A prospective analysis of 3525 esophagogastroduodenoscopies performed by surgeons.

BACKGROUND: This study was undertaken to evaluate the safety and efficacy of surgeons performing esophagogastroduodenoscopy (EGD) and to use these results to assess existing credentialing guidelines for surgeons. METHODS: A prospective outcomes study was designed to accept input from members of SAGES. End points were the time taken and rate of success in reaching the duodenum, the frequency of arriving at a diagnosis, and complications of EGD as related to operator experience. RESULTS: Information from a total of 3,525 EGDs was prospectively entered into a database between December 2001 and December 2002. Common indications were abdominal pain/nausea/vomiting (34.8%), gastroesophageal reflux disease (24.9%) and dysphagia (17.4%). The findings were inflammation in 1,895 (53.8%), hiatus hernia in 1,010 (28.7%), nonbleeding ulcer in 462 (13.1%), bleeding ulcer in 59 (1.7%), stricture in 344 (9.8%), and polyp/tumor in 206 (5.8%). Biopsies were obtained in 2080 (59.0%). Concomittant procedures performed were dilation in 253 (7.2%), removal of a foreign body (FB) or removal/insertion of a percutaneous endoscopic gastrostomy tube (PEG) in 190 (5.4%), and polypectomy in 59 (1.7%). The EGD was completed to the duodenum in 3282 patients (93.1%) with a mean procedure time of 9.2 min (range 1-60 min). Examination of the duodenum was not attempted in 231 patients for reasons such as previous gastric surgery ( n = 119), obstruction ( n = 58) or because the EGD was done for FB/PEG removal or PEG placement ( n = 36). Attempted EGD could not be completed in 12 patients (0.3%). The most common complication was hypoxia ( n = 57, 1.6%), which was treated with supplemental oxygen and observation. New bleeding occurred in eight patients and the procedure failed to control bleeding in three others. No complications occurred in 3447 patients (97.8%). Completion rates and major complications were not correlated to experience, but there was a significant association between experience and the time required for completion of the procedure ( p < 0.0001). CONCLUSIONS: This study shows that surgeons can perform EGD with a high degree of success and low morbidity. On the basis of this large prospective study, no minimum number of cases could be proposed for credentialing surgeons to safely perform either diagnostic or therapeutic esophagogastroduodenoscopy.

Groin pain in the absence of hernia: a new syndrome.

Groin pain may be produced by a true hernia, trauma to the groin structures or peripheral nerve, or root compression at various levels. Approximately 4,000 patients underwent inguinal herniorrhaphy (group A). An additional 134 patients complaining of groin pain and exhibiting no evidence of primary or recurrent hernia fell into two categories: 30 patients who had a previous herniorrhaphy (group B) and 104 patients without previous surgery (group C). Group B patients underwent a diagnostic nerve block which, when positive, suggested ilioinguinal nerve compromise at the wound. Those who failed conservative measures underwent nerve division. Group C patients were advised to decrease recreational and occupational activities; if that failed, they underwent lumbosacral spine imaging. There were no neuralgias in group A. Eight group B patients responded to conservative measures; the 22 others required ilioinguinal nerve division which relieved their pain. In group C, 42 patients responded to physical activity restriction plus NSAIDs; the remaining 62 underwent imaging which revealed lumbosacral bone pathology producing root compression and were referred to orthopedists. Lumbosacral spine pathology should be suspected in patients who complain of groin pain in the absence of hernia or previous herniorrhaphy. Recognition of this syndrome may avoid negative exploratory herniorrhaphies.

Ionic implantation of silicone chronic venous access devices does not alter thrombotic complications: a double-blinded, randomized clinical trial.

BACKGROUND: Ion implantation of silicone vascular catheters has been shown in preclinical and pilot studies to alter the thrombogenicity of silicone surfaces through the reduced adherence of thrombin. This prospective, randomized double-blinded study was designed to detect differences in function related to thrombotic events between ion-implanted and standard silicone chronic venous access devices (CVAD) placed in patients with cancer who are receiving chemotherapy. METHODS: Patients with nonleukemic malignancies who required venous access for chemotherapy and who were not receiving anticoagulants were randomized to receive standard or ion-implanted CVAD. Postoperative functional assessments of the ease of infusion or aspiration were performed by oncology nurses caring for the patients. RESULTS: Follow-up, available for 100 of 106 randomized patients, showed more episodes of occlusion to aspiration in the ion implantation group (47%) than in the control group (39%) but this difference was not significant. There were no significant differences between the 2 groups in the number of occasions when anticoagulation or local thrombolytic therapy was required nor were there differences in the numbers of infection or deep venous thromboses. CONCLUSIONS: Ion implantation of silicone catheter material does not alter the incidence of local thrombotic complications of CVAD. Although there were no serious complications resulting from this treatment, the use of ion-implanted catheters cannot be recommended on the basis of this trial.

