PubMed Health⌕ Search

Biomedical subjects

Ravi P Kiran

Publications and source records attributed to Ravi P Kiran.

18 recordsLinked to original sources
PubMed2006

Outcome of laparoscopic colectomy for polyps not suitable for endoscopic resection.

BACKGROUND: Large colonic polyps or polyps that lie in anatomical locations that are difficult to access at endoscopy may not be suitable for endoscopic resection and therefore may require partial colectomy. This approach eradicates the polyp and allows an oncologic resection should the polyp prove to be malignant. The purpose of this study was to assess outcomes of a laparoscopic approach for the management of these polyps. METHODS: Patients referred for laparoscopic colectomy for colonic polyps were identified from the prospective colorectal laparoscopic surgery database. Demographics, operative details, and final pathology were reviewed. RESULTS: Fifty-one consecutive patients (27 male) with a mean age of 68 +/- 11.4 years, ASA classification (1/2/3/4) of 0/21/27/3, and body mass index (BMI) of 26.5 +/- 4.9 were identified. Right (RHC) and left (LHC) colectomy was performed for 39 right and 12 left colonic polyps. Mean operating time (OT) was 87 +/- 30 min (81 for RHC, 105 for LHC) and mean hospital stay was 3.1 +/- 1.9 days. There were six complications (17.7%), including anastomotic leak (n = 1), small bowel obstruction (n = 2), abscess (n = 1), and exacerbation of preexisting medical conditions (n = 2). Four patients were readmitted (7.8%); one required CT scan-guided abscess drainage (1.9%) and two required reoperation (3.9%). Five patients (9.8%) were converted because of adhesions (n = 3), obesity (n = 1), and inability to identify the area that was tattooed at colonoscopy (n = 1). Mean polyp size was 3.1 cm, and pathology revealed tubular (n = 14), tubulovillous (n = 33) and villous adenoma (n = 2), pseudopolyp (n = 1), and prolapse of the appendix into the cecum mimicking an adenoma (n = 1). High-grade dysplasia was seen in four tubular (33%) and five tubulovillous adenomas (15.5%). Adenocarcinoma not identified at colonoscopy was found in 11 polyps (20%), 9 tubulovillous (27.8%) and both villous adenomas (100%). CONCLUSIONS: Large colonic polyps unresectable at colonoscopy are associated with a high rate of unsuspected cancer. This requires a formal colectomy rather than transcolonic polypectomy. Laparoscopic colectomy offers safe and effective management of these polyps with the benefits of accelerated postoperative recovery.

Abscess↗
PubMed2006

A randomized controlled trial comparing simultaneous intra-operative vs sequential prophylactic ureteric catheter insertion in re-operative and complicated colorectal surgery.

OBJECTIVES: Prophylactic insertion of ureteric stents aids intra-operative identification of ureters and may allow easier visualization of any direct ureteric injury. Traditionally, ureteric catheters are inserted sequentially, before starting the abdominal part of the operation. This study determines the safety and efficacy of simultaneous intra-operative ureteric catheter insertion during complicated and re-operative colorectal surgery. MATERIALS AND METHODS: After institutional review board (IRB) approval, 24 patients were randomized into two groups, sequential (SEQ) and simultaneous (SIM) depending upon the timing of stent placement relative to abdominal incision. Time taken from induction to abdominal incision (AIT), induction to peritoneal entry (PET), catheter insertion time (CIT), and urinary tract infection rates were recorded. Degree of difficulty for stent insertion was graded on a scale of 1-10. RESULT: Demographics were similar between groups. Mean AIT (22 +/- 4 vs 41 +/- 7; p = 0.0001) and mean PET (26 +/- 4.2 vs 44 +/- 7.6; p = 0.0001) were shorter in the SIM group. There was no significant difference in mean CIT in SIM and SEQ groups (17.9 +/- 4.9 vs 17.6 +/- 5.9 min, p = 0.8). The stents were unsuccessful bilaterally in one patient in the SEQ group and unilaterally in two other patients, one in each group. The median difficulty score for catheter insertion was 3 (1-10) and 2 (1-10), (p = 0.12), respectively, in SIM and SEQ groups. There were no ureteric injuries in either group. One patient in SIM developed a urinary tract infection. CONCLUSION: Simultaneous ureteric catheter insertion during abdominal procedures reduces operating times without a significant increase in morbidity. Furthermore, this permits a policy of selective stent insertion as required by the intra-abdominal findings after laparotomy.

