Reduced hospitalization cost for patients with pectus excavatum treated using minimally invasive surgery

BACKGROUND

Currently, few data exist regarding the relative costs associated with open and minimally invasive pectus excavatum repair. The aim of this study was to compare the surgical and hospitalization costs for these two surgical techniques and to identify factors responsible for cost differences.

METHODS

A retrospective review of hospital charts, patient and parent questionnaires, and hospital accounting records was performed for 68 patients who underwent surgical correction of pectus excavatum between June 1996 and December 1999.

RESULTS

In this series, 25 patients underwent open repair, whereas 43 patients underwent minimally invasive repair of pectus excavatum (MIRPE). The patient ages ranged from 4 to 19 years. The average ages for open repair (12 years) and MIRPE (11 years) did not differ significantly. As compared with open repair, MIRPE was associated with a 27% lower overall cost of hospitalization ( p < 0.05). The operating room costs were 12% higher for the patients who underwent MIRPE ( p < 0.05). The mean operative time for open repair was 3 h 15 min, whereas MIRPE required 1 h 10 min ( p < 0.001). The hospital stay for open repair averaged 4.4 days, as compared with 2.4 days for MIRPE ( p < 0.001). In contrast to other published series, the postoperative analgesia after MIRPE in this series consisted of narcotics, ketorolac, and methocarbamol. No patient received epidural analgesia, regardless of the repair technique selected. The postoperative complication rate was 4% in the open group and 14% in the MIRPE group. Most of the patients treated with either open or MIRPE reported postoperative oral narcotic usage for 2 weeks or less and returned to routine activities within 3 weeks. The patients and parents alike reported good to excellent overall outcomes in 85% or more of the open repair cases and 90% or more of the MIRPE cases.

CONCLUSIONS

These data demonstrate for the first time that the use of an alternate pain management strategy including, narcotics, NSAIDs, and methocarbamol, but without epidural catheters, results in reduced hospital length of stay and decreased overall hospitalization costs for MIRPE, as compared with open pectus repair. This cost benefit was achieved without compromising pain management or patient satisfaction with surgical care.

Handsewn or stapled esophagogastric anastomoses after esophagectomy for cancer: meta-analysis of randomized controlled trials

Gastric transposition with esophagogastric anastomosis is a common method of reconstruction after esophagectomy for cancer. The anastomosis can be fashioned using a handsewn or stapled technique. The choice of anastomotic technique is often debated but there is little evidence to support the use of one method over the other. We performed a meta-analysis of randomized controlled trials (RCTs) to determine the effect of esophagogastric anastomotic method (handsewn or circular stapled) on patient outcomes. Medline and manual searches were done (completed independently and in duplicate) to identify all published RCTs that addressed the issue of handsewn or stapled esophagogastric anastomosis after esophagectomy for cancer. The selection process was inclusive; no trials were excluded. Trial validity assessment was done and a trial quality score was assigned. Major outcomes for quantitative data synthesis included operative mortality, anastomotic leaks, anastomotic strictures, cardiac morbidity, and pulmonary morbidity. A random-effects model was used and relative risk was the principal measure of effect. Systematic qualitative review was used for other outcomes such as duration of operation and time to complete the anastomosis. Data on cancer survival were not available in the RCTs. Five RCTs were selected with quality scores ranging from 2 to 3 (5-point Jadad scale). Selection and validity agreement was strong. Relative risk (95% confidence interval, CI; P-value), expressed as handsewn vs. stapled (treatment vs. control), was 0.45 (0.20, 1.00; P=0.05) for operative mortality, 0.79 (0.44, 1.42; P=0.43) for anastomotic leaks, 0.60 (0.27, 1.33; P=0.21) for anastomotic strictures, 0.99 (0.55, 1.77; P=0.97) for cardiac morbidity, and 0.93 (0.63, 1.37; P=0.72) for pulmonary morbidity. Data synthesized from existing RCTs show that handsewn and circular stapled esophagogastric anastomotic techniques give similar results for anastomotic outcomes, such as leaks and strictures. The stapled anastomotic method appears to increase operative mortality (P=0.05). Although it is difficult to explain this finding, it should not be dismissed. Several hypotheses are discussed.

