Úvodem jsou shrnuty základní aspekty předoperační přípravy nemocných před implantací náhrady kolenního kloubu. Následuje přehled zásad správné pooperační péče. Uveden je přehled nejběžněj- ších pooperačních komplikací, jako jsou poruchy hojení operační rány, různé typy infektů, instabi- lity, zlomeniny v okolí implantátu, flebotrombóza apod. Pro každou komplikaci jsou uvedeny její typické příznaky, terapeutický postup a zásady prevence vzniku. V závěru práce je uvedeno opti- mální schéma pooperačních kontrol.
In the introduction the author summarizes the basic aspects of preoperative preparation of patients before implantation of prostheses of the knee joint. This is followed by a review of principles of correct postoperative care. He gives an account of the most common postoperative complications such as impaired healing of the surgical wound, various types of infections, instability, fractures near the implant, phlebothrombosis etc. He mentions the typical symptoms of each complication as well as the therapeutic procedure and principles of prevention of its development. In the conclusion an optimal pattern of postoperative control examinations is outlined.
Úvod: Větší operace představuje pro pacienta významnou zátěž a stav výživy patří k faktorům, které mají zásadní vliv na konečný výsledek chirurgické léčby. Předoperačně zjištěná malnutrice nebo zvýšené nutriční riziko právě u této skupiny pacientů vyžaduje maximální snahu o minimalizaci tohoto negativního vlivu již před plánovanou operací. Cílem práce bylo zhodnotit míru dodržování doporučených postupů týkajících se předoperační nutriční přípravy na našem chirurgickém pracovišti. Metody: Retrospektivní deskriptivní sledování bylo zaměřeno na období od 1. 1. 2017 do 30. 6. 2020. Pacienti podstupující větší operační zákrok byli při indikaci k výkonu podrobeni nutričnímu zhodnocení pomocí dotazníku a podle dosaženého skóre byla zvolena jejich předoperační nutriční příprava. Výsledky: Ve sledovaném období bylo operováno 240 pacientů s onemocněním kolorekta a žaludku. Screening byl při indikaci k operaci proveden u 208 (87 %) z nich. Všem 125 pacientům s normálním stavem výživy byla doporučena úprava jídelníčku. Celkem 95 pacientů bylo v nutričním riziku a všem (100 %) byla předepsána ambulantní nutriční příprava pomocí sippingu. Všech 20 malnutričních pacientů (100 %) bylo připravováno k operaci za hospitalizace. Závěr: Stav výživy u pacienta před velkým chirurgickým zákrokem je jedním z predikčních ukazatelů možných komplikací. Míra dodržení doporučení ERAS týkající se nutričního screeningu a předoperační nutriční přípravy je na našem pracovišti v současné době vysoká.
Introduction: Major surgery poses a significant stress to the patient. The nutritional status is one of crucial factors that have a substantial impact on the final outcome of the surgery. Preoperatively established malnutrition or an increased nutritional risk in this group of patients requires a maximum effort to minimize this negative impact as soon as the operation is scheduled. The aim of this retrospective study was to assess compliance with guidelines focused on preoperative nutrition management at our site. Methods: Our retrospective descriptive observation was focused on the period from January 1, 2017 to June 30, 2020. All patients scheduled for major surgery were screened for nutritional status using a nutritional questionnaire, and an appropriate type of nutritional intervention was indicated based on the achieved score. Results: Two hundred and forty gastrointestinal operations were performed during the study period. In total, 208 (87%) of patients were screened at the time of counselling. Diet adjustments with an increased protein intake were recommended to all 125 (100%) patients with normal nutrition status. In total, 95 patients were at nutritional risk and sipping was prescribed to all of them (100%) in the outpatient setting. All 20 malnourished patients (100%) underwent preoperative nutritional optimization as inpatients. Conclusion: Nutritional status of patients before major surgery is considered a predictive indicator of potential postoperative complications. Compliance with recent ERAS guidelines concerning preoperative screening and nutritional support is high in our department.
