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Biomedical subjects

Brent D Matthews

Publications and source records attributed to Brent D Matthews.

At least 19 recordsLinked to original sources
PubMed2006

Pooled data analysis of laparoscopic vs. open ventral hernia repair: 14 years of patient data accrual.

BACKGROUND: The purpose of this study was to analyze the published perioperative results and outcomes of laparoscopic (LVHR) and open (OVHR) ventral hernia repair focusing on complications and hernia recurrences. METHODS: Data were compiled from all English-language reports of LVHR published from 1996 through January 2006. Series with fewer than 20 cases of LVHR, insufficient details of complications, or those part of a larger series were excluded. Data were derived from 31 reports of LVHR alone (unpaired studies) and 14 that directly compared LVHR to OVHR (paired studies). Chi-squared analysis, Fisher's exact test, and two-tailed t-test analysis were used. RESULTS: Forty-five published series were included, representing 5340 patients (4582 LVHR, 758 OVHR). In the pooled analysis (combined paired and unpaired studies), LVHR was associated with significantly fewer wound complications (3.8% vs. 16.8%, p < 0.0001), total complications (22.7% vs. 41.7%, p < 0.0001), hernia recurrences (4.3% vs. 12.1%, p < 0.0001), and a shorter length of stay (2.4 vs. 4.3 days, p = 0.0004). These outcomes maintained statistical significance when only the paired studies were analyzed. In the pooled analysis, LVHR was associated with fewer gastrointestinal (2.6% vs. 5.9%, p < 0.0001), pulmonary (0.6% vs. 1.7%, p = 0.0013), and miscellaneous (0.7% vs. 1.9%, p = 0.0011) complications, but a higher incidence of prolonged procedure site pain (1.96% vs. 0.92%, p = 0.0469); none of these outcomes was significant in the paired study analysis. No differences in cardiac, neurologic, septic, genitourinary, or thromboembolic complications were found. The mortality rate was 0.13% with LVHR and 0.26% with OVHR (p = NS). Trends toward larger hernia defects and larger mesh sizes were observed for LVHR. CONCLUSIONS: The published literature indicates fewer wound-related and overall complications and a lower rate of hernia recurrence for LVHR compared to OVHR. Further controlled trials are necessary to substantiate these findings and to assess the health care economic impact of this approach.

Female↗
PubMed2006

Textile analysis of heavy weight, mid-weight, and light weight polypropylene mesh in a porcine ventral hernia model.

BACKGROUND: The purpose of this study was to assess the burst strength and stiffness of heavy weight (HW), mid-weight (MW), and light weight (LW) polypropylene mesh pre-implantation and 5 months post-implantation in a porcine ventral hernia model. MATERIALS AND METHODS: HW (95 g/cm2), MW (45 g/cm2), and LW (28 g/cm2) polypropylene were tested as dry samples (n = 8/mesh) before implantation using a stamp strain machine. Three weeks after creating four hernia defects in each mini-pig (n = 18), the polypropylene meshes (8 x 10 cm; 24/mesh type) were implanted in the preperitoneal space, ensuring 2 cm overlap circumferentially. At 5 months, the mesh was harvested en bloc with the abdominal wall. Testing of burst strength and stiffness was repeated on the ex vivo specimens. RESULTS: After implantation in the pig for 5 months, the mean burst strength and stiffness of HW and MW meshes remains the same. LW mesh with an absorbable monofilament in its weave has significant reductions in mean burst strength (P = 0.01) and mean stiffness (P < 0.0001). The burst strength for all meshes tested was much higher than measured for the abdominal wall fascia alone. The degree of shrinkage of the various weight meshes did not differ. CONCLUSION: A reduction in mean burst strength and stiffness occurs after 5 months implantation of LW polypropylene mesh with an absorbable monofilament. All meshes exhibited burst strengths that were much greater than the burst strength of the abdominal wall fascia alone. After tissue incorporation, the LW polypropylene mesh maintains mean burst strength comparable to MW polypropylene mesh, while becoming less stiff than HW mesh. Long-term, this may contribute to more physiological abdominal wall compliance after LW polypropylene mesh implantation.

