Jeffrey S. Bender

Hospital Volume Can Serve as a Surrogate for Surgeon Volume for Achieving Excellent Outcomes in Colorectal Resection

OBJECTIVE To examine the association of surgeon and hospital case volumes with the short-term outcomes of in-hospital death, total hospital charges, and length of stay for resection of colorectal carcinoma. METHODS The study design was a cross-sectional analysis of all adult patients who underwent resection for colorectal cancer using Maryland state discharge data from 1992 to 1996. Cases were divided into three groups based on annual surgeon case volume--low (< or =5), medium (5 to 10), and high (>10)--and hospital volume--low (<40), medium (40 to 70), and high (> or =70). Poisson and multiple linear regression analyses were used to identify differences in outcomes among volume groups while adjusting for variations in type of resections performed, cancer stage, patient comorbidities, urgency of admission, and patient demographic variables. RESULTS During the 5-year period, 9739 resections were performed by 812 surgeons at 50 hospitals. The majority of surgeons (81%) and hospitals (58%) were in the low-volume group. The low-volume surgeons operated on 3461 of the 9739 total patients (36%) at an average rate of 1.8 cases per year. Higher surgeon volume was associated with significant improvement in all three outcomes (in-hospital death, length of stay, and cost). Medium-volume surgeons achieved results equivalent to high-volume surgeons when they operated in high- or medium-volume hospitals. CONCLUSIONS A skewed distribution of case volumes by surgeon was found in this study of patients who underwent resection for large bowel cancer in Maryland. The majority of these surgeons performed very few operations for colorectal cancer per year, whereas a minority performed >10 cases per year. Medium-volume surgeons achieved excellent outcomes similar to high-volume surgeons when operating in medium-volume or high-volume hospitals, but not in low-volume hospitals. The results of low-volume surgeons improved with increasing hospital volume but never equaled those of the high-volume surgeons.

Routine pulmonary artery catheterization does not reduce morbidity and mortality of elective vascular surgery: Results of a prospective, randomized trial

OBJECTIVE The authors determined whether the preoperative placement of a pulmonary artery catheter (PAC) with optimization of hemodynamics results in outcome improvement after elective vascular surgery. SUMMARY BACKGROUND DATA The PAC commonly is used not only in patients who are critically ill, but also perioperatively in major elective surgery. Few prospective studies exist documenting its usefulness. METHODS One hundred four consecutive patients were randomized to have a PAC placed the morning of operation (group I) or to have a PAC placed only if clinically indicated (group II). Group I patients were resuscitated to preestablished endpoints before surgery and kept at these points both intraoperatively and postoperatively. Group II patients received standard care. RESULTS There was one death in each group. An intraoperative or postoperative complication developed in 13 patients in group I versus 7 patients in group II (p = not significant). Group I patients received more fluid than did group II patients (5137 +/- 315 mL vs. 3789 +/- 306 mL; p < 0.003). There was no significant difference in either overall or surgical intensive care unit length of stay. Only one patient in group II required a postoperative PAC. CONCLUSIONS Routine PAC use in elective vascular surgery increases the volume of fluid given to patients without demonstrable improvement in morbidity or mortality.

The effects of hypothermia and injury severity on blood loss during trauma laparotomy.

To assess the relationships between core temperature (T) and other factors relating to operating room (OR) blood loss and mortality following abdominal injury, the records of 122 patients undergoing laparotomy for trauma at Detroit Receiving Hospital over a 1-year period (1989) were reviewed. Most injuries were penetrating (86%) and the mortality rate was 8.2%. Overall, 57 of 122 (47%) had hypothermia (T < or = 35 degrees C) upon arrival in the OR. There was a significant correlation between admission blood pressure and lowest intraoperative temperature (r = 0.60; p < 0.001). Multiple regression analysis revealed that the patients lowest temperature (p < 0.001) and Trauma Score (TS); p < 0.0015), but not Abdominal Injury Severity Score (AISS) (p = 0.25) correlated with OR blood loss. The 28 patients with high TS (15 or 16) and AISS > or = 9 had significantly less blood loss when the OR temperature was maintained above 35 degrees C versus 33 degrees-35 degrees C (540 +/- 580 mL vs. 1820 +/- 1160 mL; p < 0.003). This suggests that hypothermia may exacerbate OR blood loss independent of degree of physiologic or anatomic injury. Thus hypothermia is common in patients undergoing a laparotomy for trauma. Trauma scores and the presence of shock preoperatively correlate with the development of intraoperative hypothermia. Hypothermic patients with similar injury severity have greater blood loss. Prevention and rapid correction of hypothermia during resuscitation and surgery appear to be extremely important in reducing blood loss in this patient population.

