Clostridium difficile colitis: factors associated with outcome and assessment of mortalit…

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Hospitalization for Complications of Cirrhosis: Does Volume Matter?

J Gastrointest Surg. 2010 Nov 25;

Authors: Singla A, Hart JL, Li Y, Tseng JF, Shah SA

INTRODUCTION: Close to 30,000 people die of cirrhosis in the USA each year. Previous studies have shown a survival advantage with high-volume (HV) hospitals for complex surgical procedures. We examined whether a volume benefit exists for hospitals dealing with specialized disorders like complications of cirrhosis. METHODS: Using the Nationwide Inpatient Sample, we identified all cases of cirrhosis-related complications (n?=?217,948) from 1998 to 2006. Hospital volume was divided into tertile-based admissions for cirrhosis per year. RESULTS: The primary outcome was in-hospital mortality, and secondary endpoints included length of stay (LOS) and hospital charges. The number of admissions for cirrhosis increased over time (p?<?0.0001). HV centers were more likely to be large (86.8%) and teaching (81.5%) hospitals compared to lower volume centers. The average LOS and hospital charges were greater at the HV centers, but hospitalization at a HV center resulted in an adjusted mortality benefit (HR 0.88; 95% CI 0.83-0.92) compared to care at lower volume hospitals. CONCLUSION: Despite increased LOS and hospital cost, a mortality benefit exists at HV centers. Future studies are necessary to determine other processes of care that may exist at HV centers that may account for this survival benefit.

PMID: 21108014 [PubMed - as supplied by publisher]

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Conservative management of acute appendicitis.

J Gastrointest Surg. 2009 May;13(5):966-70

Authors: Malik AA, Bari SU

BACKGROUND: The acute appendicitis is the most common abdominal emergency, and the primary treatment has been appendicectomy. Antibiotics are started preoperatively and continued postoperatively as needed. METHODS: This prospective study was carried out at Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Kashmir, India to determine the role of antibiotics as the only treatment in acute appendicitis and the analgesic consumption needed. Total of 80 patients were included in the study with a duration of abdominal pain less than 72 h. Out of 80 patients, 40 patients received antibiotics intravenously for 2 days followed by oral treatment for 7 days, while another 40 patients considered as controls were randomized to surgery. RESULTS: Patients managed conservatively were discharged within 3 days except for two–patients who required surgery after 12 and 24 h, respectively, because of peritonitis due to perforated appendicitis. Four patients were readmitted within 1 year as a result of recurrent appendicitis and had to undergo surgery when appendicitis was confirmed. The diagnostic accuracy within the operated group was 90%. Two patients had perforated appendicitis at operation. CONCLUSION: Our conclusion is that antibiotic treatment in the patients with acute appendicitis is quite effective, and these patients may not need surgery. The patients managed conservatively with antibiotics alone experience less pain and require less analgesia but have high recurrent rate.

PMID: 19277796 [PubMed - indexed for MEDLINE]

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Surgical therapy of pancreatic pseudocysts.

J Gastrointest Surg. 2008 Dec;12(12):2231-9

Authors: Behrns KE, Ben-David K

BACKGROUND: Pancreatic pseudocysts are a common complication associated with acute and chronic pancreatitis. Fifteen percent and 40% of patients diagnosed with either acute or chronic pancreatitis, respectively, develop pseudocysts (Grace and Williamson, Br J Surg, 80:573-581, 1993). The treatment of pancreatic pseudocysts has evolved since the early 1980s, and changes in management have lead to an improved understanding of the pathophysiology of pseudocysts as well as necessary treatment paradigms. CONCLUSIONS: It has become evident that not all pseudocysts are equal. Pseudocysts arising in the setting of acute pancreatitis have a different pathophysiologic basis than those arising from chronic pancreatitis. Moreover, even those pseudocysts that arise in acute pancreatitis exhibit unique features. Pseudocysts that develop from a mild episode of pancreatitis, complicated by pancreatic duct disruption, differ significantly from those developed as a consequence of severe acute necrotizing pancreatitis with severe distortion of the pancreatic parenchyma or pancreatic duct. This review will focus on the surgical therapy of pancreatic pseudocysts in the context of the underlying pathophysiology and alternative nonoperative therapies.

PMID: 18461418 [PubMed - indexed for MEDLINE]

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Endoscopic drainage of pancreatic pseudocysts.

J Gastrointest Surg. 2008 Feb;12(2):369-72

Authors: Baron TH

Pancreatic pseudocysts arise as a complication of acute and chronic pancreatitis, pancreatic trauma, or after surgery. Endoscopic treatment of pancreatic pseudocysts can be achieved using transpapillary and/or transmural (transgastric or transduodenal) approaches with acceptable success rates, complication rates, and recurrence rates. Advantages of endoscopic drainage is the avoidance of external pancreatic fistula.

PMID: 17906903 [PubMed - indexed for MEDLINE]

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Early ERCP for gallstone pancreatitis: for whom and when?

J Gastrointest Surg. 2008 Apr;12(4):629-33

Authors: Behrns KE, Ashley SW, Hunter JG, Carr-Locke D

The indications for early endoscopic retrograde cholangiopancreatography (ERCP) in gallstone pancreatitis are unclear, and the examination is often requested or performed without substantial supporting evidence. Several trials have been performed to determine the benefit of early ERCP in pancreatitis, yet the results of these studies are inconsistent. To more closely analyze these studies, we performed an evidence-based review of the outcomes of early ERCP in gallstone pancreatitis. To obtain the best available evidence, a PubMed search using the MeSH terms “gallstones” and “pancreatitis” was performed and further refined to identify appropriate studies. We included five randomized trials, a meta-analysis, and a Cochrane Database Systematic Review in our detailed examination of the pertinent literature. Collectively, these studies suggest that early ERCP does not alter mortality in gallstone pancreatitis. In addition, few patients with mild pancreatitis benefit from the procedure, whereas some studies indicate that patients with severe pancreatitis or documented biliary obstruction may experience fewer complications if ERCP is performed. The data in the studies are confounding because of heterogeneity of the patient population and the inability to confirm gallstones in up to one third of patients. In conclusion, ERCP is not indicated for patients with mild pancreatitis. In select patients with severe disease or biliary obstruction, ERCP may be indicated. A multicenter trial designed to study the effect of early ERCP in severe pancreatitis only may provide additional useful information in patients with documented gallstones.

PMID: 17846851 [PubMed - indexed for MEDLINE]

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