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H Kehlet

Publications and source records attributed to H Kehlet.

At least 73 records · Page 4Linked to original sources
PubMed2001

Quality assessment of 26,304 herniorrhaphies in Denmark: a prospective nationwide study.

BACKGROUND: Groin hernia repair is one of the most frequent operations, but there is no consensus about surgical or anaesthetic technique. Furthermore, no nationwide studies have been done. Our aim was to investigate outcome results of groin hernia surgery to improve quality of treatment. METHODS: We prospectively recorded 26304 groin hernia repairs done in Denmark from Jan 1, 1998, to June 30, 2000, in a nationwide Danish hernia database. FINDINGS: 93% of all groin herniorrhaphies done in Denmark in the 30 months of the study were recorded in the database. Kaplan-Meier estimates of reoperation rates 30 months after anterior mesh repair and laparoscopic repair were significantly lower than after sutured posterior wall repairs in primary inguinal hernia (2.2% and 2.6% vs 4.4%; p<0.0001). Reoperation rates were also lower with anterior mesh repair (6.1%; p<0.0001) and laparoscopic repair (3.4%; p<0.0001) than with sutured posterior wall repair (10.6%) after recurrent hernia. Use of Lichtenstein mesh repair increased from 33% in January, 1998, to 62% in June, 2000, whereas use of laparoscopic repair remained constant at about 5%. Kaplan-Meier estimates of reoperation rates were 2.8% in the first 15 months and 1.6% in the second (p=0.03). For elective repairs, only 59% of patients were treated on an outpatient basis, and only 18% had local anaesthesia. INTERPRETATION: Mesh repairs have a lower reoperation rate than conventional open repairs. Systematic prospective recording of treatment and outcome variables in a national clinical database improved the overall quality of surgical care. However, there is a large potential for cost savings and more efficient patient care with extended use of mesh techniques, outpatient surgery, and local anaesthesia.

Adult↗
PubMed2001

[Abbreviated surgical stay programs--a professional and administrative challenge].

Accelerated surgical stay programs represent a multi-modal, multi-disciplinary concept to reduce postoperative morbidity, hospitalisation and convalescence based upon recent advantages in surgical pathophysiology and pain treatment. Preliminary data from a variety of surgical procedures suggest major improvements in quality of surgical care and cost reduction and call for further controlled or large-size multicenter studies.

Convalescence↗
PubMed2001

[Surgical physiopathology. New results of importance for optimization of the postoperative course].

Complications after major surgery may be related to factors in the surgical stress response with endocrine-metabolic and inflammatory changes. In order to prevent these complications, it is important to understand the stress reaction of each organ system. The inflammatory response may be partly prevented by a minimal invasive surgical technique or by preoperative administration of high-dose steroids. Prevention of the endocrine-metabolic changes is best achieved with neural blockade. Unimodal intervention cannot eliminate morbidity and mortality after major surgery. Thus, multi-modal intervention with attenuation of the surgical stress response, effective dynamic treatment of pain, enforced mobilisation, and nutrition should be employed when possible.

Humans↗
PubMed2001

[Accelerated rehabilitation after colon resection].

INTRODUCTION: The stay in hospital after colonic resection is usually 7-12 days, with a complication rate of 20%. A multi-modal rehabilitation regimen, comprising epidural analgesia, early mobilisation, and oral nutrition, reduced the hospital stay to 2-3 days after colonic resection. METHODS: One hundred patients underwent elective colonic resection with a planned postoperative stay of two days in hospital and a regimen with epidural analgesia, oral nutrition, and mobilisation. Anaesthesia, the surgical technique, and nursing care programme were standardised. Postoperative follow-up visits were arranged for day 8 and day 30. RESULTS: The median age was 73 years. Forty patients were at high risk, ASA III-IV. Gastrointestinal function (defecation) occurred within 48 hours, except for five patients, and the median hospital stay was two days. The readmission rate was 18% with no acute, potentially lethal conditions. The total hospital stay was three days. None of the patients had cardiopulmonary complications, except for one patient, who died from cardiac failure 36 hours after surgery. Three patients had anastomotic dehiscence, two of whom were treated conservatively. CONCLUSION: The usual postoperative ileus, "medical complications", and hospital stay were reduced in high-risk patients undergoing colonic resection with a multi-modal rehabilitation programme. These results call for further comparative studies with conventional care programmes and laparoscopic colonic resection.

Adult↗
PubMed2001

[Laparoscopic surgery--an update of current status].

Recent developments have allowed most intra-abdominal procedures to be performed by the laparoscopic technique. Potential clinical advantages are supported by the reduced pathophysiological changes demonstrated in the surgical stress response, as compared with open surgery. However, a critical assessment of randomised, controlled studies and meta-analyses comparing laparoscopic and open surgery has not convincingly shown that laparoscopic surgery improves the outcome, except in a few operations. Because the concept of minimal invasive surgery is based on well-documented pathophysiological advantages, future randomised studies comparing laparoscopic and open surgery should include a revision of perioperative care regimens with early rehabilitation, in order to demonstrate more significant benefits of laparoscopic surgery.

