The accuracy and role of cross-sectional imaging in the diagnosis of acute appendicitis

Based on current literature review, most patients with suspected or possible appendicitis should undergo cross-sectional imaging. CT scanning is preferred in most patients; US is recommended in children or pregnant women. MRI is usually indicated in women or children with nondiagnostic US. Thin young men with classic history, laboratory studies, and examination are best managed with standard appendectomy without imaging. Most other patients should undergo cross-sectional imaging (i.e., CT scan).

Treatment of gastrointestinal radiation injury with hyperbaric oxygen

BACKGROUND

Chronic radiation enteritis develops in 5-20% of patients following abdominal and pelvic radiation. Current treatments are largely ineffective.

OBJECTIVE

To assess the effectiveness of hyperbaric oxygen therapy (HBO2) as a treatment for chronic radiation enteritis and evaluate the relative effectiveness in treatment of the proximal and distal gastrointestinal tract.

DESIGN

Case series of 65 consecutive patients with chronic radiation enteritis treated between July 1991 and June 2003 with HBO2.

SETTING

A tertiary referral academic medical center.

PATIENTS

65 patients (37 male, 28 female; mean age 65 years) were treated with HBO2 for radiation damage to the alimentary tract.

INTERVENTIONS

Patients were treated with an initial series of 30 daily treatments, each administering 90 minutes of 100% oxygen at 2.36 atmospheres absolute pressure. Thirty-two patients with partial symptom response or endoscopic evidence of healing received an additional 6 to 30 treatments.

RESULTS

The primary indication for HBO2 was bleeding (n = 54) with 16 patients requiring transfusions. Additional indications were pain, diarrhea, weight loss, fistulas and obstruction. Follow-up ranged from 1 to 60 months (mean = 23 months). The main outcome measures were effects on bleeding, pain, diarrhea, weight loss, fistulas and obstruction. Endoscopic documentation of healing was used when available. The response rate was 68%, with a complete and partial response rate of 43 and 25%, respectively. The response rate for rectal disease was 65% and for proximal sites was 73%. The response rate for bleeding was 70% and for other symptoms was 58%.

CONCLUSION

This series represents the largest clinical series reported using HBO2 for treatment of radiation injury to the GI tract. The findings suggest that HBO2 results in healing or clinically significant improvement in two thirds of patients with chronic radiation enteritis.

Effect of Roux-en-Y gastric bypass on satiety and food likes: the role of genetics

Among factors influencing the outcome of bariatric surgery may be genetics and familial risk. The purpose of this study was to assess the etiology of obesity and its impact on hunger, satiety, and food likes in obese patients undergoing Roux-en-Y gastric bypass (RYGB). This study was based on 76 patients undergoing RYGB procedures performed by a single surgeon. A previously described 100-point obesity risk index (ORI) was used to assess familial obesity risk. Hunger and satiety were assessed using a standardized Visual Analog Scale "Snickers" test, and food preferences for regular vs. low-fat potato chips were measured preoperatively and postoperatively. Patients were stratified preoperatively into high ORI (n = 34) and low ORI (n = 42) groups. Before operation, high-ORI patients preferred high-fat (regular) potato chips to low-fat (baked) potato chips, whereas the low-ORI patients liked both food types equivalently (P < 0.05). After operation (n = 43), both groups showed lower preferences for high-fat potato chips (P < 0.05 for high-ORI group). As anticipated, hunger was dramatically suppressed after RYGB. However, there was more satiety in the high-ORI group (P < 0.05, ANOVA). Most patients undergoing bariatric surgery had a strong familial or genetic component to their disease. RYGB in high-ORI patients was associated with a significant decline in preference of fatty food and a significantly prolonged drop in hunger ratings after a fast and after a standard 282 kcal meal. The success of bariatric surgery may be influenced by the etiology of obesity.

