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Biomedical subjects

L W Traverso

Publications and source records attributed to L W Traverso.

At least 55 records · Page 3Linked to original sources
PubMed1997

Pancreatoduodenectomy for chronic pancreatitis: anatomic selection criteria and subsequent long-term outcome analysis.

OBJECTIVE: The authors sought to provide a framework through outcome analysis to evaluate operations directed toward the intractable abdominal pain of severe chronic pancreatitis centered in the pancreatic head. Pancreatoduodenectomy (PD) was used as an example. SUMMARY BACKGROUND DATA: Head resection for severe chronic pancreatitis is the treatment of choice for a ductal system in the head obliterated by severe disease when associated with intractable abdominal pain. To evaluate the effectiveness of promising head resection substitutes for PD, a framework is necessary to provide a reference standard (i.e., an outcome analysis) of PD. METHODS: Inclusion criteria were severe chronic pancreatitis centered in the pancreatic head, intractable abdominal pain, and a main pancreatic duct obstruction or stricture resulting in absent drainage into the duodenum from the uncinate process and adjacent pancreatic head areas or the entire gland. Since 1986, 57 consecutive cases with these criteria underwent PD (47 head only and 10 total pancreatectomy). Clinical and anatomic predictor variables were derived from the history, imaging studies, and pathologic examination. These variables then were tested for association with the following outcome events gathered during annual follow-up: pain relief, onset of diabetes, body weight maintenance, and peptic ulceration. RESULTS: Operative mortality was zero. In 57 patients with a mean follow-up of 42 months, the 5-year outcome event for survival was 93% and the onset of diabetes was 32%. All new cases of diabetes occurred more than 1 year after resection. In 43 cases > or =1 year postoperative with a mean follow-up of 55 months, all patients indicated significant pain relief and 76% were pain free. Pain relief was more common in patients with diabetes or in those patients with a pancreatic duct disruption. Death was more common in patients with diabetes. Weight maintenance was more common if preoperatively severe ductal changes were not present. Total pancreatectomy was associated with peptic ulceration. CONCLUSIONS: Using selection criteria, the outcome analysis standardized anatomic and clinical variables as to how they were associated with the outcome events (calibrated the effects of the operation with each variable). In these selected patients, PD is safe and significantly relieves pain. Sequelae are from diabetes, provided total pancreatectomy is avoided.

Abdominal Pain↗
PubMed1996

[Current indications for pylorus saving duodenopancreatic head resection in malignancy].

The Whipple procedure has been improved by preservation of a functioning pylorus. A functioning pylorus is important because marginal ulceration is avoided and, compared to the standard Whipple procedure with gastric resection, more patients can gain weight postoperatively. The most common indications are carcinomas of ampulla of Vater and periampullary tumors. In patients with pancreatic adenocarcinoma the pylorus-preserving variety results in equal or better survival rates. In 56 patients with pylorus preservation, 32 with ductal carcinoma, and 28 with Kausch-Whipple between 1985 and 1993, our results showed slightly better survival rates and better postoperative nutrition. The weakest aspect of the radical resection addresses the retroperitoneal margin of the pancreas head and not the gastric resection.

Adenocarcinoma↗
PubMed1996

A prospective cost analysis of pancreatoduodenectomy.

BACKGROUND: In our cost-conscious health care system hospitals are finding that costs are as important as charges or reimbursements, especially as hospitals compete for managed care contracts. We have prospectively gathered cost data for more than 60 common operations performed at our institution over the last 3 years. METHODS: Over a 25-month period, from January 1993 to February 1995, 30 pancreaticoduodenectomy procedures were performed for which cost data were available. Cases were divided according to diagnosis (neoplastic or benign) and were evaluated for complications which prolonged length of stay (LOS). Costs were analyzed by an item-by-item prospective micro-cost analysis technique. Items were grouped into two areas: operating room (OR) costs and hospital (ward) costs. OR costs included disposable equipment, nondisposable equipment, OR room, OR staff, postanesthesia care, and anesthesia costs. Ward costs included hospital room, pharmacy, and radiology costs. RESULTS: OR costs for the 30 PD patients were similar and represented approximately 21% of total hospital costs. Of the 30 patients, complications resulting in a prolonged LOS occurred in 10 (33%): intra abdominal abscess in 3 (2 with pancreatic leaks), superficial marginal ulceration in 2, delayed return of gastrointestinal function in 2 (1 with pulmonary edema) and 1 each of bile leak, urosepsis, and chylous ascites. No cost differences were observed when comparing neoplasm versus chronic pancreatitis for all parameters. When comparing patients who had complications versus those who did not, however, there was a statistically significant cost difference for both hospital ward or total costs. Regardless of whether a PD was performed for neoplastic or benign disease, postoperative complications increased hospital ward costs by 76% due to increased LOS. CONCLUSIONS: This cost analysis study is an example of the methodology that would allow surgeons to investigate any common surgical procedure by first identifying areas of increased costs. This quantitative knowledge focuses the clinician on areas to improve quality which will then lower costs.