Appendectomy↗
PubMed2001

[Accelerated surgical stay programs. A professional and administrative challenge].

Accelerated surgical stay programs represent a multi-modal, multi-disciplinary concept to reduce postoperative morbidity, hospitalisation and convalescence based upon recent advantages in surgical pathophysiology and pain treatment. Preliminary data from a variety of surgical procedures suggest major improvements in quality of surgical care and cost reduction and call for further controlled or large-size multi-center studies.

Convalescence↗
PubMed2001

Factors determining convalescence after uncomplicated laparoscopic cholecystectomy.

HYPOTHESIS: Detailed information on duration and limiting factors for convalescence after uncomplicated laparoscopic cholecystectomy is lacking. Duration of convalescence may be associated with patients' expectations, given recommendations, and postoperative complaints such as pain and fatigue. DESIGN: Prospective, descriptive study. SETTING: A university hospital. PATIENTS: Two hundred consecutive patients who underwent uncomplicated elective laparoscopic cholecystectomy. INTERVENTION: For sedentary, light, or moderate workload or main recreational activity, we recommended 2 days of postoperative convalescence; for strenuous workload or recreational activity, we recommended 1 week. MAIN OUTCOME MEASURES: Duration and reasons for absence from work. RESULTS: Convalescence from work (n = 85) and recreational activity (n = 198) was 6 days (range, 0-28 days) and 2 days (range, 0-24 days), respectively, in patients recommended for 2 days' convalescence. In patients recommended for 1 week of convalescence, convalescence from work (n = 25) was 10 days (range, 0-52 days), and convalescence from main recreational activity (n = 2), 8 days (range, 5-11 days). Among 87 patients who resumed work or activity later than recommended, pain was a contributory cause in 41 patients, fatigue in 35 patients, and convalescent period falling on a weekend in 26 patients, while 29 patients had arranged vacation or sick leave preoperatively. Preoperative expectation of convalescence and pain were independent contributory factors (P<.01) for convalescence from work for longer than 2 days in patients recommended for 2 days' convalescence. CONCLUSIONS: The period of convalescence after uncomplicated laparoscopic cholecystectomy is about 1 week from work and 2 days from recreational activity when 2 days of convalescence is recommended. Improved pain relief and patient information may further reduce convalescence.

Adult↗
PubMed2001

Laparoscopic cholecystectomy causes less sleep disturbance than open abdominal surgery.

BACKGROUND: The aim of this study was to examine subjective sleep quality before and after laparoscopic vs open abdominal surgery. METHODS: Twelve patients undergoing laparoscopic cholecystectomy and 15 patients undergoing laparotomy were evaluated with the aid of a sleep questionnaire from 4 days before until 4 weeks after surgery. RESULTS: Following laparoscopic surgery, total sleep time increased during the 1st week after the operation compared with preoperative values (p = 0.02), whereas sleep duration during weeks 2, 3, and 4 did not differ from the times reported preoperatively. Following laparotomy, sleep duration increased during the 1st, 3rd, and 4th weeks after the operation compared with preoperative values (p < 0.05). All patients experienced postoperative circadian sleep disturbance, with significantly more sleep during the daytime compared with preoperative values; the disturbance was present 1 week after laparoscopy and 4 weeks after laparotomy. CONCLUSIONS: After laparotomy, total sleep time increased and there was a change in diurnal sleep distribution. These sleep alterations were less pronounced after laparoscopic cholecystectomy. Thus, sleep architecture was disturbed for ?4 weeks after major abdominal surgery but for only 1 week after laparoscopic cholecystectomy.

Abdomen↗
PubMed2001

Operative findings in recurrent hernia after a Lichtenstein procedure.

BACKGROUND: Recurrence after inguinal herniorraphy continues to be a problem, although the Lichtenstein technique (anterior, open fixated sheet mesh) is associated with reduced recurrence rates. Recurrence after Lichtenstein repair is suspected to be caused by insufficient fixation and overlap at the pubic tubercle. METHODS: A review was made of 87 records from operations for recurrence after a previous Lichtenstein procedure, based upon national and large area data bases, recording 95% (Denmark) and 50% (Sweden) of all inguinal hernia operations. RESULTS: Direct recurrences were found in 62%, whereas the remaining recurrences were either indirect (17%), femoral (13%), or other/unclassified (8%). CONCLUSION: The most plausible explanation for the development of the direct recurrences is an insufficient medial mesh fixation and overlap over the pubic tubercle. Avoidance of more than half of the recurrences after the Lichtenstein repair may be obtained by increased attention to this specific technical aspect of the operation.