Prevention of postoperative abdominal adhesions by a novel, glycerol/sodium hyaluronate/carboxymethylcellulose-based bioresorbable membrane: a prospective, randomized, evaluator-blinded multicenter study

INTRODUCTION

Postoperative abdominal adhesions are associated with significant morbidity and mortality, placing a substantial burden on healthcare systems worldwide. Development of a bioresorbable membrane containing up to 23 percent glycerol and chemically modified sodium hyaluronate/carboxymethylcellulose offers ease of handling and has been shown to provide significant postoperative adhesion prevention in animals. This study was designed to assess the safety of glycerol hyaluronate/carboxymethylcellulose and to evaluate its efficacy in reducing the incidence, extent, and severity of postoperative adhesion development in surgical patients.

METHODS

Twelve centers enrolled 120 patients with ulcerative colitis or familial polyposis who were scheduled for a restorative proctocolectomy and ileal pouch-anal anastomosis with diverting loop ileostomy. Before surgical closure, patients were randomized to no anti-adhesion treatment (control) or treatment with glycerol hyaluronate/carboxymethylcellulose membrane under the midline incision. At ileostomy closure, laparoscopy was used to evaluate the incidence, extent, and severity of adhesion formation to the midline incision.

RESULTS

Data were analyzed using the intent-to-treat population. Treatment with glycerol hyaluronate/carboxymethylcellulose resulted in 19 of 58 patients (33 percent) with no adhesions compared with 6 of 60 adhesion-free patients (10 percent) in the no treatment control group (P = 0.002). The mean extent of postoperative adhesions to the midline incision was significantly lower among patients treated with glycerol hyaluronate/carboxymethylcellulose compared with patients in the control group (P < 0.001). The severity of postoperative adhesions to the midline incision was significantly less with glycerol hyaluronate/carboxymethylcellulose than with control (P < 0.001). Adverse events were similar between treatment and no treatment control groups with the exception of abscess and incisional wound complications were more frequently observed with glycerol hyaluronate/carboxymethylcellulose.

CONCLUSIONS

Glycerol hyaluronate/carboxymethylcellulose was shown to effectively reduce adhesions to the midline incision and adhesions between the omentum and small bowel after abdominal surgery. Safety profiles for the treatment and no treatment control groups were similar with the exception of more infection complications associated with glycerol hyaluronate/carboxymethylcellulose use. Animal models did not predict these complications.

The role of epidural anesthesia and analgesia in surgical practice

OBJECTIVE

To review the potential and proven benefits and complications of epidural anesthesia/analgesia.

SUMMARY BACKGROUND DATA

Advances in analgesia/anesthesia have improved patient satisfaction and perioperative outcomes. Epidural anesthesia/analgesia is one of these advances that is gaining rapid acceptance due to a perceived reduction in morbidity and overall patient satisfaction.

METHODS

A MEDLINE search was conducted for all pertinent articles on epidural anesthesia/analgesia.

RESULTS

Retrospective, prospective, and meta-analysis studies have demonstrated an improvement in surgical outcome through beneficial effects on perioperative pulmonary function, blunting the surgical stress response and improved analgesia. In particular, significant reduction in perioperative cardiac morbidity ( approximately 30%), pulmonary infections ( approximately 40%), pulmonary embolism ( approximately 50%), ileus ( approximately 2 days), acute renal failure ( approximately 30%), and blood loss ( approximately 30%) were noted in our review of the literature. Potential complications related to epidural anesthesia/analgesia range from transient paresthesias (<10%) to potentially devastating epidural hematomas (0.0006%).

CONCLUSIONS

Epidural anesthesia/analgesia has been demonstrated to improve postoperative outcome and attenuate the physiologic response to surgery.

A genetic "obesity risk index" for patients with morbid obesity

BACKGROUND

The influence of genetics on obesity is well established. Adoption studies and twin studies suggest that about 80% of the obesity risk is genetic. We designed a tool to predict outcomes of treatments in patients with sporadic or familial obesity.

METHODS

Two factors best correlate with multifactorial genetic risk: 1) familial history and 2) age of onset. 147 morbidly obese adults self- or physician-referred for possible surgery for morbid obesity (age 17-66 y, BMI 35-82) were studied. Six elements were selected to measure the genetic influence on patients' weight: 3 personal weight milestones (weight at age 10, 20 and 30), and 3 family history factors (parents' weight, siblings' weight and second degree relatives' weight. These 6 elements of personal and family history information were collected prospectively on 35 obese patients and a feasible scoring system devised, with 0 points signifying no genetic component and 100 points suggesting the maximal possible genetic risk for obesity. Prospective data were then collected on 147 consecutive patients seen in consultation for possible bariatric surgery, to provide this "obesity risk index" (ORI).

