Benefits of laparoscopic peritoneal lavage for complicated sigmoid diverticulitis.

BACKGROUND: The traditional therapy for perforated sigmoid diverticulitis with peritonitis is emergency colectomy usually with colostomy. We report laparoscopic exploration with peritoneal lavage as an alternative in seven patients who required emergency surgery for diverticulitis. METHODS: Six patients presented with diffuse peritonitis and one with a failure of percutaneous therapy. All patients were explored laparoscopically and the peritoneal cavity was lavaged with saline in addition to receiving intravenous antibiotics. Patient demographics, clinical response, length of stay, and complications were recorded. RESULTS: Six patients had resolution of peritonitis resolved and patients were discharged from the hospital. One of these patients who developed a pelvic abscess required a percutaneous drainage postoperatively. This patient ultimately returned 3 months later with recurrent symptoms and underwent colectomy with primary anastomosis. One patient failed to improve initially and underwent colectomy with primary anastomosis on the same admission. Five patients subsequently had elective sigmoid resections, four laparoscopic and one open. Mean length of stay was 7.7 days. There was no mortality. CONCLUSION: We conclude that laparoscopic exploration and peritoneal lavage can be performed safely in patients with diffuse, purulent peritonitis. Using this approach, most patients with purulent peritonitis can avoid emergent laparotomy with the risk of colostomy, and the need for a second surgery.

A randomized controlled trial of holistic neuropsychologic rehabilitation after traumatic brain injury.

OBJECTIVE: To evaluate the effectiveness of comprehensive, holistic neuropsychologic (NP) rehabilitation compared with standard, multidisciplinary rehabilitation for people with traumatic brain injury (TBI). DESIGN: Randomized practical controlled trial. SETTING: Postacute brain injury rehabilitation center within a suburban rehabilitation hospital. PARTICIPANTS: Participants with TBI were recruited from clinical referrals and referrals from the community. Sixty-eight participants who met inclusion criteria were randomly allocated to treatment conditions. Most participants (88%) had sustained moderate or severe TBI, and greater than half (57%) were more than 1 year postinjury at the beginning of treatment. INTERVENTIONS: Treatment was conducted 15 hours per week for 16 weeks. Standard neurorehabilitation consisted primarily of individual, discipline specific therapies (n=34). Intensive cognitive rehabilitation emphasized the integration of cognitive, interpersonal, and functional interventions within a therapeutic environment (n=34). MAIN OUTCOME MEASURES: Primary outcomes were the Community Integration Questionnaire (CIQ) and Perceived Quality of Life scale (PQOL). Secondary outcomes included NP functioning, perceived self-efficacy, and community-based employment. RESULTS: NP functioning improved in both conditions. Intensive cognitive rehabilitation participants showed greater improvements on the CIQ (effect size [ES]=0.59) and PQOL (ES=0.30) as well as improved self-efficacy for the management of symptoms (ES=0.26) compared with standard neurorehabilitation treatment. These gains were maintained at the 6-month follow-up. Standard neurorehabilitation participants showed improved productivity at the 6-month follow-up associated with the need for continued rehabilitation. CONCLUSIONS: Improvements seen after intensive cognitive rehabilitation may be related to interventions directed at the self-regulation of cognitive and emotional processes and the integrated treatment of cognitive, interpersonal, and functional skills. The results show the effectiveness of comprehensive holistic NP rehabilitation for improving community functioning and quality of life after TBI compared with standard rehabilitation.

Combination propofol/ketamine is a safe and efficient anesthetic approach to anorectal surgery.

PURPOSE: Concerns persist regarding respiratory complications from combination deep intravenous sedation and local anesthesia for prone position anorectal surgery. We examined the safety and efficacy of this approach by using a propofol-based and ketamine-based technique. METHODS: A retrospective review was conducted on all patients undergoing anorectal surgery. Outcomes (perioperative times, specific complications) were compared with respect to operative position and anesthetic approach. Significance was determined using Student's t-test and chi-squared analysis. RESULTS: Surgery was performed on 448 patients during a three-year period. There was no significant difference in the two anesthetic groups with regard to age and gender. There were 19 anesthesia-related adverse events occurring in the study group (Monitored Anesthesia Care Group): nausea and vomiting (n = 8), airway obstruction necessitating conversion to general anesthesia (n = 2), excessive pain (n = 2), urinary retention (n = 5), and hospital readmission (n = 2). These occurred in <5 percent of those receiving the combination technique (19/407). Although there was no difference in total procedural time, there was a significant difference in total time spent in the operating room (P = 0.001) and in the hospital overall (P = 0.002). Of the patients receiving combination technique anesthesia, only 31 (7 percent) required the use of the postanesthesia care unit. All patients receiving general anesthesia (n = 23) required the postanesthesia care unit. CONCLUSIONS: Combination deep intravenous sedation with local anesthesia based on propofol and ketamine is a safe and effective technique for prone-position anorectal surgery. It results in decreased use of the postanesthesia care unit and earlier hospital discharge, reflecting a more efficient use of hospital resources.

Community integration and satisfaction with functioning after intensive cognitive rehabilitation for traumatic brain injury.

OBJECTIVE: To evaluate the effectiveness of an intensive cognitive rehabilitation program (ICRP) compared with standard neurorehabilitation (SRP) for persons with traumatic brain injury (TBI). DESIGN: Nonrandomized controlled intervention trial. SETTING: Community-based, postacute outpatient brain injury rehabilitation program. PARTICIPANTS: Fifty-six persons with TBI. INTERVENTIONS: Participants in ICRP (n=27) received an intensive, highly structured program of integrated cognitive and psychosocial interventions based on principles of holistic neuropsychologic rehabilitation. Participants in SRP (n=29) received comprehensive neurorehabilitation consisting primarily of physical therapy, occupational therapy, speech therapy, and neuropsychologic treatment. Duration of treatment was approximately 4 months for both interventions. MAIN OUTCOME MEASURES: Community Integration Questionnaire (CIQ); and Quality of Community Integration Questionnaire assessing satisfaction with community functioning and satisfaction with cognitive functioning. Neuropsychologic functioning was evaluated for the ICRP participants. RESULTS: Both groups showed significant improvement on the CIQ, with the ICRP group exhibiting a significant treatment effect compared with the SRP group. Analysis of clinically significant improvement indicated that ICRP participants were over twice as likely to show clinical benefit on the CIQ (odds ratio=2.41; 95% confidence interval, 0.8-7.2). ICRP participants showed significant improvement in overall neuropsychologic functioning; participants with clinically significant improvement on the CIQ also showed greater improvement of neuropsychologic functioning. Satisfaction with community functioning was not related to community integration after treatment. Satisfaction with cognitive functioning made a significant contribution to posttreatment community integration; this finding may reflect the mediating effects of perceived self-efficacy on functional outcome. CONCLUSIONS: Intensive, holistic, cognitive rehabilitation is an effective form of rehabilitation, particularly for persons with TBI who have previously been unable to resume community functioning. Perceived self-efficacy may have significant impact on functional outcomes after TBI rehabilitation. Measures of social participation and subjective well-being appear to represent distinct and separable rehabilitation outcomes after TBI.