Hernia, Inguinal↗
PubMed2001

Review of postoperative ileus.

Postoperative ileus (POI) is an inevitable adverse consequence of surgical procedures. In fact, prolonged POI can lead to patient discomfort, decreased mobility, delayed enteral feeding, and ultimately, prolonged hospitalizations and increased costs. It is believed that POI occurs as a result of inhibitory neural reflexes and inflammatory processes. The use of postoperative opioids also appears to contribute to ileus. Recently, the potential influence of endogenous opioids, in addition to exogenous opioids, on the pathogenesis of ileus has come to light and spurred investigations into new treatment strategies. Over the years, several treatment modalities have become accepted management options for POI; chief among these are nasogastric suction and prokinetic agents. However, data demonstrating that these agents reduce the duration of POI are limited. Of current treatment modalities, use of epidural local anesthetics appears to be the most effective means of reducing POI. Other potentially effective treatments include early enteral feeding and less invasive surgical procedures. Together, these techniques have reduced the length of stay after colonic surgery to 2 to 3 days. Future studies, including those incorporating investigational agents, such as kappa-opioid agonists and peripheral mu-opioid antagonists, into a multimodal regimen, may offer new treatment options to further impact POI duration.

Analgesics, Opioid↗
PubMed2001

Fast track hysterectomy.

OBJECTIVE: To identify factors limiting early discharge after laparoscopically assisted vaginal hysterectomy (LAVH) and abdominal hysterectomy, in a fast track setting with emphasis on information, treatment of pain, early mobilization, and early food intake. STUDY DESIGN: A prospective, descriptive study of 32 unselected women allocated to either abdominal hysterectomy (n=16) or LAVH (n=16). The patients received the same information, care, and advice for the perioperative period except for an assumed 1-day hospital stay in the LAVH-group and 2 days in the abdominal group. RESULTS: Patients were discharged median 1 day (1-3) after LAVH and 2 days (2-4) after abdominal hysterectomy. Work was resumed median 23 days after abdominal hysterectomy and 28 days after LAVH (P > 0.05). CONCLUSIONS: The study questions the previously proposed advantages of shortened hospitalization and convalescence after LAVH compared with abdominal hysterectomy. Further studies with active rehabilitation are needed to demonstrate real differences between laparoscopic and open hysterectomy.

Adult↗
PubMed2001

Normal gastrointestinal transit after colonic resection using epidural analgesia, enforced oral nutrition and laxative.

BACKGROUND: Postoperative ileus usually lasts for 2-5 days after colonic surgery and may contribute to discomfort and pulmonary complications. With multimodal rehabilitation (epidural analgesia, early oral nutrition and mobilization, and laxative) defaecation occurs 1-2 days after colonic surgery. The aim of this study was to assess the transit rate of the entire gastrointestinal tract after colonic resection with multimodal rehabilitation. METHODS: Gastrointestinal motility was assessed by means of a scintigraphic method in 12 patients undergoing open colonic resection with multimodal rehabilitation and in 12 matched healthy volunteers. After intragastric or oral administration of 4 MBq 111In-labelled diethylenetriamine penta-acetic acid, images of the abdomen were taken at 24 and 48 h with a double-headed gamma camera. RESULTS: Patient and volunteer demographics were similar. The first defaecation occurred a median of 1 day after operation in the patients. Some 57 per cent of the tracer was excreted in faeces of patients and 53 per cent in faeces of volunteers (P > 0.05) within 48 h, indicating rapid recovery of the entire gastrointestinal motility after colonic resection with multimodal rehabilitation. CONCLUSION: This study documents early normalization of the entire gastrointestinal motility assessed by an 111In scintigraphic method in patients undergoing open colonic resection with a multimodal rehabilitation programme.

Aged↗
PubMed2001

Feasibility of local infiltration anaesthesia for recurrent groin hernia repair.

OBJECTIVE: To describe the the feasibility of and patients' satisfaction with day case repair of recurrent inguinal hernias under unmonitored local anaesthesia. DESIGN: Prospective study. SETTING: Public service university hospital, Denmark. SUBJECTS: All patients with a reducible recurrent inguinal or femoral hernia unselectedly referred for elective repair during the 4-year period 1 September 1994 to 31 August 1998. INTERVENTIONS: Data were collected prospectively and consecutively from standardised, detailed files, a questionnaire 4 weeks postoperatively, and the Copenhagen Hospitals electronic patient data management system. MAIN OUTCOME MEASURES: Feasibility of local anaesthesia in the day case setting, patient satisfaction and morbidity. RESULTS: 215 consecutive operations for recurrent hernias were performed under unmonitored local anaesthesia. No conversion to general anaesthesia took place and no patients developed urinary retention. After 207 operations, the patients were discharged on the day of operation (96%), and the median time from the end of operation to discharge was 90 minutes (IQR 75-140). After 6 operations (3%), patients had complications that required surgical intervention. The 4-week questionnaire was returned after 208 operations (97%). 30 patients were dissatisfied, mainly because of intraoperative pain (17 patients, 8%). No mortality or cardiopulmonary morbidity was recorded during the first 30 days postoperatively. CONCLUSIONS: Open day-case repair of recurrent inguinal hernias can safely be conducted under unmonitored local anaesthesia with minimal morbidity. Intraoperative pain is the main topic that requires improvement.

