Elective conventional colectomy in the era of laparoscopic surgery.

Laparoscopic surgery, since its introduction into the general surgery, has reduced hospital stay. Can lessons learned from laparoscopic surgery about aggressive postoperative care be applied to elective conventional colectomy? Between August 1994 and February 1995, a prospective study was conducted on 24 consecutive patients undergoing elective conventional colectomy with primary anastomosis. A comparison of 30 consecutive patients in the 7 months immediately before this study were used as a historical control group. Both groups were comparable in age, indications for operation, type of operation, and operative time. The protocol consisted of an outpatient bowel prep, hospital admission on day of surgery, and intravenous metoclopramide starting before the operation and continued every 6 hours with diet started at 24 hours. Patients were discharged on regular diet after a bowel movement and were continued on oral metoclopramide for a total of 7 days. Hospital stay was reduced from 8 days (range 4-19 days) to 4 days (range 2-7 days) on the protocol P < 0.001). Hospital charges were also reduced by 20 per cent (from $18,450 to $14,586) (P = 0.066). Complication rate and postoperative emergency room visits as a measure of quality of care did not differ between the two groups. By implementing this protocol, hospital costs and length of stay for elective conventional colectomy were reduced without compromising patient care.

Laparoscopic cholecystectomy for gallbladder torsion.

Although torsion of the gallbladder is most commonly a disease of the elderly, an 18-year-old woman presented with this condition. This is the first reported case of laparoscopic cholecystectomy for gallbladder torsion. Signs and symptoms of gallbladder volvulus are often subtle. Radiologic evaluation may be normal. A high index of suspicion is necessary to make the preoperative diagnosis. If treated laparoscopically, gallbladder decompression and detorsion prior to cholecystectomy are helpful techniques to avoid bile duct injury. A literature review of this uncommon problem is provided.

Laparoscopic appendectomy for acute appendicitis: is there really any benefit?

Laparoscopic appendectomy is emerging as a popular treatment modality for acute appendicitis. Although claims have been made to potential superiority over traditional appendectomy, comparisons of operative difficulty, hospital stay, hospital costs, complication rates, postoperative pain, and convalescence have not been well studied. Two hundred consecutive patients presenting with signs and symptoms of acute appendicitis underwent appendectomy. Traditional appendectomy was employed in 101 patients, while 99 underwent laparoscopy. Successful laparoscopic appendectomy was possible in 89 patients who were compared with the 101 patients with traditional appendectomy. There were two pregnant patients with appendicitis in each group. The incidence of acute appendicitis was 72 per cent for traditional appendectomy and 74 per cent for laparoscopic appendectomy. Operating time was significantly longer with laparoscopic appendectomy (60.1 vs 45.4 minutes, P = 0.0001). This was reflected in higher (although not significant) hospital costs ($8,683 vs $6,213). Post-op hospital stay was shorter for laparoscopic appendectomy (2.7 vs 3.8 days, P = 0.001). Complication rates were no different between the two groups. Post-op pain, as evaluated by a patient grading scale, was less for laparoscopic appendectomies up to the third post-op week (P = 0.003). The amount of IM pain medication was greater with traditional appendectomy (P = 0.009). Convalescence was significantly shorter with laparoscopic appendectomy as measured by: 1) return to normal household activity (7.8 vs 13.2 days, P = 0.016), 2) returned ability to exercise (19.7 vs 29.0 days, P = 0.009), 3) patient feeling well enough to return to work (14.1 vs 19.2 days, P = 0.032), and 4) actual return to work (15.4 vs 20.5 days, P = 0.038).(ABSTRACT TRUNCATED AT 250 WORDS)

Open breast biopsy. A critical analysis.

A retrospective study of open breast biopsies performed from January 1, 1988 to December 31, 1988 was undertaken to compare the malignancy rate of the authors with that generally reported in the literature. This was done to determine if biopsy of mammographically demonstrated nonpalpable lesions had a favorable impact on outcome, and to identify factors with high relative risk or predictive value for malignancy. Office records of 518 patients who underwent breast biopsies were reviewed, 122 of which (23.6%) proved to be malignant. The malignancy rate for needle localized excisions of nonpalpable lesions was 17.5 per cent. Of these, 28 per cent were stage tumor in situ (TIS), 60 per cent stage 1, and 12 per cent stage 2. A higher percentage of palpable lesions were malignant than were nonpalpable lesions (29.0%). Of the palpable malignancies, 28 per cent were stage 1, 51 per cent stage 2, 13 per cent stage 3, and 8 per cent stage 4. Those who were older than 40 years of age yielded a significantly higher malignancy rate when compared with the less than 40 age group (28.6% versus 6.7%, P less than 0.001). Lesions that appeared on mammogram as nodules, calcium, or both had a higher malignancy rate than those where no lesion was identified (25.3% versus 14.2%, P less than 0.001). None of these factors alone or in combination ruled out malignancy. Biopsy of nonpalpable mammographically demonstrated lesions lead to detection of breast cancer at an earlier stage. Age greater than forty years, demonstrable lesion by mammogram, and palpable lesion were significant predictors of malignancy.(ABSTRACT TRUNCATED AT 250 WORDS)

Operative strategy for thyroid cancer. Is total thyroidectomy worth the price?

The authors conducted a retrospective analysis with 5- to 30-year follow-up on 109 patients in order to determine the optimum management of nonmedullary thyroid cancer. Results of total thyroidectomy were compared to partial thyroidectomy, among patients well matched for prognostic indicators. No differences in cancer mortality or recurrence rates were evident. However, there were significantly more complications when total thyroidectomy was employed. In view of these results, partial thyroidectomy is recommended as the treatment of choice for nonmedullary thyroid cancer.