Long-term outcome in elderly patients after operation for traumatic intracranial hemorrhage.

OBJECTIVE: This study examined outcomes in elderly TBI patients who underwent a cranial operation. METHODS: We identified TBI patients > or = 65 who underwent a cranial operation from January 1, 2004 to December 31, 2008. Data collected included: age, admission GCS, mechanism of injury, ISS, Head AIS, type of operation, hemorrhage acuity, time to operation, pre-hospital warfarin or clopidogrel, and in-hospital death. Survivors were contacted by phone to determine an Extended Glasgow Outcome Score (GOSE). A favorable outcome was defined as having a GOSE of > or = 5 at follow-up, an unfavorable outcome was defined as: in-hospital death, death within one year of injury, and a GOSE < 5 at follow-up. Chi-square and student's t-test were used. RESULTS: One hundred sixty-four elderly TBI patients underwent cranial surgery. Mean age was 79.2 +/- 7.6 years. Most patients: had a ground level fall (86.0%), suffered a subdural hematoma (95.1%), and underwent craniotomy (89.0%). Twenty-eight percent died in the hospital and another 20.1% died within one year. Fifty-six patients were eligible for a GOSE interview of these: 17 were lost to follow-up, seven refused the GOSE interview, 22 had a GOSE > or = 5, and ten had a GOSE < 5. Mean follow-up was 42.6 +/- 14.9 months. Of all the factors analyzed, only older age was associated with an unfavorable outcome. CONCLUSIONS: While age was associated with outcome, we were unable to demonstrate any other early factors that were associated with long-term functional outcome in elderly patients that underwent a cranial operation for TBI.

Training mothers in infant cardiopulmonary resuscitation with an instructional DVD and manikin.

CONTEXT: Classes in infant cardiopulmonary resuscitation (CPR) can be time consuming and costly. OBJECTIVE: To determine whether mothers in an obstetric unit could learn infant CPR by using a 22-minute instructional kit and to assess the value and confidence they gained by learning CPR. DESIGN: Quasi-experimental study with enrollment between January and December 2008. SETTING: Obstetric unit in Lehigh Valley Hospital, a suburban teaching hospital in Allentown, Pennsylvania. PARTICIPANTS: Mothers at least 18 years old who had given birth within the previous 24 hours. INTERVENTION: The experimental group included mothers without prior CPR training who watched a 22-minute instructional DVD and practiced on a manikin. The control group included mothers with prior conventional CPR training. MAIN OUTCOME MEASURES: In both groups, knowledge and proficiency were assessed with written and practical examinations developed by certified CPR instructors. Participant surveys were conducted at 3 times: immediately before dissemination of course materials, within 24 hours after the mother agreed to participate in the study, and 6 months after initial evaluation. RESULTS: A total of 126 mothers were enrolled in the study: 79 in the experimental group, 25 in the control group, and 22 who withdrew from the study. Written and practical examinations were used to determine proficiency, and composite scores were generated, with a maximum composite score of 12. The composite scores were statistically significantly higher in the experimental group than in the control group, with median scores of 10 and 7, respectively (P<.001). Twenty-two mothers (21%) had been previously offered CPR training. In the experimental group, 76 mothers (96%) felt more confident as caregivers after learning CPR. Before training in both groups, 84 mothers (81%) stated that learning CPR was extremely important, compared with 100 mothers (96%) after training (P=.001). CONCLUSION: Use of an instructional kit is an effective method of teaching CPR to new mothers. Mothers reported that learning CPR is extremely important and that it increases their confidence as caregivers.

Weight status and perception of colorectal cancer risk.

