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Biomedical subjects

H Kehlet

Publications and source records attributed to H Kehlet.

At least 109 records · Page 6Linked to original sources
PubMed2000

A clinical pathway to accelerate recovery after colonic resection.

OBJECTIVE: To investigate the feasibility of a 48-hour postoperative stay program after colonic resection. SUMMARY BACKGROUND DATA: Postoperative hospital stay after colonic resection is usually 6 to 12 days, with a complication rate of 10% to 20%. Limiting factors for early recovery include stress-induced organ dysfunction, paralytic ileus, pain, and fatigue. It has been hypothesized that an accelerated multimodal rehabilitation program with optimal pain relief, stress reduction with regional anesthesia, early enteral nutrition, and early mobilization may enhance recovery and reduce the complication rate. METHODS: Sixty consecutive patients undergoing elective colonic resection were prospectively studied using a well-defined postoperative care program including continuous thoracic epidural analgesia and enforced early mobilization and enteral nutrition, and a planned 48-hour postoperative hospital stay. Postoperative follow-up was scheduled at 8 and 30 days. RESULTS: Median age was 74 years, with 20 patients in ASA group III-IV. Normal gastrointestinal function (defecation) occurred within 48 hours in 57 patients, and the median hospital stay was 2 days, with 32 patients staying 2 days after surgery. There were no cardiopulmonary complications. The readmission rate was 15%, including two patients with anastomotic dehiscence (one treated conservatively, one with colostomy); other readmissions required only short-term observation. CONCLUSION: A multimodal rehabilitation program may significantly reduce the postoperative hospital stay in high-risk patients undergoing colonic resection. Such a program may also reduce postoperative ileus and cardiopulmonary complications. These results may have important implications for the care of patients after colonic surgery and in the future assessment of open versus laparoscopic colonic resection.

Adult↗
PubMed1999

[Hospitalization and convalescence after hysterectomy. Open or laparoscopic surgery?].

Approximately 6,000 hysterectomies are performed per year in Denmark. The major part of these are performed by laparotomy, although the use of laparoscopically assisted techniques is increasing. Laparoscopic surgery seems to lead to a reduction in the need for postoperative hospitalization and convalescence, which is confirmed in the few available randomised and to our knowledge all retrospective studies. The length of stay seems to be reduced from four to two days if the patient is hysterectomised by the laparoscopically assisted or vaginal techniques. The introduction of endoscopic techniques has caused a change in routines and recommendations, but not for women operated by the classical open procedures. In this article we question the relevance of comparing different types of operations given the fact that the routines and recommendations are different.

Convalescence↗
PubMed1999

Effect of preoperative abstinence on poor postoperative outcome in alcohol misusers: randomised controlled trial.

OBJECTIVE: To evaluate the influence of preoperative abstinence on postoperative outcome in alcohol misusers with no symptoms who were drinking the equivalent of at least 60 g ethanol/day. DESIGN: Randomised controlled trial. SETTING: Copenhagen, Denmark. SUBJECTS: 42 alcoholic patients without liver disease admitted for elective colorectal surgery. INTERVENTIONS: Withdrawal from alcohol consumption for 1 month before operation (disulfiram controlled) compared with continuous drinking. MAIN OUTCOME MEASURES: Postoperative complications requiring treatment within the first month after surgery. Perioperative immunosuppression measured by delayed type hypersensitivity; myocardial ischaemia and arrhythmias measured by Holter tape recording; episodes of hypoxaemia measured by pulse oximetry. Response to stress during the operation were assessed by heart rate, blood pressure, serum concentration of cortisol, and plasma concentrations of glucose, interleukin 6, and catecholamines. RESULTS: The intervention group developed significantly fewer postoperative complications than the continuous drinkers (31% v 74%, P=0.02). Delayed type hypersensitivity responses were better in the intervention group before (37 mm2 v 12 mm2, P=0.04), but not after surgery (3 mm2 v 3 mm2). Development of postoperative myocardial ischaemia (23% v 85%) and arrhythmias (33% v 86%) on the second postoperative day as well as nightly hypoxaemic episodes (4 v 18 on the second postoperative night) occurred significantly less often in the intervention group. Surgical stress responses were lower in the intervention group (P</=0.05). CONCLUSIONS: One month of preoperative abstinence reduces postoperative morbidity in alcohol abusers. The mechanism is probably reduced preclinical organ dysfunction and reduction of the exaggerated response to surgical stress.