Animals↗
PubMed2006

Outcomes of laparoscopic paraesophageal hernia repair in elderly and high-risk patients.

BACKGROUND: This study examines the impact of age and comorbidities on complications and outcomes of laparoscopic (Lap) paraesophageal hernia (PEH) repair. METHODS: Data were collected prospectively on all patients who underwent Lap PEH repair from January 1995 through June 2005. Pre- and postoperative variables including complications were analyzed. Patients were stratified by age (Group [Gr.] 1, <65 years; Gr. 2, 65 to 74 years; Gr. 3, >/=75 years) and American Society of Anesthesiology (ASA) class (1 and 2 vs 3 and 4). Statistical analysis was performed using 1-way ANOVA, chi-square, and Fisher exact test. RESULTS: Overall, 171 patients underwent Lap PEH repair. Mean patient age was 65 +/- 15 years, mean ASA class 2.4 +/- 0.5, gender 72% female, and mean operating time 173 +/- 49 min. Patients in Gr. 3 had a significantly higher ASA class (Gr. 1, 2.3 +/- 0.6; Gr. 2, 2.5 +/- 0.5; Gr. 3, 2.6 +/- 0.5) and longer postoperative length of stay (LOS) compared with Gr. 1 (P < 0.05). Esophageal lengthening was required in 10.4% of patients in Gr. 3 versus 2.6% in Gr. 1 and 2.1% in Gr. 2 (P = 0.079). Total complication rates were 17.1% in Gr. 1, 22.4% in Gr. 2, and 27.7% in Gr. 3 (P = not significant [NS]). Most complications were minor; grade 2 or higher complications occurred in 10.5% of patients in Gr. 1, 8.3% in Gr. 2, and 8.5% in Gr. 3 (P = NS). There was 1 death (Gr. 2) on postoperative day 18 due to a myocardial infarction (mortality rate = 0.6%). Mean follow-up was 25.3 +/- 20.6 months. Postoperative symptoms of heartburn and regurgitation were similar between groups as was antisecretory medication use. Anatomic failure of the repair occurred in 23.7% of patients with adequate follow-up: 26.7% in Gr. 1, 15.4% in Gr. 2, and 27.8% in Gr. 3 (P = NS). Reoperation was performed in 1 of 32 (3.1%) failures. CONCLUSIONS: Lap PEH repair is safe in elderly and properly selected high-risk patients, although complication rates are higher than in younger patients. Most patients have a good symptomatic outcome irrespective of their age, but the anatomic recurrence rates remain a concern for all age groups.

Adult↗
PubMed2006

Laparoscopic ventral hernia repair in obese patients: a new standard of care.

HYPOTHESIS: Ventral abdominal hernias represent a frequent and often formidable clinical problem, especially in obese patients. Because laparoscopic ventral hernia repair (LVHR) results in few complications and a low recurrence rate, the use of minimally invasive techniques in this subgroup of patients may minimize perioperative complications and failure rates. DESIGN: Retrospective review of prospectively collected data. SETTING: Tertiary care hospital. PATIENTS: One hundred sixty-three obese patients (body mass index [calculated as weight in kilograms divided by the square of height in meters], > or =30) who underwent LVHR at our institution between July 1, 1998, and December 31, 2003. INTERVENTION: Laparoscopic ventral hernia repair with an expanded polytetrafluoroethylene mesh. MAIN OUTCOME MEASURES: Patient age, sex, body mass index, size of fascial defect and mesh, operating time, operative blood loss, length of hospitalization, complications, and hernia recurrences. RESULTS: Ninety-eight women and 65 men, with a mean body mass index of 38, underwent LVHR. Twenty patients (12.3%) had 21 postoperative complications. There was no perioperative mortality. The mean length of hospital stay was 2.6 days. The recurrence rate was 5.5% at a mean follow-up of 25 months (range, 1-73 months). CONCLUSIONS: A low rate of conversion to laparotomy, minimal perioperative morbidity, and the absence of perioperative mortality in this series indicate the safety of LVHR in obese patients with complex hernias. In addition, a success rate of more than 94.5% suggests improved efficacy of LVHR compared with the historical rates among control subjects undergoing open surgery. In experienced hands, LVHR may be the approach of choice for most patients with a body mass index of 30 or more.