BACKGROUND: Preoperative consultations by internal medicine physicians facilitate documentation of comorbid disease, optimization of medical conditions, risk stratification, and initiation of interventions intended to reduce risk. Nonetheless, the impact of these consultations, which may be performed by general internists or specialists, on outcomes is unclear. METHODS: We used population-based administrative databases to conduct a cohort study of patients 40 years or older who underwent major elective noncardiac surgery in Ontario, Canada, between 1994 and 2004. Propensity scores were used to assemble a matched-pairs cohort that reduced differences between patients who did and did not undergo preoperative consultation by general internists or specialists. The association of consultation with mortality and hospital stay was determined within this matched cohort. As a sensitivity analysis, we evaluated the association of consultation with an outcome for which no difference would be expected: postoperative wound infection. RESULTS: Of 269,866 patients in the cohort, 38.8% (n=104,695) underwent consultation. Within the matched cohort (n=191,852), consultation was associated with increased 30-day mortality (relative risk [RR], 1.16; 95% confidence interval [CI], 1.07-1.25; number needed to harm, 516), 1-year mortality (1.08; 1.04-1.12; number needed to harm, 227), mean hospital stay (difference, 0.67 days; 0.59-0.76), preoperative testing, and preoperative pharmacologic interventions. Notably, consultation was not associated with any difference in postoperative wound infections (RR, 0.98; 95% CI, 0.95-1.02). These findings were stable across subgroups as well as sensitivity analyses that tested for unmeasured confounding. CONCLUSIONS: Medical consultation before major elective noncardiac surgery is associated with increased mortality and hospital stay, as well as increases in preoperative pharmacologic interventions and testing. These findings highlight the need to better understand mechanisms by which consultation influences outcomes and to identify efficacious interventions to decrease perioperative risk.
- MeSH
- Surgical Procedures, Operative mortality MeSH
- Chronic Disease MeSH
- Length of Stay statistics & numerical data MeSH
- Adult MeSH
- Confounding Factors, Epidemiologic MeSH
- Financing, Organized MeSH
- Risk Assessment MeSH
- Confidence Intervals MeSH
- Comorbidity MeSH
- Referral and Consultation statistics & numerical data MeSH
- Middle Aged MeSH
- Humans MeSH
- Odds Ratio MeSH
- Preoperative Care methods standards statistics & numerical data MeSH
- Retrospective Studies MeSH
- Aged MeSH
- Sensitivity and Specificity MeSH
- Case-Control Studies MeSH
- Internal Medicine MeSH
- Outcome and Process Assessment, Health Care MeSH
- Check Tag
- Adult MeSH
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Aged MeSH
- Female MeSH
- Geographicals
- Ontario MeSH
OBJECTIVE: To define the influence of preoperative immune modulating nutrition (IMN) on postoperative outcomes in patients undergoing surgery for gastrointestinal cancer. BACKGROUND: Although studies have shown that perioperative IMN may reduce postoperative infectious complications, many of these have included patients with benign and malignant disease, and the optimal timing of such an intervention is not clear. METHODS: The Embase, Medline, and Cochrane databases were searched from 2000 to 2018, for prospective randomized controlled trials evaluating preoperative oral or enteral IMN in patients undergoing surgery for gastrointestinal cancer. The primary endpoint was the development of postoperative infectious complications. Secondary endpoints included postoperative noninfectious complications, length of stay, and up to 30-day mortality. The analysis was performed using RevMan v5.3 software. RESULTS: Sixteen studies reporting on 1387 patients (715 IMN group, 672 control group) were included. Six of the included studies reported on a mixed population of patients undergoing all gastrointestinal cancer surgery. Of the remaining, 4 investigated IMN in colorectal cancer surgery, 2 in pancreatic surgery, and another 2 in patients undergoing surgery for gastric cancer. There was 1 study each on liver and esophageal cancer. The formulation of nutrition used in all studies in the treated patients was Impact (Novartis/Nestlé), which contains ω-3 fatty acids, arginine, and nucleotides. Preoperative IMN in patients undergoing surgery for gastrointestinal cancer reduced infectious complications [odds ratio (OR) 0.52, 95% confidence interval (CI) 0.38-0.71, P < 0.0001, I = 16%, n = 1387] and length of hospital stay (weighted mean difference -1.57 days, 95% CI -2.48 to -0.66, P = 0.0007, I = 34%, n = 995) when compared with control (isocaloric isonitrogeneous feed or normal diet). It, however, did not affect noninfectious complications (OR 0.98, 95% CI 0.73-1.33, P = 0.91, I = 0%, n = 1303) or mortality (OR 0.55, 95% CI 0.18-1.68, P = 0.29, I = 0%, n = 955). CONCLUSION: Given the significant impact on infectious complications and a tendency to shorten length of stay, preoperative IMN should be encouraged in routine practice in patients undergoing surgery for gastrointestinal cancer.
