Suchergebnisse

Background: Healthcare processes in hospitals, likewise processes in companies or governmental organizations, may accumulate problems and obstacles over time, which consequently cause the processes to become ineffective. BPM (Business Process Management) is an approach to process modeling, improvement and automating, which has been used with great success for process improvement. Methods: This work was to examine the possibility of improving healthcare process by using BPM. To implement BPM ideas, a revised TAD (Tabular Application Development) methodology was developed, representing an important contribution to BPM. The first three phases of the TAD methodology were introduced in a step-bystep approach. The first phase deals with process identification, the second develops the "as-is" model, and the third phase discusses process improvement by developing a "to-be" model. Results: We found that (a) the Surgery process is efficient and well organized; (b) patient stay in the Department could be shortened; however for humane and social reasons the leadership prefers to leave the residence time as it is; (c) the process is associated with some time-consuming activities that are performed by other departments and represent the bottleneck of the process. Conclusions: The following were concluded (a) BPM proved to be a suitable approach for carrying out healthcare process improvement; (b) the revised TAD methodology showed to be consistent and efficient in performing BPM approach; (c) The Surgery process discussed was found to be an effective one and no changes or improvements are needed; (d) Concerning time-consuming activities, the leadership decided to discuss this problem with the management of the departments where the activities are executed.

BACKGROUND: Gastrointestinal paralysis, nausea and vomiting and pain are major clinical problems following abdominal surgery. Anaesthetic and analgesic techniques that reduce pain and postoperative nausea and vomiting (PONV), while preventing or reducing postoperative ileus, may reduce postoperative morbidity, duration of hospitalization and hospital costs. This review was first published in 2001 and was updated by new review authors in 2016. OBJECTIVES: To compare effects of postoperative epidural analgesia with local anaesthetics versus postoperative systemic or epidural opioids in terms of return of gastrointestinal transit, postoperative pain control, postoperative vomiting, incidence of anastomotic leak, length of hospital stay and costs after abdominal surgery. SEARCH METHODS: We identified trials by conducting computerized searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 12), MEDLINE (from 1950 to December 2014) and EMBASE (from 1974 to December 2014) and by checking the reference lists of trials retained. When we reran the search in February 2016, we added 16 potential new studies of interest to the list of 'Studies awaiting classification' and will incorporate these studies into formal review findings during the next review update. SELECTION CRITERIA: We included parallel randomized controlled trials comparing effects of postoperative epidural local anaesthetic versus regimens based on systemic or epidural opioids. DATA COLLECTION AND ANALYSIS: We rated the quality of studies by using the Cochrane 'Risk of bias' tool. Two review authors independently extracted data and judged the quality of evidence according to the GRADE (Grades of Recommendation, Assessment, Development and Evaluation Working Group) scale. MAIN RESULTS: We included 128 trials with 8754 participants in the review, and 94 trials with 5846 participants in the analysis. Trials included in the review were funded as follows: charity (n = 19), departmental resources (n = 8), governmental sources (n = 15) ...

Background: The burden of HIV/AIDS in Sub-Saharan Africa has presented unusual and challenging acute surgical problems across all specialties. Thoraco-abdominal surgery cuts through muscle and thereby disrupts the normal anatomy and activity of the respiratory muscles leading to reduced lung volumes and putting the patients at greater risk of developing post-operative pulmonary complications (PPCs). PPCs remain an important cause of post-operative morbidity, mortality, and impacts on the long-term outcomes of patients post hospital discharge. The objective of the study was to determine the pulmonary complications developing after abdominal and thoracic surgery and the associated risks factors. Methods: A retrospective records review of all abdominal and thoracic surgery patients admitted at a central hospital from January 2014 to October 2014 was done. Data collected included demographic data, surgical history, comorbidities and the PPCs present. Results: Out of the 92 patients whose records were reviewed, 55 (59.8%) were males and 84 (91.3%) had abdominal surgery. The mean age of the patients was 42.6 years (SD = 18.4). The common comorbidities were HIV infection noted in 14(15.2%) of the patients and hypertension in 10 (13.0%). Thirty nine (42.4%) developed PPCs and the most common complications were nosocomial pneumonia in 21 (22.8%) patients, ventilator associated pneumonia in 11 (12.0%), and atelectasis in 6 (6.5%) patients. Logistic regression showed that a history of alcohol consumption, prolonged surgery, prolonged stay in hospital or critical care unit, incision type, and comorbidities were significant risk factors for PPCs (p < 0.05). The mortality rate was 10.9%. Conclusion: PPCs like nosocomial and ventilator associated pneumonia were common and were associated with increased morbidity and adversely affected clinical outcomes of patients. HIV and hypertension presented significant comorbidities which the health team needed to recognize and address. Strategies to reduce the occurrence of PPCs have to be implemented through coordinated efforts by the health practitioners as a team during the entire perioperative period.