Adult↗
PubMed2006

Comparison of mechanical and in vivo performance of new and reprocessed harmonic scalpels.

OBJECTIVES: To compare the mechanical and clinical performance of new and reprocessed harmonic scalpels (HS). METHODS: A total of 89 reprocessed and 90 new HS (laparoscopic coagulating shears with a curved blade and 5-mm-diameter shaft) were subjected to visual inspection, destructive testing, and nondestructive mechanical testing. Subsequently, new HS, randomly selected reprocessed HS, and selected reprocessed HS with known abnormalities were graded on clinical performance by 14 surgeons in a porcine model. RESULTS: Visual inspection of the HS discriminated between the new and reprocessed instruments in 11 of the 12 visual criteria (P < or = 0.02). In vitro mechanical testing revealed greater clamp arm dislodge forces for the new HS (P < 0.01) and greater midshaft temperatures for reprocessed HS (P < 0.01). Overall, 65 (73%) of 89 reprocessed and 7 (7.8%) of 90 new HS had gross abnormalities noted on inspection and mechanical evaluation (P < 0.01). The surgeons' evaluation of the instruments during in vivo testing demonstrated that the new instruments manifested significantly greater hemostatic control compared with randomly selected reprocessed HS (P = 0.01) and were significantly better for tissue sticking (P = 0.01), tissue transection (P = 0.02), tissue dissection (P < 0.01), grasping (P < 0.01), and hemostatic control (P = 0.04) compared with reprocessed HS with obvious defects. CONCLUSIONS: In vitro and in vivo data demonstrated significantly greater performance for new HS compared with reprocessed HS. Mechanical testing of reprocessed HS could not adequately distinguish which HS would result in decreased performance. These findings raise important issues of clinical safety in the contemporary quest for cost-effectiveness.

Disposable Equipment↗
PubMed2005

Normal intraabdominal pressure in healthy adults.

BACKGROUND: Intraabdominal pressure (IAP) has been considered responsible for adverse effects in trauma and other abdominal catastrophes as well as in formation and recurrence of hernias. To date, little information is available concerning IAP in normal persons. Our purpose in this study was to measure the normal range of IAP in healthy, nonobese adults and correlate these measurements with sex and body mass index (BMI). METHODS: After Institutional Review Board approval, 20 healthy young adults (< or =30 years old) with no prior history of abdominal surgery were enrolled. Pressure readings were obtained through a transurethral bladder (Foley) catheter. Each subject performed 13 different tasks including standing, sitting, bending at the waist, bending at the knees, performing abdominal crunches, jumping, climbing stairs, bench-pressing 25 pounds, arm curling 10 pounds, and performing a Valsalva and coughing while sitting and also while standing. Data were analyzed by Student's t-test and Pearson's correlation coefficients. RESULTS: Intraabdominal pressure was measured in 10 male and 10 female subjects. The mean age of the study group was 22.7 years (range, 18-30 years), and BMI averaged 24.6 kg/m(2) (range, 18.4-31.9 kg/m(2)). Mean IAP for sitting and standing were 16.7 and 20 mm Hg. Coughing and jumping generated the highest IAP (107.6 and 171 mm Hg, respectively). Lifting 10-pound weights and bending at the knees did not generate excessive levels of pressure with the maximum average of 25.5 mm Hg. The mean pressures were not different when comparing males and females during each maneuver. There was a significant correlation between higher BMI and increased IAP in 5 of 13 exercises. CONCLUSION: Normal IAP correlates with BMI but does not vary based on sex. The highest intraabdominal pressures in healthy patients are generated during coughing and jumping. Based on our observations, patients with higher BMI and chronic cough appear to generate significant elevation in IAP. Thus, this group of patients may potentially be at increased risk for abdominal wall hernia formation following surgery.

