Systematic review of long-term effectiveness of endoscopic gastrojejunostomy in patients presenting with gastric outlet obstruction from periampullary malignancies.

BACKGROUND: Recently, endoscopic ultrasound-guided (EUS) gastrojejunostomy (GJ) has emerged as an alternative option to surgical palliation and endoscopic duodenal stenting for malignant gastric outlet obstruction (GOO). Although early success rates are commonly reported with the technique, there is a paucity of data regarding the long-term efficacy of this approach. In this study, we investigated long-term outcomes in patients that underwent EUS-guided GJ for palliation of periampullary malignancies. METHODS: From a total of 192 studies that were reviewed, 6 studies with a follow-up time frame of a minimum of 5 months were analyzed, totaling 238 patients. Outcome variables included technical success rate, clinical success rate, adverse events, symptom recurrence, and re-intervention rates. RESULTS: The cohort of 238 patients had a technical success rate of 93.7% and a clinical success rate of 92.9%. A total of 25 patients (10.5%) experienced adverse events associated with EUS-GJ. A total of 14 patients (5.9%) experienced recurrence of GOO symptoms within 5 months. A total of 14 patients (5.9%) underwent re-intervention with the first 5 months. CONCLUSIONS: This systematic review shows that data are scarce regarding long-term effectiveness of EUS-guided GJ. Even though early success rates have been reported, further studies are needed to focus on long-term efficacy of this approach. Until such studies become available, surgical palliation should continue to be the treatment of choice for patients with malignant GOO with a prolonged life expectancy.

Benefits of EUS-guided gastroenterostomy over surgical gastrojejunostomy in the palliation of malignant gastric outlet obstruction: a large multicenter experience.

BACKGROUND AND AIMS: Palliation of malignant gastric outlet obstruction (mGOO) allows resumption of peroral intake. Although surgical gastrojejunostomy (SGJ) provides durable relief, it may be associated with a higher morbidity, interfere with chemotherapy, and require an optimum nutritional status. EUS-guided gastroenterostomy (EUS-GE) has emerged as a minimally invasive alternative. We aimed to conduct the largest comparative series to date between EUS-GE and SGJ for mGOO. METHODS: This multicenter retrospective study included consecutive patients undergoing SGJ or EUS-GE at 6 centers. Primary outcomes included time to resumption of oral intake, length of stay (LOS), and mortality. Secondary outcomes included technical and clinical success, reintervention rates, adverse events (AEs), and resumption of chemotherapy. RESULTS: A total of 310 patients were included (EUS-GE, n = 187; SGJ, n = 123). EUS-GE exhibited significantly lower time to resumption of oral intake (1.40 vs 4.06 days, P < .001), at lower albumin levels (2.95 vs 3.33 g/dL, P < .001), and a shorter LOS (5.31 vs 8.54 days, P < .001) compared with SGJ; there was no difference in mortality (48.1% vs 50.4%, P = .78). Technical (97.9% and 100%) and clinical (94.1% vs 94.3%) success was similar in the EUS-GE and SGJ groups, respectively. EUS-GE had lower rates of AEs (13.4% vs 33.3%, P < .001) but higher reintervention rates (15.5% vs 1.63%, P < .001). EUS-GE patients exhibited significantly lower interval time to resumption of chemotherapy (16.6 vs 37.8 days, P < .001). Outcomes between the EUS-GE and laparoscopic (n = 46) surgical approach showed that EUS-GE had shorter interval time to initiation/resumption of oral intake (3.49 vs 1.46 days, P < .001), decreased LOS (9 vs 5.31 days, P < .001), and a lower rate of AEs (11.9% vs 17.9%, P = .003). CONCLUSIONS: This is the largest study to date showing that EUS-GE can be performed among nutritionally deficient patients without affecting the technical and clinical success compared with SGJ. EUS-GE is associated with fewer AEs while allowing earlier resumption of diet and chemotherapy.

Comparison between transpapillary versus transmural endoscopic ultrasound-guided decompression for biliary obstruction: a meta-analysis.