RESULTS

The final scoring system for the ORI assigned 50 possible points for personal weight milestones and 50 possible points for family history factors. At age 10, patients receive 10 or 20 points for being 2 or 3 SD above the mean BMI for age, respectively. At age 20, 10 or 20 points are received for BMI > 30 or 40, respectively. At age 30, 5 or 10 points are received for BMI > 35 or 50, respectively. 0 to 28 points are awarded for parental obesity, with 7 or 14 points for each parent with BMI > 30 or 40, respectively. The mean BMI of all siblings was calculated, with 6 or 12 points received for mean BMI greater than 30 or 40, respectively. Two points are awarded for each second degree relative with BMI > 35, to a maximum of 10 points. The mean (+/- SEM) score for our first 114 patients was 32 +/- 2 (range 0 to 87). The median score was 28.13% of patients had scores < 10; conversely, 13% scored points on all 6 elements.

CONCLUSION

An ORI has been devised to quantify the genetic contribution to an individual's weight. Using this scoring system, we found that about 85% of patients who are candidates for bariatric surgery have elements in their history to suggest a genetic risk for morbid obesity. About 15% have extremely strong genetic ORIs.

Small Bowel Obstruction

The optimal treatment of patients with small bowel obstruction should be predicated upon answering the following diagnostic questions in each patient: 1) does the patient have mechanical bowel obstruction or an ileus?, 2) could the patient have colonic obstruction or a cause of obstruction other than adhesions (eg, hernia, cancer, Crohn's disease)?, 3) is the obstruction partial or complete?, and 4) is strangulation present, and hence immediate operation necessary, or is a period of observation appropriate? The most efficient way to answer these questions in many patients is by performing a careful history and physical examination, laboratory tests, and CT scanning. Surgical intervention should occur within 48 hours of admission in the vast majority of patients with complete small bowel obstruction due to adhesions. The chance for durable endoscopic treatment of any patient with SBO, in our opinion, is remote.

A prospective evaluation of dietary status and symptoms after near-total esophagectomy without gastric emptying procedure

BACKGROUND

After esophagectomy, the stomach is the most commonly utilized reconstructive conduit. There remains debate among surgeons regarding the requirements for pyloroplasty/pyloromyotomy following reconstruction. We present a series of patients having undergone near total esophagectomy and reconstruction with gastric tube without gastric emptying procedure to analyze critically these patients' ability to reestablish a subjectively acceptable and nutritionally adequate eating pattern without significant side effects of early satiety, dumping, or diarrhea.

METHODS

Between 1991 and 1998, 48 patients underwent esophagectomy utilizing this technique and were available for long-term follow-up and nutritional assessment. Patient weights were recorded at 2 weeks, 6 months, and 1 year and a telephone interview conducted at a mean of 36 months postoperatively for the evaluation of eating patterns and symptoms. A subgroup of these patients (32 of 48) completed a 3-day dietary record that was assessed by a certified nutritionist. This patient group included 10 patients (21%) who had received perioperative chemoradiotherapy.

RESULTS

Dietary intake was characterized as normal or minimally limited in 41 patients (85%). Those who had received perioperative chemoradiotherapy needed no significant increased time to return to a normal dietary baseline (6.1 versus 5.9 months). Mean weight loss prior to surgery was 3 kg. Weight loss continued for the first 6 months (mean 10 kg); however, 63% were able to gain weight from 6 months to 1 year following surgery (mean 3 kg). Most patients were overweight prior to operation (mean 115% of ideal body weight) and achieved a new postoperative baseline (mean 104% of ideal body weight) at 1 year. Patients demonstrated a mean daily caloric intake of 2,179 kilocalories per day, which was 98% of recommended according to their ideal body weight. Postoperative symptoms of short-term nausea (19%), occasional dysphagia with certain foods (38%), mild increased stool frequency (15%), and occasional regurgitation (25%) were noted.