Survival after conservative (palliative) management of pleural malignant mesothelioma

BACKGROUND AND OBJECTIVES

Malignant mesothelioma is a lethal disease. Aggressive multimodality treatment protocols are reportedly associated with improved survival, but the apparent survival benefits may simply reflect patient selection and the variable natural history of this malignancy. Before embarking on our own protocol of experimental treatment for mesothelioma, we sought to identify important prognostic factors and document the survival of patients treated conservatively (with palliative intent only) in our region.

METHODS

We performed a retrospective review of all patients with a diagnosis of malignant mesothelioma seen at our center between 1987 and 1999. Since curative intent treatment had not been given, we assumed that measured survival would largely reflect the natural history of the malignancy.

RESULTS

There were 101 patients (80 males and 21 females). Mean age was 65 +/- 9.2 years. Symptoms of disease were present for a median time of 5 months before the diagnosis was established. The most common presenting symptoms were dyspnea (46 patients), chest pain (30 patients), and weight loss (22 patients). Sixty-eight patients (68%) had a history of asbestos exposure. Mesothelioma subtypes included epithelial (43 patients), sarcomatous (26 patients), mixed (19 patients), desmoplastic (4 patients), and unspecified (9 patients). All 101 patients were treated with palliative intent. Talc pleurodesis was performed in 70 patients. At the time of analysis, 90 patients had died and 11 remained alive. Median survival was 213 (95% CI 137-289) days. Survival for the three major histological subtypes was significantly different (log rank, P = 0.0016). Histological subtype (epithelial favorable) was the only significant independent prognostic factor (Cox proportional hazard regression, P = 0.0009).

CONCLUSIONS

Patients with epithelial mesothelioma survive longer than those with other histological subtypes. Conservatively managed patients with pleural malignant mesothelioma have a median survival of approximately 7 months. These data from conservatively treated patients can serve as baseline information for future studies of experimental treatments.

Anastomotic leaks after esophagectomy for esophageal cancer: a comparison of thoracic and cervical anastomoses

BACKGROUND AND OBJECTIVES

Esophagogastric anastomotic leaks remain a significant problem after esophagectomy for esophageal cancer. Many investigators have reported that leaks are more frequent after cervical, as opposed to thoracic, esophagogastric anastomoses. We conducted a retrospective review to assess the effect of anastomotic location (thoracic or cervical) on anastomotic leak incidence and severity.

METHODS

Seventy-four consecutive patients with esophageal cancer underwent esophagectomy and esophagogastric anastomoses at our institution over a four-year period. Their charts were reviewed retrospectively and data was collected on age, gender, histology, stage, resection margin status, adjuvant therapy, cancer survival, anastomotic location, anastomotic leaks, and operative mortality.

RESULTS

Cervical anastomoses were done in 19 patients and thoracic anastomoses were done in the other 55 patients. The two groups were similar with respect to age, gender, histology, stage, adjuvant therapy, and overall survival. Operative mortality for the entire group of 74 patients was 4% (3 patients). Resection margins were positive for residual tumor in 2 of 19 (11%) patients with cervical anastomoses and 9 of 55 (16%) patients with thoracic anastomoses (p=0.42). Leaks complicated 1 of 19 (5%) cervical and 9 of 55 (16%) thoracic esophagogastric anastomoses (p=0.21). Positive resection margins and anastomotic leaks were not significantly related (p=0.54). One of 9 (11%) leaks in the thoracic group proved fatal.

CONCLUSIONS

In our experience cervical esophagogastric anastomoses do not have a higher incidence of leaks than thoracic anastomoses.

