Biomedical subjects

R Lefering

Publications and source records attributed to R Lefering.

64 records · Page 4Linked to original sources

PubMed1995

Costs of Laparoscopic cholecystectomy. Analysis of potential savings.

Despite the growing acceptance of laparoscopic cholecystectomy the costs remain unclear. Therefore, a detailed cost analysis was performed to determine potential savings. As part of a continuing audit, data of 508 consecutive laparoscopic cholecystectomies have been prospectively collected. Pre-, intra-, and postoperative variables were assessed by standardized questionnaires. These data were used to estimate the average use of diagnostics, drug consumption, operation time, and hospital stay. In addition, costs for loss in income, "hotel services", diagnostic procedures, and for the operation itself were calculated in detail. The total costs for a standard laparoscopic cholecystectomy were 3,395 deutsche marks (DM). The costs for the operation itself represented 19%, "hotel services" and medical treatment except the operation such as nursing, visits, or diagnostic procedures represented 47%, and the loss of income another 33% of the total costs. Thus, most effective savings may be achieved by shortening the hospital stay and the time of inability to work. However, each additional 30 min of operating time costed 146 DM (4.88 DM/min) and an "ideal" operation performed within 40 mins and with a 3-day hospital stay would save 20% of the total and 31% of the hospital costs. An increase in the number of operations per year would not have a relevant impact on the cost. Disposable instruments would have increased the costs by 1,118 DM (33%). The costs for cleaning, packing, and disposal were only marginal. Reusable instruments were not related to any disadvantage either to the patients or to the staff.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1995

Steroid controversy in sepsis and septic shock: a meta-analysis.

OBJECTIVE: The use of corticosteroids in patients with sepsis or septic shock has been controversial for many decades. Clinical studies have reported beneficial, as well as negative results. We conducted a meta-analysis to assess the clinical evidence and to evaluate treatment effects in specific subgroups of patients. DESIGN: Meta-analysis. DATA SOURCES: A comprehensive search of the literature revealed 49 publications investigating the effect of corticosteroids in patients with sepsis and septic shock. STUDY SELECTION: Only ten of the 49 publications were prospective, randomized, controlled trials with an exact description of dosage and regimen. DATA EXTRACTION: Treatment effects on mortality were calculated as rate differences in each study (negative values favor steroids), and were combined with respect to the variability in each study. DATA SYNTHESIS: Only one study showed a significantly positive effect of steroid treatment. Overall, no positive effect was observed: -0.2% (95% confidence interval: -9.2, 8.8). There were no differences observed when comparing low- vs. high-dose or type of corticosteroid used. Comparing patients with proven Gram-positive or Gram-negative infection showed a slight but not significant difference. The Gram-negative group demonstrated better outcome (-5.6% vs. 1.8%). A quality rating of each trial showed a remarkable increase in quality over time. Adverse events (gastrointestinal bleeding, secondary infections, hyperglycemia) were not more frequent in patients treated with steroids compared with controls. CONCLUSIONS: No overall beneficial effect of corticosteroids in patients with septic shock was observed; however, there is some evidence for a positive effect in patients with Gram-negative septicemia.

Adrenal Cortex Hormones↗

PubMed1994

Technology assessment of endoscopic surgery.

Endoscopic surgery is considered a milestone in the evolution of surgical technique in nearly all fields of surgery. However, the inappropriate use of the new technology in medicine has also been heavily criticised. Systematic technology assessment of endoscopic surgical techniques is mandatory to prove the real benefits and complications, so defining the indications for their appropriate use. This article describes methods of technology assessment suitable for endoscopic techniques with emphasis on relevant endpoints for surgeons and patients. The general stages of a comprehensive technology assessment include: 1. feasibility (safety and technical performance) 2. efficacy (patient benefits in pioneering places) 3. effectiveness (patient benefits in average hospitals in the community as a whole) and 4. economic evaluation (cost-benefit analyses). We used the example of laparoscopic cholecystectomy to describe the methods of technology assessment. A cohort study on 500 patients revealed that laparoscopic cholecystectomy is as safe as the conventional standard open technique. The results on efficacy strongly support the hypothesis of more comfort and less trauma with the endoscopic technique. Major endpoints evaluated were postoperative pain, convalescence, fatigue and quality of life. Data on effectiveness and economics are still in a "premature" state and should be the subject of further analyses. It is concluded, that other disciplines such as neurosurgery should evaluate their endoscopic surgical techniques according to the rules of technology assessment outlined in this paper.

