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PubMed1997

Comparing patient satisfaction, outcomes and costs between cataract day surgery and inpatient surgery for elderly people.

The study reported in this paper examined the characteristics of elderly people undergoing cataract surgery and compared patient perspectives and satisfaction, outcome, costs, reported health problems and social circumstances of day surgery patients and hospital inpatients. The study sample was drawn from the client database of a health insurance fund and covered 291 people aged 60 years or more who had recently undergone cataract surgery. Overall, both day surgery patients and inpatients indicated a high level of satisfaction with their eye surgery (about 80 per cent for both groups). The majority of patients from both groups reported an improved level of vision, with vision outcome in the day surgery group being as good as in the inpatient group. Overall, inpatient treatment was more costly and involved higher out of pocket expenses. The study results indicate a potential to increase the number of patients undergoing cataract surgery as a day patient procedure. Pre-operative preparation contributed to patient satisfaction and the availability of family and/or social support was an important factor influencing day surgery admission. Whilst patients reporting health problems were less inclined to have cataract surgery than were day patients, this only accounted for one-fifth of the total inpatient group. Developing systematic and appropriate case selection criteria and effective case management will contribute to more efficient use of hospital resources, an increased use of day surgery facilities, and hence a more cost-effective overall cataract surgery service for elderly people.

Aged↗

PubMed1999

Access to coronary artery bypass surgery by race/ethnicity and gender among patients who are appropriate for surgery.

OBJECTIVE: The study sought to determine if there were race/ethnicity or gender differences in access to coronary artery bypass graft (CABG) surgery among patients who have been designated as appropriate and as necessary for that surgery according to the RAND methodology. METHODS: RAND appropriateness and necessity criteria were used to identify a race/gender stratified sample of postangiography patients who would benefit from coronary artery bypass graft surgery. These patients were tracked for 3 months to determine if they had undergone coronary artery bypass graft surgery in New York State. Subjects were a total of 1,261 postangiography patients in eight New York hospitals in 1994 to 1996. Measures included percentages of patients for whom coronary artery bypass graft surgery was appropriate and necessary undergoing surgery by race/ethnicity and gender, as well as multivariate odds ratios for race/ethnicity and gender. RESULTS: After controlling for age, payer, number of vessels diseased, and presence of left main disease, African-American and Hispanic patients were found to be significantly less likely to undergo coronary artery bypass graft surgery than white non-Hispanic patients (respective odds ratios 0.64 and 0.60). When "necessity" was used as a criterion instead of "appropriateness," significant differences in access for African-American patients remained. The gatekeeper physician recommended surgery only 10% of the time that patients did not undergo "appropriate" coronary artery bypass graft surgery, and this percentage did not vary significantly by race/ethnicity or gender of the patient. CONCLUSIONS: Even after controlling for appropriateness and necessity for coronary artery bypass graft surgery in a prospective study, African-American patients had significant access problems in obtaining coronary artery bypass graft surgery. These problems appeared not to be related to patient refusals.

Black or African American↗

PubMed2006

Restoration of accommodation.

PURPOSE OF REVIEW: This review examines the current status of accommodation restoration concepts with reference to the recent, published peer-reviewed literature with an emphasis on physiological aspects of accommodation and presbyopia. RECENT FINDINGS: The mechanisms of accommodation and the causes of presbyopia are described. The physiological amenability of the accommodative structures in the presbyopic eye to accommodation restoration is discussed. General theoretical concepts of accommodation restoration are introduced. The methods that have been used to assess accommodation restoration, including the use of animal models, drug stimulated accommodation, subjective near-vision tests and objective measurements, are reviewed. SUMMARY: While physiological and clinical evidence supports the notion that accommodation can be restored to the presbyopic eye, progress in this potentially exciting area is hindered by the scarcity of good, large-scale clinical studies using objective measurement techniques to evaluate the outcomes of accommodation restoration concepts.

Accommodation, Ocular↗

PubMed1997

Colorectal surgery in the elderly: an audit of surgery in octogenarians.

