Bayesian estimation of the accuracy of ICD-9-CM- and CPT-4-based algorithms to identify cholecystectomy procedures in administrative data without a reference standard.

PURPOSE: To estimate the accuracy of two algorithms to identify cholecystectomy procedures using International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) and Current Procedural Terminology (CPT-4) codes in administrative data. METHODS: Private insurer medical claims for 30 853 patients 18-64 years with an inpatient hospitalization between 2006 and 2010, as indicated by providers/facilities place of service in addition to room and board charges, were cross-classified according to the presence of codes for cholecystectomy. The accuracy of ICD-9-CM- and CPT-4-based algorithms was estimated using a Bayesian latent class model. RESULTS: The sensitivity and specificity were 0.92 [probability interval (PI): 0.92, 0.92] and 0.99 (PI: 0.97, 0.99) for ICD-9-CM-, and 0.93 (PI: 0.92, 0.93) and 0.99 (PI: 0.97, 0.99) for CPT-4-based algorithms, respectively. The parallel-joint scheme, where positivity of either algorithm was considered a positive outcome, yielded a sensitivity and specificity of 0.99 (PI: 0.99, 0.99) and 0.97 (PI: 0.95, 0.99), respectively. CONCLUSIONS: Both ICD-9-CM- and CPT-4-based algorithms had high sensitivity to identify cholecystectomy procedures in administrative data when used individually and especially in a parallel-joint approach.

Medicinal treatments of cholesterol gallstones: old, current and new perspectives.

Cholesterol cholelithiasis is one of the most common and costly digestive diseases. Although gallstones are usually asymptomatic and no treatment is generally required, it is imperative to treat symptomatic gallstones with or without complicated conditions. Laparoscopic cholecystectomy is first-line therapy for symptomatic gallstones. By contrast, a cautious study on the natural history of the disease and costs of therapy, indicates that non-surgical treatment of gallstones is currently restricted to a subgroup of patients with mild symptoms or with small radiolucent cholesterol gallstones in a functioning gallbladder. Appropriate selection of patients suitable for medical therapy is therefore of key importance. Oral litholysis with the hydrophilic bile acid ursodeoxycholic acid induces cholesterol desaturation of bile and may lead to gallstone dissolution in patients with small, radiolucent, cholesterol-enriched stones in a functioning gallbladder with a patent cystic duct. Recent studies from experimental animal models and preliminary findings in humans also suggest that blocking intestinal absorption of cholesterol with the powerful, specific, and effective NPC1L1 inhibitor ezetimibe, may offer a novel and exciting strategy for the treatment of cholesterol gallstones. A similar possibility might arise from manipulation of specific nuclear receptors involved in cholesterol and bile acid homeostasis. Current views and perspectives on medicinal treatment of cholesterol gallstone disease are discussed here.

Surgical Management of Common Bile Duct Stones at Saint Paul's Hospital; Addis Ababa; Ethiopia

Background: This study was aimed at evaluating the trend and outcome of surgical management of choledocholithiasis in St. Paul Teaching Hospital Addis Ababa; Ethiopia. Methods: This was a clinical based retrospective analysis. The operation register was used to identify the cases that were operated for biliary lithiasis. Their clinical records were obtained from the record office of the hospital and data collected and recorded on a predesigned format. Data was analyzed by SPSS statistical software. Pearson's chi-square test was used for statistical analysis. P-value 0.05 was considered significant. Results: A total of 1230 underwent open cholecystectomy over 5 year period of which 98 patients where found to have choledocholithiasis constituting 7. Of the 98 patients who underwent common bile duct (CBD) exploration; the records of 78 patients were found and made the basis of this analysis. Fifty-nine (75.6) patients were females and 19(24.4) were males; with a male to female ratio 1: 3. The mean age was 49.15 years. The most common symptoms were right upper quadrant pain and jaundice. The most frequent physical findings was right upper quadrant tenderness. Choledocholithotomy with T-tube insertion was done in 39 patients; side to side choledochoduodenostomy in 34 patients; and hepaticojejunostomy in 5 patients. Twenty-four (71.6) choledochoduodenostomy patients were discharged in less than ten days after operation while 36(87.1) of those with T-tube were discharged after 10 days (p0.019). The re-operation rate was 12.8for the T-tube insertion group and 2.9for choledochoduodenostomy patients. There were 3(8.8) deaths in the former and 1(2.9) in the group of choledochoduodenostomy. The overall complication rate was 11 (30.6) for the T-tube insertion and 3 (8.8) for the choledochoduodenostomies. Conclusion: Choledochoduodenostomy is a better option than Choledocholithotomy with T-tube insertion in the treatment of choledocholithiasis in African setting. We recommend choledochoduodenostomy (CD) for multiple CBD calculi; big calculi in the CBD; much dilated CBD (2cm); primary CBD stones; hepatic stones; recurrent stones; and elderly patients where the size of the CBD is 15mm and above

[Surgical treatment of an acute cholecystitis (critical evaluation of now existing rules)].

