The association between body mass index and severe biliary infections: a multivariate analysis.

BACKGROUND: Obesity has been associated with worse infectious disease outcomes. It is a risk factor for cholesterol gallstones, but little is known about associations between body mass index (BMI) and biliary infections. We studied this using factors associated with biliary infections. METHODS: A total of 427 patients with gallstones were studied. Gallstones, bile, and blood (as applicable) were cultured. Illness severity was classified as follows: none (no infection or inflammation), systemic inflammatory response syndrome (fever, leukocytosis), severe (abscess, cholangitis, empyema), or multi-organ dysfunction syndrome (bacteremia, hypotension, organ failure). Associations between BMI and biliary bacteria, bacteremia, gallstone type, and illness severity were examined using bivariate and multivariate analysis. RESULTS: BMI inversely correlated with pigment stones, biliary bacteria, bacteremia, and increased illness severity on bivariate and multivariate analysis. CONCLUSIONS: Obesity correlated with less severe biliary infections. BMI inversely correlated with pigment stones and biliary bacteria; multivariate analysis showed an independent correlation between lower BMI and illness severity. Most patients with severe biliary infections had a normal BMI, suggesting that obesity may be protective in biliary infections. This study examined the correlation between BMI and biliary infection severity.

Predictors of long-term outcome after laparoscopic esophagomyotomy and Dor fundoplication for achalasia.

OBJECTIVE: To identify predictors of long-term outcome of laparoscopic Heller myotomy for achalasia, including predictors of heartburn and recurrent dysphagia, which occasionally develop postoperatively. DESIGN: Retrospective review using interviews of patients. SETTING: Academic university hospital. PATIENTS: One hundred sixty-five patients with achalasia who underwent a laparoscopic esophagomyotomy and Dor fundoplication. MAIN OUTCOME MEASURES: Dysphagia and heartburn before and after the operation were assessed on a 4-point Likert scale, as were postoperative dilations, reoperations, and antacid use. Potential predictors were age, race, sex, body mass index, weight loss, duration of symptoms, manometry findings, esophageal diameter, previous treatment, and operative technique. RESULTS: Follow-up averaged 62 (range, 1-174) months. Dysphagia frequency was once a week or less in 128 patients (78%), several times per week in 25 (15%), and daily in 12 (7%). Satisfaction scores averaged 3.7 on a 4-point scale. Thirty patients (18%) required a postoperative dilation, and 6 (4%) underwent another operation. The only predictor of postoperative dysphagia was duration of symptoms longer than 10 years (odds ratio, 0.2; P = .03). Preoperative dilations predicted the need for postoperative dilations (odds ratio, 2.4; P = .03). Only 20 patients (12%) reported heartburn more than once weekly, although 75 (45%) reported taking antacids. No variable predicted postoperative heartburn or antacid use. CONCLUSIONS: Long-term outcomes after laparoscopic esophagomyotomy were excellent across a wide spectrum of disease severity and presentations. Previous treatments, such as balloon dilation or botulinum toxin (Botox) injection, did not portend worse outcomes. When the myotomy was extended 2 cm onto the stomach and a Dor fundoplication was performed, severe heartburn was rare.

Operative reports: form and function.

HYPOTHESIS: Little is known about how closely operative reports reflect what was actually performed during an operation, nor has the construction of operative reports been adequately studied with the aims of clarifying the objectives of those reports and improving their efficacy. We hypothesized that if more attention is paid to the objectives of operative reports, their content will more predictably contain the most relevant information, which might channel thinking in beneficial directions during performance of the operation. DESIGN: Multivariate analysis of 250 laparoscopic cholecystectomy operative reports (125 uncomplicated and 125 with bile duct injury). SETTING: Academic research. PARTICIPANTS: University (105 cases) and community (145 cases) hospitals. MAIN OUTCOME MEASURES: Variations in content and design of operative reports. Cognitive task analysis of laparoscopic cholecystectomy was conducted, and a model operative report was generated and compared with the actual operative reports. RESULTS: Descriptions of key elements in adequate dissection of the Calot triangle were present in 24.8% and 0.0% of operative reports from uncomplicated and bile duct injury cases, respectively. Thorough dissection of the Calot triangle, identification of the cystic duct-infundibulum junction, and lateral retraction of the infundibulum correlated with uncomplicated cases, while irregular cues (eg, perceived anatomic or other deviations) correlated with bile duct injury cases. CONCLUSIONS: Current practice generates operative reports that vary widely in content and too often omit important elements. This research suggests that the construction of operative reports should be constrained such that the reports routinely include the fundamental goals of the operation and what was performed to meet them. Cognitive task analysis is based on the ways the mind controls the performance of tasks; it is an excellent method for determining the extra content needed in operative reports. The resulting designs should also serve as mental guidelines to facilitate learning and to enhance the safety of the operation.

