POSSUM scoring for laparoscopic cholecystectomy in the elderly.

BACKGROUND: Physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) scoring is a validated scoring system in the audit of surgical outcomes; however, evaluation of this system has mostly been applied to open surgical techniques. The present study examines the validity of POSSUM in predicting morbidity and mortality in patients undergoing laparoscopic cholecystectomy (LC) with the recognized risk factor for postoperative mortality of advanced age. METHODS: All patients aged 80 years or over undergoing LC in one surgical unit between January 1993 and December 1999 were identified from the surgical operations database of the hospital. Case-note review was used to collate data in terms of clinical and operative factors as described in POSSUM. Observed/POSSUM estimated (O/E) ratio of morbidity and 30-day mortality were calculated. RESULTS: Laparoscopic cholecystectomy was performed in 76 patients aged 80 years or over during the study period. Of these patients, case notes for 70 patients (92%) were available for review. Median (range) age was 83 years (80-93 years) and median (range) American Society of Anesthesiologists score was 2 (2-4). Twenty-six (34%) of 70 patients underwent cholecystectomy during an acute admission. The mean physiology severity score was 23 and operative severity score, 8. A significant postoperative morbidity was observed in 15 (22%) of 70 patients. There was no 30-day mortality. Using exponential analysis, POSSUM predicted morbidity in 15 patients and mortality in seven patients. Thus, O/E ratios for morbidity and mortality were 1 and 0, respectively. CONCLUSION: POSSUM scoring performs well in predicting morbidity, but overpredicts mortality, after LC in patients aged over 80 years. An assessment of its application to other laparoscopic procedures merits evaluation.

Fasting homocysteine levels in adults with type 1 diabetes and retinopathy.

BACKGROUND AND METHODS: Whether hyperhomocysteinemia is associated with diabetic retinopathy is still being debated. We measured homocysteine and thrombomodulin, a marker of endothelial cell damage, in patients with type 1 diabetes mellitus and retinopathy (n=25) and in a well-matched group of diabetic patients without retinopathy (n=23). All patients had normal serum creatinine and no macroalbuminuria. RESULTS: Fasting homocysteine levels were higher in the group with retinopathy than in the group without retinopathy (8.75+/-1.9 vs. 7.69+/-1.6 micromol/l, P<0.05). Microalbuminuria was more prevalent in the group with diabetic retinopathy and it correlated with homocysteine levels in this group (p<0.05). Microalbuminuria was the most powerful independent determinant of homocysteine levels in multiple regression analysis in the group with retinopathy (p<0.01). Thrombomodulin levels were not different in the two groups (36.6+/-9.7 vs. 34.9+/-11.1, p>0.1) and there was no correlation between homocysteine and thrombomodulin levels in either group. CONCLUSIONS: The slight rise in homocysteine levels in patients with diabetic retinopathy was possibly caused by the early nephropathy as indicted by microalbuminuria. This small rise in homocysteine levels was not associated with endothelial dysfunction, as measured by serum thrombomodulin levels.

Laparoscopic totally extraperitoneal mesh repair for femoral hernia.

BACKGROUND: The role of laparoscopic repair for femoral hernia has not been clearly defined, although the advantages of this technique for repair of inguinal hernia are well recognized. AIM: The aim of this study was to assess the outcome of laparoscopic total extraperitoneal (TEP) repair of femoral hernia. METHODS: Case records of patients who had laparoscopic TEP repair of femoral hernia between 1994 and 2002 were reviewed retrospectively. Patients' demographic details, presentation, operative details, and follow-up information were gathered from the clinical records. Postoperative complications, chronic pain, and recurrence of the hernia were assessed. RESULTS: Fifteen patients, 10 males and 5 females, with a mean age of 55 years (range, 33-84 years) underwent laparoscopic TEP femoral hernia repair. Fourteen patients (93.3%) had a primary femoral hernia, and one had a recurrent femoral hernia. In 9 (60%) patients the hernia was irreducible but not obstructed. There were no postoperative complications or chronic pain. One patient (7%) with a small (11 x 6 cm) mesh developed an inguinal recurrence. CONCLUSION: Laparoscopic TEP repair is a suitable technique for repair of femoral hernia, including irreducible but not obstructed femoral hernias.

The effect of surgical subspecialization on outcomes in peptic ulcer disease complicated by perforation and bleeding.

BACKGROUND: Emergency surgical services in Edinburgh were restructured in July 2002 to deliver subspecialist management of colorectal and upper-gastrointestinal emergencies on separate sites. The effect of emergency subspecialization on outcome from perforated and bleeding peptic ulceration was assessed. METHODS: All patients admitted with complicated peptic ulceration (January 2000-February 2005) were identified from a prospectively compiled database. RESULTS: Perforation: 148 patients were admitted with perforation before the service reorganization (period A - 31 months) of whom 126 (85.1%) underwent surgery; 135 patients were admitted in period B (31 months) of whom 114 (84.4%) were managed operatively. The in-hospital mortality was lower in period B (14/135, 10.4%) than period A (30/148, 20.3%; P = 0.023; relative risk (RR), 0.51; 95% confidence interval (CI), 0.28-0.91). There was a significantly higher rate of gastric resection in the second half of the study (period A 1/126 vs. period B 8/114; P = 0.015; RR, 8.84; 95% CI, 1.48-54.34). Length of hospital stay was similar for both groups. Bleeding: 51 patients underwent operative management of bleeding peptic ulceration in period A and 51 in period B. There were no differences in length of stay or mortality between these two groups. CONCLUSION: Restructuring of surgical services with emergency subspecialization was associated with lower mortality for perforated peptic ulceration. Subspecialist experience, intraoperative decision-making, and improved postoperative care have all contributed to this improvement.

Outcome of laparoscopic cholecystectomy in patients 80 years and older.

Advanced age is associated with an increase in postoperative complications. This study assesses the indications and outcome for laparoscopic cholecystectomy (LC) in patients aged 80 years or older. Consecutive, unselected patients aged 80 years or over undergoing LC between 1991 and 2000 were included. A retrospective case review enabled analysis of clinical and operative factors together with in-hospital morbidity, 30-day mortality, and duration of hospital stay. A series of 117 patients, 79 women and 38 men with a median age of 83 years (range 80-93 years), underwent LC. Indications for LC were chronic cholecystitis in 62 (53%) patients, acute cholecystitis in 28 (24%), gallstone pancreatitis in 12 (10%), and other conditions in 15 (13%). Six (5%) patients required conversion to an open procedure. Overall, 26 (22%) patients developed a postoperative complication. There were no bile leaks or bile duct injuries. One patient, with gangrenous cholecystitis, died after LC. The median postoperative hospital stay was 3 days (range 1-31 days). LC can be performed safely with low morbidity in patients over age 80 years.