Steven L. Lee

Comparison of pulmonary function and postoperative pain after laparoscopic versus open gastric bypass: A randomized trial

BACKGROUND Impairment of pulmonary function is common after upper abdominal operations. The purpose of this study was to compare postoperative pulmonary function and analgesic requirements in patients undergoing either laparoscopic or open Roux-en-Y gastric bypass (GBP). STUDY DESIGN Seventy patients with a body mass index of 40 to 60 kg/m2 were randomly assigned to undergo laparoscopic (n = 36) or open (n = 34) GBP. The two groups were similar in age, gender, body mass index, pulmonary history, and baseline pulmonary function. Pulmonary function studies were performed preoperatively and on postoperative days 1, 2, 3, and 7. Oxygen saturation and chest radiographs were performed on both groups preoperatively and on postoperative day 1. Postoperative pain was evaluated using a visual analog scale and the amount of narcotic consumed was recorded. Data are presented as mean +/- standard deviation. RESULTS Laparoscopic GBP patients had significantly less impairment of pulmonary function than open GBP patients on the first three postoperative days (p < 0.05). By the 7th postoperative day, all pulmonary function parameters in the laparoscopic GBP group had returned to within preoperative levels, but only one parameter (peak expiratory flow) had returned to preoperative levels in the open GBP group. On the first postoperative day, laparoscopic GBP patients used less morphine than open GBP patients (46 +/- 31 mg versus 76 +/- 39 mg, respectively, p < 0.001), and visual analog scale pain scores at rest and during mobilization were lower after laparoscopic GBP than after open GBP (p < 0.05). Fewer patients after laparoscopic GBP than after open GBP developed hypoxemia (31% versus 76%, p < 0.001) and segmental atelectasis (6% versus 55%, p = 0.003). CONCLUSION Laparoscopic gastric bypass resulted in less postoperative suppression of pulmonary function, decreased pain, improved oxygenation, and less atelectasis than open gastric bypass.

A simplified approach to the diagnosis of elevated intra-abdominal pressure.

BACKGROUND Previous methods described to measure bladder pressure require additional setup, making these techniques complex and time consuming. We describe a simple U-tube technique and investigate its accuracy for measuring intra-abdominal pressure (IAP). METHODS Warm saline was infused into the peritoneum of five pigs to increase IAP. Indirect methods of measuring IAP included bladder, inferior vena cava (IVC), and gastric pressures. Bladder pressure was measured by both the standard and U-tube technique. IVC pressure was measured via a femoral line and gastric pressure was transduced through an orogastric tube. In addition, 30 patients undergoing laparoscopy were prospectively investigated. Insufflated abdominal pressure readings were obtained and compared with bladder pressures measured by the U-tube technique (n = 20) and standard technique (n = 10). RESULTS In the animal study, U-tube manometry had the highest degree of correlation (r(2) = 0.98) and the lowest bias (0.51 +/- 1.63 mm Hg). The bladder pressure measured by the U-tube technique was between 0.1 and 0.9 mm Hg less than the directly measured IAP (95% confidence interval). There was a high degree of correlation between IAP and the standard technique for bladder pressure (r(2) = 0.93), IVC pressure (r(2) = 0.93), and gastric pressure (r(2) = 0.90). Strong correlation also existed between the U-tube and standard techniques for measuring bladder pressure (r(2) = 0.96). In humans, a strong correlation between insufflated abdominal pressure and bladder pressure (U-tube technique, r(2) = 0.79; standard technique, r(2) = 0.53) was also encountered. CONCLUSION The accuracy of the U-tube manometry technique for measuring intra-abdominal pressure is comparable to previously described techniques. The U-tube technique is simple, does not require additional equipment, and can be performed by any member of the medical team.