BACKGROUND: Morbidity and mortality rates are higher in elderly compared to younger patients undergoing colorectal cancer surgery. This study was undertaken to see whether this finding applied to all colorectal surgery in the elderly and if so to try to identify the determining factors. METHODS: All patients undergoing colorectal surgery between 1975 and 1990 were entered into a computerized database. Patients were divided into two groups, those less than 80 years (< 80) and those 80 years and more (80+), and compared with regard to the type of surgery performed, the patient's race, the seniority of the surgeon, the patient's disease, the operation performed and the postoperative morbidity and mortality. In addition, patients undergoing major resectional surgery and patients undergoing colorectal cancer surgery were compared separately. RESULTS: Of 2011 admissions, 88 were for patients of 80+. The male to female admission rate was 1:0.79 in the < 80 group and 1:1.25 in the 80+ group. More surgical procedures were performed by consultants in older patients. More emergency admissions were for 80+ patients. Rectal, sigmoid and right colonic pathology was more common in the elderly. Very few elderly patients were admitted with minor anorectal problems. Rectal prolapse and colorectal cancer were the commonest causes for admission in octogenarians. There were more pulmonary and cardiovascular postoperative complications in 80+ patients. Urinary tract infections were also more common. The postoperative mortality rate was higher in older patients (7.9 vs 1.4%). Four hundred and sixty-two patients underwent major resectional surgery and 45 were 80+. Surgery for diverticular disease was more frequent in younger patients (13.4 vs 2.2%) and cancer surgery in older patients (93.3 vs 70.5%). The postoperative mortality rate was higher in the elderly (11.1 vs 3.6%). Three hundred and thirty-six major resections were for cancer and 42 were 80+. Emergency surgery was performed more commonly in the older group (38.1 vs 14.9%). The rate of advanced disease seemed to be similar in both groups. The postoperative death rate was higher in the elderly (11.9 vs 3.4%). CONCLUSIONS: Elderly patients were more likely to die from cardiopulmonary problems after surgical interventions than either from their primary disease or from the surgery undertaken for it. Good postoperative cardiopulmonary support should thus be provided for all such patients.

Aged↗

PubMed2006

Investigation of the stability of one-piece acrylic intraocular lenses in cataract surgery and in combined vitrectomy surgery.

BACKGROUND: To compare the degrees of intraocular lens (IOL) movement between eyes that received a one-piece acrylic IOL and those that received a three-piece acrylic IOL after cataract surgery, and also among eyes that received a one-piece acrylic IOL after a combined vitrectomy surgery for cataract. METHODS: In the first study, we report on 50 patients who were implanted with a one-piece acrylic IOL in one eye and a three-piece acrylic IOL in the contralateral eye for senile cataract. In the second study, we report on 50 patients who were implanted with a one-piece acrylic IOL in combined vitrectomy surgery for cataract and retinal diseases. The degree of IOL decentration and tilt, and anterior chamber depth (ACD) were measured using Scheimpflug video photography at 1 week, 1 month, 3 months and 6 months after surgery in both the studies. The postoperative refractive status was also examined. RESULTS: The mean decentration and tilt showed no marked changes during the follow-up in eyes with either IOL implanted, and no marked differences were noted in either study throughout the follow-up. The ACD did not change after surgery with one-piece IOL implantation, for either the cataract surgery group or the combined surgery group, except for 1 week after surgery in eyes requiring gas tamponade. In contrast, marked shallowing in ACD was observed in the three-piece group after cataract surgery. The spherical equivalent did not change markedly in either study. CONCLUSIONS: The one-piece acrylic IOL was stable in the capsular bag, both horizontally and vertically, after cataract surgery, and also after combined surgery.

Acrylic Resins↗

PubMed2002

Sham surgery controls: intracerebral grafting of fetal tissue for Parkinson's disease and proposed criteria for use of sham surgery controls.

