It's not just an ileus: disparities associated with ileus following ventral hernia repair.

PURPOSE: We sought to identify risk factors associated with postoperative ileus following ventral hernia repair. METHODS: Utilizing the Nationwide Inpatient Sample (NIS) from 2008 to 2012, we identified adult patients that underwent either open or laparoscopic hernia repair for umbilical and ventral hernias with a diagnosis of umbilical/ventral hernia. We excluded cases with diagnosis of obstruction and bowel gangrene that underwent bowel resection, or with missing data. Risk variables of interest were age, sex, race, income status, insurance status, elective admission, comorbidity status (using the validated van Walraven Score), complications (mechanical, respiratory, postoperative infection, cardiovascular, intraoperative), morbid obesity, procedure type, conversion to open, mesh use, hospital type (rural, urban non-teaching, urban teaching), bed size, and region (northeast, midwest, south, west). Univariate analysis comparing patients with ileus vs control was performed. We then performed multivariable analysis using logistic regression, adjusting for all the risk variables, with ileus as the dependent variable. RESULTS: 30,912 patients were identified that met criteria. Of these, 2660 (8.61%) had postoperative ileus during their stay at the hospital. Univariate analysis showed all risk variables were associated with development of ileus with the exception of income status (p = 0.2903), elective admission (p = 0.7989), mesh use (p = 0.3620), and hospital bed size (p = 0.08351). Median length of stay was 7 days in the ileus cohort vs 3 days in control (p < 0.0001). Median total charges (adjusted to 2012 dollars) was $54,819 vs $35,058 (p < 0.0001). We then performed logistic regression adjusting for all risk variables and found that age (OR 1.66, p < 0.0001), male sex (OR 1.51, p < 0.0001), Black race (OR 1.49, p < 0.0001), comorbidity status (OR 1.12, p < 0.0001), laparoscopic cases converted to open (OR 1.55, p < 0.0001), postoperative complications (mechanical: OR 2.32, p < 0.0001, respiratory: OR 1.54, p < 0.0001, postoperative infection: OR 2.12, p < 0.0001, cardiovascular: OR 1.57, p = 0.0006, intraoperative: OR 1.29, p = 0.0200) were independently associated with increased risk of ileus. However, laparoscopic vs open (OR 0.76, p < 0.0001), elective admission (OR 0.91, p = 0.0378), and northeast vs south hospital region (OR 0.74, p < 0.0001) were independently associated with decreased risk of ileus. CONCLUSION: We performed a large observational study looking for risk factors associated with ileus following ventral hernia repair. Race and region of treatment are independent risk factors associated with ileus following ventral hernia repair, and a potential source of disparities in care and increased admission length and higher cost of care. Further prospective studies are warranted.

Obesity and surgical complications of pancreaticoduodenectomy: An observation study utilizing ACS NSQIP.

