Using outcomes data to justify instituting new technology: a single institution's experience.

BACKGROUND: The PILLAR II trial demonstrated PINPOINT is safe, feasible to use with no reported adverse events and resulted in no anastomotic leaks in patients who had a change in surgical plan based on PINPOINT's intraoperative assessment of tissue perfusion during colorectal resection. Whether the cost savings associated with this reduction in anastomotic complications can offset the cost of investing in PINPOINT is unknown. METHODS: We performed a retrospective analysis of all patients (N = 347) undergoing colectomy with primary anastomosis from January 2015 to April 2016. These patients were stratified based on whether fluorescence imaging was used intraoperatively. The clinical outcomes of these patients were then evaluated based on their development of an anastomotic leak or stricture. The direct hospital costs per case were then calculated, and the economic impact of using fluorescence imaging was examined to assess whether decreased direct costs would justify the initial expenditures to purchase new technology (PINPOINT System, NOVADAQ, Canada). RESULTS: Fluorescence imaging in colorectal surgery using PINPOINT reduced the anastomotic failure rate in patients who underwent colon resection. The PINPOINT group (n = 238) had two (0.84%) anastomotic failures, while the non-PINPOINT group (n = 109) had six (5.5%) anastomotic failures. In the PINPOINT group, 11 (4.6%) patients had a change in the resection margin based on the results of the fluorescence imaging, and none of these patients experienced an anastomotic failure. Cost per case was less in the PINPOINT group secondary to fewer direct costs associated with complications. CONCLUSIONS: These results validate the findings of the PILLAR II trial and confirm the decrease in direct costs due to reduction in anastomotic failures as a result of using PINPOINT justified the expense of the new technology after just 143 cases.

Laparoscopic treatment of a benign splenic cyst.

With an understanding of the spleen's important immunologic function, splenectomy for benign splenic disorders has given way to a variety of splenic conservation techniques. Treatment options for benign nonparasitic splenic cysts include partial splenectomy, total cystectomy, or partial cyst decapsulation. External cyst wall decapsulation is a simplified operative procedure that carries no increased risk of cyst recurrence. However, a conventional upper abdominal laparotomy may subject patients to significant morbidity. We successfully performed a laparoscopic partial cyst decapsulation, achieving meticulous hemostasis with use of a laparoscopic-GIA stapling device. The patient tolerated the procedure well and was discharged on postoperative day 2. Follow-up has demonstrated no evidence of recurrent cyst formation.

Laparoscopic resection of a nonparasitic liver cyst.

The spectrum of treatment options for symptomatic, benign, nonparasitic hepatic cysts has ranged from percutaneous aspiration to liver transplantation. Most large series have demonstrated that complete resection of the cyst is associated with the lowest rate of recurrence. However, a conventional open laparotomy may subject these patients to unacceptable morbidity given the benign nature of most of these lesions. We successfully performed a complete resection of a large hepatic cyst using a laparoscopic approach. Using an endoscopic GIA stapling device we were able to remove the cyst with minimal blood loss and in minimal operative time. The patient tolerated the procedure well, was discharged home on postoperative day 2, and in follow-up has been without recurrent symptoms.

Respiratory patterns after cholecystectomy. Effects of posture and CO2 stimulation.

A marked reduction in the ratio of abdominal to rib cage motion has been observed after upper abdominal surgery. This study seeks to determine the effects on respiratory pattern of stimulation with CO2 and a change in posture from supine to semirecumbent posture (hips flexed, head of bed elevated at 30 degrees to the horizontal) in patients having undergone cholecystectomy. Canopy spirometry and respiratory inductive plethysmography were used to measure minute ventilation, tidal volume, and rib cage and abdominal motion in 14 otherwise healthy women, prior to elective cholecystectomy and on the first and third postoperative days. Preoperatively, the relative contribution of the chest wall compartment to tidal volume (Vc/VT) was increased both by moving from the supine to the semirecumbent posture and by stimulation with 4 percent inhaled CO2. On the first postoperative day, there was a reduction in abdominal motion. In contrast to what happened in the preoperative period, there was no change in the relative contribution of the rib cage and abdomen when the patients moved from the supine to semirecumbent position. With CO2 stimulation, there was a further increase in the already increased absolute tidal volume of the chest. On the third postoperative day, there was an increase in abdominal motion in the supine and sitting position and during 4 percent CO2 stimulation. These results demonstrate that the response to a change in posture and to 4 percent CO2 stimulation are markedly altered in the postoperative period by the reduction in abdominal motion.

Diaphragmatic breathing maneuvers and movement of the diaphragm after cholecystectomy.

