Novel operative anoscope for Ferguson hemorrhoidectomy: a feasibility study and comparative cohort analysis.

BACKGROUND: Operative hemorrhoidectomy can result in pain and altered continence from excessive excision of anoderm or surrounding tissue. We assessed a novel low-profile slotted anoscope to determine if the device would promote safe dissection, lessen trauma, and reduce operative times for hemorrhoidectomy. METHODS: Patients requiring hemorrhoidectomy (June 2008 - January 2010) underwent a prospective phase-2 trial evaluating a new operating anoscope (CAD, Ethicon Endosurgery, Cincinnati, OH). Demographics and perioperative end points including bleeding, pain, fecal incontinence, stenosis, and symptom recurrence were analyzed at 4 weeks, 3 months, 6 months, and 1 year postoperatively. We compared these to patients undergoing hemorrhoidectomy (February 2010 - November 2012) with a traditional Hill-Ferguson anoscope (THF). RESULTS: 40 patients (CAD, 20 vs THF, 20) were included. Presenting symptoms were similar, whereas mean duration of symptoms was longer for CAD (41.2 ± 8.4 vs 27 ± 9.5 months; P < .05). Estimated blood loss was lower for CAD [8.3 mL (range = 2-40 mL) vs 11.3 mL THF (range = 5-35 mL; P = .87)]. Mean operative times were lower for the CAD than the THF group (15.6 ± 3.4 vs 26.1 ± 4.1 minutes; P < .05). Visual analog pain scores were non-significantly increased in the THF group at 4 weeks (P = .23). At 3 months, 6 months, and 1 year, there was no difference in continence. CONCLUSION: The CAD anoscope reduced operative times for modified Ferguson (closed) hemorrhoidectomy when compared with traditional retractors. There was no difference in incontinence or pain between groups.

Uterine Dehiscence: A Rare Cause of Postpartum Puerperal Sepsis.

Uterine dehiscence (partial or complete) is a rare complication of lower segment cesarean section (LSCS). Puerperal sepsis with intra-abdominal abscess following this event has been rarely reported. The delay in diagnosis and management of the condition can result in significant morbidity and mortality. We herein report three cases of puerperal sepsis along with intra-abdominal abscess associated with uterine dehiscence following LSCS. These patients in the current case series presented with complaints of fever and abdominal pain. Early recognition and prompt treatment with diagnostic laparoscopy and or laparotomy with drainage were effective in the management of these patients.

Preoperative findings predict conversion from laparoscopic to open cholecystectomy.

BACKGROUND: Previous studies evaluating predictive factors for conversion from laparoscopic to open cholecystectomy have drawn conflicting conclusions. We evaluated objective preoperative variables to create an accurate, accessible risk score to predict conversion. METHODS: A retrospective review was performed of laparoscopic cholecystectomy patients at an urban tertiary care center. Seventy characteristics were subjected to bivariate and multivariate logistic regression analysis to identify parameters that independently predict conversion to open cholecystectomy. A model was created based on this analysis. RESULTS: Laparoscopic cholecystectomy was performed on 1377 patients for benign gallbladder disease over a 71-month period. There were 112 (8.1%) conversions to open cholecystectomy. The correlation between the preoperative clinical diagnosis and pathologic diagnosis for acute and chronic cholecystitis was 48.6% and 94.6%, respectively. Multivariate analysis identified male gender, elevated white blood cell count, low serum albumin, ultrasound finding of pericholecystic fluid, diabetes mellitus, and elevated total bilirubin as independent predictors of conversion. These 6 factors were also associated with the pathologic diagnosis of acute cholecystitis. A model to calculate the risk for conversion was created with an area under the receiver operator curve of 0.83. The risk for conversion also can be estimated based on the number of factors identified present and ranged from 2% when 1 factor was present to 89% with 6 factors. CONCLUSIONS: These results demonstrate that conversion to open cholecystectomy can be predicted based on parameters available preoperatively. Conversion is more likely in patients who have acute cholecystitis; however, the correlation between its clinical and pathologic diagnosis is poor. Improvements in the ability to determine the risk for conversion have important implications for surgical care.

Bacterial species-specific hospital mortality rate for intra-abdominal infections.

BACKGROUND: Intra-abdominal infections (IAIs) are a major cause of morbidity and death. We hypothesized that the involvement of specific organisms would predict death independently. PATIENTS AND METHODS: All patients with IAIs treated at an academic tertiary-care facility over eight years (June 1999-June 2007) were included. The data collected were demographics, co-morbidities, source of infection, intra-abdominal culture results, type of infection (community-acquired vs. nosocomial), type of intervention (operative vs. percutaneous drainage), and outcome. The Charlson Comorbidity Index and multiple organ dysfunction score (MODS) were used in the analysis. RESULTS: A total of 389 patients were admitted for 452 infection episodes (IEs) during the study period. None of the 129 patients with appendiceal-related infections died, and these patients were excluded from further analysis. Thus, 323 non-appendiceal IEs were evaluated. The overall mortality rate was 8.7%. The mean age of the patients was 54 y, and 50% of them were male. Intra-abdominal cultures were obtained from 303 IEs (93.8%). The most common cause of IAI was post-operative infection (44%). There were 49 distinct species isolated. The most common were Enterococcus (105), Escherichia coli (75), Streptococcus (62), Staphylococcus (51), and Bacteroides (46). Bivariable analysis revealed multiple risk factors associated with death. Logistic regression demonstrated that independent risk factors for death were age ≥65 years (odds ratio [OR] 3.92), cardiac event (OR=8.17), catheter-related blood stream infection (OR=6.16), and growth of Clostridium (OR=13.03). The growth of Streptococcus was predictive of survival. The C statistic was 0.89. CONCLUSIONS: In addition to age and intrinsic patient factors, the presence of specific bacterial organisms independently predicts death in patients with non-appendiceal IAI.

