Optimal testing parameters for blood cultures.

The effects of volume of blood, number of consecutive cultures, and incubation time on pathogen recovery were evaluated for 37,568 blood cultures tested with the automated BACTEC 9240 instrument (Becton Dickinson Diagnostic Instrument Systems) at a tertiary care center over the period of 12 June 1996 through 12 October 1997. When the results for this study were compared with previous data published for manual broth-based blood culture systems and patient samples obtained in the 1970s and 1980s, the following were found: (1) the percentage increase in pathogen recovery per milliliter of blood is less, (2) more consecutive blood culture sets over a 24-h period are required to detect bloodstream pathogens, and (3) a shorter duration of incubation is required to diagnose bloodstream infections. Guidelines developed in the 1970s and 1980s for processing and culturing blood may require revision.

Laparoscopic ultrasonography: a training model.

PURPOSE: The purpose of this study was to develop a surgical training program and to test the accuracy of laparoscopic ultrasound in detecting injected lesions in pig livers. METHODS: Pig livers were divided into eight segments and injected with Surgilube "malignant" and silicone "benign" lesions. All were examined by laparoscopic ultrasound followed by liver explantation to confirm results. First, a pilot study was conducted on six swine by injecting Surgilube lesions and performing laparoscopic ultrasound through 3 different ports (left upper quadrant (I), umbilicus (II), and right lower quadrant (III)) to determine per-segment accuracy and to optimize port placement. Second, blinded injection of Surgilube and silicone implants was done on 18 pigs with laparoscopic ultrasound conducted through the two most accurate ports from the pilot study. This model was then tested during a resident training workshop. RESULTS: In the pilot study, per-lesion and per-segment sensitivity was 96 percent, with no difference among the three ports used. Ports I and II were chosen for the blinded study for their convenience in performing laparoscopic colectomy. In the blinded study, per-segment sensitivity, specificity, and accuracy were 97 percent, 94 percent, and 96 percent and 99 percent, 94 percent, and 97 percent for ports I and II, respectively. At the conclusion of a pilot workshop, trainee per-segment sensitivity, specificity, and accuracy were 60 percent, 80 percent, and 70 percent, respectively. The major difficulty was differentiating benign from malignant lesions. CONCLUSIONS: A useful liver laparoscopic ultrasound training model for surgeons was developed with good preliminary results. It is anticipated that further training will enhance laparoscopic ultrasound accuracy rates before application of this modality in humans.

Detection of herpes simplex virus DNA in genital and dermal specimens by LightCycler PCR after extraction using the IsoQuick, MagNA Pure, and BioRobot 9604 methods.

We evaluated two automated systems, MagNA Pure (Roche Molecular Biochemicals, Indianapolis, Ind.) and BioRobot 9604 (Qiagen, Inc., Chatsworth, Calif.) as effective replacements for the manual IsoQuick method (Orca Research, Inc., Bothell, Wash.) for extraction of herpes simplex virus (HSV) DNA from dermal and genital tract specimens prior to analysis by LightCycler PCR. Of 198 specimens (152 genital, 46 dermal), 92 (46.2%) were positive for HSV DNA by LightCycler PCR after automated extraction of specimens with either the MagNA Pure or BioRobot 9604 instrument. The manual IsoQuick method yielded HSV DNA (total n = 95) from three additional specimens that were negative by the automated method (P = 0.25, sign test). Although the mean numbers of LightCycler PCR cycles required to reach positivity differed statistically significantly among all three of the methods of extraction, the estimated means differed by no more than 1.5 cycles (P < 0.05). Seventy (76%) of the 92 specimens that were LightCycler PCR positive by all three extraction methods were also positive by shell vial cell culture assay. HSV DNA was detected by a lower LightCycler PCR cycle number (26.1 cycles) in specimens culture positive for the virus than in culture-negative samples (33.3 cycles) (P < 0.0001). The manual IsoQuick and automated MagNA Pure and BioRobot 9604 methods provide standardized, reproducible extraction of HSV DNA for LightCycler PCR. The decision to implement a manual versus an automated procedure depends on factors such as costs related to the number of specimens processed rather than on the minimal differences in the technical efficiency of extraction of nucleic acids among these methods.

A prospective randomized comparison of laparoscopic appendectomy with open appendectomy: Clinical and economic analyses.