Adult↗
PubMed2006

Bilateral V-Y advancement flaps for the management of extensive defects of the perianal skin.

Premalignant and malignant conditions of the skin may sometimes require excision of extensive areas of the skin and subcutaneous tissues. Coverage of the ensuing raw area may be afforded by allowing healing by secondary intention, skin grafts, or flaps. Wide excision of the perianal skin poses special problems. We describe the use of bilateral V-Y advancement flaps for the management of an extensive defect resulting from the wide excision of squamous cell carcinoma arising in scarred perianal skin.

Aged↗
PubMed2006

Adenosquamous carcinoma of the colon: a rare tumor.

Adenosquamous carcinoma of the colon is rare. A paraneoplastic syndrome presenting as hypercalcemia may occasionally occur in association with these tumors. Survival for more advanced stages of disease is lower than for patients with adenocarcinoma at a corresponding stage. We report a patient who presented with a primary adenosquamous carcinoma of the rectosigmoid junction and we review the literature regarding the clinical presentation, management, and prognosis of this tumor.

Aged, 80 and over↗
PubMed2005

Diagnosis-related group assignment in laparoscopic and open colectomy: financial implications for payer and provider.

PURPOSE: In carefully matched patients, the length of hospital stay after laparoscopic colectomy is shorter than after open surgery. Higher operating room costs for laparoscopic surgery are offset by lower costs for hospitalization because of less utilization of pharmacy, laboratory, and nursing services. Clinical outcome is comparable. We examined the effect of the surgical approach for colectomy (open vs. laparoscopic) regarding the reasons for disease-related group assignment to disease-related group 148, and institutional cost under Part A of the U.S. Medicare system. METHODS: Colectomy patients were assigned to either disease-related group 148 (colorectal resection with complications) or disease-related group 149 (colorectal resection without complications) with significant institutional reimbursement implications (disease-related group 149, US 8,310 dollars; disease-related group 148, US 20,291 dollars). A total of 100 consecutive disease-related group 148 patients undergoing laparoscopic colectomy from July 2000 to September 2002 were identified from a prospective database and case-matched with 100 patients undergoing open colectomy. Patients were matched for gender, age, operative procedure, and pathology. A certified coder determined the reason(s) for disease-related group 148 assignment, which were grouped into: preoperative comorbidity, a combination of preoperative comorbidity/postoperative complications, or postoperative complications alone. RESULTS: Significantly more lapararoscopy patients were assigned to disease-related group 148 solely because of preoperative comorbidities (62 percent vs. 21 percent; P < 0.0001). Significantly more patients in the open surgery group were classified as disease-related group 148 solely because of postoperative complications (22 percent vs. 42 percent; P < 0.0001). An additional group of patients were assigned to the disease-related group 148 category based on a combination of preoperative and postoperative diagnoses (16 percent vs. 37 percent). The mean direct hospital costs were significantly less for laparoscopy patients (US 3971 dollars vs. US 5997 dollars; P = 0.0095). Increased cost to Part A of Medicare for 20 open surgery patients who "migrated" to disease-related group 148 because of postoperative complications was US 239,620 dollars. CONCLUSIONS: Our data are the first to demonstrate that disease related group assignment can change solely because of a differential rate of postoperative complications for two competing operative techniques. This change occurred at twice the rate for open colectomy and resulted in significantly increased cost to the insurer under a prospective payment program. The savings to the institution coupled with the shortened length of stay offset the potential loss in revenue to the institution.