Evaluation of Intra-abdominal Pressure after Laparoscopic and Open Gastric Bypass

Background: Increased intra-abdominal pressure (IAP) postoperatively can adversely affect cardiovascular, pulmonary,and renal function. In this prospective, randomized trial, we compared the IAP in morbidly obese patients after laparoscopic and open gastric bypass (GBP) surgery. Methods: 64 patients with a body mass index of 40 to 60 kg/m2 were randomized to undergo laparoscopic or open GBP.IAPs were obtained at baseline (after induction of anesthesia), immediately after the operation, and on post-operative day (POD) 1, 2, and 3. Intraoperative and postoperative fluid requirements, urine output, and creatinine clearance were recorded. Results: Demographics of the two groups were similar. IAP increased from baseline immediately after laparoscopic and open GBP (p < 0.05). IAP returned to baseline by POD 2 after laparoscopic GBP but remained elevated through POD 3 after open GBP. In fact, IAP was lower after laparoscopic GBP than after open GBP on POD 1, 2 and 3 (p < 0.05).The amount of intraoperative IV fluid was similar between groups, but laparoscopic GBP required less IV fluid and facilitated higher urine output post-operatively than open GBP.There was no significant difference in creatinine clearance between groups. Conclusions: Laparoscopic GBP resulted in significantly lower IAP, less postoperative fluid required, and greater postoperative urine output than open GBP.

Laparoscopic vs Open Appendectomy in Children: Outcomes Comparison Based on Age, Sex, and Perforation Status

HYPOTHESIS Outcomes of laparoscopic appendectomy (LA) will be similar to open appendectomy (OA) in children of all ages. DESIGN Retrospective cohort study using discharge abstract data. SETTING Twelve regional hospitals in Southern California. PATIENTS Seven thousand six hundred fifty patients underwent appendectomy for acute appendicitis (LA = 3551, OA = 4099). INTERVENTION Laparoscopic appendectomy or OA. MAIN OUTCOME MEASURES Thirty-day morbidity (wound infection, abscess drainage, and readmission) and length of hospitalization. RESULTS Use of laparoscopy increased from 22% in 1998 to 70% in 2007. Overall, patients undergoing LA were older (mean [SD] age, 12.8 [3.2] vs 10.4 [3.7] years; P < .001) and had a lower perforation rate (24% vs 34%; P < .001). Multivariable logistic regression demonstrated a decreased odds ratio for wound infection (odds ratio, 0.6; 95% confidence interval, 0.5-0.8) and abscess drainage (odds ratio, 0.6; 95% confidence interval, 0.4-0.7) following LA compared with OA. Multivariable linear regression also showed decreased length of hospitalization following LA compared with OA. CONCLUSION Now the preferred operation for children with appendicitis, LA was associated with a decreased risk of wound infection, abscess drainage, and length of hospitalization compared with OA.

Effect of Race and Socioeconomic Status in the Treatment of Appendicitis in Patients With Equal Health Care Access

BACKGROUND Lower socioeconomic and minority racial/ethnic status have been linked to delays in surgical care and thus higher appendiceal perforation rates. HYPOTHESIS Equal access to health care eliminates the previously reported socioeconomic and racial/ethnic disparities in rates of appendiceal perforation. DESIGN Retrospective cohort study using discharge abstract data and US census data. SETTING Twelve regional Kaiser Permanente hospitals in southern California. PATIENTS A total of 16,156 patients treated for appendicitis. Patients were divided into low, medium, and high groups based on annual household income and educational level, as well as racial/ethnic status (white, black, Hispanic, and Asian). MAIN OUTCOME MEASURES Appendiceal perforation (AP) rate and length of hospitalization (LOH). RESULTS The adjusted odds ratio for AP was lower in Hispanics and similar in blacks and Asians compared with whites. The odds ratio for AP was similar in high- and medium-income families compared with low-income families. The odds ratio for AP was higher in patients with high educational levels and similar in those with medium educational levels compared with low educational levels. The adjusted LOH was longer in blacks, shorter in Hispanics, and similar in Asians compared with whites. The LOH was similar in high- and medium-income families compared with low-income families. The LOH was higher in patients with medium educational levels and similar in those with high educational levels compared with low educational levels. CONCLUSIONS Lower socioeconomic background and minority race/ethnicity did not correlate with higher AP rates or a clinically longer LOH in patients with equal access to care. Based on these findings, we believe that equal health care access leads to equivalent outcomes in all patients with appendicitis.

