Resection and advancement of esophageal mucosa. A potential therapy for Barrett's esophagus.

BACKGROUND: Barrett's esophagus affects 5-10% of patients with gastroesophageal reflux disease (GERD) and is associated with a 40-fold increased risk of malignant transformation. Ablative therapies may lead to esophageal perforation or stricture formation if applied too liberally and residual glandular tissue and persistent cancer risk if utilized too sparingly. METHODS: Ten pigs underwent gastrotomy. Mucosa below the gastroesophageal (GE) junction was elevated by saline injections, circumferentially incised, and secured to an orogastric tube. By traction, the distal esophageal mucosa was inverted 10 cm proximally, then returned to the gastric lumen. In group A (n = 4), the mucosa (5 cm) was resected and the remnant was allowed to retract. In group B (n = 4), the mucosa was simply sutured back into its native position. In group C (n = 2), the mucosa (5 cm) was resected and the proximal segment was advanced and sutured to the gastric mucosa. At 6 weeks, or sooner if stricture developed, the animals were killed. Stricture formation was determined by ex vivo barium esophagram and gross assessment. The extent of fibrosis and epithelial healing were established histologically. RESULTS: Group A (mucosa resected) developed weight loss and anorexia within 4 weeks. Pathology revealed dense fibrotic stricture without reepithelialization. Group B (mucosa elevated/replaced) gained weight after the operation. Histology demonstrated mucosal healing without significant stricture or fibrosis. Group C (mucosa resected/advanced) also thrived postoperatively. Histology confirmed mucosal healing without evidence of retraction or dense stricture. CONCLUSIONS: Exposure of submucosal tissues causes esophageal stricture. Mucosal coverage minimizes submucosal fibrosis after injury. Mucosal resection and advancement allows healing without stricture and may have therapeutic potential for patients with Barrett's esophagus.

Bile duct injury during laparoscopic cholecystectomy: results of a national survey.

OBJECTIVE: To determine whether surgical residency training has influenced the occurrence of common bile duct injuries during laparoscopic cholecystectomy, and to asses the anatomic and technical details of bile duct injuries from the practices of surgeons trained in laparoscopic cholecystectomy after residency versus surgeons trained in laparoscopic cholecystectomy during residency. SUMMARY BACKGROUND DATA: Shortly after the introduction of laparoscopic cholecystectomy, the rate of injury to the common bile duct increased to 0.5%, and injuries were more commonly reported early in each surgeon's experience. It is not known whether learning laparoscopic cholecystectomy during surgery residency influences this pattern. METHODS: An anonymous questionnaire was mailed to 3,657 surgeons across the United States who completed an Accreditation Council for Graduate Medical Education (ACGME)-approved residency between 1980 and 1990 (group A) or 1992 and 1998 (group B). All surgeons in group A learned laparoscopic cholecystectomy after residency, and all those in group B learned laparoscopic cholecystectomy during residency. Information obtained included practice description, number of laparoscopic cholecystectomies completed since residency, postgraduate training in laparoscopy, and annual volume of laparoscopic cholecystectomy in the surgeon's hospital. In addition, technical details queried included the completion of a cholangiogram, the interval between injury and identification, the method of repair, and the site of definitive treatment. The primary endpoint was the occurrence of a major bile duct injury during laparoscopic cholecystectomy (bile leaks without a major bile duct injury were not tabulated). RESULTS: Forty-five percent (n = 1,661) of the questionnaires were completed and returned. Mean practice experience was 13.6 years for group A and 5.4 years for group B. At least one injury occurrence was reported by 422 surgeons (37.6%) in group A and 143 surgeons (26.5%) in group B. Forty percent of the injuries in group A occurred during the first 50 cases compared with 22% in group B. Thirty percent of bile duct injuries in group A and 32.9% of all injuries in group B occurred after a surgeon had performed more than 200 laparoscopic cholecystectomies. Independent of the number of laparoscopic cholecystectomies completed since residency, group A surgeons were 39% more likely to report one or more biliary injuries and 58% more likely to report two or more injuries than their counterparts in group B. Bile duct injuries were more likely to be discovered during surgery if a cholangiogram was completed than if cholangiography was omitted (80.9% vs. 45.1%). Sixty-four percent of all major bile duct injuries required biliary reconstruction, and most injuries were definitively treated at the hospital where the injury occurred. Only 14.7% of injuries were referred to another center for repair. CONCLUSIONS: Accepting that the survey bias underestimates the true frequency of bile duct injuries, residency training decreases the likelihood of injuring a bile duct, but only by decreasing the frequency of early "learning curve" injuries. If one accepts a liberal definition of the learning curve (200 cases), it appears that at least one third of injuries are not related to inexperience but may reflect fundamental errors in the technique of laparoscopic cholecystectomy as practiced by a broad population of surgeons in the United States. Intraoperative cholangiography is helpful for intraoperative discovery of injuries when they occur. Most injuries are repaired in the hospital where they occur and are not universally referred to tertiary care centers.