This open access book looks at the dramatic history of ovariotomy, an operation to remove ovarian tumours first practiced in the early nineteenth century. Bold and daring, surgeons who performed it claimed to be initiating a new era of surgery by opening the abdomen. Ovariotomy soon occupied a complex position within medicine and society, as an operation which symbolised surgical progress, while also remaining at the boundaries of ethical acceptability. This book traces the operation's innovation, from its roots in eighteenth-century pathology, through the denouncement of those who performed it as 'belly-rippers', to its rapid uptake in the 1880s, when ovariotomists were accused of over-operating. Throughout the century, the operation was never a hair's breadth from controversy.

BACKGROUND : Advances in intra-abdominal pressure (IAP) measurement have enabled better monitoring and physiological manipulation of patients with intra-abdominal hypertension or abdominal compartment syndrome. This study aimed to determine the correlation between transvesical (TV), transgastric (TG) and direct transperitoneal (TP) IAP monitoring at different IAPs in porcine models. OBJECTIVES : To assess the statistical agreement between TV, TG and TP pressure monitoring in a pneumoperitoneum and an intestinal obstruction intra-abdominal hypertension model at different IAPs. METHODS : Fifty-nine pigs were divided into six groups: a control group (Cr; n=5), three pneumoperitoneum groups at pressures of 20 mmHg, 30 mmHg, and 40 mmHg (Pn20, Pn30, Pn40; n=40), and two intestinal-occlusion groups at pressures of 20 mmHg and 30 mmHg (Oc20, Oc30; n=14). IAP was simultaneously measured in each pig using the three methods at different times. The control group did not have any intervention to increase the IAP. Intra-class correlation was used to assess agreement between the methods. RESULTS : At pressures >20 mmHg, all three methods showed good correlation with each other (Pn20=0.87; Pn30=0.96; Pn40=0.88; Oc20=0.69; Oc30=0.86). Correlation between TP and TG (Cr=0.0; Pn20=0.85; Pn30=0.94; Pn40=0.90; Oc20=0.78; Oc30=0.78); TP and TV (Cr=0.0; Pn20=0.83; Pn30=0.95; Pn40=0.86; Oc20=0.59; Oc30=0.88); and importantly between TV and TG (Cr=0.0; Pn20=0.95; Pn30=0.98; Pn40=0.88; Oc20=0.69; Oc30=0.91) was good. CONCLUSION : All three measurement methods showed good correlation at pressures >20 mmHg and were unaffected by the type of IAP model. These results suggest that either transvesical or transgastric pressure measurements can be used for IAP measurement when TP pressures are >20 mmHg. ; Grant from Extremadura Regional Government through the Plan Regional de Investigación de Extremadura (PRI09A161 to Minimally Invasive Surgery Center Jesús Usón). ; http://www.sajcc.org.za ; am2018 ; Statistics

A case is presented where a patient referred to the General Surgery Service from the Luanda Main Military Hospital, Angola, has suffered a great loss of abdominal wall, fibrinopurulent peritonitis and severe sepsis due to firearm abdominal wound, and had improved its general condition in spite of divergent criteria about its state. ; Se presenta un paciente atendido en el Servicio de Cirugía General del Hospital Militar Principal de Luanda, Angola, con gran pérdida de la pared abdominal, peritonitis fibrino-purulenta y sepsis grave debido a una herida abdominal (ocasionada por un arma de fuego) que evoluciona favorablemente, a pesar de criterios diferentes ante su grave estado.

WOS: 000442113000012 ; PubMed: 28196654 ; Adrenal hemorrhage following blunt abdominal trauma is extremely rare. Most of the lesions are unilateral and right sided. Although often asymptomatic, life-threatening adrenal insufficiency may develop in the bilateral adrenal gland hemorrhage. Isolated adrenal injuries are very rare. They are often associated with other organ injuries. The mortality rates of patients range from 7% to 32%. In this report, we present the computed tomography and magnetic resonance imaging findings of unilateral adrenal hemorrhages in two patients with a history of fall from a height. (c) 2017 Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. Production and hosting by Elsevier B.V.