Long-term Antireflux Medication Use Following Pediatric Nissen Fundoplication

HYPOTHESIS Nissen fundoplication decreases the use of antireflux medications. DESIGN Retrospective cohort study using discharge abstract data and pharmacy data. SETTING Twelve regional Kaiser Permanente hospitals in southern California. PATIENTS Three hundred forty-two patients underwent Nissen fundoplication. INTERVENTION Nissen fundoplication. MAIN OUTCOME MEASURE Use of antireflux medications. RESULTS The number of patients requiring antireflux medications decreased from 233 patients (68.1%) before Nissen fundoplication to 197 (57.6%) after Nissen fundoplication. Of the 233 patients, 176 (75.6%) were restarted on antireflux medications within 1 year after Nissen fundoplication. Use of antireflux medication decreased in neurologically healthy patients but was unchanged in neurologically impaired children. CONCLUSIONS Use of antireflux medication decreased after Nissen fundoplication. Neurologically healthy children showed the biggest decrease in antireflux medication use after Nissen fundoplication.

The extended surgical time-out: does it improve quality and prevent wrong-site surgery?

PURPOSE To review the initial results of implementing an extended surgical time-out (STO) in pediatric surgery. METHODS Starting in January 2006, all members of our surgical team implemented and used an extended STO, confirming the patients identity, technical and anesthetic details, administered and available medications, and need for blood products and special equipment. To avoid disrupting work flow, the STO was initially after anesthesia induction. Starting in October 2007, the STO was done before anesthesia induction. Initial results, elapsed time to incision, and surgical team surveys were reviewed before and after implementing the preinduction STO. RESULTS The elapsed time to incision was similar for elective and urgent operations before and after implementing the preinduction STO. All antibiotics were administered and confirmed during the STO. Four significant equipment findings were detected, altering the planned procedure (two before and two after implementing the preinduction STO). Operating room staff felt more confident and prepared for the operations because communication was improved. One near-miss occurred during the postinduction STO. One wrong-site operation occurred despite the preinduction STO, because of inadequate marking. Root-cause analysis demonstrated that this was due to a systems error. CONCLUSIONS Using the extended STO before anesthesia induction improved communication among the surgical team members and did not disrupt work flow. An extended STO may also have broader value, such as confirming timely antibiotic administration or meeting other quality measures. The extended STO did not eliminate wrong-site surgery. However, implementation of the STO placed the responsibility for wrong-site surgery with the whole team and system, rather than with the individual surgeon.

Antibiotics-First Versus Surgery for Appendicitis: A US Pilot Randomized Controlled Trial Allowing Outpatient Antibiotic Management

Study objective Randomized trials suggest that nonoperative treatment of uncomplicated appendicitis with antibiotics‐first is safe. No trial has evaluated outpatient treatment and no US randomized trial has been conducted, to our knowledge. This pilot study assessed feasibility of a multicenter US study comparing antibiotics‐first, including outpatient management, with appendectomy. Methods Patients aged 5 years or older with uncomplicated appendicitis at 1 US hospital were randomized to appendectomy or intravenous ertapenem greater than or equal to 48 hours and oral cefdinir and metronidazole. Stable antibiotics‐first‐treated participants older than 13 years could be discharged after greater than or equal to 6‐hour emergency department (ED) observation with next‐day follow‐up. Outcomes included 1‐month major complication rate (primary) and hospital duration, pain, disability, quality of life, and hospital charges, and antibiotics‐first appendectomy rate. Results Of 48 eligible patients, 30 (62.5%) consented, of whom 16 (53.3%) were randomized to antibiotics‐first and 14 (46.7%) to appendectomy. Median age was 33 years (range 9 to 73 years), median WBC count was 15,000/&mgr;L (range 6,200 to 23,100/&mgr;L), and median computed tomography appendiceal diameter was 10 mm (range 7 to 18 mm). Of 15 antibiotic‐treated adults, 14 (93.3%) were discharged from the ED and all had symptom resolution. At 1 month, major complications occurred in 2 appendectomy participants (14.3%; 95% confidence interval [CI] 1.8% to 42.8%) and 1 antibiotics‐first participant (6.3%; 95% CI 0.2% to 30.2%). Antibiotics‐first participants had less total hospital time than appendectomy participants, 16.2 versus 42.1 hours, respectively. Antibiotics‐first‐treated participants had less pain and disability. During median 12‐month follow‐up, 2 of 15 antibiotics‐first‐treated participants (13.3%; 95% CI 3.7% to 37.9%) developed appendicitis and 1 was treated successfully with antibiotics; 1 had appendectomy. No more major complications occurred in either group. Conclusion A multicenter US trial comparing antibiotics‐first to appendectomy, including outpatient management, is feasible to evaluate efficacy and safety.