The efficacy of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4863 cases.

OBJECTIVES: Medical team training (MTT) has been touted as a way to improve teamwork and patient safety in the operating room (OR). METHODS: OR personal completed a 1-day intensive MTT training. A standardized briefing/debriefing/perioperative routine was developed, including documentation of OR miscues, delays, and a case score (1-5) assigned by the OR team. A multidisciplinary MTT committee reviewed and rectified any systems problems identified. Debriefing items were analyzed comparing baseline data with 12 and 24-month follow-up. A safety attitudes questionnaire was administered at baseline and 1 year. RESULTS: A total of 4863 MTT debriefings were analyzed. One year following MTT, case delays decreased (23% to 10%, P < 0.0001), mean case score increased (4.07-4.87, P < 0.0005), and both changes were sustained at 24 months. One-year and 24-month follow-up data demonstrated decreased frequency of preoperative delays (16%-7%, P = 0.004), hand-off issues (5.4%-0.3%, P < 0.0001), equipment issues/delays (24%-7%, P < 0.0001), cases with low (<3) case scores (23%-3%, P < 0.0005), and adherence to timing guidelines for prophylactic antibiotic administration improved (85%-97%, P < 0.0001). Surveys documented perception of improved teamwork and patient safety. A major systems issue regarding perioperative medication orders was identified and corrected. CONCLUSIONS: MTT produced sustained improvement in OR team function, including decreased delays and improved case scores. When combined with a high-level debriefing/problem-solving process, MTT can be a foundation for improving OR performance. This is the largest case analysis of MTT and one of the few to document an impact of MTT on objective measures of operating room function and patient safety.

Excellent outcomes of laparoscopic esophagomyotomy for achalasia in patients older than 60 years of age.

BACKGROUND: The effectiveness of an esophagomyotomy for dysphagia in elderly patients with achalasia has been questioned. This study was designed to provide an answer. METHODS: A total of 162 consecutive patients with achalasia who had a laparoscopic myotomy and Dor fundoplication and who were available for follow-up interview were divided by age: < 60 years (range, 14-59; 118 patients), and ≥ 60 years (range, 60-93; 44 patients). Primary outcome measures were severity of dysphagia, regurgitation, heartburn, and chest pain before and after the operation as assessed on a four-point Likert scale, and the need for postoperative dilatation or revisional surgery. RESULTS: Follow-up averaged 64 months. Older patients had less dysphagia (mean score 3.6 vs. 3.9; P < 0.01) and less chest pain (1.0 vs. 1.8; P < 0.01). Regurgitation (3.0 vs. 3.2; P = not significant (NS)) and heartburn (1.6 vs. 2.0, P = NS) were similar. Older patients were no different in degree of esophageal dilation, manometric findings, number of previous pneumatic dilatations, or previous botulinum toxin therapy. None of the older patients had previously had an esophagomyotomy, whereas 14% of younger patients had (P < 0.01). After laparoscopic myotomy, older patients had better relief of dysphagia (mean score 1.0 vs 1.6; P < 0.01), less heartburn (0.8 vs. 1.1; P = 0.03), and less chest pain (0.2 vs. 0.8, P < 0.01). Complication rates were similar. Older patients did not require more postoperative dilatations (22 patients vs. 10 patients; P = 0.7) or revisional surgery for recurrent or persistent symptoms (3 vs. 1 patients; P = 0.6). Satisfaction scores did not differ, and more than 90% of patients in both groups said in retrospect they would have undergone the procedure if they had known beforehand how it would turn out. CONCLUSIONS: This retrospective review with long follow-up supports laparoscopic esophagomyotomy as first-line therapy in older patients with achalasia. They appeared to benefit even more than younger patients.

