Melissa Camp

Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients.

Objective:A single institution retrospective analysis of 200 patients with major bile duct injuries was completed. Three patients died without surgery due to uncontrolled sepsis. One hundred seventy-five patients underwent surgical repair, with a 1.7% postoperative mortality and a complication rate of 42.9%. Summary Background Data:The widespread application of laparoscopic cholecystectomy (LC) has led to a rise in the incidence of major bile duct injuries (BDI). Despite the frequency of these injuries and their complex management, the published literature contains few substantial reports regarding the perioperative management of BDI. Methods:From January 1990 to April 2003, a prospective database of all patients with a BDI following LC was maintained. Patients’ charts were retrospectively reviewed to analyze perioperative surgical management. Results:Over 13 years, 200 patients were treated for a major BDI following LC. Patient demographics were notable for 150 women (75%) with a mean age of 45.5 years (median 44 years). One hundred eighty-eight sustained their BDI at an outside hospital. The mean interval from the time of BDI to referral was 29.1 weeks (median 3 weeks). One hundred nine patients (58%) were referred within 1 month of their injury for acute complications including bile leak, biloma, or jaundice. Twenty-five patients did not undergo a surgical repair at our institution. Three patients (1.5%) died after delayed referral before an attempt at repair due to uncontrolled sepsis. Twenty-two patients, having intact biliary-enteric continuity, underwent successful balloon dilatation of an anastomotic stricture. A total of 175 patients underwent definitive biliary reconstruction, including 172 hepaticojejunostomies (98%) and 3 end-to-end repairs. There were 3 deaths in the postoperative period (1.7%). Seventy-five patients (42.9%) sustained at least 1 postoperative complication. The most common complications were wound infection (8%), cholangitis (5.7%), and intraabdominal abscess/biloma (2.9%). Minor biliary stent complications occurred in 5.7% of patients. Early postoperative cholangiography revealed an anastomotic leak in 4.6% of patients and extravasation at the liver dome-stent exit site in 10.3% of patients. Postoperative interventions included percutaneous abscess drainage in 9 patients (5.1%) and new percutaneous transhepatic cholangiography and stent placement in 4 patients (2.3%). No patient required reoperation in the postoperative period. The mean postoperative length of stay was 9.5 days (median 9 days). The timing of operation (early, intermediate, delayed), presenting symptoms, and history of prior repair did not affect the incidence of the most common perioperative complications or length of postoperative hospital stay. Conclusions:This series represents the largest single institution experience reporting the perioperative management of BDI following LC. Although perioperative complications are frequent, nearly all can be managed nonoperatively. Early referral to a tertiary care center with experienced hepatobiliary surgeons and skilled interventional radiologists would appear to be necessary to assure optimal results.

Disparities in Osteoporosis Screening Between At-Risk African-American and White Women

BACKGROUND: Despite a lower prevalence of osteoporosis in African-American women, they remain at risk and experience a greater mortality than white women after sustaining a hip fracture. Lack of recognition of risk factors may occur in African-American women, raising the possibility that disparities in screening practices may exist.OBJECTIVE: To determine whether there is a difference in physician screening for osteoporosis in postmenopausal, at-risk African-American and white women.METHODS: We conducted a retrospective chart review at an urban academic hospital and a suburban community hospital. Subjects included 205 African-American and white women, age ≥65 years and weight ≤127 pounds, who were seen in Internal Medicine clinics. The main outcome was dual-energy x-ray absorptiometry (DXA) scan referral. We investigated physician and patient factors associated with referral. Secondary outcomes included evidence of discussion of osteoporosis and prescription of medications to prevent osteoporosis.RESULTS: Significantly fewer African-American than white women were referred for a DXA scan (OR 0.39%, 95% confidence interval (CI): 0.22 to 0.68). Physicians were also less likely to mention consideration of osteoporosis in medical records (0.27, 0.15 to 0.48) and to recommend calcium and vitamin D supplementation for this population (0.21, 0.11 to 0.37). If referred, African-American women had comparable DXA completion rates when compared with white women. No physician characteristics were significantly associated with DXA referral patterns.CONCLUSIONS: Our study found a significant disparity in the recommendation for osteoporosis screening for African-American versus white women of similar risk, as well as evidence of disparate osteoporosis prevention and treatment, confirming results of other studies. Future educational and research initiatives should target this inequality.

Necrotizing Enterocolitis in 20 822 Infants: Analysis of Medical and Surgical Treatments

Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency of the neonate. Previous information about this disease has largely been gathered from limited series. We analyzed 13 years of the National Inpatient Sample (NIS) and 3 years of the Kids’ Inpatient Database (KID; 1997, 2000, 2003) to generate the most comprehensive profile of outcomes to date of medically versus surgically treated NEC. We identified 20 822 infants with NEC, of whom 15 419 (74.1%) and 5403 (25.9%) were undergoing medical and surgical management, respectively. Overall, surgical patients had greater length of stay, total hospital charges, and mortality. Among infants dying during admission, there was no significant difference in length of stay or charges between the medical and surgical groups. These findings highlight the need for developing a clinically relevant risk stratification tool to identify NEC patients at high risk for death.