Gastrointestinal Stromal Tumour involving rectum and anal canal is an extremely rare entity. This is a case report of a 47 years lady presented with fresh rectal bleed associated with rectal pain and foul smelling rectal mucus discharge. On rectal examination, she had a firm mass palpable about 1.5 cm from anal verge. Considering the size of the tumour and its close proximity with cervix and involvement of levator muscles, extralevator abdominal perineal excision of rectum was undertaken with good recovery after surgery. It was followed by imatinib therapy.

This project by the ICVR (International Consortium of Vascular Registries), a collaboration of 11 vascular surgical quality registries, was designed to evaluate international variation in the contemporary management of abdominal aortic aneurysm (AAA) with relation to recommended treatment guidelines from the Society for Vascular Surgery and the European Society for Vascular Surgery. ; Registry data for open and endovascular AAA repair (EVAR) during 2010 to 2013 were collected from 11 countries. Variations in patient selection and treatment were compared across countries and across centers within countries. ; Among 51 153 patients, 86% were treated for intact AAA (iAAA) and 14% for ruptured AAA. Women constituted 18% of the entire cohort (range, 12% in Switzerland-21% in the United States; P<0.01). Intact AAAs were repaired at diameters smaller than recommended by guidelines in 31% of men (<5.5 cm; range, 6% in Iceland-41% in Germany; P<0.01) and 12% of women with iAAA (<5 cm; range, 0% in Iceland-16% in the United States; P<0.01). Overall, use of EVAR for iAAA varied from 28% in Hungary to 79% in the United States (P<0.01) and for ruptured AAA from 5% in Denmark to 52% in the United States (P<0.01). In addition to the between-country variations, significant variations were present between centers in each country in terms of EVAR use and rate of small AAA repair. Countries that more frequently treated small AAAs tended to use EVAR more frequently (trend: correlation coefficient, 0.51; P=0.14). Octogenarians made up 23% of all patients, ranging from 12% in Hungary to 29% in Australia (P<0.01). In countries with a fee-for-service reimbursement system (Australia, Germany, Switzerland, and the United States), the proportions of small AAA (33%) and octogenarians undergoing iAAA repair (25%) were higher compared with countries with a population-based reimbursement model (small AAA repair, 16%; octogenarians, 18%; P<0.01). In general, center-level variation within countries in the management ...

OBJECTIVES: Inflammation is critical in the pathogenesis of abdominal aortic aneurysm (AAA) disease. Combined (18)F-fludeoxyglucose ((18)F-FDG) positron emission tomography with computed tomography (PET-CT) and ultrasmall superparamagnetic particles of iron oxide (USPIO)-enhanced magnetic resonance imaging (MRI) are non-invasive methods of assessing tissue inflammation. The aim of this study was to compare these techniques in patients with AAA. MATERIALS AND METHODS: Fifteen patients with asymptomatic AAA with diameter 46 ± 7 mm underwent PET-CT with (18)F-FDG, and T2*-weighted MRI before and 24 hours after administration of USPIO. The PET-CT and MRI data were then co-registered. Standardised uptake values (SUVs) were calculated to measure (18)F-FDG activity, and USPIO uptake was determined using the change in R2*. Comparisons between the techniques were made using a quadrant analysis and a voxel-by-voxel evaluation. RESULTS: When all areas of the aneurysm were evaluated, there was a modest correlation between the SUV on PET-CT and the change in R2* on USPIO-enhanced MRI (n = 70,345 voxels; r = .30; p < .0001). Although regions of increased (18)F-FDG and USPIO uptake co-localised on occasion, this was infrequent (kappa statistic 0.074; 95% CI 0.026-0.122). (18)F-FDG activity was commonly focused in the shoulder region whereas USPIO uptake was more apparent in the main body of the aneurysm. Maximum SUV was lower in patients with mural USPIO uptake. CONCLUSIONS: Both (18)F-FDG PET-CT and USPIO-MRI uptake identify vascular inflammation associated with AAA. Although they demonstrate a modest correlation, there are distinct differences in the pattern and distribution of uptake, suggesting a differential detection of macrophage glycolytic and phagocytic activity respectively. ; This research was supported by grants from the National Institutes of Health Research (NIHR) Efficacy and Mechanism Evaluation Programme (11/20/03), the British Heart Foundation (PG/09/083) and the Evelyn Trust (09/22). Dr. McBride is supported by the Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine. Dr. Joshi is supported by Chief Scientist Office (ETM/160). Dr. van Beek is supported by the Scottish Imaging Network e a Platform of Scientific Excellence. The work of Dr. Rudd is part-supported by the NIHR Cambridge Biomedical Research Centre, the British Heart Foundation and the Wellcome Trust. Dr. Newby is supported by the British Heart Foundation (CH/09/002). The Wellcome Trust Clinical Research Facility and the Clinical Research Imaging Centre are supported by National Health Service Research Scotland through National Health Service Lothian. ; This is the final version of the article. It first appeared from Elsevier via http://dx.doi.org/10.1016/j.ejvs.2015.12.018