There were operated on 3268 patients for an acute cholecystitis (ACH). The operations classification was proposed, depending on the terms of their performance. Comparative estimation of morphological changes of gallbladder, analysis of frequency and causes of complications, conversions and lethality occurrence in various terms postoperatively were conducted. The cholecystostomy place in surgical treatment of an ACH was determined.

Actual recurrence patterns and risk factors influencing recurrence after curative resection with stage II gallbladder carcinoma.

Despite the advances in imaging techniques, most patients can only be diagnosed at advanced stage: The prognosis is very poor. Recent studies showed that aggressive radical resection for advanced gallbladder carcinoma can give an acceptable prognosis. However, recurrence frequently remains the main problem after curative resection of advanced gallbladder carcinoma. The aim of this study was to identify the patterns and risk factors of recurrence after curative resection for stage II gallbladder carcinoma. Between January 1991 and December 2003, 100 patients received radical curative resection for gallbladder carcinoma at Yonsei University Medical Center. Of these, 77 were defined with stage II gallbladder carcinoma according to the Union Internationale Contre Le Cancer classification (sixth edition). Of the 77 patients, 67 were reviewed for the predictors of tumor recurrence. Among the 67 patients, 38 (56.7%) suffered a recurrence. The mean length to the recurrence was 21.1 +/- 26.7 months, with the most common site being the intraabdominal organs: liver and aortocaval lymph nodes. Infiltrating and poorly differentiated types were identified as independent prognostic factors of recurrence after curative resection for stage II gallbladder carcinoma and it suggests that large multicenter randomized control trials are necessary to clarify the role of adjuvant chemotherapy in these patients.

Rotura vesicular secundaria a traumatismo abdominal cerrado / Secondary gallbladder rupture to close abdominal traumatism

Varón de 45 años de edad que ingresa por urgencias con un traumatismo abdominal cerrado, tras sufrir un accidente de tráfico. Se le realiza una TC abdominal sin y con contraste, visualizándose la vesícula biliar contraida y con contenido intraluminal hiperdenso sugerente de hemobilia. Existe además líquido libre intraperitoneal. No se encontraron otras lesiones abdominales. Con el diagnóstico de rotura vesicular por imagen, se realizó CPRE y colecistectomía que localizaron la rotura y confirmaron el diagnóstico (AU)

Estudio ergonómico del cirujano durante la colecistectomía por vía abierta y laparoscópica / Ergonomic study of the surgeon during open and laparoscopic cholecystectomy

Introducción. La ingeniería del factor humano (la ergonomía) ha investigado muy poco el trabajo quirúrgico. Nuestro objetivo es determinar la carga postural de la colecistectomía laparoscópica y compararla con la abierta, para establecer el nivel de riesgo de lesión musculosquelética y buscar soluciones ergonómicas que mejoren la comodidad del cirujano y la eficacia del acto quirúrgico. Material y método. Se recogieron datos sobre 16 intervenciones quirúrgicas (11 laparoscópicas y 5 abiertas) aplicando el método OWAS (Ovako Working Posture Analysis System) y se compararon ambas técnicas quirúrgicas respecto a la carga estática. Resultados. Encontramos diferencias importantes entre la colecistectomía laparoscópica y la abierta respecto a la posición de los brazos (p < 0,001), piernas (p < 0,001) y cabeza (p < 0,001). En la colecistectomía laparoscópica se mantiene una postura más erguida, con sobrecarga de la cintura escapular, y en la técnica abierta hay una flexión casi permanente cervical. Los niveles de riesgo de lesión asociados a estas posturas sobrepasan los ideales, precisando corrección ergonómica. Conclusiones. Ambas técnicas de colecistectomía comportan un nivel de riesgo de lesión musculosquelética más que moderado. La aplicación de criterios ergonómicos derivados del mundo industrial en el diseño del instrumental quirúrgico y del quirófano pueden mejorar la comodidad del cirujano y, por tanto, la eficacia de su trabajo (AU)

Identification of factors contributing to increased length of stay in two diagnosis related groups.