Laparoscopic bile duct injuries: timing of surgical repair does not influence success rate. A multivariate analysis of factors influencing surgical outcomes.

BACKGROUND: Many factors contribute to the success of biliary reconstructions following laparoscopic bile duct injury. We previously reported that control of intra-abdominal infection, complete preoperative cholangiography, surgical technique and surgical experience affected the results. There is no consensus, however, on whether the timing of the operation is important. METHODS: We examined factors influencing the success of the first repair of 307 major bile duct injuries following laparoscopic cholecystectomy. Factors were assessed for cases initially repaired either by the primary surgeon or a biliary specialist. Bivariate and multivariate analyses were used to determine the significance of comparisons. RESULTS: A total of 137 injuries were initially repaired by a biliary surgeon and 163 injuries were initially repaired by the primary surgeon; seven were managed non-surgically. Repairs by primary surgeons were performed earlier than those by biliary surgeons (11 vs. 59 days; P < 0.0001). Bivariate analysis of the entire cohort suggested that later repairs might have been more successful than earlier ones (17 vs. 50 days; P = 0.003). Multivariate analysis, however, showed that the timing of the repair was unimportant (P = 0.572). Instead, success correlated with: eradication of intra-abdominal infection (P = 0.0001); complete preoperative cholangiography (P = 0.002); use of correct surgical technique (P = 0.0001), and repair by a biliary surgeon (P = 0.0001). Separate multivariate analyses of outcomes for primary and biliary surgeons revealed that timing was unrelated to success in either case. CONCLUSIONS: The success of biliary reconstruction for iatrogenic bile duct injuries depended on complete eradication of abdominal infection, complete cholangiography, use of correct surgical technique, and repair by an experienced biliary surgeon. If these objectives were achieved, the repair could be performed at any point with the expectation of an excellent outcome. We see no reason to delay the repair for some arbitrary period.

Has recognition of the relationship between mortality rates and hospital volume for major cancer surgery in California made a difference?: A follow-up analysis of another decade.

BACKGROUND: Previous reports showed that in California during the early 1990s, operative mortality rates for esophageal, pancreatic, and hepatic cancers were inversely related to hospital volume. It is unknown whether this information has affected referral patterns or operative mortality rates. OBJECTIVES: Data were analyzed for the 10 years that followed the period covered in the initial studies to determine if: (a) the operative mortality rates had decreased; and (b) a greater proportion of patients with esophageal, pancreatic, and hepatic cancers were treated at high-volume centers. METHODS: Hospital discharge data were obtained for 8901 patients who had resections for cancer of the esophagus, 2404 patients; pancreas, 5294 patients; and liver, 1203 patients in California between 1995 and 2004. Logistic regression models were used to calculate adjusted mortality rates at high- and low-volume centers by year. The data were compared with the published results for California during the years 1990-1994. RESULTS: Operative mortality rates decreased for esophageal, pancreatic, and hepatic resections during the more recent 10 years. Concomitantly, the proportion of patients treated at high-volume centers increased, as did the number of high-volume centers. There was a substantial increase in the proportion of esophagectomies performed in high-volume hospitals, while the overall number of esophagectomies dropped by 22%. For the other 2 operations, total volume and the volume in high-volume hospitals increased greatly, and the volume in low-volume hospitals was about the same during the 3 periods. The mortality rates decreased at all levels of the volume range. Finally, the performance from one period to the next in individual hospitals was mostly similar, but an occasional outlier was also noted. CONCLUSIONS: More resections for esophageal, pancreatic, and hepatic cancer were performed at high volume centers, but mortality rates decreased for all hospital categories. The data suggest that modern hospitals act as complex adaptive systems, whose outputs are determined from the interactions between internal agents and are resistant to analysis by isolating and studying the individual contributions. It is tempting to attribute the desirable changes in these data (eg, more operations being done in high volume centers and better mortality rates at all levels) as consequences of pressures over the past few decades on hospitals to assume greater responsibility for their quality of care and to become more integrated internally.Thus, many factors appear to influence the volume-outcome relationships, and the identity and individual contributions of these influences may be immune to reductionist analysis. There is substantial evidence that high volume should be part of high quality for these complex operations. Nevertheless, measuring outcomes directly, rather than concentrating on their correlates, may be a more reliable index of hospital performance.