Routine chest roentgenography is unnecessary in the work-up of stage I and II breast cancer.

PURPOSE: Clinical practice guidelines of many professional societies call for routine staging chest x-rays (SCXR) for all patients with invasive cancer. Given the estimated 157,000 patients annually for whom this recommendation pertains, this screening examination represents a considerable health care expenditure. If it were shown that SCXR rarely changed the management of low-risk subsets of this population, it might be possible to selectively omit this practice from the care of these patients with substantial resultant cost savings. PATIENTS AND METHODS: All patients with clinical stage I and II breast cancer presenting to the Baystate Medical Center from 1989 through 1997 were identified through the Tumor Registry. Their hospital records were reviewed for clinical presentation and documentation of SCXR. RESULTS: One thousand four hundred ninety-four patients were identified with clinical stage I and II disease. SCXR were available for review on 1,003 patients. Only one asymptomatic patient was upstaged to stage IV based on a SCXR. Two patients with primary lung tumors were also identified. These data demonstrate an asymptomatic pulmonary metastasis detection rate of 0. 099% (95% confidence interval, 0.0% to 0.6%). The total charges of SCXR for this group approached $180,000. CONCLUSION: These data demonstrate the low diagnostic yield and high cost of routine SCXR in the management of asymptomatic patients with clinical stage I and stage II breast cancer. Because other studies have shown that SCXR changes neither quality of life nor overall survival, SCXR should be limited to symptomatic patients in whom metastatic disease is suspected.

The unsatisfactory margin in breast cancer surgery.

BACKGROUND: Surgical margin involvement with breast cancer usually results in obligatory reexcision or mastectomy. While unalterable occult host and pathologic factors may interfere with margin clearance during the initial excision, it is possible that alterations in surgical technique might increase the likelihood of obtaining satisfactory margins. METHODS: Two hundred and thirty-five patients who were candidates for breast conservation therapy were identified for 1991 and 1996 using the Tumor Registry. Margins were defined as "unsatisfactory" if there was microscopic involvement with tumor or the margin was close at initial excisional biopsy and the surgeon opted for reexcision. Multiple logistic regression analyses of factors associated with margin status were performed. RESULTS: One hundred thirty-two (56%) patients had positive or close (unsatisfactory) margins; this rate increased from 51% in 1991 to 59% in 1996. Patients with unsatisfactory margins underwent more procedures (mean 2.0 versus 1.2; P <0.0001) than patients whose margins were satisfactory. The breast conservation rate for patients with unsatisfactory margins was 64% compared with 99% for patients with satisfactory margins. A multiple logistic regression demonstrated that patients with unsatisfactory margins were 67 times more likely to have a mastectomy than patients whose margins were satisfactory after adjusting for other significant factors (P <0.0001). The practice of fine needle aspiration biopsy, orientation of specimen margins by the surgeon, and reexcision of tumor at the first operation were statistically significant technical factors in obtaining satisfactory margins. Significant pathology factors were extensive intraductal component (EIC), lobular or ductal extension, and tumor size. CONCLUSION: These data show that technical factors in the surgical management of breast cancer, as well as biological factors such as EIC, can influence the success of breast conservation.

Long-term complications associated with prosthetic repair of incisional hernias.

OBJECTIVE: To determine whether the type of prosthetic material and technique of placement influenced long-term complications after repair of incisional hernias. DESIGN: Retrospective cohort analytic study. SETTING: University-affiliated hospital. PATIENTS: Two hundred patients undergoing open repair of abdominal incisional hernias with prosthetic material between 1985 and 1994. INTERVENTIONS: Four types of prosthetic material were used and placed either as an onlay, underlay, sandwich, or finger interdigitation technique. The materials were monofilamented polypropylene mesh (Marlex, Davol Inc, Cranston, RI), double-filamented mesh (Prolene, Ethicon Inc, Somerville, NJ), expanded polytetrafluroethylene patch (Gore-Tex, WL Gore & Associates, Phoenix, Ariz) or multifilamented polyester mesh (Mersilene, Ethicon Inc). MAIN OUTCOME MEASURES: The incidence of recurrence and complications such as enterocutaneous fistula, bowel obstruction, and infection with each type of material and technique of repair were compared with univariate and multivariate analysis. RESULTS: On univariate analysis, multifilamented polyester mesh had a significantly higher mean number of complications per patient (4.7 vs 1.4-2.3; P<.002), a higher incidence of fistula formation (16% vs 0%-2%; P<.001), a greater number of infections (16% vs 0%-6%; P<.05), and more recurrent hernias (34% vs 10%-14%; P<.05) than the other materials used. The additional mean length of stay to treat complications was also significantly longer (30 vs 3-7 days; P<.001) when polyester mesh was used. The deleterious effect of polyester mesh on long-term complications was confirmed on multiple logistic regression (P=.002). The technique of placement had no influence on outcome. CONCLUSION: Polyester mesh should no longer be used for incisional hernia repair.