Coached efforts at diaphragmatic breathing were assessed as a means of increasing diaphragmatic movement in postoperative patients. Inductive plethysmography was used to measure compartmental tidal volumes of the abdomen (Vab) and the chest (Vc) in eight women (aged 41 +/- 16 years) who had no history of cardiovascular or pulmonary disease. These patients were studied before and after (POD1,3) elective cholecystectomy. In preoperative studies, DB increased the supine value of Vab. The corresponding increase on POD1 represents a similar proportion of the resting value. The postoperative fall in resting and stimulated values of Vab is attributed to the known effects of abdominal surgery on diaphragmatic movement. Hence, DB warrants investigation as a method of prophylaxis against the pulmonary complications of surgery, because diaphragmatic movement is largely responsible for ventilation of the lower lung fields, where atelectasis and infection occur most often.

Percutaneous drainage of intra-abdominal abscesses following abdominal trauma.

Between January 1, 1984, and June 30, 1987, we performed percutaneous catheter drainage (PCD) of 28 intra-abdominal abscesses in 21 postoperative trauma patients. During this period only three patients had abdominal re-exploration for drainage of abdominal abscess. The PCD patients were predominantly young men who had sustained penetrating abdominal injuries (81% GSW or SW; 19% MVA). Seventeen (81%) patients had multiple abdominal organ injuries with the colon being the most frequently injured (57%). Multiple abscesses were identified in 33% of the patients. All 21 patients had successful treatment of their abscesses by PCD alone. There was one complication (4.8%) from PCD (pneumothorax) and no deaths in this group. Our data suggest that in most cases, PCD can be safe, effective, and definitive treatment for postoperative intra-abdominal abscesses following abdominal trauma. We recommend PCD in all postoperative trauma patients who develop accessible abdominal abscesses before resorting to re-exploration.

Effect of incentive spirometry on diaphragmatic function after surgery.

Many of the alterations in lung function that occur after upper abdominal surgery are attributable to reduced diaphragmatic activity. This study was undertaken to determine whether incentive spirometry produces a voluntary activation of diaphragmatic movement in patients with postoperative diaphragmatic dysfunction. Inductance plethysmography was used to measure the tidal volumes of the abdomen and chest in eight women before cholecystectomy and on the first and third postoperative days. In resting patients the relative contribution of the abdominal compartment decreased from 0.520 +/- 0.100 preoperatively to 0.274 +/- 0.265 on postoperative day 1 (p less than 0.01), reflecting the effect of surgery on diaphragmatic function. Inspiratory flow (an index of inspiratory drive) was unaltered by surgery during both resting and incentive spirometry breaths, despite changes in tidal volume. Preoperatively, incentive spirometry increased the tidal volume of the abdominal compartment from 141 +/- 26 ml to 285 +/- 188 ml (p less than 0.005) as a result of increased diaphragmatic movement. This effect was not seen postoperatively; instead, postoperative patients responded to incentive spirometry by increasing the tidal excursion of the chest compartment (158 +/- 37 to 630 +/- 253, p less than 0.005), without any increase in abdominal tidal volume. Thus, incentive spirometry failed to increase diaphragmatic movement in postoperative patients.

Placement of Hickman-Broviac catheters in the cephalic vein.

By approaching the cephalic vein with an incision placed high in the deltopectoral triangle, instances in which the cephalic vein is absent or too small to cannulate will almost always result in the successful cannulation of an alternative vein located in this region. In those rare instances in which there is no vein which can be cannulated on one side, contralateral dissection is likely to be successful. Occasionally, a catheter will be seen to pass over the clavicle into the external jugular vein. The catheter should be withdrawn and rethreaded because repeat attempts at central placement will usually be successful.

The critically ill surgical patient: nutritional considerations.

The nutritional care of the patient in the surgical intensive care unit is one of the most challenging in the field of nutritional support. Each patient must be assessed individually and specific goals of nutritional support established. Specialized nutritional solutions may be needed for the patient with significant renal, hepatic, or pulmonary disease, as well as patients in a chronic septic state. Knowledge of the infectious and metabolic complications that frequently occur in this population is essential in order to keep nutritionally related morbidity at a minimum. Finally, the realization that, in the surgical intensive care unit, nutritional therapy is often a supportive measure used in an attempt to gain time to eradicate the primary process will enable the clinician to establish the proper approach to the nutritional care of these patients.

The influence of preoperative total parenteral nutrition upon morbidity and mortality.