BACKGROUND: Obesity increases the risk of many cancers including colorectal cancer (CRC). METHODS: This is secondary data analysis of the 2010 National Health Interview Survey data. A total of 9360 obese and overweight participants, aged 50 to 80 years, were analyzed according to their perception of their personal cancer risk. RESULTS: Having a perception of increased risk for cancer was associated with higher CRC screening rates. However, when compared with their normal-weight counterparts, overweight and obese individuals did not perceive themselves as being at an increased risk for cancer in general or for CRC specifically. Subgroup analysis revealed one notable exception. Obese black women appeared to recognize themselves as being at higher risk for CRC. CONCLUSIONS: Most obese and overweight individuals fail to recognize their increased cancer risk. Individuals who perceive themselves as being at increased risk for cancer, especially CRC, are more likely to have undergone CRC screening. Unfortunately, obese and overweight individuals do not seem to recognize the increased cancer risk conferred by their body weight. Education is needed so that obese and overweight individuals are aware that their excess body weight is a risk factor for cancer.

Components of the metabolic syndrome differ between young and old adults in the US population.

Prevalence of the metabolic syndrome (MetS) is high in the United States and is associated with increased risk of cardiovascular disease and diabetes. The authors examined whether the prevalence of the MetS and its components differs across age groups. Data were analyzed from 4 National Health and Nutrition Examination Surveys between the years 1999 and 2006. Prevalence of MetS as defined by the Third Report of the Adult Treatment Panel criteria and prevalence of associated cardiac risk factors were determined in 41,474 participants aged 18 years and older without a history of cardiovascular disease (CVD). All estimates were weighted. Prevalence of MetS among asymptomatic adults without CVD was 20.5% and remained stable for the total population during survey periods. Prevalence of MetS increased with age: 6.6% in young adults (age 18-29 years) and 34.6% in older adults (70 and older). Components of MetS differed between young and old adults. Young adults had lower levels of high-density lipoprotein cholesterol, less glucose intolerance, and less hypertension. This study provides an estimate of MetS prevalence in asymptomatic adults in the United States during an 8-year period revealing that MetS affects a large number of Americans. Components of MetS differ between young and old adults and may have important implications in their clinical management.

The relationship of peripheral arterial disease and metabolic syndrome prevalence in asymptomatic US adults 40 years and older: results from the National Health and Nutrition Examination Survey (1999-2004).

Peripheral arterial disease (PAD) is a subclinical marker of coronary artery disease and identifies asymptomatic individuals at high risk for cardiovascular disease (CVD) events. The metabolic syndrome (MetS) is a constellation of clinical factors that increases the risk of developing diabetes and CVD. The authors' objectives were to estimate the prevalence of MetS in patients with PAD and to determine the prevalence of PAD in the population of asymptomatic US adults 40 years and older with MetS. The authors analyzed data from 3 National Health and Nutrition Examination Surveys (NHANES, 1999-2004). Prevalence of MetS as defined by the Third Report of the Adult Treatment Panel criteria and prevalence of associated cardiac risk factors were determined in 5376 asymptomatic participants 40 years and older. Presence of PAD was defined as ankle-brachial index <0.9. Estimates were weighted with the sample weights accounting for the unequal selection probability of complex NHANES sampling and over sampling of selected population subgroups. Prevalence of PAD in asymptomatic US adults 40 years and older was 4.2%. PAD prevalence in persons with MetS was 7.0% compared with 3.3% in persons without MetS. A total of 38% of the population with PAD also had MetS. High rates of abdominal obesity, hypertension, hyperglycemia, and low high-density lipoprotein cholesterol are significant contributors to both MetS and PAD. Persons with MetS have twice the risk of having PAD. Of persons with PAD, almost 40% have MetS. The presence of either PAD or MetS should warrant screening for both conditions so that risk stratification and management of risk factors may be performed.

Gender disparity in emergency department non-ST elevation myocardial infarction management.

BACKGROUND: Many studies have looked at differences between men and women with acute coronary syndrome. These studies demonstrate that women have worse outcomes, receive fewer invasive interventions, and experience delay in the initiation of established medical therapies. OBJECTIVE: Using innovative technology, we set out to unveil and resolve any gender disparities in the evaluation and treatment of patients presenting with a positive troponin while in the emergency department. Our goal was to assess the feasibility of using a business management query system to create an automated data report that could identify deficiencies in standards of care and be used to improve the quality of treatment we provide our patients. METHODS: Over a 12-month period, key markers for patients with non-ST elevation myocardial infarction (NSTEMI) were tracked (e.g., time to electrocardiogram, door to medications). During this time, educational endeavors were initiated utilizing McKesson's Horizon Business Insight™ (McKesson Information Solutions, Alpharetta, GA) to illustrate gender differences in standard therapy. Subsequently, indicators were evaluated for improvement. RESULTS: Substantial improvements in key indicators for management of NSTEMI were obtained and gender differences minimized where education was provided. CONCLUSION: The integration of these information systems allowed us to create a successful performance improvement tool and, as an added benefit, nearly eliminated the need for manual retrospective chart reviews.