Chronic Disease↗
PubMed1996

The meaning of equivocal pancreatic cytology in patients thought to have pancreatic cancer.

INTRODUCTION: Fine needle aspirations (FNAs) and endoscopic retrograde cholangiopancreatography (ERCP)-guided brushings (BRUSH) are useful tools in the differentiation between malignant and benign disease of the pancreas. Once the decision to obtain a cytologic confirmation of one's clinical suspicion is made, the interpretation of the findings, especially an equivocal or negative cytology finding, can be unclear. This study seeks to evaluate the utility of cytologic studies in the evaluation of a patient with suspected pancreatic malignancy. METHODS: A retrospective review of 224 cytologic reports, including 174 FNAs and 50 BRUSHs, from all pancreatic FNAs and BRUSHs performed between January 1989 and June 1995, was performed. Subsequent confirmation of the cytologic diagnosis was made either by histologic or strict clinical criteria. RESULTS: Forty-three percent of the cytologic reports were read as malignant, all others reported as suspicious, atypical, or negative. All cytology studies read as malignant and all FNAs reported as suspicious were histologically or clinically confirmed to be malignant. Of those reported as atypical or negative, 55% and 49% were confirmed to be malignant. Both FNA and BRUSH were 100% specific, 75% sensitive, and 80% accurate. CONCLUSIONS: We conclude that a cytological diagnosis of malignant or suspicious is reliable and useful for further therapy planning in the patient suspected to have a pancreatic malignancy. The reason for the cytologic tests was a strong clinical suspicion, therefore, a high incidence of cancer was found in the patients with atypical or negative readings. A diagnosis of atypical or negative is equivocal and requires further diagnostic maneuvers, frequently including surgery, to make the definitive diagnosis.

Biopsy, Needle↗
PubMed1996

Do preoperative indicators predict the presence of common bile duct stones during laparoscopic cholecystectomy?

BACKGROUND: Criteria have been suggested to help decide if an intraoperative cholangiogram (IOC) should be performed during laparoscopic cholecystectomy (LC). They are a clinical history of passing a common bile duct (CBD) stone, elevated serum amylase, elevated liver function tests, or ultrasound findings suggesting a CBD stone. What is the sensitivity and specificity of the above criteria when the presence or absence of CBD stones is already known by IOC? What is the probability that these criteria will predict a CBD stone or be normal if a stone is absent, ie, the positive predictive value (PPV) and negative predictive value (NPV)? METHODS: We reviewed 420 cases of elective LC done between May 1990 and December 1992. In our teaching hospital, IOC is routine and acted as the reference standard for the presence of CBD stones. All 420 films were reviewed as well as the results of any preoperative endoscopic retrograde cholangiopancreatography (ERCP) (30 were done). The following preoperative indicators of CBD stones were recorded: any clinical history of CBD stones; an elevated amylase, SGOT, alkaline phosphatase, or bilirubin level; and ultrasound findings. The sensitivity, specificity, PPV, and NPV were calculated. RESULTS: CBD stones were found in 12% of these elective LC cases. The sensitivity, specificity, PPV, and NPV, respectively, for each preoperative indicator were: a history suggestive of CBD stones (36%, 94%, 45%, and 91%), serum biochemistries as a group (43%, 86%, 30% and 91%), and ultrasound findings of CBD stones (22%, 92%, 28% and 89%). We compared any elevation versus > 2x from the normal range of the serum indicators and did not improve their accuracy. Combination of the indicators increased sensitivity and NPV but lowered specificity and PPV. The best predictor of CBD stones was the history (45%) and this was in a hospital with a CBD stone prevalence rate of 12%. CONCLUSION: There are no predictive tests that can sufficiently increase an observer's probability estimate of the presence or absence of CBD stones to allow for "selective" IOC decisions.