This study was done to examine the criteria for determining the adequacy of preoperative total parenteral nutrition (TPN). We hypothesized that an important criterion for adequate preoperative nutrition should be a contraction of the expanded extracellular fluid compartment known to occur in malnourished patients undergoing surgical treatment. Clinical evidence of this included a rise in the serum albumin level and weight loss. Fifty-nine patients requiring preoperative nutritional support for at least five days were admitted to the study. The patients were divided into three groups (group 1, group 2a and group 2b) based upon the response of the patients to TPN. Group 1 consisted of 23 patients who demonstrated a rise in serum albumin value, loss in body weight and diuresis after seven days of TPN. Group 2 was made up of 36 patients who failed to demonstrate a rise in the albumin level in response to nutritional support for one week. Of these patients, 20 underwent operation at the end of a week of nutritional support (group 2a) while 16 patients received four to six weeks of nutritional support preoperatively (group 2b). The complication rate in the three groups was 4.3 per cent for those in group 1; 45 per cent for those in group 2a and 12.5 per cent for those in group 2b (p less than 0.05), group 2a versus group 2b). The results of this study demonstrate a high mortality and morbidity in patients who fail to increase the serum albumin level after one week of TPN. The data suggest that a prolonged period of parenteral nutrition results in a substantial decrease in perioperative complications in this group of patients.

Nutrition and lung water.

Lung water homeostasis and the subsequent prevention of pulmonary edema involve a balance of many forces and safety factors. Malnutrition and its effects on fluid distribution within body compartments and on oncotic pressure gradients can play a crucial role in this balance of forces. These forces are discussed, with emphasis on the complications of superimposed malnutrition.

Effect of immediate postoperative nutritional support on length of hospitalization.

This study is a retrospective review of the effect of nutritional support on duration of hospitalization in patients undergoing radical cystectomy. Thirty-five patients were randomly assigned to receive either 5% dextrose (D5W) solution plus electrolytes or total parenteral nutrition (TPN) following operation. The assigned nutritional regimen was continued for 1 week after operation until oral intake resumed. If the patients receiving D5W remained incapable of oral intake after 1 week, TPN was instituted. The group receiving immediate postoperative TPN had a median duration of hospitalization of 17 days, while the median duration for the group receiving 5% dextrose solution was 24 days. All other patient characteristics, such as age, sex, stage/grade of tumor, and extent of preoperative radiotherapy, were similar in the two groups. These results demonstrate that immediate postoperative institution of nutritional support reduced hospitalization time following radical cystectomy. This indicates that the routine use of 5% dextrose as postoperative nutrition should be reevaluated.

Response to total parenteral nutrition in the extremely malnourished patient.

Changes in serum albumin levels and body weight are often used as indicators of the efficiency of a nutritional support regimen. Patients with moderate nutritional depletion demonstrate two distinct patterns of response during refeeding. The first is characterized by a decrease in the previously expanded extracellular fluid space with a rise in serum albumin and a loss of weight and the second by continued fluid retention with weight gain and no rise in serum albumin concentration. The second pattern has been observed in patients with ongoing stress such as infection. This study examines severely malnourished patients with no apparent inflammatory complications and demonstrates that this group responds to nutritional support in a pattern similar to that seen in the stressed patient. Eight patients with profound malnutrition were studied during the 1st week of nutritional support. Nitrogen balance was measured and the findings confirmed that all patients were anabolic. Sodium balances were used as an indicator of changes in the extracellular fluid compartment. Body weight and serum albumin were assessed daily. Body weight increased from 59 +/- 4 to 62 +/- 4% of normal (p less than 0.01) while serum albumin changed insignificantly (3.00 +/- 0.27 to 2.85 +/- 0.23 g/100 ml, NS) during the initial week of an adequate nutritional support regimen (nitrogen balance was +21.0 +/- 4.3 g, p less than 0.05). These changes were associated with a positive sodium balance (+215 +/- 20 mEq, p less than 0.05). These data confirm that some extremely malnourished patients do not experience a diuresis during the initial phase of nutritional support but rather may retain water and increase body weight.(ABSTRACT TRUNCATED AT 250 WORDS)

Splanchnic substrate balance in malnourished patients during parenteral nutrition.

Twenty-four-hour values for splanchnic substrate balance, O2 consumption, and CO2 production were estimated in nutritionally depleted patients, once while receiving 5% dextrose (D5W) and again after 6 or more days of glucose-based total parenteral nutrition (TPN). Nitrogen balance and whole body gas exchange were also measured. The majority of protein loss during D5W administration and the net protein synthesis during TPN occurred in the periphery. Increases in whole body and splanchnic O2 consumption occurred with TPN administration, but in both cases the splanchnic region accounted for 20% of whole body O2 consumption. Uptake of substrates by the splanchnic region was sufficient to meet splanchnic energy requirements. During TPN infusion uptake by the splanchnic region accounted for 60% of amino acids infused, whereas peripheral uptake accounted for 40%. Splanchnic uptake of glucose accounted for 20% of the glucose infused during TPN. During TPN the splanchnic region took up more glucose and amino acids than was required for energy needs and protein synthesis. It was assumed that the remainder of this substrate was used for lipogenesis. The splanchnic region accounted for 50 +/- 19% of whole body lipogenesis.

