Dana A. Telem

Laparoscopy: a safe approach to appendicitis during pregnancy

BackgroundThe aim of this study was to evaluate laparoscopic versus open surgery for suspected appendicitis during pregnancy.MethodsA hospital-based retrospective review of 65 consecutive pregnant patients who underwent surgery for suspected appendicitis from 1999 to 2008 was performed. Significance was determined by Pearson’s χ2 test, Fisher’s exact test, Mann–Whitney test, and Kruskal–Wallis test.ResultsOf the 65 patients, 48 cases were laparoscopic and 17 open. Use of the laparoscopic versus open approach was significantly increased in the first (100% vs. 0%, pxa0<xa00.001) and second trimesters (73% vs. 27%, pxa0<xa00.001). The open approach was used more frequently in third-trimester patients (71% vs. 29%, pxa0=xa0NS). Significance was demonstrated in mean length of hospital stay in the laparoscopic versus open group (3.4 vs. 4.2xa0days, pxa0=xa00.001). No maternal mortalities occurred. Follow-up of fetal outcome was achieved in 89% of patients. No difference was demonstrated in fetal loss (1 in laparoscopic group), APGAR score, birth weight, and preterm delivery rate by operative approach. Adverse outcome was associated with maternal temperature greater than 38°C, leukocytosis greater than 16xa0×xa0109/l, or more than 48xa0h between onset of symptoms and emergency room presentation.ConclusionsThis article is the largest hospital-based series evaluating the laparoscopic versus open approach for pregnant patients with presumed acute appendicitis. While methodological limitations preclude a definitive recommendation, laparoscopy appears to be a safe, feasible, and efficacious approach for pregnant patients with presumed acute appendicitis. We conclude that it is likely not the surgical approach but the underlying diagnosis combined with maternal factors that determine the risk for pregnancy complications. A benefit of laparoscopy is the diagnostic ability to identify other intra-abdominal pathology which may mimic appendicitis and harbor pregnancy risks.

Factors That Predict Outcome of Abdominal Operations in Patients With Advanced Cirrhosis

BACKGROUND & AIMSnPatients with cirrhosis have an increased risk of complications during surgery that is relative to the severity of liver disease; it is a challenge to determine which patients are the best candidates for surgery. We performed a hospital-based study to identify factors that might facilitate selection of operative candidates and guide their management.nnnMETHODSnA retrospective review was performed of 100 cirrhotic patients (50 classified as Child-Turcotte-Pugh [CTP] A, 33 as CTP B, and 17 as CTP C) who underwent abdominal surgery at an institution specializing in liver medicine and transplant from 2002-2008. Significant univariate variables were evaluated by multivariate logistic regression models to identify factors that correlate with outcome.nnnRESULTSnThe overall, 30-day postoperative mortality rate was 7%. The mortality for patients who were CTP A was 2%, CTP B was 12%, and CTP C was 12%; 33 patients had a Model for End-Stage Liver Disease (MELD) score >or=15, with 29% mortality. On the basis of multivariate analyses, risk factors for adverse outcome were American Society of Anesthesiologists (ASA) score >3; procedures being emergent; intraoperative blood transfusion; intraoperative blood loss >150 mL; presence of ascites; total bilirubin level >1.5 mg/dL; and albumin level <3 mg/dL. Addition of serum albumin to MELD score showed that patients with MELD score >or=15 and albumin <or=2.5 mg/dL (vs >2.5 mg/dL) had significantly increased mortality (60% vs 14%, P < .01) and independently increased probability of adverse outcome (odds ratio, 8.4; P = .015).nnnCONCLUSIONSnFor patients with MELD scores >or=15, the preoperative albumin level correlates with outcome and could guide operative decisions. Intraoperative packed red blood cell transfusion correlates with adverse outcome and should be limited.

Integration of a formalized handoff system into the surgical curriculum: resident perspectives and early results.

