Benjamin K. Poulose

Cystadenomas of the pancreas: Is enucleation an adequate operation?

OBJECTIVE The objective was to determine whether surgical enucleation of mucinous cystadenoma of the pancreas is a safe and adequate operation. SUMMARY BACKGROUND DATA Mucinous cystadenomas of the pancreas are premalignant cystic lesions. Resection is the preferred treatment but often requires a pancreatoduodenectomy or a distal pancreatectomy with or without a splenectomy. Although these procedures can now be performed with a low mortality rate, substantial morbidity still occurs, especially in patients who have an otherwise normal pancreas. METHODS Between January 1990 and June 1997, 36 mucinous cystadenomas of the pancreas were resected at The Johns Hopkins Hospital. Most of these patients underwent pancreatoduodenectomy or distal pancreatectomy. However, 10 patients (28%) underwent enucleation of their cystic tumor. These 10 patients had a mean age of 63 years, and 6 were men. The cystic lesion was demonstrated by computed tomography in all patients. Enucleation of the cyst was performed in each patient, and four underwent another concomitant abdominal procedure. These 10 patients were followed with periodic computed tomographic scans and clinical examinations. RESULTS Enucleation took less time and was associated with less blood loss than resection. Pancreatic fistulas occurred more frequently after enucleation, but the incidence of major complications was similar between the two groups. Follow-up after enucleation averaged 43 months, and none of the patients developed late sequelae or recurrence. CONCLUSIONS This experience suggests that enucleation of mucinous cystadenomas of the pancreas can be performed safely and that the recurrence rate is low after this procedure. The authors conclude that enucleation is an adequate procedure for benign cystic neoplasms of the pancreas.

Resident Work Hour Limits and Patient Safety

Objective:This study evaluates the effect of resident physician work hour limits on surgical patient safety. Background:Resident work hour limits have been enforced in New York State since 1998 and nationwide from 2003. A primary assumption of these limits is that these changes will improve patient safety. We examined effects of this policy in New York on standardized surgical Patient Safety Indicators (PSIs). Methods:An interrupted time series analysis was performed using 1995 to 2001 Nationwide Inpatient Sample data. The intervention studied was resident work hour limit enforcement in New York teaching hospitals. PSIs included rates of accidental puncture or laceration (APL), postoperative pulmonary embolus or deep venous thrombosis (PEDVT), foreign body left during procedure (FB), iatrogenic pneumothorax (PTX), and postoperative wound dehiscence (WD). PSI trends were compared pre- versus postintervention in New York teaching hospitals and in 2 control groups: New York nonteaching hospitals and California teaching hospitals. Results:A mean of 2.6 million New York discharges per year wereanalyzed with cumulative events of 33,756 (APL), 36,970 (PEDVT), 1,447 (FB), 10,727 (PTX), and 2,520 (WD). Increased rates over time (expressed per 1000 discharges each quarter) were observed in both APL (0.15, 95% confidence interval, 0.09–0.20, P<0.05) and PEDVT (0.43, 95% confidence interval, 0.03–0.83, P<0.05) after policy enforcement in New York teaching hospitals. No changes were observed in either control group for these events or New York teaching hospital rates of FB, PTX, or WD. Conclusions:Resident work hour limits in New York teaching hospitals were not associated with improvements in surgical patient safety measures, with worsening trends observed in APL and PEDVT corresponding with enforcement.

Risk factors for pressure ulcers in acute care hospitals

Selection of patients for preventive measures to protect against pressure ulcers relies on clinical scales and provider judgment, which vary widely. Our objectives were to: (a) identify risk factors by clinical classification and report demographic differences in pressure ulcer risk and (b) develop criteria for identification of high‐risk patients. Patients with pressure ulcer as a discharge diagnosis were identified from the 2003 Nationwide Inpatient Sample (NIS). The effect of discharge diagnosis was examined using the Agency for Healthcare Research and Quality Clinical Classification Software (CCS). Multiple regression analysis for survey data was used to assess risk factors. The 2003 NIS listed 94,758 with a discharge diagnosis of pressure ulcer, identified as International Classification of Disease‐9 code 707.0–707.09, for an overall incidence of 143 per 10,000. Forty‐five CCS discharge diagnoses were present in at least 5% of these patients and 28 of these CCS diagnoses had odds ratios >2.0. African‐American race and advanced age were identified as risk factors for pressure ulcer diagnosis. Disorders of skin integrity, organ system failure, and infection were found to be broad categories of risk factors as well. Using the NIS, risk factors for pressure ulcer including diagnoses and demographic factors have been identified.

National analysis of in-hospital resource utilization in choledocholithiasis management using propensity scores

BackgroundTwo treatment options exist for choledocholithiasis (CDL): endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct exploration (CBDE). Resource utilization measured by total in-hospital charges (THC) and length of stay (LOS) was compared using the propensity score (PS). In this study, PS was the probability that a patient received CBDE based on comorbidities and demographics. The power of this method lies in balancing groups on variables by PS, resulting in 90% bias reduction and improved inferential validity compared to traditional analytic techniques.MethodsLaparoscopic cholecystectomy (LC) patients with CDL who had ERCP or CBDE were identified in the 2002 U.S. Nationwide Inpatient Sample. Patients were ordered into five PS balanced strata. Mean THC, LOS, and estimated costs were compared. A linear regression model was used to estimate the contribution that LOS had on estimated costs. Monetary values were adjusted to 2004 dollars.ResultsA total of 40,982 patients underwent LC with CDL in 2002; 27,739 had either ERCP (93%) or CBDE (7%). Mean age was 52.7 ± 0.4 years, with 74% women. Mean THC were less for CBDE (

Cost perspectives of laparoscopic and open appendectomy.

25,200 ±

How should we establish the clinical case numbers required to achieve proficiency in flexible endoscopy

1,800) than for ERCP (

Multicenter, prospective, longitudinal study of the recurrence, surgical site infection, and quality of life after contaminated ventral hernia repair using biosynthetic absorbable mesh: The COBRA study

29,900 ±

Design and implementation of the Americas Hernia Society Quality Collaborative (AHSQC): improving value in hernia care

800, p < 0.05). Mean LOS was less for CBDE (4.9 ± 0.2 days) than for ERCP (5.6 ± 0.1 days, p < 0.05). PS adjusted analysis revealed an estimated overall cost savings of

Prospective Evaluation of Surgeon Physical Examination for Detection of Incisional Hernias

4,500 ±

Efficient multi-atlas abdominal segmentation on clinically acquired CT with SIMPLE context learning

1,600 and reduced LOS (0.6 ± 0.2 days) per hospitalization for CBDE. Mean THC, LOS, and estimated costs across PS score balanced strata were generally higher in the ERCP group compared to the CBDE group. LOS contributed 53% to increased THC and 62% of estimated costs. A higher cumulative incidence of complications was evident with CBDE (0.5–4.6%) compared to ERCP (0.3–3.6%).ConclusionsBased on this PS analysis, CBDE incurs less THC, reduces LOS, and has less estimated costs for CDL compared to ERCP. Furthermore, CBDE appears to be dramatically underutilized.