Sham surgery is a controversial and rarely used component of randomised clinical trials evaluating surgical interventions. The recent use of sham surgery in trials evaluating efficacy of intracerebral fetal tissue grafts in Parkinson's disease has highlighted the ethical concerns associated with sham surgery controls. Macklin, and Dekkers and Boer argue vigorously against use of sham surgery controls. Macklin presents a broad argument against sham surgery controls while Dekkers and Boer present a narrower argument that sham surgery is unnecessary in the specific setting of fetal tissue engraftment for Parkinson's disease. I defend sham surgery controls against both these criticisms. Appropriate clinical trial design, sometimes including sham surgery, is needed to ensure that false positive trial results do not occur and endanger public safety. Results of a completed trial of fetal tissue grafting for Parkinson's disease are used to illustrate the potential benefits of, and problems associated with, sham surgery controls. Sham surgery controls, however, should be employed only when absolutely necessary. I suggest criteria for appropriate use of sham surgery controls.

Brain Tissue Transplantation↗

PubMed2000

Endovascular sclerotherapy, surgery, and surgery plus sclerotherapy in superficial venous incompetence: a randomized, 10-year follow-up trial--final results.

The study was planned to evaluate efficacy and costs of endovascular sclerotherapy (ES) in comparison with surgery and surgery associated with sclerotherapy in a prospective (10-year follow-up), good-clinical-practice study. Patients with varicose veins and pure, superficial venous incompetence were included. Of the patients randomized into the three groups 39 (group A) were treated with ES, 40 (B) with surgery + sclerotherapy, and 42 with surgery only (C). Surgery consisted of ligation of the SFJ (saphenofemoral junction) and of incompetent veins detected with color duplex. Of the preselected 150 patients, 121 subjects entered the study; 96 completed the 10-year follow-up (mean age 52.6 +/- 6 years; 51 men, 45 women). Dropouts were due to nonmedical problems. At 10 years no incompetence was observed in subjects treated with SPJ ligation (B and C). In the ES group 18.8% of the SFJs were patent and incompetent and in 43.8% of limbs the distal (below-knee) venous system was still incompetent [16.1% in the surgery + sclerotherapy group (p < 0.05) and 36% in the group treated with surgery only (p < 0.05 vs B and 0.05 vs A)]. Color duplex of the long saphenous vein indicated atrophy or obstruction of a segment (average 6.7 cm) after SFJ ligation (4.2 cm after ES). The cost of ES was 68% of surgery while the cost of surgery and sclerotherapy was 122% of surgery only. Endovascular sclerotherapy is an effective, cheaper treatment option, but surgery after 10 years is superior.

Adult↗

PubMed2001

Antibiotic prophylaxis in clean surgery: breast surgery and hernia repair.

Use of prophylactic antibiotics in clean surgery is still controversial. We reviewed the literature of the last 10 years to identify the best way to approach clean surgery. The question is more important for patients undergoing breast surgery. The presence of an infected breast wound delays the beginning of postoperative adjuvant anticancer therapy: there is good evidence to suggest that delayed adjuvant therapy compromises the outcome for patients in terms of both local control and survival. There are several clinical trials that have addressed the efficacy of prophylactic antibiotics for patients undergoing breast surgery and hernia repair. Platt et al assessed the efficacy of preoperative antibiotic prophylaxis in a clinical trial of 1218 patients undergoing clean surgery with an absolute reduction rate of 39% in wound infections. Gupta et al reported no influence on the incidence of infective complications by antibiotic prophylaxis in 357 patients undergoing elective breast surgery. Like breast surgery, use of prophylaxis in hernia repair is not clear: a prospective, randomized, double-blind, multicenter study of 619 patients assessed no benefit of antibiotic prophylaxis. On the other hand Lewis et al reported a 75% reduction of infections in low-risk patients when a single dose of cefotaxime was used in clean operations. A particularly interesting point is the use of prosthetic mesh in hernia repair and primary reconstructive surgery in breast surgery. Amland et al reported a significant reduction of the incidence of wound infections in a group of patients undergoing reconstructive breast surgery, receiving azithromycin vs placebo (5% vs 20%). In hernia repair we stress the need to prevent wound infections: currently Liechtestein's technique is widely performed all over the world. Mesh infection is an unpleasant event that requires prosthesis removal. The lack of conclusive studies about antibiotic prophylaxis in clean surgery suggests that a single-dose of cephalosporin at the induction of anesthesia may be prudent. This procedure is certainly inexpensive and safe and, more importantly, probably does not have an impact on antibiotic resistance.