BACKGROUND: Recent advances have led to the development of transmural endoscopic ultrasound guided biliary drainage (EUS-BD) for cases where the duodenal papilla cannot be accessed. OBJECTIVES: We performed a meta-analysis comparing efficacy and complications of both approaches for biliary drainage. REVIEW METHODS: English articles were searched in PubMed. Primary outcomes included technical success and complications. Secondary outcomes were clinical success and subsequent stent malfunction. Patient demographics and etiology of obstruction were collected and relative risk ratios and 95% CIs were calculated. P-value <0.05 was considered as statistically significant. RESULTS: Initial database search yielded 245 studies from which 7 were chosen based upon inclusion criteria for final analysis. There was no statistically different relative risk for technical success when comparing primary EUS-BD to endoscopic retrograde cholangiopancreatography (ERCP) (RR: 1.04) or overall procedural complication rate (RR 1.39). EUS-BD did have increased specific risk of cholangitis (RR: 3.01). Likewise, primary EUS-BD and ERCP had similar RR for clinical success (RR: 1.02) and overall stent malfunction (RR: 1.55), but stent migration was higher in the primary EUS-BD group (RR: 5.06). CONCLUSIONS: Primary EUS-BD may be considered when the ampulla cannot be accessed, when there is gastric outlet obstruction, or presence of a duodenal stent.

Vagotomy/drainage is superior to local oversew in patients who require emergency surgery for bleeding peptic ulcers.

OBJECTIVE: To compare early postoperative outcomes of patients undergoing different types of emergency procedures for bleeding or perforated gastroduodenal ulcers. BACKGROUND: Although definitive acid-reducing procedures are being used less frequently during emergency ulcer surgery, there is little published data to support this change in practice. METHODS: A retrospective analysis of data for patients from the 2005-2011 American College of Surgeons National Surgical Quality Improvement Program database who underwent emergency operation for bleeding or perforated peptic ulcer disease was performed to determine the association between surgical approach (local procedure alone, vagotomy/drainage, or vagotomy/gastric resection) and 30-day postoperative outcomes. Multivariable regression analysis was used to adjust for a number of patient-related factors. RESULTS: A total of 3611 patients undergoing emergency ulcer surgery (775 for bleeding, 2374 for perforation) were included for data analysis. Compared with patients undergoing local procedures alone, vagotomy/gastric resection was associated with significantly greater postoperative morbidity when performed for either ulcer perforation or bleeding. For patients with perforated ulcers, vagotomy/drainage produced similar outcomes as local procedures but required a significantly greater length of postoperative hospitalization. Conversely, vagotomy/drainage was associated with a significantly lower postoperative mortality rate than local ulcer oversew when performed for bleeding ulcers. CONCLUSIONS: Simple repair is the procedure of choice for patients requiring emergency surgery for perforated peptic ulcer disease. For patients requiring emergency operation for intractable ulcer bleeding, vagotomy/drainage is associated with lower postoperative mortality than with simple ulcer oversew.

Functional status determines postoperative outcomes in elderly patients undergoing hepatic resections.

BACKGROUND: With the aging population and increasing incidence of hepatic malignancies in elderly patients, establishing the safety of hepatic resections is crucial. The present study investigates early postoperative morbidity and mortality in elderly patients undergoing hepatic resection using a nationally validated database. METHODS: The National Surgical Quality Improvement Program Participant User Files (NSQIP-PUF) for 2005-2009 were used for the retrospective analysis of all patients undergoing hepatic resection. The primary outcome measures were 30-day postoperative mortality, overall complication rate, and serious complication rate. The primary predictor variable was patient age, which was treated as a dichotomous variable (age ≤ 70 years, age ≥ 70 years). RESULTS: Five thousand seven hundred six patients were included in the final analysis, 1,280 of which were ≥ 70 years of age. Thirty-day postoperative mortality (≤ 70 years 1.9% vs. ≥ 70 years 4.5%, P < 0.0001), serious complications (≤ 70 years 15.2% vs. ≥ 70 years 18.4%, P < 0.006) and overall complications (≤ 70 years 23.1% vs. ≥ 70 years 26.6%, P < 0.01) were more common in the elderly group. Elderly patients had significantly more wound infections, pneumonia, prolonged ventilator support, unplanned re-intubations, renal failure, strokes, myocardial infarction, cardiac arrests, and septic shock. The median length of hospitalization was also significantly longer in the elderly. CONCLUSIONS: This study shows significantly higher complication rates and mortality following hepatic resections in elderly patients. These findings should be taken into account when considering hepatectomy in this population.