CONCLUSIONS

Near-total esophagectomy with verticalized gastric tube without a gastric emptying procedure is well tolerated and allows a return to subjectively acceptable and nutritionally appropriate dietary eating pattern without significant associated side effects.

The long-term benefit of surgery on health-related quality of life in patients with inflammatory bowel disease

HYPOTHESES

Health-related quality of life (HRQL) has been shown to improve dramatically shortly after surgery in patients with inflammatory bowel disease (IBD). Our hypotheses were that (1) improved HRQL would be maintained long term in patients after surgery for ulcerative colitis and (2) the improved HRQL in patients with Crohn disease would decline with long-term follow-up.

DESIGN

Consecutive series of patients undergoing surgery for IBD between June 1994 and January 2000 prospectively investigated as a cohort outcomes study.

PATIENTS

Data were obtained in 139 patients. The diagnoses were Crohn disease (n = 56) and ulcerative colitis (n = 83).

INTERVENTION

Patients with Crohn disease underwent resections with or without stricturoplasties; all but 5 patients with ulcerative colitis underwent ileal pouch-anal anastomoses.

MAIN OUTCOME MEASURE

Health status was measured using the Health Status Questionnaire (HSQ) preoperatively and then every 3 months postoperatively.

RESULTS

Preoperative HSQ scores were very low in all 8 scales of the HSQ. Postoperatively, HRQL measures improved significantly (P<.05) both in patients with Crohn disease and ulcerative colitis, with scores equal to or better than published scores in the general population. In patients with Crohn disease, the scores improved significantly after surgical resection and steadily increased despite disease recurrence and reoperations. The HRQL at last follow-up was equivalent to the general population. The improvements were statistically significant in patients followed up for more than 1 year in 7 of 8 scales of the HSQ.

CONCLUSIONS

These results confirm that HRQL is poor in patients with IBD referred for possible operation. Surgical resection resulted in significant improvement in HRQL. More important, the results were durable. With follow-up up to 6 years, the HRQL in this cohort was equal to or better than norms for the general population both in patients with ulcerative colitis and with Crohn disease. We believe these data justify aggressive surgical intervention in many patients with IBD and support the prospective study of HRQL by surgeons treating patients with chronic diseases.

Risk factors and true incidence of pouchitis in patients after ileal pouch-anal anastomoses

Total colectomy, mucosal proctectomy, and ileal J pouch-anal anastomosis (IPAA) has become the procedure of choice for patients with ulcerative colitis and familial adenomatous polyposis. The purpose of this study was to determine the short- and long-term outcomes of patients undergoing IPAA by a single surgeon, correlating intraoperative technical aspects with outcomes, and to characterize better the clinical syndrome of pouchitis. A retrospective review was performed of 114 consecutive patients who underwent IPAA by a single surgeon between December 1987 and August 1996. Clinical follow-up and operative notes were reviewed, and patient questionnaires were obtained for all patients. The mean follow-up was 3 years (range 0.5-8.0 years). The average age of the patients was 39 years (range 16-72 years). There were 64 males and 50 females. Indications for operation were ulcerative colitis (n = 101) and familial polyposis coli (n = 13). Long-term morbidity occurred in 41% of patients (small bowel obstruction 10%, anastomotic stricture 9%). Pouch excision was required in only three patients. Stool frequency (mean +/- SE) was 6.1 +/- 0.2 and did not change with duration of follow-up. Only 7% of patients reported fecal soilage. The incidence of pouchitis was 59% (n = 67), with 4.2 +/- 0.3 episodes of pouchitis per patient. Using multivariate analysis, the factors significantly associated with the incidence of pouchitis were gender (p = 0.008) and duration of follow-up (p = 0. 02). A total of 37 of 50 women (74%) but only 30 of 64 men (47%) developed pouchitis. The incidence of pouchitis increased with the duration of follow-up. The incidences of pouchitis in patients followed for 6 months, 1 year, and 3 years were 25%, 37%, and 50%, respectively. Of patients followed more than 6 years, the incidence of pouchitis was 94% (15/16). There was not a significant correlation between anastomotic tension or the extent of arterial dissection of the ileal mesentery required to achieve IPAA and the incidence of pouchitis. The best antibiotics for pouchitis were metronidazole (54% of patients) and ciprofloxacin (37%). Eleven patients have required nearly continuous antibiotics. Patient satisfaction with the outcome is high, with a mean satisfaction of 8. 4 (0, dissatisfied; 10, extremely satisfied). This review demonstrates a high incidence of pouchitis in patients after IPAA, which is due to the more liberal definition of the syndrome and the complete follow-up achieved in this report compared to previous series. This study also is unique in identifying the significantly higher incidence of pouchitis in women, although the overall satisfaction with the clinical outcome in patients undergoing IPAA remains high.

