Assessment of surgical discharge summaries and evaluation of a new quality improvement model.

BACKGROUND: Discharge summaries after hospitalization provide the most reliable description and implications of the hospitalization. A concise discharge summary is crucial for maintaining continuity of care through the transition from inpatient to ambulatory care. Discharge summaries often lack information and are imprecise. Errors and insufficient recommendations regarding changes in the medical regimen may harm the patient's health and may result in readmission. OBJECTIVES: To evaluate a quality improvement model and training program for writing postoperative discharge summaries for three surgical procedures. METHODS: Medical records and surgical discharge summaries were reviewed and scored. Essential points for communication between surgeons and family physicians were included in automated forms. Staff was briefed twice regarding required summary contents with an interim evaluation. Changes in quality were evaluated. RESULTS: Summaries from 61 cholecystectomies, 42 hernioplasties and 45 colectomies were reviewed. The average quality score of all discharge summaries increased from 72.1 to 78.3 after the first intervention (P < 0.0005) to 81.0 following the second intervention. As the discharge summary's quality improved, its length decreased significantly. CONCLUSIONS: Discharge summaries lack important information and are too long. Developing a model for discharge summaries and instructing surgical staff regarding their contents resulted in measurable improvement. Frequent interventions and supervision are needed to maintain the quality of the surgical discharge summary.

Laparoscopic repair of giant diaphragmatic hernias: evolving technical aspects and outcomes.

BACKGROUND: Laparoscopic repair of giant diaphragmatic hernias (GDH) can be challenging, especially when partial or complete volvulus of the herniated stomach is encountered. OBJECTIVES: To review our experience with laparoscopic repair of GDH, emphasizing preoperative investigation, technical aspects, and outcome. METHODS: We conducted a retrospective review of patients operated on for GDH who were diagnosed when at least half the stomach was found in the mediastinum at surgery. Technical aspects and surgical outcomes were evaluated. RESULTS: Fifty patients underwent laparoscopic GDH repair during an 8 year period. Four patients admitted with acute symptomatic volvulus of the stomach were initially treated by endoscopic decompression followed by surgery during the same admission. Two cases were converted to open surgery. Initial surgery was successful in 45 patients; 3 had an immediate recurrence, 1 was reoperated for dysphagia during the same admission, and 1 had a mediastinal abscess. During long-term follow-up, six patients required reoperation for recurrent hernias. Another four patients had asymptomatic partial herniation of the stomach. The main reason for failure was incomplete reduction of the hernia sac, especially the posterior component. No correlation was found between the type of repair and surgical failure. Most patients who did not undergo an anti-reflux procedure had postoperative reflux unrelated to their preoperative workup. CONCLUSIONS: Laparoscopic repair of GDH is challenging, but practical and safe. It should be the treatment of choice for this potentially life-threatening condition. Careful attention to pitfalls, such as the posterior element of the sac, and routine performance of an anti-reflux procedure are crucial.

Long-term follow-up on the effect of silastic ring vertical gastroplasty on weight and co-morbidities.