BACKGROUND: Previous randomized studies of laparoscopic appendectomy produced conflicting recommendations, and the adequacy of sample sizes is generally unknown. We compared clinical and economic outcomes after laparoscopic and open appendectomy in a sample of predetermined statistical power. METHODS: A pre-study power analysis suggested that 200 randomized patients would yield 80% power to show a mean decrease of 1.3 days' hospitalization. One hundred ninety-eight patients with a preoperative diagnosis of acute appendicitis were randomized prospectively to laparoscopic or open appendectomy. Economic analysis included billed charges, total costs, direct costs, and indirect costs associated with treatment. RESULTS: Laparoscopic appendectomy took longer to perform than open appendectomy (median, 107 vs 91 minutes; P <.01) and was associated with fewer days to return to a general diet (mean, 1.6 versus 2.3 days; P <.01), a shorter duration of parenteral analgesia (mean, 1.6 versus 2.2 days; P <.01), fewer morphine-equivalent milligrams of parenteral narcotic (median, 14 mg versus 34 mg; P =.001), a shorter postoperative hospital stay (mean, 2.6 versus 3.4 days; P <.01), and earlier return to full activity (median, 14 versus 21 days; P <.02). However, operative morbidity and time to return to work were comparable. Billed charges and direct costs were not significantly different in the 2 groups ($7711 versus $7146 and $5357 versus $4945, respectively), but total costs (including indirect costs) of laparoscopic appendectomy were, on average, nearly $2400 less, given the shorter length of stay and abbreviated recuperative period ($11,577 versus $13,965). Subgroup analyses suggested the benefit of a laparoscopic approach for uncomplicated appendicitis and for patients with active lifestyles. CONCLUSIONS: While laparoscopic appendectomy is associated with statistically significant but clinically questionable advantages over open appendectomy, a laparoscopic approach is relatively less expensive. The estimated difference in total costs of treatment (direct and indirect costs) was at least $2000 in more than 60% of the bootstrapped iterations. The economic significance and implications favoring a laparoscopic approach cannot be ignored.

Characteristics and evolution of extraintestinal manifestations associated with ulcerative colitis after proctocolectomy.

AIMS: Describe the characteristics of extraintestinal manifestations complicating ulcerative colitis present preoperatively and determine their evolution after surgery. METHODS: Between 1976 and 1986, 281 patients with ulcerative colitis exhibiting one or more extraintestinal manifestations (EIM) before either IPAA (n = 147), Brooke ileostomy (n = 71), Kock pouch (n = 48) or ileorectostomy (n = 15) were assessed retrospectively. The clinical evolution of each manifestation was classified as having disappeared, improved, remained unchanged or aggravated postoperatively. An efficacy index was designed to assess the ratio of the number of cases cured or improved over the number of cases unchanged or aggravated. The relationship between EIM and gender, age, duration of disease and the type of surgery was also ascertained. RESULTS: 433 EIM were observed in 281 patients. The most common were arthralgias of the large joints (n = 146), of the sacroiliac joint (n = 59) and the small joints (n = 51). In comparison to patients without EIM having received the same operation during the same period of time, EIM were seen more often in women, younger patients, than those with longer duration of disease and the ileoanal anastomosis group. 60% had only one EIM at a time. Based on the efficacy index, thromboembolic accidents and erythema nodosum were the most commonly cured or improved. Ocular manifestations and primary sclerosing cholangitis were unaffected. The other EIM responded favorably but variably with improvement in two thirds of patients. The presence of a rectal remnant (IRA) or ileal reservoir did not affect the evolution of the EIM. CONCLUSIONS: Thromboembolic complications which are life-threatening, erythema nodosum and arthralgia of the small and large joints which impair quality of life, benefited the most from proctocolectomy. Those conditions may be considered preoperatively when making the decision for surgery.

Surgical repair of chronic rotator cuff tears. A prospective long-term study.