- MeSH
- Digestive System Surgical Procedures methods MeSH
- Enteral Nutrition methods MeSH
- Gastrointestinal Neoplasms immunology therapy MeSH
- Immunologic Factors pharmacology MeSH
- Humans MeSH
- Nutritional Status * MeSH
- Postoperative Cognitive Complications prevention & control MeSH
- Preoperative Care methods MeSH
- Check Tag
- Humans MeSH
- Publication type
- Journal Article MeSH
- Meta-Analysis MeSH
- Research Support, Non-U.S. Gov't MeSH
- Systematic Review MeSH
BACKGROUND: Identifying those of patients with metastatic renal cell carcinoma (mRCC) who are most likely to benefit from cytoreductive nephrectomy (CN) is challenging. We tested the association between preoperative value of Systemic Immune-Inflammation Index (SII) and overall survival (OS) as well as cancer-specific survival (CSS) in mRCC patients treated with CN. METHODS: mRCC patients treated with CN at different institutions were included. After assessing for the optimal pretreatment SII cut‐off value, we found 710 to have the maximum Youden Index value. The overall population was therefore divided into two SII groups using this cut‐off (low, <710 vs. high, ≥710). Univariable and multivariable Cox regression analyses tested the association SII and OS as well as CSS. The discrimination of the model was evaluated with the Harrel's Concordance Index (C-Index). The clinical value of the SII was evaluated with decision curve analysis (DCA). RESULTS: Among 613 mRCC patients, 298 (49%) patients had a SII≥710. Median follow-up was 31 (IQR 16-58) months. On univariable analysis, high preoperative serum SII was significantly associated with worse OS (HR: 1.28, 95% CI: 1.07-1.54, P=0.01) and CSS (HR: 1.29, 95% CI: 1.08-1.55, P=0.01). On multivariable analysis, which adjusted for the effect of established clinicopathologic features, SII≥710 was associated with OS (HR: 1.25, 95% CI: 1.04-1.50, P=0.02) and CSS (HR: 1.26, 95% CI: 1.05-1.52, P=0.01). The addition of SII only slightly improved the discrimination of a base model that included established clinicopathologic features (C-index: 0.637 vs. 0.629). On DCA, the inclusion of SII did not improve the net-benefit of the prognostic model. On multivariable analyses, SII≥710 remained independently associated with the worse OS and CSS in IMDC intermediate risk group (both: HR: 1.31, 95% CI: 1.02-1.67, P=0.03). In the subgroup analyses based on the BMI, among patients with BMI ≥ 25, SII was significantly associated with OS (HR: 1.29, 95% CI: 1.04-1.61, P=0.02) and CSS (HR: 1.31, 95% CI: 1.05-1.63, P=0.02). CONCLUSIONS: We found an independent association of high SII prior to CN with unfavorable clinical outcomes, particularly in patients with intermediate risk mRCC and patients with increased BMI. Despite these results, it does not seem to add any prognostic or clinical benefit beyond that obtained by currently available clinicopathologic characteristics as sole worker.