Initial experience from a large referral center with robotic-assisted Ivor Lewis esophagogastrectomy for oncologic purposes.

BACKGROUND: We report our initial experience of patients undergoing robotic-assisted Ivor Lewis esophagogastrectomy (RAIL) for oncologic purposes at a large-referral center. METHODS: A retrospective review of all consecutive patients undergoing RAIL from 2010-2011 was performed. Basic demographics were recorded. Oncologic variables recorded included: tumor type, location, postoperative tumor margins, and nodal harvest. Immediate 30-day postoperative complications also were analyzed. RESULTS: Fifty patients underwent RAIL with median age of 66 (range 42-82) years. The mean body mass index was 28.6 ± 0.7 kg/m(2); 54% and the majority had an American Society of Anesthesiologists classification of 3. The mean and median number of lymph nodes retrieved during surgery was 20 ± 1.4 and 18.5 respectively. R0 resections were achieved in all patients. Postoperative complications occurred in 14 (28%) patients, including atrial fibrillation in 5 (10%), pneumonia in 5 (10%), anastomotic leak in 1 (2%), conduit staple line leak in 1 (2%), and chyle leak in 2 (4%). The median ICU stay and length of hospitalization (LOH) were 2 and 9 days respectively. Total mean operating time calculated from time of skin incision to wound closure was 445 ± 85 minutes; however, operative times decreased over time. Similarly, there was a trend toward lower complications after the first 29 cases but this did not reach statistical significance. There were no in-hospital mortalities. CONCLUSIONS: We demonstrated that RAIL for esophageal cancer can be performed safely and may be associated with fewer complications after a learning curve, shorter ICU stay, and LOH.

A comparison between patients with gastrointestinal stromal tumours diagnosed with isolated liver metastases and liver metastases plus sarcomatosis.

OBJECTIVES: This study was conducted to compare overall survival (OS) in patients presenting with isolated hepatic metastases with that of patients with synchronous metastatic disease to the liver and sarcomatosis on a background of gastrointestinal stromal tumours (GISTs). METHODS: Patients presenting with metastatic GISTs during 1999-2009 were identified. Survival outcomes were compared between groups. RESULTS: Of the 193 patients with GISTs, 43 patients presented with isolated hepatic metastases and 16 presented with synchronous metastases to the liver and sarcomatosis. Thirteen patients with metastases to the liver and sarcomatosis underwent surgery, and 34 patients with metastatic disease solely to the liver underwent hepatic resection. The proportion of patients treated with preoperative tyrosine kinase inhibitor (TKI) therapy was similar in both groups. Similar OS was observed in both groups (isolated liver metastases group: 40.5 months; liver metastases and sarcomatosis group: 28.7 months; P = 0.620). CONCLUSIONS: Overall survival in patients with GIST and metastatic disease to the liver and sarcomatosis is similar to that in patients with isolated metastatic liver disease. Although patients with a greater disease burden might be expected to show worse survival, these data do not reflect this assumption.

Ex vivo evaluation of preoperatively treated rectal cancer specimens of patients undergoing radical resection.

BACKGROUND: Previous reports have suggested that a subset of patients with advanced rectal cancer that demonstrate minimal or no residual disease after neoadjuvant treatment may either be followed closely or may undergo local resection. We prospectively evaluated ex vivo local excision specimens of patients undergoing radical resection after preoperative chemoradiation. METHODS: Patients with newly diagnosed rectal cancer received preoperative chemoradiotherapy followed by total mesorectal excision. Once removed, an ex vivo excision of the tumor bed mimicking a local excision was performed on the back table. Both the ex vivo and mesorectal specimens were inked and assessed. RESULTS: Thirty-seven rectal cancer patients (38% stage II, 62% stage III) were prospectively enrolled onto this study. Tumor downstaging occurred in 35% and nodal status downstaging in 16% of patients. The margins around the primary tumor on all ex vivo local excision specimens were negative. Twenty-nine percent of preoperatively staged stage II cancers either remained at stage II or were upstaged to stage III (21%), while 52% of stage III tumors remained node positive at final pathologic examination. The overall complete response rate was 14%. CONCLUSIONS: A significant number of stage II cancers will have positive nodes at final pathology, and most stage III rectal cancers will remain so at final pathologic examination. Given the high percentage of patients with positive lymph nodes after chemoradiation, radical resection is still recommended for cure for stage II and III rectal cancers.