BACKGROUND: An estimated 38% of US adults are obese. Obesity is associated with socioeconomic disparities and increased rates of comorbidities, and is a known risk factor for development of pancreatic cancer. As a fourth leading cause of death in the United States, pancreatic cancer is commonly treated with a pancreatico-duodenectomy (PD), or Whipple procedure. Data regarding the effects of obesity on post-operative complication rate primarily comes from specialized centers, however the results are mixed. Our aim is to elucidate the effects that obesity has on outcomes after PD for pancreatic head cancer using a national prospectively maintained clinical database. METHOD: The 2010-2015 American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) Participant Use Files (PUF) were used as the data source. We identified cases in which PD was performed (CPT code 48150) in the setting of a postoperative diagnosis of pancreatic cancer (ICD9 code 157.0). We excluded cases that had emergency admissions, BMI ≤18.5 kg/m2, intraoperative wound classification of III or IV, and disseminated cancer. Cases with missing BMI, preoperative albumin, operative time, LOS data were also excluded. Multiple imputation for missing sex, race, functional status, and ASA classification using chained equations was performed.16 Patients that had BMI ≥30 kg/m2 were considered obese, and patients with BMI <30 kg/m2 were used as control. RESULTS: 3484 patients underwent pancreaticoduodenectomy for pancreatic cancer. 860 patients were identified as obese. Propensity score analysis was performed matching age, sex, race, functional status, presence of dyspnea, diabetes, hypertension, acute renal failure, dialysis dependence, ascites, steroid use, bleeding disorders, history of chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), weight loss, American Society of Anesthesiologists (ASA) classification, and preoperative albumin levels. After matching, obese patients had higher risk of 30-day postoperative complications compared to control, including organ space wound infections (OR 1.38, 95% CI 1.07-1.79, p = 0.0128), returning to the operating room (OR 1.39, 95% CI 1.01-1.91, p = 0.0461), failure to extubate for greater than 48 h (OR 1.60, 95% CI 1.09-2.34, p = 0.0153), death (OR 1.68, 95% CI 1.01-2.78, p = 0.0453), septic shock (OR 2.22, 95% CI 1.46-3.38, p = 0.0002), pulmonary embolism (OR 2.42, 95% CI 1.07-5.45, p = 0.0332), renal insufficiency (OR 2.67, 95% CI 1.33-5.38, p = 0.0058). Sensitivity analysis yielded similar results with the exception of risk for return to the operating room, death, and pulmonary embolism, P > .05. CONCLUSION: In this large observational study using a national clinical database, obese patients undergoing PD for head of pancreas cancer had increased risk of postoperative complications and mortality in comparison to controls.

Commentary: quality of care and cost containment are the hospital-based ambulatory surgery challenges for the future.

Cost containment and quality of care represent the most important objectives of all health care professionals. Because of its progressive growth over the past decade, ambulatory surgery has become an area where these 2 issues need to be addressed. The goal of this paper is to discuss the economic and quality of care challenges faced by hospitals as they strive to become competitive in the 21st century. The quality of care in ambulatory surgery has been improving because of multidisciplinary activities. Hospitals tend to hire the staff on the basis of their expertise in certain areas, and those personnel do not have to cover other hospital roles. Moreover, the hospital staff is able to seek information at any time from coworkers in other areas of specialty. Ambulatory surgery in a hospital offers advantages, such as multiple operating rooms, multiple skilled health care providers, and the ability to stay overnight if needed. The consolidation of supplies makes it easier to contract for a better price. Aggressive contract negotiations and implementation of cost-effective and cost-efficient strategies are the keys to success in the future. Quality improvement (QI) initiatives and quality of care (QC) indicators need to be developed to address various problems in the ambulatory surgery setting such as unnecessary admissions, inadequate staffing, efficient operating room (OR) utilization, quality of care, and assessment outcome. These initiatives should be addressed at regular meetings where opportunities to improve the ambulatory services are discussed. The number of ambulatory surgery procedures performed each year will continue to increase, although perhaps not at the rate we experienced in the past. Procedures that once were performed in an inpatient setting can now be accomplished on an outpatient basis or even in the physician's office. We will continue to see this shift of volume as technologic advancements and anesthetic agents allow more complex procedures to be performed on an outpatient basis.

Standardization of surgeon-controlled variables: impact on outcome in patients with acute cholecystitis.