Hemobilia complicating hepatic cryosurgery.

We describe a 58-year-old man who developed hemobilia following hepatic cryotherapy. This was complicated by acute pancreatitis and recurrent cholangitis, which necessitated multiple endoscopic procedures (including biliary stenting) for successful management. As cryotherapy becomes more widely applied in the management of patients with liver tumors, it is essential that surgeons safeguard against the development of arteriobilious fistulae.

A method to track surgical site infections.

We present an approach to assessing the impact of surveillance for surgical site infections and providing feedback to surgeons on their progress, as part of continuous quality improvement. Adjusting for patient risk factors using the Standardized Mortality Ratio, there was a marked decrease over time in both SMR (1.3 to 0.27) and crude infection rates (32 to 10 per thousand operations per year). These declines cannot be explained by decreased length of hospital stay.

Fluoroscopy-free placement of standard chest wall subcutaneous chronic venous access devices.

BACKGROUND: This study was undertaken to evaluate the potential benefits of using an electromagnetic detection system to guide the intraoperative placement of chronic venous access devices (CVADs). STUDY DESIGN: An electromagnetic detection system was used to guide catheter placement during 54 procedures. Surgery and radiation exposure times were recorded. An oncology nursing follow-up questionnaire assessed device function. A cost analysis was performed. Outcomes were compared to similar data from a fluoroscopic historical control group. RESULTS: Eight study patients required intraoperative fluoroscopy; in 46 procedures (85%) the electromagnetic detection system was the sole modality employed to guide CVAD placement. One line was subsequently found in the internal mammary vein (2% false negative rate). Mean surgery times for placement of CVADs were 79.5 and 84.5 minutes for the study and control groups (p = NS). Mean radiation exposure rates were 0.16 and 0.86 minutes per patient for the study and control groups (p < 0.01). There was no significant difference in device function between groups. Major complications in the study group were rare. Mean cost of CVAD placement was $1993 and $2517 for the study and control groups (p = 0.005), respectively. CONCLUSIONS: The use of the electromagnetic detection system resulted in accurate placement of chest wall CVADs in the majority of patients. This resulted in significant reductions in radiation exposure and cost of CVAD placement.

Laparoscopic screening of surgical candidates with pancreatic cancer or liver tumors.

BACKGROUND: Patients with colorectal or pancreatic cancers may have peritoneal implants which are too small to be detected by current radiologic imaging techniques. Since such implants often preclude surgical removal of the primary tumor or isolated metastasis, their detection prior to open abdominal exploration may spare patients the morbidity of a large abdominal incision when there is no benefit to resection and lifespan is limited. METHODS: In the past 30 months, patients with pancreatic cancer, hepatoma, or isolated colorectal cancer metastases, who were candidates for surgical resection on the basis of standard radiologic scans, were examined with the laparoscope through a 10-mm periumbilical incision prior to undertaking open abdominal exploration. If unexpected implants were noted, biopsy was obtained through a 5-mm port placed through a convenient site. RESULTS: Since January 1993, 11 patients with pancreatic carcinoma, three patients with primary hepatic malignancies, and 12 patients with isolated metastases from colorectal cancers have undergone laparoscopic examination prior to celiotomy. Eight of these patients had unexpected peritoneal or liver involvement which precluded resection. Laparoscopy was successful in detecting disease in six such patients (75%). CONCLUSION: Although adding 20-30 min to the operative time when unrevealing, laparoscopy provided an effective way to avoid celiotomy in patients with carcinomatosis.

[10 year results of preoperative radiotherapy in treatment of rectal carcinoma]. / 10-Jahres-Ergebnisse der präoperativen Radiotherapie in der Behandlung des Rectumcarcinoms.