Twenty cases of peristomal pyoderma gangrenosum: diagnostic implications and management

HYPOTHESIS

Our experience with peristomal ulcers suggested that peristomal pyoderma gangrenosum (PPG) is an infrequent and usually unrecognized complication of inflammatory bowel disease. We hypothesized that a review of our experience with PPG would clarify the essentials of its diagnosis, evaluation, and treatment.

DESIGN

A case series of 20 consecutive patients with PPG complicating inflammatory bowel disease were treated at our institution between 1986 and 1999. There were 15 women and 5 men. At the time of development of peristomal pyoderma, 10 of 20 patients had a diagnosis of Crohn disease (CD), while 9 had a diagnosis of ulcerative colitis (UC). One patient was diagnosed as having CD only after first developing PPG.

MAIN OUTCOME MEASURE

Healing of PPG.

INTERVENTIONS

All patients had failed local enterostomal care prior to referral. Debridements and/or stomal revisions were uniformly unsuccessful. Biopsies, when performed, did not provide clinically important information. Treatment was directed toward inflammatory bowel disease, with variable clinical responses to corticosteroids, metronidazole, cyclosporine, sulfasalazine, and infliximab.

RESULTS

Ultimately, 13 patients had a diagnosis of CD. Of these patients, 12 (92%) of 13 developed PPG coincident with recurrent disease. Two patients had a remote history of proctocolectomy for UC and subsequent evaluation revealed CD. One patient developed PPG adjacent to a urinary Kock pouch after cystectomy; ultimately, a diagnosis of CD was made. No patients were lost to follow-up, but in 1 case of UC, no evaluation for latent CD was carried out. The final diagnosis was CD disease in 13 (65%) of 20 and UC in 7 (35%) of 20 patients. All PPG ulcers healed completely, within an average of 11.4 months (median, 8 months; range, 1-41 months). Ulcer resolution was achieved with medical therapy alone in 14 (70%) of 20 cases. Resection of active gastrointestinal CD resulted in healing in 5 (83%) of 6 cases. One case healed 2 months after conservative therapy only.

CONCLUSIONS

This review of the largest reported series of PPG suggests the following: (1) PPG complicating inflammatory bowel disease is uncommon and often misdiagnosed by clinicians; (2) local wound care measures have little role in the healing of PPG; (3) PPG usually heralds active CD; (4) in patients with prior history of UC, PPG indicates CD until proven otherwise; (5) prolonged medical therapy (11 months), usually with immunosupression, is required for healing of PPG; and (6) if feasible, surgical resection of all active CD leads to the healing of PPG ulcers.

Effect of surgery on health-related quality of life in patients with inflammatory bowel disease: a prospective study

BACKGROUND

Health-related quality of life (HRQL) has increasingly become a factor in management decisions in patients with chronic diseases.

OBJECTIVE

To measure the effect of surgical resection on quality of life in patients with inflammatory bowel disease (IBD).

DESIGN

A consecutive series of patients undergoing surgery for IBD between June 1994 and December 1997 were prospectively investigated as a cohort outcomes study.

PATIENTS

Data were obtained in 63 patients. The primary diagnoses were Crohn's disease (n = 36) and ulcerative colitis (n = 27).

INTERVENTION

Patients with Crohn's disease underwent resection with or without stricturoplasty for intractable disease; all but 3 patients with ulcerative colitis underwent ileoanal anastomoses with ileoanal reservoir.

MAIN OUTCOME MEASURE

Health status was measured using the Health Status Questionnaire preoperatively and every 3 months postoperatively.

