay ◽

Perforated Diverticulitis ◽

Continuous Variables ◽

Single Center Experience ◽

End Colostomy ◽

Laparoscopic Closure

The aim of this study was to review our experience with laparoscopic end colostomy closure. A retrospective review of a prospectively entered database was performed. Proportions and continuous variables were compared using the Fisher's exact and the Mann-Whitney U tests, respectively. Within the study period, 53 patients underwent closure of end colostomies. The main reasons for the colonic resections were perforated diverticulitis (52.7%) and neoplasms (20.8%). In 28 patients (53%), laparoscopic closure (LC) was attempted. Demographics did not differ between the attempted LC and the primary open closure (OC) group. The conversion rate from an LC to an OC was 50 per cent (14 of 28), mostly as a result of adhesions (71.4%). Hospital length of stay (HLOS) was significantly longer for the OC than with the attempted LC group (15.4 ± 11.9 days vs 11.3 ± 8.5 days, P = 0.046). The overall complication rate was not different between the completed LC and the OC groups (43 vs 56%, P = 0.634). The majority of complications detected (91.1%) were minor and could be treated conservatively. The role of laparoscopy to close end colostomies is questionable, because the conversion rate is high. However, a shorter HLOS can be expected when laparoscopy is successful. To reduce morbidity resulting from prolonged operation times, it is crucial to convert early and pre-emptively if hostile adhesions are found.

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Obesity Is Associated with Significant Morbidity after Multiligament Knee Surgery

The Journal of Knee Surgery ◽

10.1055/s-0039-1681027 ◽

2019 ◽

Vol 33 (06) ◽

pp. 525-530

Author(s):

Jayson Lian ◽

Neel K. Patel ◽

Michael Nickoli ◽

Ravi Vaswani ◽

James J. Irrgang ◽

...

Keyword(s):

Wound Infection ◽

Lateral Meniscus ◽

Hospital Length Of Stay ◽

Categorical Variables ◽

Future Research ◽

Complication Rates ◽

Obese Patients ◽

Estimated Blood Loss ◽

Duration Of Surgery ◽

Nonobese Patients

AbstractThe objective was to report the effect of obesity, utilizing a body mass index (BMI) threshold of 35 kg/m2, on outcomes and complications of multiple ligament knee injury (MLKI). It was hypothesized that obese patients would have longer intraoperative times and hospital length of stay, greater estimated blood loss, and higher rates of wound infection requiring irrigation and debridement (I&D) and revision ligament surgery. A retrospective review was performed on 143 individuals who underwent surgery for an MLKI between 2011 and 2018 at a single academic center. Patients were included if there was a plan for potential surgical repair/reconstruction of two or more ligaments. Patients with prior surgery to the affected knee or intra-articular fracture requiring reduction and fixation were excluded. Comparisons between obese and nonobese patients were made using two-sample t-test and either chi-square or Fisher's exact test for continuous and categorical variables, respectively. Significance was set at p < 0.05. Of 108 patients meeting inclusion criteria, 83 had BMI < 35 kg/m2 and 25 had BMI ≥ 35 kg/m2. Obese patients sustained higher rates of MLKI due to ultralow velocity mechanisms (28.0 vs. 1.2%; p = 0.0001) and higher rates of concomitant lateral meniscus injury (48.0 vs. 25.3%; p = 0.04). Among patients undergoing single-staged surgery, obese patients had significantly longer duration of surgery (219.8 vs. 178.6 minutes; p = 0.02) and more wound infections requiring I&D (20.0 vs. 4.8%; p = 0.03). In contrast, nonobese patients had higher rates of arthrofibrosis requiring manipulation under anesthesia and/or arthrolysis (25.3 vs. 0%; p = 0.003). Obese patients undergoing surgery of an MLKI have longer operative times, greater rates of wound infection requiring I&D, and lower rates of arthrofibrosis. Surgeons may consider these results when counseling patients on their postoperative course and risk for complications. Future research might focus on strategies to reduce complication rates in obese patients with MLKI. This is a Level III, retrospective comparative study.

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Laparoscopic versus Open Colon Resections in California: A Cross-Sectional Analysis

The American Surgeon ◽

10.1177/000313481207801011 ◽

2012 ◽

Vol 78 (10) ◽

pp. 1063-1065 ◽

Cited By ~ 4

Author(s):

Supriya S. Patel ◽

Madhukar S. Patel ◽

Sanjit Mahanti ◽

Adrian Ortega ◽

Glenn T. Ault ◽

...

Keyword(s):

Length Of Stay ◽

Laparoscopic Colectomy ◽

Laparoscopic Approach ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Case Volume ◽

Cross Sectional ◽

Perioperative Morbidity ◽

Laparoscopic Techniques ◽

Sectional Analysis

Laparoscopic surgery is associated with decreased hospital length of stay, improved perioperative morbidity, and faster return to work compared with open procedures. Despite these benefits, laparoscopy has not been universally adopted with recent implementation estimates ranging from 10 to 30 per cent. The purpose of this study was to analyze the adoption of laparoscopic techniques for colon resections in California in 2009 based on institutional colectomy volume status. A total of 14,736 patients from 320 hospitals was analyzed. The laparoscopic to open case ratios for the low (zero to 17 cases/year), medium (18 to 50 cases/year), and high (greater than 50 cases/year) volume centers were: 0.32, 0.50, and 0.92, respectively. Although the data confirmed that a laparoscopic approach reduced length of stay (LOS) regardless of volume, lower adopters of laparoscopic colectomy had a longer overall total LOS, likely related to preponderance of open cases. Therefore, the data show that higher-volume institutions appear to have implemented laparoscopic colectomy for more of their case volume, and this adoption may account for the better institutional outcomes observed in these centers.

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