Neuroendocrine tumors of the ampulla of Vater: biological behavior and surgical management.

OBJECTIVES: To describe the biological behavior and surgical management of ampullary neuroendocrine tumors in 7 patients. DESIGN: Case series and literature review. SETTING: University hospital. PATIENTS: Seven patients with ampullary neuroendocrine tumors. MAIN OUTCOME MEASURES: Clinical presentation, pathologic findings, and survival. RESULTS: The patients presented with jaundice (3 patients), anemia (1 patient), gastric outlet obstruction (1 patient), or incidental discovery (2 patients). No patients had neurofibromatosis. Preoperative biopsy was diagnostic in 5 of 6 patients. All of the tumors expressed chromogranin and synaptophysin. Even when the tumor expressed gastrin, vasoactive intestinal peptide, or somatostatin, no patient had a hypersecretion syndrome. Five patients were treated by pancreaticoduodenectomy, 4 for low-grade neuroendocrine tumors and 1 for high-grade neuroendocrine carcinoma. The lesions measured 1.0 to 3.5 cm in diameter. Computed tomographic scans failed to detect nodal metastases that were present in 4 patients. One patient with a high-grade malignant neoplasm died after 15 months. The rest were disease-free after 19 to 48 months. Two patients had transduodenal local resections, one for a 1.1-cm paraganglioma (disease-free, 11 years) and the other for a 0.6-cm carcinoid tumor (disease-free, 7 months). CONCLUSIONS: This is one of the largest series of neuroendocrine tumors of the ampulla. Preoperative biopsy was accurate, but computed tomographic scans were insensitive in detecting nodal metastases. Unlike duodenal carcinoid tumors, hypersecretion syndromes were absent and small tumor size did not preclude locoregional metastases. Tumor grade predicted survival. We recommend pancreaticoduodenectomy for this disease, with local resection reserved for mobile, superficial lesions.

Tumors of the ampulla of vater: histopathologic classification and predictors of survival.

BACKGROUND: The histology and clinical behavior of ampullary tumors vary substantially. We speculated that this might reflect the presence of two kinds of ampullary adenocarcinoma: pancreaticobiliary and intestinal. STUDY DESIGN: We analyzed patient demographics, presentation, survival (mean followup 44 months), and tumor histology for 157 consecutive ampullary tumors resected from 1989 to 2006. Histologic features were reviewed by a pathologist blinded to clinical outcomes. Survival was compared using Kaplan-Meier/Cox proportional hazards analysis. RESULTS: There were 33 benign (32 adenomas and 1 paraganglioma) and 124 malignant (118 adenocarcinomas and 6 neuroendocrine) tumors. One hundred fifteen (73%) patients underwent a Whipple procedure, 32 (20%) a local resection, and 10 (7%) a palliative operation. For adenocarcinomas, survival in univariate models was affected by jaundice, histologic grade, lymphovascular, or perineural invasion, T stage, nodal metastasis, and pancreaticobiliary subtype (p < 0.05). Size of tumor did not predict survival, nor did cribriform/papillary features, dirty necrosis, apical mucin, or nuclear atypia. In multivariate models, lymphovascular invasion, perineural invasion, stage, and pancreaticobiliary subtype predicted survival (p < 0.05). Patients with pancreaticobiliary ampullary adenocarcinomas presented with jaundice more often than those with the intestinal kind (p = 0.01) and had worse survival. CONCLUSIONS: In addition to other factors, tumor type (intestinal versus pancreaticobiliary) had a major effect on survival in patients with ampullary adenocarcinoma. The current concept of ampullary adenocarcinoma as a unique entity, distinct from duodenal and pancreatic adenocarcinoma, might be wrong. Intestinal ampullary adenocarcinomas behaved like their duodenal counterparts, but pancreaticobiliary ones were more aggressive and behaved like pancreatic adenocarcinomas.