Open lung biopsy as an outpatient procedure

BACKGROUND

Lung biopsies are frequently needed to diagnose diffuse interstitial lung diseases. Both limited thoracotomy (open lung biopsy) and thoracoscopy can be used for lung biopsies, but both procedures have traditionally required hospital admission. We report a series of patients that underwent outpatient open lung biopsy to show the safety and effectiveness of this practice.

METHODS

We reviewed records of ambulatory, nonoxygen dependent patients with a clinical diagnosis of diffuse interstitial lung disease that underwent outpatient open lung biopsy between January 1997 and December 1999. All procedures were done by a senior surgeon using single lumen endotracheal anesthesia, a small anterolateral thoracotomy without rib spreading, stapled wedge resection, and no chest tube. Patients were discharged the same day.

RESULTS

Thirty-two patients with a clinical diagnosis of diffuse interstitial lung disease underwent outpatient open lung biopsy. Mean age was 58 years (range, 21 to 74 years). Preoperative forced expiratory volume in 1 second was 74.3%+/-7.0% of predicted. A pathologic diagnosis was established in all patients: usual interstitial pneumonia, 26 patients; sarcoidosis, 2; metastatic carcinoma, 2; desquamative interstitial pneumonia, 1; and mixed dust pneumoconiosis, 1 patient. No patient required a chest tube, overnight observation, or hospital admission. No complications occurred.

CONCLUSIONS

Selected patients with a clinical diagnosis of diffuse interstitial lung disease can safely and effectively undergo diagnostic outpatient open lung biopsy. However, careful patient selection and attention to operative detail are essential.

Local recurrence after total or subtotal esophagectomy for esophageal cancer

Cancer recurrence is a common problem after esophagectomy for esophageal cancer. Local recurrence is especially problematic because it often negates the palliative benefit of esophagectomy. We conducted a retrospective review to assess the effect of extent of esophageal resection (subtotal or total esophagectomy) on local cancer recurrence. Seventy-four consecutive patients with esophageal cancer underwent esophagectomy at our institution over a four-year period. Their charts were reviewed retrospectively and data was collected on age, gender, histology, stage, tumor location, operation, resection margin status, anastomotic leaks, operative mortality, adjuvant therapy, cancer survival, and local recurrence. Total esophagectomy was done in 19 patients (transhiatal - 3; McKeown - 16) and subtotal esophagectomy was done in the other 55 patients (Lewis - 25; left thoracoabdominal - 30). The two groups were similar with respect to age, gender, histology, stage, anastomotic leaks, operative mortality, adjuvant therapy, and overall survival. Resection margins were positive for residual tumor in 2 out of 19 (11%) total esophagectomies and 9 out of 55 (16%) subtotal esophagectomies (p=0.42). Local recurrence occurred in 3 of 19 (16%) patients treated with total esophagectomy and 23 out of 55 (42%) patients treated with subtotal esophagectomy (p=0.04). We conclude that total esophagectomy is associated with fewer local cancer recurrences than subtotal esophagectomy. We, therefore, recommend total esophagectomy for the surgical treatment of esophageal cancer.

Influence of epidermal growth factor and transforming growth factor beta-1 on patterns of fetal mouse lung branching morphogenesis in organ culture