Cardiopulmonary resuscitation prescription program: a pilot randomized comparator trial.

BACKGROUND: The American Heart Association wants to increase the number of citizens who know how to perform cardiopulmonary resuscitation (CPR). It is unknown whether giving patients a prescription (Rx) to learn CPR is effective. We sought to determine if patients with, or at risk for, heart disease and their families were more likely to follow prescriptive advice to buy a CPR Anytime™ kit (American Heart Association, Dallas, TX) or to take a CPR class. METHODS: This was a prospective randomized pilot study of a convenience sample of 162 patients who presented to one of three recruiting sites: a suburban community emergency department (ED), an office-based primary care (IM), or cardiology (CD) setting. After consent was obtained, CPR-naïve participants aged>44 years were randomized to one of two study arms. One group received a Rx for a CPR Anytime™ self-learning kit, consisting of a CPR mannequin and a 22-minute DVD. The comparator group was prescribed a CPR class. RESULTS: At the IM office, 7/29 (24%), at the CD office 3/25 (12%), and at the ED 2/23 (9%) patients purchased the CPR kit. Across both investigational arms, 4 were lost to follow-up, yielding approximately 15% (12/77) who followed Rx advice to purchase the CPR kit and 0% (0/79) who took a CPR class. Cumulatively, a participant was significantly more likely to purchase a kit than to take a class (p=0.0004). CONCLUSION: Patients can be motivated to purchase CPR Anytime™ kits but not to take a CPR class from prescribed advice.

Plastic surgeon compliance with national safety initiatives: clinical outcomes and "never events".

BACKGROUND: Venous thromboembolism and surgical-site infection have been identified as preventable complications that are addressed by the National Quality Forum and the Surgical Care Improvement Project. The authors examined compliance of faculty with venous thromboembolism and surgical-site infection prophylaxis and incidence of adverse outcomes in patients at risk. METHODS: The authors performed retrospective chart reviews on 243 patients who underwent abdominoplasty or panniculectomy from 2000 to 2007 and documented demographics and adverse outcomes. Analysis was completed using Pearson's chi-square and Fisher's exact test for categorical variables. Significance was set at p < 0.05. Obesity was defined as body mass index more than 30 and morbid obesity was defined as body mass index more than 40. RESULTS: Of 243 patients, 144 (59 percent) were obese. Seventeen patients (7 percent) suffered complications. All 243 patients received at least one form of venous thromboembolism prophylaxis. One patient had a deep venous thrombosis, and two had pulmonary embolism. These three patients were morbidly obese. Seventy-four percent of patients received appropriate antibiotics. Thirteen patients (5.3 percent) developed significant postoperative infection requiring hospitalization, 12 (92 percent) of whom received appropriate antibiotics. Eleven of these 13 patients (85 percent) were obese, and seven (54 percent) were morbidly obese. Obesity proved to be the only significant risk factor (p > 0.05). CONCLUSIONS: Despite very good compliance with safe practice initiatives, significant adverse outcomes occurred. Obesity was the only pervasive risk factor. This study highlights the potential need for compliance with quality measures and demonstrates that adverse outcomes may result despite adherence to best surgical practices.

Delaware's inclusive trauma system: impact on mortality.

