Epidemiology of constipation (EPOC) study in the United States: relation of clinical subtypes to sociodemographic features.

OBJECTIVE: Constipation is a common heterogeneous condition, possibly encompassing different clinical subtypes. Little is known about the comparative epidemiology of constipation subtypes. This study was conducted to estimate the prevalence of constipation subtypes and determine whether subtypes differ by sociodemographic factors. METHODS: Between June and September 1997, a telephone interview was conducted with individuals about their bowel habits in the preceding 3 months. Survey data on 15 constipation-related symptoms were used to identify individuals who met prespecified symptom criteria for the following mutually exclusive subgroups: functional constipation, irritable bowel syndrome (IBS), outlet obstruction or delay (outlet), both IBS and outlet (IBS-outlet), and frequent laxative users (i.e., at least every other day). A total of 10,018 eligible individuals in the United States 18 yr of age or older completed the interview. Test-retest reliability of reporting symptoms was assessed in a separate national survey. The Spearman's correlation coefficient for reporting symptoms ranged from 0.54 to 0.83; all but three symptoms had correlations above 0.68. RESULTS: The overall prevalence of constipation was 14.7%. By subtype, prevalence was 4.6% for functional, 2.1% for IBS, 4.6% for outlet, and 3.4% for IBS-outlet. An additional 1.8% of respondents reported laxative use at least every other day. Outlet was the most common subtype among women, whereas functional constipation was the most common subtype among men. The gender ratio varied by subtype, with elevated ratios for outlet (F/M = 1.65) and IBS-outlet (F/M = 2.27) subtypes. The age pattern differed among each of the four subtypes. Prevalence of functional subtype decreased with increasing age. In contrast, outlet subtype did not seem to vary by age, and IBS (both men and women) and IBS-outlet (women only) subtypes increased to age 35 yr and declined thereafter. Prevalence of functional constipation increased with increasing education. Outlet type was more common in nonwhites compared to whites. Finally, 45% of individuals with constipation reported having the condition for 5 yr or more. CONCLUSIONS: Constipation is a heterogeneous condition. Differences in epidemiological profile by age, sex ratio, and relation to other sociodemographical factors support the distinction of two and possibly more symptom-based subtypes.

Standardizing laparoscopic procedure time and determining the effect of patient age/gender and presence or absence of surgical residents during operation. A prospective multicenter trial.

BACKGROUND: Most of the expense of laparoscopic cholecystectomy (LC) is incurred while the patient is in the operating room (OR). Half of this operating room cost is equipment and the other half is personnel. What is an acceptable LC procedure time and how much variation is there? What are the effects of age, gender, and expertise on the mean LC procedure time? METHODS: A prospective, multicenter gathering of LC procedure times and task component times was performed through the cooperative effort of members of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) at 11 hospitals. The effect of LC time of age, gender, and surgical resident was recorded. RESULTS: The mean LC time for 359 cases was 73 +/- 28 min. The percent of this LC time for the following component tasks included: to place and remove trocars, 34%; total dissection time, 40%; intraoperative cholangiogram, 15%; and removing the gallbladder, 7%. Age and gender did not change LC time, but the presence of a surgical resident prolonged LC time from 53 to 79 min due to an increase in all LC component task times. CONCLUSIONS: LC time was globally calibrated in 11 North American hospitals and was found to be affected by expertise but not by gender or age. The mean and standard deviation of LC time can be used for purposes of self-assessing quality performance.

Estimated costs of biliary tract complications in laparoscopic cholecystectomy based upon Medicare cost/charge ratios. A case-control study.

BACKGROUND: Costs of laparoscopic cholecystectomy (LC)-associated biliary tract complications are poorly documented. METHODS: A retrospective, case-controlled study attempted to define costs in an institution-specific manner, as compared to a group of patients who underwent an uncomplicated LC at the same institution. Costs were estimated by obtaining actual hospital billing charges and multiplying them by each hospital's specific Medicare cost-to-charge ratio (MCCR). This is considered a reasonable estimate of cost. The MCCR is calculated annually and is the hospital's actual cost estimate divided by what it charges. RESULTS: Twelve complications consisting of six common bile duct transection/excisions (CBDTE), one CBD leak/stricture (CBDLS), and five cystic duct leaks (CDL) were identified and matched to a control group (having an uncomplicated LC) for age, sex, and institution where the LC had been completed. Mean cost for CBDTE was $9,061 +/- $5,112 vs $2,689 +/- $1,469 for controls (p = 0.015), and $6,937 +/- $3,317 for CDL vs the controls cost of $1,343 +/- $417 (p = 0.006). The single CBDLS injury cost $5,804 vs $3,611 for the control. While the costs of these complications are statistically significantly greater than the controls, they are dramatically less than the costs reported in the literature for these problems ($30,000-$300,000). CONCLUSIONS: Costs of LC-associated biliary tract complications, as calculated using MCCR multiplied by hospital charges, for each complication type were statistically significantly higher than for the control groups. Although more expensive than the controls, these complications do not appear to be as costly as has been reported in the past.