Cholecystectomy, Laparoscopic↗

PubMed1994

Pain after laparoscopic cholecystectomy. Intensity and localization of pain and analysis of predictors in preoperative symptoms and intraoperative events.

It is postulated that laparoscopic cholecystectomy as "patient-friendly surgery" leads to more comfort and in particular to less pain. A prospective study on pain was performed on all patients undergoing the operation over the period of 1 year (n = 382) out of a series of more than 1,000 patients who have undergone the operation in our clinic. Pain was measured by a 100-point visual analogue scale (VAS), by a five-point verbal rating scale, and by the consumption of analgesics. Pain was the most frequent symptom, both before and after the operation. The mean level of pain was 37 VAS points 5 h after the operation and declined to 16 points on the third day. In 106 patients (27.8%) the intensity of pain was higher than 50 VAS points. Analgesics were used by 282 patients (73.8%), opioids by 112 (29.3%). Pain was significantly higher in female than male patients (P < 0.05), but consumption of analgesics was similar in both groups. The most severe pain was localized to the abdominal wall wounds by 157 (41.1%) and to the right upper abdomen by 138 patients (36.1%) on the first postoperative day. Patients who needed opioids and/or had a pain level of > 50 VAS points (n = 138) had higher preoperative pain levels (P = 0.018) and preoperatively complained more frequently about nausea, vomiting, bloating, and a feeling of abdominal pressure (P = 0.003-0.031). However, predictive values of these variables were too small to be of clinical benefit.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal Pain↗

PubMed1994

Prehospital detection of uncontrolled haemorrhage in blunt trauma.

The field strategy for trauma victims is still controversial. The first randomized study in penetrating truncal trauma by Martin et al. (1992) supported experimental findings (Gross et al., 1988, 1989; Kowalenko et al., 1992; Krausz et al., 1992b) that fluid therapy in uncontrolled haemorrhage increases mortality. No controlled data in blunt trauma are available. In this retrospective analysis of blunt trauma victims (n = 353), the parameters systolic blood pressure, capillary refilling time and Traumascore (Champion et al., 1981) were evaluated in the prehospital detection of uncontrolled bleeding. With the CART methodology (Breiman et al., 1984) systolic blood pressure (BP) was the most sensitive parameter. Uncontrolled haemorrhage was found in nearly 50% of patients whose BP was below 90 mmHg and in 66% of those whose BP was below 50 mmHg. An accompanying traumatic brain injury (TBI) impaired the ability of BP to detect uncontrolled bleeding. Future studies evaluating prehospital fluid therapy in severe blunt trauma with a mixture of injuries, should take into account that BP in our study population classified less than 50% patients with uncontrolled haemorrhage.

Adult↗

PubMed1994

[Do costs decide? Disposable or reusable instruments in laparoscopic cholecystectomy?].

UNLABELLED: Laparoscopic cholecystectomy requires new and specially designed instruments. Both, disposable and reusable instruments are available and frequently used. The purpose of this analysis was to compare these instruments with regard to safety and costs. A complete and detailed calculation comprising all cost components was performed using data from 534 patients. SAFETY of the procedure was assessed by the documentation of all events during and after laparoscopic cholecystectomy in 1000 consecutive patients. COSTS: A standard operation with reusable instruments costs DM 3395. One third of these costs are non-hospital costs. Every postoperative day in hospital adds DM 234.44, every minute of operation time adds DM 4.88. Using a complete of disposable instruments causes an increase in total costs of DM 1117, which mainly results from the costs of the instruments themselves. SAFETY: Among 1000 operations all performed with reusable instruments, 82.3% were uneventful for the patient. The wound infection rate was 2.3%. Until today no injuries of the staff caused by these instruments were observed. These findings demonstrate that reusable instruments are safe and cost-effective.

Adolescent↗

PubMed1992

Evaluation of routine upper digestive tract endoscopy before laparoscopic cholecystectomy.