Anti-Bacterial Agents↗

PubMed2003

[Elective laparoscopic surgery in diverticular disease. A comparative study with conventional operative surgery ].

BACKGROUND: Elective surgery in diverticular disease (DD) consists classically in performing an open sigmoidectomy. Laparoscopic surgery of the colon can have results that are comparable to those of open surgery. AIM: To compare the results of laparoscopic and conventional surgery for DD. MATERIALS AND METHODS: Retrospective review of preoperative, operative and postoperative variables of patients operated by laparoscopic surgery between the years 2000 and 20002. These results were compared with those of patients treated with conventional surgery in the same period. RESULTS: Thirty nine patients, mean age 59 years old, were operated via laparotomy and 18 patients, mean age 47 years old, were treated with laparoscopic surgery. Both groups were comparable in gender, amount of previous laparotomies, type of surgery performed and American Society of Anestesiologists classification. The operative time was significantly higher in the laparoscopic surgery group (230 v/s 130 min), but the opioid requirements, stay in an intensive surgical care ward, postoperative ileus and hospital stay were significantly shorter in the laparoscopic group. Eleven percent of the patients included in the laparoscopic group and 31% of the patients treated with operative surgery had complications (p = 0.07). The length of the excised colon, the degree of inflammation and treatment costs were comparable. CONCLUSIONS: Laparoscopic surgery in DD is feasible, safe, requires less analgesia and allows a faster recovery of post-operative ileus and a lower hospital stay.

Adult↗

PubMed1991

MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. European Carotid Surgery Trialists' Collaborative Group.

The European Carotid Surgery Trial is a multicentre trial of carotid endarterectomy for patients who, after a carotid territory non-disabling ischaemic stroke, transient ischaemic attack, or retinal infarct, are found to have a stenotic lesion in the relevant (ipsilateral) carotid artery. Over the past 10 years 2518 patients have been randomised, and the mean follow-up is now almost 3 years among the 2200 thus far available for analysis of the incidence of strokes that lasted more than 7 days. For the patients with "moderate" (30-69%) stenosis on their prerandomisation angiogram the balance of surgical risk and eventual benefit remains uncertain, and full recruitment continues. For 374 patients with only "mild" (0-29%) stenosis there was little 3-year risk of ipsilateral ischaemic stroke, even in the absence of surgery, so any 3-year benefits of surgery were small, and were outweighed by its early risks. For 778 patients with "severe" (70-99%) stenosis, however, the risks of surgery were significantly outweighed by the later benefits: although 7.5% had a stroke (or died) within 30 days of surgery, during the next 3 years the risks of ipsilateral ischaemic stroke were (by life-table analysis) an extra 2.8% for surgery-allocated and 16.8% for control patients (a sixfold reduction, p less than 0.0001). There was also a small reduction in other strokes, and at 3 years the total risk of surgical death, surgical stroke, ipsilateral ischaemic stroke, or any other stroke was 12.3% for surgery and 21.9% for control (difference 9.6% SD 3.3, 2p less than 0.01). The main concern was to avoid disabling or fatal events, and, among severe stenosis patients, 3.7% had a disabling stroke (or died) within 30 days of surgery, an extra 1.1% surgery versus 8.4% control (p less than 0.0001) had a disabling or fatal ipsilateral ischaemic stroke by 3 years, and the total 3-year risk of any disabling or fatal stroke (or surgical death) was 6.0% surgery versus 11.0% control (overall difference 5.0% SD 2.3, 2p less than 0.05); but, for disabling or fatal stroke the control risks seemed to diminish after the first year, so delay of surgery by just a few months after clinical presentation might make this overall difference non-significant.

Arterial Occlusive Diseases↗

PubMed1998

[Ambulatory surgery in French public hospitals. Present and future. "Public hospitals" group of the French Association of Ambulatory Surgery].