Colectomy↗
PubMed2005

Is laparoscopic colectomy applicable to patients with body mass index >30? A case-matched comparative study with open colectomy.

PURPOSE: The benefits of early postoperative recovery, reduced postoperative pain, pulmonary dysfunction, and hospitalization after laparoscopic colectomy may improve outcome over open colectomy in obese patients. This case-matched study compares outcomes after open and laparoscopic colectomy. METHODS: A total of 94 laparoscopic colectomy patients with a body mass index >30 (Jan 1999-June 2003) were identified from a prospective database and matched to open colectomy cases for age, gender, body mass index, American Society of Anesthesiologists class, procedure, indication, and date of surgery. Operating time, length of stay, conversion, intraoperative and postoperative complications, reoperation, 30-day readmission rate, and costs were compared. Data are presented as means +/- standard deviations, and appropriate statistical tests were used. RESULTS: The two groups were matched for age (P = 0.06), gender (P = 1), American Society of Anesthesiologists class (P = 0.2), body mass index (P = 0.4), indication for surgery (P = 1), and procedure (P = 1). By using intention-to-treat-type analysis, there was no difference in median operating time (100 vs. 110 (mean, 123 vs. 112) minutes; P = 0.1), complications (21 vs. 24 percent; P = 0.74), readmission (17 vs. 10.6 percent; P = 0.3), reoperation rates (6.4 vs. 4.3 percent; P = 0.75), or direct costs (median, US. 3,368 dollars vs. US 3,552 dollars; mean, US 4,003 dollars vs. US 4,037 dollars; P = 0.14) between laparoscopic colectomy or open colectomy; however, the median length of stay (3 vs. 5.5 (mean, 3.8 vs. 5.8) days; P = 0.0001) was significantly shorter after laparoscopic colectomy. Twenty-eight patients required conversion for adhesions (n = 11), bleeding (n = 3), obesity-hindering vision or dissection (n = 9), large phlegmon or tumor (n = 4), and ureteric injury (n = 1). The mean operating time for conversions was 142 minutes and length of stay was 6.4 days. Compared with laparoscopically completed cases, the median length of stay (5 vs. 2 (mean, 6.4 vs. 2.8) days; P = 0.0001) and median operating times (150 vs. 95 (mean, 142 vs. 115) minutes; P = 0.02) were significantly higher in the converted group, but there was no difference in the complication (P = 0.8), readmission (P = 1), or reoperation (P = 0.7) rates. Compared with open colectomy, the operating time (P = 0.02) was significantly higher in the converted group but there were no significant differences in the length of stay (P = 0.18), complication (P = 1), readmission (P = 0.35), or reoperative (P = 1) rates. CONCLUSIONS: Laparoscopic colectomy can be performed safely in obese patients, with shorter postoperative recovery than that with open colectomy. Although obesity is associated with a high conversion rate, outcome in these converted cases is comparable to the matched open cases.

Body Mass Index↗
PubMed2004

Operative blood loss and use of blood products after laparoscopic and conventional open colorectal operations.

HYPOTHESIS: Blood loss, measured by estimated blood loss, drop in hemoglobin levels, and transfusion requirements, is lower in patients undergoing laparoscopic colectomy compared with patients undergoing conventional open colectomy. DESIGN: Case-matched study. SETTING: A university hospital. PATIENTS: Patients undergoing laparoscopic colectomy between January 2000 and December 2001 were matched in a prospective database for age, sex, comorbidity, and surgical procedure with patients undergoing open colectomy during the same period. MAIN OUTCOME MEASURES: Estimated blood loss, drop in hemoglobin levels, and transfusion requirements after surgery were compared. RESULTS: One hundred forty-seven patients undergoing the same operation using either an open or laparoscopic approach could be matched for age, sex, and diagnosis related grouping. There was no significant difference in American Society of Anesthesiologists class, body mass index, or preoperative and postoperative hemoglobin levels, but the open colectomy group required significantly more units of blood (P =.003) to maintain similar hemoglobin levels after surgery. Estimated blood loss (P<.001) and the number of patients who received transfusions on the day of surgery (P =.002), during the first 48 hours after surgery (P =.005), and during the entire hospital stay (P =.003) were significantly higher in the open colectomy group. CONCLUSION: A laparoscopic approach for colorectal surgery led to significantly less blood loss than matched open colectomy cases.