Endoscopy of the upper digestive tract was performed in 376 patients with symptomatic gallstone disease before elective laparoscopic cholecystectomy. Abnormalities were found in 60 patients (16.0 per cent); these included peptic ulcer (n = 14), gastric erosions (n = 15) and oesophagitis (n = 11). Thirty patients were treated medically and two by endoscopic polypectomy. In four patients endoscopy led to cancellation of cholecystectomy; in two the complaints have persisted. Statistical analysis of 28 variables showed few significant differences in symptoms between patients with normal and those with abnormal appearances at endoscopy. It is concluded that routine endoscopy before laparoscopic cholecystectomy is neither clinically useful nor cost effective in patients with symptomatic gallstone disease. This conclusion is related exclusively to patients with typical gallstone symptoms according to the definition used in this department.

Adolescent↗

PubMed1992

[Routine gastroscopy before laparoscopic cholecystectomy: evaluation of the technology in 376 patients].

We performed endoscopy of the upper digestive tract in 376 patients before elective laparoscopic cholecystectomy. Abnormalities were found in 60 (15.9%); 14 patients had peptic ulcers, 15 gastric erosions, and 11 oesophagitis. Because of endoscopic findings 30 patients were treated medically and 2 by endoscopic polypectomy. Endoscopy lead us to cancel cholecystectomy in 4 patients; in 2 the complaints have persisted. Patients with abnormal endoscopic findings showed few significant differences in 40 variables (history and symptoms) compared with patients with normal findings. The incidence of ulcers, erosions or oesophagitis in patients over 72 years of age without loss of weight was 28.6%, compared with an overall incidence of 10.6%. Endoscopy confined to this group of patients, however, would have shown only 15% of all lesions. Consequently these predictors for endoscopic abnormalities had no practical benefit. Technology assessment according to the criteria of Fineberg et al. showed a health improvement for only 2 patients (0.5%). We conclude that routine endoscopy before laparoscopic cholecystectomy is not clinically useful in patients with symptomatic gallstone disease. This is exclusively related to patients with typical gallstone symptoms according to our definition.

Adolescent↗

PubMed1991

Conventional versus laparoscopic cholecystectomy and the randomized controlled trial. Cholecystectomy Study Group.

We considered using a randomized trial to assess the value of laparoscopic cholecystectomy in the treatment of symptomatic gallstones. The pros and cons for the timing of such a trial were in favour of not beginning the trial until surgeons learned to use the new procedure safely and effectively, and until key endpoints and outcome indices could be identified and assessed using valid measures. Instead an observational study was implemented to monitor the learning curve of surgeons as they mastered the laparoscopic equipment and procedures, and to assess the responses of the patients to the procedure. In the first 100 patients, the procedure proved to be as safe and feasible to use as conventional surgery, and there were strong benefits in terms of quicker recovery of the patients with less pain, discomfort, and a reduced length of hospital stay. The responses of the surgeons and the patients to the new procedure now place ethical constraints on the planning of a randomized controlled trial. Currently, comprehensive surveillance and monitoring of laparoscopic cholecystectomy is the only realistic method with which to assess the impact of this new technology in our clinic.

Adult↗

PubMedDate not supplied

Preincisional local anesthesia with bupivacaine and pain after laparoscopic cholecystectomy. A double-blind randomized clinical trial.

The aim of this study was to investigate whether local anesthesia of abdominal wall wounds prior to laparoscopic cholecystectomy leads to decreased pain beyond the immediate postoperative period and thus improves the comfort of the patient. In a randomized, double-blind study 50 patients scheduled for laparoscopic cholecystectomy were divided into two groups. In one group (n = 25) the skin, subcutis, fascia, muscle, and preperitoneal space were infiltrated with 8 ml of bupivacaine 0.5% 5 min before each abdominal wall incision. The control group (n = 25) received normal saline. The intensity of pain was assessed by a 100-point visual analogue scale (VAS) at rest and during movement and by the consumption of analgesics. Analgesic therapy was provided by on-demand analgesia with piritramide intravenously for 24 h and continued by ibuprofen orally on request. The mean intensity of pain at rest and during movement was lower but not statistically significant in patients who received bupivacaine compared to the control group up to the second postoperative day. The difference was between 4 and 9 VAS points and therefore of doubtful clinical relevance. Similar statistically nonsignificant results were found for the mean consumption of piritramide up to 16 h after the operation. Three patients (12%) in the bupivacaine group localized the most severe pain up to the second postoperative day to the right lower abdominal wall wound where the gallbladder had been extracted compared to 11 patients (44%) of the control group (P = 0.012). These results indicate that bupivacaine was effective at the site where it was administered.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