RESULTS

Preoperative measures of HRQL of the patients were low, with values well below the general population in all 8 scales of the Health Status Questionnaire. Postoperatively, HRQL measures improved significantly (P < .05) in both patients with Crohn's disease and those with ulcerative colitis, with scores equal to the general population in most scales. For example, average raw scores for general health in previously studied patient groups were 59 in patients with asthma, 55 in those with diabetes mellitus, 74 in the general population, and 54 and 73 preoperatively and postoperatively, respectively, in the present study.

CONCLUSIONS

The results of this study confirm that HRQL scores are low in many patients with IBD referred for operation and HRQL scores improve postoperatively to levels comparable to those of the general population. We believe these data justify early surgical intervention in many patients with symptomatic IBD.

Standardized perioperative care protocols and reduced length of stay after colon surgery

BACKGROUND

Recent studies have suggested that critical pathways and standard order sets decrease hospital length of stay and improve quality of care. A recently conducted prospective, randomized study at our institution found that patients undergoing elective colon resections had earlier return of bowel function if perioperative epidural anesthesia and analgesia were provided. All patients in the study were also placed on a standardized perioperative regimen. We hypothesized that the standardized perioperative protocol used in this study contributed to early return of bowel function and hospital discharge compared with similar patients managed off protocol.

STUDY DESIGN

To test this hypothesis, we performed a case-controlled study comparing the hospital courses of 36 study patients to 36 control patients undergoing colorectal surgery by the same surgeons during the same calendar year. The distribution of types of operations and anesthetic techniques was similar in both groups.

RESULTS

As dictated by the protocol, all study patients had their nasogastric tubes removed, were started on a low fat liquid diet, and ambulated in the first postoperative day. Nasogastric tubes were removed in control patients and study patients 2.2 +/- 0.9 (mean value +/- SD) and 1.0 +/- 0.0 days postoperatively, respectively. Control patients were started on an oral diet, usually clear liquids, an average of 2.9 +/- 1.1 days postoperatively, a specific liquid diet was started 1.0 day postoperatively in study patients (p < 0.001). Return of bowel function, as determined by bowel tones, flatus, and bowel movements, occurred approximately 1 day earlier in study patients. Study patients were discharged 1 day sooner than control patients.

CONCLUSIONS

Our results suggest that the return of bowel function and the length of stay of patients undergoing colon surgery are improved if patients are entered into a standardized protocol that eliminates variation in intraoperative and postoperative anesthesia and postoperative surgical care. We believe these results can be reproduced in routine clinical surgery by having a clearly outlined protocol for perioperative care similar to that used in this study.

Extracorporeal shock-wave lithotripsy for bile duct calculi

BACKGROUND

Bile duct calculi (BDC) can be cleared or treated with modern endoscopic techniques in most patients. However, large stones, bile duct strictures, or unusual anatomy may make endoscopic clearance difficult. The purpose of the present study was to determine the efficacy of extracorporeal shock-wave lithotripsy (ESWL) in treating patients with complicated BDC.

METHODS

Between 1989 and January 1995, 16 patients with BDC were treated at our institution with ESWL using a Dornier HM-3 lithotropter. The average age of patients was 62 years (range 32 to 88). Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and attempted stone extraction (100%), nasobiliary drainage (83%), and biliary stents (6%) were used prior to ESWL. Eleven patients (61 %) had solitary stones, ranging in diameter from 0.5 to 2.6 cm, whereas 7 patients had multiple stones, ranging in diameter from 0.5 to 5.0 cm. The indications for ESWL were stone impaction (56%), stone size (38%), and bile duct stricture (6%).

RESULTS

The 16 patients received 27 ESWL treatments (mean = 2101 shock at 21 kV); with 4 patients (22%) requiring multiple treatments. Stone fragmentation was achieved in 94% of patients. All patients had ERCP performed post-ESWL, and only 2 (13%) patients required immediate operations. At discharge, 94% of patients were stone-free. Minor complications (eg, pain, hematuria) were common. With an average follow-up of 3 years, only 1 patient (6%) has required retreatment for BDC. Hepatic transplantation was required in an additional patient.