The impact of vascular resection on early postoperative outcomes after pancreaticoduodenectomy: an analysis of the American College of Surgeons National Surgical Quality Improvement Program database.

BACKGROUND: Several single-center reports suggest that vascular resection (VR) during pancreaticoduodenectomy (PD) for patients with pancreatic adenocarcinoma is feasible without affecting early postoperative mortality or morbidity. Our objective is to review the outcomes associated with VR during PD using a large multicenter data source. METHODS: A retrospective cohort analysis was performed using the National Surgical Quality Improvement Program Participant User Files for 2005-2009. All patients undergoing PD for a postoperative diagnosis of malignant neoplasm of the pancreas were included. Forward stepwise multivariate regression analysis was used to determine the association between VR during PD and 30-day postoperative mortality and morbidity after adjustment for patient demographics and comorbidities. RESULTS: 3,582 patients were included for analysis, 281 (7.8 %) of whom underwent VR during PD. VR during PD was associated with significantly greater risk-adjusted 30-day postoperative mortality [5.7 % with VR versus 2.9 % without VR, adjusted odds ratio (AOR) 2.1, 95 % confidence interval (CI) 1.22-3.73, P = 0.008] and overall morbidity (39.9 % with VR versus 33.3 % without VR, AOR 1.36, 95 % CI 1.05-1.75, P = 0.02). There was no significant difference in risk-adjusted postoperative mortality or morbidity between those patients undergoing VR by the primary surgical team versus those patients undergoing VR by a vascular surgical team. CONCLUSIONS: Contrary to the findings of several previously published single-center analyses, the current study demonstrates increased 30-day postoperative morbidity and mortality in PD with VR when compared with PD alone.

Clinical and Financial Implications of Consulting Physicians in the Management of Surgical Patients.

BACKGROUND: The present study was designed to evaluate the immediate consequences that the number of consulting physicians has on length of stay (LOS), in-hospital mortality, 30-day readmission rates, direct health care costs, and contribution margins. METHODS: A retrospective review of administrative databases for the years 2013 and 2014 was performed at the Florida Hospital Adventist Healthcare System. RESULTS: 11 274 patients were included in the analysis. Total and variable costs increased by $1347 and $592, respectively, with each consulting physician service per patient. The contribution margin decreased by $354 per patient/consulting physician. Each consulting physician increased LOS by .72 days and increased odds ratio of mortality and 30-day readmission by 5% and 3%, respectively. CONCLUSIONS: Our research suggests that each consulting physician added to the care of an individual surgical patient negatively affected LOS, readmission rates, in-hospital mortality, and costs.

Pre- and intraoperative variables affecting early outcomes in elderly patients undergoing pancreaticoduodenectomy.

BACKGROUND: Conflicting data exist regarding the safety of pancreatic resections in elderly patients. In this study we compared early complication and mortality rates between patients younger and older than 80 years of age who underwent pancreaticoduodenectomy using a validated national database. METHODS: The National Surgical Quality Improvement Program (NSQIP) database for 2005-2009 was used for this retrospective analysis. The primary outcome measures for our analysis were 30-day postoperative mortality, major complication rate and overall complication rate. RESULTS: A total of 6293 patients who underwent PD for any cause were included in the analysis. Of these, 9.4% were aged ≥80 years. The incidence of 30-day mortality was significantly higher in patients aged ≥80 years (6.3%) than in those aged <80 years (2.7%). Older patients were also noted to have higher rates of overall complications and serious complications. On multivariate analysis, age, ASA (American Society of Anesthesiologists) classification, reduced functional status, history of dyspnoea, and need for intraoperative transfusion were risk factors associated with the occurrence of overall complications, serious complications and postoperative mortality. CONCLUSIONS: This study shows that age among other factors is a determinant of postoperative morbidity and mortality following PD.