Blood transfusion and oxygen consumption in surgical sepsis

ObjectiveTo evaluate the use of serum lactic acid values to predict flow-dependent increases in oxygen consumption (&OV0616;o2) in response to increasing oxygen delivery (&U1E0A;o2) after blood transfusion in surgical sepsis. DesignProspective study. SettingTertiary care, trauma center. PatientsTwenty-one patients, postsurgical or posttrauma, judged septic by defined criteria. InterventionsSerum lactic acid concentrations, &U1E0A;o2, and &OV0616;o2 were measured before and after transfusion therapy. Measurements and Main ResultsOverall, the &U1E0A;o2 increased from 532 ± 146 to 634 ± 225 (sd) mL/min.m2 (p < .001), and the &OV0616;o2 increased from 145 ± 39 to 160 ± 56 mL/min.m2 (p = .02). These changes occurred with an Hgb increase from 9.3 ± 1.1 to 10.7 ± 1.5 g/dL (p < .001). The patients were grouped by their pretransfusion serum lactic acid values. In those patients with normal (< 1.6 mmol/dL) serum lactic acid (n = 10), &U1E0A;o2 increased from 560 ± 113 to 676 ± 178 mL/min.m2 (p < .02), and &OV0616;o2 increased from 150 ± 25 to 183 ± 46 mL/min.m2 (p < .02). However, in the increased serum lactic acid group (n = 17), &OV0616;o2 was not significantly changed after transfusion (143 ± 46 to 146 ± 58 mL/min.m2) despite increased &OV0616;o2 (515 ± 163 to 609 &U1E0A;251 mL/min.m2, p < .01). ConclusionsBlood transfusion can be used to augment &OV0616;o2 and &U1E0A;o2 in septic surgical patients. Increased serum lactic acid values do not predict patients who will respond. The absence of lactic acidosis should not be used in this patient population to justify withholding blood transfusions to improve flow-dependent &OV0616;o2. Patients who have increased lactate concentrations may have a peripheral oxygen utilization defect that prevents improvement in &OV0616;o2 with increasing &U1E0A;o2. (Crit Care Med 1991; 19:512)

The role of magnetic resonance cholangiography in the management of patients with Gallstone pancreatitis

Objective:To examine the utility of magnetic resonance cholangiography (MRC) in the preoperative evaluation of patients with gallstone pancreatitis. Summary Background Data:Gallstone pancreatitis is often associated with the presence of common bile duct (CBD) stones that may require endoscopic removal prior to planned laparoscopic cholecystectomy. No reliable clinical criteria exist, however, that can accurately predict CBD stones and the need for preoperative endoscopic retrograde cholangiopancreatography (ERCP). Methods:Sixty-four patients were identified with gallstone pancreatitis based on clinical presentation and imaging studies over a three-and-a-half-year period. All patients underwent MRC, and the images were evaluated for gallstones, CBD stones, cholecystitis, and pancreatitis Results:Seventeen of the 64 patients (27%) with gallstone pancreatitis were found to have CBD stones confirmed by ERCP. MRC correctly predicted CBD stones in 16 of the 17 patients (sensitivity = 94%). In 1 additional patient, MRC demonstrated CBD stones not seen at ERCP, consistent with probable passage. By comparison, the sensitivities of other criteria for predicting CBD stones were (1) elevated bilirubin ≥2.0 mg/dL = 65%; (2) dilated duct on ultrasound = 55%; and (3) CBD stones on ultrasound = 27%. MRC was able to visualize gallbladder stones in 57 of 62 patients (94%) and correctly predicted acute cholecystitis in 6 of 8 patients. MRC also detected peripancreatic edema and inflammatory changes consistent with acute pancreatitis in 45 of 64 patients (70%). Conclusions:These results demonstrate that MRC can accurately identify CBD stones preoperatively in patients with gallstone pancreatitis and provide valuable information with respect to other biliary pathology, including cholelithiasis, acute cholecystitis, and pancreatitis. MRC is an effective noninvasive screening tool for CBD stones, appropriately selecting candidates for preoperative ERCP and sparing others the need for an endoscopic procedure with its associated complications.