Abdomen↗
PubMed2005

Evaluation of adhesion formation and host tissue response to intra-abdominal polytetrafluoroethylene mesh and composite prosthetic mesh.

BACKGROUND: The purpose of this study was to measure the extent of adhesion formation to ePTFE mesh (DualMesh, W.L. Gore & Associates, Inc, Flagstaff, AZ) and two composite prosthetic materials, ePTFE and polypropylene (Bard Composix, C.R. Bard, Inc, Murray Hill, NJ) and hyaluronic acid/carboxymethylcellulose and polypropylene (Sepramesh, Genzyme Corp, Cambridge, MA) after their intra-abdominal placement on an intact peritoneum, simulating laparoscopic ventral hernia repair, and to evaluate host tissue response to the prosthetic biomaterials. MATERIALS AND METHODS: Through a midline laparotomy, a 2 x 2 cm piece of mesh (n = 60) was sewn to an intact peritoneum on each side of a midline incision in 30 New Zealand white rabbits. Mesh adhesions were scored using a modified Diamond scale (0 = 0%, 1 = 1-25%, 2 = 26-50%, 3 >50%) at 1, 3, 9, and 16 weeks by serial microlaparoscopy (2 mm). All laparoscopic evaluations were videotaped for blinded scoring by three surgeons. Host tissue response was graded (1-4) for inflammation, tissue ingrowth, and mesothelialization. The predominant cell type (polymorphonuclear leukocytes versus foreign body giant cell) was recorded. Statistical differences (P value <0.05*) were measured using a two-tailed t test and Kruskal-Wallis test. RESULTS: The mean adhesion score was significantly (P < 0.001) less for ePTFE mesh at 1, 3, 9, and 16 weeks compared with the two composite prosthetic materials. There were no differences in the mean adhesion scores between the two biosurgical composite meshes at any of the time intervals. There were no differences in the mean score for inflammation, tissue ingrowth and mesothelialization between any of the prosthetic biomaterials. The predominant cell type on all histological evaluations was polymorphonuclear leukocytes. CONCLUSIONS: Placing ePTFE mesh (DualMesh) intra-abdominal against an intact peritoneum results in significantly fewer adhesions than the composite prosthetic meshes during a 4-month follow-up. The host tissue response is equivalent for the three prosthetic biomaterials. The long-term consequences of increased adhesion formation to the composite meshes and the ultimate biocompatibility of the nonabsorbable and absorbable barriers on the polypropylene mesh are to be determined.

Abdomen↗
PubMed2005

Gas embolism during laparoscopic cholecystectomy.

Advancements in laparoscopic surgery have resulted in decreased length of hospitalization, reduced postoperative pain, and better cosmesis following general surgical procedures. Carbon dioxide gas embolism is a rare occurrence that can be fatal. We report the case of a patient with a venous gas embolism during laparoscopic cholecystectomy. A 63-year-old woman presented with intermittent right upper quadrant pain, and her abdominal ultrasound showed a possible gallbladder polyp. A laparoscopic cholecystectomy was planned. A Veress needle was placed in the right upper quadrant to initiate abdominal access. Shortly after carbon dioxide insufflation, the patient's hemodynamic status deteriorated, her oxygen saturation dropped, and her end-tidal CO2 decreased. Gas insufflation was immediately stopped, and the patient was resuscitated. She stabilized quickly, and the procedure was performed without further event. She did well postoperatively and was discharged home the next day. Carbon dioxide embolism during laparoscopy, albeit rare, can be a fatal complication of the procedure. Whenever sudden changes in hemodynamic stability occur, venous gas embolism should be considered. As laparoscopic techniques and applications are expanded, the general surgeon must be aware of this entity.

Carbon Dioxide↗
PubMed2005

Laparoscopic curative resection of pheochromocytomas.