- MeSH
- Cytoreduction Surgical Procedures * MeSH
- Carcinoma, Renal Cell * immunology pathology surgery MeSH
- Humans MeSH
- Kidney Neoplasms * immunology pathology surgery MeSH
- Nephrectomy * methods MeSH
- Preoperative Care MeSH
- Prognosis MeSH
- Inflammation immunology pathology MeSH
- Check Tag
- Humans MeSH
- Publication type
- Journal Article MeSH
In image-guided percutaneous interventions, a precise planning of the needle path is a key factor to a successful intervention. In this paper we propose a novel method for computing a patient-specific optimal path for such interventions, accounting for both the deformation of the needle and soft tissues due to the insertion of the needle in the body. To achieve this objective, we propose an optimization method for estimating preoperatively a curved trajectory allowing to reach a target even in the case of tissue motion and needle bending. Needle insertions are simulated and regarded as evaluations of the objective function by the iterative planning process. In order to test the planning algorithm, it is coupled with a fast needle insertion simulation involving a flexible needle model and soft tissue finite element modeling, and experimented on the use-case of thermal ablation of liver tumors. Our algorithm has been successfully tested on twelve datasets of patient-specific geometries. Fast convergence to the actual optimal solution has been shown. This method is designed to be adapted to a wide range of percutaneous interventions.
- MeSH
- Ablation Techniques MeSH
- Algorithms * MeSH
- Models, Anatomic * MeSH
- Surgery, Computer-Assisted methods MeSH
- Liver physiopathology surgery MeSH
- Humans MeSH
- Liver Neoplasms surgery MeSH
- Computer Simulation * MeSH
- Preoperative Period * MeSH
- User-Computer Interface MeSH
- Imaging, Three-Dimensional MeSH
- Check Tag
- Humans MeSH
- Publication type
- Journal Article MeSH
- Research Support, Non-U.S. Gov't MeSH
BACKGROUND: Hypoalbuminemia, a biomarker of malnutrition, has been associated with adverse surgical outcomes;, however, its impact on breast reduction surgery is not yet well-documented. METHODS: We queried the American college of surgeons national surgical quality improvement program database to identify patients who underwent breast reduction surgery between 2008 and 2022. Patients were grouped by preoperative normal albumin levels (≥3.5 g/dL) and hypoalbuminemia (<3.5 g/dL). Preoperative, intraoperative, and 30-day postoperative outcomes, including complications and readmissions, were compared using the univariate tests and multivariable logistic regression. RESULTS: We included a total of 7277 cases, among whom 96% (n = 6964) had normal albumin values and 4% (n = 298) had hypoalbuminemia (n = 298). Patients with hypoalbuminemia showed a significantly higher body mass index (37.1 ± 8.1 vs. 33.3 ± 6.3 kg/m2, p < 0.001) and were more likely to be Black or African American (49.0 vs. 27.8%, p < 0.001). Comorbidities such as diabetes (14.7 vs. 7.4%, p < 0.001), chronic obstructive pulmonary disease (4.0 vs. 1.0%, p < 0.001), and hypertension (35.2 vs. 26.3%, p = 0.002) were significantly more prevalent in the hypoalbuminemia group. Hypoalbuminemia was associated with a significantly increased risk of complications (13.8 vs. 6.1%, p < 0.001), with higher rates of superficial incisional infections (7.0 vs. 2.6%, p = 0.001) and unplanned readmissions (3.4 vs. 1.4%, p = 0.05). Multivariable analysis confirmed hypoalbuminemia as an independent predictor of postoperative complications (OR 1.96, p = 0.001), medical complications (OR 2.62, p = 0.02), and surgical complications (OR 1.91, p = 0.02). CONCLUSION: Hypoalbuminemia significantly raises the risk of 30-day postoperative complications in breast reduction surgery. Preoperative nutritional assessment and optimization are crucial in improving surgical outcomes, particularly in patients with high body mass index and comorbidities.
