Growing use of laparoscopic cholecystectomy in the national Veterans Affairs Surgical Risk Study: effects on volume, patient selection, and selected outcomes.

OBJECTIVE: To study the introduction of laparoscopic cholecystectomy to the 43 tertiary-care university-affiliated Veterans Administration medical centers (VAMCs) participating in the National Veterans Affairs Surgical Risk Study from October 1991 through December 1993. SUMMARY BACKGROUND DATA: Previous studies in the private sector have documented growth in the number of cholecystectomies and falling clinical thresholds for cholecystectomy with the introduction of laparoscopic cholecystectomy. METHODS: The following were analyzed for changes over time: measures of patient preoperative risk, complexity of surgery, severity of biliary disease, numbers of procedures, postoperative length of stay, and 30-day postoperative mortality and general complication rates. RESULTS: The number of cholecystectomies performed laparoscopically increased, but the total number of cholecystectomies performed remained stable over time. The proportion of patients with acute cholecystitis, emergent cholecystectomies, and technically complex cholecystectomies did not change or increased slightly over time. Adjusted odds for postoperative general complications were lower for laparoscopic than for open cholecystectomy, but 30-day postoperative mortality and general complication rates for all cholecystectomies remained constant over time. Postoperative length of stay for all cholecystectomies fell significantly. Implementation rates of laparoscopic cholecystectomy varied widely between hospitals. Laparoscopic cholecystectomy was adopted more slowly and used in a lower percentage of cholecystectomies than in non-VA settings. CONCLUSIONS: In contrast to non-VA studies showing increases in overall cholecystectomy volume since the introduction of laparoscopic cholecystectomy, these VAMCs implemented laparoscopic cholecystectomy without growth in cholecystectomies or a change in the clinical threshold for cholecystectomy. Laparoscopic cholecystectomy was associated with better outcomes, but its introduction in the setting of stable cholecystectomy volume and biliary disease case mix did not change postoperative mortality and complication rates. The stable cholecystectomy volume and biliary disease case mix, slower adoption, and lower use of laparoscopic cholecystectomy contrast with previous reports and may result from differences in patients and organization and financing of VA versus non-VA settings.

The role of laparoscopy in the management of suspected pancreatic and periampullary malignancies.

Laparoscopic evaluation of patients with suspected periampullary malignancies has been utilized more frequently in recent years. Its exact role with regard to staging and surgical bypass for palliation have yet to be clearly defined. To better define the role of laparoscopy in the evaluation and palliation of periampullary malignancy, a retrospective review of the Duke experience was carried out. Fifty-three patients with suspected pancreatic or periampullary malignancies were referred for surgical evaluation at Duke University Medical Center between 1993 and 1995. All patients underwent CT scanning and lesions were classified as resectable or unresectable based on previously established criteria. Patients either underwent laparoscopic evaluation (n = 30; 11 with laparoscopic palliation) or proceeded directly to celiotomy (n = 23). Charts were reviewed for postoperative course including complications, length of stay, and hospital costs. Although laparoscopy had a sensitivity of 93.3% for metastatic disease, CT scans accurately staged 86.8% of patients missing only one patient with peritoneal/hepatic disease. Based on these results, laparoscopy may not be beneficial for every patient with a suspected pancreatic malignancy. Retrospectively an attempt was made to determine which patients benefited from laparoscopy and which patients are best served by proceeding directly to open exploration. From these data we devised an algorithm that outlines an efficient and cost-effective approach for this patient population.

Laparoscopic ventral and incisional hernioplasty.

BACKGROUND: While the first laparoscopic ventral hernia repair was reported in 1992, there have been no studies comparing laparoscopic to conventional ventral herniorrhaphy. METHODS: Twenty-one ventral hernias repaired laparoscopically are compared to a similar group of 16 patients undergoing traditional open repair during a 2-year period. Operative and hospital courses along with outcomes and cost analysis are analyzed. RESULTS: There was no statistical difference between groups in number of previous abdominal operations, prior hernia repairs, and comorbidities. Patients undergoing open repair were older with larger fascial defects. Open repairs had a shorter operative time as compared to the laparoscopic group, but statistically longer postoperative stays and costs. Postoperative complications occurred in 31% of the open group and 23% of the laparoscopic group. There were two recurrences in each group. CONCLUSIONS: Laparoscopic herniorrhaphy is as safe and effective as the traditional open technique with shorter length of stay and decreased hospital costs.

Quality of life after treatment for pancreatitis.

OBJECTIVE: The authors evaluated the morbidity, mortality, and quality of life after pancreatic debridement for necrosis and compared these values to those for quality of life after elective medical and surgical management for chronic pancreatitis. SUMMARY BACKGROUND DATA: Quality of life after pancreatic debridement for necrosis has received little attention. Although quality of life after other pancreatic surgery has been evaluated and is though to be good, management of patients with pancreatic necrosis can be labor intensive and require extraordinary resources. Therefore, further evaluation of the quality of life achieved after treatment is appropriate. METHODS: Forty patients (group 1) underwent operative debridement for necrosis between 1986 and 1994. Medical records of these patients were reviewed for morbidity, mortality, and in-hospital costs. Follow-up of quality of life was assessed by the Short Form-36 Health Survey. Patients in group 2 (n = 89) underwent medical management of chronic pancreatitis. Group 3 included 47 patients who underwent elective operations for ductal abnormalities. The Short Form-36 Health Surveys were administered to all three groups and compared statistically. RESULTS: Mortality and morbidity from pancreatic debridement was 18% and 77%, respectively. Quality-of-life evaluations in groups 1 through 3 and age-matched controls were statistically similar. CONCLUSIONS: Pancreatic debridement for necrosis requires intense application of resources and is associated with a high mortality and morbidity. Long-term follow-up shows good quality of life for patients who survive this morbid disease. This study supports the continued aggressive approach to the management of pancreatic necrosis, given that long-term outcome about quality of life is good.