PURPOSE: Pheochromocytomas are relatively uncommon tumors whose operative resection has clear medical and technical challenges. While the safety and efficacy of laparoscopic adrenalectomy are relatively well documented, few studies with extended follow-up have been conducted to measure the success of the procedure for the most challenging of the adrenal tumors. In addition, several reports question the applicability of a minimally invasive approach for sizeable pheochromocytomas. The purpose of our investigation was to assess the outcomes of laparoscopic adrenalectomy for pheochromocytomas in the largest study to date when performed by experienced laparoscopic surgeons. METHODS: All pheochromocytomas removed by the authors from January 1995 to October 2004 were reviewed under an Institutional Review Board approved protocol. Eighty-five percent were documented in a prospective fashion. RESULTS: Eighty consecutive patients underwent laparoscopic resection of 81 pheochromocytomas. Seventy-nine were found in the adrenal (42 left, 35 right, 1 bilateral); 2 were extra-adrenal paragangliomas. Eight patients had multiple endocrine neoplasia syndrome. Two lesions were malignant. There were 48 females and 32 males with a mean age of 45 years (range, 15-79 years). Mean tumor size was 5.0 cm (range, 2-12.1 cm); 41 of these lesions were 5 cm in size or larger. Average operative time and blood loss were 169 minutes (range, 69-375 minutes) and 97 mL (range, 20-500 mL), respectively. Intraoperative hypertension (systolic blood pressure, >170 mm Hg) was reported in 53% of patients and hypotension (systolic blood pressure, <90 mm Hg) in 28% of patients. There were no conversions to open surgery. Mean length of stay was 2.3 days (range, 1-10 days). There were 6 perioperative morbidities (7.5%) and no mortalities. No patient required a blood transfusion. No recurrence of endocrinopathy has been documented at a mean follow-up of 21.4 months. CONCLUSION: Laparoscopic resection of pheochromocytomas, including large lesions, can be accomplished safely by experienced surgeons. A short hospital stay with minimal operative morbidity and eradication of endocrinopathy support the minimally invasive approach for adrenalectomy in the setting of pheochromocytoma.

Adolescent↗
PubMed2005

National study of the effect of patient and hospital characteristics on bariatric surgery outcomes.

The influence of patient and hospital demographics on gastric bypass (GB) outcomes is unknown. We analyzed year 2000 data from the Nationwide Inpatient Sample database for all GB patients. In 2000, 5876 GB were performed in the 137 sample hospitals (M:F, 14%:86%). Length of stay (LOS, days), charges, comorbidities, and morbidity were higher for those aged >60 years compared to < 40 years. LOS, charges, comorbidities, morbidity, and mortality were highest in males. LOS was longest in African Americans compared to Caucasians and Hispanics. Charges and comorbidities were greatest in African Americans and Hispanics compared to Caucasians. Medicare and Medicaid-insured patients have higher LOS, charges, comorbidities, morbidity, and mortality compared to privately insured and self-pay patients. Lower income patients have higher LOS and total charges. Nonteaching hospitals have an increased LOS and charges and treat patients with more comorbidities compared to teaching hospitals. LOS, charges, and morbidity are directly proportional to hospital size. Urban hospitals have lower LOS and higher charges compared to rural hospitals. As hospital GB volume increases, LOS, charges, and morbidity decrease with no mortality effect. After controlling for all other covariates, male gender, increased age, and large hospital size were predictors of increased morbidity. Having had a complication predicted increased mortality, while female gender had a protective effect. Patient income, insurance status, and race did not play a role in morbidity or mortality. Neither academic, teaching status of the hospital or hospital gastric bypass volume influenced patient outcomes. Patient and hospital demographics do affect the outcomes of patients undergoing GB. Increasing age, male gender, and surgery performed in large hospitals are predictors of morbidity. Male gender and postoperative complications predict increased mortality. Neither comorbidities, race, payer, income, hospital academic status, location, nor hospital volume affect the outcome after GB.

Adult↗
PubMed2005

Prospective, blinded evaluation of accuracy of operative reports dictated by surgical residents.