- MeSH
- Biomarkers blood MeSH
- Adult MeSH
- Hypoalbuminemia * complications blood MeSH
- Middle Aged MeSH
- Humans MeSH
- Mammaplasty * adverse effects methods MeSH
- Postoperative Complications * epidemiology etiology blood MeSH
- Preoperative Period MeSH
- Retrospective Studies MeSH
- Risk Factors MeSH
- Patient Readmission statistics & numerical data MeSH
- Check Tag
- Adult MeSH
- Middle Aged MeSH
- Humans MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
OBJECTIVE: To assess the value of preoperative albumin to globulin ratio for predicting pathologic and oncological outcomes in patients with upper tract urothelial carcinoma treated with radical nephroureterectomy in a large multi-institutional cohort. MATERIALS AND METHODS: Preoperative albumin to globulin ratio was assessed in a multi-institutional cohort of 2492 patients. Logistic regression analyses were performed to assess the association of the albumin to globulin ratio with pathologic features. Cox proportional hazards regression models were performed for survival endpoints. RESULTS: The optimal cut-off value was determined to be 1.4 according to a receiver operating curve analysis. Lower albumin to globulin ratios were observed in 797 patients (33.6%) compared with other patients. In a preoperative model, low preoperative albumin to globulin ratio was independently associated with nonorgan-confined diseases (odds ratio 1.32, P = 0.002). Patients with low albumin to globulin ratios had worse recurrence-free survival (P < 0.001), cancer-specific survival (P = 0.001) and overall survival (P = 0.020) in univariable and multivariable analyses after adjusting for the effect of standard preoperative prognostic factors (recurrence-free survival: hazard ratio (HR) 1.31, P = 0.001; cancer-specific survival: HR 1.31, P = 0.002 and overall survival: HR 1.18, P = 0.024). CONCLUSIONS: Lower preoperative albumin to globulin ratio is associated with locally advanced disease and worse clinical outcomes in patients treated with radical nephroureterectomy for upper tract urothelial carcinoma. As it is difficult to stage disease entity, low preoperative serum albumin to globulin ratio may help identify those most likely to benefit from intensified care, such as perioperative systemic therapy, and the extent and type of surgery.
- MeSH
- Adult MeSH
- Middle Aged MeSH
- Humans MeSH
- Urinary Bladder Neoplasms blood mortality pathology surgery MeSH
- Nephroureterectomy MeSH
- Preoperative Period MeSH
- Prognosis MeSH
- Proportional Hazards Models MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Serum Globulins analysis MeSH
- Serum Albumin analysis MeSH
- Check Tag
- Adult MeSH
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Multicenter Study MeSH
BACKGROUND: Elevated preoperative plasma levels of the angiogenesis-related marker VEGF have been associated with worse oncological outcomes in various malignancies. OBJECTIVE: To investigate the predictive/prognostic role of VEGF in patients with urothelial carcinoma of the bladder (UCB) treated with radical cystectomy (RC). DESIGN, SETTING, AND PARTICIPANTS: VEGF plasma levels were measured preoperatively in 1036 patients with UCB who underwent RC. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The correlation between plasma VEGF levels and pathological and survival outcomes was assessed using logistic regression and Cox regression analyses. Discrimination was assessed using the concordance index (C index). The clinical net benefit was evaluated using decision curve analysis (DCA). RESULTS AND LIMITATIONS: Patients with higher pretreatment plasma VEGF levels had poorer recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) according to log-rank tests (all p < 0.001). Higher VEGF levels were not independently associated with higher risk of lymph node metastasis, ≥pT3 disease, or non-organ-confined disease (all p > 0.05). Preoperative plasma VEGF levels were independently associated with RFS, CSS, and OS in preoperative and postoperative multivariable models. However, in all cases the C index increased by <0.02 and there was no improvement in net benefit on DCA. A limitation is that none of the patients received current elements of standard of care such as neoadjuvant chemotherapy. CONCLUSIONS: Elevated plasma VEGF levels were associated with features of biologically and clinically aggressive disease such as worse survival outcomes among patients with UCB treated with RC. However, VEGF appears to have relatively limited incremental additive value in clinical use. Further study of VEGF for UCB prognostication is warranted before routine use in clinical algorithms. PATIENT SUMMARY: Currently available models for predicting outcomes in bladder cancer are less than optimal. A protein called vascular endothelial growth factor (VEGF), which is a marker of the formation of blood vessels (angiogenesis), may have a role in predicting survival outcomes in bladder cancer.