OBJECTIVE: To examine the effect of standardization of surgeon-controlled variables on patient outcome after cholecystectomy for two cohorts of patients with acute cholecystitis (AC). SUMMARY BACKGROUND DATA: Laparoscopic cholecystectomy (LC), when performed efficiently and safely, offers patients with AC a more rapid recovery and decreases the length of stay, thus reducing the health care utilization. Numerous studies have focused on the characteristics of patients with AC that may predict the conversion of LC to open cholecystectomy. However, analysis of these factors offers little insight for improving the outcome of patients with AC, because patient-controlled variables are difficult to influence. In the present study, treatment variables that were under the surgeon's control were standardized and the effects of these changes on the outcome of patients with AC were quantified. METHODS: Beginning in August 1997, a standardized treatment protocol was initiated for patients with suspected AC. LC was initiated as early as practical from the time of admission. All operations were performed in a specially equipped and staffed laparoscopic surgery suite, and all patients were supervised by one of two attending surgeons with a special interest in laparoscopic interventions. Two cohorts of patients with AC were retrospectively analyzed: 39 patients from the 12 months before initiation of this protocol (period 1) and 49 patients from the 12 months after its inception (period 2). Medical records were reviewed for demographic, perioperative, and outcome data. Surgical reports were reviewed to ascertain the reason for conversion and whether laparoscopic technical modifications were used. RESULTS: No significant difference was noted between the groups with regard to patient demographics, clinical presentation, or radiologic or laboratory parameters. After protocol initiation, patients received definitive treatment closer to the time of admission and had a greater percentage of laparoscopically completed cholecystectomies. Furthermore, the patients in period 2 had a significantly decreased postoperative length of stay and hospital charges than the earlier ones. Complications were infrequent and not significantly different between the groups. Two or more laparoscopic technical modifications were used in 95% of the successful LCs during period 2 versus 33.3% during period 1. CONCLUSIONS: By controlling when, where, and by whom LC for AC was performed, the authors have significantly improved the percentage of cholecystectomies that were completed laparoscopically. This has led to improved outcomes and lower hospital charges for patients with AC at this municipal hospital.

Anatomic, age, and sex distribution of colorectal cancer in a New York City Hispanic population.

This study was undertaken to examine the regional distribution of colorectal cancer, the age of presentation for different subsite locations of the disease and whether there is any intersex difference in frequency of the disease, in New York City Hispanics. The charts of Hispanic patients on file with the tumor registry at Bellevue Hospital Center in New York City from 1976 to 1995 were reviewed. Demographic and pathologic data including patient age and cancer location were analyzed. Lesions of the distal colon and rectum accounted for more than 70%, while right-sided lesions were found in 20.7% of patients. The male to female ratio was 47.6% to 52.4%. The overall mean age of patients was 60.4 years. Proximal lesions presented at a later age than distal lesions, 63.2 years for the right colon and 58.5 years for the rectum; this difference in ages was significant. These results suggest that Hispanic-American patients with colorectal cancer appear to be presenting at an earlier age than the general American population. Further study is needed to determine whether Hispanic women are presenting with a higher frequency of colorectal cancer than their male counterparts and whether Hispanic patients are presenting at an earlier age than the general population with colorectal malignancies and why.

Use of artificial intelligence to analyze clinical database reduces workload on surgical house staff.

BACKGROUND: The current quantity and diversity of hospital clinical, laboratory, and pharmacy records have resulted in a glut of information, which can be overwhelming to house staff. This study was performed to measure the impact of artificial intelligence analysis of such data on the junior surgical house staff's workload, time for direct patient care, and quality of life. METHODS: A personal computer was interfaced with the hospital computerized patient data system. Artificial intelligence algorithms were applied to retrieve and condense laboratory values, microbiology reports, and medication orders. Unusual laboratory tests were reported without artificial intelligence filtering. RESULTS: A survey of 23 junior house staff showed a requirement for a total of 30.75 man-hours per day, an average of 184.5 minutes per service twice a day for five surgical services each with an average of 40.7 patients, to manually produce a report in contrast to a total of 3.4 man-hours, an average of 20.5 minutes on the same basis (88.9% reduction, p < 0.001), to computer generate and distribute a similarly useful report. Two thirds of the residents reported an increased ability to perform patient care. CONCLUSIONS: Current medical practice has created an explosion of information, which is a burden for surgical house staff. Artificial intelligence preprocessing of the hospital database information focuses attention, eliminates superfluous data, and significantly reduces surgical house staff clerical work, allowing more time for education, research, and patient care.

Significant trends in the treatment of hepatic trauma. Experience with 411 injuries.