BACKGROUND: Rotator cuff disease or injury is one of the most frequently seen orthopaedic conditions, and surgical repair of rotator cuff tears is a common procedure. A prospective analysis of the operation, with consistent assessment of patient characteristics, variables associated with the rotator cuff tear and repair techniques, and outcome factors, was performed. METHODS: One hundred and five shoulders with a chronic rotator cuff tear underwent open surgical repair and acromioplasty between 1975 and 1983. The patients were followed for an average of 13.4 years (range, two to twenty-two years). There were sixteen small tears, forty medium tears, thirty-eight large tears, and eleven massive tears. The tears were repaired directly (seventy-two tears), by V-Y plasty (twelve), by tendon transposition (twenty), or by reinforcement with a fascia lata graft (one). The long head of the biceps had been previously torn in eleven shoulders and was tenodesed in three other shoulders. In fifty-six shoulders, the distal part of the clavicle was excised for treatment of degenerative arthritic changes, often associated with osteophyte formation. RESULTS: Satisfactory pain relief was obtained in ninety-six shoulders (p < 0.0001). There was significant improvement in active abduction (p < 0.001) and external rotation (p < 0.007) as well as in strength in these directions of movement (p < 0.03 and p < 0.002, respectively). At the latest follow-up evaluation, the result was rated as excellent for sixty-eight shoulders, satisfactory for sixteen, and unsatisfactory for twenty-one. Tear size was the most important determinant of outcome with regard to active motion, strength, rating of the result, patient satisfaction, and need for a reoperation. Older age, less preoperative active motion, preoperative weakness, distal clavicular excision, and a transposition repair technique were all associated with larger tear size. There were eight reoperations; five were for rerepair of a persistent or recurrent rotator cuff tear. CONCLUSIONS: Standard tendon repair techniques combined with anterior acromioplasty, postoperative limb protection, and monitored physiotherapy can produce consistent and lasting pain relief and improvement in range of motion. Improving the results of this procedure will depend upon the development of new techniques to address the active motion and strength deficiencies following repair of massive rotator cuff tears.

Trauma in pregnancy.

OBJECTIVE: To determine whether the severity of maternal injury or other maternal and fetal variables will predict the outcome of pregnancy in the injured pregnant patient. PATIENTS AND METHODS: In this retrospective review of pregnant patients hospitalized at a level 1 trauma center from 1986 to 1996, we analyzed the maternal Injury Severity Score, maternal mortality, fetal-neonatal mortality, maternal hypotension, and fetal heart rate. RESULTS: Sixty-one pregnant women were identified who were hospitalized after trauma. The mean +/- SD maternal age was 26.6 +/- 6.6 years. The distribution of trauma per gestational age was 21%, 20%, and 59% for the first, second, and third trimester, respectively. The most common mechanism of injury was motor vehicle crashes. Long-term pregnancy outcome was available in 53 patients (87%). There was 1 maternal death. Fetal-neonatal death occurred in 8 (15%) of 53 pregnancies. Most maternal physiologic variables were not predictors of pregnancy outcome. We were unable to detect a difference in the distribution of Injury Severity Scores between viable and nonviable pregnancies. However, maternal hypotension and low fetal heart rate were common in nonviable pregnancies (P = .02). CONCLUSIONS: Maternal hypotension and fetal heart rate are potential predictors of pregnancy outcome after trauma. Other maternal and fetal physiologic variables are poor measures of fetal well-being and are unable to predict fetal outcome. Fetal-neonatal death does not necessarily correlate with severity of maternal injury.

Redefined duplex ultrasonographic criteria for diagnosis of carotid artery stenosis.

