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Biomedical subjects

A J Voitk

Publications and source records attributed to A J Voitk.

At least 19 recordsLinked to original sources
PubMed2001

The umbilicus in laparoscopic surgery.

BACKGROUND: This study examines the factors related to infection and incisional herniation after laparoscopy at the umbilicus, as compared with those at remote sites. METHODS: From a prospective database of 561 cholecystectomies, 190 inguinal hernia repairs, 71 Nissen fundoplications, and 51 ventral hernia repairs, 873 consecutive Hasson cannula sites, 748 umbilicus sites, and 125 remote sites were analyzed. RESULTS: The wound infection rate was found to be 6%: 7% at the umbilicus (9% after cholecystectomy and 2% after other operations [p < 0.05]) and 0% at remote sites (p < 0.05). Excluding cholecystectomy, the umbilical infection rate was 2%, similar to that at remote sites. The postoperative ventral hernia rate was at 0.8%, the same at the umbilicus as elsewhere. The rate was similar for gallbladder and nongallbladder operations and correlated with the postoperative wound infection rate, but not with the preexisting fascial defect rate. CONCLUSIONS: Wound infection at the umbilicus is similar to that at other sites, except after cholecystectomy. Postoperative ventral hernia at the umbilicus is similar to that at other sites and not related to preexisting fascial defects.

Adult↗
PubMed2001

The tail of the learning curve for laparoscopic cholecystectomy.

BACKGROUND: This study estimates the number of laparoscopic cholecystectomies required until improvement ceases, assesses the magnitude of such improvement, and provides some insight into the mechanism by which it takes place. METHODS: Data from 500 consecutive laparoscopic cholecystectomies were analyzed from a prospective data base for number of short and long operations and operative time. RESULTS: There was a 40% decrease (P <0.05) in average operative time over the first 200 operations. Significant decrease in the number of longer operations, increase of shorter cases, and decrease in the range of operative time were noted. The major contributor was a marked shortening of longer cases, without much increased speed of shorter operations. CONCLUSIONS: For laparoscopic cholecystectomy, improvement persists for about 200 operations, resulting in a 40% reduction in operative time. The primary mechanism of improvement seems to be an ability to deal more effectively with difficult cases.

Cholecystectomy, Laparoscopic↗
PubMed2000

The road to ambulatory laparoscopic management of perforated appendicitis.

BACKGROUND: This study examines the contribution of increased laparoscopic skills to ambulatory management of perforated appendicitis. METHODS: All 38 perforated appendicitides from 151 laparoscopic appendectomies done by one surgeon were studied and ambulatory management (discharge less than 24 hours after surgery) of the last 18 perforations reported. RESULTS: Over 4 years, rate of attempted laparoscopic appendectomy rose from 67% to 100% for perforations. Conversion rate fell from 100% to 22%. Ileus and pain control were not problems for most laparoscopic perforations, so by the end of 1997, experience suggested these patients might be discharged within 24 hours. Ambulatory rate was 57% (conversions excluded). There were no readmissions for wound infections or postoperative abdominal abscesses. CONCLUSIONS: Increasing laparoscopic skills allows laparoscopic treatment of complicated appendicitis with a low conversion rate and no infectious complications. Over one half of these patients can be managed as outpatients without jeopardy to outcome.

Adult↗
PubMed1998

The role of cost analysis in deciding whether to provide laparoscopic cholecystectomy in remote communities.

To review the role of cost analysis in deciding whether to provide laparoscopic cholecystectomy in a remote community, cholecystectomies for Baffin Region residents were reviewed. Actual cost was calculated using known travel costs, per diem costs, and length of stay (LOS) data. Laparoscopic cost was estimated using LOS and conversion data from the literature. Between 1992 and 1995, 72 patients from the Baffin Region had a cholecystectomy, 61 in Iqaluit and 11 in Montreal. Fifty-seven and five, respectively, were suitable candidates for laparoscopic surgery. LOS was 5.6 days in Iqaluit and 3.5 in Montreal. Annual cost was $167,465 (Canadian). Comparable laparoscopic cholecystectomy cost is $45,411, an annual saving of $122,054. Even after equipment depreciation, laparoscopy provides a calculated saving of over $100,000 a year. However, even maximal decrease in bed utilization is less than 0.5 bed per day. Such small decreases do not allow staffing reduction and, thus, most of the projected savings cannot be realized in practice. Therefore, neither costs nor savings can play a supportive role in a decision to provide laparoscopic cholecystectomy in remote communities. This decision would have to be based on other considerations.