The outcome of laparoscopic Heller myotomy for achalasia is not influenced by the degree of esophageal dilatation.

In the past, a Heller myotomy was considered to be ineffective in patients with achalasia and a markedly dilated or sigmoid-shaped esophagus. Esophagectomy was the standard treatment. The aims of this study were (a) to evaluate the results of laparoscopic Heller myotomy and Dor fundoplication in patients with achalasia and various degrees of esophageal dilatation; and (b) to assess the role of endoscopic dilatation in patients with postoperative dysphagia. One hundred and thirteen patients with esophageal achalasia were separated into four groups based on the maximal diameter of the esophageal lumen and the shape of the esophagus: group A, diameter<4.0 cm, 46 patients; group B, esophageal diameter 4.0-6.0 cm, 32 patients; group C, diameter>6.0 cm and straight axis, 23 patients; and group D, diameter>6.0 cm and sigmoid-shaped esophagus, 12 patients. All had a laparoscopic Heller myotomy and Dor fundoplication. The median length of follow-up was 45 months (range 7 months to 12.5 years). The postoperative recovery was similar among the four groups. Twenty-three patients (20%) had postoperative dilatations for dysphagia, and five patients (4%) required a second myotomy. Excellent or good results were obtained in 89% of group A and 91% of groups B, C, and D. None required an esophagectomy to maintain clinically adequate swallowing. These data show that (a) a laparoscopic Heller myotomy relieved dysphagia in most patients with achalasia, even when the esophagus was dilated; (b) about 20% of patients required additional treatment; (c) in the end, swallowing was good in 90%.

Elderly patients have more severe biliary infections: influence of complement-killing and induction of TNFalpha production.

BACKGROUND: Biliary bacteria are more common in elderly patients and cause more serious illnesses. The reasons for this are unclear. We noted previously that bacterial serum-sensitivity and induction of TNFalpha production in sera (iTNFsera) were associated with severe biliary infections. We examined the influence of age and these factors on illness severity. METHODS: Three-hundred and forty patients were studied. Gallstones and bile were cultured. Illness was staged as none (no clinical infection or inflammation), SIRS (fever, leukocytosis), severe (cholangitis, abscess, empyema), or MODS (bacteremia, hypotension, organ dysfunction/failure). Bacterial serum-sensitivity and TNFalpha induction were measured. Younger (< 70 years) and elderly (> or = 70 years) patients were compared. RESULTS: Biliary bacteria were more common in elderly (64% vs 41%, P < .0001). Among patients with biliary bacteria, the elderly had more serious illnesses: none: 44% younger, 19% elderly; SIRS: 16% younger, 22% elderly; severe: 22% younger, 21% elderly; MODS 18% younger, 38% elderly (P = .003). Bacteria from elderly patients induced more TNFalpha (580 vs 310 pg/ml, P = .023). In both groups, serum-sensitive bacteria caused infectious manifestations and induced abundant TNFalpha; however, serum-resistant bacteria from elderly usually (69%) caused infectious manifestations and abundant TNFalpha, while serum-resistant bacteria from younger patients rarely (8%) caused infectious manifestations and minimal TNFalpha. Elderly patients with high iTNFsera bacteria had more severe illnesses. CONCLUSIONS: Biliary bacteria were more common in elderly patients and produced more serious illnesses. Many younger patients with biliary bacteria displayed no infectious manifestations. Elderly patients harbored more virulent bacteria, and had a heightened response to high iTNFsera bacteria, as well as bacteria largely tolerated by younger patients.

Evaluation of the biliary intestinal limb of a Roux-en-Y choledochojejunostomy using computed tomographic cholangiography.