BACKGROUND: The impact of implementing an inclusive state trauma system on injury-related mortality for patients with life-threatening injuries was assessed. METHODS: Using the state trauma registry, trauma patients evaluated in all of Delaware's acute care hospitals from 1998 to 2007 were identified. Patients were categorized by injury severity score (ISS) groups (1-9, 10-15, 16-24, and >24). Each category was analyzed by mortality and interfacility transfer rate to the Level I trauma center for each year. An analysis of the National Trauma Data Bank (NTDB) for these ISS groups and mortality was performed to provide a comparative benchmark. Chi(2) and analysis of variance were used where appropriate (p 24 group. For this group, there was an incremental mortality decrease from 45.7% (1998) to 20.5% (2007) (p 24 group managed at the Level I hospital significantly increased over the same period. CONCLUSION: Since its inception, Delaware's trauma system, in which all acute care hospitals participate, has been associated with an incremental, significant decrease in mortality of the most critically injured patients. This decrease is more substantial than that experienced nationally as depicted within the NTDB. These findings and our evolving experience support the concept and benefits of an "inclusive" trauma system.

Odontoid fractures in the elderly: should we operate?

BACKGROUND: : Treatment of odontoid fractures remains controversial. There are conflicting data in the literature with regard to timing of operative fixation (OP), as well as whether OP should be performed. Within our own institution, treatment is variable depending largely on surgeon preference. This study was undertaken in an attempt to develop management consensus by examining outcomes in elderly patients with odontoid fractures and comparing OP to a nonoperative (non-OP) approach. METHODS: : The trauma registry of our level I trauma center was queried for elderly (age > or = 60) patients with odontoid fractures from January 2000 to May 2006. Patients were then grouped according to treatment, early-OP (< or =3 days posttrauma), late-OP (>3 days), or non-OP treatment. Patient characteristics that were evaluated and compared among the three groups included age, Injury Severity Score, preexisting conditions, and the type of odontoid fracture. Outcomes evaluated included in-hospital mortality, ventilator days, hospital length of stay (HLOS), need for tracheostomy and percutaneous endoscopic gastrostomy (PEG), and the complications of urinary tract infection (UTI), deep vein thrombosis (DVT), and pneumonia. Differences among groups were tested using analysis of variance, Students t test, chi, and Fishers exact test. RESULTS: : The non-OP patients were significantly older than either operative group (mean, 82.4 for non-OP; 77.4 for early-OP; and 76.4 for late-OP; p = 0.006 non-OP compared with either operative group). Injury Severity Score, number of preexisting conditions, mechanism of injury, and distribution of type of odontoid fractures were similar among all three groups. There was no statistically significant difference in mortality among the three groups (11.7% early-OP, 8.7% late-OP, and 17.6% non-OP). There was also no difference among all three groups with respect for the need for tracheostomy and PEG and the development of UTI or pneumonia. However, there were significantly less DVTs in the non-OP group compared with the early-OP group (2.9% vs. 17.6%, p = 0.02). The percentage of patients discharged to a skilled nursing facility was similar among all three groups. The non-OP group had a significant decrease in both ventilator days and HLOS when compared with the operative groups. Only 2.9% of non-OP patients returned for OP for nonunion of the odontoid fracture. CONCLUSIONS: : Despite being an older population, elderly patients with odontoid fracture who were managed non-OP had similar mortality, UTI, and pneumonia rates compared with their younger counterparts who underwent OP. The need for tracheostomy and PEG and discharge disposition was similar among all three groups. Elderly patients with odontoid fracture managed non-OP had a reduction in HLOS and ventilator days compared with either operative group and less DVT compared with the early operative group. Based on these results, non-OP management should be given strong consideration in elderly patients with traumatic odontoid fractures.

Hindfoot alignment valgus moment arm increases in adult flatfoot with Achilles tendon contracture.