BACKGROUND: Silastic ring vertical gastroplasty (SRVG) is a simple, effective and reproducible restrictive operation for the treatment of morbid obesity. Over the last years, it has lost its popularity due to the development of adjustable gastric banding systems performed laparoscopically. In order to evaluate the long-term effect of SRVG on weight loss and co-morbidities, we reviewed the results of SRVG operations in our institution. METHODS: We reviewed SRVG operations performed in our University-affiliated General Hospital. Data was collected from the patients' in-patient records, their outpatient-clinic files, and from a telephone interview. RESULTS: Between 1989 and 2001, 162 patients were operated upon. Complete follow-up was obtained of 115 patients (71%). The mean follow-up was 7.1 +/- 3 years (range 4 to 16 years). Mean preoperative BMI was 47 kg/m2 (range 34 to 69 kg/m2). Maximal weight loss was obtained within 1 year to a mean BMI of 29 kg/m2, with a mean excess BMI loss of 67%. Subsequently, there was a small increase in BMI, which stabilized at 34 kg/m2 up to 15 years after the operation. A rapid, significant improvement in obesity-related co-morbidities was observed regarding hypertension (81%), diabetes (100%), sleep disorders (90%), osteoarthritis (83%) and ischemic heart disease (75%). There was no peri-operative mortality. Early complication rate was 10%. Late complications included postoperative ventral hernia (18%), esophagitis (31%), ring stricture (19%), ring erosion (2 patients), failure of staple line (8%) and obstruction of the pouch with food (19%). 35 patients (30%) required another procedure, 8 of them were eventually converted to other bariatric operations, and 2 patients had the ring removed and refused another bariatric procedure. The overall satisfaction rate was 86%. CONCLUSIONS: SRVG is a simple, safe and effective bariatric operation in selected patients with morbid obesity. It results in a rapid, excellent effect on obesity-related co-morbidities and good long-term effect in weight loss, which compares positively with other, more complicated bariatric operations.

The effect of the somatostatin analogue octreotide on experimental intestinal obstruction in rats

Background: Somatostatin has an inhibitory effect on the endocrine and exocrine secretions of the gut. It may have a beneficial effect in the conservative treatment of intestinal obstruction. The aim of the present study is to investigate the effect of octreotide in mechanical intestinal obstruction in rats. Method: Intestinal obstruction was induced in rats by ligation of a segment of the distal ileum. Animals were treated with the somatostatin analogue octreotide (n=16), or saline (n=16). Eight rats were operated but their intestine was not ligated (n=8) serving as sham controls. Forty eight hours after the operation, the animals were operated upon again and blood samples from the femoral vein were tested for electrolytes, urea, glucose, lactic acid, amylase, ph and bicarbonate. Portal vein blood samples were also obtained and tested for lactic acid and amylase. Results: Intestinal obstruction resulted, after 48 hours, in severe dilatation of bowel loops. A significant increase in plasma levels of urea, amylase and lactic acid was observed. Plasma pH decreased. In blood samples from the portal vein, a significant increase in lactic acid was observed, indicating metabolic acidosis, probably secondary to bowel ischemia. Octreotide treatment, resulted in less acidosis, with concomitant lower urea and lactic acid levels in the plasma and especially in the portal vein. Conclusion: Octreotide treatment may have a beneficial effect in the conservative treatment of selected cases of intestinal obstruction.

Objetivo: A somatostatina tem efeito inibidor nas secrees endcrina e excrina do intestino. Poderß ter efeito benfico no tratamento conservador da obstruo intestinal. O objetivo do presente estudo investigar o efeito do octreotide na obstruo mecnica do intestino delgado de ratos. Mtodo: A obstruo intestinal foi induzida em ratos pela ligadura do segmento distal do ileum. Os animais foram tratados com somatostatina anßloga octreotide (n=16) ou com soluo salina (n=16). Oito ratos foram operados mas o intestino delgado no foi ligado (n=8) servindo como o grupo sham. Quarenta oito horas aps a operao os animais foram re-operados e submetidos a colheita de sangue da veia femoral a fim de verificar os eletrlitos, uria, glicose, ßcido lßtico, amilase, pH e bicarbonato. Obteve-se tambm amostra de sangue da veia porta para verificar os nveis de ßcido lßtico e amilase. Resultados: Aps 48 horas de obstruo houve intensa dilatao das alas intestinais. Observou-se aumento significante dos nveis plasmßticos de uria, amilase e ßcido lßtico. Diminuiu o pH plasmßtico. Observou-se aumento do ßcido lßtico no sangue portal, indicando acidose metablica, provavelmente secundßria a isquemia intestinal. O tratamento com octreotide resultou em menos acidose, com nveis baixos de uria e ßcido lßtico no plasma, e especialmente na veia porta. Concluso: O emprego de octreotide pode ter efeito benfico no tratamento conservador de casos selecionados de obstruo intestinal.