The management of flail chest injury : factors affecting outcome

The records of 57 patients presenting with flail chest injury from 1981 through 1987 were reviewed to determine factors affecting morbidity and mortality. Fifteen patients (26%) had 8+ rib fractures with a unilateral flail and seven (12%) had multiple rib fractures with a bilateral flail. Thirty-two (56%) had moderate-severe pulmonary contusions and 44 (77%) required chest tubes for hemo-pneumothorax. Ventilatory assistance was used in 36 (63%). The major factors determining the need for ventilatory assistance were: an ISS greater than or equal to 23, blood transfusions in the first 24 hours, moderate-severe associated injuries (fractures, head injuries or truncal organs requiring operation), and shock on admission (p less than 0.001). An adverse outcome occurred in 15 (28%); nine required ventilatory assistance greater than or equal to 14 days and six died of sepsis with pneumonia. The main factors associated with an adverse outcome were: an ISS greater than or equal to 31 (p less than 0.001), moderate-severe associated injuries (p less than 0.001), and blood transfusions (p less than 0.005). Although the primary determinants of an adverse outcome were the associated injuries and blood loss, a bilateral flail (p less than 0.01) and age greater than or equal to 50 years (p less than 0.02) were contributing factors.

Utility of magnetic resonance cholangiography in the evaluation of biliary obstruction.

BACKGROUND Evaluation of suspected biliary obstruction has traditionally involved a variety of imaging modalities including ultrasound, CT, and invasive cholangiography. These techniques have limitations because of poor visualization of intraductal stones (ultrasound and CT) and the need for an invasive procedure (ERCP and percutaneous transhepatic cholangiography). Magnetic resonance cholangiography (MRC) is a noninvasive imaging modality that provides good visualization of the hepatobiliary system. The aim of the present study was to determine the utility of MRC in evaluating patients with suspected biliary obstruction. STUDY DESIGN One hundred forty-three patients were identified with suspected acute biliary obstruction and underwent MRC. Patient selection was based on clinical criteria including an elevation in serum liver chemistries or evidence of biliary ductal dilatation on conventional imaging. MRC was performed using a half-Fourier acquisition single-shot turbo spin-echo sequence involving single breath-hold rapid image acquisition. A final diagnosis was determined in each patient based on invasive cholangiography, findings at surgery, and clinical course. RESULTS Of the 143 patients, 73 had an obstructing biliary lesion. A malignant process was identified in 25 patients with final diagnoses of pancreatic cancer (n = 15), ampullary cancer (n = 4), cholangiocarcinoma (n = 3), and hepatic or nodal metastases (n = 3). MRC correctly identified biliary obstruction in all these patients and accurately identified the level of biliary obstruction in 24 of 25 patients. Based on the MRC images alone, a malignant process was suspected in 21 of the 25 patients. Forty patients were found to have common bile duct stones and eight patients had a benign distal bile duct stricture. MRC correctly identified common bile duct stones in 37 patients with one false-positive exam (sensitivity = 92%; specificity = 99%). MRC also correctly identified distal biliary strictures in eight patients. In the remaining 70 patients, no definite biliary obstruction was identified by MRC, and in all patients the absence of mechanical obstruction was confirmed by invasive cholangiography or overall clinical course. CONCLUSIONS This study demonstrates that MRC is able to accurately identify the level and cause of biliary obstruction in both malignant and benign disease. MRC may prove to be an important noninvasive tool in preoperative evaluation of patients with suspected biliary obstruction and identification of patients most likely to benefit from an invasive radiologic or surgical procedure.