BACKGROUND: Adult acquired flatfoot is often associated with Achilles tendon contracture and may be associated with isolated spring ligament insufficiency without Achilles tendon contracture. We have studied the hypothesis that standing valgus hindfoot alignment moment arm is increased in adult acquired flatfoot with Achilles tendon contracture when compared to adult acquired flatfoot without Achilles tendon contracture. MATERIALS AND METHODS: The standing hindfoot alignment, standing lateral tibial-calcaneal angle, lateral talo-first metatarsal angle, lateral medial cuneiform arch height, and anteroposterior talonavicular coverage angle were measured in 22 patients with a clinical diagnosis of adult acquired flatfoot with one foot with clinical Achilles tendon contracture and one without that diagnosis. We compared the adult acquired flatfoot group to a control group of 15 patients with no foot or ankle deformities or previous foot or ankle surgeries. RESULTS: In patients with flatfoot and Achilles tendon contracture, there was a significantly increased valgus hindfoot alignment, talo-first metatarsal angle, talonavicular coverage angle, tibiocalcaneal angle and a decreased arch height when compared to the control group. In all flatfeet, we found an increased tibiocalcaneal angle. In both flatfoot groups, an increasing tibiocalcaneal angle and an increasing talo-first metatarsal angle was correlated to a decreasing arch height. In adult acquired flatfoot without Achilles tendon contracture diagnosed by clinical exam, an increasing talonavicular coverage angle was correlated to an increasing talo-first metatarsal angle and a decreasing arch height. CONCLUSION: Adults with flatfoot and Achilles tendon contracture have a significantly increased standing hindfoot valgus alignment moment arm and other associated deformities.

Strokes after cardiac surgery and relationship to carotid stenosis.

OBJECTIVE: To critically examine the role of significant carotid stenosis in the pathogenesis of postoperative stroke following cardiac operations. DESIGN: Retrospective cohort study. SETTING: Single tertiary care hospital. PARTICIPANTS: A total of 4335 patients undergoing coronary artery bypass grafting, aortic valve replacement, or both. MAIN OUTCOME MEASURES: Incidence, subtype, and arterial distribution of stroke. RESULTS: Clinically definite stroke was detected in 1.8% of patients undergoing cardiac operations during the same admission. Only 5.3% of these strokes were of the large-vessel type, and most strokes (76.3%) occurred without significant carotid stenosis. In 60.0% of cases, strokes identified via computed tomographic head scans were not confined to a single carotid artery territory. According to clinical data, in 94.7% of patients, stroke occurred without direct correlation to significant carotid stenosis. Undergoing combined carotid and cardiac operations increases the risk of postoperative stroke compared with patients with a similar degree of carotid stenosis but who underwent cardiac surgery alone (15.1% vs 0%; P = .004). CONCLUSIONS: There is no direct causal relationship between significant carotid stenosis and postoperative stroke in patients undergoing cardiac operations. Combining carotid and cardiac procedures is neither necessary nor effective in reducing postoperative stroke in patients with asymptomatic carotid stenosis.

Preinjury warfarin worsens outcome in elderly patients who fall from standing.

INTRODUCTION: Fall from standing (FFS) has become one of the most common mechanisms of injury for admission to the trauma center in the elderly population. Many of these patients present anticoagulated with warfarin. This two-center study was designed to examine the effects of preinjury warfarin use on outcome in the elderly. METHODS: A retrospective review of prospectively collected registry data at two Level I trauma centers was conducted from 2003 to 2006. The study population included patients age > or = 65 admitted to the trauma center after an FFS. These centers are relatively close geographically and have similar patient demographics. Data collected included: age, Injury Severity Score, Abbreviated Injury Score (AIS) for head, mortality, admission Glasgow Coma Score, and admission international normalized ratio (INR). Patients were divided into two groups based on the preinjury condition of warfarin use. Statistical differences were determined by unpaired t test for continuous variables and chi and odds ratios (ORs) for dichotomous variables. RESULTS: Of the 27,812 patients admitted to these two trauma centers over this time period, 2,791 (10.0%) were of age > or = 65 and admitted after an FFS. INR was 2.8 +/- 1.1 in warfarin group (+warf). The number of patients with AIS head 4 and 5 was similar between groups (-warf 22.1%, +warf 25.9%). Overall, preinjury warfarin use had a negative effect on the in-hospital mortality rate, +warf 8.6% and -warf 5.7% (OR 1.54, 1.09-2.19, p = 0.015). There was no difference in mortality between groups in patients with an AIS head < 4. The negative impact of preinjury warfarin use on mortality was most pronounced in patients with an AIS head 4 and 5 who presented awake (Glasgow Coma Score 14 and 15), +warf 13.5% and -warf 6.4% (OR 2.30, 95% confidence interval 1.12-4.70, p = 0.019). CONCLUSION: Preinjury warfarin use has an adverse effect on outcome (mortality) in elderly FFS patients. Importantly, this effect is most prominent in patients admitted awake with significant findings on computed tomography scan. This argues for rapid emergency department triage to computed tomography scan and rapid INR correction in this population.