Several significant advances in the treatment of hepatic injuries have evolved over the past decade. These trends have been incorporated into the overall treatment strategy of hepatic injuries and are reflected in experiences with 411 consecutive patients. Two hundred fifty-eight patients (63%) with minor injuries (grades I to II) were treated by simple suture or hemostatic agents with a mortality rate of 6%. One hundred twenty-eight patients (31%) sustained complex hepatic injuries (grades III to V). One hundred seven patients (83.5%) with grades III or IV injury underwent portal triad occlusion and finger fracture of hepatic parenchyma alone. Seventy-three surviving patients (73%) required portal triad occlusion, with ischemia times varying from 10 to 75 minutes (mean, 30 minutes). The mortality rate in this group was 6.5% (seven patients) and was accompanied by a morbidity rate of 15%. Fourteen patients (11%) with grade V injury (retrohepatic cava or hepatic veins) were managed by prolonged protal triad occlusion (mean cross-clamp time, 46 minutes) and extensive finger fracture to the site of injury. In four of these patients an atrial caval shunt was additionally used. Two of these patients survived, whereas six of the 10 patients managed without a shunt survived, for an overall mortality rate of 43%. Over the past 4 years, six patients (4.7%) with ongoing coagulopathies were managed by packing and planned re-exploration, with four patients (67%) surviving and one (25%) developing an intra-abdominal abscess. One additional patient (0.8%) was managed by resectional debridement alone and survived. During the past 5 years, 25 hemodynamically stable and alert adult patients (6%) sustaining blunt trauma were evaluated by computed tomography scan and found to have grade I to III injuries. All were managed nonoperatively with uniform success. The combination of portal triad occlusion (up to 75 minutes), finger fracture technique, and the use of a viable omental pack is a safe, reliable, and effective method of managing complex hepatic injuries (grade III to IV). Juxtahepatic venous injuries continue to carry a prohibitive mortality rate, but nonshunting approaches seem to result in the lowest cumulative mortality rate. Packing and planned reexploration has a definitive life-saving role when used adjunctively in the presence of a coagulopathy. Nonoperative management of select hemodynamically stable adult patients, identified by serial computed tomography scans after sustaining blunt trauma is highly successful (95-97%).

Randomized, prospective comparison of cefoxitin and gentamicin-clindamycin in the treatment of acute colonic diverticulitis.

In a randomized, prospective study, single-drug antibiotic therapy with cefoxitin (CFX) was compared to combination therapy with gentamicin and clindamycin (G/C) as definitive treatment for acute colonic diverticulitis. Excluding individuals requiring immediate operation, 51 patients with a clinical diagnosis of diverticulitis, who were hospitalized at five different medical centers, were randomized to receive CFX (30 patients) or G/C (21 patients). Age, sex, and the severity of diverticulitis were similar in the two groups. The cure rates of 90% and 85.7% observed for CFX and G/C, respectively, did not differ significantly. Leukocytosis resolved in a shorter time period in patients treated with CFX than in those treated with G/C (2.5 +/- 0.4 vs 4.1 +/- 0.6 days, respectively) (P = 0.03, Student's t test, unpaired data). Two cases of possibly antibiotic-related toxicity occurred in the CFX group versus three cases in the G/C group. The average cost of a course of CFX therapy was $417 compared with $488 for G/C. In this study, cefoxitin demonstrated efficacy and tolerability similar to that of gentamicin-clindamycin in the treatment of acute colonic diverticulitis and may be preferred in view of its narrower antimicrobial spectrum and lower cost.

Parotid gland metastasis from renal carcinoma.

The salivary gland most frequently involved with secondary cancer is the parotid gland. Metastases are responsible for 21-42% of malignant parotid tumors. Malignant melanoma and squamous cell cancer are the two most common tumors to metastasize to the parotid gland. Metastatic adenocarcinoma to this site has rarely been reported. Secondary renal cell carcinoma has been reported in many structures, including the brain, sinonasal tract, lungs, abdomen, genitourinary tract, bone, soft tissue, and lymphatics. Histologically proven parotid metastasis has been previously reported in only one patient. Two patients have recently been diagnosed and treated at our institution for this rare disease. The clinical presentation of each patient was quite different. One patient presented with parotid and pulmonary metastases seven years after resection of a renal tumor. Another patient had resection of a parotid mass revealing an occult metastasis from a renal cell carcinoma. Further evaluation revealed a locally extensive asymptomatic hypernephroma. The survival from the time of discovery of the parotid metastasis was 46 months for the former patient, while the latter patient is alive after 20 months. Differentiation of these tumors from vascular disorders (aneurysm or arteriovenous fistula) required selective angiography and computed tomography. Surgical excision via superficial parotidectomy with facial nerve preservation is necessary for palliation, particularly to avoid massive hemorrhage which may occur upon tumor extension into the oropharynx.

