Outpatient laparoscopic appendectomy for acute appendicitis.

Am Surg. 2012 Feb;78(2):213-5

Authors: Cash CL, Frazee RC, Smith RW, Davis ML, Hendricks JC, Childs EW, Abernathy SW

Abstract
Laparoscopic appendectomy is the widely accepted treatment for acute appendicitis. This approach offers the potential of less pain, shorter hospital stay, and quicker return to activities. Traditionally, patients are hospitalized for 24 hours after laparoscopic appendectomy. This practice can be questioned due to the good results of other outpatient laparoscopic surgery. A retrospective review of 119 patients undergoing laparoscopic appendectomy for uncomplicated acute appendicitis was undertaken from January through September 2009; outpatient and inpatient laparoscopic appendectomies were compared. Patients were selected for outpatient management based upon physician discretion and their clinical course in operation and recovery rooms. Forty-two patients were dismissed on the day of surgery and 77 were admitted for 1 to 5 days postoperatively. No significant differences in age, gender, and preoperative comorbidities between outpatient and inpatient groups were found. Postoperative complications occurred in 2.4 per cent of outpatients and 11.7 per cent of inpatients (P = 0.16). Complications included superficial wound infections, urinary retention, urinary tract infection, intra-abdominal bleeding, pneumonia, and infected hematoma. Based upon this study, outpatient laparoscopic appendectomy can be performed safely in selected patients. This study provides the background for the present prospective protocol for routine outpatient laparoscopic appendectomy at our institution.

PMID: 22369831 [PubMed - indexed for MEDLINE]

Physician Behavior: Not Ready for 'Never'land.

Am Surg. 2011 Dec;77(12):1600-5

Authors: Goettler CE, Butler TS, Shackleford P, Rotondo MF

Abstract
Disruptive physician behavior, particularly by surgeons, is a common perception. Increasing awareness and regulatory oversight is being felt in medical practice; however, little data exist regarding the frequency of these behaviors. This study was undertaken to determine the prevalence and type of reported behavioral issues. Blinded data for 2 years of physician behavior reports were reviewed for department, gender, event summary, and peer review conclusions. Chi-square analysis was used with statistical significance at P < 0.05. One hundred ninety-one behavior issues were reported in our 751-bed hospital, which employs 640 active physicians. One hundred fourteen (18%) physicians were reported. Forty-four (7%) physicians had multiple reports, accounting for 121 (63%) reports. Twenty-seven physicians were reported twice, eight 3 times, four 4 times, three 5 times, and one 6 times. Multiple-report physicians compared with single-report physicians showed no difference in distribution of outcomes, but more communication issues and fewer unacceptable behaviors. Specialty groups with a higher incidence of reported behaviors included anesthesia, cardiology, hospitalists, orthopedics, trauma, and obstetrics/gynecology. Female physicians were less likely to be reported. Staff reports were mainly against physicians within their hospital practice area (75 of 94 [80%]), whereas physician reports were mainly against physicians outside their practice area (18 of 25 [72%]). Disruptive physician behavior is variable and culturally defined. Although all reports should be taken seriously, fewer than 1 per cent of reported incidents were found to be definably disruptive and valid. As quality and oversight groups consider making disruptive physician behavior a "never" event, firm definitions and full peer review are mandatory.

PMID: 22273216 [PubMed - in process]

Central line-associated blood stream infection in the critically ill trauma patient.

Am Surg. 2011 Aug;77(8):1038-42

Authors: Smith JW, Egger M, Franklin G, Harbrecht B, Richardson JD

Abstract
Blood stream infections in the critically ill are a common cause of morbidity. Strict adherence to sterile technique can reduce central line-associated blood stream infections (CLBSIs) and has become a quality improvement measure. We did a retrospective review of 6,014 trauma admissions representing 10,370 catheter days. CLBSI was defined as a positive blood culture with central venous access without evidence of other infectious sources. Thirty-five CLBSIs were identified in the study period (3.26/1,000 line days). The average Injury Severity Score was 32, the average intensive care unit stay was 24 days, and the average overall length of stay was 34 days, which is higher than that of nonCLBSI patients. In 25/35 cases, there was a break in sterile technique during central venous catheter placement (71%). Of the 25 cases, 16 of them were performed in the intensive care unit (64%), five in the operating room (20%), and four in the emergency department (16%). Twenty of the 35 patients with CLBSI (57%) had a total of 24 infections, a 2-fold increase in infectious complications for a given Injury Severity Score. Seventeen (17) of the 25 "dirty" central lines (68%) were changed within 24 hours in an effort to reduce the risk of CLBSI without success. A large percentage of CLBSI can be traced to the initial placement of a central venous line under less than ideal sterile technique. Changing a line within 24 hours may not be sufficient to reduce the risk of CLBSI. Every effort should be made to adhere to proper sterile technique while placing central venous catheter.