Transforming growth factor-beta (TGF-beta), a potent inhibitor of epithelial cell proliferation, and epidermal growth factor (EGF), a mitogenic polypeptide that binds to cell surface receptors, are important regulators of cell differentiation; however, their distinct role(s) in lung development and their mechanisms of action are not well understood. We evaluated the effects of these factors on lung morphogenesis in murine fetal lungs at gestational day 14 (time:zero) and again after 7 days in culture. Baseline controls were cultured after tracheal transection in supplemented BGJb medium, and other tracheally transected lungs were cultured following addition of EGF (10 ng/ml BGJb), TGF-beta1 (2 ng/ml BFJb), or with both in combination added to the medium. The control lungs in culture had poorly developed airways and an absence of defined acinar structures. The addition of EGF resulted in hyperplasia of primary airways with stunted outgrowths, monopodial branching, and absence of distinct acinar structures. Addition of TGF-beta1 alone, led to significant elongation of primary airways, without normal airway branching; however, terminal dipodial branching was seen and the prospective pulmonary acini were well defined. Combination of these growth factors (GF) resulted in a more normal branching pattern and differentiation, suggesting their epigenetic role in lung morphogenesis and mutual interactive mechanisms that regulate lung development. These lungs had more abundant and larger lamellar bodies than those after other treatments. Control lungs remained immature with prominent glycogen aggregates with occasional dense lamellar bodies. The total protein and DNA contents were highest with EGF treatment, followed by combination treatment; these observations were supported by immunohistochemical localization of proliferating cell nuclear antigen, an indication of the proliferative state of tissues. All the surfactant proteins were relatively unaltered and their messages were up-regulated for SP-A, but down-regulated for SP-B and SP-C in the lungs treated with growth factors. In conclusion, we have demonstrated enhanced biochemical and structural development of lungs treated in vitro with GF, and propose that further research in this area may lead to therapeutic uses of GF alone or in combination with other agents for the treatment of newborn respiratory distress due to lung immaturity or hypoplastic lung development.

Esophageal/pyloric ligation enhances development of the murine fetal stomach in organ culture

PURPOSE

The authors hypothesized that increased intraluminal pressure in the fetal stomach would enhance development in a murine organ culture model.

METHODS

Gestation day 14 (Gd14) fetal stomachs from time-dated pregnant CD-1 mice (term, 20 days) were maintained in organ culture for 7 days. Some stomachs were ligated at the gastroesophageal (GE) and pyloroduodenal (PD) junctions. Others were left unligated. Gd14, Gd16, and Gd18 stomachs were taken as well to compare organogenesis in vivo. Tissues were processed for histological, morphometric, and immunohistochemical analysis, as well as total protein and DNA determination.

RESULTS

The ligated stomachs were visibly distended compared with unligated stomachs in organ culture after 7 days. The length and width of the 7-day in vitro ligated stomachs were significantly increased compared with unligated (2.97+/-0.04 mm v 2.48+/-0.05 mm and 2.14+/-0.04 mm v 1.57+/-0.08 mm, respectively, P < .05). Mucosal epithelial cells showed nuclear polarization, and there was a distinct outer muscle layer in the ligated stomachs, but not in the unligated stomachs, which demonstrated pseudostratified epithelial cells in the mucosa. The ligated stomachs had increased in mucosal thickness compared with unligated (31.4+/-1.3 microm vs 24.9+/-0.9 microm, p < 0.05). The ligated stomachs also had significantly increased protein and DNA content when compared with unligated stomachs (65.8+/-3.1 microg and 23.3+/-1.2 microg v 55.0+/-2.7 microg and 19.0+/-1.2 microg, respectively, P < .05). However, there were no significant differences noted between the protein to DNA ratios. Immunohistochemical staining for proliferating cell nuclear antigen (PCNA), a marker for cell proliferation, demonstrated increased proliferative activity of the mucosal epithelial cells in the ligated stomachs.

CONCLUSIONS

Esophageal and pyloric ligation enhanced the development of the fetal stomach in vitro in comparison with unligated stomachs cultured under similar conditions. Developmental characteristics of the ligated stomachs paralleled that of Gd16 stomachs in vivo.

Regenerative healing of incisional wounds in midgestational murine hearts in organ culture

OBJECTIVE

Using an organ-culture fetal heart repair model, we explored fetal repair in tissues other than dermis.