Biliary tract complications of laparoscopic cholecystectomy are detected more frequently with routine intraoperative cholangiography.

Controversy over whether intraoperative cholangiography (IOC) should be done routinely has intensified since the advent of laparoscopic cholecystectomy (LC). As yet, no study has demonstrated a clear benefit to its use, although their have been suggestions in the literature that routine use may confer an advantage to detection of injuries. One-hundred seventy-seven biliary tract complications occurring secondary to LC were identified from the combined data of seven institutions. The goal of this retrospective study was to examine the impact of IOC on the occurrence, recognition, and correction of such complications. The complications identified include 39 cystic duct leaks, 69 major ductal leaks or strictures, and 69 major ductal transection or excision injuries. Whether IOC was performed was known in 157 (88%) patients with 53 patients definitely having and 104 not having an IOC. Data concerning IOC were unavailable in 20 cases. More injuries were detected intraoperatively in the group having IOC (P < 0.001). Conversion of the LC to a laparotomy, often for repair of the injury, occurred more commonly in the group having a correctly interpreted IOC (P < 0.001). Conversion resulted in detection of injuries sooner, resulting in fewer operative procedures to correct the injury (P < 0.001). A transecting injury was prevented in at least seven patients when no visualization of the proximal biliary tree was documented by IOC. These partial ductal incisions were treated by t-tube placement. Incorrect interpretation of the IOC occurred in at least eight patients, with no identification of the proximal biliary tree in six.(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopy and major retroperitoneal vascular injuries (MRVI).

Injury to major retroperitoneal vessels is a potential serious complication of laparoscopy occurring when the Veress needle or trocar is inserted. This report is a review of major retroperitoneal vascular injuries (MRVI) occurring during laparoscopy, as these injuries have not been well documented in the literature. A retrospective, observational review of general surgical laparoscopy cases was conducted over a 3.5-year period in three community, university-affiliated hospitals. We identified 4 MRVI in 3591 laparoscopic procedures. These cases were critically analyzed and compared. The incidence of MRVI was approximately 0.1%. All cases occurred with the closed (blind) insertion technique of Veress needle and primary trocar insertion technique with disposable "safety" shield trocars. All patients sustaining MRVI had acute hypotension introperatively and significant blood loss necessitating postoperative transfusions. Recognition and rapid conversion to laparotomy are keys to enhancing outcome. There is significant potential for morbidity and mortality with laparoscopic MRVI, although each patient in this series was discharged without obvious short-term problems. The advantages of an open approach for primary trocar insertion are numerous and should alleviate the risk of MRVI associated with general laparoscopic surgery.

Successful treatment of bleeding pseudoaneurysms of chronic pancreatitis.

A ruptured pseudoaneurysm is the most rapidly fatal complication encountered in patients with chronic pancreatitis, with a reported mortality rate of 12.5% in treated patients to > 90% in those untreated. Although reportedly a rare complication of chronic pancreatitis, a pseudoaneurysm is encountered in 6-9.5% of patients with chronic pancreatitis and as many as 17% of all patients operated on for chronic pancreatitis. Timely diagnosis and treatment seems to result in markedly reduced mortality. Four patients with bleeding pseudoaneurysms associated with chronic pancreatitis and pseudocysts were encountered recently at Virginia Mason Medical Center. These patients' charts, as well as the English literature, were reviewed in detail. All of our cases occurred in alcoholic males. Pseudocysts with pancreatic ductal or pseudocyst rupture were seen in three cases. All had a history of crescendo-decrescendo pain episodes and had evidence of bleeding or were bleeding at presentation. Splenic vein occlusion was identified in 50% of the cases. A pseudoaneurysm was documented by angiography in all patients. Embolization was successfully attempted without complication in two patients. Three patients were ultimately treated with a pylorus-sparing (2) or standard (1) pancreaticoduodenectomy. These three are alive and doing well at 16, 26, and 52 months from the time of their procedure. A fourth patient was treated nonoperatively, because of severe comorbid disease and aberrant anatomy, with successful embolization of the pseudoaneurysm and biliary and pancreatic stenting. The pseudocyst resolved and he is asymptomatic 12 months after therapy. We advocate preoperative arteriography in all patients with suspected or known arterial pseudoaneurysm.(ABSTRACT TRUNCATED AT 250 WORDS)

Cystic duct leaks in laparoscopic cholecystectomy.