Mortality for intra-abdominal infection is associated with intrinsic risk factors rather than the source of infection.

BACKGROUND: Intra-abdominal infections (IAIs) are an important cause of mortality and morbidity. Nosocomial IAIs (NIAIs) have been associated with higher mortality than community-acquired IAIs (CIAIs). We hypothesized that intrinsic risk factors were a better predictor of mortality than the type of infection. METHODS: Patients with IAI treated at a single urban academic hospital over 8 years (June 1999-June 2007) were retrospectively reviewed. Data collected included demographics, comorbidities, source of infection, type of infection (community vs nosocomial), type of intervention (operation versus percutaneous drainage), and postoperative complications. Charlson Comorbidity Index and multiple organ dysfunction (MOD) scores were evaluated at admission and on postoperative day 7 (POD-7). RESULTS: There were 452 patients; 234 (51.8%) had CIAI and 218 (48.2%) had NIAI. The mean age was 51.3 +/- 0.8. The most common source of CIAI was the appendix (n = 129, 28.5%); 137 patients with NIAI had postoperative infections (30.3%). When patients with appendicitis were excluded, there was no difference in mortality or complications between patients with CIAI and NIAI. Logistic regression analysis demonstrated catheter-related bloodstream infection (P < .001; OR 7.3, 95% CI, 2.5-22.2), cardiac event (P < .001; OR 6.0, 95% CI, 2.3-16.1), and age > or = 65 (P = .009; OR 3.8, 95% CI, 1.4-8.8) to be independent risk factors for mortality. Among patients who failed initial therapy, a non-appendiceal source of infection (P < .001; OR 4.7, 95% CI, 2.3-9.8) and a Charlson score > or =2 (P = .033; OR 1.6, 95% CI, 1.0-2.6) were determined to be independent risk factors. Non-appendiceal source of infection (P = .001, OR 3.3, 95% CI, 1.6-7.0) and POD-7 MOD score > or =4 (P < .001; OR 3.4, 95% CI, 1.9-6.0) were found to be independent predictors for re-intervention. CONCLUSION: These results suggest mortality from IAI is strongly related to age and organ dysfunction; however, catheter-related bloodstream infection and postoperative cardiac events have a greater effect on outcome.

Predictive factors for surgical site infection in general surgery.

BACKGROUND: Global parameters, such as wound class, the American Society of Anesthesiologists' physical classification score, and prolonged operative time, have been associated with the risk of surgical site infection (SSI). We hypothesized that additional risk factors for SSI would be identified by controlling for these parameters and that deep and organ/space SSI may have different risk factors for occurrence. METHODS: A retrospective review was performed on general and vascular surgical patients who underwent an operation between June 2000 and June 2006 at a single institution. Patients with SSI were matched with a case-control cohort of patients without infection (no SSI) according to age, sex, ASA score, wound class, and type of operative procedure. Data were analyzed using bivariate and regression analyses. RESULTS: Overall, 10,253 general surgical procedures were performed during the 6-year period; 316 patients (3.1%) developed SSI. In all, 300 patients with 251 superficial (83.6%), 22 deep (7.3%), and 27 organ/space (9%) SSIs were matched for comparison. Multivariate logistic regression analysis identified previous operation (odds ratio [OR], 2.4; 95% confidence interval [CI] = 1.6-3.7), duration of operation >or=75th percentile (OR, 1.8; 95% CI = 1.2-2.8), hypoalbuminemia (OR, 1.8; 95% CI = 1.1-2.8), and a history of chronic obstructive pulmonary disease (OR, 1.7; 95% CI = 1.0-2.8) as independent risk factors for SSI. Only hypoalbuminemia (OR, 2.9; 95% CI = 1.4-6.3) and a previous operation (OR, 2.0; 95% CI = 1.0-4.4) were significantly associated with deep or organ/space infections. CONCLUSIONS: These results demonstrate additional factors that increase the risk of developing SSI. Deep and organ/space infections have a different risk profile. This information should guide clinicians in their assessment of SSI risk and should identify targets for intervention to decrease the incidence of SSI.

Life-threatening neck hematoma complicating thyroid and parathyroid surgery.

BACKGROUND: Observation following thyroidectomy and parathyroidectomy has been progressively shortened. The challenge has been to reduce the duration of postoperative observation without jeopardizing patient safety. METHODS: A retrospective review of patients who underwent thyroidectomy and/or parathyroidectomy between July 1990 and March 2007 was completed to determine the frequency of life-threatening hematoma and hospital readmission and their impact on postoperative observation. RESULTS: Of 1,050 patients, life-threatening hematoma developed in 6 (.6%) patients, 5 following bilateral and 1 following unilateral thyroidectomy. Hematoma developed 10 minutes to 7 days postoperatively, four within 4 hours, one at 21 hours, and one at 7 days. Twelve patients were readmitted an average of 5 days postoperatively for hypocalcemia, hematoma, infection, or respiratory distress. CONCLUSION: Without factors contributing to bleeding, unilateral thyroidectomy and parathyroidectomy can be performed as an ambulatory procedure. To maximize safety, we recommend 4-hour and 23-hour observation following unilateral and bilateral thyroidectomy, respectively.