https://www.lfb.lv/files/ESVS-AAA-guidelines.pdf

Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery.

Summary Background Video-assisted thoracoscopic surgery (VATS) is used increasingly as an alternative to thoracotomy for lobectomy in the treatment of early-stage non-small-cell lung cancer, but remains controversial and worldwide adoption rates are low. Non-randomised studies have suggested that VATS reduces postoperative morbidity, but there is little high-quality evidence to show its superiority over open surgery. We aimed to investigate postoperative pain and quality of life in a randomised trial of patients with early-stage non-small-cell lung cancer undergoing VATS versus open surgery. Methods We did a randomised controlled patient and observer blinded trial at a public university-based cardiothoracic surgery department in Denmark. We enrolled patients who were scheduled for lobectomy for stage I non-small-cell lung cancer. By use of a web-based randomisation system, we assigned patients (1:1) to lobectomy via four-port VATS or anterolateral thoracotomy. After surgery, we applied identical surgical dressings to ensure masking of patients and staff. Postoperative pain was measured with a numeric rating scale (NRS) six times per day during hospital stay and once at 2, 4, 8, 12, 26, and 52 weeks, and self-reported quality of life was assessed with the EuroQol 5 Dimensions (EQ5D) and the European Organisation for Research and Treatment of Cancer (EORTC) 30 item Quality of Life Questionnaire (QLQ-C30) during hospital stay and 2, 4, 8, 12, 26, and 52 weeks after discharge. The primary outcomes were the proportion of patients with clinically relevant moderate-to-severe pain (NRS ≥3) and mean quality of life scores. These outcomes were assessed longitudinally by logistic regression across all timepoints. Data for the primary analysis were analysed by modified intention to treat (ie, all randomised patients with pathologically confirmed non-small-cell lung cancer). This trial is registered with ClinicalTrials.gov, number NCT01278888. Findings Between Oct 1, 2008, and Aug 20, 2014, we screened 772 patients, of whom 361 were eligible for inclusion and 206 were enrolled. We randomly assigned 103 patients to VATS and 103 to anterolateral thoracotomy. 102 patients in the VATS group and 99 in the thoracotomy group were included in the final analysis. The proportion of patients with clinically relevant pain (NRS ≥3) was significantly lower during the first 24 h after VATS than after anterolateral thoracotomy (VATS 38%, 95% CI 0·28–0·48 vs thoracotomy 63%, 95% CI 0·52–0·72, p=0·0012). During 52 weeks of follow-up, episodes of moderate-to-severe pain were significantly less frequent after VATS than after anterolateral thoracotomy (p vs nine patients in the thoracotomy group), re-operation for bleeding (two vs none), twisted middle lobe (one vs three) or prolonged air leakage over 7 days (five vs six), arrhythmia (one vs one), or neurological events (one vs two). Nine (4%) patients died during the follow-up period (three in the VATS group and six in the thoracotomy group). Interpretation VATS is associated with less postoperative pain and better quality of life than is anterolateral thoracotomy for the first year after surgery, suggesting that VATS should be the preferred surgical approach for lobectomy in stage I non-small-cell lung cancer. Funding Simon Fougner Hartmanns Familiefond, Guldsmed AL & D Rasmussens Mindefond, Karen S Jensens legat, The University of Southern Denmark, The Research Council at Odense University Hospital, and Department of Cardiothoracic Surgery, Odense University Hospital.

https://thelancet.com/pdfs/journals/lanonc/PIIS1470-2045(16)00173-X.pdf

Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: a randomised controlled trial

To quantify benefit and harm of epidural analgesia, compared with systemic opioid analgesia, in adults having surgery under general anesthesia.

/pdf/impact-of-epidural-analgesia-on-mortality-and-morbidity-2wgiul87hw.pdf

Impact of epidural analgesia on mortality and morbidity after surgery: systematic review and meta-analysis of randomized controlled trials.