BACKGROUND: Cystic duct leak (CDL) appears to complicate laparoscopic cholecystectomy (LC) more often than open cholecystectomy (OC). No mention of CDL was found in a literature review that covered 48,822 OCs and their complications. PATIENTS AND METHODS: Fifty-four patients who developed biliary tract injuries following LC were reviewed for: the time from LC to presentation, presenting symptoms, method of diagnosis, treatment, outcome, and follow-up. RESULTS: Seventeen of 54 biliary tract complications (31%) were CDLs. The CDLs presented at a median of 4 days after LC with pain (76%) and nausea and/or vomiting (35%). Endoscopic retrograde cholangiopancreatography (ERCP) defined the diagnosis and the anatomy of the leak in 11 patients (65%). Biliary endoprosthesis placement was employed in 8 patients, with concomitant sphincterotomy in 5 (63%), and resolved CDL in every case. Seven (88%) of these patients were asymptomatic at a median interval of 10 months after stent retrieval. Six patients (35%) underwent reoperation. Five had laparotomy with ligation of the cystic duct stump and 1 underwent laparoscopic examination with reclipping of the cystic duct stump. Five (83%) were asymptomatic at a median follow-up of 26 months. CDLs may result from inaccurate clip placement, perforations proximal to the clips, and stump necrosis, as documented at reoperation. CONCLUSIONS: CDLs occur more frequently in LC than in the OCs reported in the literature. Most leaks require intervention. ERCP with stent placement is the diagnostic and therapeutic procedure of choice and has a high success rate of resolving leaks. To forestall CDLs, it is important to place clips accurately and avoid electrocautery in the vicinity of the cystic duct.

Characteristics of biliary tract complications during laparoscopic cholecystectomy: a multi-institutional study.

We collected the records of 81 patients with biliary tract injuries occurring during laparoscopic cholecystectomy (LC) who were referred to 3 referral centers during a 33-month (May 1990 to March 1993) period. All records were reviewed to provide data concerning the anatomy of the lesion induced, method of injury, timing of injury detection, role of intraoperative cholangiography (IOC), methods of treatment, and outcome of these injuries. Injuries were classified by our own method as follows: (1) cystic duct leaks (n = 15), (2) bile leaks and/or ductal strictures (n = 27), and (3) ductal transections or excisions (n = 39). Peak occurrence by quarter of the year was 4th quarter, 1990 (Lahey), and 3rd quarter, 1991 (Mason), and 1st quarter, 1992 (Mayo). The majority (62%) of the injuries were recognized after LC. At the time of LC, 31 of 81 (38%) injuries were recognized and converted to open procedures. Data regarding IOC were available in 63 of 81 (78%) cases. In patients in whom IOC was not performed, 14 of 38 (37%) operations were converted; if an IOC was obtained and interpreted correctly, 13 of 21 (62%) operations were converted. Primary repair was attempted in 11 leaks and/or strictures, but 36% required additional treatment. Primary repair was used in six transections or excisions, and 17% have required further intervention. In patients who had biliary-enteric bypass (BEB) performed outside (17) versus at the referral institution (29), 94% (16 patients) versus 0%, respectively, required additional operative (e.g., revision of a hepaticojejunostomy) or nonoperative (e.g., radiologic or endoscopic stenting or balloon dilation) procedures. When used as initial therapy or after a primary ductal repair, stents (with or without balloon dilation) resolved 100% of simple cystic duct leaks and 91% of leaks and/or strictures. In conclusion, the peak incidence of LC-related biliary injuries appears to have passed. A completed and correctly interpreted IOC increases the chance of detection of biliary injuries intraoperatively and should assist surgeons who use routine IOC. Nonsurgical techniques allow treatment of most simple cystic duct leaks, major ductal leaks and/or strictures, and postoperative BEB strictures, although follow-up is limited. The poor results of pre-referral BEB is not surprising since all of these patients were selected for referral because their treatments had not been successful.

Sparing a replaced common hepatic artery during pancreaticoduodenectomy.

A patient with a replaced common hepatic artery originating from the superior mesenteric artery successfully underwent a pylorus-sparing pancreaticoduodenectomy for chronic pancreatitis. This anomalous vessel was discovered by preoperative angiography but at operation the artery coursed ventral to the head of the pancreas, not, as one would predict, through the substance of the pancreas or dorsal to the pancreatic head and lateral to the portal vein. To our knowledge, this is the first case of a replaced common hepatic artery in this position reported in the English literature. Preservation of the entire blood supply to the liver and biliary tree is important to prevent biliary fistula after a Whipple procedure, and, in some cases, hepatic ischemia. In this case the artery was slightly larger and in the same position as the gastroduodenal artery, predisposing the patient to significant potential morbidity with a standard dissection.

Oncotic pressure, albumin and ileus: the effect of albumin replacement on postoperative ileus.

