Piotr Gorecki

Antibiotic Administration in Patients Undergoing Common Surgical Procedures in a Community Teaching Hospital: The Chaos Continues

Abstract. The influence of recently published guidelines by the Surgical Infection Society (SIS) on current surgical practice are not well documented. The appropriateness of antibiotic administration in a cohort of surgical patients undergoing elective and emergency surgery in a department of surgery in an urban, community-based, private, 560-bed teaching hospital was retrospectively reviewed. The following were the criteria defining administration as appropriate as modified from SIS guidelines: Prophylactic use: (1) started prior to operation; (2) spectrum appropriate to the specific operation; (3) duration ≤ 24 hours. Therapeutic use: (1) started prior to operation; (2) spectrum appropriate to pathology; (3) Duration ≤ 24 hours for contamination or “resectable” infection and ≤ 5 days for established infection in the absence of clinical evidence of persisting infection. Any switchover from an appropriate agent to another appropriate or inappropriate agent in the same patient in the absence of microbiologic or clinical indication was considered inappropriate administration. We reviewed the charts of 211 randomly selected patients who underwent elective (n= 132) or emergency (n= 79) procedures during 1996. The operations included gastrectomy (n= 22), appendectomy (n= 27), open (n= 5) or laparoscopic (n= 27) cholecystectomy, colectomy (n= 28), hysterectomy (n= 8), laparotomy for intestinal obstruction (n= 11), mastectomy (n= 26), and ventral hernia repair (n= 37). A total of 17 antibiotics were used for prophylaxis and 21 for therapy. In 156 patients (74%) the administration was considered inappropriate. Eight patients in the inappropriate group developed diarrhea (two cases of Clostridium difficile-induced colitis) compared to two cases of diarrhea in the appropriate group (nonsignificant). The average duration of administration after elective and emergency operations was 3.3 and 5.7 days, respectively. The total expense for excessive duration of administration was

Selective nonoperative management of leaks after gastric bypass: Lessons learned from 2675 consecutive patients

18,533. Many surgeons are not familiar with the spectrum of antimicrobials and often do not distinguish between prophylactic and therapeutic administration. Antibiotic usage in current surgical practice is often inappropriate, excessive, and chaotic.

Abdominal compartment syndrome from intractable constipation

Objective:To compare outcomes of patients with leaks after primary Roux-en-Y gastric bypass (GBP) managed operatively with those managed nonoperatively and subsequently derive indications for selective nonoperative management. Summary of Background Data:There is no consensus on the management of leaks complicating GBP, which remains the commonest cause of death. Methods:We evaluated 2675 consecutive GBP procedures, determining incidence and outcomes of leaks in a program emphasizing early detection, routine drainage, and selective nonoperative management. Results:Leaks occurred in 46 patients (41 women) with mean (±SD) age of 46.9 ± 8.7 years, weight and body mass index (BMI) of 307.8 ± 56.9 lb and 51.2 ± 9.5 kg/m2, respectively. Leaks were initially identified by upper gastrointestinal contrast swallow (UGI) on the first postoperative day (22), abnormal drain output (11), delayed UGI (3), or on clinical suspicion (10) with a respective interval to diagnosis of 1.1*, 6.5, 7, and 7.9 days (*P < 0.007 vs. other groups). Leaks were located in the gastrojejunal (GJ) anastomosis (37), gastric pouch (4), gastric remnant (2), jejuno-jejunostomy (1), Roux limb (1), and cervical esophagus (1), and were radiologically contained (40) or diffuse (3) or not demonstrable (3). Contained leaks were treated nonoperatively (31), by operation (7), or required no treatment (2). Patients with diffuse leaks or bilious drain output were operatively managed. They were similar in duration for nil per oral order, drain and antibiotic use and readmission rates, whereas hospital stays were longer in the operative group, P < 0.01. There were no deaths. Conclusions:Many leaks after gastric bypass are radiologically contained GJ and pouch leaks and can be safely managed nonoperatively. Radiologic features and bilious drainage were key determinants of treatment, with operative treatment used for diffuse GJ leaks, bilious drainage, or clinical suspicion with a negative UGI. Outcomes were similar in both groups.

Concurrent prophylactic placement of inferior vena cava filter in gastric bypass and adjustable banding operations in the Bariatric Outcomes Longitudinal Database

A 13-year-old boy with a history of chronic constipation since infancy presented with increasing abdominal distention and discomfort. The abdomen was very distended and tense, and the lower extremities were numb and mottled with palpable pulses (A). Rectal examination revealed massive fecal impaction. Foley catheter revealed no urine and an intraabdominal pressure of 47cm of H2O (normal 0–10cm H2O). Chest x-ray showed a massively distended colon and both diaphragms markedly elevated (B). The patient had severe metabolic acidosis. An emergency laparotomy was undertaken to decompress the intraabdominal hypertension causing an abdominal compartment syndrome. Operative findings included a massively distended, thickened, and apparently ischemic, rectosigmoid (C), which was resected. Abdominal decompression (D) to intraabdominal pressure of 7cm of H2O promptly restored peripheral perfusion.

Lower Extremity Compartment Syndrome Following a Laparoscopic Roux-en-Y Gastric Bypass.