bjective: The purpose of this systematic review was to review the evidence base for exercise in critically ill patients. Data Sources and Study Selection: Using keywords critical care and physical therapy and related synonyms, randomized controlled trials, meta-analyses, and systematic reviews were identified through electronic database searches and citation tracking. Clinical trials with outcomes of mortality, length of hospital and ICU stay, physical function and quality of life, muscle strength, and ventilator-free days were included. Data Extraction and Synthesis: Two reviewers abstracted data and assessed quality independently. Effect sizes and 95% confidence intervals were calculated. From 3,126 screened abstracts, 10 randomized controlled trials and five reviews were found. The mean Physiotherapy Evidence Database score was 5.4. Overall there was a significant positive effect favoring physical therapy for the critically ill to improve the quality of life (g = 0.40, 95% confidence interval 0.08, 0.71), physical function (g = 0.46, 95% confidence interval 0.13, 0.78), peripheral muscle strength (g = 0.27, 95% confidence interval 0.02, 0.52), and respiratory muscle strength (g = 0.51, 95% confidence interval 0.12, 0.89). Length of hospital (g = -0.34, 95% confidence interval -0.53, -0.15) and ICU stay (g = -0.34, 95% confidence interval -0.51, -0.18) significantly decreased and ventilator-free days increased (g = 0.38, 95% confidence interval 0.16, 0.59) following physical therapy in the ICU. There was no effect on mortality. Conclusion: Physical therapy in the ICU appears to confer significant benefit in improving quality of life, physical function, peripheral and respiratory muscle strength, increasing ventilator-free days, and decreasing hospital and ICU stay. However, further controlled trials of better quality and larger sample sizes are required to verify the strength of these tentative associations.

Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis

Background
Enhanced recovery programmes (ERPs) have been developed over the past 10 years to improve patient outcomes and to accelerate recovery after surgery. The existing literature focuses on specific specialties, mainly colorectal surgery. The aim of this review was to investigate whether the effect of ERPs on patient outcomes varies across surgical specialties or with the design of individual programmes.

Methods
MEDLINE, Embase, CINAHL and the Cochrane Central Register of Controlled Trials were searched from inception to January 2013 for randomized or quasi-randomized trials comparing ERPs with standard care in adult elective surgical patients.

Results
Thirty-eight trials were included in the review, with a total of 5099 participants. Study design and quality was poor. Meta-analyses showed that ERPs reduced the primary length of stay (standardized mean difference −1·14 (95 per cent confidence interval −1·45 to −0·85)) and reduced the risk of all complications within 30 days (risk ratio (RR) 0·71, 95 per cent c.i. 0·60 to 0·86). There was no evidence of a reduction in mortality (RR 0·69, 95 per cent c.i. 0·34 to 1·39), major complications (RR 0·95, 0·69 to 1·31) or readmission rates (RR 0·96, 0·59 to 1·58). The impact of ERPs was similar across specialties and there was no consistent evidence that elements included within ERPs affected patient outcomes.

Conclusion
ERPs are effective in reducing length of hospital stay and overall complication rates across surgical specialties. It was not possible to identify individual components that improved outcome. Qualitative synthesis may be more appropriate to investigate the determinants of success.

Systematic review and meta-analysis of enhanced recovery programmes in surgical patients.

Endovascular treatment (EVT) of acute traumatic lesions of the descending thoracic aorta--7 years' experience.

Background and aims
Fast-track programs have been introduced in many surgical fields to minimize postoperative morbidity and mortality. Morbidity after elective open infrarenal aneurysm repair is as high as 30%; mortality ranges up to 10%. In terms of open infrarenal aneurysm repair, no randomized controlled trials exist to introduce and evaluate such patient care programs.

/pdf/prospective-randomized-controlled-trial-to-evaluate-fast-7731yqcs9b.pdf

Prospective randomized controlled trial to evaluate "fast-track" elective open infrarenal aneurysm repair.

Seit 1996 erfolgt in der Thoraxchirurgie eine Rechnungsstellung unter Berucksichtigung von Sonderentgelten (SE). Der Gesetzgeber geht davon aus, das durch das SE die Operationskosten gedeckt sind und eine Absenkung des Pflegesatzes um 20 % gerechtfertigt ist. Zur Prufung dieser Annahme fuhrten wir eine Kostenanalyse thoraxchirurgischer Operationen durch. Fur 5 verschiedene durch Sonderentgelte erfaste Eingriffsarten, atypische Lungenresektion mit mehr als 3 entfernten Keilen (AR: n = 8), Lobektomie (LE: n = 8), Pneumonektomie (PE: n = 5), thoracoskopische atypische Resektion (VR: n = 6) und die Resektion eines Mediastinaltumors (MR: n = 3), wurden der Personal- und Sachbedarf sowie die Zeit der Operationssaalbereitstellung bei insgesamt 30 Fallen prospektiv dokumentiert. Anschliesend erfolgte anhand vorgegebener Anhaltszahlen eine Kalkulation der Gesamtkosten der jeweiligen Operation. Die Kosten fur eine LE lagen bei 9.927 DM um 4.904 DM hoher als das entsprechende SE. Die Kosten einer PE betrugen 10.562 DM, einer VR 12.477 DM und einer MR 7.532 DM – sie lagen damit um 5.539 DM, 2.435 DM bzw. 1.907 DM uber dem jeweiligen SE. Das SE fur eine AR lag um 866 DM uber den tatsachlichen Kosten von 6.922 DM. Nur bei einer kleinen Zahl thoraxchirurgischer Operationen kann von einer Kostendeckung durch das SE ausgegangen werden. Auch weiterhin mussen die Operationskosten zumindest anteilig aus dem Pflegesatz gedeckt werden.

