Predicting conversion of laparoscopic cholecystectomy for acute cholecystitis.

BACKGROUND AND OBJECTIVES: Laparoscopic cholecystectomy can be safely performed in patients with acute cholecystitis. However, the rate of conversion to open cholecystectomy remains higher when compared with patients with chronic cholecystitis. Preoperative clinical or laboratory parameters that could predict the need for conversion may assist the surgeon in preoperative or intraoperative decision making. This could have cost-saving implications. METHODS: A retrospective review of 46 patients undergoing laparoscopic cholecystectomy for acute cholecystitis was performed. Records were assessed for preoperative clinical, laboratory and radiographic parameters on admission. Temperature and laboratory parameters were also recorded prior to surgery after an initial period of hospitalization that included intravenous antibiotics. The effect of admission and preoperative parameters as well as the trend in these parameters prior to surgery upon the rate of conversion to open cholecystectomy was assessed. RESULTS: Ten patients (22%) required conversion to open cholecystectomy. Conversion was required more often in males (43%) when compared with females (4%) (p=0.003). Conversion rate was 30% in patients with increased wall thickness by ultrasound compared with 12% for patients without wall thickening (p=ns). No admission or preoperative laboratory values predicted conversion. The trend in the patient's temperature (p=0.0003) and serum LDH value (p=0.043) predicted the need for conversion to open surgery. CONCLUSIONS: Preoperative prediction of the need for open cholecystectomy remains elusive. Male patients and patients with rising temperature and LDH levels while on intravenous antibiotics require conversion at increased frequency. However, the benefits of laparoscopic cholecystectomy warrant an attempt at laparoscopic removal in most patients with acute cholecystitis.

Patient satisfaction and results of vertical banded gastroplasty and gastric bypass.

BACKGROUND: Morbid obesity contributes to many health risks, including physical, emotional, and social problems. Various surgical treatments for morbid obesity have developed and have so far met with good results. This study compares vertical banded gastroplasty (VBG) with gastric bypass (GBP) and the patients' satisfaction with either procedure. METHODS: Between April 1993 and July 1997, 63 bariatric surgical procedures were performed at Eisenhower Army Medical Center. Of those, complete follow-up was obtained for 29 patients. The parameters evaluated included age, preoperative and postoperative weights, body mass index (BMI), type of surgery, complications, and the patient's level of satisfaction. RESULTS: The study group consisted of 27 women and 2 men. The average preoperative weight was 135 kg, and the average preoperative BMI was 48.3 kg/m2. There were 17 VBGs and 12 GBPs performed. The average total weight loss was 45.1 kg. The average postoperative BMI was 33.2 kg/m2. There were no statistically significant differences in weight loss between VBG and GBP. Four of 17 patients had complications after VBG, and three of 12 patients had complications after GBP. After VBG, 94.1 % of patients were satisfied, and after GBP, 100% were satisfied. Twenty-seven of 28 patients stated that they would have the surgery again. CONCLUSION: There were no statistically significant differences in weight loss or complications after VBG or GBP. Patient satisfaction was high after both procedures. Therefore, bariatric surgery is important in the treatment of appropriately selected, morbidly obese patients.

When it's not appendicitis.

Other pathology besides appendicitis may be found in patients with right lower quadrant pain. This has led some to advocate diagnostic laparoscopy/laparoscopic appendectomy for all such cases. This policy would substantially raise the costs of care without a priori proof of its efficacy. However, a selective approach on when to proceed with diagnostic laparoscopy will depend on the frequency of finding unexpected, nonappendiceal pathology. To determine this, we reviewed our experience with 202 appendectomies. For females < 50 years old, 33 per cent had normal appendices, 12 per cent had periappendicitis, 47 per cent had acute appendicitis, 12 per cent had perforated appendicitis, and 26 per cent had other nonappendiceal pathology. For males < 50 years old, 13 per cent had normal appendices, 8 per cent had periappendicitis, 67 per cent had acute appendicitis, 15 per cent had perforated appendicitis, and 5 per cent had other pathology. For patients > 50 years old, 7 per cent had normal appendices, 13 per cent had periappendicitis, 33 per cent had acute appendicitis, 60 per cent had perforated appendicitis, and 20 per cent other pathology. Other nonappendiceal pathology was found in 42 per cent of females < 50 with normal appendices, 57 per cent with periappendicitis, and 14 per cent with acute/perforated appendicitis. In males < 50 years, 50 per cent of those with normal appendices, 10 per cent of those with periappendicitis, and 0.7 per cent of those with acute appendicitis had nonappendiceal pathology. In conclusion, women of childbearing age and patients > 50 years old have a significant incidence of nonappendiceal pathology. In this group of patients, a diagnostic laparoscopy appears justifiable to identify the cause of the abdominal pain.

Massive hemorrhage from proximal gastric vascular ectasias.

Gastric vascular ectasias are rare lesions of the gastric antrum that may be the cause of iron deficiency anemia in the elderly. We report a case of proximal gastric vascular ectasias in a young man which caused rapidly fatal hemorrhage. This case is instructive because of the patient's youth, the location of the lesions, and the rapidly fatal hemorrhage.

Quality of life scale for gastroesophageal reflux disease.

BACKGROUND: Treatment of uncomplicated gastroesophageal reflux disease (GERD) is primarily to improve the symptoms of the patient. However, measurement of symptomatic outcome is difficult because it is as the patient perceives it to be and not "objective." This creates a need to develop a simple and understandable instrument to measure symptomatic outcome. STUDY DESIGN: All patients referred for evaluation of GERD were eligible for this prospective study. During the initial visit, patients were asked to complete the Gastroesophageal Reflux Data Sheet. This ten-item questionnaire included an overall assessment of satisfaction; the best possible score was 0, and the worst was 45. The evaluation included history, physical examination, and additional studies, including upper gastrointestinal series, esophagogastroduodenoscopy, esophageal manometry, and 24-hour esophageal pH monitoring as indicated. Initial treatment was medical with histamine2-blockers, omeprazole, cisapride, or both. If a patient was dissatisfied with medical treatment and had both a hypotensive lower esophageal sphincter and abnormal results of the 24-hour pH monitoring, then operative treatment with either laparoscopic or open Nissen or Toupet fundoplication was offered. After approximately three months of medical treatment or one month after operative treatment, patients were asked to complete the questionnaire again. Data were analyzed using nonparametric tests and linear regression analysis. RESULTS: A total of 72 patients were assessed, and 100 percent of them completed the questionnaire. Patients who were satisfied with their condition had a median health-related quality of life (HRQL) score of five, and those who were dissatisfied had a median score of 26 (p < 0.000001). Patients who ultimately chose surgical therapy had a median preoperative score of 28, compared with 15 for patients who chose to continue medical therapy (p = 0.0001). The change in HRQL score from before treatment to after treatment for surgical patients was 27 compared with 11 for medically treated patients (p < 0.002). Items 1 through 6 of the questionnaire were individually sensitive to the effects of treatment. However, there was no correlation between HRQL and the composite pH score or with the lower esophageal sphincter pressure. CONCLUSIONS: This HRQL score has advantages over standard health status instruments for GERD including simplicity for patients (and therefore a high compliance rate), ease of understanding for physicians, and sensitivity to the effects of treatment. In addition, it may help determine, early in the course of treatment, patients who may ultimately require surgical therapy, thereby avoiding prolonged, but futile, medical therapy.