HYPOTHESISnThe Situation, Background, Assessment, and Recommendation model (SBAR) provides an excellent framework for communication in daily resident handoffs.nnnOBJECTIVEnTo evaluate implementation of SBAR into the surgical curriculum.nnnDESIGNnA curriculum using video and role-play scenarios to augment a didactic lecture on SBAR was implemented for general surgery residents. Resident assessment was achieved via an anonymous survey administered after training. Outcome was evaluated by assessing sentinel events and resident order entry 30 days before and after training. Surgical subspecialty resident order entries were used as controls. Duplicated, cancelled, and wrong patient orders were attributed to failed communication.nnnSETTINGnAcademic department of surgery.nnnPARTICIPANTSnForty-five general surgery residents at our institution.nnnRESULTSnSurvey response rate was 100%. Poor communication was identified as the leading cause of handoff failure, with nurse-to-resident handoffs considered the most problematic. Overall, the curriculum was well received. Outcomes analysis demonstrated no difference in sentinel events. A 2.3% decrease in pretraining and posttraining order entry errors (14.5% vs 12.2%; P = .003) was demonstrated. No difference was demonstrated in controls who did not undergo SBAR training (12.9% vs 13.6%; P = .47).nnnCONCLUSIONSnMost of the residents indicate that the SBAR curriculum addressed frequently encountered communication issues and taught clinically beneficial communication skills. The identified specific communication deficiencies will direct future curriculum goals. The SBAR model is an effective and valuable tool to standardize communication. Early outcomes analysis demonstrates a decrease in order entry errors after training. Sentinel events are infrequent and will require long-term evaluation.

Laparoscopic subtotal colectomy for medically refractory ulcerative colitis: the time has come.

PurposeTo evaluate laparoscopic versus open subtotal colectomy (STC) in patients with ulcerative colitis (UC) requiring urgent or emergent operative intervention.MethodsA retrospective review was performed of 90 patients with medically refractory UC who underwent STC with end ileostomy at The Mount Sinai Medical Center from 2002 to 2007. Patients with toxic megacolon were excluded. Univariate analysis was conducted by unpaired Student t-test and chi-square test. Results are presented as meanxa0±xa095% confidence interval.ResultsNinety patients underwent STC, 29 by laparoscopic and 61 by open approach. In patients undergoing laparoscopic versus open STC, intraoperative blood loss was decreased (130.4xa0±xa038.4 vs. 201.4xa0±xa043.2xa0ml, pxa0<xa00.05) and operative time prolonged (216.4xa0±xa020.2 vs. 169.9xa0±xa014.4xa0min, pxa0<xa00.01). In the absence of postoperative complication, hospital length of stay (4.5xa0±xa00.7 vs. 6xa0±xa01.3xa0days, pxa0<xa00.001) was shorter in laparoscopic versus open group. No mortalities occurred. Overall morbidity, 30-day readmission, and reoperation were equivalent regardless of operative approach. Wound complications were absent in the laparoscopic group compared with 21.4% in the open group (pxa0<xa00.01). Follow-up at a mean of 36xa0months demonstrated no difference in restoration of gastrointestinal continuity.ConclusionLaparoscopic STC confers the benefits of improved cosmesis, reduced intraoperative blood loss, negligible wound complications, and shorter hospital stay. Laparoscopy is a feasible and safe alternative to open STC in patients with UC refractory to medical therapy requiring urgent or emergent operation.

Complicated hernia presentation in patients with advanced cirrhosis and refractory ascites: Management and outcome

BACKGROUNDnOur purpose was to determine optimal management of and outcome after umbilical herniorrhaphy in patients with advanced cirrhosis and refractory ascites.nnnMETHODSnA retrospective chart review was performed of 21 patients with advanced cirrhosis who underwent umbilical herniorrhaphy at The Mount Sinai Medical Center from 2002 to 2008. Univariate, multivariate, and Kaplan-Meier analysis was performed.nnnRESULTSnTwenty-one patients had refractory ascites: 15 presented with incarceration and 6 with spontaneous umbilical rupture. The mortality rate was 5% and morbidity rate 71%. Two patients required perioperative liver transplantation, and 5 developed ascites-related wound complications. Follow-up at a mean of 36 months demonstrated a 20% mortality rate due to liver disease; 5% required liver transplantation and 6% had a recurrent hernia. In addition to diuretics and albumin, perioperative management of ascites consisted of preoperative transjugular intrahepatic portosystemic shunt (TIPS; n = 6), postoperative TIPS (n = 2), and closed-suction drains (n = 7). The wound complication rate was 17% in patients who underwent preoperative TIPS versus 27% in patients who did not undergo preoperative TIPS (P = NS). TIPS placement postoperatively controlled ascites adequately without additional complication in 2 patients. In this series, use of closed-suction drains did not appear to decrease ascites-related complications. Spontaneous umbilical rupture was an independent risk factor for adverse outcome. For patients presenting with umbilical rupture, preoperative TIPS and semi-elective repair appeared to improve perioperative and 36-month outcome as compared with emergent repair.nnnCONCLUSIONnPreoperative TIPS in conjunction with semi-elective repair when feasible appears preferable, particularly for patients with spontaneous umbilical rupture. The lower than anticipated mortality rate was attributed to institutional experience and to the multidisciplinary approach to patient care.