Adult↗
PubMed1999

Early discharge after external anal sphincter repair.

PURPOSE: The aim of this study was to describe an accelerated-stay program for repair of the external anal sphincter. METHODS: Twenty consecutive patients undergoing overlapping repair of the external anal sphincter were included in the study. Effect parameters were length of hospitalization and complications within 30 days after the operation. Surgery was performed during the period of March 1993 to May 1997. The accelerated-stay program included preoperative information, no premedication, a surgical procedure without colostomy, single-dose prophylactic antibiotics, paracetamol for analgesia, free oral fluid and food immediately after the operation supplemented by laxatives, and enforced mobilization. Follow-up by questionnaire was performed at a median of 14 (range, 4-52) months after the operation. RESULTS: Median hospital stay was one day. Fifteen patients were discharged the day after surgery and 5 patients stayed for 48 hours after the operation. There was no 30-day morbidity, and no patient received a colostomy in conjunction with the sphincter repair. Fourteen of 19 patients available for follow-up reported a significantly improved functional result compared with preoperative state. CONCLUSION: We have described a safe accelerated-stay program (24 to 48 hours) for overlapping repair of external anal sphincter.

Anal Canal↗
PubMed1999

Surgical stress response: does endoscopic surgery confer an advantage?

"Open" surgical procedures are followed by profound changes in endocrine metabolic function and various host defense mechanisms, impaired pulmonary function, and hypoxemia. These physiologic changes are supposed to be involved in the pathogenesis of postoperative morbidity. Endoscopic surgery, mostly studied during laparoscopy, when compared with similar open operations, has no important effects on classic endocrine metabolic responses but may slightly reduce inflammatory responses and various immune functions, although the data are not consistent. In contrast, most data show improvement of postoperative pulmonary function and less hypoxemia with endoscopic operation. The slight modification of surgical stress responses by endoscopic surgery is in contrast to the common, though not universal, demonstration of less pain, shorter hospital stay, and less morbidity after endoscopic surgery. In conclusion, endoscopic surgery has so far not been demonstrated to have important modifying effects on classic endocrine metabolic responses and only a slight inhibitory effect on various inflammatory responses, but with improved pulmonary function and less hypoxemia. More data are needed from major operations where differences are more likely to be found. The clinical consequences of these findings in relation to all over surgical outcome remain to be defined, but effective pain treatment, stress reduction by other techniques, and provision of an active rehabilitation program with early mobilization and oral feeding may be more important than the choice between an endoscopic technique versus "open" operation per se to improve outcome.

Early Ambulation↗
PubMed1999

Acute pain control and accelerated postoperative surgical recovery.

Postoperative pain relief continues to demand our awareness, and surgeons should be fully aware of the potential physiologic benefits of effective dynamic pain relief regimens and the great potential to improve postoperative outcome if such analgesia is used for rehabilitation. To achieve advantageous effects, accelerated multimodal postoperative recovery programs should be developed as a multidisciplinary effort, with integration of postoperative pain management into a postoperative rehabilitation program. This requires revision of traditional care programs, which should be adjusted according to recent knowledge within surgical pathophysiology. Such efforts must be expected to lead to improved quality of care for patients, with less pain and reduced morbidity leading to cost efficiency.

Analgesia↗
PubMed1999

Pain after primary inguinal herniorrhaphy: influence of surgical technique.