Surgical resection for colorectal hepatic metastases.

Hepatic resection of metastatic disease due to primary colorectal cancer provides a relatively safe and reliable method to control this otherwise fatal disease. At New York University 45 hepatic resections have been performed in 42 patients over the last fifteen years. Preoperative screening was performed by liver chemistry and intraoperative exploration in synchronous lesions and by liver chemistry, carcinoembryonic antigen, and computed tomography in metachronous lesions. Careful monitoring of fluid management, glucose utilization, and albumin requirements are essential for low postoperative morbidity and mortality. In major hepatic resections, changes in coagulation profile correlate with normalization of hepatic function as evidenced by decrease in serum bilirubin levels and increase bile production. The incidence of major operative morbidity was 17%; operative mortality was 4%. Hepatic resection gives the greatest possibility of extended survival, in our patients providing a 22% crude five year survival rate and a mean duration of survival of 33 months.

Experience with selective operative and nonoperative treatment of splenic injuries in 193 patients.

During the past decade splenic salvage procedures rather than splenectomy have been considered the preferred treatment for traumatic splenic injuries. Splenic preservation has been most often accomplished by splenorrhaphy and more recently by a controversial nonoperative approach. This report delineates indications, contraindications, and results with splenectomy, splenorrhaphy, and nonoperative treatment based on an 11-year experience (1978 to 1989) in which 193 consecutive adult patients with splenic injuries were treated. One hundred sixty-seven patients (86.5%) underwent urgent operation. Of these, 111 (66%) were treated by splenorrhaphy or partial splenectomy and 56 (34%) were treated by splenectomy. During the last 4 years, 26 additional patients (13.5%) were managed without operation. Patients considered for nonoperative treatment were alert, hemodynamically stable with computed tomographic evidence of isolated grades I to III splenic injuries. Overall 24% of the injuries resulted from penetrating trauma, whereas 76% of the patients sustained blunt injuries. Complications were rare, with two patients in the splenorrhaphy group experiencing re-bleeding (1.8%) and one patient (4%) failing nonoperative treatment. The mortality rate for the entire group was 4%. This report documents that splenorrhaphy can safely be performed in 65% to 75% of splenic injuries. Splenectomy is indicated for more extensive injuries or when patients are hemodynamically unstable in the presence of life-threatening injuries. Nonoperative therapy can be accomplished safely in a small select group (15% to 20%), with a success rate of nearly 90% if strict criteria for selection are met.

Abdominal mycobacterial infections in immunocompromised patients.

A review of the discharge diagnoses and mycobacterial cultures of patients admitted to a major New York City hospital over an 18-month period revealed 21 patients with abdominal mycobacterial infections (17 male, 4 female) with an average age of 36 years. Acquired immunodeficiency syndrome (AIDS) or an identifiable AIDS risk was present in 14. The disease was manifest by peritoneal (eight patients), ileocecal (seven), and hepatic involvement (three), and psoas abscess (three). Diffuse abdominal pain was the most frequent presenting symptom. However, absence of pain (19 percent) and lack of abdominal findings (28 percent) were not uncommon. The erythrocyte sedimentation rate was significantly elevated (mean 72 mm/hour), whereas the white blood cell count was normal in 18 patients. Computed tomography findings were abnormal in all patients studied and suggested mycobacterial infection in 67 percent. Ten patients (48 percent) required surgery. Although there were no individual differences in clinical or laboratory presentation between the operative and nonoperative patient groups, more patients with pain and higher fever were operated upon. There was one postoperative death. The overall mortality rate was 24 percent, and the mean survival and follow-up 10.2 months and 12.2 months, respectively.

Giant renal cell carcinoma: CT and MR characteristics.