The technique of visceral packing : recommended management of difficult fascial closure in trauma patients

Since 1986, we have cared for 17 patients whose abdomen could not be closed because of bowel edema and loss of abdominal wall compliance. These patients were managed by a technique of visceral packing with the intestines kept in place by a combination of rayon cloth, gauze packs, and retention sutures. This packing was changed in the operating room under general anesthesia until the edema was sufficiently resolved to allow for closure. Two patients died within 24 hours of operation from irreversible shock. The remaining 15 patients had their fascia successfully closed with an average of two additional anesthetics. There was one case of fasciitis associated with the development of an intra-abdominal abscess and one patient died of late sepsis. There was no early postoperative ventilatory compromise or acute oliguric renal failure. Other direct complications have been minor with no enterocutaneous fistulae, dehiscence, or incisional hernia. Visceral packing of posttraumatic abdominal wounds circumvents expected complications of intraperitoneal hypertension and enhances the chance for survival. Its ease and low morbidity also lends itself to a wide variety of other uses.

Transplantation of single and paired pediatric kidneys into adult recipients

BACKGROUND The transplantation of kidneys from cadaveric donors < or = 5 years of age into adult recipients is controversial. The large disparity between donor renal mass and recipient body mass is feared to be problematic. Controversy also exists whether to transplant kidneys from these young donors individually or as a pair into a single recipient. STUDY DESIGN We retrospectively reviewed our experience from January 1991 to January 1995 with 22 adult renal transplantations using kidneys from cadaveric donors < or = 5 years of age. Ten patients received single allografts. Twelve received organs paired en bloc. Fifty-two adult recipients from cadaveric donors aged 18-55 years served as controls. All patients received cyclosporine-based immunosuppression. Recipient characteristics did not differ significantly between the groups. RESULTS Actuarial patient and graft survival rates were similar for the two groups. The incidence of urinary complications was higher in the recipients of pediatric kidneys than in the adult-donor group (18.2% versus 3.8%, respectively, p = not significant). No grafts were lost from urinary complications. Renal function, as determined by the calculated creatinine clearance, was significantly greater in the pediatric group (76.1 +/- 4.0 versus 61.4 +/- 23.2 mL/min, p = 0.035) by 6 months after transplantation. Recipients of paired pediatric kidneys initially had better renal function (63.9 +/- 21.4 mL/min) than those receiving single pediatric kidneys (38.2 +/- 11.6 mL/min) (p = 0.004), but by 6 months, no significant difference existed. At 2 years, renal function in the pediatric-donor group remained significantly better than in the adult-donor group. Hematocrit levels as a measure of erythropoiesis were similar for single pediatric, paired pediatric, and adult-donor recipients. CONCLUSIONS Kidneys from cadaveric donors < or = 5 years of age are suitable for transplantation into adults. Pediatric kidneys provide excellent renal function despite an initially tremendous disparity between renal mass and recipient body mass. Rapid true renal growth probably occurs. No appreciable advantage is achieved by using two pediatric kidneys for a single recipient.

Immediate laparoscopic cholecystectomy as definitive therapy for acute cholecystitis.

The objective of this study was to determine the safety and efficacy of immediate laparoscopic cholecystectomy in the management of acute calculous cholecystitis. A prospective data collection was performed on all patients admitted to one surgical service over a 2-year period. The patients were managed by a uniform protocol consisting of (1) preoperative ERCP when common duct stones were suspected; (2) operation within 24 h of diagnosis; and (3) selective operative cholangiography. Previous surgery was not a contraindication to inclusion. The setting was an urban teaching hospital. There were 52 patients, 34 females and 18 males. Nineteen had undergone previous abdominal surgery. Five patients had preoperative ERCP and five had intraoperative cholangiography. The patients underwent laparoscopic cholecystectomy 0.8±0.4 days postadmission. Four (7.7%) were converted to open cholecystectomy. Fifty-eight percent had spillage of bile and/or stones. Patients went home 2.3±1.6 days postoperatively. There were no deaths and two complications: a subhepatic biloma and a superficial wound infection. Follow-up of all patients has revealed no late complications. We conclude: (1) Immediate laparoscopic cholecystectomy is safe and effective for acute cholecystitis even when complicated by previous surgery, inflammatory adhesions, and gangrene. (2) Intraoperative spillage of bile and stones does not lead to an increase in early complications. (3) Cholangiography is needed only when clinically indicated. (4) Laparoscopic cholecystectomy should be the treatment of choice for patients admitted for acute cholecystitis.