Cholangiography↗
PubMed1996

Malignant obstructive jaundice. Evaluation and management.

A large number of laboratory tests, radiologic studies, and endoscopic techniques are available for the evaluation of the jaundiced patient. Similarly, the therapeutic options have increased with the development and improvement of endoscopic, percutaneous, and laparoscopic procedures, and the morbidity and mortality rates associated with open surgery have decreased. The challenge is to select, on an individual basis, the most efficient and cost-effective evaluation as well as the management with the lowest morbidity and mortality rates and the best short- and long-term goals.

Cholestasis↗
PubMed1996

Technology and surgery. Dilemma of the gimmick, true advances, and cost effectiveness.

The key to evaluating a procedure in regard to a true advance versus a gimmick is to determine its value. This can be done only by physicians cognizant of a disease process. The value is determined by assessing a procedure's utilization, outcomes, and costs. Utilization allows early treatment and avoids neglected disease. Therefore, the appropriateness of the utilization can be determined only by an outcome study. An outcome study is another term for quality assessment. Outcomes deal with morbidity, mortality, and also the long- and short-term effects of the procedure on the disease. Overall, an increase of quality in a global perspective decreases the costs of the procedure to the health care community. Costs must remain secondary to outcomes. An attempt to decrease costs directly is a maneuver that, when applied by nonmedical individuals, will most likely decrease quality. When the quality can be maintained (as assessed only by a practitioner), then a decrease in global costs will increase value. The concept of increasing value by increasing quality without an attempt to decrease costs is a very important principle that the health care system must learn in our ever-challenging medical environment. Is a new procedure a gimmick or a true advance? The decision is made jointly by the stakeholders in our health care system--the patient, provider, payer, employer, and industry. If the procedure does not receive negative votes, then its adoption is almost assured. Comparing two procedures through these perspectives ultimately allows us to determine the potential for new procedures. A procedure not adopted through this method could be called a gimmick.

Cost-Benefit Analysis↗
PubMed1996

The laparoscopic surgical value package and how surgeons can influence costs.

"Quality first and costs second" should be our motto. As surgeons we need to get involved with our procedures, but with the knowledge of the strengths and weaknesses of both outcome and cost analysis-that is, value assessment. The key to evaluating a procedure is to determine its value. This can be done only by physicians cognizant of the disease process and value assessment. The value is determined by assessing a procedure's utilization, outcomes, and costs. Utilization allows early treatment and avoids neglected disease. Therefore, the appropriateness of the utilization can be determined only by an outcome study. An outcome study is another term for quality assessment. Outcomes deal with morbidity, mortality, and the long- and short-term effects of the procedure. Overall, an increase of quality in a global perspective decreases the costs of the procedure to the health care community. Costs must remain secondary to outcomes. A cost analysis of LC has shown that surgeons can influence the majority of OR costs, and these are the direct variable type. Costs are usually not comparable between hospitals. Within each hospital, costs can be successfully used to assess efficiency and demand elasticity. An attempt to decrease costs directly is a maneuver that, when applied solely by nonmedical individuals, will most likely decrease quality. When the quality can be maintained (as assessed only by a practitioner), then a decrease in global costs increases value. The concept of increasing value by increasing quality without an attempt to decrease costs is a very important principle that the health care system must learn in our ever-challenging medical environment. Business administrators have decreased costs without consideration of quality assessment. Consider the additional impact of taking these cost savings and paying dividends to investors rather than reinvesting the monies into medical research or new technology. Quality declines first in patient choice, then referring physician choice, and finally short- and long-term results. When will this decline be apparent if quality assessments are not completed concurrently with cost analysis?

Cost Control↗
PubMed1996

Pancreatic fistulas: etiology, consequences, and treatment.

Pancreatic fistulas can be internal or external and the consequence of acute or chronic pancreatitis, malignancy, or trauma (to include pancreatic surgery, pseudocyst drainage, and percutaneous biopsy). Contingent on the presence of concomitant pseudocyst, downstream ductal obstruction, or a disconnected duct syndrome, treatment may include maneuvers to decrease pancreatic secretion (NPO, hyperalimentation, pancreatic enzymes, octreotide), attempts to effect serosal apposition (diuretics, thoracentesis, paracentesis), various types of percutaneous tube manipulation, or surgery. Transpapillary pancreatic duct stents have recently been used for refractory ductal leaks and may work either by direct occlusion of the fistula or by lowering the duodenal-pancreatic pressure gradient.