Computed tomographic (CT) findings involving the biliary intestinal limb of a Roux-en-Y choledochojejunostomy may be ambiguous because oral agents frequently do not reflux into that limb. We describe 2 cases where antegrade biliary intestinal limb opacification by intravenous CT cholangiography in the left lateral decubitus position obviated the need for biopsy of an apparent enlarging mass in the biliary intestinal limb. We conclude that CT cholangiography may help clarify the status of a Roux-en-Y choledochojejunostomy.

Laparoscopic enucleation of insulinomas.

HYPOTHESIS: Laparoscopic enucleation of insulinomas is safe and effective and is associated with a short hospital stay. DESIGN: Case series identified through retrospective review of medical records. SETTING: University of California, San Francisco Medical Center, a tertiary care referral hospital. PATIENTS: Nine patients with insulinomas that were thought to be suitable for laparoscopic enucleation. INTERVENTION: Laparoscopic enucleation of solitary insulinomas of the pancreas. MAIN OUTCOME MEASURES: Successful enucleation, conversion to open operation, postoperative complications, and duration of hospitalization. RESULTS: Seven of 9 patients had curative laparoscopic enucleations of insulinomas. In the 2 other patients, the laparoscopic approach was converted to an open operation to perform a distal pancreatectomy. All patients were cured. Computed tomography (CT) localized the tumor in 5 of 9 patients; laparoscopic enucleation was successful in all 5. Endoscopic ultrasonography correctly identified the lesions in 2 of 3 patients with nondiagnostic CT scans. Both lesions were successfully enucleated laparoscopically. Postoperative pancreatic fistulas occurred in 7 of 9 patients, but they caused little morbidity. No patient required another operation. Five of 7 patients treated laparoscopically were discharged to home on the first postoperative day. CONCLUSIONS: Laparoscopic enucleation was safe and effective. If the lesion was seen on CT, it could be removed laparoscopically. Endoscopic ultrasonography was useful for identifying lesions in patients whose CT scans were nondiagnostic. Pancreatic fistulas were common, but they resolved spontaneously and produced little morbidity. Laparoscopic enucleation resulted in a short hospitalization and rapid recovery for most patients.

Characterization of cystic pancreatic masses: relative accuracy of CT and MRI.

OBJECTIVE: The objective of our study was to determine the role and relative accuracy of CT and MRI in the characterization of cystic pancreatic masses. MATERIALS AND METHODS: We retrospectively identified 58 patients with histopathologically proven cystic pancreatic masses at our institution who underwent preoperative CT (n = 40), MRI (n = 6), or both (n = 12). Two radiologists independently recorded their leading diagnoses with levels of diagnostic certainty (0-100%), their estimates of overall likelihood of malignancy (0-100%), and the morphologic characteristics of the tumors. Data were analyzed to determine relative accuracy in the diagnosis of malignancy, relationship between diagnostic certainty and accuracy, and frequency of malignancy in unilocular thin-walled cysts smaller than 4 cm. RESULTS: Twenty-one (36%) of 58 masses were malignant. CT and MRI were equally accurate in establishing the diagnosis of malignancy (area under the receiver operating characteristic curve [A(z)] = 0.91 and 0.85 for reviewers 1 and 2 at MRI vs 0.82 and 0.76 at CT, respectively; p > 0.05). The leading diagnosis given by reviewers 1 and 2 was correct in 46% (32/70) and 43% (30/70) of the studies, respectively. When reviewer diagnostic certainty was 90% or more, the corresponding values were not significantly (p > 0.05) improved at 55% (12/22) and 48% (10/21), respectively. Two (15%) of 13 unilocular thin-walled cysts smaller than 4 cm were frankly malignant. CONCLUSION: CT and MRI are reasonably and similarly accurate in the characterization of cystic pancreatic masses as benign or malignant; limitations include a substantial rate of misdiagnosis even when reviewer certainty is high and a moderate frequency of malignancy in small morphologically benign-appearing cysts.