Canada↗
PubMed1998

The learning curve in laparoscopic inguinal hernia repair for the community general surgeon.

OBJECTIVE: To determine the learning curve (number of operations required) to stabilize operating times and complication rates for a general surgeon doing laparoscopic inguinal hernia repair in a community practice. DESIGN: A prospective analysis. SETTING: A 256-bed secondary-care community hospital. PATIENTS: Ninety-eight consecutive patients booked for elective laparoscopic hernia repair on an outpatient basis. INTERVENTIONS: Using the transbdominal preperitoneal approach, 100 operations were carried out to repair 138 groins and a total of 164 separate hernial defects. OUTCOME MEASURES: The number of operations required to decrease operative times and complication rates to a steady level. RESULTS: There were no deaths. There were 5 conversions and 10 admissions, all occurring between the 1st and 46th operations. Two reoperations for reasons other than recurrence were required between the 45th and 55th operations. There were 24 other complications. Complications and surgical times began to level off after 50 operations. The 1 readmission was after the 42nd operation. There were 4 recurrences (2.9% recurrence rate), 2 in each group of 50 operations. Both groups of 2 recurrence occurred within the first 10 operations involving the use of a new stapler. Twenty-two other patients had open hernia repairs because laparoscopy was unsuitable for them. CONCLUSION: The learning curve for laparoscopic inguinal hernia repair in the hands of a general surgeon in community practice who is experienced in open herniorraphy and laparoscopic cholecystectomy is at least 50 operations.

Adult↗
PubMed1997

Is outpatient cholecystectomy safe for the higher-risk elective patient?

BACKGROUND: This study was done to determine the safety of outpatient cholecystectomy for the higher-risk patient. METHODS: All patients over age 70 or with American Society of Anesthesiologists physical status classification of 3 or greater, from all 515 consecutive patients booked for elective cholecystectomy between April 1, 1994, and March 31, 1996, were reviewed. RESULTS: Of 85 higher-risk patients, 77 were booked as outpatients. Sixty-one were successfully completed as outpatients, with no complications or readmissions related to their outpatient status. Of 24 admitted patients, 15 had specific indications for hospitalization. Nine were admitted for reasons of "precaution." One of these developed a complication, possibly related to her inpatient status. The other eight could have been managed as outpatients. CONCLUSIONS: Outpatient cholecystectomy is safe for the higher-risk patient. Patients who recover uneventfully from surgery can be discharged without harmful effects. "Precautionary" hospitalization may be harmful.

Acute Disease↗
PubMed1997

Establishing outpatient cholecystectomy as a hospital routine.

OBJECTIVE: To determine the rate of outpatient cholecystectomies done voluntarily by surgeons and to identify any "correctable" factors leading to hospital admission, also to reassess the outpatient cholecystectomy rate after correcting the identified factors. DESIGN: A prospective analysis. SETTING: A 256-bed non-teaching acute-care community hospital on the outskirts of a major urban centre, served by 4 general surgeons. PATIENTS: All 515 patients booked for elective cholecystectomy at the hospital between Apr. 1, 1994, and Mar. 31, 1996, inclusive. INTERVENTION: Elective outpatient cholecystectomy. MAIN OUTCOME MEASURE: A successful procedure without compromise of safety. RESULTS: In the preliminary study, outpatient cholecystectomy was done in 75% of the patients. Variations in individual surgical practice, preoperative patient selection and inappropriate day surgery facilities were thought to be correctable factors leading to admission. After correction of the these factors (follow-up study), the rate of outpatient cholecystectomy rose to 95% (p < 0.001). Variations in individual surgical practice disappeared, and no patient required processing through inappropriate day surgery facilities. No patient suffered untoward effects from outpatient management. CONCLUSIONS: Outpatient cholecystectomy is a safe hospital routine for all elective procedures without selection. Voluntary acceptance of this routine leads to an initial 75% outpatient rate. Identifying and correcting modifiable factors led to a significant increase in the institutional outpatient rate, comparable to reported individual rates.