Aged↗
PubMed2001

Pain and convalescence after laparoscopic cholecystectomy.

Pain and speed of convalescence are the two main problems after uncomplicated laparoscopic cholecystectomy. We therefore identified interventional and descriptive studies in electronic databases and supplemented them with manual searches. Pain and interventional analgesic studies were analysed with reference to the effects on specific pain components after laparoscopic cholecystectomy. Convalescence and factors associated with early recovery were also analysed. Pain after cholecystectomy is most intense for the first 2-3 days with a high interindividual variability and dominated by incisional pain rather than other pain components. Early pain after cholecystectomy is reduced by minimising residual pneumoperitoneum and by giving incisional local anaesthetics, epidural analgesia, and non-steroidal anti-inflammatory drugs. There are inconclusive data about type and pressure of pneumoperitoneum, the use of intraperitoneal local anaesthetics, and the type of general anaesthesia. Pain and medico-cultural traditions are the main factors responsible for prolonged convalescence after laparoscopic cholecystectomy. To minimise pain and the duration of convalescence, we recommend multi-modal analgesic treatment in combination with short, standardised instructions to resume work and normal activity.

Analgesics↗
PubMed2001

Postural stability after inguinal herniorrhaphy under local infiltration anaesthesia.

OBJECTIVE: To investigate postural stability in patients after inguinal herniorrhaphy under local infiltration anaesthesia, to see if the anaesthetics and analgesics used influenced it and therefore hindered early discharge. DESIGN: Open study. SETTING: Teaching hospital, Denmark. SUBJECTS: 55 patients listed for elective inguinal herniorrhaphy. INTERVENTIONS: Preoperative and intraoperative infiltration anaesthesia by bupivacaine 2.5 mg/ml (median dose 41 ml, range 30-84 ml), and sedation with midazolam intraoperatively (median dose 3 mg, range 0-10 mg). Lichtenstein tension-free technique with polypropylene mesh repair (Prolene). Measurement of postural stability before operation and 30 and 60 minutes afterwards using the "Basic Balance Master" system, and balance assessed by visual analogue scale and verbal rating scale. MAIN OUTCOME MEASURES: Postural stability and subjectively assessed balance. RESULTS: Dynamic postural stability was impaired 30 min (p < 0.05), but not 60 minutes postoperatively. All but two patients were discharged shortly after the measurement at 60 minutes, because of pain in one and an attack of asthma in the other. Balance also returned to normal within an hour. CONCLUSION: Objectively measured postural stability and subjectively assessed balance return to normal within 60 minutes after inguinal herniorrhaphy under local infiltration anaesthesia, thereby permitting early discharge.

Adult↗
PubMed2001

Multimodal perioperative management--combining thoracic epidural analgesia, forced mobilization, and oral nutrition--reduces hormonal and metabolic stress and improves convalescence after major urologic surgery.

We sought in this prospective study to use a multimodal approach to reduce stress and improve recovery in patients undergoing major surgery. During an initial study period, 30 patients were randomly allocated to receive general anesthesia (GA; Group 1) or a combination of GA and intraoperative thoracic epidural analgesia (TEA; Group 2) when undergoing radical cystectomy. Parenteral nutrition was provided for 5 days after surgery. During the second period, 15 patients were treated with a multimodal approach (Group 3) consisting of intraoperative GA and TEA, postoperative patient-controlled TEA, early oral nutrition, and enforced mobilization. Data for plasma and urine catecholamines, plasma cortisol, the nitrogen balance, the postoperative inflammatory nutrition index, pain relief, fatigue, sleep, overnight recovery, recovery of bowel function, and mobilization were recorded up to the fifth postoperative day. Plasma concentrations of catecholamines and cortisol were comparable in all patients, but those in Group 3 had lower levels of urinary catecholamine excretion. Protein intake was more effective with parenteral nutrition. Nitrogen balances were less negative, and the postoperative inflammatory nutrition index score increased significantly in the traditional groups but not in Group 3. Multimodally treated patients reported less fatigue and better overnight recovery. Along with improved pain relief, recovery of bowel function, and ambulation, there were no differences in the postoperative complication rates among the three groups. The multimodal approach reduced stress and improved metabolism and recovery after radical cystectomy.

Adult↗