Bacteria entombed in the center of cholesterol gallstones induce fewer infectious manifestations than bacteria in the matrix of pigment stones.

PURPOSE: The clinical significance of bacteria in the pigment centers of cholesterol stones is unknown. We compared the infectious manifestations and characteristics of bacteria from pigment stones and predominantly cholesterol stones. METHODS: Three hundred forty patients were studied. Bile was cultured. Gallstones were cultured and examined with scanning electron microscopy. Level of bacterial immunoglobulin G (bile, serum), complement killing, and tumor necrosis factor-alpha production were determined. RESULTS: Twenty-three percent of cholesterol stones and 68% of pigment stones contained bacteria (P < 0.0001). Stone culture correlated with scanning electron microscopy results. Pigment stone bacteria were more often present in bile and blood. Cholesterol stone bacteria caused more severe infections (19%) than sterile stones (0%), but less than pigment stone bacteria (57%) (P < 0.0001). Serum and bile from patients with cholesterol stone bacteria had less bacterial-specific immunoglobulin G. Cholesterol stone bacteria produced more slime. Pigment stone bacteria were more often killed by a patient's serum. Tumor necrosis factor-alpha production of the groups was similar. CONCLUSIONS: Bacteria are readily cultured from cholesterol stones with pigment centers, allowing for analysis of their virulence factors. Bacteria sequestered in cholesterol stones cause infectious manifestations, but less than bacteria in pigment stones. Possibly because of their isolation, cholesterol stone bacteria were less often present in bile and blood, induced less immunoglobulin G, were less often killed by a patient's serum, and demonstrated fewer infectious manifestations than pigment stone bacteria. This is the first study to analyze the clinical relevance of bacteria within cholesterol gallstones.

Gallstones containing bacteria are biofilms: bacterial slime production and ability to form pigment solids determines infection severity and bacteremia.

OBJECTIVE: Gallstone bacteria provide a reservoir for biliary infections. Slime production facilitates adherence, whereas beta-glucuronidase and phospholipase generate colonization surface. These factors facilitate gallstone formation, but their influence on infection severity is unknown. METHODS: Two hundred ninety-two patients were studied. Gallstones, bile, and blood (as applicable) were cultured. Bacteria were tested for beta-glucuronidase/phospholipase production and quantitative slime production. Infection severity was correlated with bacterial factors. RESULTS: Bacteria were present in 43% of cases, 13% with bacteremia. Severe infections correlated directly with beta-glucuronidase/phospholipase (55% with vs 13% without, P < 0.0001), but inversely with slime production (55 vs 8%, slime <75 or >75, P = 0.008). Low slime production and beta-glucuronidase/phospholipase production were additive: Severe infections were present in 76% with both, but 10% with either or none (P < 0.0001). beta-Glucuronidase/phospholipase production facilitated bactibilia (86% with vs 62% without, P = 0.03). Slime production was 19 (+/-8) vs 50 (+/-10) for bacteria that did or did not cause bacteremia (P = 0.004). No bacteria with slime >75 demonstrated bacteremia. CONCLUSIONS: Bacteria-laden gallstones are biofilms whose characteristics influence illness severity. Factors creating colonization surface (beta-glucuronidase/phospholipase) facilitated bacteremia and severe infections; but abundant slime production, while facilitating colonization, inhibited detachment and cholangiovenous reflux. This shows how properties of the gallstone biofilm determine the severity of the associated illness.

Biliary bacterial factors determine the path of gallstone formation.