Outcomes assessment and minimally invasive surgery: historical perspective and future directions.

BACKGROUND: Outcomes assessment is being used increasingly to shape practice patterns in all areas of medicine. Although outcomes assessment is not a new concept, the widespread application of outcomes measurement for modifying practice is novel. Instead of focusing on results of interventions in highly controlled environments, outcomes studies usually report results as they occur in uncontrolled, real-world environments. Recently, the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) has initiated a society-wide initiative to monitor outcomes in patients undergoing various laparoscopic operations. METHODS: Pertinent literature is reviewed as it relates to outcomes assessment. The historical background underpinning the modern interest in outcomes is outlined. Definitions of terms useful for understanding outcomes research are given. The impact of outcomes assessment on minimally invasive surgery, both positive and negative, are examined. The SAGES outcome initiative is introduced. CONCLUSIONS: Although outcomes studies usually do not provide information on the causes of observations made, they have gained in popularity because they provide information about patient perceptions of disease, disability, and treatment. Minimally invasive surgical procedures often are reported in terms of outcomes assessment because a controlled clinical trial was rendered impossible by early and widespread application of laparoscopic surgery. The SAGES outcomes initiative will provide the necessary tools for the participation of surgeons in the process of practice profiling.

Heartburn is more likely to recur after Toupet fundoplication than Nissen fundoplication.

Toupet (270 degrees) fundoplication is commonly recommended for patients with gastroesophageal reflux (GER) and esophageal dysmotility. However, Toupet fundoplication may be less effective at protecting against reflux than Nissen (360 degrees) fundoplication. We therefore compared the effectiveness and durability of both types of fundoplication as a function of preoperative esophageal motility. From January 1992 through January 1998, 669 patients with GER underwent laparoscopic fundoplication (78 Toupet, 591 Nissen). Patients scored heartburn, regurgitation, and dysphagia preoperatively, and at 6 weeks and 1 year postoperatively, using a 0 ("none") to 3 ("severe") scale. We compared symptom scores (Wilcoxon rank sum test) and redo fundoplication rates (Fisher exact test) in Toupet and Nissen patients. We also performed subgroup analyses on 81 patients with impaired esophageal motility (mean peristaltic amplitude, <30 mm Hg or peristalsis <70% of wet swallows) and 588 patients with normal esophageal motility. Toupet and Nissen patients reported similar preoperative heartburn, regurgitation, and dysphagia. At 6 weeks after operation, heartburn and regurgitation were similarly improved in both groups, but dysphagia was more prevalent among Nissen patients. After 1 year, heartburn and regurgitation were re-emerging in Toupet patients, and dysphagia was again similar between groups. Patients with impaired motility who have Nissen fundoplication are no more likely to suffer persistent dysphagia than their counterparts who have Toupet fundoplication. In addition, patients with normal motility are more likely to develop symptom recurrence after Toupet fundoplication than Nissen fundoplication, with no distinction in dysphagia rates. We conclude that since Toupet patients suffer more heartburn recurrence than Nissen patients, with similar dysphagia, selective use of Toupet fundoplication requires further study.

The use of sheet autografts to cover extensive burns in patients.

We previously have reported on the enhanced cosmetic and functional outcome with the use of sheet autografts. The recent goal has been to cover larger surface areas with sheet grafts, or for patients with larger burns, covering the hands and face with sheet grafts, if possible. To evaluate the use of sheet grafts in burns of more than 30% total body surface area (TBSA), the percentage covered with sheet and meshed autograft was reviewed in 105 patients admitted between January 1, 1990, and August 30, 1994. Results were that 18 patients (17%), with a mean of 44.3% TBSA burns, had all of their full-thickness wounds (mean, 36.5% +/- 2.2%; range, 20% to 55.5%) covered with sheet grafts (Group 1). Seventeen patients (16%), with mean burn size of 64.3%, had their wounds (mean, 35.1% +/- 4.4%; range, 15% to 79%) covered solely with mesh graft (Group 2). The lower percentage covered by mesh alone was skewed by the high mortality rate (53%) in this group. Seventy patients, 58.4% +/- 19% (range, 30% to 92%) TBSA burn, had their full-thickness wounds covered with a combination of mesh and sheet graft (Group 3). In Group 3, the mean percentage of TBSA covered by sheet grafts was 15.0% +/- 1.4% (range, 1% to 42.5%) and that covered by meshed grafts was 39.4% +/- 2.6% (range, 4% to 93%). Three quarters (73%) of patients in this group had sheet grafts placed on the face, whereas 63% had them placed on the hands. Extremities and the trunk were more often grafted with mesh graft. Sheet grafts were the sole coverage in patients with burns up to 55.5%. With even larger burns, sheet grafts were used to cover the face and hands. Because of its superior cosmetic and functional outcome, sheet autografting should be considered for covering moderately sized burns. Sheet autografting should be considered for more important cosmetic and functional areas, such as the face and hands, for massive burns.