OBJECTIVES: To assess ambulatory surgery practices in France, make an inventory of projects for the creation of ambulatory structures and analyze the perception of different hospital personnel of ambulatory surgery. METHODS: A questionnaire was sent to 541 public hospitals with a surgery unit in France. The first part of the questionnaire was used to record current activity and existing projects for ambulatory surgery. The questionnaire also collected opinions concerning the analysis of difficulties encountered and possibilities offered by ambulatory surgery. RESULTS: Overall participation rate was 59%. Ambulatory surgery was practised in 81% of the hospitals. Sixty-six percent had a projects under consideration, including several at the decision making stage (17%). 1550 ambulatory surgery clinics could be created by the year 2000. In 66% of the cases, the future facility would be integrated into the traditional surgery unit. There was favorable opinion concerning the development of ambulatory surgery clinics in public hospitals in 83% of the cases. Inconveniences suggested generally involved organizational aspects, particularly concerning medical organization. Foreseen obstacles to the development of ambulatory surgery clinics were regulatory procedures, unfavorable exchange rate, insufficient investment funds and the lack of a policy favoring their development. CONCLUSION: The development of ambulatory surgery clinics in public hospitals in France can be expected in the near future. Budgeting and regulatory procedures must however be adapted to promote implementation of the existing projects.

Attitude of Health Personnel↗

PubMed2004

[From the French Society of Plastic and Reconstructive Surgery to the French Society of Plastic Reconstructive and Aesthetic Surgery].

(The) 3rd December 1952, 11 surgeons and other specialists found the French Society of Plastic and Reconstructive Surgery (SFCPR) which was officially published on (the) 28 September 1953. The first congress was during October 1953 and the first president as Maurice Aubry. The first secretary was Daniel Morel Fatio. The symposiums were after about three of four times each year and the thematic subjects were initially according the reconstructive surgery. The review "Annales de chirurgie plastique" was free in 1956. The members of the Society were about 30 initially, but their plastic surgery in the big hospitals at Paris and other big towns in France. The "specialty" of plastic surgery was created in 1971. On "syndicate", one French board of plastic reconstructive and aesthetic surgery, the increasing of departments of plastic surgery were the front of increasing of the plastic surgery in French and of the number of the French Society of Plastic Reconstructive surgery (580 in 2003). The French Society organized the International Congress of Plastic Surgery in 1975. The society SFCPR became the French Society of plastic reconstruction and Aesthetic Surgery (SFCPRE) in 1983 and the "logo" (front view) was in the 1994 SOF.CPRE.

Congresses as Topic↗

PubMed2004

Redefining the future of trauma surgery as a comprehensive trauma and emergency general surgery service.

BACKGROUND: Dwindling operative opportunities in trauma care may have a detrimental impact on career satisfaction among trauma surgeons and on career attractiveness to surgical trainees. Addition of emergency general surgery may alleviate some of these concerns. STUDY DESIGN: The trauma service at our institution incorporated nontrauma emergency general surgery over a 3-year period. The institution's trauma registry and hospital perioperative database were queried. The changes in operative caseload are described. Current trauma faculty anonymously completed a Web-based questionnaire about the addition of emergency general surgery to the trauma service. RESULTS: Operations for trauma decreased in 2002 compared with 1999, despite a higher number of penetrating injuries and total trauma contacts. Nontrauma general surgery operations performed by trauma faculty increased in proportion to coverage provided by the trauma service. In 2002, 57% of all cases performed by trauma surgeons were emergency general surgery, which accounted for 32% to 74% of an individual surgeon's caseload. In anonymously completed Web-based questionnaires, current trauma faculty expressed satisfaction with the combined trauma and emergency general surgery model. CONCLUSIONS: The combined trauma and nontrauma surgery service increased operative caseloads and improved satisfaction of trauma surgeons. A comprehensive trauma and emergency general surgery service may be an attractive model for the future of trauma surgery and provide logistical and medical advantages to the emergency general surgery patient population.

Clinical Competence↗

PubMed2004

Safety and efficacy of median sternotomy versus video-assisted thoracic surgery for lung volume reduction surgery.