Laparoscopic Heller myotomy using hook electrocautery: a safe, simple, and inexpensive alternative.

BACKGROUND: Laparoscopic Heller myotomy (LHM) currently is considered the standard surgical therapy for achalasia. Historically, LHM has been associated with an intraoperative esophageal perforation rate of 5% to 10%. Recent literature has suggested that robotically assisted Heller myotomy is safer due to a reported lower incidence of intraoperative esophageal perforation than with conventional techniques. This study evaluated the results of LHM in a large series using simple hook electrocautery. METHODS: All patients undergoing LHM with Dor fundoplication (LHMDF) for achalasia by a single surgeon (A.D.P.) from 2003 through 2006 were reviewed retrospectively at a multicenter academic institution. Demographic, perioperative, and follow-up data were collected. RESULTS: A total of 54 patients (52% female and 48% male) underwent LHMDF for the treatment of achalasia. The average age of these patients was 50 years, although 6 patients were younger than 18 years. The average body mass index (BMI) was 26.7, although four patients had a BMI exceeding 35. The average operative time was 113 min, and the estimated blood loss was 23 ml. The average length of hospital stay was 34 h. Only one patient (1.9%) underwent conversion to an open procedure, because of inadequate exposure attributed to an enlarged liver. One intraoperative esophageal perforation (1.9%) occurred in the series, which was sutured during the original operation without sequelae. Preoperatively, Botox injection therapy was administered for 24% of the patients and endoscopic dilation for 43%. Despite evidence that preoperative Botox increases the risk of esophageal perforation, this was not demonstrated in the patient population of this study. No postoperative leaks occurred, and only 3.7% of the patients had persistent dysphagia during an average follow-up period of 5 months. CONCLUSIONS: According to the findings, LHMDF using simple hook electrocautery is safe, inexpensive, and effective for the treatment of achalasia. The current series demonstrates that with meticulous surgical technique, intraoperative esophageal perforation is a rare event with this procedure. Hook electrocautery provides safety comparable with that of robotically assisted Heller myotomy, avoiding the added expense and operative time of a robotic system.

Evaluation of peri-operative chemotherapy using a prognostic nomogram for survival after resection of colorectal liver metastases.

INTRODUCTION: Nomograms are statistical tools designed to predict outcomes. This study evaluates the effects of peri-operative chemotherapy on the accuracy of a prognostic nomogram for disease-specific survival (DSS) after resection of colorectal liver metastases (CRLM) established at Memorial-Sloan Kettering Cancer Center (MSKCC). METHODS: An external cohort of 203 patients who underwent resection of CRLM between 1996 and 2006 was used to assess the nomogram. RESULTS: After median follow-up of 30.4 months (range 0.33-150), Kaplan-Meier (KM) estimates for 3-, 5- and 8-year post-resection DSS were 56%, 41%, and 32%, respectively; similar to nomogram-predicted probabilities for DSS. The concordance index for the nomogram was higher (0.602) than for the Fong colorectal risk score (CRS; 0.533). KM DSS was longer for patients (n= 50) treated with at least 6 months of peri-operative irinotecan or oxaliplatin compared with all other patients (median 66 vs. 40 months, P= 0.06). KM DSS was greater than nomogram predicted DSS for treated patients and less than nomogram predicted DSS for all other patients. CONCLUSIONS: The CRLM nomogram was validated by an external cohort and more accurately predicted post-resection survival than the commonly used CRS. Differences in observed and nomogram-predicted survival may reflect the effect of treatment factors, such as peri-operative chemotherapy.

Early experience with the Senhance®-laparoscopic/robotic platform in the US.

The introduction of new robotic platforms will grow considerably in the near future as several manufacturers are in the developing stages of different innovative systems. One of the newest systems, the Senhance® platform (TransEnterix Surgical Inc., Morrisville, NC, USA) has been utilized in a variety of cases in Europe but only recently approved for limited clinical use in the United States. Here, we present our initial experience with this state-of-the-art system in patients requiring a variety of procedures.