For many reasons, laparoscopic surgery has been performed worldwide. Due to logistical constraints its first steps occurred in Lubumbashi only in 2008. The aim of this presentation was to report authors' ten-month experience of laparoscopic surgery at Lubumbashi Don Bosco Missionary Hospital (LDBMH): problems encountered and preliminary results. The study was a transsectional descriptive work with a convenient sampling. It only took in account patients with abdominal surgical condition who consented to undergo laparoscopic surgery and when logistical constraints of the procedure were found. Independent variables were patients' demographic parameters, staff, equipments and consumable. Dependent parameters included surgical abdominal diseases, intra-operative circumstances and postoperative short term mortality and morbidity. Between 1(st)April 2009 and 28(th) February 2010, 75 patients underwent laparoscopic surgery at the LDBMH making 1.5% of all abdominal surgical activities performed at this institution. The most performed procedure was appendicectomy for acute appendicitis (64%) followed by exploratory laparoscopy for various abdominal chronic pain (9.3%), adhesiolysis for repeated periods of subacute intestinal obstruction in previously laparotomised patients (9.3%), laparoscopic cholecystectomy for post acute cholecystitis on gall stone (5.3%) and partial colectomy for symptomatic redundant sigmoid colon (2.7%). There were 4% of conversion to laparotomy. Laparoscopic surgery consumed more time than laparotomy, mostly when dealing with appendicitis. However, postoperatively, patients did quite well. There was no death in this series. Nursing care was minimal with early discharge. These results are encouraging to pursue laparoscopic surgery with DRC Government and NGO's supports. ; Peer reviewed

We report the case of a four years-old female proceeding from rural nor-oriental Colombia, without previous medical history, who was admitted to our institution with an abdominal mass that was noted one month previous to the consult, associated to ictericia, weight loss and hiporexia. A bilateral Wilms tumor was documented on diagnostic images. The patient received preoperative chemotherapy and was treated with bilateral partial nephrectomy. ; En este artículo se reporta el caso de una niña de cuatro años de edad, sin antecedentes perinatales o patológicos de importancia, procedente de área rural, en la región nororiental de Colombia, quien ingresó al Hospital Militar Central de Bogotá, Colombia, remitida por un cuadro de cinco meses de evolución que inició con tinte ictérico, pérdida de peso e hiporexia. Posteriormente, distensión abdominal y masa palpable abdominal de un mes de evolución. Por imágenes diagnósticas se documenta tumor de Wilms bilateral, el cual se trata con quimioterapia preoperatoria y nefrectomía parcial bilateral.

For today damage control surgery is an actual and original direction of the modern medical science and practical medicine. The purpose of our research is representation of possible dangers and complications, that can develop in the group of seriously injured patients with damages of internal organs and further bleeding from these organs. In the same time in our work indicates the list of urgent measures, that necessary to realize in such cases. The material of research were injured persons after severe combined, associated and multiple damages with bleeding from internal organs. Among them considerable rate were persons, who got gunshort wounds, including abdominal cavity, during military actions. In our work used analytic method of investigation. One of danger of damage control surgery is hypothermia. It leads to cardiac arrhythmia, decreasing of cardiac output, supresses immune system also. Long term hypoperfusion of injured persons provokes anaerobic metabolism and development of lactate acidosis. Traumatic damages causing disorders of blood coagulation and fibrinolysis balance. In such cases develops coagulopathy. In considerable amount of cases an enumerated dangers appear simultaneously. Such symptom complex named as ―lethal triad‖. The most severe complication of damage control surgery is appearance of abdominal compartment – syndrome. In remote postoperative period stated a cases of abdominal burst and suppuration of operational wounds. Thus, timely diagnosing and correction of ―lethal triad‖ leads to increasing of survival frequency of severe injured persons; during revealing of dangers and complications of damage control surgery all efforts should be directed on restoration of physiologic processes in the patients. ; Вступ. На сьогодні хірургія damage control представляє собою актуальний та своєрідний напрям сучасної медичної науки та практичної медицини.Мета дослідження. Ознайомлення з можливими небезпеками та ускладненнями, які можуть розвиватися у категорії важко травмованих пацієнтів з пошкодженнями внутрішніх органів і подальшою кровотечою з них. Водночас у роботі вказується перелік невідкладних заходів, які необхідно реалізувати у таких випадках.Матеріали та методи дослідження. Матеріалом дослідження були травмовані особи, які перенесли важкі комбіновані, поєднані, також множинні пошкодження з кровотечою з внутрішніх органів. Серед них значний відсоток становили особи, які отримали вогнепальні поранення, в тому числі черевної порожнини, під час бойових дій. У роботі був застосований аналітичний метод дослідження. Однією з небезпек хірургії damage control є гіпотермія. Вона призводить до серцевої аритмії, зменшення серцевого викиду, також пригнічує імунну систему. Тривала гіпоперфузія травмованих осіб зумовлює анаеробний метаболізм та розвиток лактатного ацидозу. Травматичні пошкодження спричиняють порушення балансу зсідання та протизсідання крові. При цьому розвивається коагулопатія. У значній кількості випадків вищевказані небезпеки виникають водночас. Такий симптомокомплекс називається «летальна тріада». Найважчим ускладненням хірургії damage control є виникнення абдомінального компартмент-синдрому. У віддаленому післяопераційному періоді констатовано випадки евентерації та нагноєння операційних ран. Отже, вчасне діагностування та корекція «летальної тріади» призводить до збільшення частоти виживання важко травмованих осіб; при виявленні небезпек та ускладнень хірургії damage control всі зусилля повинні бути спрямовані на відновлення фізіологічних процесів у пацієнтів.