BACKGROUND: The National Emphysema Treatment Trial, a randomized trial comparing lung volume reduction surgery with medical therapy for severe emphysema, included randomized and nonrandomized comparisons of the median sternotomy and video-assisted thoracoscopic approaches for lung volume reduction surgery. METHODS: Lung volume reduction surgery was performed by median sternotomy only at 8 centers and video-assisted thoracoscopy only at 3 centers; 6 centers randomized the approach to lung volume reduction surgery. Mortality, morbidity, functional status, and costs were assessed. RESULTS: In the nonrandomized comparison, 359 patients received lung volume reduction surgery by median sternotomy, and 152 patients received lung volume reduction surgery by video-assisted thoracoscopy. The 90-day mortality was 5.9% for median sternotomy and 4.6% for video-assisted thoracoscopy (P =.67). Overall mortality was 0.08 deaths per person-year for median sternotomy and 0.10 deaths per person-year for video-assisted thoracoscopy (video-assisted thoracoscopy-median sternotomy risk ratio, 1.18; P =.42). Complication rates were low and not statistically different for the 2 approaches. The median hospital length of stay was longer for median sternotomy than for video-assisted thoracoscopy (10 vs 9 days; P =.01). By 30 days after surgery, 70.5% of median sternotomy patients and 80.9% of video-assisted thoracoscopy patients were living independently (P =.02). Functional outcomes were similar for median sternotomy and video-assisted thoracoscopy at 12 and 24 months. Costs for the operation and the associated hospital stay and costs in the 6 months after surgery were both less for video-assisted thoracoscopy than for median sternotomy (P <.01 in both cases). Similar results were noted for the randomized comparison. CONCLUSIONS: Morbidity and mortality were comparable after lung volume reduction surgery by video-assisted thoracoscopy or median sternotomy, as were functional results. The video-assisted thoracoscopic approach to lung volume reduction surgery allowed earlier recovery at a lower cost than median sternotomy.

Aged↗

PubMed2005

Mortality data in adult cardiac surgery for named surgeons: retrospective examination of prospectively collected data on coronary artery surgery and aortic valve replacement.

OBJECTIVES: To present named surgeon mortality for isolated first time coronary artery surgery and aortic valve surgery. DESIGN: Retrospective analysis of prospectively collected data. SETTING: All NHS hospitals undertaking adult cardiac surgery in north west England. PARTICIPANTS: 25 consultant surgeons carrying out coronary artery surgery and aortic valve replacement between April 2001 and March 2004. MAIN OUTCOME MEASURES: Mortality for both operations according to surgeon. EuroSCORE to stratify patients into low and high risk. RESULTS: 10,163 patients underwent surgery under 25 surgeons. The average number of patients per surgeon was 363 for coronary artery surgery and 44 for aortic valve replacement. Seventeen per cent of the patients undergoing coronary artery surgery and half of those undergoing aortic valve surgery were considered high risk. The average mortality was 1.8% (range 0-3.8%) for coronary surgery and 1.9% (0-12.5%) for aortic valve surgery. Mortality for all surgeons fell below 99% control limits of the national mean for both operations. CONCLUSIONS: The presented mortality figures for the two cardiac operations fell within accepted limits for all surgeons. The division of outcomes according to low and high risk patients is imperfect but may help to inform the public about the complexities of this type of analysis and prevent surgeons avoiding high risk patents who may benefit from an operation.

Adult↗

PubMed2001

Surgery for ulcerative colitis in elderly persons: changes in indications for surgery and outcome over time.