The relevance of transition zones on computed tomography in the management of small bowel obstruction

BACKGROUNDnFrequently, radiologists emphasize radiographic transition zones (RTZs) on computed tomography (CT), which are areas of abrupt change from dilated to collapsed bowel, as pathognomonic for small-bowel obstruction (SBO) diagnosis and location. The relevance of RTZs to patient management remains unknown. The purpose of this study was to determine the surgical predictive value and intraoperative accuracy of RTZ.nnnMETHODSnA retrospective review of 200 patients with SBO who underwent abdominal CT at a single institution from 2002 to 2007 was performed. Statistical analysis was conducted using an unpaired t test, a Chi-square test, and multivariate analysis.nnnRESULTSnOf the 200 patients with SBO, 150 (75%) had an RTZ. Seventy-five (38%) patients required operative intervention; 58 (39%) patients had RTZ and 17 (34%) patients did not have RTZ (P=NS). The presence of RTZ was not associated with increased probability of operative versus nonoperative management (odds ratio=1.19; 95% confidence interval [0.61-2.32]). The mean time to operative intervention was 3.6 days. Immediate operative intervention (<24 h) was equivalent in patients with versus without RTZ (57% vs 53%; P=NS) as was intervention for failed nonoperative management (43% vs 47%; P=NS). For patients who required operative intervention, RTZ correlated with intraoperative site of obstruction in only 31 (63%) patients.nnnCONCLUSIONnThe presence of RTZs does not increase the likelihood of operative intervention or identify patients who will fail nonoperative management. RTZ should, therefore, not be used as a major criterion influencing operative versus nonoperative management decisions in patients with SBO. For patients who required operative intervention, RTZ had a 63% correlation with intra-operative findings, which makes it a useful adjunct to pre-operative planning.

Prolonged preoperative hospitalization correlates with worse outcomes after colectomy for acute fulminant ulcerative colitis

BACKGROUNDnAlthough total abdominal colectomy has long been considered definitive treatment for fulminant ulcerative colitis refractory to medical management, the optimal timing of surgery remains controversial. Early surgical intervention may be beneficial to patients with acute ulcerative colitis. Our goal was to compare outcomes after colectomy for fulminant ulcerative colitis and to identify preoperative factors that are predictive of poor outcome.nnnMETHODSnThe charts of 107 patients treated by total abdominal colectomy with ileostomy for fulminant ulcerative colitis between 2004 and 2009 were retrospectively reviewed. Twenty-nine patients sustained a major postoperative complication; 78 patients recovered uneventfully. Perioperative statistics, 30-day readmission/reoperation rates, and perioperative morbidity and mortality were compared using the Student t and Fisher exact tests and χ(2) analysis where appropriate.nnnRESULTSnWhite blood cell count at admission was significantly higher among patients who developed postoperative complications, but there were no differences in patient characteristics, other acute illness measures, or disease extent. Univariate analysis revealed that patients who developed postoperative complications underwent colectomy significantly later (3.6 vs 7.4 days; P = .01) than those who recovered uneventfully. Laparoscopic colectomy took significantly longer than open surgery, but did not affect postoperative morbidity. Multivariate analysis revealed duration of preoperative medical treatment to be the only significant predictor of increased risk of postoperative morbidity. Follow-up data revealed that similar percentages of patients in both groups eventually underwent ileal pouch anal anastomosis (IPAA; 68% vs 77%; P = .5).nnnCONCLUSIONnProlonged duration of preoperative medical treatment correlates with poor postoperative outcomes after total abdominal colectomy for fulminant ulcerative colitis. In addition, sustaining postoperative complications did not prevent patients from eventually undergoing IPAA.

Laparoscopic umbilical hernia repair is the preferred approach in obese patients.

INTRODUCTIONnThe optimal method of umbilical hernia repair (UHR) in the obese population, laparoscopic vs open, is not standardized. The purpose of this study was to determine the optimal surgical option for UHR in the obese population.nnnMETHODSnA retrospective chart review was conducted on 123 obese patients (body mass index [BMI] >30) who underwent UHR from 2003 to 2009 at a single institution. Patients were grouped by surgical approach (open vs laparoscopic). Intraoperative and postoperative courses were compared. Follow-up in the postoperative period was obtained from patient records and telephone interviews.nnnRESULTSnOf the 123 patients undergoing UHR, 40 and 83 patients were operated on with the laparoscopic and open approach, respectively. Patients were well matched by demographics as well as comorbidities. No difference in the mean BMI was shown between the laparoscopic and open groups (37 vs 35, P = not significant, respectively). The operative time was significantly prolonged in the laparoscopic group (106 vs 71 minutes, P < .01). Intraoperatively, no complications occurred in either group. In the immediate postoperative period, 1 patient who underwent laparoscopic UHR was readmitted for small bowel obstruction, and 2 patients in the open group were readmitted, 1 for pain control and 1 for wound infection. Follow-up was achieved in 63% of the laparoscopic group and 58% of the open group with a mean follow-up of 15 months in the laparoscopic group and 20 months in the open group (P = not significant). A significant increase in wound infection was reported in the open group with mesh insertion when compared with the laparoscopic procedure (26% vs 4%, P < .05, respectively). No hernia recurrence was shown in the laparoscopic vs the open group with mesh insertion (0% vs 4%, P = not significant, respectively).nnnCONCLUSIONSnIn obese patients, the laparoscopic approach was associated with a significantly lower rate of postoperative infection and no hernia recurrence. Laparoscopic hernia repair may be the preferred option in the obese patient.