Adult↗
PubMed1996

Outpatient cholecystectomy.

One hundred consecutive patients requiring elective cholecystectomy in one surgeon's practice were booked as outpatients between April 1994, and July 1995. Two patients had massive adhesions and 18 had acute disease. Outpatient surgery was successful for 94 patients, who spent an average of less than 6 h in hospital. Six patients required postoperative admission, four because of conversion and two for other causes. There were three readmissions, unrelated to outpatient status: one to treat a wound infection, one to drain a subphrenic abscess, and one to repair an umbilical hernia. Complications were one subphrenic abscess, one case of significant atelectasis, and, at the umbilical incision seven wound infections, one hematoma and one postoperative hernia. Advanced age and increased comorbidity correlated significantly with the need for hospital admission, but were not contraindications, either alone or in combination, to outpatient surgery. Patient satisfaction was high.

Acute Disease↗
PubMed1995

Routine outpatient laparoscopic cholecystectomy.

OBJECTIVE: To determine what proportion of patients booked for elective cholecystectomy can be treated on an outpatient basis and what criteria will predict the need for hospital admission. DESIGN: A prospective analysis. SETTING: A 306-bed, nonteaching, acute-care community hospital on the outskirts of a major urban centre. PATIENTS: One hundred consecutive patients in private referral practice scheduled for outpatient laparoscopic surgery between November 1992 and January 1994. INTERVENTION: Laparoscopic cholecystectomy. MAIN OUTCOME MEASURES: The proportion of patients who successfully avoided hospital admission, the degree of discomfort, complications and the objective criteria that assist in predicting the need for initial or eventual hospital admission. RESULTS: Outpatient cholecystectomy was successful in 87% of the patients, and patient acceptance of the procedure was good. Advanced age, major associated health problems, acute cholecystitis and longer operations were the criteria most likely to lead to hospital admission, although none of these factors, alone or in combination, was a contraindication to outpatient cholecystectomy. CONCLUSIONS: Outpatient laparoscopic cholecystectomy can be performed successfully in most patients. There are four criteria that increase the likelihood of hospital admission after this procedure.

Adult↗
PubMed1989

Perforated diverticulitis after surgery.

The authors report on three patients who had a perforated sigmoid diverticulum after unrelated surgery. If the preceding operation is remote in time from the perforation, detection is relatively easy, but if the perforation occurs shortly after major abdominal surgery, its presentation may be totally masked by the postoperative state. Awareness of this possibility may help alert the clinician to the presence of perforation of a sigmoid diverticulum in unexplained postoperative collapse. Although discovery of these three cases suggests that diverticular perforation is not uncommon after surgery, a causal relationship is not known, and the authors could not find any previous reports of such a relationship.

Abscess↗
PubMed1988

Is incidental appendectomy a safe practice?

In an attempt to determine the safety of appendectomy performed as an incidental procedure, the authors reviewed 853 operations (458 hysterectomies and 395 cholecystectomies) performed by five surgeons at one hospital between 1981 and 1984 and compared the results in 35% of the patients who underwent incidental appendectomy with those in the remainder. Factors studied were operative time, postoperative stay, postoperative fever and leukocytosis, the need for intravenous fluids, parenteral analgesia and antibiotics, and infectious complications. Most of these variables differed between individual surgeons, but the addition of incidental appendectomy did not significantly alter any variable for an individual surgeon or for the group as a whole. Incidental appendectomy seems to be a safe practice and one that does not alter the outcome of hysterectomy or cholecystectomy but does protect against subsequent appendicitis.

Appendectomy↗
PubMed1987

Acute abdomen in severely mentally retarded patients.