OBJECTIVE: To evaluate duplex ultrasonographic criteria for the determination of 50% or more and 70% or more stenosis of the diameter of the internal carotid artery based on conventional angiography in order to align ultrasonographic diagnostic categories with current clinical management schemes. PATIENTS AND METHODS: Between January 1, 1995, and June 30, 1999, 915 patients underwent both carotid duplex ultrasonography and cerebral angiography within 30 days at Mayo Clinic, Rochester, Minn. Of these patients, 294 were excluded from this study because of occlusion of one or both of the internal carotid arteries or atypical flow characteristics. In the remaining 621 patients (61 % male, 39% female; mean age, 67.7 years [range, 14-88 years]), 1218 vessels were available for correlation. Several Doppler ultrasonographic velocity variables were compared with the angiographic findings by use of receiver operating characteristic curve analysis. The primary end point was verification of optimal ultrasonographic criteria to diagnose 70% or more internal carotid artery stenosis. The secondary end point was establishment of threshold values to detect stenosis of 50% or more. RESULTS: At angiography, 382 patients had internal carotid arteries with 70% or more stenosis. Peak systolic and end diastolic velocities of the internal carotid artery and internal carotid artery:common carotid artery peak systolic velocity ratios were measured. For an internal carotid artery stenosis of 70% or more, a peak systolic velocity of 230 cm/s or more resulted in a sensitivity of 86.4%, a specificity of 90.1%, a positive predictive value of 82.7%, a negative predictive value of 92.3%, and an accuracy of 88.8%. An end diastolic velocity of 70 cm/s or more and an internal carotid artery:common carotid artery ratio of 3.2 or more yielded similar values. For an internal carotid artery stenosis of 50% or more, a peak systolic velocity of 130 cm/s or more resulted in a sensitivity of 92.1 %, a specificity of 89.5%, a positive predictive value of 90.3%, a negative predictive value of 91.3%, and an overall accuracy of 90.8%. An internal carotid artery:common carotid artery ratio of 1.6 or more yielded similar values. CONCLUSION: In our ultrasonography laboratory, a carotid artery stenosis of 70% or more (for which carotid endarterectomy is typically recommended in symptomatic patients) is diagnosed reliably with the following duplex ultrasonographic criteria: a peak systolic velocity of 230 cm/s or more, an end diastolic velocity of 70 cm/s or more, or an internal carotid artery:common carotid artery ratio of 3.2 or more.

Gastrointestinal carcinoid tumors: long-term prognosis for surgically treated patients.

To evaluate long-term survival of patients with gastrointestinal carcinoid tumors and to assess factors that may influence prognosis, 154 patients (49% females, 51% males), median age 62 years (range 12-84 years) treated at our institution during 1972-1982 have been followed long term. Tumor location included the foregut (7%), midgut (62%), and hindgut (30%). Ninety-five percent of the patients underwent surgical or endoscopic excision of the primary tumor, with overall operative mortality and postoperative morbidity rates of 2. 6% and 11%, respectively. At follow-up, 60 patients (39%) were alive (median follow-up 18 years; range 1-26 years). The main causes of death included carcinoid tumor burden (32%), unrelated causes (45%), other malignancy (19%), and unknown causes (4%). Observed overall 5- and 10-year survivals were 69% and 53%, respectively. Survival was not related to gender or symptoms at presentation. However, age, embryologic origin, tumor size, depth of invasion, nodal status, and stage of disease proved to be of statistical significance (log-rank). In a multivariate Cox' model, only older age (> 62 years) [P = 0. 001, odds ratio (OR) = 3.4) and embryologic origin (midgut versus foregut) (P = 0.045, OR = 0.45) provided independent prognostic power when death from any cause was taken as the end-point. This study confirms that patient's age and the site of the primary tumor have prognostic significance. Carcinoid tumors are neuroendocrine tumors with a relatively good prognosis, and long-term survival is possible despite advanced stages of disease.

Are patients with multiple endocrine neoplasia type I prone to premature death?

Multiple endocrine neoplasia type I (MEN-I) is an autosomal dominant disorder characterized by endocrinopathies involving the anterior pituitary gland, parathyroid glands, and pancreas. The long-term prognosis for patients affected with this disorder is uncertain. To better characterize this prognosis, we performed a retrospective review of all patients with MEN-I treated at a single institution during the period 1951-1997. A group of 233 patients served as the study population. Their records were analyzed for confirmation of diagnosis, treatments received, long-term survival, and cause of death. Altogether, 108 eight male patients (46%) and 125 female patients (54%) were identified. At the conclusion of the study, 164 (70%) were alive and 69 (30%) were deceased, with a median follow-up for patients alive at last contact of 13.4 years (range < 1 month to 54.3 years). The cause of death was reliably obtained in 60 patients. Of these patients, 17 (28%) died of causes related to MEN-I, most commonly metastatic islet cell tumors (10 patients). The remaining patients died of causes unrelated to MEN-I, most commonly coronary artery disease and nonendocrine malignancies (14% each). The overall 20-year survival of MEN-I patients was 64% (95% CI was 56-72%), and that of an age- and gender-matched upper Midwest population was 81% (p < 0.001). Patients with MEN-I appear to be at increased risk of premature death. Earlier diagnosis and treatment of potentially malignant pancreatic islet cell neoplasms may result in a decrease of this premature mortality.