Diagnosis of gastrointestinal anastomotic dehiscence after hospital discharge: Impact on patient management and outcome

BACKGROUNDnAnastomotic leaks are inevitable complications of gastrointestinal surgery. Early hospital discharge protocols have increased concern regarding outpatient presentation with anastomotic leaks.nnnMETHODSnOne hundred anastomotic leaks in 5,387 intestinal operations performed at a single institution from 2002 to 2007 were identified from a prospectively maintained database. Statistical analysis was conducted by the unpaired t test, Chi-square test, and analysis of variance.nnnRESULTSnOverall anastomotic leak with a rate of 2.6% for colonic and 0.53% for small bowel anastomoses. Mean time to anastomotic leak diagnosis was 7 days after operation. Twenty-six patients presented after discharge, with mean time to diagnosis 12 days versus 6 days for inpatients (P<.05). Patients presenting after hospital discharge were younger, had lesser American Society of Anesthesiologists (ASA) scores, and were more likely to have colon cancer and less likely to have Crohns disease. Ninety-two patients required operative management, of whom 81 (90%) underwent diversion. No difference in management, intensive care unit (ICU) requirement, duration of stay, or mortality between inpatient versus outpatient diagnosis was demonstrated. Follow-up at mean of 36 months demonstrated no difference in readmission, reoperation, or mortality rate between outpatient and inpatient diagnosis. Restoration of gastrointestinal continuity was achieved in 61-67% in the outpatient and 59% in the inpatient group (P=NS).nnnCONCLUSIONnOutpatient presentation delays diagnosis but does not alter management or clinical outcome, or decrease the probability of ostomy reversal. Prolonging hospital stay to capture patients who develop anastomotic leak seems to be unwarranted. For patients requiring operative management, we recommend diversion as the safest option with a subsequent 61% reversal rate.

Selective Management of Patients with Acute Biliary Pancreatitis

BackgroundDetection of common bile duct (CBD) stones in patients with acute biliary pancreatitis (ABP) proves challenging. We hypothesized that grouping clinically significant predictors would increase reliability of detection.MethodsA retrospective review was performed of 144 consecutive patients who presented to a single tertiary care institution from 2002 to 2007 with ABP.ResultsOf the 144 patients, 32 had a persistent CBD stone. Following multivariate analysis, admission CBD size on ultrasound, gamma glutamyl transferase (GGT), alkaline phosphatase (AP), total bilirubin (TB), and direct bilirubin (DB) significantly correlated with persistent CBD stone. Receiver operator curve analysis and linear regression were applied to obtain optimal and equitable predictive values, and variables combined. Optimal values were: CBDu2009≥u20099xa0mm; APu2009≥u2009250xa0U/l; GGTu2009≥u2009350xa0U/l; TBu2009≥u20093xa0mg/dl; and DBu2009≥u20092xa0mg/dl. Presence of five variables had an associated odds ratio (OR) of 53.1 (pu2009<u20090.001) and four variables an OR of 8.97 (pu2009=u20090.004) for presence of persistent CBD stone. Zero variables conferred a significantly decreased probability of CBD stone, OR 0.15 (pu2009<u20090.001). Presence of one to three variables did not predict presence of CBD stone.ConclusionPresence of four or five variables significantly correlated with persistent CBD stone. Biliary evaluation by endoscopic retrograde cholangiopancreatography is suggested, as initial magnetic resonance cholangiopancreatography (MRCP) may only increase cost and delay time to intervention. In the absence of any variable, biliary evaluation by intraoperative cholangiogram may be sufficient. Decisions regarding patients with one to three variables should occur on a case-to-case basis. Initial biliary evaluation by MRCP is likely preferable, however, as no increased probability of CBD stone was identified, thus not warranting risks associated with intervention.