Incomplete or inaccurate operative notes result in delayed, reduced, or denied reimbursement. Deficient reports may be more common when dictated by the surgical residents. We performed a blinded study to assess the accuracy of residents' dictations and their effect on the appropriate level of coding for reimbursement. A prospective, blinded study was performed comparing operative reports dictated by senior surgical residents (postgraduate years 3, 4, and 5) to reports dictated by attending surgeons. All residents had previously undergone group instruction on the importance and structure of operative notes. The trainees were blinded to the fact that the attending surgeons were dictating the operative reports on a separate dictation system. The dictations were analyzed by faculty reimbursement billing personnel for accuracy and completeness. Fifty operative reports of general surgical procedures dictated by both surgical residents and attending physicians were reviewed. A total of 97 CPT codes were used to report services rendered. Residents' dictations resulted in incorrect coding in 14 cases (28% error rate). The types of inaccuracies were a completely missed procedure (4) and insufficient documentation for an appropriate CPT code and/or modifier (10). All deficiencies occurred in complex, multicode, and/or laparoscopic cases. Sixty-seven per cent of late dictations were incomplete. The financial analysis revealed that deficiencies in resident dictations would have reduced the reimbursement by $18,200 (9.7%). For cases with deficient dictations, 29.5 per cent of charges would have been missed, delayed, or denied if the resident-dictated note was used to justify charges. Operative reports dictated by surgical residents are often incomplete or inaccurate, likely leading to reduced or delayed reimbursement. Dictations of complex, multicode, or laparoscopic surgeries, especially if delayed beyond 24 hours, are likely to contain significant deficiencies that affect billing. Attending surgeons may be better equipped to dictate complex cases. Formal housestaff education, mentorship by the attending faculty, and ongoing quality control may be paramount to minimize documentation errors to ensure appropriate coding for the services rendered.

Current Procedural Terminology↗
PubMed2004

Optimal closure method of five-millimeter trocar sites.

BACKGROUND: Although many surgeons use absorbable sutures for skin closure of 5-mm trocar sites, effective alternative materials exist. We compared 5-mm trocar site closures using a vicryl suture (VS), cyanoacrylate tissue adhesive (CTA), or skin tape (ST). METHODS: Patients rated wound pain and appearance at 1 and 6 weeks after surgery. Seven surgeons masked to the closure method rated wound photographs at these time points using the Hollander wound evaluation scale. Logistic regression analysis was used to evaluate the ratings of each closure group. RESULTS: The 137 wounds of 48 patients undergoing laparoscopic procedures were randomized among three closure method groups. Patient demographics and procedure type were similar for all groups. Long closure times (>30 seconds) was significantly higher for VS compared with CTA and ST. Patients favored VS over ST and CTA at 1 week with respect to pain and wound appearance (P = 0.04 and P = 0.02, respectively). They rated CTA closures more likely to have pain and poor wound appearance at 6 weeks (P = 0.05 and P = 0.03, respectively). Surgeons rated VS less likely (P = 0.02) and CTA more likely (P = 0.003) to show moderate to severe scar formation. Vicryl suture was less likely to have wound separation and edge inversion (P = 0.017 and P = 0.006, respectively). Cyanoacrylate tissue adhesive was more likely to yield step-off (P = 0.03), contour irregularities (P = 0.005), separation (P = 0.004), excessive distortion (P = 0.001), and edge inversion (P = 0.03). CONCLUSIONS: Although VS closure time of 5-mm trocar sites takes longer than CTA and ST, VS scar formation and comfort is superior to CTA and ST. Cyanoacrylate tissue adhesive yields poor results with respect to both wound healing and pain.

Equipment Design↗
PubMed2004

Laparoscopic splenectomy reverses thrombocytopenia in patients with hepatitis C cirrhosis and portal hypertension.