Ask and act: Delaware physicians demonstrate the effectiveness of the American Academy of Family Physicians' initiative to promote tobacco cessation counseling.

The Ask and Act program of the American Academy of Family Physicians promotes family physician tobacco cessation counseling. Smoking and cessation counseling rates were obtained by cross-sectional analysis of electronic medical record data before and after initiation of the Ask and Act program in Delaware. Before the intervention, 24% of the patient population sampled were smokers and 70% of smokers had been counseled to quit smoking. After the intervention, 17% of the patient population sampled were smokers and 98% of smokers had been counseled. Our observations suggest that the Ask and Act program increases counseling, thereby increasing smoking cessation.

Robotic camera holder as good as expert camera holder: a randomized crossover trial.

INTRODUCTION: This study aimed to compare the impact of robotic camera holder (RCH) and human camera holder (HCH) on product quality and procedure effectiveness of a simulated laparoscopic procedure. METHODS: This was a prospective randomized crossover trial including voluntary surgical residents. Block randomization generated RCH-HCH or HCH-RCH sequence allocation. The task was suturing a duodenal perforation on foam stomach with intracorporeally knot tying in a simulator. The camera was operated by the same robot and same expert. Product quality was measured by accuracy error, tissue damage, sliding knot, and leak. Procedure effectiveness was measured by operating time, nongoal directed actions, and dangerous actions. Kendall's coefficient tau_b was used for interrater reliability between 2 blinded assessors. RESULTS: Forty-four subjects performed their tasks as allocated. Product quality and procedure effectiveness were similar when first attempt of task was compared with the repeat task by same subject ignoring the type of camera holder. There was no evidence of significant unequal carryover effect when comparison was stratified by RCH-HCH or HCH-RCH sequences. There were no differences in product quality and procedure effectiveness when RCH was compared with HCH. Coefficient tau_b was > or = 0.80 for all but dangerous actions (0.72, P=0.08). CONCLUSIONS: RCH and HCH had similar impact on product quality and procedure effectiveness of simulated laparoscopic procedure.

Laparoscopic intracorporeal ileocolic resection for Crohn's disease: is it safe?

PURPOSE: The aim of this study was to assess the impact of laparoscopic ileocolic resection with intracorporeal vascular division and anastomosis on the outcome of patients with terminal ileal Crohn's disease. METHODS: Prospective data on patients undergoing laparoscopic ileocolic resection for Crohn's disease confined to terminal ileum and cecum with or without fistulas were reviewed. Exclusion criteria were frozen abdomen, recurrent Crohn's disease following resection, and perforated Crohn's disease. Laparoscopic ileocolic resection involved a lateral-to-medial approach encompassing ten sequential steps. Values were medians (range). RESULTS: From January 1992 to June 2006, 80 laparoscopic ileocolic resections were attempted with a 1.2 percent conversion rate. Sixty-two women and 18 men, age 40 (19-55) years, had a body mass index of 26 (18-37) and an American Society of Anesthesiologists' score of 1 (1-3), and 23.7 percent had previously undergone abdominal surgery. Operating time was 155 (130-210) minutes. Estimated blood loss was 250 (50-600) ml. Length of the skin incision at the specimen extraction site was 35 (30-44) mm. The complication/reoperation rate was 7.5 percent. The readmission rate was 3.7 percent. Except for smoking (P < 0.005), there were no significant differences between patients with and those without complications. The recurrence rate was 30 percent (24 of 80). The median time to recurrence was 64 months. CONCLUSION: Laparoscopic ileocolic resection with intracorporeal vascular division and anastomosis resulted in a favorable outcome in selected patients with refractory terminal ileal Crohn's disease.