Change in diagnosis among orthopedists compared to non-orthopedists in the management of acute knee injuries.

OBJECTIVE: Uncertainty regarding diagnosis is associated with lower patient satisfaction and can lead to delays in definitive treatment and to inappropriate use of resources. We sought to compare change in diagnosis among orthopedists and non-orthopedists caring for a community based cohort of individuals with incident acute knee injuries. METHODS: We conducted a longitudinal investigation of a population based cohort of Olmsted County residents with their first episode of acute knee injury occurring between January 1, 1993, and December 31, 1995. We reviewed the entire (inpatient and outpatient) medical records for these patients and collected extensive clinical data on all diagnoses made (including possible and probable) and the specialty of the attending physician(s) making them. Diagnoses were categorized as: (1) meniscus injury, cruciate injury, or osteochondral fracture; (2) ligament injury, patellar instability, patellar injury; or (3) sprain, strain, injury (unspecified). Diagnostic switches were defined as changes from one diagnostic category to another, or the addition or subtraction of a diagnostic category. We then examined the quality of the documented evidence supporting meniscal, ligamentous, and cruciate diagnoses (at initial evaluation) by comparing the clinical evidence to the recommendations outlined by the American Academy of Orthopaedic Surgeons clinical algorithm on acute knee injury. Analyses were conducted comparing (1) the number of diagnostic switches and (2) the quality of the documented evidence among those cases initially cared for by orthopedists and those cared for by non-orthopedists, using logistic regression analysis adjusting for age, sex, and injury severity. The influence of these variables on costs of care was also examined. RESULTS: There were 664 patients (361 men and 303 women) in our study population, with an average age of 36.0 years (minimum 17, maximum 87). Of these, 324 were excluded because they only had one clinical encounter for their acute knee injury. Of the remaining 340, 59 (17.4%) were initially cared for by an orthopedist and 211 (62.1%) were cared for by an orthopedist at some time during their care. Diagnostic switches were significantly less frequent in the group who were cared for by orthopedists (55% vs 74%, p < 0.001). This result persisted after adjusting for age, sex, and severity (p = 0.003). The proportion of cases whose diagnoses were supported by evidence was significantly higher among the group whose first attending physician was an orthopedist (63.0% vs 37.6%, p = 0.002). Both change in diagnosis (p < 0.001) and physician specialty (p < 0.001) were statistically significant predictors of costs of care. CONCLUSION: Compared to non-orthopedic care, orthopedic care for acute knee injury was associated with fewer changes in diagnosis, and diagnoses made by orthopedists were more likely to be supported by evidence. However, even after adjusting for severity, orthopedic care remained significantly more costly than non-orthopedic care.

Effects of 4 hand-drying methods for removing bacteria from washed hands: a randomized trial.

OBJECTIVE: To evaluate the effects of 4 different drying methods to remove bacteria from washed hands. SUBJECTS AND METHODS: One hundred adult volunteers participated in this randomized prospective study. All bacterial counts were determined using a modified glove-juice sampling procedure. The difference was determined between the amounts of bacteria on hands artificially contaminated with the bacterium Micrococcus luteus before washing with a nonantibacterial soap and after drying by 4 different methods (cloth towels accessed by a rotary dispenser, paper towels from a stack on the hand-washing sink, warm forced air from a mechanical hand-activated dryer, and spontaneous room air evaporation). The results were analyzed using a nonparametric analysis (the Friedman test). By this method, changes in bacterial colony-forming unit values for each drying method were ranked for each subject. RESULTS: The results for 99 subjects were evaluable. No statistically significant differences were noted in the numbers of colony-forming units for each drying method (P = .72). CONCLUSION: These data demonstrate no statistically significant differences in the efficiency of 4 different hand-drying methods for removing bacteria from washed hands.

Intraoperative topical tetracycline sclerotherapy following mastectomy: a prospective, randomized trial.