BACKGROUND: Pain is an important problem after ambulatory hernia repair. To assess the influence of the surgical technique on postoperative pain, two separate randomized, patient-blinded, controlled trials were performed in men with an indirect inguinal hernia. STUDY DESIGN: In study A, 48 patients with an internal inguinal ring smaller than 1.5 cm were randomly allocated to either simple extirpation of the hernial sac or extirpation plus annulorrhaphy. In study B, 84 patients with an internal inguinal ring wider than 1.5 cm were randomly allocated to extirpation plus annulorrhaphy or extirpation plus Lichtenstein mesh repair (modified). All operations were performed under unmonitored local anesthesia with standardized perioperative analgesia using methadone and tenoxicam. Pain was scored daily for the first postoperative week and after 4 weeks on a four-point verbal-rank scale (no, light, moderate, or severe pain) during rest, while coughing, and during mobilization (rising to the sitting position). Use of supplementary analgesics (paracetamol) was recorded. Cumulative daily pain scores for the first postoperative week and the number of patients who used supplementary analgesics were the main outcome measures. RESULTS: There were no significant differences in cumulative pain scores or use of supplementary analgesics between the treatment groups in either study. Cumulative pain scores were significantly higher during coughing and mobilization than during rest in both studies. CONCLUSIONS: Choice of surgical technique for open repair of a primary indirect inguinal hernia has no influence on postoperative pain.

Adolescent↗
PubMed1999

Computerized monitoring of physical activity and sleep in postoperative abdominal surgery patients.

OBJECTIVE: Assessment of early postoperative activity is important in the documentation of improvements of peri-operative care. This study was designed to validate computerized activity-based monitoring of physical activity and sleep (actigraphy) in patients after abdominal surgery. METHODS: The study included twelve hospitalized patients after major abdominal surgery studied on day 2 to 4 after operation and twelve unhospitalized healthy volunteers. Measurements were performed for 24 consecutive hours. The actigraphy measurements were compared with self-reported activity- and sleep registration. The actigraphy output was obtained by the zero-crossing mode (ZCM) and time-above-threshold mode (TATM). RESULTS: The overall results showed comparable mean agreement between actigraphy and self-reported activity registrations for patients of 80% (SD 12%) and volunteers of 84% (SD 6%) (p = 0.15). In both study groups, all correlation coefficients between actigraphy measurements and self-reported activity data were statistically significant (r, values for patients 0.4 to 0.8 and volunteers 0.6 to 0.9). A higher mean agreement between automated actigraphy sleep detection and self-reported sleep registration were found in the volunteers (85%, SD 15%) compared with the patients (77%, SD 11%) (p < 0.05). The mean activity value awake was higher in the volunteers than in the patients (p < 0.05). CONCLUSION: Computerized activity monitoring by actigraphy is a reliable and easy method for monitoring physical activity and sleep-wake cycles after major abdominal surgery.

Abdomen↗
PubMed1999

Ventilatory pattern and associated episodic hypoxaemia in the late postoperative period in the general surgical ward.

Episodic oxygen desaturation is frequent in the late postoperative period and seems most pronounced on the second and third postoperative nights. However, the ventilatory pattern has not been described systematically during this period. We studied the ventilatory pattern and associated arterial oxygenation using the Edentrace II equipment (impedance pneumography and pulse oximetry) on the second and third postoperative nights in 28 patients undergoing major abdominal surgery. Ventilatory disturbances were common and included periods of hypopnoea, and obstructive, central and mixed apnoeas. Overall, the median (range) respiratory disturbance index (apnoeas + hypopnoeas per h) was 12 (0-121), with the patients spending 6% (0-65%) of the night in some kind of ventilatory disturbance. It was not possible from pre-operative snoring habits to predict patients who developed postoperative ventilatory disturbances. Overall, 23% (0-100) of the hypopnoeas and 7% (0-100) of the apnoeas were associated with episodic hypoxaemia. In conclusion, ventilatory disturbances were common in the late postoperative period in the general surgical ward and often associated with episodes of oxygen desaturation.