Testicular damage after surgical groin exploration for elective herniorrhaphy.

BACKGROUND/PURPOSE Controversy exists whether to explore the contralateral groin in boys during unilateral herniorrhaphy. Proponents claim there is minimal risk of injury to the cord structures and developing testicle with contralateral exploration. However, findings have shown testicular atrophy occurred in 1% to 2% of patients after herniorrhaphy, and vasal damage is possible after routine manipulation of the spermatic cord. This study investigated the effect of routine surgical exploration of the prepubertal groin on testicular development and future fertility. METHODS Twenty-four prepubertal Wistar rats were divided equally into 2 groups. Group 1 (sham) rats underwent unilateral inguinoscrotal incision only. Group 2 (experimental) rats underwent unilateral inguinoscrotal exploration with manipulation of the cord structures as in human inguinal exploration. At maturation, the fertility and fecundity of the males were assessed. After mating, testes were examined for mass, volume, mean seminiferous tubule diameter (MSTD), and mean testicular biopsy score (MTBS). The vasa were examined for histological injury and vasal diameter. Statistical comparisons were made by paired t test and Mann-Whitney rank sum test. RESULTS There was a difference between the volumes of the testes when comparing the operative and nonoperative side of the 2 groups (experimental, deltavol = -0.063+/-0.123; sham, deltavol = +0.067+/-0.137; P = .029). There also was a trend toward a smaller testicular mass when comparing the two sides (experimental, deltamass = -0.045+/-0.101; sham, Amass = +0.048+/-0.123; P = .057) but did not reach significance. The MSTD and MTBS were similar between the ipsilateral and contralateral testes in both groups. Likewise, the MSTD and MTBS were similar when comparing the 2 groups. All male rats in both groups were fertile. The number of offspring produced and the number of female rats impregnated were similar between the 2 groups. There was no histological evidence of vasal injury in any of the experimental spermatic cords. The vasal diameters were similar between the 2 groups. CONCLUSION Surgical manipulation of the prepubertal spermatic cord imparts a small, but statistically significant morphological change in testicular size without a deleterious effect on testicular development, fertility, or fecundity.

Comparison of Pediatric Laparoscopic Appendectomy Outcomes Between Teaching and Nonteaching Hospitals: A Multi-Institutional Study

PURPOSE With heightened emphasis on patient safety, it is important to document the effect of residents acting as the surgeon. This study compares the outcomes of laparoscopic appendectomy (LA) in children between teaching and nonteaching institutions. METHODS A retrospective review of all patients <18 years undergoing LA for appendicitis over a 10-year period was performed. The outcomes from 2 teaching institutions were compared with 10 nonteaching institutions. Study outcomes included postoperative morbidity (wound infection, abscess drainage, and readmission) and length of hospitalization (LOH). RESULTS Five hundred forty-two patients were treated at the teaching institution (mean age = 11 years, 62% male) and 3012 at the nonteaching institution (mean age = 13 years, 60% male). The perforated appendicitis rate was 33% at the teaching institution and 22% at the nonteaching institution (P < 0.0001). In patients with nonperforated appendicitis, rates of wound infection, abscess drainage, and readmission were similar between the institutions. However, for perforated appendicitis, rates of wound infection, abscess drainage, and readmission were all lower at the teaching institutions. LOH was longer at the teaching institutions for both nonperforated and perforated appendicitis. CONCLUSIONS The morbidity for LA was significantly lower in children with perforated appendicitis at the teaching institutions, whereas morbidity for nonperforated appendicitis was similar. LOH was longer in the teaching institutions. Overall, the presence of surgical trainees had minimal adverse impact on the outcomes of LA in children with appendicitis.