Wie teuer sind thoraxchirurgische operationen? eine prospektive kostenanalyse thoraxchirurgischer eingriffe

Background: Despite advances in perioperative patient care major surgical procedures are still associated with certain morbidity and mortality. Open abdominal aortic aneurysm repair is related to morbidity up to 30 % and mortality up to 10 %. Further improvements by single interventions seem not to be possible. As a consequence multimodal concepts, i.e. fast track programs, have been introduced to further ameliorate patients’ outcome. As for open infrarenal aortic aneurysm repair no multimodal approaches exist to reduce morbidity and mortality. The aim of our study was therefore to establish and to evaluate a fast track program for open infrarenal aneurysm repair in a prospective, randomized and controlled trial. Methods: Patients with infrarenal aortic aneurysm and an indication for elective open repair have been randomly assigned either to a traditional or a fast track patient management. Main differences between the two groups consist in preoperative bowel preparation (none vs. 3l cleaning solution) and perioperative analgesia (epidural anesthesia in the fast track group). Study endpoints analyzed include morbidity and mortality, necessity of postoperative ventilation, length of ICU stay, time to complete food intake and patient satisfaction. Results: To date 45 patients have been enrolled — 23 for the traditional, 22 for the fast track program. Both groups are comparable in terms of age, aneurysm diameter and ASA Score. In both groups the transperitoneal as well as the retroperitoneal approach to aneurysm exclusion is performed. In the traditional group the need for postoperative ventilation is significantly increased (39 % vs. 9 %, p < 0.05) The length of ICU stay is decreased in the fast track group: 43 h vs. 21 h (median). In the fast track group parenteral nutrition could be finished earlier (2.5 vs. 5 days, median), complete oral food intake was achieved earlier (5.5 vs. 7 days, median). The median time to discharge from hospital was 10 days in the fast track, 11 days in the traditional group. Mortality in both groups was 0%, morbidity in fast track group decreased to 13.6 % vs. 39 % in the traditional group. Conclusion: For open infrarenal aneurysm repair the feasibility and safety of a fast track program could be demonstrated. In terms of postoperative ventilation a significant advantage for the fast track regimen could be detected. As for the length of ICU treatment, time to complete oral food intake and morbidity the fast track program appears to be superior to the traditional regimen.

«Fast track» in der Aneurysmachirurgie — erste Ergebnisse einer prospektiven, randomisierten und kontrollierten Studie

Seit Marz 1999 wurden bei 48 Patienten 52 Stentgraftsysteme unmittelbar posttraumatisch im Akutstadium der thorakalen Aortenruptur innerhalb der Polytraumaprimarversorgung appliziert. Bei Aortendurchmessern von 12–30 mm kamen jeweils die kleinsten Systeme der Fa. Gore, Medtronic und Cook zum Einsatz. Die primare Erfolgsrate (Abdichtung der Blutung) betrug 100%. 3 Patienten verstarben aortenunabhangig an ihren schwersten Begleitverletzungen. Von 3 gesehenen akuten Stentkompressionssyndromen verlief eines letztendlich letal. Die spezielle Problematik des jugendlichen Aortenbogens gestattet mit den zurzeit erhaltlichen Stentgraftsystemen keine ideale Anpassung an die Aortenbogenkrummung, sodass Abhebungswinkel an der inneren Kurvatur entstanden, die endsystolisch bis 63° betrugen. Dennoch lag im luckenlos erfassten Langzeitverlauf aller Patienten die Konversionsrate bis zu 10 Jahren bei 0%. Zweiteingriffe nach 30 Tagen waren ebenfalls nicht erforderlich. Zwei weitere Patienten verstarben im Langzeitverlauf nach 3 bzw. 5 Jahren nicht aortenbedingt. Alle anderen Patienten sind in einem MRT-Uberwachungsprogramm. Die Mehrzahl der Patienten ist inzwischen wieder arbeitsfahig. Alle Patienten sind wohlauf und werden regelmasig bei Nachuntersuchungsterminen gesehen. Erst der weitere Langzeitverlauf jenseits von 10 Jahren wird den endgultigen Stellenwert der gezeigten Methode bestimmen.

Endovaskuläre Versorgung der traumatischen Aortenruptur im Akutstadium

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