Adult↗
PubMed2004

Early results with infrainguinal cutting balloon angioplasty limits distal dissection.

Infrainguinal angioplasty has less initial and long-term success compared with more proximal sites. These suboptimal initial technical results may be related to the heavy calcific burden in the femoral and popliteal arteries and, subsequently, higher incidence of distal dissection. Cutting balloon angioplasty (CBA) is a newer technique that is thought to limit distal dissection in heavily calcified vessels; although CBA has been evaluated in the coronary circulation, there are few reports of its use in peripheral vessels. This study evaluates our initial experience with CBA for the management of femoropopliteal disease. Eleven patients underwent infrainguinal CBA for symptomatic limb ischemia at a community hospital. Ten procedures (91%) were technically successful, with no distal dissections, iatrogenic vessel perforations, or surgical target vessel revascularizations. In eight patients available for follow-up, the limb salvage rate was 100% and of seven and eight CBA sites (88%) were still widely patent (mean follow-up, 3 months; range, 2-12 months). This preliminary study suggests that CBA is safe and feasible for electively performed femoropopliteal chronic occlusive disease with acceptable success rates on short-term follow-up. Long-term results and comparison with other endovascular modalities require evaluation.

Aged↗
PubMed2004

Use of laser for rectal lesions in poor-risk patients.

BACKGROUND: This study evaluates laser ablation of large polyps and cancer of the rectum in poor-risk surgical patients. METHODS: We performed a retrospective review of treatment of rectal lesions with the neodymium yttrium aluminium garnet (Nd:YAG) laser. Biopsy was performed before the first and subsequent therapies. Large lesions were initially debulked by diathermy snare. Biopsies were performed on suspicious areas at follow-up after completion of therapy. RESULTS: Three patients with unresectable rectal cancer had symptom control over a mean period of 15.7 months and 12 patients with large polyps over 60.6 months since the start of therapy. Indications in polyps were carpeting of the rectum (n = 3), proximity to sphincter (n = 1), or comorbidity (n = 8). No complication occurred; however, there was 1 treatment failure. None of the patients with polyps developed cancer during a mean follow-up interval of 14 months after final treatment. CONCLUSIONS: Outpatient laser therapy is safe, repeatable, and effective in the local control of rectal lesions.

Adenocarcinoma↗
PubMed2004

Outcomes and prediction of hospital readmission after intestinal surgery.

BACKGROUND: Clinical care pathways reduce postoperative stay after major bowel operations. Concerns about unexpected early readmissions and delays in diagnosis of complications remain unanswered. The objectives of this study were determination of readmission rate and outcomes for patients undergoing intestinal operations. STUDY DESIGN: Patients readmitted (PR) within 30 days of discharge after intestinal operations were compared with patients who were not readmitted (NR). Variables that might predict readmission were evaluated. RESULTS: Of 553 patients, 56 (10.1%) were readmitted after 10 days (interquartile range [IQR] 4.5 to 15.5 days). PR and NR groups had similar age, gender, diagnosis, preoperative comorbidities, and index operations. Discharge hemoglobin level, white cell count, antibiotic use, or presence of stoma did not affect readmission. PR had a greater frequency of steroid use (p = 0.03) during index admission. Median length of stay for the index hospitalization was 5 days (IQR 4 to 8 days) for the NR and 6 days (IQR 4.8 to 9 days) for the PR group (p = 0.049). Duration of readmission was 4 days (IQR 2 to 9 days) in the PR group, with equal total median length of stay identical for PR and NR patients with complications (median 12 days). Clinical outcomes for PR patients and NR patients with complications were similar. CONCLUSIONS: Early readmission is an unpredictable sequel of major bowel operations; it does not correlate with shorter hospital stay. Identification of unpredictable complications after discharge that require later invasive intervention does not adversely affect clinical outcomes. Readmission within 30 days of a patient who has attained standardized discharge criteria may not be a valid indicator of poor quality of care.