Age as a prognostic indicator for adjuvant therapy in patients who underwent pancreatic resections for cancer.

PURPOSE: In pancreatic cancer, the greatest increase in survival is attained by surgical resection followed by adjuvant chemotherapy. Although surgical complications and functional status are recognized as independent factors for halting adjuvant therapy in patients that undergo pancreatic resections, other elements may play a role in deciding which patients get treated postoperatively. Here we determined demographic and clinical characteristics of patients receiving adjuvant chemotherapy, with the primary intent to investigate if age alone affects rates of adjuvant therapy. METHODS/MATERIALS: National Cancer Database (NCDB) was queried for patients that underwent surgery for pancreatic cancer. Groups were divided into: adjuvant chemotherapy (n=17,924) and no adjuvant chemotherapy (n=12,947). Basic demographics and treatment characteristics were analyzed. Age was compared with an independent means test; other comparisons used Chi-square test of independence. RESULTS: There was a statistical difference in age (adjuvant therapy 64.86±9.89 vs. no therapy 67.78±11.22, p<0.001), insurance type, facility type, and cancer stage for patients that received adjuvant therapy and those that did not. Average age of patients not receiving chemotherapy was significantly older at each pathologic stage. Subset analysis of patients treated with chemotherapy showed that the majority of patients received single agent regimens (62%), at an average of 59days following surgery, and at academic cancer programs (52%). CONCLUSIONS: Regardless of postoperative complications and functional status, age alone appears to affect rates of adjuvant therapy in patients with resected pancreatic cancer. Older patients should be offered tailored regimens that would allow them to complete the intended extent of treatment.

T1R2 receptor-mediated glucose sensing in the upper intestine potentiates glucose absorption through activation of local regulatory pathways.

OBJECTIVE: Beyond the taste buds, sweet taste receptors (STRs; T1R2/T1R3) are also expressed on enteroendocrine cells, where they regulate gut peptide secretion but their regulatory function within the intestine is largely unknown. METHODS: Using T1R2-knock out (KO) mice we evaluated the role of STRs in the regulation of glucose absorption in vivo and in intact intestinal preparations ex vivo. RESULTS: STR signaling enhances the rate of intestinal glucose absorption specifically in response to the ingestion of a glucose-rich meal. These effects were mediated specifically by the regulation of GLUT2 transporter trafficking to the apical membrane of enterocytes. GLUT2 translocation and glucose transport was dependent and specific to glucagon-like peptide 2 (GLP-2) secretion and subsequent intestinal neuronal activation. Finally, high-sucrose feeding in wild-type mice induced rapid downregulation of STRs in the gut, leading to reduced glucose absorption. CONCLUSIONS: Our studies demonstrate that STRs have evolved to modulate glucose absorption via the regulation of its transport and to prevent the development of exacerbated hyperglycemia due to the ingestion of high levels of sugars.

Functional evaluation of the grafted wall with porcine-derived small intestinal submucosa (SIS) to a stomach defect in rats.

BACKGROUND: Small intestinal submucosa (SIS) represents a novel bio-scaffolding material that may be used to repair hollow-organ defects. However, it is unclear whether neurophysiologic responses return to SIS-grafted areas in the gut. We evaluated the functional recovery of a stomach defect grafted with the porcine-derived SIS. METHODS: Twelve rats had a full-thickness defect created in the stomach. SIS was secured to the gastric wall. After 6 months, muscle strips were harvested from within the grafted area to perform both a histologic and a functional study. Additional full-thickness muscle strips were harvested from the posterior in the same stomach as controls. A dose response curve was obtained with carbachol (CCH) or sodium nitroprusside (SNP). Activation of intrinsic nerves was achieved by electrical field stimulation (EFS). RESULTS: The response to CCH and amplitude in EFS showed tonic contraction in both controls and SIS strips in a concentration-dependent and frequency-dependent manner. The magnitude after each stimulation was significantly lower in SIS strips compared with controls (P < .01). However, the contraction ratio of EFS to ED(50) of CCH was not significantly different between the groups. Additionally, SNP produced relaxation in both strips in a concentration-dependent manner. Histologic findings revealed that an insufficient amount of smooth-muscle cells existed in the muscularis propria, whereas compensated growth was observed in the submucosa with nerve regeneration. CONCLUSIONS: This study demonstrates that SIS provides a template for nerve migration to the graft in the rodent stomach. Innervations showed a similar distribution to that observed in the controls. The clinical implications of such findings warrant additional investigation.