CONCLUSIONS

In this cohort of patients with both major medical comorbidities and/or technical contraindications to standard methods of endoscopic and surgical clearance of BDC, we found that ESWL facilitated stone clearance in 94% of patients with minimal morbidity and no mortality. In our opinion, ESWL should be used more frequently in the treatment of these complex patients.

Transpapillary stenting for pancreaticocutaneous fistulas

Because transpapillary stents have been successfully placed to treat the ductal disruptions associated with pseudocysts, pancreatic ascites and pleural effusions, and pancreaticoenteric fistulas, we reviewed our experience with endoscopically placed prostheses in patients who had persistent pancreaticocutaneous fistulas but an otherwise intact duct. Nine patients who underwent endoscopic transpapillary stent placement for ongoing pancreaticocutaneous fistulas at our institution were retrospectively reviewed. Fistulas were present for a mean (+/-SEM) of 35 +/- 11 days and averaged 225 +/- 55 ml of output daily. Etiology of the fistulas included percutaneous pseudocyst drainage in four patients, pancreatic necrosis in two, complications of pancreatic surgery in two, and perforation of the duct of Santorini at the time of minor sphincterotomy in one. All patients had an otherwise intact duct at the time of endoscopic retrograde cholangiopancreatography. Six patients had transpapillary stents placed that did not bridge the area of leakage and three had prostheses placed across the ductal disruption. Eight of nine fistulas were successfully closed by means of this technique including five within 48 hours. There was one instance of stent migration and one patient developed prosthesis occlusion and an infected pseudocyst, which was treated with stent exchange. Stents were retrieved 10 to 14 days after fistula closure and no patient has had a recurrence at a median follow-up of 3 years. Transpapillary stents appear to effect closure of pancreaticocutaneous fistulas that fail to respond to conventional therapy.

Pectin and methyl cellulose do not affect intestinal function in patients after ileal pouch-anal anastomosis

OBJECTIVES

Although ileal pouch-anal anastomosis is the procedure of choice for most patients with ulcerative colitis or familial adenomatous polyposis, most patients have problems with stool frequency and/or consistency. Although most clinicians recommend fiber supplementation for these patients, we could find no studies that prove the efficacy of this practice. The first purpose of this study was to document the effect of fiber supplementation on intestinal function in patients after ileal pouch-anal anastomosis. Because pectin, a soluble fiber supplement, has been reported to slow gastric and intestinal transit, we also hypothesized that pectin would be a superior fiber supplement in these patients. The second purpose, therefore, was to determine whether the effects of pectin on intestinal transit would result in decreased stool frequency in patients with an ileal pouch.

METHODS

Thirteen patients who had undergone ileal pouch-anal anastomosis for ulcerative colitis were entered into a 9-wk crossover study. The protocol consisted of three 2-wk study periods, each of which was preceded by a 1-wk washout period. During the three study periods patients supplemented their diets, in random order, with Citrucel, 1 tablespoon twice daily; pectin, 1 tablespoon twice daily; or no supplement. Patients maintained detailed dietary and bowel function diaries.

RESULTS

The effects (mean +/- SE) of Citrucel and pectin supplementation are summarized in Table 1. There was no significant effect of either supplement on stool frequency, pouch function, bloating, or stool consistency. In addition, there were no differences in continence.

CONCLUSIONS

We found no evidence to support the common practice of fiber supplementation in patients with an ileal pouch. Furthermore, this study did not find that stool frequency decreased during supplementation with pectin. We conclude that there is little role for fiber supplementation in patients with an ileal pouch.

The shift toward a managed care environment in a multispecialty group practice model. Looking for reciprocal benefits

Managed care is notably affecting the practice of surgery in the United States. Four principal elements are subject to change: (1) patient care patterns, (2) ethics, (3) education and research, and (4) surgeon compensation. The Virginia Mason Clinic, a multispecialty group practice, is adapting to the demands of managed and capitated care. With the patient as the primary focus of effort, the goal is to create optimum value in health care. The principles of Continuous Quality Improvement are used to increase value in health care by ensuring appropriate treatment with optimum outcome at reasonable cost. Practice patterns are shifting to provide value to patients and payers. Ethical conflicts threaten but have been avoided. Surgical education remains unaffected, but future funding is problematic. The emphasis in surgical research has shifted toward outcome-based studies. The conflict between work effort and resource conservation as determinants of physician compensation is less for surgical than for medical practitioners. Although the principal benefactors of the shift toward managed care have been the payers, patients have gained modestly through efficiencies in the health care process and more stable insurance premiums. The satisfaction level of the surgeons in our multispecialty group practice remains high. Surgical research is thriving, volumes and case mix remain excellent, and changes in practice pattern have enabled us to increase efficiency without compromising patient care.