Case-Control Studies↗
PubMed2003

Quality of life improves within 30 days of surgery for Crohn's disease.

BACKGROUND: The effect of surgery on quality of life (QOL) in the early postoperative period is important in Crohn's disease because of the multiple surgical procedures that patients undergo and the acute QOL benefits that might occur as a result of modifications of medical treatment. Earlier studies of the effect of surgery on QOL have been retrospective and assessed changes 3 to 24 months after surgery. This study prospectively assesses the effect of surgery on QOL in the early postoperative period. STUDY DESIGN: Patients requiring surgical management of sequelae of Crohn's disease were obtained from a prospectively entered database including data on QOL. Preoperative and 30-day postoperative QOL were determined in 82 patients using Cleveland Global Quality of Life (CGQL) scores (range from 0 [worst] to 10 [best possible] QOL). Preoperative and postoperative scores were compared using a paired t-test to determine the significance of any change in QOL after surgery. The effect of other variables on change in QOL after surgery was assessed using the t-test or analysis of variance. Multifactor analysis of variance was used to assess the effect of several independent variables. RESULTS: Eighty-two patients (41 women) of 142 patients who had had surgery (58%) had complete preoperative and 30-day postoperative scores. The incidence of complications was 23% (11% were major). There was a significant improvement in QOL 30 days after surgery as measured by CGQL (0.6 +/- 0.2 preoperative to 0.7 +/- 0.2 postoperative; mean +/- SD; p < 0.001). The mean preoperative CGQL was 0.56 +/- 0.24 and the mean improvement was 0.11 +/- 0.20 toward a better QOL. Female patients (p < 0.05) and those who did not develop complications within 30 days of surgery (p < 0.05) had a significantly greater improvement in CGQL after surgery than other groups. No other factor was predictive of improved outcomes. CONCLUSIONS: QOL as measured by CGQL improves early after surgery (30 days postoperatively). Improvement in CGQL is greater in female patients and patients who do not develop complications in the postoperative period. It is not affected by other patient characteristics, nature of disease, indication, or procedure performed. Most patients who undergo surgery for Crohn's disease feel that surgery has helped them and would undergo surgery again.

Adult↗
PubMed2003

Case-matched comparison of clinical and financial outcome after laparoscopic or open colorectal surgery.

OBJECTIVE: Comparison of outcome and costs after laparoscopic and open colectomy. SUMMARY BACKGROUND DATA: Previous studies comparing laparoscopic and open colectomy report conflicting results with regard to clinical outcome and costs. METHODS: Laparoscopic colectomy patients from a prospective database were matched for age, gender, and disease-related grouping to patients who underwent the same operation by the open approach over the same period (2000 to 2001). Data for the latter group was gathered by retrospective analysis and the 2 groups were compared for outcome and direct costs. RESULTS: Laparoscopic colectomy patients (n = 150) were compared with the same number of open colectomy patients. American Society of Anesthesiologists classification (P = 0.09), body mass index (P = 0.17), diagnosis (P = 0.12), complications (P = 0.14), and rate of readmission within 30 days (P = 0.44) were similar for both groups. Operating room costs were significantly higher after laparoscopic colectomy (P < 0.0001), but length of hospital stay was significantly lower (P < 0.0001). This resulted in significantly lower total costs (P = 0.0007) owing to lower pharmacy (P < 0.0001), laboratory (P <0.0001), and ward nursing costs (P = 0.0004). CONCLUSIONS: Laparoscopic colectomy results in significantly lower direct costs compared with open colectomy for carefully matched patients.