BACKGROUND: We have previously reported improvements in survival and disease-free survival at five years using preoperative radiation in the treatment of rectal cancer. The current update was undertaken to determine if these favorable results were durable with longer follow-up. METHODS: Patients found to have resectable rectal cancer between 1972 and 1979 were treated with 40-45 Gy of preoperative radiation (40 patients) or resection alone (109 patients). Follow-up information beyond five years was obtained from the Tumor Registry, physician contact and a survey of the National Death Index. Of the 149 patients followed for five years, 144 were evaluable at ten years. RESULTS: After a median follow-up of 125 months, survival of the irradiated patients was significantly better than that of controls (77 versus 57% at 5 years and 74 versus 41% at 10 years, p = 0.0044). Disease-free survival of those patients whose resection margins were free was also superior for the irradiated group (85 versus 59% at 5 years and 80 versus 45% at 10 years, p = 0.0045). CONCLUSIONS: The results show that the survival advantage for 40 to 45 Gy preoperative radiation in the treatment of rectal cancer persist at 10 years follow-up.

The influence of local tumor ulceration on the effectiveness of endocavitary radiation for patients with early rectal carcinoma.

BACKGROUND: Endocavitary radiation therapy is an alternative to surgical therapy for some early rectal carcinomas. Careful patient selection is necessary to ensure good results. The purpose of this study was to examine the authors' experience with endocavitary radiation at their institution from 1984 to 1991 to determine which factors were associated with treatment failure to provide for better future patient selection. METHODS: Thirty-two patients with carcinoma of the rectum, not apparently involving the muscle wall, underwent 75-120 Gy of endocavitary radiation as potentially curative therapy. Treatment was given as a series of 2-4 doses of 30 Gy at three weekly intervals. Twenty-two patients had polypoid tumors, 5 sessile, and 5 ulcerated. RESULTS: After a mean follow-up of 43 months (range, 6-103 months), 4 of 5 patients (80%) with ulcerated tumors developed local recurrences, compared with only 4 of 27 (15%) with sessile or polypoid lesions. Not only was the incidence of local recurrence greater for patients with ulcerated tumors (P = 0.009), but the time to recurrence was shorter also (P = 0.0001). Tumor size, anterior or posterior location, and dose of radiation received did not affect the rate of recurrence. CONCLUSIONS: These results indicate that superficial polypoid and sessile rectal tumors can be managed successfully with endocavitary radiation. Ulcerating tumors are likely to recur locally within a short time and therefore should be considered for surgical treatment initially.

Preceptored introduction of laparoscopic techniques for cholecystectomy into a large university-affiliated medical center.

Faced with the task of introducing laparoscopic techniques for cholecystectomy into the practice of a large department composed of individuals with varied backgrounds and experience, our surgical staff decided to grant provisional provileges to five surgeons, two from the full-time faculty and three from the community, who had completed a formal course in laparoscopic cholecystectomy. These five surgeons agreed to assist one another through 10 cases a piece before performing any procedures on their own or serving as preceptors for additional surgeons. Other surgeons could obtain credentials for this procedure by satisfying the same course criteria and receiving assistance from one of the five original surgeons during their first 10 cases. In the 14 months after September 1990, 250 laparoscopic cholecystectomies were performed by 19 different attending surgeons at our hospital. One death from hemorrhage (0.4%) and two bile duct injuries (0.8%) occurred in these patients. One of the bile duct injuries occurred after conversion to open cholecystectomy, as did the hemorrhage, which was from a vessel within the parenchyma of the gallbladder bed which rebled even after temporary control through open ligature technique. The second bile duct injury, the result of injudicious application of hemoclips for hemostasis, was minor in degree and the only injury to occur in a procedure conducted exclusively through the laparoscope. This experience demonstrates that laparoscopic techniques can be safely introduced into an environment involving multiple surgeons by adherence to a careful protocol of preceptored assistance.

Evaluation of gastrointestinal hemorrhage in patients with neurofibromatosis.

Over a 3-year period, two patients with neurofibromatosis were referred to our medical center for evaluation of repeated episodes of melena. Upper endoscopy was unrevealing in each case, as was colonoscopy. Arteriography during active hemorrhage was helpful in localizing the source of bleeding in one patient but not in the other. The source of bleeding in each patient was obvious at surgical exploration. Large neurofibromas protruded from the serosal surface of a short region of jejunum in both cases and an additional segment of ileum in one case. Hemorrhage had occurred as a result of erosion of mucosa stretched over these tumors. Local resection of the involved segments produced long-term control of the hemorrhage. Since these tumors were grossly visible on the serosal surface of the involved intestinal segments, laparoscopic evaluation could have been used to hasten diagnosis in each case.