METHODS

Wounded fetal mouse hearts of 14 and 18 days' gestation (term = 20 days), as well as hearts of 22 days' gestation (newborn), were maintained in serum-free medium. Specimens were fixed at 2, 7, and 11 days and then processed for histologic examination. Small fragments of fetal hearts from all time points were cultured as explants. The migration of cells from the periphery of the explants was compared at day 4, and the pattern of microfilaments in these cells was assessed.

RESULTS

In 14-day hearts (n = 18), tissue architecture was rapidly reestablished without an inflammatory response or scarring, constituting regenerative repair. In 18-day hearts (n = 18), no reestablishment of muscle fibers or wound closure occurred. In the 22-day explants (n = 12) the wounds closed by scarring. Cell migration from 14-day explants was 4.7 +/- 2.3 ocular units; from 18-day explants, it was 2.6 +/- 1.1 ocular units; and from 22-day explants, it was 0.9 +/- 0.4 ocular units. Microfilaments of 14-day cells were arranged at the periphery of the cell consistent with cardiomyocytes. Microfilaments of 18- and 22-day cells were arranged in parallel arrays (stress fibers) that were consistent with fibroblasts.

CONCLUSIONS

We propose that regenerative healing of 14-day fetal hearts is by the migration of cardiomyocytes. At 18 and 22 days, cardiomyocytes are too differentiated and unable to migrate; hence cell migration is limited to resident fibroblasts, which are deficient at 18 days but sufficient at 21 days to be repaired by the scarring process.

Transition from fetal to adult repair occurring in mouse forelimbs maintained in organ culture

In previous wound healing experiments with the use of midgestation murine fetal forelimb explants, wounds were made before or immediately after amputation from the fetus. This experimental technique allows one to ask the question: do circulatory elements initiate or sustain the repair process in vitro? The hypotheses tested in the current study were that repair occurs in organ culture in the absence of systemic influences and that the in vivo transition from fetal-like to adult-type repair persists in an unperfused in vitro system. Gestational day-14 mouse forelimbs were harvested and placed in serum-free culture medium. Before amputation, control forelimbs received linear full-incision microscalpel wounds that were closed primarily. The animals in the other group were not immediately wounded but cultured for 4 days and then wounded with primary wound closure. All limbs were cultured for 7 days after wounding and then processed for histologic analysis. In the immediately wounded limbs, scarless healing occurred with collagen fibers deposited in a reticular form. In contrast, the delay-wounded limbs had collagen organized in parallel arrays (disordered), constituting repair by scarring. Wound repair proceeded as a local phenomenon in the absence of systemic mediators. We conclude that day-14 gestation forelimbs undergo maturation in culture, causing a transition from scarless to adult scar repair.