BACKGROUND AND OBJECTIVES: Postoperative wound seromas are a frequent and troublesome occurrence after mastectomy. Recent reports have suggested the efficacy of topical sclerosants at reducing their formation. METHODS: A prospective, randomized, double-blinded trial was performed to examine the effect of intraoperatively administered topical tetracycline on the occurrence of postoperative mastectomy seromas. Thirty-two women were randomized to the control arm (normal saline) and 30 women to the tetracycline arm. In the treatment group, 100 ml (2 g) of tetracycline solution was administered topically to the chest wall and skin flaps prior to skin closure. The control group received an equal volume of normal saline. Patients were monitored for the development of postoperative wound seroma. RESULTS: There were no significant differences between groups regarding total volume of closed suction drainage, numbers of patients leaving hospital with drains in place, or duration of catheter drainage. Seroma formation 2 weeks postoperatively was greater in the tetracycline group than the control group (53% vs. 22%, P = 0.01). There were no differences between groups regarding the degree of postoperative pain, wound infection, or seroma formation 1 month postoperatively. CONCLUSIONS: Topical tetracycline is not effective at preventing post-mastectomy wound seromas.

Physiologic responses to laparoscopic aortofemoral bypass grafting in an animal model.

OBJECTIVE: To measure and compare the physiologic, metabolic, and hemodynamic responses to aortofemoral bypass grafting by three techniques: open or conventional laparotomy, laparoscopic-assisted (minilaparotomy), and totally laparoscopic grafting. METHODS: Twenty-four laboratory-bred hounds were randomized to one of three groups (open, laparoscopic-assisted, or totally laparoscopic). Four sets of parameters were measured: hemodynamic (intraoperative continuous cardiac output monitoring), inflammatory or hematologic (serial leukocyte and platelet levels), metabolic responses (serial blood glucose, serum cortisol and insulin, plasma epinephrine, plasma norepinephrine, and dopamine levels), and catabolic (24-hour urinary nitrogen excretion). RESULTS: Cardiac output increased transiently with aortic cross-clamping, more in the laparoscopic-assisted and total laparoscopic groups than in the open group, but the differences were not significant. White blood counts nearly doubled within 12 hours of surgery but were similar in all three groups. Platelet counts decreased significantly in all three groups, but no significant intergroup effects were observed. Metabolic parameters (e.g., blood glucose, cortisol, and catecholamine) rose significantly during surgery but fell to normal within 24 hours, with no important difference between groups. For the first 24 hours, urinary urea excretion fell by 50% but returned to normal by 7 days in all three groups. CONCLUSIONS: In the experimental animal model, the hemodynamic, hematologic, and metabolic responses to laparoscopic and laparoscopic-assisted aortofemoral bypass grafting are similar to those produced by conventional laparotomy graft placement. These data call into question whether laparoscopic techniques for aortic surgery have a significant physiologic advantage in humans.

Safety and advantages of laparoscopic vs. open colectomy in the elderly: matched-control study.

PURPOSE: The aim of this study was to determine rates of complications and extent of benefits for laparoscopic-assisted colectomy compared with open colectomy in patients older than age 75. METHODS: Forty-two patients undergoing laparoscopic-assisted colectomy (1992-1998) were matched to 42 open colectomy patients for gender, age, year of surgery, operating surgeon, and procedure. Health status (American Society of Anesthesiology score), previous abdominal surgery, conversion rate, surgical outcome, and need for assistance at admission and dismissal (independence vs. home with assistance vs. nursing facilities) were reviewed. RESULTS: Mean ages were 81.2 and 80.5 years for laparoscopic-assisted colectomy and open colectomy, respectively (P = not significant). Twenty-one laparoscopic-assisted colectomy and 23 open colectomy patients were females. American Society of Anesthesiology scores were comparable, as were rates of previous abdominal surgery (57 percent for laparoscopic-assisted colectomy vs. 62 percent for open colectomy; P = not significant). Mean operative times were longer for laparoscopic-assisted colectomy (190 minutes for laparoscopic-assisted colectomy vs. 142 minutes for open colectomy; P < 0.001); operating room times progressively decreased from 221 minutes in 1992 to 1995 to 147 in 1998 for laparoscopic right hemicolectomy (P < 0.001). The conversion rate for laparoscopic-assisted colectomy was 14.3 percent. There were no deaths in either group, and laparoscopic-assisted colectomy was associated with fewer morbidities (14.3 percent for laparoscopic-assisted colectomy vs. 33.3 percent for open colectomy; P = 0.04), narcotic usage (2.7 vs. 4.8 days; P < 0.001), time to return to bowel movements (3.9 vs. 5.9 days; P < 0.001), and length of hospital stay (6.5 vs. 10.2 days; P < 0.001). Independent status at admission in 37 laparoscopic-assisted colectomy and 38 open colectomy patients was maintained at discharge by 35 laparoscopic-assisted colectomy vs. 29 open colectomy patients (P = 0.025). CONCLUSIONS: Laparoscopic-assisted colectomy is safe and beneficial, including preservation of postoperative independence, to the elderly when compared with open colectomy.