Over 5 years, 25 severely retarded institutionalized patients accounted for 29 admissions for laparotomy due to acute abdomen. The patients' symptoms were always of short duration, yet 38% of operations were judged to be delayed. This was thought to be due to the patients' inability to communicate and to altered pain sensation. Pica (depraved appetite) accounted for 48% of admissions and perforation was common (41%). The death rate was high (4 (14%) of the 29 admissions and 3 (21%) of the admissions associated with pica). An unexpected high incidence (24%) of peptic ulcer was also seen. Unless the patient was admitted in a state of shock, usual clinical determinations often failed to distinguish early from advanced disease. Young males seem at increased risk and a history of pica is ominous.

Abdomen, Acute↗
PubMed1986

A fatal pulmonary embolus composed of gross liver tissue.

A snowmobile accident caused a pulp injury to the liver and tear of the vena cava of a 21-year-old man. Improvement after fluid resuscitation, right hepatic lobectomy and caval repair was followed by sudden hemodynamic collapse and death. Autopsy revealed pulmonary embolism caused by liver tissue. Presumably the pieces of liver entered the vena cava through the tear and travelled to the lung when blood flow improved. The authors believe that this is the first report of fatal pulmonary embolism caused by macroscopic liver tissue.

Accidents, Traffic↗
PubMed1985

Fatal, overwhelming sepsis after splenectomy in the community hospital.

Charts of all patients who underwent splenectomy between 1965 and 1981 at the Orillia Soldiers' Memorial Hospital were reviewed. At the end of 1983, the patient, relatives or family physician were contacted for follow-up. Eighty spleens were removed, 36 for medical reasons, 30 for trauma and 14 because of iatrogenic injury. Of the patients followed up, 51 were alive and 13 had died. Three died in the postoperative period and seven died of unrelated causes. Three patients died of overwhelming sepsis, 1, 3 and 7 years after splenectomy. If the three postoperative deaths are excluded and it is assumed none of the 16 untraced patients died of overwhelming sepsis, the incidence of death from this cause was 3.9%.

Acute Disease↗
PubMed1983

Carpal tunnel syndrome in pregnancy.

One thousand consecutive postpartum patients were interviewed by questionnaire to establish the incidence of carpal tunnel syndrome in pregnancy. Hand symptoms had been noted by 34%: 25% had had symptoms of carpal tunnel syndrome, 2% symptoms of ulnar nerve compression and 7% ill defined hand symptoms. Maternal and fetal age, parity and weight change did not correlate with the presence of symptoms. The rate of ring removal because of swelling was twice as great for the symptomatic women (73%) as for the asymptomatic women (36%), and the rates of pre-eclampsia, hypertension and edema were higher for the women with symptoms. Three quarters of the women had bilateral symptoms, and half of the multigravidas had had similar symptoms in previous pregnancies. Hand function and sleep were disturbed in 75% of the symptomatic women, yet only 46% of all those with symptoms mentioned their symptoms to their doctors; treatment was given to only 16% (35% of those who complained), and relief was obtained by only half of these.

Adult↗
PubMed1976

Abdominoperineal resection: Treatment of choice for carcinoma of the rectum.

Abdominoperineal resection cure adenocarcinoma of the rectum was performed in 62 patients between 1965 and 1969 at the Winnipeg General Hospital. Mean age was 64, ranging from 41 to 83; 40 patients were male and 22 female. Distribution by Dukes' staging was: A, 11; B, 28; C, 23. Complications occurred in 22 patients (35%). Average hospital stay was 29 days, 27 days in uncomplicated patients and 36 days in those with complications. There were two deaths, a 3.2% operative mortality rate. Sixty of the 62 patients were available for 5-year followup. Crude survival rate was 52%: A, 91%; B, 59%; C, 25%. Two patients died of an operation that permanently cured three patients in whom disease had spread beyond local confines. Abdominoperineal resection offered a 52% 5-year survival rate, increased the rate of cures in the unstaged patient by at least 5% over that afforded by local therapy, gave a 14% chance of cure in stage C disease compared with 0% with local therapy, and, compared with local therapy, was at least 67% more likely to offer cure than to kill in the event of disease spread to regional lymph nodes.

Abdomen↗