The effect of decreased colloid oncotic pressure, as seen in hypoalbuminemia and hypoproteinemia, upon intestinal function has been well delineated in the surgical literature. Patients undergoing abdominal aortic aneurysm resection or aortoiliac or aortofemoral bypass grafts are almost uniformly hypoalbuminemic postoperatively; with these two facts in mind, a prospective, randomized clinical study was undertaken to identify the role of serum albumin concentration on the length of postoperative ileus in this population. The main hypothesis was that patients whose albumin levels dropped below 3.5 gm/dL would have a more prolonged postoperative hospital course as a result of delay in return of bowel function when compared with those patients in whom the low albumin levels were exogenously acutely replenished to > 3.5 gm/dL. Albumin was replaced to a level greater-than or equal to 3.5 g/dL in one group of 37 patients (AR), with a control group of 32 patients (NR) not receiving any albumin. Return of bowel function was measured by the postoperative day that flatus was documented, as well as the postoperative day oral intake was resumed. Mean values were determined for each group, and t tests did not reveal a significant difference in postoperative day of flatus (AR mean = 4.06 days, NR mean = 4.16 days) or postoperative day of oral intake (AR mean = 4.0, NR mean = 3.75). Additional comparisons between the groups involving the number of postoperative days until a regular diet was begun (AR mean = 6.06, NR mean = 5.48) and length of postoperative hospital stay (AR mean = 9.16, NR mean = 8.43) failed to reveal significant differences.(ABSTRACT TRUNCATED AT 250 WORDS)

Cystic duct remnant fistulization to the gastrointestinal tract.

Cystic duct remnant (CDR)-enteric fistulization is a rare entity, with only four recorded cases in the literature. CDRs can be found in at least 30% of patients after cholecystectomy and have been reported in as many as 83% of these patients. Calculous obstruction of the CDR or the common bile duct in a patient with a CDR must be present for fistulization to occur. Patients with a CDR-enteric fistula will have biliary tract symptoms after cholecystectomy and may have biliary sepsis. The septic episode or cholangitis may and can resolve when the CDR decompresses through the fistula. In a patient with persistent biliary tract symptoms, CDR should be considered as a possible cause, and common bile duct stones are often associated with CDRs. Signs of systemic infection in patients with biliary symptoms after cholecystectomy may indicate CDR fistulization. If a CDR is suspected, endoscopic retrograde cholangiopancreatography is the diagnostic and potentially therapeutic test of choice. If the patient cannot be successfully treated with endoscopic retrograde cholangiopancreatography or has recurrent symptoms, operative therapy is indicated, including division of the fistula, excision of the CDR, and common bile duct exploration. There may be an increase in the number of complications associated with CDRs, considering the increasing frequency of laparoscopic cholecystectomy resulting in more lengthy CDRs.

Congenital genitourinary anomalies. Is there a predilection for multiple primary malignant neoplasms?

A case of simultaneous uterine and renal cell carcinoma in an elderly woman who had a septate vagina, double cervix, uterus didelphys, and a single kidney secondary to contralateral renal agenesis is reported. She was treated for a period of 8 months, first with pelvic irradiation followed by total abdominal hysterectomy and bilateral salpingo-oophorectomy and subsequently with heminephrectomy. Her renal function was normal postoperatively. The patient died of congestive heart failure in June 1990 after being free of carcinoma for approximately 18 years. The authors believe that this is the only case of its kind currently reported in the literature. Four of her family members died of either gastric (n = 3) or lung (n = 1) cancer, and one sister is alive with colon cancer. Only 19 proven cases of this constellation of congenital anomalies have been reported in the literature, and none have been associated with genitourinary (GU) carcinomas. There is a 50% to 70% incidence rate of genital tract anomalies in female patients with unilateral renal agenesis, secondary to the intimate association of the mesonephric and müllerian ducts. It has been suggested that the GU tract is prone to multiple primary malignant neoplasms, and there are families genetically predisposed to the development of large bowel and GU carcinomas. No conclusions can be drawn concerning the development of carcinoma in patients with congenital GU anomalies because of the small number of patients and the lack of follow-up in the literature.

Viral Transcription During Autographa californica Nuclear Polyhedrosis Virus Infection: a Novel RNA Polymerase Induced in Infected Spodoptera frugiperda Cells.

Autographa californica nuclear polyhedrosis virus-specific RNA synthesis in isolated nuclei of Spodoptera frugiperda cells in culture was monitored at different times postinfection. Up to 8 h postinfection viral RNA synthesis remained sensitive to 5 mug of alpha-amanitin per ml. During the course of infection this sensitivity decreased, and at 24 h postinfection RNA synthesis was completely resistant to alpha-amanitin. DEAE-Sephadex profiles of RNA polymerase isolated at 24 h postinfection showed a new, chromatographically distinct, alpha-amanitin-resistant form whose kinetics and response to divalent cations differed from those of the host RNA polymerases. The possibility that this enzyme may be responsible for viral late transcription is discussed.