New developments in surgery: Natural Orifice Transluminal Endoscopic Surgery (NOTES).

Natural orifice transluminal endoscopic surgery refers to the method of accessing the abdominal cavity through a natural orifice under endoscopic visualization. Since its introduction in 2004, numerous reports have been published describing different surgical interventions. Recently, a group of expert laparoscopic surgeons and endoscopists outlined the limitations of this approach and issued recommendations for progress toward human trials. Herein we review the published data and propose a series of questions to be considered for future investigations. We also address the controversy involved in the incorporation of this new technology into surgical practice.

A description of the preterm fetal sheep systemic and central responses to maternal general anesthesia.

BACKGROUND: The second trimester is recommended as the optimal time to conduct a surgical procedure on pregnant patients, even though the fetal responses to anesthesia at this age are not known. Here we assessed the responses of preterm fetal sheep to a standard anesthetic regimen of midazolam, thiopental, and isoflurane. METHODS: Variables were monitored in previously instrumented preterm pregnant sheep before, during, and after 4 h of general anesthesia. Isoflurane produced moderate fetal hypotension and bradycardia, whereas extubation was accompanied by increases in fetal heart rate and mean arterial blood pressure. RESULTS: We observed an initial increase in fetal Sao2 followed by a gradual decline to baseline. Within the fetal brain, oxygenated hemoglobin changed by <10% (nonsignificant) and deoxygenated hemoglobin and total hemoglobin varied by <5%. Overall, although O2 levels within the preterm fetal brain were not independently enhanced by isoflurane (as occurs in the older fetus and in the adult), they did remain constant even as fetal mean arterial pressure decreased by more than 20%. By extension, we failed to identify changes in cerebral oxygenation that could be construed as injurious. CONCLUSION: Any adverse preterm fetal response to maternal surgery should not be attributed solely to the actions of general anesthesia upon the fetus.

Comparative analysis of vagotomy and drainage versus vagotomy and resection procedures for bleeding peptic ulcer disease: results of 907 patients from the Department of Veterans Affairs National Surgical Quality Improvement Program database.

BACKGROUND: The purpose of this study was to determine postoperative outcomes and risk factors for morbidity and mortality in patients requiring surgery for bleeding peptic ulcer disease (PUD). Vagotomy and drainage procedures are technically simpler but are usually associated with higher ulcer recurrence rates. In contrast, vagotomy and resection approaches offer lower ulcer recurrences but represent much more challenging operations and are associated with considerable morbidity and mortality. STUDY DESIGN: Data collected through the Department of Veterans Affairs National Surgical Quality Improvement Program database from 1991 to 2001 were submitted for stepwise logistic regression analysis for prediction of 30-day postoperative morbidity and mortality, rebleeding, and postoperative length of stay. The study population included all patients operated on for bleeding PUD within an 11-year period. RESULTS: The 30-day morbidity, mortality, and rebleeding rates were comparable between surgical groups. Age, American Society of Anesthesiologists class, presence of ascites, coma, diabetes, functional status, hemiplegia, and history of steroid use were predictors of postoperative death. Risk factors for rebleeding included dependent functional status, history of congestive heart failure, smoking, steroid use, and preoperative transfusions. Having a resective procedure, American Society of Anesthesiologists class, hemiplegia, history of COPD, and requiring ventilator-assisted respirations before surgery were positively associated with increased length of hospital stay. CONCLUSIONS: No differences were observed in 30-day mortality, morbidity, or rebleeding rates between surgical groups. Having a resective procedure was a predictor of prolonged postoperative stay. Dependent status and chronic use of steroids were predictors of both rebleeding and postoperative mortality.