Use of the EEA stapling instrument for control of bleeding esophageal varices.

Transection of the esophagus with the EEA stapling device (United States Surgical Corp.) has been used to treat 20 patients with bleeding esophageal varices. Their ages ranged from 38 to 73 years (mean 56.7 years). Sixteen patients (80%) had Laënnec's cirrhosis. A previous occluded portosystemic shunt was present in five patients. Based on Child's classification, there were one class A patient, 18 class C patient, and one patient who was unclassified. Five patients underwent elective operation; four survived (80%). The cases of the remaining 15 patients were treated as emergencies or semiemergencies after intensive preoperative intervention including intravenous administration of vasopressin (Pitressin) (100%), balloon tamponade in 11 (73%), and sclerotherapy in three (20%) failed to control the hemorrhage adequately. None of the patients had rebleeding from varices during the postoperative period. However, 11 of the 15 patients (73%) died. All deaths were related to liver failure, except for two patients who died of irreversible acidosis secondary to shock. Technical difficulty was encountered six times with use of the stapling device, resulting in three perforations of the esophagus, which were recognized and repaired at the time. No deaths were attributed to this complication. Of the eight patients who survived the early postoperative period, three have since died--two of variceal hemorrhage and the other of hepatic failure. Two others have had recurrent variceal hemorrhage controlled by sclerotherapy. The duration of follow-up ranges from 10 to 60 months (mean 31 months). Transection of the esophagus with the EEA stapling device for acute variceal hemorrhage is associated with an excessively high mortality rate despite the fact that it controls variceal hemorrhage. It appears to be of value when used on an elective basis for selected patients who cannot benefit from other modes of treatment.

Synthesis of beta-L-fucopyranosyl phosphate and L-fucofuranosyl phosphates by the MacDonald procedure.

Fusion of beta-L-fucopyranose tetraacetate with phosphoric acid for 1 min at 50 degrees gives a 9:1 anomeric mixture of the alpha- and beta-pyranosyl phosphates. Longer fusion times give the alpha-anomer exclusively. The L-fucofuranose tetraacetates were synthesized for the first time by acetolysis of methyl-2,3,5-tri-O-acetyl-beta-L-fucofuranoside. Fusion of the furanose tetraacetates with phosphoric acid gave a mixture of the fucofuranosyl phosphates in which the beta-anomer predominated (beta/alpha= 2.4). Anomeric pairs in the fucofuranose series appear to be distinguishable by the chemical shift of the C-6 methyl protons, as already shown by Sinclair and Sleeter in the pyranose series.

Laparoscopic vs. open wedge biopsy of the liver.

This study was a post-hoc evaluation of laparoscopic versus open wedge biopsy of the liver performed as part of prospective phase I antibiotic trial. Consenting patients undergoing elective cholecystectomy were enrolled in a protocol which required samples of bile, blood, the gallbladder, and 1 gram of liver tissue. The study occurred during the evolution of laparoscopic surgery. Liver biopsy was done in standard fashion and laparoscopic liver biopsy was accomplished with cauterized scissors. Twenty-four patients, 4 male and 20 female averaging 42.1 years of age, were entered in this study. Eighteen patients underwent laparoscopic surgery and six patients underwent open surgery. They did not differ significantly in age (43.9 vs 42.1 years), operating room time (58.3 min vs 55.8 min), or complications (2/18 vs 2/6). Patients undergoing laparoscopic surgery, however, did have a shorter hospital stay (1.1 days vs 3.5 days, p < 0.001). All liver specimens were considered adequate. There were no complications related to the liver biopsy. Laparoscopic wedge biopsy of the liver is both a feasible and viable alternative to open wedge biopsy.

Physician review improves hospital DRG reimbursement in injury.

This was a prospective study of all DRG reimbursed trauma patients discharged during an 11-month period. Initial DRGs were assigned by hospital coding specialists (HCS). A surgeon (SURG) subsequently reviewed each chart and assigned DRGs to maximize reimbursement. The data for 244 patients were: age = 36.5 years, Trauma Score (TS) = 13.8, Injury Severity Score (ISS) = 16.9, and length of stay (LOS) = 10.3 days. Total charges for the 244 patients were $4,261,208 with an initial HCS projected reimbursement of $1,687,963. The SURG review resulted in a total projected reimbursement of $1,956,476, an increase of $268,513 in revenue (p less than 0.001). Charges correlated strongly with LOS and ISS. The HCS-coded and SURG-coded reimbursements also correlated positively with LOS and ISS, but to a lesser extent. The SURG review of DRG assignment improved hospital reimbursement for the injured patients. However, this reimbursement fell well below hospital billings.

Colorectal trauma: primary repair or anastomosis with intracolonic bypass vs. ostomy.

This prospective, randomized, controlled study was undertaken to compare primary repair or anastomosis with intracolonic bypass vs. ostomy in severe colon and intraperitoneal rectal injury. Patients were randomized at surgery following confirmation of injury. Data collected included demographics, mechanism and location of injury, trauma score (TS), injury severity score (ISS), penetrating abdominal trauma index (PATI), complications, length of hospital stay, and hospital charges. Twenty-two patients were studied: 11 with intracolonic bypass and 11 controls. The experimental and control groups were statistically similar in demographics and mechanism of injury, severity of injury (TS = 13.8 vs. 12.8; ISS = 27.5 vs. 24.2; PATI = 40.5 vs. 35.0), and complication rate. Length of stay (12.2 days vs. 20.7 days) and charges $27,885 vs. $53,599) tended to be greater in controls, and the comparison did not include subsequent colostomy closure. This study supports intracolonic bypass as a safe alternative to ostomy in severe colon and intraperitoneal rectal trauma.