Long-term outcomes for surgically resected craniopharyngiomas.

OBJECTIVE: This retrospective study critically analyzed the long-term functional outcomes and tumor recurrence rates for surgically treated craniopharyngiomas. METHODS: This study used an outcome classification system that included functioning vision, independent versus dependent living, Karnofsky Performance Scale scores, academic levels, work status, and psychological status. Tumor recurrence rates were analyzed with respect to the extent of surgical resection and adjunctive radiotherapy. RESULTS: For 121 patients, with a mean follow-up period of 10 years, the overall "good outcome" rate was 60.3%. Factors associated with poor outcomes included lethargy at presentation, visual deterioration, papilledema, tumor calcification, hydrocephalus, and tumor adhesiveness at surgery. Gross total resection was associated with good outcomes (P = 0.017) and decreased risk of recurrence (P = 0.024). Subtotal resection was associated with increased risk of tumor recurrence (P = 0.0235). The highest risk of recurrence was in the subtotal resection/no radiation group (P = 0.0001). There were no differences in outcomes or recurrence rates between pediatric and adult patients. There were also no differences in outcomes or recurrence rates between papillary and adamantinous tumors. Approximately one-third of patients exhibited morbid obesity, and permanent diabetes insipidus was observed for 25 patients. CONCLUSION: A rigorous evaluation of outcomes for tumors such as craniopharyngiomas must consider not only the extent of resection, as judged by postoperative imaging, but also the long-term physical, intellectual, and psychological functioning of the patients.

Venting intraluminal drains in pancreaticoduodenectomy.

The utility of placing biliary, pancreatic, or enteric "venting"tubes (externally draining devices traversing the bowel or bile duct that have their distal tip located intraluminally near the biliary or pancreatic anastomosis) when performing a pancreaticoduodenectomy has received little attention to date. We hypothesize that these venting tubes do not decrease the morbidity or mortality associated with pancreaticoduodenectomy and may actually be a source of additional morbidity. To characterize our use of and the effect of these drains, we retrospectively analyzed 136 pancreaticoduodenectomies (127 partial, 9 total) performed over a 24-month period. Venting drain use, drain type and size, drain location, duration of intubation, hospital course, and postoperative complications were noted. Venting tubes were used in 80 patients (59%). The use of these drains had no significant relationship to postoperative length of stay, the development of major complications, overall morbidity, or mortality (P>0.05). Such drains also did not significantly shorten the length of hospital stay (P>0.05) or improve outcome when available to augment local control following luminal leak (n = 6) or regional abscess (n = 7). These drains were removed at a median interval of 29 days postoperatively (range 6 to 77 days). Seven patients had complications that were directly related to the venting drain; four of these patients had a documented intra-abdominal luminal leak from the site of drain removal, whereas the other three were hospitalized for presumed leakage secondary to immediate, severe abdominal pain following removal of the drain. These seven patients were elderly (mean age 70 years) and often harbored pancreatic ductal carcinoma (n = 6). Intraluminal drains afford no distinct advantage in terms of shortening the postoperative length of stay, decreasing operative morbidity and mortality, or improving local control with regional sepsis in pancreaticoduodenectomies. Furthermore, they may add an additional source of morbidity and we no longer employ them routinely.

Long-term results of biliary reconstruction after laparoscopic bile duct injuries.

