The economic impact of incorporating flexible endoscopy into a community general surgery practice.

BACKGROUND: Flexible endoscopy is a vital component of gastrointestinal surgery. It has and will replace many of the surgical procedures now commonly performed. Flexible endoscopy, unfortunately, is not an integral part of surgical residency training based on resident operative experience as reported by the Residency Review Committee. Moreover, general surgeons have deferred the practice of flexible endoscopy to the gastroenterologists because of concerns over turf battles and referral patterns. The purpose of this study was to assess the overall case load and the economic impact of flexible endoscopy on the practice of general surgery in a community hospital setting. METHODS: This retrospective review was performed over a 6-month period. The total cases and the total billings of inpatient and outpatient procedures for a group practice of five general surgeons in a community hospital were evaluated. The billings were the actual charges based on current procedural terminology (CPT) codes for these procedures using the Medicare fee schedule. RESULTS: Of the 2,159 procedures performed, 1,154 involved flexible endoscopy cases accounting for 54% of all cases (1,154 of 2,159) performed from February 1, 2003 to July 31, 2003. Flexible endocopy accounted for 43% of the total charges. A. total of 46 surgical procedures and 216 future endoscopies were generated from the flexible endoscopic procedures. Future endoscopic cases were for surveillance of colonic neoplasia and Barrett's esophagus. CONCLUSIONS: Flexible endoscopy contributed to a major portion of the caseload and revenue generated by the general surgery group studied. The overall impact of flexible endoscopy is even greater than reported because of the future endoscopic surveillance cases or surgical interventions generated on the basis of endoscopic findings.

The clinical diagnosis of chronic acalculous cholecystitis.

BACKGROUND: Chronic acalculous cholecystitis (CAC), a diagnosis of exclusion, appears to be more common than was previously thought. We correlated the pathology with test results and response to treatment in a prospective study to obtain data for evidence-based management. METHODS: The study subjects were patients with chronic biliary symptoms but had normal sonogram results. They were further investigated with esophagogastroduodenoscopy, multidiscipline evaluations, and cholecystokinin-stimulated scintigraphy (CCK-HIDA). They were offered laparoscopic cholecystectomy (LC) when the symptoms were intransigent, and the main abnormality was a low ejection fraction (EF) as determined by CCK-HIDA. We analyzed the histologic findings of the gallbladder, CCK-HIDA EF, and clinical outcomes during the control period with a concurrent series of LC for calculus from the same surgeons. RESULTS: Of 176 cholecystectomies for biliary pain without stones, 152 had pathologically verified CAC. EF by CCK-HIDA was low in patients with CAC (18%) and low in normal gallbladders (26%). In the same period, 497 patients had cholecystectomies for cholelithiasis. Lasting symptom relief for CAC after LC was not different from that for calculous disease (85% vs 90%). CONCLUSIONS: The syndrome consisting of chronic biliary symptoms, stone-free sonograms, low EF in CCK-HIDA, and absence of other pain sources is highly predictive for CAC, which is well treated with LC, with results similar to those for calculous disease.

Solitary J-pouch ulcer causing pouchitis-like syndrome.

A 37-year-old man with familial polyposis coli who had undergone restorative proctocolectomy with a J-pouch as an ileal reservoir developed a solitary mucosal ulcer in the reservoir, causing a pouchitis-like syndrome. There was no endoscopic evidence of further inflammatory changes of the mucosa. The ulcer healed and symptoms subsided after six weeks of therapy with metronidazole followed by tetracycline. Possible causal and pathogenic factors are considered and discussed. Association of this patient's lesion with the nonspecific mucosal inflammatory process described in pouchitis is suggested by similar clinical manifestations and outcome.

Rectal hemorrhage from ulcerated appendiceal stump nine years after appendectomy. Report of a case.

Significant lower gastrointestinal hemorrhage from an ulcerated appendiceal stump after remote uncomplicated appendectomy is reported. The diagnosis was established by pathologic examination of the surgical specimen, but the area of bleeding was localized by preoperative colonoscopy. Angiography or isotope scan might also have identified the site of more rapid bleeding.