HYPOTHESIS: Medical therapy has changed the indications for surgery over the last 4 decades. Advances in perioperative care have significantly improved the outcome. DESIGN: The medical records of all patients 65 years and older who underwent surgery for ulcerative colitis during a 40-year period were analyzed retrospectively. SETTING: Tertiary referral center. PATIENTS: One hundred thirteen consecutive patients 65 years and older who underwent surgery for ulcerative colitis between January 1, 1960, and June 30, 1999. MAIN OUTCOME MEASURES: Changes in elective and urgent indications for surgery. Changes over time in outcome and the factors that brought about these changes. Predictors of poor outcome in an elderly population with ulcerative colitis. RESULTS: One hundred thirteen patients were divided into 3 cohorts of 38, 38, and 37 consecutive patients admitted to the hospital during the periods 1960 through 1984, 1985 through 1993, and 1994 through 1999, respectively. Indications for surgery and morbidity and mortality rates have changed with time. Dysplasia has replaced carcinoma as a major indication for elective surgery (P =.001). Toxic megacolon has become significantly less common as an indication for urgent surgery (P =.001). Surgery-associated adverse outcomes have decreased significantly from 50% (13% deaths, 37% major complications) to 27% (3% deaths, 24% major complications) (P =.04). Male sex, an albumin level of 2.8 g/dL or less, and urgent surgery were found to be independent predictors of poor outcome. CONCLUSIONS: In our referral center, the indications for urgent and elective surgery have changed during the past 4 decades from toxic megacolon and carcinoma, to disease refractory, to medical therapy and dysplasia, respectively. Morbidity and mortality have decreased dramatically over time. Urgent procedures, low levels of albumin, and male sex are all predictors of poor outcome.

Aged↗

PubMed2000

Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures.

BACKGROUND: Antibiotic prophylaxis has been established policy for major surgical operations for many years. In fracture fixation, the effectiveness, and the duration of administration, have been a matter of debate. OBJECTIVES: To assess the effects of the prophylactic administration of antibiotics in patients undergoing surgical management of hip or other long bone fractures. SEARCH STRATEGY: We searched MEDLINE, EMBASE, Current Contents, Dissertation Abstracts, and Index to UK Theses, and bibliographies of identified articles. Trials were also obtained from the Cochrane Musculoskeletal Injuries Group trials register. Date of the most recent search: end of 1997. SELECTION CRITERIA PARTICIPANTS: Any patients with a hip or other closed long bone fracture undergoing surgery for internal fixation or replacement arthroplasty. INTERVENTIONS: Any regimen of systemic antibiotic prophylaxis administered at the time of surgery. OUTCOME MEASURES: Wound infection (deep and superficial), urinary tract infection, respiratory tract infection, adverse effects of prophylaxis, economic evaluations. DATA COLLECTION AND ANALYSIS: Both reviewers independently selected trials for inclusion, and assessed methodological quality and extracted data. Where possible, data were pooled and Peto odds ratios and absolute risk reductions, each with 95% confidence intervals, calculated. MAIN RESULTS: Twenty one randomised trials of only poor or moderate quality were included. The comparisons tested fell within six comparison groups, principally multiple dose or a single dose of antibiotic versus a placebo or no treatment. Antibiotic prophylaxis reduces wound, urinary and respiratory tract infections in patients undergoing surgery for closed fracture fixation. Economic modelling has indicated that this is a cost-effective intervention. There are limited data for the incidence of adverse effects, but as expected they appear to be more common in those receiving antibiotics. REVIEWER'S CONCLUSIONS: Antibiotic prophylaxis should be offered to those undergoing surgery for closed fracture fixation. On ethical grounds, further placebo controlled randomised trials of the effectiveness of antibiotic prophylaxis in closed fracture surgery are unlikely to be justified. Trials addressing the cost-effectiveness of different effective antibiotic regimens would need to be very large and may not be feasible.

Antibiotic Prophylaxis↗

PubMed2005

[Digestive surgery and varicose vein surgery].

The thromboembolic risk related to surgery may be considered as low for varicose vein surgery and non major digestive surgery. It could be defined as moderate in case of large dissection, long duration of procedures and emergency cases. The risk may be considered as high for major abdominal surgery involving cancer surgery or not and bariatric surgery. The absence of prophylaxis can be proposed for low risk surgery (grade B). However, elastic compression stocking are effective for all cases of digestive surgery and suggested to be used (grade A). There are no data concerning the moderate risk situation. Therefore, experts recommend the use of elastic compression stockings or low doses of LMWH (grade D). High-risk surgery requires the use of high doses of LMWH recommended for reasons of efficacy, tolerance, and easiness to use (grade A). Associated elastic stockings is efficious (grade B). The duration of prophylaxis lasts generally 7-10 days. Extension to 1 month is recommended for major abdominal cancer surgery (grade A).

Ambulatory Surgical Procedures↗