Adult↗
PubMed2003

Prospective assessment of Cleveland Global Quality of Life (CGQL) as a novel marker of quality of life and disease activity in Crohn's disease.

OBJECTIVES: The Short Form 36 (SF-36) questionnaire is the most widely accepted measure of quality of life (QOL); however, it is cumbersome to use and requires complicated analysis. The Cleveland Global Quality of Life (CGQL) is a simpler tool, which has been validated in patients with ulcerative colitis undergoing restorative proctocolectomy. This study validates CGQL in patients with Crohn's disease and determines the correlation of QOL measurement systems with disease activity as measured by the Crohn's Disease Activity Index (CDAI). METHODS: All patients with Crohn's disease presenting to this department between September 2001 and February 2002 were prospectively entered into a database, including demographic data, disease manifestations, Vienna classification, age at diagnosis, and duration of Crohn's disease. SF-36, CGQL, and CDAI scores were entered concurrently. Cronbach's alpha was used to assess the internal consistency among the components of the CGQL score. Correlation among various QOL measures was assessed with Spearman's test. Relationships between QOL measures and various baseline factors were assessed by Wilcoxon rank sum test, Student's t test, Kruskal-Wallis test, and Pearson's test, depending on the type and distribution of data. Change from baseline in the CGQL was assessed with the Wilcoxon signed rank test. RESULTS: One hundred seventy-eight (178) patients were entered into the database, and 169 completed QOL and CDAI data. There was a significant correlation between SF-36 and CGQL. CGQL and SF-36 correlated similarly with CDAI. Neither patient age, gender, or smoking history were associated with CGQL. CONCLUSIONS: CGQL correlates with disease activity and is a simple measure of QOL in Crohn's disease.

Adult↗
PubMed2003

Investigation and management of ischemic colitis.

The colon is the most common site of gastrointestinal ischemia. The condition resolves completely with conservative treatment in most cases, but late diagnosis or severe ischemia can be associated with high rates of complications and death. Once ischemic colitis is diagnosed, serial physical examinations and colonoscopies are helpful to follow the condition. Prompt surgery is required for severe episodes, when conservative measures fail, and for patients with chronic symptoms.

Colitis, Ischemic↗
PubMed2003

Prospective assessment of the predictive value of alpha-glutathione S-transferase for intestinal ischemia.

Nonspecific investigations resulting in treatment delays contribute to the 30 per cent mortality associated with acute mesenteric ischemia (AMI). As preliminary studies indicate that alpha-glutathione S-transferase (alpha-GST) is elevated in AMI we compare the ability of alpha-GST against conventional biochemical tests to predict AMI. There were 58 patients prospectively evaluated for AMI. Samples for alpha-GST (Biotrin International, Dublin, Ireland), lactate, pH, amylase, base excess, and white blood cell count (WBC) were evaluated. Intestinal ischemia was confirmed by colonoscopy, angiography, or laparotomy. Ischemia was present in 35 (60%) patients: small bowel (n = 14), colonic (n = 17), and global (n = 4). Four patients without autopsy were excluded. Alpha-GST was elevated in those with AMI [22.2 (7-126) ng/mL vs 2.2 (1-3) (P = 0.001)]. Alpha-GST was more accurate at predicting intestinal ischemia (74%) than conventional tests (47-69% accuracy). Accuracy was increased to 80 per cent by combination with lactate or WBC, which increased sensitivity to 97 to 100 per cent. Alpha-GST monitoring is a useful tool for the diagnosis of intestinal ischemia. A normal alpha-GST and WBC may exclude the presence of AMI.

Acute Disease↗