Streptococcal adherence to Langerhans cells: a possible step in the pathogenesis of streptococcal pharyngitis.

Group A streptococci are nonmotile and have no structures that would enable them to penetrate submucosally into the pharynx. We have postulated that they adhere to host pharyngeal mucosal cells called Langerhans cells that are motile and could transport them into deeper tissues. We used a microscopic assay to assess the adherence of streptococci to cells from normal pharyngeal scrapings after the cells and bacteria were incubated in vitro. Langerhans cells were identified by immunofluorescent staining for the CD1a antigen. Nonstaining cells were considered to be keratinocytes. Of the 2279 cells examined from 9 subjects, 92.6% were keratinocytes and 7.4% were Langerhans cells. Only 1.8% of the 2111 keratinocytes had > 50 bacteria attached in this assay, while 76.2% of the 168 Langerhans cells had > 50 attached bacteria. Thus, under the conditions of this study, group A streptococci adhere preferentially to Langerhans cells from the pharynx. Adherence to these motile cells may provide a mechanism through which pathogenic streptococci may be transported into submucosal tissues.

Hickman catheters in association with intensive cancer chemotherapy.

Hickman catheters were the major venous access devices utilized at the University of Maryland Cancer Center from November 1978 to 1987. This study provided an opportunity to standardize insertion technique, to manage catheter-related activities and daily maintenance procedures in order to examine the progression of Hickman-catheter-related problems, to identify those factors that may minimize them, and to develop guidelines for the management and prevention of complications and malfunctions. In all, 690 Hickman catheters (368 double lumens) were placed in patients with acute leukemia and other cancers: 401 catheters were placed in patients with leukemia; 269 were placed during neutropenia; and 230 at platelet counts of < 50,000/microliters. Two surgeons inserted 490 catheters, and the remaining 200 were placed by a group of rotating surgeons. All catheters were placed with the intention that they would remain in place as long as clinically necessary. Total Hickman catheter days were 134273. Infectious complications included exit site infections (160), tunnel infections (46) and bacteremias (397). There were 438 instances of noninfectious complications including thrombosis, lack of function, catheter migration, fracture and hemorrhage. Recommendations for prevention and treatment of Hickman-catheter-related complications include the development of a select group committed to placement, daily maintenance and management of problems; prompt removal of catheters with Candida sp. fungemia and bacteremia due to Bacillus sp. or a bacteremia that persists for > 48 h after initiation of appropriate antibiotics, tunnel infections or Hickman-catheter-associated thrombosis. The majority of bacteremias and exit site infections can be effectively treated with antibiotics and local care.

Hip disarticulation for recurrent vulvar cancer in the groin.

A patient with squamous cell carcinoma of the vulva treated with a radical vulvectomy and bilateral inguinal and femoral lymphadenectomies utilizing separate groin incisions, subsequently developed a recurrence in the skin bridge between the vulvar and groin excisions. Following groin irradiation with chemosensitization, the tumor progressed to involve the superior public ramus and femoral vessels. A left hip disarticulation and resection of a portion of the superior pubic ramus was performed. The patient has been free of disease for 3 years. The advantages of this procedure over a hemipelvectomy include shorter operative time, reduced blood loss, better fascial closure of the abdomen, and the creation of a stump which is more amendable to prosthetic fitting.

Neutrophil responses to intravascular pneumococcal sonicate.

Leukopenia and pulmonary leukostasis are prominent features in patients succumbing to pneumococcal (PNC) infections. We examined mechanisms involved in recruitment of polymorphonuclear neutrophils (PMNs) into pulmonary capillaries and alveolae after PNC sonicate injection. We showed that by 15 min postinjection, PMN chemotactic activity was found in bronchoalveolar lavage (BAL) fluids and increased with time until the end point of the study at 90 min. Accompanying the increased chemotactic activity in BAL fluids was a decrease in circulating PMNs more pronounced in the femoral artery (FA) than the pulmonary artery (PA). Superoxide anion (O2-) production by peripheral PMNs was depressed following PNC sonicate injection, and comparison of FA and PA showed that FA PMNs produced less O2- than PA PMNs. PA PMNs also showed enhanced random migration when compared to the depressed random migration of FA PMNs. This study demonstrated that an intravascular challenge of PNC sonicate was associated with increased chemotactic activity for PMNs in BAL fluid. Fewer PMNs and altered PMN function resulted from passage through the pulmonary microvasculature after PNC sonicate injection.