Cost Effectiveness of a Fast-Track Protocol for Urgent Laparoscopic Cholecystectomies and Appendectomies.

BACKGROUND: Fast-track protocols (FTPs) are used to decrease length of stay (LOS) and hospital costs for elective outpatient procedures. Few institutions have implemented FTP for urgent procedures such as laparoscopic cholecystectomy (LC) and laparoscopic appendectomy (LA). STUDY DESIGN: This is a retrospective single-institution cohort study including all patients undergoing urgent LC or LA between July 1, 2010 and May 1, 2013. Exclusion criteria included conversion to open procedure, perforated appendicitis, or procedure related to intra-abdominal injury. Analysis included a comparison of the three study groups: (1) before (PRE) and after (POST) implementation of the fast-track protocol (FTP), (2) fast-track cohort (FT) and non-fast-track cohort (NFT), and (3) those completing the fast-track pathway (FT-C) and those who began but failed to complete the pathway (FT-F). RESULTS: There were significant reductions in LOS between all study groups compared: between PRE (n = 256) and POST (n = 472) cohorts by half a day (2.0 vs. 1.5 days, p < 0.02); between FT and NFT (0.68 vs. 1.82 days, p < 0.01); and FT-C and FT-F (0.49 vs. 1.05 days, p < 0.01). Total hospital charges were significantly reduced in FT compared with NFT ($22,347 vs. $30,868, p < 0.01) with an average savings of $8521. Total hospital charges were decreased in the FT-C compared with FT-F cohorts ($21,971 vs. $22,939, p = 0.3) with an average savings of $968. Readmissions, complications, and satisfaction were similar for all comparison groups. CONCLUSIONS: FTPs for urgent appendectomies and cholecystectomies can significantly reduce hospital costs by reducing LOS without compromising patient outcomes.

Techniques and cost effectiveness of enteroatmospheric fistula isolation .

UNLABELLED:  Background. The following describes successful isolation of enteroatmospheric fistulae within a negative pressure wound therapy system (V.A.C.®, KCI, San Antonio, TX). METHODS: An impermeable tubular structure was placed around the fistula with a dressing applied to the surrounding wound base, dressed with an impermeable drape and negative pressure, and then an ostomy appliance was placed over the isolated fistula stoma. Cost analysis compared traditional dressings to the NPWT isolation method. RESULTS: All patients underwent fistula isolation with complete diversion of enteric contents. Typical dressing changes occurred 3 times per week. Four patients were discharged from the hospital prior to surgical repair. CONCLUSION: Successful isolation of enteroatmospheric fistulae using a NPWT system has the potential to lower healthcare system costs by allowing for earlier hospital discharge.

Conversion of an enterocutaneous fistula associated with an open abdominal wound into a drain- controlled enterocutaneous fistula.

Open abdominal wounds with enterocutaneous fistulae present health care providers and patients with complex wound management issues. Frequently, large wounds with exposed bowel are present and require the utilization of multiple wound care modalities to provide a method of control and isolation of fistula effluent to allow for maximum wound healing. This case study presents a unique approach to management of low-output enterocutaneous fistula with an open abdominal wound. Through the use of negative pressure wound therapy, a standard surgical drain, and optimized nutrition, fistula drainage was redirected and the abdominal wound healed, leaving a drain-controlled.