Prevalence of peripheral artery disease varies significantly depending upon the method of calculating ankle brachial index.

OBJECTIVE: Peripheral artery disease (PAD) identifies individuals at high risk for future cardiovascular disease (CVD) warranting aggressive risk reduction therapies. PAD can be diagnosed noninvasively by calculating the ankle brachial index (ABI), a ratio of ankle and arm blood pressures. We examined the existing various methods of calculating ABI and the resulting estimates of PAD prevalence. METHODS: We analyzed data from three National Health and Nutrition Examination Surveys. PAD prevalence using three different methods of calculating ABI was determined in 5,376 participants, aged > or =40 years without prior history of CVD. ABI was defined as an ankle brachial index of less than 0.9. Statistical analysis was performed using SPSS V15.0. RESULTS: PAD prevalence among asymptomatic adults without CVD increased significantly during the 6-year time period (1999-2004), regardless of the method used for determining ABI. However, across the National Health and Nutrition Examination Survey assessments, ABI method significantly affected calculated PAD prevalence. Differences in calculated PAD prevalence correspond to approximately 2.2 million persons who would be reclassified as having or not having PAD. CONCLUSION: The calculated prevalence of asymptomatic PAD varies significantly by the ABI method used. Further study is required to determine the most accurate method of performing ABI.

Leg wound infections following greater saphenous vein harvesting: minimally invasive vein harvesting versus conventional vein harvesting.

Wound complications associated with long incisions used to harvest the greater saphenous vein are common and well documented. We compared leg wound infection rates, wound healing disturbances (WHDs), length of vein harvested, vein harvest time, and total surgical time between minimally invasive saphenous vein harvesting (MIVH) and conventional vein harvesting (CVH) techniques. This meta-analysis showed a significant reduction in wound infections in favor of the MIVH group (odds ratio = 0.19; 95% confidence interval = 0.14-0.25) and a significant reduction in WHDs in favor of the MIVH group (odds ratio = 0.26; 95% confidence interval = 0.20-0.34). The MIVH and CVH techniques are equivalent with respect to saphenous vein harvest time, saphenous vein harvest length, and total surgical time. A visual inspection of "funnel" plots suggests a mild to moderate publication bias. This meta-analysis suggests that leg wound infections and wound healing disturbances are reduced using MIVH techniques.

Standardized laparoscopic intracorporeal right colectomy for cancer: short-term outcome in 111 unselected patients.

PURPOSE: This study was designed to evaluate the impact of a standardized laparoscopic intracorporeal right colectomy on the short-term outcome of patients with neoplasia. METHODS: Consecutive patients with histologically proven right colon neoplasia underwent a standardized laparoscopic intracorporeal right colectomy with medial to lateral approach encompassing ten sequential steps: 1) ligation of ileocolic vessels, 2) identification of right ureter, 3) dissection along superior mesenteric vein, 4) division of omentum, 5) division of right branch of middle colic vessels, 6) transection of transverse colon, 7) mobilization of right colon, 8) transection of terminal ileum, 9) ileocolic anastomosis, 10) delivery of specimen. Values were medians (ranges). RESULTS: From July 2002 to June 2005, 111 laparoscopic intracorporeal right colectomies were attempted with a 5.4 percent conversion rate. There were 57 women and 54 men, aged 64.9 (range, 40-85) years, with body mass index of 33 (range, 20-43), American Society of Anesthesiology score of 2 (range, 2-4), 36.9 percent comorbidities, and 37.8 percent previous abdominal surgery. The indication for surgery was cancer in 109 patients. Operative time was 120 (range, 80-185) minutes. Estimated blood loss was 69 (range, 50-600) ml. Overall length of skin incisions was 66 (range, 60-66) mm; 29 (range, 2-41) lymph nodes were harvested. Length of stay was four (range, 2-30) days. Complication rate was 4.5 percent. CONCLUSIONS: A standardized laparoscopic intracorporeal right colectomy resulted in a favorable short-term outcome in unselected patients with neoplasia of the right colon.