- MeSH
- Cystectomy methods MeSH
- Carcinoma, Transitional Cell * pathology MeSH
- Humans MeSH
- Urinary Bladder pathology MeSH
- Urinary Bladder Neoplasms * pathology MeSH
- Vascular Endothelial Growth Factor A MeSH
- Check Tag
- Humans MeSH
- Publication type
- Journal Article MeSH
- Research Support, Non-U.S. Gov't MeSH
PURPOSE: Identifying which patients are likely to benefit from cytoreductive nephrectomy (CN) for metastatic renal cell carcinoma (mRCC) is important. We tested the association between preoperative serum De Ritis ratio (DRR, Aspartate Aminotransferase/Alanine Aminotransferase) and overall survival (OS) as well as cancer-specific survival (CSS) in mRCC patients treated with CN. MATERIAL AND METHODS: mRCC patients treated with CN at different institutions were included. After assessing for the optimal pretreatment DRR cut-off value, we found 1.2 to have the maximum Youden index value. The overall population was therefore divided into 2 DRR groups using this cut-off (low, <1.2 vs. high, ≥1.2). Univariable and multivariable Cox regression analyses tested the association between DRR and OS as well as CSS. The discrimination of the model was evaluated with the Harrel's concordance index (C-index). The clinical value of the DRR was evaluated with decision curve analysis. RESULTS: Among 613 mRCC patients, 239 (39%) patients had a DRR ≥1.2. Median follow-up was 31 (IQR 16-58) months. On univariable analysis, high DRR was significantly associated with OS (hazard ratios [HR]: 1.22, 95% confidence interval [CI]: 1.01-1.46, P = 0.04) and CSS (HR: 1.23, 95% CI: 1.02-1.47, P = 0.03). On multivariable analysis, which adjusted for the effect of established clinicopathologic features, high DRR remained significantly associated with both OS (HR: 1.26, 95% CI: 1.04-1.52, P = 0.02) and CSS (HR: 1.26, 95% CI: 1.05-1.53, P = 0.01). The addition of DRR only minimally improved the discrimination of a base model that included established clinicopathologic features (C-index = 0.633 vs. C-index = 0.629). On decision curve analysis, the inclusion of DRR did not improve the net-benefit beyond that obtained by established subgroup analyses stratified by IMDC risk groups, type of systemic therapy, body mass index and sarcomatoid features, did not reveal any prognostic value to DRR. CONCLUSION: Despite the statistically significant association between DRR and OS as well as CSS in mRCC patients treated with CN, DRR does not seem to add any further prognostic value beyond that obtained by currently available features.
- MeSH
- Alanine Transaminase blood MeSH
- Aspartate Aminotransferases blood MeSH
- Cytoreduction Surgical Procedures * MeSH
- Carcinoma, Renal Cell blood mortality secondary surgery MeSH
- Middle Aged MeSH
- Humans MeSH
- Survival Rate MeSH
- Kidney Neoplasms blood mortality pathology surgery MeSH
- Nephrectomy methods MeSH
- Preoperative Period MeSH
- Retrospective Studies MeSH
- Treatment Outcome MeSH
- Check Tag
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Research Support, Non-U.S. Gov't MeSH