Abdomen↗
PubMed1999

Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme.

BACKGROUND: Hospital stay after colonic surgery is usually between 5 and 10 days, limiting factors being pain, ileus, organ dysfunction and fatigue. Single-modality intervention to reduce these factors with laparoscopic surgery usually requires a hospital stay of 5 days. This paper reports the results of a multimodal rehabilitation regimen after open sigmoidectomy. METHODS: Sixteen unselected patients scheduled for elective sigmoid resection (median age 71 years) underwent operation under combined spinal-epidural anaesthesia. After operation, epidural analgesia was continued for 48 h, with immediate oral nutrition and mobilization, and with planned discharge 2 days after surgery. RESULTS: The median postoperative hospital stay was 2 (range 2-6) days (48 h), patients being mobilized for a median of 5 h on the second postoperative day (24-48 h) and for 10 h on the third day (48-72 h). Within 48 h of operation 14 patients had an oral intake of 2000 ml or more and 15 had resumed defaecation. Fatigue and pain scores were low during the first 8-9 days after operation, with a median of 13 h of mobilization per day after discharge. There were no medical or surgical complications during 30 days of follow-up, except for two patients who suffered postspinal headache. CONCLUSION: Postoperative recovery after open colonic surgery may be accelerated by effective pain relief integrated into an accelerated rehabilitation programme.

Adult↗
PubMed1999

Preoperative alcoholism and postoperative morbidity.

BACKGROUND: Preoperative risk assessment has become part of daily clinical practice, but preoperative alcohol abuse has not received much attention. METHODS: A Medline search was carried out to identify original papers published from 1967 to 1998. Relevant articles on postoperative morbidity in alcohol abusers were used to evaluate the evidence. RESULTS: Prospective and retrospective studies demonstrate a twofold to threefold increase in postoperative morbidity in alcohol abusers, the most frequent complications being infections, bleeding and cardiopulmonary insufficiency. Wound complications account for about half of the morbidity. The pathogenic mechanisms include preoperative immune incompetence, subclinical cardiac insufficiency and haemostatic imbalance. In addition, surgical trauma and/or postoperative abstinence result in an exaggerated stress response, which may further contribute to postoperative morbidity. CONCLUSION: Alcohol consumption should be included in the preoperative assessment of likely postoperative outcome. Reduction of postoperative morbidity in alcohol abusers may include preoperative alcohol abstinence to improve organ function, or perioperative alcohol administration to avoid the abstinence response.

Alcoholism↗
PubMed1999

Prospective study of chronic pain after groin hernia repair.

BACKGROUND: The aim was to provide a detailed description of any residual pain 1 year after elective day-case open groin hernia repair under local anaesthesia. METHODS: This was a prospective consecutive case series study by questionnaire of 500 consecutive operations in 466 unselected adult patients 1 year after surgery. Pain was scored (none, mild, moderate or severe) at rest, while coughing and during mobilization, and compared with similar data collected 1 and 4 weeks after operation. RESULTS: Some 419 questionnaires were returned (response rate 93 per cent); 20 patients had died within the year and 30 data sets from patients who had a subsequent operation during the study were excluded. Eighty patients (19 per cent) reported some degree of pain, and 25 (6 per cent) had moderate or severe pain. Pain restricted daily function in 24 patients (6 per cent). The incidence of moderate or severe pain was higher after repair of recurrent than primary hernias (14 versus 3 per cent; P < 0.001). The risk of developing moderate or severe pain was increased in patients who had a high pain score 1 week after operation (9 versus 3 per cent; P < 0.05) and also in patients who had moderate or severe pain 4 weeks after operation (24 versus 3 per cent; P < 0.001). CONCLUSION: Chronic pain is a significant problem after open groin hernia repair. It may be worse after surgery for a recurrent hernia and may be predicted by the intensity of early postoperative pain.

Adult↗