Humans↗
PubMed1995

A prospective cost and outcome comparison of inguinal hernia repairs. Laparoscopic transabdominal preperitoneal versus open tension-free preperitoneal.

We previously showed that patients undergoing transabdominal preperitoneal laparoscopic inguinal herniorrhaphy (TAPP) returned to activity twice as fast as open herniorrhaphy without mesh but that TAPP was twice as expensive. However, it was not clear if the immediate postoperative benefits offered by TAPP resulted from smaller incisions and less tissue dissection or from the requisite tension-free placement of mesh. We have therefore completed a prospective outcome and cost analysis comparing TAPP (n = 59) to open preperitoneal mesh herniorrhaphy (PPO) (n = 40) to determine the differences between the two different surgical techniques. When comparing unilateral repairs, there was no difference in hernia type. PPO patients were older (P < 0.05) and their operations were shorter (P < 0.01). Comparison of outcome parameters of pill days, out-of-house activity, and intial day to full activity revealed no difference. Cost analysis showed that total costs, disposable equipment costs, and operating room time costs were significantly less for PPO (P < 0.01). There were two major complications (3%) and twelve minor complications (20%) in the TAPP group while PPO exhibited no major and five minor complications (12%). Follow-up data revealed one recurrence in the TAPP group. There were no recurrences in the PPO group at only 7 months average follow-up. We conclude that since both procedures had similar outcomes in the immediate postoperative period, the increased cost of TAPP and increased potential for both major and minor complications make it difficult to justify its routine use.

Abdomen↗
PubMed1995

Biliary tract complications of laparoscopic cholecystectomy are detected more frequently with routine intraoperative cholangiography.

Controversy over whether intraoperative cholangiography (IOC) should be done routinely has intensified since the advent of laparoscopic cholecystectomy (LC). As yet, no study has demonstrated a clear benefit to its use, although their have been suggestions in the literature that routine use may confer an advantage to detection of injuries. One-hundred seventy-seven biliary tract complications occurring secondary to LC were identified from the combined data of seven institutions. The goal of this retrospective study was to examine the impact of IOC on the occurrence, recognition, and correction of such complications. The complications identified include 39 cystic duct leaks, 69 major ductal leaks or strictures, and 69 major ductal transection or excision injuries. Whether IOC was performed was known in 157 (88%) patients with 53 patients definitely having and 104 not having an IOC. Data concerning IOC were unavailable in 20 cases. More injuries were detected intraoperatively in the group having IOC (P < 0.001). Conversion of the LC to a laparotomy, often for repair of the injury, occurred more commonly in the group having a correctly interpreted IOC (P < 0.001). Conversion resulted in detection of injuries sooner, resulting in fewer operative procedures to correct the injury (P < 0.001). A transecting injury was prevented in at least seven patients when no visualization of the proximal biliary tree was documented by IOC. These partial ductal incisions were treated by t-tube placement. Incorrect interpretation of the IOC occurred in at least eight patients, with no identification of the proximal biliary tree in six.(ABSTRACT TRUNCATED AT 250 WORDS)

Bile Ducts↗
PubMed1995

Management and long-term follow-up of patients with positive cholangiograms during laparoscopic cholecystectomy.

BACKGROUND: With a goal of minimal invasion during laparoscopic cholecystectomy, the surgeon confronts a judgement decision if the intraoperative cholangiography (IOC) is positive for common bile duct (CBD) stones. The options are postoperative endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic papillotomy (EP), transcystic laparoscopic techniques (LAP), open CBD exploration, or clinical observation. PATIENTS AND METHODS: To gather this information, we reviewed the clinical course and IOC of 55 patients with positive IOC during laparoscopic cholecystectomy. Long-term follow-up (1.8 years) was obtained in 50 patients. RESULTS: After review, 48 patients were felt to have CBD stones, and a LAP without choledochoscopy was the initial management in 32 (67%) patients. The remaining patients underwent EP (n = 10), CBD exploration (n = 1), or observation (n = 5). By discharge, 19 (59%) of the 32 LAP patients were successful and had avoided EP while the success rate at follow-up was 48% (14/29). There were no complications after LAP, but we observed a 9.5% (2/21) post-EP pancreatitis rate that required readmission. The success rate for CBD stone clearance with LAP was associated with single stones (87%) and surgeon experience (100% in the last year). The average hospital stay was 1.7 days for LAP and 3.3 days for EP. CONCLUSIONS: LAP is safe and eliminates the need for EP in the majority of cases. Although EP is more often successful, it results in a longer hospital stay with an increased risk of complication. We recommend LAP as the initial procedure of choice for a positive IOC.