A case of an unusually large cystic renal cell carcinoma demonstrated on plain film, CT, and magnetic resonance (MR) is presented. Though the origin of huge abdominal tumors can be difficult to determine, the CT and MR findings were able to correctly diagnose the mass as a malignant cystic kidney tumor.

Factors involved in antibiotic selection in elective colon and rectal surgery.

During a 24-month period, 350 patients were prospectively studied in an effort to determine the perioperative factors in the development of infections after colon and rectal resections. All patients received standard mechanical bowel preparation; perioperative parenteral cefoxitin (group A) or preoperative oral neomycin and erythromycin, in addition to perioperative cefoxitin (Group B), were also given. Both groups were comparable with respect to age, sex, associated diseases, and primary diagnosis. Wound infections developed in nine of 169 (5%) group B patients and in 15 of 141 (11%) group A patients. Stratification by type of operative procedure revealed that the rectal resections involved the highest rate of infection in group A (22%) and in group B (11%). In patients requiring intraperitoneal colon resection, the rates of wound sepsis were similar (3% in both groups). Analysis of length of operation revealed that in operations lasting 215 minutes or more the infection rate was 12%; in those lasting less than 215 minutes the rate was 4%. Patients with rectal resection and operative times of 215 minutes or more had a wound infection rate of 19% compared to 2% (p less than 0.05) in those with shorter nonrectal operations. Group B patients with the longer rectal operations had lower infection rates (11%) than group A patients (27%), while there was no difference among those who had shorter operations. Intra-abdominal abscesses (p less than 0.01) and anastomotic dehiscence (p less than 0.05) were also significantly reduced in group B patients. Postoperative wound infection is associated with length of operation and location of colon resection and can be significantly lowered by a combination of oral and parenteral antibiotics.

Improved results from a standardized approach in treating patients with necrotizing fasciitis.

Necrotizing fasciitis has been associated with significant morbidity and mortality. Thirty-three patients were studied over a 3-year period. Predisposing factors included intravenous drug abuse (30%), diabetes (21%), and obesity (18%). Severe pain (94%) and abnormal temperature (88%) were present, whereas laboratory data and x-ray were nonspecific. Gram-positive organisms were most frequently recovered (B-hemolytic streptococcus 45%). Treatment consisted of antibiotics, surgical debridement, re-exploration 24 hours before surgery, nutritional support, and early soft tissue coverage as needed. Mean duration from admission to operation was 43 hours. The average number of operative debridements was three and the average length of hospitalization was 47 days. Patients operated on less than 12 hours from admission or greater than 48 hours had shorter hospital stays (36 and 38 days). The critical time period was 12-48 hours after admission; all deaths and amputations were in this group and the average hospital stay was 62 days (p less than 0.05). The number of operations did not correlate to hospital stay. Despite antibiotics and aggressive debridement, significant morbidity exists if operation is delayed more than 12 hours. Methods of early detection such as local bedside diagnostic incision and fascial inspection may be needed in high risk patients to further reduce the morbidity and mortality.

The management of juxtahepatic venous injuries without an atriocaval shunt: preliminary clinical observations.

Juxtahepatic venous injuries are usually fatal. The optimal method of dealing with these injuries remains controversial, but most experience has been with the insertion of an atriocaval shunt. However, the mortality rate with atriocaval shunting remains prohibitively high (60% to 100%). The experience at the Bellevue Hospital Trauma and Shock Unit during a 9-year period revealed a 50% mortality rate in four consecutive patients who underwent atriocaval shunting. As such, a different approach was used in the following five patients, all of whom survived. One additional patient died in the operating room before any definitive repair could be undertaken. Four steps are considered essential to the successful management of these patients: (1) compression of the injury site until adequate resuscitation has been achieved; (2) early recognition that a juxtahepatic venous injury exists, as indicated by failure of the Pringle maneuver to adequately arrest hemorrhage; (3) prolonged portal triad occlusion with hepatocyte protection by means of large doses of steroids and topical hypothermia (portal triad occlusion time in the nonshunted group ranged from 20 to 64 minutes with a mean occlusion time of 46 minutes; although a transient rise in liver function test results seemed to correlate with the length of ischemia time, neither hepatic dysfunction nor hepatic necrosis occurred; and (4) extensive finger fracture of the liver to the site of vascular injury for primary repair or ligation; the extent of the finger fracture varied from 15 to 30 cm in length and from 5 to 15 cm in depth. The successful results achieved in five consecutive patients who sustained juxtahepatic venous injuries treated without a shunt serve as a basis for recommending this operative approach.