For today damage control surgery is an actual and original direction of the modern medical science and practical medicine. The purpose of our research is representation of possible dangers and complications, that can develop in the group of seriously injured patients with damages of internal organs and further bleeding from these organs. In the same time in our work indicates the list of urgent measures, that necessary to realize in such cases. The material of research were injured persons after severe combined, associated and multiple damages with bleeding from internal organs. Among them considerable rate were persons, who got gunshort wounds, including abdominal cavity, during military actions. In our work used analytic method of investigation. One of danger of damage control surgery is hypothermia. It leads to cardiac arrhythmia, decreasing of cardiac output, supresses immune system also. Long term hypoperfusion of injured persons provokes anaerobic metabolism and development of lactate acidosis. Traumatic damages causing disorders of blood coagulation and fibrinolysis balance. In such cases develops coagulopathy. In considerable amount of cases an enumerated dangers appear simultaneously. Such symptom complex named as ―lethal triad‖. The most severe complication of damage control surgery is appearance of abdominal compartment – syndrome. In remote postoperative period stated a cases of abdominal burst and suppuration of operational wounds. Thus, timely diagnosing and correction of ―lethal triad‖ leads to increasing of survival frequency of severe injured persons; during revealing of dangers and complications of damage control surgery all efforts should be directed on restoration of physiologic processes in the patients. ; Вступ. На сьогодні хірургія damage control представляє собою актуальний та своєрідний напрям сучасної медичної науки та практичної медицини.Мета дослідження. Ознайомлення з можливими небезпеками та ускладненнями, які можуть розвиватися у категорії важко травмованих пацієнтів з пошкодженнями внутрішніх органів і подальшою кровотечою з них. Водночас у роботі вказується перелік невідкладних заходів, які необхідно реалізувати у таких випадках.Матеріали та методи дослідження. Матеріалом дослідження були травмовані особи, які перенесли важкі комбіновані, поєднані, також множинні пошкодження з кровотечою з внутрішніх органів. Серед них значний відсоток становили особи, які отримали вогнепальні поранення, в тому числі черевної порожнини, під час бойових дій. У роботі був застосований аналітичний метод дослідження. Однією з небезпек хірургії damage control є гіпотермія. Вона призводить до серцевої аритмії, зменшення серцевого викиду, також пригнічує імунну систему. Тривала гіпоперфузія травмованих осіб зумовлює анаеробний метаболізм та розвиток лактатного ацидозу. Травматичні пошкодження спричиняють порушення балансу зсідання та протизсідання крові. При цьому розвивається коагулопатія. У значній кількості випадків вищевказані небезпеки виникають водночас. Такий симптомокомплекс називається «летальна тріада». Найважчим ускладненням хірургії damage control є виникнення абдомінального компартмент-синдрому. У віддаленому післяопераційному періоді констатовано випадки евентерації та нагноєння операційних ран. Отже, вчасне діагностування та корекція «летальної тріади» призводить до збільшення частоти виживання важко травмованих осіб; при виявленні небезпек та ускладнень хірургії damage control всі зусилля повинні бути спрямовані на відновлення фізіологічних процесів у пацієнтів.