Alla Y. Zemlyak

Colonoscopy is superior to neostigmine in the treatment of Ogilvie's syndrome

BACKGROUND Colonic pseudo-obstruction in critically ill patients may lead to devastating colonic perforation. Neostigmine is often the first-line intervention, because colonoscopy is more invasive and labor intensive. METHODS A retrospective 10-year review at a tertiary medical center identified 100 patients with Ogilvies syndrome, in whom treatment course and clinical and radiographic response were evaluated. RESULTS Colonoscopy was significantly more successful than neostigmine (defined as no further therapy) after 1 or 2 interventions (75.0% vs 35.5%, P = .0002, and 84.6% vs 55.6%, P = .0031, respectively). One colonoscopy was more effective than 2 neostigmine administrations (75.0% vs 55.6%, P = .044). Clinical response (poor, fair, or good) was significantly better after colonoscopy than neostigmine after 1 or 2 interventions (P = .0028 and P = .00079). Cecal diameters decreased significantly more after colonoscopy than neostigmine (from 10.2 ± .5 cm to 7.1 ± .4 cm vs from 10.5 ± .5 cm to 8.8 ± .5 cm, P = .026). Neostigmine administration before colonoscopy did not affect outcomes. There were 3 perforations (3.7%): 1 each after colonoscopy, neostigmine, and no intervention. Neostigmine dose or repetition did not affect radiographic (P = .41) or clinical (P = .31) response. CONCLUSIONS Colonoscopy is superior to neostigmine for Ogilvies syndrome and should be considered first-line therapy, although neostigmine is useful in select patients and repeat interventions.

Medical malpractice and hernia repair: An analysis of case law

BACKGROUND Litigation analysis and clinician education are essential to reduce the number and cost of malpractice claims. This study evaluates the clinical characteristics and legal outcomes of medical malpractice litigation initiated by patients having undergone a hernia repair operation. MATERIALS AND METHODS Published civil suits were obtained from a legal database for state and federal decisions constituting case law. The published material includes information on defendants, plaintiffs, allegations, outcomes, and a variety of legal issues. A retrospective review of 44 published cases from 25 states was performed. RESULTS Complications were present in 20 of 44 (45%) suits, four (9%) of which were because of infection. Death occurred in five (11%) cases, and failure to obtain informed consent was alleged in seven (16%) of the suits. Retained foreign bodies were present in 7 of the 44 (16%) suits. Other allegations included incorrect surgical technique, insufficient need for surgery, and emotional distress. Most (64%) patients initiating malpractice litigation were male, and inguinal, hiatal, and ventral hernia repairs account for 39%, 27%, and 14% of cases, respectively. Most suits (40%) were initiated in Southern states. Surgical mesh was indicated in 5 of 44 (11%) suits but four of five were unrelated to the suit. One patient initiated litigation because of the fact that the surgeon did not use mesh during surgery, which was discussed preoperatively during the informed consent. The court ruled in favor of the plaintiff in 12 of 44 (27%) suits, with compensation ranging from roughly

Nationwide inpatient sample: have antireflux procedures undergone regionalization?

19,000 to

Diagnostic Laparoscopy in the Intensive Care Unit.

8,000,000. Louisiana and New York had six and seven suits each, which appears disproportionate given their respective populations. CONCLUSION Complications and death resulting from alleged clinical negligence play a significant role in both the initiation and the outcome of malpractice litigation. Retained foreign bodies and lack of informed consent account for roughly one-third of malpractice litigation associated with hernia repairs. Many of these suits may be avoided with proper patient education and documentation of such along with standard operative preventative measures.

809 Nationwide Inpatient Sample: Have Antireflux Procedures Undergone Regionalization?

The Nissen fundoplication was introduced in 1956 by Rudolph Nissen and is a proven, effective treatment for gastroesophageal reflux disease (GERD). The laparoscopic technique was first described in 1991 by Bernard Dallemagne and has also been shown to be safe and effective in treatment of GERD. From 1990 to 1997, antireflux surgery rates almost tripled and peaked in 1999, which was followed by a steady decline through 2006. The decline in surgical volume has been partially attributed to a question of the longterm effectiveness of antireflux surgery, where re-operation can often become required, and many patients require acid suppression medications post-operatively. –11 The decline of operative intervention has also been attributed to the availability of over-the-counter proton pump inhibitors, new endoscopic therapies for treating GERD, and the rise of bariatric surgery. 7 Increasing outpatient antireflux procedures has also been examined as a potential cause for the decrease of inpatient cases. However, analysis of outpatient data in several states has revealed that the decrease in inpatient procedures in not nearly matched by the volume of outpatient procedures. The effect of hospital volume on mortality has been demonstrated since the 1970s, but the literature describing this effect rapidly increased in the late 1990s. –17 This lead to a call for regionalization of many procedures on a national level by the year 2000. Regionalization has been demonstrated for many complex procedures, oncologic and otherwise. 20 The timing of the national call for regionalization coincided closely with the peak of antireflux surgery. The purpose of this study is to examine trends in antireflux surgery to determine the extent of regionalization, if any at all, in the decade following the zenith of antireflux surgery.