BACKGROUND: Bacteria cause pigment gallstones and can act as a nidus for cholesterol gallstone formation. Bacterial factors that facilitate gallstone formation include beta-glucuronidase (bG), phospholipase (PhL), and slime. The current study sought to determine whether bacterial factors influence the path of gallstone formation. METHODS: A total of 382 gallstones were cultured and/or examined using scanning electron microscopy (SEM). Bacteria were tested for bG and slime production. Gallstone composition was determined using infrared spectrography. Ca-palmitate presence documented bacterial PhL production. Groups were identified based upon bacterial factors present: slime and bGPhL (slime/bGPhL), bGPhL only, and slime only. Influence of bacterial stone-forming factors on gallstone composition and morphology was analyzed. RESULTS: Bacteria were present in 75% of pigment, 76% of mixed, and 20% of cholesterol stones. Gallstones with bGPhL producing bacteria contained more pigment (71% vs. 26%, P < .0001). The slime/bGPhL group was associated (79%) with pigment stones, bGPhL was associated (56%) with mixed stones, while slime (or none) only was associated (67%) with cholesterol stones (P < .031, all comparisons). CONCLUSIONS: Bacterial properties determined the path of gallstone formation. Bacteria that produced all stone-forming factors promoted pigment stone formation, while those that produced only bGPhL promoted mixed stone formation. Bacteria that only produced slime lacked the ability to generate pigment solids, and consequently were more common in the centers of cholesterol stones. This shows how bacterial characteristics may govern the process of gallstone formation.

Bipolar pulse coagulation for resection of the cirrhotic liver.

BACKGROUND: The major technical challenge of liver surgery is controlling bleeding during transection of the parenchyma. The Gyrus hand piece (GHP) is a bipolar diathermy pulsation instrument that is similar in design to a large hemostat (Péan) clamp that divides tissue while the clamp remains closed. MATERIALS AND METHODS: We retrospectively analyzed the peri-operative data from 10 patients with early cirrhosis (stage 1-4) who underwent liver resection for hepatocellular cancer between February 2004 and July 2005. Five consecutive patients who underwent resection using the GHP were compared to five other patients who underwent resection using the traditional "crush clamp technique" (CCT). Six patients underwent minor hepatectomy (<3 segments) and four underwent major hepatectomy (>3 segments). RESULTS: When the GHP was used, the mean Pringle time was 13 +/- 5 min, mean blood loss was 520 mL +/- 118, and mean operative time was 252 +/- 15 min. When the CCT was used, the average Pringle time was 13 +/- 3 min, mean blood loss was 630 +/- 67 mL, and mean operative time was 312 +/- 29 min. There were 2 major complications in the GHP group and 3 in the CCT group. Major complications included transient hepatic failure (i.e., ascites/encephalopathy) and biloma formation. CONCLUSIONS: One patient from each group suffered a minor wound complication. The average hospital stay was 8 days (range, 6-9) for the GHP group, and 8 days (range, 7-10) for CCT group. The operative mortality rate was 0%. Our preliminary results demonstrate that GHP provides an excellent and safe alternative to CCT for dividing the liver parenchyma in cirrhotic patients.

Laparoscopic fundoplication in elderly patients with gastroesophageal reflux disease.

HYPOTHESIS: It is unclear if age should be considered a factor in the choice of treatment for gastroesophageal reflux disease (GERD) and if fundoplication in elderly patients is as safe and effective as it is in younger patients. We hypothesized that the outcome of laparoscopic antireflux operations in patients younger than 65 years is similar to that of patients 65 years and older. DESIGN: Retrospective review of findings from a prospectively acquired database. SETTING: University-based tertiary care center. PATIENTS: Three hundred four consecutive patients underwent laparoscopic fundoplication for GERD. Two hundred forty-one patients were younger than 65 years (group A; median age, 46 years), and 63 patients were 65 years or older (group B; median age, 69 years). MAIN OUTCOME MEASURES: Presence, duration, and severity of GERD symptoms; presence of a hiatal hernia or esophageal stricture; duration of operation; incidence of complications; and length of hospital stay. RESULTS: Elderly patients more often had regurgitation and respiratory symptoms in addition to heartburn. Hiatal hernias were more common among elderly patients (77% vs 51%). The duration of the operation was similar for the 2 groups. The incidence of intraoperative and postoperative complications was low and similar in the 2 groups. The median hospital stay was 24 hours for each group. Heartburn resolved in approximately 90% of patients in each group. CONCLUSIONS: Elderly patients more often had hiatal hernias and respiratory symptoms. Laparoscopic antireflux surgery was as safe in elderly patients as it was in younger patients, and clinical outcomes were as good.