Adolescent↗
PubMed1995

A prospective cost analysis of laparoscopic cholecystectomy.

BACKGROUND: In order to improve the value of laparoscopic cholecystectomy (LC), we completed a prospective micro-cost analysis at a large, multispecialty referral hospital. METHODS: After a line-item cost database had been established, the following cost data were retrieved over a 1-year period (May 1993 through May 1994): operating room (OR), radiology, pharmacy, anesthesia supplies, recovery room, and hospital room. OR cost data was further divided into costs for room-staff, room setup, radiology, plus disposable and nondisposable equipment. Sixty uncomplicated LC cases were collected (30 cases each for 2 surgeons to examine the surgeon variable). RESULTS: Sixty percent of the hospital costs occurred in the OR. Disposable laparoscopic equipment accounted for 17% of the total hospital costs and 28% of the OR costs. Staff charges in the OR (cost estimated by the hospital using minutes in the LC room) represented 24% and 41%, respectively, of the above costs to the hospital. CONCLUSIONS: The areas in which hospitals and surgeons can improve the surgical value package (ie, decrease costs while maintaining quality) are in disposable equipment and efficient minimization of in-the-room time.

Cholangiography↗
PubMed1995

What symptoms does cholecystectomy cure? Insights from an outcomes measurement project and review of the literature.

BACKGROUND: The increasing application of cholecystectomy has increased the need to assess the effects of cholecystectomy on presenting symptoms. PATIENTS AND METHODS: Three surgeon-derived and two patient-derived data forms were collected for each patient in a series of 225 laparoscopic cholecystectomies. RESULTS: Eighty-two percent of patients had documented gallstones preoperatively, 91% had biliary pain, and 77% had both biliary pain and documented gallstones prior to surgery. Fifteen percent of patients were believed to have acalculous cholecystitis. Eighty-two percent also had bothersome nonpain symptoms (gassiness, bloating, indigestion, fatty-food intolerance, and nausea). The cure rate for biliary colic was 82% if stones were documented preoperatively, and 52% when they were not (P = 0.002). Atypical pain was cured 80% of the time, and nonpain symptoms, 44% of the time. CONCLUSIONS: Most patients (82%) with biliary colic and gallstones have complete relief of upper abdominal pain after cholecystectomy. Pain relief in patients felt to have acalculous cholecystitis was only 52%. Nonpain symptoms were common preoperatively (82%) and were relieved in 44% of patients.

Abdominal Pain↗
PubMed1995

Successful treatment of bleeding pseudoaneurysms of chronic pancreatitis.

A ruptured pseudoaneurysm is the most rapidly fatal complication encountered in patients with chronic pancreatitis, with a reported mortality rate of 12.5% in treated patients to > 90% in those untreated. Although reportedly a rare complication of chronic pancreatitis, a pseudoaneurysm is encountered in 6-9.5% of patients with chronic pancreatitis and as many as 17% of all patients operated on for chronic pancreatitis. Timely diagnosis and treatment seems to result in markedly reduced mortality. Four patients with bleeding pseudoaneurysms associated with chronic pancreatitis and pseudocysts were encountered recently at Virginia Mason Medical Center. These patients' charts, as well as the English literature, were reviewed in detail. All of our cases occurred in alcoholic males. Pseudocysts with pancreatic ductal or pseudocyst rupture were seen in three cases. All had a history of crescendo-decrescendo pain episodes and had evidence of bleeding or were bleeding at presentation. Splenic vein occlusion was identified in 50% of the cases. A pseudoaneurysm was documented by angiography in all patients. Embolization was successfully attempted without complication in two patients. Three patients were ultimately treated with a pylorus-sparing (2) or standard (1) pancreaticoduodenectomy. These three are alive and doing well at 16, 26, and 52 months from the time of their procedure. A fourth patient was treated nonoperatively, because of severe comorbid disease and aberrant anatomy, with successful embolization of the pseudoaneurysm and biliary and pancreatic stenting. The pseudocyst resolved and he is asymptomatic 12 months after therapy. We advocate preoperative arteriography in all patients with suspected or known arterial pseudoaneurysm.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