Antimicrobial therapy in abdominal surgery: factors to consider in antibiotic selection.

Infection continues to be the cause of significant morbidity and mortality in abdominal surgery patients, despite recent advances in antimicrobial prophylaxis and therapy. Cost analyses reveal that billions of additional dollars are spent on these patients, making this an area of particular concern to P & T Committees. To determine precise antibiotic usage, risk factors are classified by individual operative procedure rather than by general groups, and factors such as the patient's immune status are also considered. Guidelines concerning antibiotic usage must be based not only on pharmacologic information, but also on clinical information determined in prospective randomized trials.

Hepatic resection for metastatic colon and rectal cancer. An evaluation of preoperative and postoperative factors.

Hepatic resection for metastatic colorectal cancer has been reported in over 700 patients. However, approximately 5000 patients each year are candidates for surgical excision. Since 1972, 25 patients have undergone hepatic resection for colorectal metastases at New York University. Potentially curable synchronous lesions were detected by preoperative liver chemistries and operative palpation. Patients were screened for metachronous lesions by serial liver chemistries and carcinoembryonic antigen (CEA) determinations; when clinical findings or laboratory findings were either positive or equivocal, then scanning techniques were used. Most patients had solitary lesions (20). Thirteen of 25 lesions were synchronous; 12 were metachronous. Anatomic lobectomy was performed in 13 patients (6 extended resections); and wedge resection was performed in 12. The operative mortality rate was four per cent; the 2-year survival rate, 65%; the 5-year survival rate, 25%. Hypertonic dextrose solutions were administered during and after operation. Post-operative albumin requirements ranged from 200 to 300 grams/day. Coagulation factors II, V, VII, and fibrinogen decreased after surgery to 30 to 50% of their preoperative levels. Subsequent elevation of these factors correlated with increased bile production and improvement in liver chemistries 10 to 14 days after operation. At present, hepatic resection for colorectal metastases provides the only potential method of salvage, offering a 20 to 25% long-term survival rate.

Management of penetrating wounds of the back and flank.

The results of a retrospective and prospective study of patients with penetrating wounds of the back and flank showed that physical examination alone was accurate in 72 and 83 per cent, respectively. The inaccuracy was primarily due to false-negative examinations. The most commonly injured organs were the liver and kidney. The presence of gross hematuria and intravenous pyelography proved to have an accuracy rate of 95 per cent in patients studied prospectively. Peritoneal lavage, although similarly accurate (95 per cent), was associated with a 10 per cent false-negative result when the wound was located in the back. Guidelines for the management of these patients include hospital admission, careful physical examination, urinalysis by dipstick and cell count, intravenous pyelography and peritoneal lavage. Initial hypotension usually is associated with visceral injury and is an indication for exploratory laparotomy. Strict adherence to these guidelines was associated with a negative exploration rate of less than 10 per cent and a decrease in the number of patients observed with visceral injury from 50 to 6 per cent.

Surgical management of diffuse cavernous hemangioma of the colon, rectum and anus.

Operative approaches which attempt to spare the rectal sphincter mechanism in patients with diffuse cavernous hemangioma of the sigmoid colon, rectum and anal canal have associated high morbidity and have failed to provide continence in at least 2 per cent of the patients. Sphincter-saving operations should be reserved for the rarer lesions which spares the lower part of the rectum and anal canal. Abdominoperineal resection by the combined synchronous approach with temporary vascular control of the hypogastric vessels provides a safe effective method of managing patients with diffuse cavernous hemangioma of the sigmoid colon, rectum and anus.