INTRODUCTION Postoperative pulmonary embolism (PE) is a leading cause of morbidity and mortality after bariatric surgery. However, the concurrent prophylactic placement of an inferior vena cava filter (CPIVCF) in patients undergoing bariatric operations remains controversial. This study used the Bariatric Outcomes Longitudinal Database (BOLD) to establish associated characters and determine outcomes of CPIVCF for patients undergoing Roux-en-Y gastric bypass (GB) and adjustable gastric banding (AB) surgeries. METHODS We analyzed BOLD, a database of bariatric surgery patient information. GB and AB operations were categorized into open and laparoscopic approaches. Univariate logistic regressions were used to compare between non-CPIVCF and concurrent CPIVCF groups. Significant variables (P < .05) were subsequently input into multivariate regression models: CPIVCF was retained in each model. RESULTS A total of 322 CPIVCFs (0.33%) were identified from 97,218 GB and AB operations performed between 2007 and 2010 in this retrospective registry study. Significant differences were identified in male gender (21.1% vs 31.4%; P < .001), preoperative body mass index (BMI; 44.5 ± 6.6 vs 45.3 ± 7; P < .001), and African-American race (10.5% vs 18%; P < .001) between non-CPIVCF and CPIVCF groups. The CPIVCF group had more patients with previous nonbariatric surgery (50% vs 43.6%; P = .02), a history of venous thromboembolism (VTE; 21.4% vs 3.1%; P < .001), impairment of functional status (7.8% vs 3.1%; P < .001), lower extremity edema (47.2% vs 27.1%; P < .001), obesity hypoventilation syndrome (7.1% vs 2.1%; P < .001), obstructive sleep apnea syndrome (58.1% vs 43.3%; P < .001), and pulmonary hypertension (13% vs 4.1%; P < .001). Patients in the CPIVCF group were more likely to receive GB than gastric banding (77% vs 58.1%; P < .001) and an open surgical approach (21.4% vs 4.8%; P < .001). Operative duration was longer in the CPIVCF group (119 ± 67 vs 89 ± 52 minutes; P < .001). The CPIVCF group also had a longer length of hospital stay (3 ± 2 vs 2 ± 6 days; P = .048), was associated with higher incidence of deep venous thrombosis (DVT; 0.93% vs 0.12%; P < .001), and had a higher mortality (0.31% vs 0.03%; P = .003) from PE and indeterminate causes. In multivariate analysis, male gender, African-American race, previous nonbariatric surgery, a high BMI, obesity hypoventilation syndrome, history of VTE, lower extremity edema, and pulmonary hypertension were preoperative factors associated with CPIVCF. CONCLUSIONS CPIVCF was associated with specific clinical features, increased health care resource utilization, and a higher mortality in patients undergoing bariatric operations. Although selected patient characteristics influence surgeons to perform CPIVCF, this study was unable to establish an outcome benefit for CPIVCF.

DRG, Costs and Reimbursement following Roux-en-Y Gastric Bypass: an Economic Appraisal

Background: Bariatric surgery has the potential for serious complications. A case is presented of unilateral lower extremity compartment syndrome after a laparoscopic Roux-en-Y gastric bypass performed in the modified lithotomy position. Case report: A 38-year-old female (weight 134.5 kg, BMI 49.6) underwent a laparoscopic Roux-en-Y gastric bypass (operating time 375 min). Postoperatively, she complained of bilateral lower extremity pain that gradually subsided over the course of the day. However, on the 1st postoperative day she developed numbness on the dorsum of the foot and compartment syndrome was diagnosed (anterior compartment pressure 71 mmHg). She underwent emergency fasciotomy,which resulted in a reduction of the pain and numbness on the dorsum of the foot. The next day she ambulated without difficulty and was discharged home on the 5th postoperative day. 12 days after her operation, delayed primary closure of the fasciotomy wound was done with the assistance of a novel device (Proxiderm) that applies constant tension to the wound edges. Subsequent recovery was uneventful, and at 4- month follow-up the patient had a weight loss of 28 kg without any right leg motor or sensory deficits. Conclusion: Bariatric surgeons should be aware of compartment syndrome as a rare but serious complication. Prevention, early recognition, and prompt fasciotomy are crucial for a favorable outcome.

Prevalence of Helicobacter pylori infection in bariatric patients: a histologic assessment

Background: There is disagreement regarding hospital and physician reimbursement fees when DRG codes are used. We have found that physicians and hospitals are rewarded differently depending on the type of insurance coverage - per diem HMO (Health Maintenance Organization) vs public. Methods: 133 patients were retrospectively analyzed in a single institution. There were 59 privately-insured and 74 publicly-insured patients. Using DRG 288, hospital and surgeon reimbursement rates, complications, length of stay, blood loss and basic demographics were evaluated on all patients. Reimbursement rates were then compared to inpatient hospital costs per case for both open and laparoscopic Roux-en-Y gastric bypass (RYGBP). Statistical analysis used Students t-test and standard deviation. Results: The 2 groups were similar in terms of age, sex and BMI. There was a large difference in physician reimbursement when comparing public to private insurance (

Fecal Impaction Causing Megarectum-Producing Colorectal Catastrophes

931±73 vs

Jan Mikulicz-Radecki (1850–1905) – The Creator of Modern European Surgery

2356±822, P<0.001). Likewise, there was a large difference in hospital reimbursement (public

Intraabdominal partitioning of the laparoscopic sleeve gastrectomy remnant optimizes the specimen extraction ergonomics and postoperative pain and is an attractive technique in teenage patients.

11773 ± 4462 vs private