The response to TPN. A form of nutritional assessment.

Malnutrition in surgical patients is associated with an increased incidence of postoperative mortality and morbidity. Preoperative nutritional support has been shown to be efficacious in reducing the incidence of these complications, although the postoperative complication rate in these patients continues to be greater than in their wellnourished counterparts. This study attempts to determine whether the postoperative course can be either influenced by or predicted from the preoperative response to nutritional support. Thirty-two patients with nutritional depletion who received an average of 1 week of total parenteral nutrition prior to a major abdominal operation were studied. These patients were followed for postoperative complications. Of the 16 patients who exhibited the characteristic response to early nutritional support, diuresis of the expanded extracellular fluid compartment with a resultant loss of weight (127.9 +/- 5.7 to 124.6 +/- 5.8 (SEM) lbs, p less than .001) and rise in serum albumin (3.21 +/- 0.14 to 3.46 +/- 0.15 gms%, p less than 0.001), only one developed a complication in the postoperative period. The other 16 patients did not exhibit this response. They retained additional fluid, gained weight (119.3 +/- 8.1 to 121.3 +/- 8.2 lbs, p less than .025), and showed a decrease in serum albumin levels (3.14 +/- 0.14 to 3.00 +/- 0.14%), p less than 0.01). Eight of these patients developed a total of 15 postoperative complications (p less than 0.01). This study demonstrates that the response to preoperative TPN is an important factor in assessing operative risk and morbidity. The need to individualize preoperative nutritional support and the timing of surgical intervention is clearly demonstrated.

Nutritional support of the acutely ill patient.

Administration of nutritional support in acutely ill patients can be seen as a balance between the need to provide nutrients and the known complications associated with infusions of each of the three major nutrients--glucose, fat, and protein. It is prudent to maintain calorie intake within reasonable limits. If facilities for measurements of O2 consumption and hence metabolic rate are available, these should be utilized. Otherwise, metabolic rate should be estimated. In patients who are in satisfactory nutritional condition and who are being nourished to preserve lean body mass, diets designed to maintain body cell mass should be utilized. Practically speaking this means an energy intake of 1.0 to 1.2 times the daily energy expenditure and an N intake of 200 to 300 mg/kg/day. In patients where the goal is restoration of lean body tissue, a nutritional regimen designed to achieve a positive calorie and N balance should be used. This generally means an energy intake of 1.4 to 1.6 times the energy expenditure, with a N intake of 250 to 400 mg/kg/day. The nonprotein calories are administered as 50% glucose and 50% fat. These recommendations are based on studies performed to data. The area of nutritional support of the acutely ill patient is under extensive investigation. It is likely that as more data are collected, these guidelines will be revised.

The effect of parenteral nutritional repletion on muscle water and electrolytes. Implications for body composition.

Nutritional depletion and repletion are associated with changes in the size of the extracellular and intracellular fluid compartments. Although the effect of nutrition on whole body composition is well established, the distribution of changes among the various body tissues is not. This study correlates changes in skeletal muscle composition with whole body electrolyte and nitrogen balance in an attempt to establish the contribution made by skeletal muscle to the changes in whole body fluid and electrolyte composition. Total parenteral nutrition was administered to ten patients for 16 to 25 days. Oxygen consumption, CO2 production, and balances of N, Na, and K were measured daily. Muscle biopsies were taken prior to administration of TPN, in the middle, and at the end of the nutritional regimen. Prior to administration of parenteral nutrition, muscle concentrations of water, sodium, and chloride were significantly higher than normal. With institution of the nutritional support regimen, all three concentrations decreased. The calculated loss in muscle water could account, at most, for only one-sixth of the loss in total body water. Muscle Na loss could account for approximately one-half of the whole body change. Potassium concentrations in the depleted patients were not significantly decreased from normal values and showed a negligible increase with TPN. Since the ratio of K to dry fat-free solids in muscle was constant, most of the whole body changes could be accounted for by assuming that nearly all N is deposited in muscle. Nutritional support results in restoration of cell mass with a contraction of the extracellular fluid (ECF) compartment. The changes in the ECF must occur in tissues other than muscle, while the restoration of cell mass occurs primarily in muscle.

The saphenous system for long-term parenteral nutrition.

Three case reports describing the use of inferior vena caval catheterizations for total parenteral nutrition (TPN) are presented. Five anterior femoral vein cutdowns were advanced through the saphenous bulb, femoral, and iliac veins into the inferior vena cava. Four catheters were used for the purpose of TPN administration, the 5th for blood product administration and intraoperative monitoring. Five catheters were left in place without thrombotic or septic complications for a total of 10 months. The technique of elastomer catheter insertion in the tributary of the greater saphenous vein under local anesthesia is described.