Management of Positive Sub-areolar/Nipple Duct Margins in Nipple-Sparing Mastectomies

We evaluated management of positive sub‐areolar/nipple duct margins in nipple‐sparing mastectomies (NSM) at our institution. Retrospective chart review of all NSM from January 2007 to April 2012 was performed and patient, tumor, and treatment information was collected. Sub‐areolar/nipple duct margins included ductal tissue from within the nipple. Of 438 NSM, 22 (5%) had positive sub‐areolar/nipple duct margins; 21 of 220 cancer‐bearing breasts (10%) and 1 of 218 prophylactic mastectomies (0.5%). Positive margins included four with invasive lobular carcinoma and 18 with ductal carcinoma in situ (DCIS). Management included removal of eight nipples and nine nipple areola complexes (NAC). Four of 17 nipple/NAC specimens had evidence of residual DCIS and none had residual invasive cancer. The majority of nipple/NAC specimens excised for a positive margin had no residual malignancy. Future studies are needed to determine the extent of NAC tissue removal required for positive margins.

The agency for healthcare research and quality (ahrq) pediatric quality indicators (pdis): Accidental puncture or laceration during surgery in children

Context:The Agency for Healthcare Research and Quality (AHRQ) pediatric quality indicators (PDIs) are measures designed to evaluate the quality of pediatric healthcare. They specifically focus on adverse events that are potentially avoidable, including complications and iatrogenic events. PDI 1 refers to accidental puncture or laceration. Objective:To determine risk factors and outcomes associated with PDI 1 in a population of pediatric surgical patients. Design, Setting, and Patients:The Nationwide Inpatient Sample and Kids Inpatient Database were used to identify hospitalized pediatric surgical patients in the United States (age: 0–18) from 1988 to 2005. The data from these 1,939,540 patients was linked to the AHRQ PDIs using AHRQ WinQI software, and 7033 pediatric patients with PDI 1 were identified. A 1:3 matched case control design was implemented with 6459 cases (patients with PDI 1) and 19,377 controls (patients without PDI 1) matched on age, race, gender, and hospital ID. Cases and controls were stratified into procedure categories based on diagnosis related group procedure codes. Main Outcome Measures:To examine the relationship between PDI 1 and procedure category, as well as the outcomes of in-hospital mortality, length of stay, and total hospital charges for cases compared with controls. Results:Of the 4627 patients with PDI 1 stratified into procedure categories, the highest proportion of PDI 1 cases occurred in the gastrointestinal (30.19%), cardiothoracic (19.6%), and the orthopedic (11.13%) categories. Logistic regression analysis for PDI 1, controlling for admission type and insurance status, revealed a statistically significant higher odds of PDI 1 in the gynecology (OR: 1.69, P < 0.001) and transplant (OR: 1.45, P: 0.026) procedure categories. Multivariable regression analysis revealed patients with PDI 1 were more likely to die (OR: 1.91, P < 0.001), had a 4.81 day longer length of stay (95% CI: 4.26–5.36, P < 0.001) and had

Burden of preoperative cardiovascular disease risk factors on breast cancer surgery outcomes

36,291 higher total hospital charges (95% CI:

Missing Consent Forms in the Preoperative Area: A Single-Center Assessment of the Scope of the Problem and Its Downstream Effects

32,583–

Predictors of radiation-induced acute skin toxicity in breast cancer at a single institution: Role of fractionation and treatment volume

40,000, P < 0.001) compared with patients without PDI 1. Conclusions:Cases of PDI 1 were most commonly associated with the gastrointestinal, cardiothoracic, and orthopedic procedure categories, and these were also 3 of the most common procedure categories overall. Controlling for type of procedure and other variables, the procedure categories having the highest likelihood of PDI 1 were gynecology and transplant. PDI 1 was found to be associated with greater mortality, longer length of stay, and greater total hospital charges.

Cost Comparison of Radiation Treatment Options After Lumpectomy for Breast Cancer

Cardiovascular comorbidities have been studied sporadically in breast cancer surgery. No study has provided a comprehensive assessment of the severity and relative influence of preoperative cardiac risk factors on surgical outcomes.

Application of ACOSOG Z0011 Criteria Reduces Perioperative Costs

Missing consent forms at surgery can lead to delays in patient care, provider frustration, and patient anxiety. We sought to assess the scope and magnitude of this problem at our institution. We surveyed key informants to determine the frequency and effect of missing consent forms. We found that 66% of patients were missing signed consent forms at surgery and that this caused a delay for 14% of operative cases. In many instances, the missing consent forms interfered with team rounds and resident educational activities. In addition, residents spent less time obtaining consent and were often uncomfortable obtaining consent for major procedures. Finally, 40% of faculty felt dissatisfied with resident consent forms, and more than two-thirds felt patients were uncomfortable with being asked for consent by residents. At our center, missing consent forms led to delayed cases, burdensome and inadequate consent by residents, and extra work for nursing staff.