Pegylated-interferon (IFN) plus ribavirin remains the most effective therapeutic regimen for patients with chronic hepatitis C infection. Thrombocytopenia is a common side effect of this treatment, often leading to discontinuation of a potentially curative therapy. We sought to determine the safety and efficacy of laparoscopic splenectomy in correcting thrombocytopenia, thus allowing completion of IFN therapy. Data were collected prospectively from September 2000 to May 2003 on all patients undergoing laparoscopic splenectomy for thrombocytopenia associated with IFN therapy and/or hepatitis C cirrhosis with portal hypertension. Demographic data, model of end-stage liver disease (MELD) score, platelet count, operative time, blood loss, spleen weight, complications, length of stay, and follow-up time were calculated. Eleven patients (7 men, 4 women) underwent laparoscopic splenectomy; their mean age was 45.4 years (range 27 to 55 years) and mean body mass index was 27 kg/m(2) (range 21 to 44 kg/m(2)). All patients were Child's class A, with a mean preoperative MELD score of 9.1 (range 6 to 11). Mean operative time was 189 minutes (range 70 to 245 minutes), and blood loss averaged 141 ml (range 10 to 600 ml). A hand-assisted laparoscopic technique was used in four cases. Six patients received empiric intraoperative platelet administration. None required transfusion with packed red cells. Splenic weight averaged 1043 g (range 245 to 1650 g). Average length of stay was 2.6 days (range 1 to 6 days). Four patients had the following minor postoperative complications: self-limited atrial fibrillation (n=1), trocar site cellulitis (n=1), and atelectasis (n=2). There have been no major complications over an average follow-up of 11 months (range 1 to 18 months). Mean postoperative MELD score was 8.3 (range 6 to 10). Platelet counts improved from a preoperative mean of 55000/ul (16000 to 88000/microl) to 439000/microl (200000 to 710000/microl) postoperatively and have remained above 100000/microl (104000 to 397000/microl) during subsequent pegylated-IFN therapy. Three patients have completed a full course of IFN therapy and have obtained a sustained virologic response. Treatment is ongoing in the remaining patients. Laparoscopic splenectomy is safe in the setting of portal hypertension and thrombocytopenia associated with chronic hepatitis C infection. It can be performed with little blood loss, no need for red cell transfusion, and minimal perioperative morbidity. Laparoscopic splenectomy appears to effectively reverse thrombocytopenia and may allow these patients to safely complete IFN therapy.

Adult↗
PubMed2004

Laparoscopic splenectomy for splenic abscess.

Splenic abscess is a rare clinical entity, and splenectomy remains the treatment of choice. We sought to determine the safety and efficacy of laparoscopic splenectomy in this setting. Using a prospective database of laparoscopic splenectomy, we identified 4 patients who underwent surgery for splenic abscess (3 male, 1 female). Mean age was 55.5 (range 42-78) years. Patient symptoms included: fever and abdominal pain in 4 patients, pleural effusions in 2, and nausea and leukocytosis in 1. Risk factors for splenic abscess included septic emboli from bacterial endocarditis in 2 patients and acquired immune deficiency syndrome in 1. All patients underwent successful laparoscopic splenectomy. Mean operative time was 200 (range 160-220) minutes, and blood loss was 220 (range 100-450) mL. There were no postoperative complications or deaths; postoperative length of stay averaged 14 (range 2-26) days. Despite the difficulty of the operation, the laparoscopic approach appears to be a safe and effective treatment of splenic abscess.

Abscess↗
PubMed2004

Surgical treatment of achalasia in the 21st century.

BACKGROUND: Achalasia is a primary motility disorder of the esophagus characterized by poor mid-esophageal motility and failure of the lower esophageal sphincter to properly relax. The optimal treatment of the disease would improve esophageal peristalsis and promote lower esophageal sphincter relaxation. Currently, such therapy is not possible, so treatment of the disorder is aimed at relief of symptoms by disruption of the lower esophageal sphincter. METHODS: Data were collected prospectively on all patients undergoing laparoscopic myotomy and Toupet fundoplication during a 6-year period. RESULTS: Fifty-nine patients with a mean age of 44 years were treated during a 6-year period. Fifty-three patients underwent laparoscopic myotomy with Toupet fundoplication (91%), and four had laparoscopic myotomy without a fundoplication (6%). Fundoplication was not performed in two patients who had a megaesophagus. Two patients required conversion to an open operation. Sixty percent of patients were discharged the day after surgery; the average length of stay for all patients was 2.1 days. Ten percent of patients had minor complications; none required reoperation. Mortality was 0%, and 96% of patients rated their postoperative swallowing ability as excellent or good. CONCLUSION: Surgical myotomy is becoming first-line therapy for all patients with achalasia. A strong working relationship between surgeon and gastroenterologist helps to optimize patient care.