Implementation of a clinical pathway decreases length of stay and hospital charges for patients undergoing total colectomy and ileal pouch/anal anastomosis.

BACKGROUND: Clinical pathways are increasingly being used by hospitals to improve efficiency in the care of certain patient populations; however, little prospective data are available to support their use. This study examined whether using a clinical pathway for patients undergoing ileal pouch/anal anastomosis, a complex procedure in which we had extensive practical experience, affected hospital charges or length of stay (LOS). METHODS: A clinical pathway was developed to serve patients undergoing elective total colectomy and ileal pouch/anal anastomosis. All operations were performed by two attending physicians (J.E.F., M.S.N.). Before implementation, 10 pilot patients were prospectively monitored to ensure that hospital charges were accurately generated. In addition, charge audits were performed by an outside agency to verify the accuracy of the hospital bills. The pathway was then implemented, and 14 patients were prospectively analyzed. RESULTS: In all patients the principal diagnosis was ulcerative colitis, with the exception of three patients with familial polyposis. Mean external audit charges were within 2% of the hospital bills; therefore the hospital bills were used in all calculations. The mean LOS decreased from 10.3 days to 7.5 days (p = 0.046) for patients on the pathway versus pilot patients. Mean hospital charges also decreased significantly, from $21,650 to $17,958 per patient (p = 0.005). CONCLUSIONS: Implementation of a clinical pathway, even for an operation in which the surgeon has much experience, is an effective method for reducing LOS and charges for patients. This is likely the result of interdisciplinary cooperation, elimination of unnecessary interventions, and streamlined involvement of ancillary services. These results support the development of clinical pathways for procedures that involve routine preoperative and postoperative care. In addition, the benefits of clinical pathways should increase proportionally with increasing case volume for a particular procedure.

Inhalation injury severity scoring system: a quantitative method.

Inhalation injury, a major contributor to burn-related mortality, has been difficult to quantify. A scoring system paralleling current adult respiratory distress syndrome systems has the potential to distinguish survivors from nonsurvivors. The utility of the PaO2/FiO2 (P/F) ratio in predicting injury severity was first examined. In a review of 120 patients with inhalation injury, those with P/F ratios greater than or equal to 300 after resuscitation were more likely to survive than those with ratios less than 300. The P/F ratio had no value when obtained before resuscitation. Next, a scoring system was developed to assist in comparing the severity of injury in ventilator-dependent patients with burns. Measurements were recorded prospectively in four categories: chest x-ray evaluation, P/F ratio, peak inspiratory pressure, and bronchoscopy. When comparing survivors (20) versus nonsurvivors (6), significant differences were found early (day 0, day 1, and week 1) for P/F ratio and overall severity score. Differences were seen later (week 1 and week 2) for chest x-ray evaluation and peak inspiratory pressure values. Because of low numbers the value of bronchoscopy could not be evaluated. The role of an inhalation injury severity scoring system for predicting survival should be examined in larger prospective trials.

Current uses and abuses of total parenteral nutrition.

Total parenteral nutrition remains a vital medical intervention, and in our institution it is considered as basic as intravenous fluids, antibiotics, and blood transfusions. As is true of most treatments, there are specific indications as well as associated risks and costs which mandate justification of its use. It is clear that the indications for TPN are diminishing as basic science and clinical studies continue to find increased benefits associated with enteral feeding, and as techniques for initiating enteral nutrition improve. Because of unproven benefits and/or increased complication rates, TPN has lost favor in the treatment of conditions that were previously thought to require parenteral alimentation, such as acute pancreatitis, pediatric and adult burns, critical care, and preoperative use in patients with mild or moderate malnutrition. Despite diminishing indications, TPN continues to generate excitement in some areas as its immunological effects become better defined. The use of TPN in patients with cancer before certain therapies, as well as in the transplant population, remains hopeful. New uses of TPN will result from a better understanding of the cellular and molecular effects of parenteral feeding. In the future, TPN may well be used as a pharmacologic agent rather than as nutritional intervention.