PMID: 21944520 [PubMed - indexed for MEDLINE]

Predictors of fatal outcome after colectomy for fulminant Clostridium difficile Colitis: a 10-year experience. dr.markelov@gmail.com.

Am Surg. 2011 Aug;77(8):977-80

Authors: Markelov A, Livert D, Kohli H

Abstract
Surgical treatment of fulminant Clostridium difficile colitis has high mortality rates. Identification of a set of preoperative characteristics that could predict outcome after surgery is necessary to optimize clinical management and guide surgical timing. Data were retrospectively collected on patients operated on for C. difficile colitis between 2000 and 2010 at our institution. Statistical analysis was performed to identify predictors of mortality. We reviewed the records of 13 inpatients diagnosed as having C. difficile colitis and who underwent colectomy during the same admission. The in-hospital mortality rate for patients undergoing colectomy for colitis was 46.2 per cent. Independent predictors of mortality included the following: white blood cell count (34,600/?L or greater), hypoalbuminemia (1.5 g/dL or less), septic shock with requirements of vasopressors, and respiratory failure. Patients who underwent colectomy earlier (mean time from presentation to surgery 2.4 ± 1.5 days) had decreased mortality (P = 0.019).). Longer length of hospital stay to the time of diagnosis was associated with higher rates of fatal outcome (P = 0.031). Parameters without significant difference (P > 0.05) included patient age, presenting symptoms, other comorbidities, creatinine levels, and CT scan findings. Identified factors can predict unfavorable outcomes after colectomy. Aggressive surgical intervention early in the course of the disease might be associated with improved survival.

PMID: 21944509 [PubMed - indexed for MEDLINE]

Current management of diverticulitis.

Am Surg. 2008 Nov;74(11):1041-9

Authors: McCafferty MH, Roth L, Jorden J

Diverticulitis is classified as uncomplicated or complicated, i.e., associated with perforation, fistula, or obstruction. CT allows more reliable characterization of an acute attack of diverticulitis. Medical management is reserved for uncomplicated diverticulitis and the initial phase of treatment of diverticulitis associated with abscess formation. Percutaneous abscess drainage is a major advance, which permits one-stage resection in a majority of cases. Diverticulitis associated with free perforation can be selectively managed with resection and primary anastomosis, although a Hartmann resection is likely to be performed. A fistula associated with diverticulitis can usually be managed with a one-stage resection. Obstruction can be managed selectively with resection with on-table bowel preparation, primary anastomosis, and proximal diversion. Laparoscopic techniques permit successful performance of elective resections most of the time. Hand assistance is of particular value when the patient has dense fibrosis.

PMID: 19062658 [PubMed - indexed for MEDLINE]

Can the MELD score predict perioperative morbidity for patients with liver cirrhosis undergoing laparoscopic cholecystectomy?

Am Surg. 2008 Feb;74(2):156-9

Authors: Bingener J, Cox D, Michalek J, Mejia A

The Model for End Stage Liver Disease (MELD) score is a mortality predictor in patients awaiting liver transplantation. We evaluated the MELD score's ability to predict morbidity for patients with cirrhosis undergoing laparoscopic cholecystectomy. From March 1991 to February 2004, data of all patients undergoing laparoscopic cholecystectomy were prospectively collected. Data of patients with liver cirrhosis were reviewed. The MELD and Child scores were correlated with outcome variables. Of 7859 patients undergoing laparoscopic cholecystectomy, 99 patients (1.3%) exhibited liver cirrhosis, 44 women and 55 men. The mean age was 55 years (range, 28 to 92 years). The mortality rate was 6.3 per cent, morbidity rate 18 per cent, and conversion rate 11 per cent. Laboratory values on 55 patients were available to calculate MELD scores. The mean MELD score was 11 (range, 6 to 23). There was no significant variation in MELD scores with gender (P = 0.61) or cirrhosis etiology, alcoholic and nonalcoholic (P = 0.52). MELD and Child's score correlated well (P < 0.001); however, the risk of complication was not related to the MELD (P = 0.94) or Child-Pugh-Turcotte score (P = 0.26). Morbidity for patients with liver cirrhosis undergoing laparoscopic cholecystectomy remains high. The MELD score is useful for transplant risk stratification for but requires further investigation regarding morbidity prediction for laparoscopic cholecystectomy.

PMID: 18306870 [PubMed - indexed for MEDLINE]