Comparative study of wound complications: Isolated panniculectomy versus panniculectomy combined with ventral hernia repair

Primary and acquired abdominal pathology accounts for a significant proportion of sepsis and SIRS in the ICU population. Abdominal processes often present a difficult diagnostic dilemma in the truly critically ill patient who, due to hemodynamic instability or severe acute respiratory distress syndrome (ARDS) requiring high-level ventilatory support, is at significant risk during transport to radiology department. Furthermore, the accuracy of radiologic studies in the ICU setting is often limited. Laparoscopy provides a “minimally invasive” definitive modality to diagnose intra-abdominal problems. It may quickly provide the necessary information to define further management. In selective circumstances, it may actually allow appropriate intervention. However, the overall mortality of patients who undergo diagnostic laparoscopy in the ICU is high regardless of diagnostic findingsduring this procedure. Although not a technically difficult procedure, diagnostic laparoscopy does require a certain skill level, especially when limited time and unfavorable patient physiology are taken into account. The use of diagnostic laparoscopy should be limited to patients in whom a therapeutic intervention is feasible.

Umbilical hernia repair with mesh: identifying effectors of ideal outcomes

Introduction: With improved outcomes demonstrated at high volume centers, many complex surgical procedures have migrated to large, specialized hospitals. The purpose of this study is to examine the extent of regionalization and outcomes in anti-reflux surgery. Methods: The Nationwide Inpatient Sample (NIS) data were analyzed from 1998-99 (T1) and 200809 (T2) for all antireflux operations in patients with gastroesophageal reflux symptoms using ICD-9-CM codes. Hospitals were stratified into high-, mid-, and low-volume centers (HVC, MVC, LVC) based on annual antireflux surgery volume. Complications and outcomes were also compared. Socio-demographic factors were examined as effectors of surgery location. Results: A total of 11804 cases were performed in T1 and 8856 in T2. In T1, 41.0% of procedures were performed in a HVC vs 35.4% in T2. LVC rates increased with time: 20.53% vs. 26.87% (p<0.0001). Rural hospitals had decreased surgical volume (19.10% vs. 10.33%, p<0.0001), while all urban hospitals increased volumes: teaching (48.23% vs. 51.03%, p<0.0001) and non-teaching (32.67% vs. 38.64%, p<0.0001). Using multivariate regression, the following were predictors of surgery at a LVC in T1: non-caucasian race (OR 1.42, p<0.0001), emergent admission (OR 2.24, p<0.0001), living in a zip code with low median income (OR 1.52 lowest vs. highest, p=0.0039), increasing age (p=0.0002), and increasing concurrent diagnosis number (p=0.0029). In T2, emergent admission (OR 1.34, p=0.038), low median income (OR 1.69 highest vs lowest, p<0.0001), and number of concurrent diagnoses (p=0.034) were independent predictors of antireflux surgery at a LVC. In T2, mean LOS at a LVC was 4.0 days vs 3.3days at a HVC (p<0.0001), but this was not significant in multivariate analysis. Total charges were lower at a LVC (

Nationwide outcomes of nontrauma splenectomy

38000 vs

Does the Volume of Laparoscopic Versus Open Cases Affect the Outcomes of Inguinal Hernia Repair

41000, p=0.0032) in multivariate analysis. Complication rates increased at all centers with time, but were twice as common in LVCs (6.39% vs. 3.16% at HVCs, p<0.0001) in T2. Controlling for confounding variables, complications remained more likely in LVCs (T1: OR 1.71, p<0.0001, T2: OR 1.49, p<0.0001). In hospital mortality decreased in all centers with time and did not differ significantly in either era. Patients at all centers have increased their mean number of concurrent diagnoses over time(3.92 vs 6.70, p<0.0001). Conclusion: Despite improved results at HVCs, LVCs have increased their percentage of antireflux operations over time. The urban non-teaching hospitals have experienced the largest gains in caseload. Overall complication rates have increased with time, possibly due to noted increased incidence of comorbidities in the patients seeking antireflux surgery. After controlling for confounding variables, complications remain more likely in LVCs. Regionalization has not occurred over time, but may improve outcomes if supported.