This paper discusses a study conducted to identify factors that contributed to increased length of stay for two diagnosis related groups (DRGs) and their consequential impact on nursing salaries. The study shows that three separate clusters of cost drivers (DRG-related, nurse-related, and patient-related) contributed to increased length of stay for DRG 177 (chronic obstructive airways disease) and DRG 367 (cholecystectomy without exploration of the common bile duct). It was not possible to establish a link between length of stay and nursing salaries due to lack of relevant data. The results of the study can be used to raise professional awareness to the difficulties encountered by nurse managers in controlling length of stay when there are substantial numbers of different DRGs in acute care wards. The results can also be used as a basis for conducting larger studies into DRGs with higher than expected lengths of stay.

Conversions in laparoscopic cholecystectomy--need for a new nomenclature.

Reasons for conversion from laparoscopic cholecystectomy (LC) to open cholecystectomy (OC) were analysed in 47 patients. In 35 patients, the surgeon converted LC to OC by choice because of difficult anatomy or difficult pathology while in 12 patients the surgeon was forced to convert from LC to OC because of complications. We propose that conversions from LC to OC should be classified into two groups-"conversions-by-choice" and "conversions-per-force".

[Primary and secondary interventions--a concept in surgical documentation]. / Haupt- und Untereingriffe--ein Konzept bei der Operationsdokumentation.

Nowadays systematic documentation of surgical procedures is absolutely necessary in all departments of surgery and will soon be required by law. Therefore code systems are essential. Amongst numerous systems the ICPM-GE classification has been chosen as basis. In the department for abdominal and transplantation surgery at Hanover Medical School the ICPM-GE classification has been extended by a concept of coding main and suboperations. This concept considers the fact that in an individual patient the surgical procedure may consist of different and standardized suboperations. This concept widens and simplifies the possibility of documentation considerably.

Profilaxis antimicrobiana en colecistectomía electiva de bajo riesgo: resultados de un estudio prospectivo, aleatorio y doblemente a ciegas / Antimicrobial prophylaxis in low risk elective cholecystectomy: results of a prospective: randomized, double-blind study

Objetivo: Determinar la eficacia de la profilaxis antimicrobiana con cefradina en la prevención de complicaciones infecciosas posteriores a colecistectomía electiva de bajo riesgo. Diseño: Estudio prospectivo, de asignación aleatoria y controlado con placebo, conducido de junio de 1987 a noviembre de 1990. Sede: Hospital universitario de investigación. Pacientes: Un otal de 141 pacientes con diagnóstico de colecistitis crónica litiasica (CCL), menores de 70 años de edad y sin factores de riesgo divididos al azar en dos grupos: Grupo de estudio 69 pacientes y grupo testigo 72. Intervenciones: Los pacientes del grupo de estudio recibieron una dosis única de cefradina 2 gramos intravenosos al momento de la inducción anestésica, los pacientes del grupo testigo recibieron agua destilada. Durante la intervención quirúrgica se tomaron muestras de bilis para cultivo. Después de la operación, los pacientes fueron seguidos por un periodo de 30 días. Mediciones y Resultados: La mayoría de los pacientes del grupo experimental y del grupo testigo se sometío a colescistectomía con o sin colangiografía (93 por ciento y 90 por ciento respectivamente). Doce pacientes requirieron exploración de la vía biliar por hallazgos transoperatorios o evidencia rediológica de coledocolitiasis. Se obtuvieron muestras de bilis en 124 pacientes y el 16 por ciento de los cultivos fueron positivos, la bacteria más frecuente fue E. coli seguida por bacilos gram negativos aeróbicos y especies de streptococcus. Cinco pacientes del grupo testigo (7 por ciento) desarrollaron infección de herida, ningún paciente del grupo experimental presentó esta complicación (P. exacta de Fisher de una cola P=< 0.05). Otras complicaciones fueron similares en ambos grupos así como los tiempos de estancia pre y postoperatoria. Conclusiones: Concluimos que una dosis única de cefradina administrada en forma intravenosa antes de la operación proveé profilaxis efectiva en contra de la infección de herida en pacientes de bajo riesgo sometidos a colecistectomía electiva.

[Disputable problems of surgical tactics in acute cholecystitis]. / Diskussionnye voprosy khirurgicheskoi taktiki pri ostrom kholetsistite.

On the grounds of literature data and their own experience, the authors came to the conclusion that clear-cut identification of the character of the pathological process is of principal importance in deciding on the time of operative intervention for acute cholecystitis. Patients with a pronounced clinical picture of acute cholecystitis and those with signs of peritonitis must be operated on as emergencies, "postponed" operations produce poor results. Indications for an emergency operation in patients with acute cholecystitis complicated by obstructive jaundice and other conditions must be considered individually. An emergency operation is carried out if there are signs of circumscribed peritonitis, in all other cases detoxication therapy is applied for 2-3 days and is followed by operation. Patients with exacerbation of chronic frequently recurring calculous cholecystitis should be operated on in a planned order.