Laparoscopic cholecystectomy in acute cholecystitis. What is the optimal timing for operation?

OBJECTIVE

To review the results of laparoscopic cholecystectomy (LC) in patients with acute cholecystitis with attention to cost and clinical outcome.

DESIGN

Retrospective study.

SETTING

Large private metropolitan teaching hospital.

PATIENTS

Four hundred forty-six patients had LCs at our institution between January 1993 and February 1995. Acute cholecystitis, confirmed by clinical, laboratory, operative, and histopathological findings, was present in 60 patients.

MAIN OUTCOME MEASURES

The medical history, laboratory findings, gallbladder ultrasounds, timing of operation from the onset of symptoms, conversion rates to open procedures, operative times, intraoperative findings, complications, postoperative length of stay, cost of operative procedures and hospitalizations, and convalescence times were collected.

RESULTS

Laparoscopic cholecystectomy was attempted in 16 patients within 72 hours of the onset of symptoms of acute cholecystitis (group 1), in 19 patients with symptoms between 4 and 7 days (group 2), and in 25 patients with symptoms lasting more than 7 days (group 3). The only factor (eg, preoperative laboratory and ultrasound findings) that affected the outcome of the operation was duration of symptoms prior to operation. Patients who had LC done within 72 hours of the onset of symptoms had lower rates of conversion to open procedures, less difficult operations, shorter operative times, less costly procedures, and a shorter convalescence than those with symptoms for longer than 72 hours prior to operation. The conversion rates in patients operated within and after 72 hours were 12% and 30%, respectively. There were no bile duct injuries and no mortalities.

CONCLUSIONS

Laparoscopic cholecystectomy can be performed safely in most patients with acute cholelithiasis. However, we found that the duration of symptoms prior to LC affected the outcome; the conversion rates, hospital costs, and convalescence times increased in operated-on patients with symptoms for more than 72 hours. In our opinion, interval cholecystectomy may be a superior option in this latter group of patients.

The meaning of equivocal pancreatic cytology in patients thought to have pancreatic cancer

INTRODUCTION

Fine needle aspirations (FNAs) and endoscopic retrograde cholangiopancreatography (ERCP)-guided brushings (BRUSH) are useful tools in the differentiation between malignant and benign disease of the pancreas. Once the decision to obtain a cytologic confirmation of one's clinical suspicion is made, the interpretation of the findings, especially an equivocal or negative cytology finding, can be unclear. This study seeks to evaluate the utility of cytologic studies in the evaluation of a patient with suspected pancreatic malignancy.

METHODS

A retrospective review of 224 cytologic reports, including 174 FNAs and 50 BRUSHs, from all pancreatic FNAs and BRUSHs performed between January 1989 and June 1995, was performed. Subsequent confirmation of the cytologic diagnosis was made either by histologic or strict clinical criteria.

RESULTS

Forty-three percent of the cytologic reports were read as malignant, all others reported as suspicious, atypical, or negative. All cytology studies read as malignant and all FNAs reported as suspicious were histologically or clinically confirmed to be malignant. Of those reported as atypical or negative, 55% and 49% were confirmed to be malignant. Both FNA and BRUSH were 100% specific, 75% sensitive, and 80% accurate.

CONCLUSIONS

We conclude that a cytological diagnosis of malignant or suspicious is reliable and useful for further therapy planning in the patient suspected to have a pancreatic malignancy. The reason for the cytologic tests was a strong clinical suspicion, therefore, a high incidence of cancer was found in the patients with atypical or negative readings. A diagnosis of atypical or negative is equivocal and requires further diagnostic maneuvers, frequently including surgery, to make the definitive diagnosis.