Adult↗
PubMed2004

Influence of demographics on colorectal cancer.

The purpose of this study was to examine the influence of race, gender, and age on colorectal cancer cases in our tumor registry between January 1987 and December 2000 and to determine the implications of these factors on screening strategies. Tumors were defined as early (Stage I/II) or late (Stage III/IV) and proximal or distal (relationship to splenic flexure). Effect of age was examined by stratifying patients into three groups (<50 years, 50-70 years, >70 years). Two time periods (1/87-12/96 and 1/97-12/00) were compared. Significance (P < 0.05) was determined by univariate and logistic regression analysis. Between January 1987 and December 2000, 1355 patients (M:F, 699:656; mean, 65.9 years) were entered into the tumor registry [998 whites, 357 African Americans (AA)]. The AA population had a significantly higher proportion of females (P = 0.0001) and patients <50 years (P = 0.01). The incidence of carcinoma in situ (CIS) was significantly higher in AA (P = 0.01). African Americans were more likely to present with late disease (P = 0.05), proximal cancers (P = 0.05), and well-differentiated tumors (P = 0.04). In the entire cohort, proximal lesions were significantly larger (P = 0.002), poorly differentiated (P = 0.002), and occurred more often in females (P = 0.03), patients >70 years (P = 0.04), and patients with family history of colon cancer compared to distal lesions. Proximal migration of tumors occurred in the latter part (1997-2000 compared to 1987-1996) of the study (P = 0.002). Patients <50 years had a higher incidence of late stage (P = 0.03) and poorly differentiated tumors (P = 0.009). The probability for a proximal tumor in an AA female >70 years was 61.9 per cent and in a white male >50 years was 35.1 per cent. Significant differences exist in the stage and location of tumors according to patient's age, race, and gender. These factors should be considered in implementing public screening strategies. Specifically, African-American patients were more likely to present with late-stage tumors, and more aggressive patient education and screening programs should be implemented. For all groups, a proximal migration of colorectal tumors was identified. This factor should eliminate use of sigmoidoscopy as a screening tool. Complete colonoscopy, instead, should be the procedure of choice to identify colonic neoplasia.

Adenocarcinoma↗
PubMed2004

Advanced age is not a prohibitive factor in laparoscopic nephrectomy for renal pathology.

Since the first procedure by Clayman and colleagues in 1990, laparoscopic nephrectomy has been performed at multiple institutions worldwide and is an accepted approach for benign and malignant renal pathology. We retrospectively compared the outcomes of laparoscopic nephrectomy for renal pathology in patients older than and less than 65 years of age. Data were collected for all patients undergoing elective nephrectomy (simple, radical, and nephroureterectomy) for renal pathology between November 2000 and June 2003. A total of 94 laparoscopic nephrectomies (62 hand-assisted, 32 totally laparoscopic) for renal disease were performed. Indications for surgery included renal cell carcinoma (63), transitional cell carcinoma (7), hypertension (9), chronic pyelonephritis (6), nonfunctioning kidney (4), complex cyst (3), and polycystic kidney disease (2). There were 33 elderly patients (> or = 65 years) and 61 adult patients (< 65 years). The elderly group had a mean operative time (238 min vs 234.3 min; P = 0.89) and blood loss (88.5 mL vs 149.8 mL; P = 0.68) similar to the adult group. Likewise, the incidence of perioperative complications was no different between the two groups (intra-op: 3.0% vs 0%; P = 0.35/post-op: 21.2% vs 16.4%; P = 0.56). The length of hospitalization was longer in the elderly population (5.7 days versus 5.0 days; P = 0.01) compared to the younger adult group. Laparoscopic nephrectomy is well tolerated in the elderly population. For all surgical indications, the use of a minimally invasive approach confers operative times, blood loss, and morbidity that are comparable to those of younger patients. Yet, length of stay remains longer for elderly patients undergoing nephrectomy.

Adolescent↗