Bronchial ligation enhances murine fetal lung development in whole-organ culture

Evidence exists from both congenital anomalies and animal models that normal fetal lung development is dependent on maintenance of fluid pressure within the developing "airways." Fetal tracheostomy, allowing free egress of airway fluids, results in lung hypoplasia, indicating that some airway distending pressure is required for normal lung development to occur. In contrast, fetal tracheal ligation, which increases fetal airway pressure, reverses lung hypoplasia in animal models. The authors' experiments test the hypothesis that large airway obstruction accelerates the development of murine lungs in vitro in whole-organ culture. Fetuses from time-dated pregnant CD-1 mice at day 14 of gestation were removed (term, 20 days), and the lungs were excised. The left bronchus of each lung was ligated (n = 26), after which the left lung was isolated and cultured at 37 degrees C (95% air, 5% CO2) in BGJb media supplemented with vitamin C and antibiotics. Some fetal lungs were cultured under similar conditions without bronchial ligation (n = 11). After 7 days in culture, the lungs were taken for various analyses. The lungs were fixed in either formaldehyde and processed for paraffin embedding for light microscopic evaluation and morphometric data collection, or were freshly minced and aliquots taken for total protein and DNA content. Several more ligated and unligated lungs were processed for ultrastructural analysis. Morphometric analysis on transverse sections of lungs showed significant differences in the lung tissue size, thickness, epithelial cell height, luminal areas, perimeters, and total number of airspaces (airway + primordial alveolar airspaces). It was evident that bronchial ligation promoted lung development. The ligated lungs displayed thinning of the primordial alveolar walls with cuboidal epithelial cells. The total number of airspaces per field was lower for better developed ligated lungs because of the increased area of airspaces compared with that of the unligated lungs. The dorsoventral tissue thickness (in micrometers) of the ligated lungs was significantly greater than that of the unligated lungs (124.1 +/- 7.0 v 89.6 +/- 8.0); the average outer perimeter of the primordial alveolar airspaces was greater for ligated lungs (404.56 +/- 19.0 microns v 256.85 +/- 17.0 microns). Similarly, the luminal diameter of the spaces of ligated lungs was almost double that of the unligated lungs (38.0 +/- 2.0 microns v 20.3 +/- 2.0 microns), as was the luminal surface area. The morphometric data, which suggest enhanced maturation of the ligated lungs, are supported by results of ultrastructural studies. Ligated lungs had significantly more lamellar bodies. Although total protein and DNA content were greater among the ligated lungs, the protein/DNA ratios did not differ among the groups. The intraluminal pressure (airway pressure) of ligated lungs was 2.9 mm Hg and 3.1 mm Hg at 2 and 4 days in organ culture; the respective pressures for unligated lungs were 1.0 mm Hg and 0.8 mm Hg. These data support the hypothesis that mechanical distending pressure resulting from airway obstruction not only improves pulmonary architecture but also accelerates lung development in vitro. Although these effects have been seen in in vivo models, this is the first proposed in vitro organ culture model. This model may prove to be a powerful tool for the study of molecular mechanisms of mammalian lung development with respect to mechanical and chemical (cytokines, hormones) stimuli.

Perforated appendicitis: past and future controversies

Although mortality rates for pediatric appendicitis have been reduced to near zero with the development of safe surgical procedures and routine perioperative antibiotic therapy, the incidence of perforated appendicitis in children has remained at a comparatively high level. This article reviews the recent literature on perforated pediatric appendicitis, including a discussion of some of the controversies concerning management of the ruptured appendix. In addition, the future of both the evaluation and treatment of this disease, including laparoscopy, the possibilities for outpatient antibiotic therapy, and the worrisome potential for a change in referral patterns as children with this disease are increasingly enrolled in managed care plans, are considered.

Regenerative healing of incisional wounds in murine fetal lungs maintained in organ culture

Although fetal dermal repair is known to be fundamentally different from adult healing, the response to wounding in other organs is less well characterized. Scarless repair in mid-gestation dermis with a transition to adult-type healing at term has been shown in fetal organ culture. A lung explant culture system was used to investigate whether wound repair in the fetal lung shows characteristics similar to those found in fetal dermis. Lungs from 14-day and 18-day Cd-1 murine fetuses and 2-day-old newborns, (term = 20 days, n = 24) were wounded by linear incision and incubated at 37 degrees C, in a 21% O2, 5% CO2 environment, in BGJb supplemented with vitamin C and antibiotics. Medium was changed daily. Samples were fixed at 7 days and embedded in paraffin. Sections were stained with hematoxalyn-eosin and Masson Trichrome. Additional 14-day and 18-day samples were frozen in freon and immunohistochemical staining for TGF-beta performed. Other frozen tissues from each time point were homogenized and used to assay for endogenous TGF-beta levels by Western blot analysis. Histology showed reconstitution of tissue architecture across the wound in 14-day and 18-day specimens. In representative histological sections, intact bronchial architecture developed across the previous wound site. No cellular inflammatory response was observed, and collagen deposition was undetectable at the site of the wound by Trichrome staining. By 22 days the lung explants showed a much less ordered repair, including disorganized collagen deposition.(ABSTRACT TRUNCATED AT 250 WORDS)