HYPOTHESIS: The Hepp-Couinaud approach to biliary enteric reconstruction for laparoscopic bile duct injuries provides a durable, long-term result in most patients. DESIGN: Retrospective study of patients who underwent operative repair of laparoscopic bile duct injuries from January 1990 through December 1997. SETTING: Academic tertiary referral center. MAIN OUTCOME MEASURES: Outcome was assessed using a grading system based on clinical symptoms, liver function tests, and need for reintervention for anastomotic stricture. The Kaplan-Meier method was employed to estimate stricture-free survival. RESULTS: Fifty-nine consecutive patients underwent operative repair of the following laparoscopic bile duct injuries (Strasberg classification): B: n = 2 (3%), C: n = 1 (1%), D: n= 2 (3%), E1: n= 5 (8%), E2: n= 16 (27%), E3: n= 25 (42%), E4: n = 5 (8%), and E5: n = 3 (5%). Forty-seven patients (80%) had 1 or more interventions prior to the index repair. The extrahepatic left bile duct (Hepp-Couinaud approach) was used in 46 of 53 patients who underwent a Roux-en-Y hepaticojejunostomy. Follow-up (mean+/-SEM, 3.7+/-0.3 years) was complete in 54 of the 57 patients still alive. Five patients developed subsequent anastomotic strictures and were treated with percutaneous transhepatic dilation (n = 3), endoscopic dilation (n = 1), and operative revision (n= 1). Excellent to good long-term results were achieved in the remaining 49 patients (91%). Life-table analysis yielded 95% and 88% chances of stricture-free survival at 2 and 5 years, respectively. CONCLUSIONS: Complex iatrogenic proximal bile duct injuries and strictures are amenable to operative repair using the extrahepatic left bile duct. The Hepp-Couinaud approach offers a durable result in more than 90% of patients, even after previous interventions have failed.

Lone atrial fibrillation in elderly persons: a marker for cardiovascular risk.

BACKGROUND: The risk of stroke in persons aged 60 years and younger with lone atrial fibrillation (LAF) is no greater than in the general population. The effect of older age on the risk of stroke in persons with LAF is less well established. PARTICIPANTS AND METHODS: The risk of stroke in persons with LAF and without substantial comorbidities was examined in a population-based study at a single institution in Olmsted County, Minnesota, and compared with that in an age- and sex-matched population. The mean age was 74 years (range, 61-97 years). The median duration of follow-up was 9.6 years until death or last follow-up. RESULTS: Of 55 patients, 26 had 31 cardiovascular events during follow-up, occurring a median of 5.1 years after diagnosis (range, 0.7-18 years). Of 11 cerebrovascular events, 6 were transient ischemic attacks and 5 were strokes. The event rates (percentage per person-year) were 0.9% for stroke, 1.1% for transient cerebral ischemia, and 2.6% for myocardial infarction, for a total cardiovascular event rate of 5.0% per person-year. The corresponding rates for the age- and sex-matched control group were 0.2%, 0%, and 1.1%, for a total of 1.3% per person-year. The incidence of total cardiovascular events was significantly greater (P< .01) in those with LAF, although there was no difference in survival. CONCLUSION: Lone atrial fibrillation occurring after age 60 years is a risk marker for a substantial increase in cardiovascular events that warrants consideration for antithrombotic therapy.

Solitary pulmonary nodules: clinical prediction model versus physicians.

OBJECTIVE: To determine whether a clinical prediction model developed to identify malignant lung nodules based on clinical data and radiologic lung nodule characteristics could predict a malignant lung nodule diagnosis with higher accuracy than physicians. MATERIAL AND METHODS: One hundred cases were obtained by using a stratified random sample from a retrospective cohort of 629 patients with newly discovered 4- to 30-mm radiologically indeterminate solitary pulmonary nodules (SPNs) on chest radiography. A chest radiologist, pulmonologist, thoracic surgeon, and general internist made predictions of a malignant lesion and recommendations for management (thoracotomy, transthoracic needle aspiration biopsy, or observation) on the basis of radiologic and clinical data used to develop the clinical prediction rule. The predictions of a malignant lung nodule were compared with the probability of malignant involvement from a previously validated clinical prediction model to identify malignant nodules on the basis of three clinical characteristics (age, smoking status, and history of cancer greater than or equal to 5 years previously) and three radiologic characteristics (nodule diameter, spiculation, and upper lobe location). RESULTS: Receiver operating characteristic analysis showed no significant difference between the logistic model and the physicians' predictions. Calibration curves revealed that physicians overestimated the probability of a malignant lesion in patients with low risk of malignant disease by the prediction rule; this finding suggests a potential for the decision rule to improve the management of patients with SPNs that are likely to be benign. CONCLUSION: The prediction model was not better than physicians' predictions of malignant SPNs. The prediction rule may have potential to improve the management of patients with SPNs that are likely to be benign.