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Biomedical subjects

Samuel E Wilson

Publications and source records attributed to Samuel E Wilson.

At least 19 recordsLinked to original sources
PubMed2006

Ertapenem versus cefotetan prophylaxis in elective colorectal surgery.

BACKGROUND: Ertapenem, a long-acting carbapenem, may be an alternative to the recommended prophylactic antibiotic cefotetan. METHODS: In this randomized, double-blind trial, we assessed the efficacy and safety of antibiotic prophylaxis with ertapenem, as compared with cefotetan, in patients undergoing elective colorectal surgery. A successful outcome was defined as the absence of surgical-site infection, anastomotic leakage, or antibiotic use 4 weeks postoperatively. All adverse events were collected until 14 days after the administration of antibiotic prophylaxis. RESULTS: Of the 1002 patients randomly assigned to study groups, 901 (451 in the ertapenem group and 450 in the cefotetan group) qualified for the modified intention-to-treat analysis, and 672 (338 in the ertapenem group and 334 in the cefotetan group) were included in the per-protocol analysis. After adjustment for strata, in the modified intention-to-treat analysis, the rate of overall prophylactic failure was 40.2% in the ertapenem group and 50.9% in the cefotetan group (absolute difference, -10.7%; 95% confidence interval [CI], -17.1 to -4.2); in the per-protocol analysis, the failure rate was 28.0% in the ertapenem group and 42.8% in the cefotetan group (absolute difference, -14.8%; 95% CI, -21.9 to -7.5). Both analyses fulfilled statistical criteria for the superiority of ertapenem. In the modified intention-to-treat analysis, the most common reason for failure of prophylaxis in both groups was surgical-site infection: 17.1% in the ertapenem group and 26.2% in the cefotetan group (absolute difference, -9.1; 95% CI, -14.4 to -3.7). In the treated population, the overall incidence of Clostridium difficile infection was 1.7% in the ertapenem group and 0.6% in the cefotetan group (P=0.22). CONCLUSIONS: Ertapenem is more effective than cefotetan in the prevention of surgical-site infection in patients undergoing elective colorectal surgery but may be associated with an increase in C. difficile infection. (ClinicalTrials.gov number, NCT00090272 [ClinicalTrials.gov].).

Adult↗
PubMed2006

Resolution of hyperlipidemia after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Hyperlipidemia is an established risk factor for development of coronary artery disease. The aim of our study was to examine the changes in serum lipid profiles of morbidly obese patients complicated by hyperlipidemia, who underwent laparoscopic gastric bypass. STUDY DESIGN: We retrospectively reviewed the charts of 95 morbidly obese patients with documented hyperlipidemia who underwent laparoscopic gastric bypass. Mean duration of hyperlipidemia was 44+/- 56 months. Hyperlipidemia was defined as an elevated level of triglycerides (> 150 mg/dL) or total cholesterol (> 200 mg/dL). Changes in lipid profile of a subset of patients with subnormal levels of high-density lipoprotein cholesterol ( 130 mg/dL), and very-low-density lipoprotein cholesterol (> 40 mg/dL) were also examined. Fasting lipid profiles were measured preoperatively and at 3-month intervals. RESULTS: There were 68 women (72%) with a mean age of 43 +/- 10 years. Mean body mass index was 47+/- 5 kg/m2. Mean percentage of excess body weight loss at 12 months postoperatively was 66%. One year after gastric bypass, mean total cholesterol levels decreased by 16%; triglyceride levels decreased by 63%; low-density lipoprotein cholesterol levels decreased by 31%; very-low-density lipoprotein cholesterol decreased by 74%; total cholesterol/high-density lipoprotein cholesterol risk ratio decreased by 60%, and high-density lipoprotein cholesterol levels increased by 39%. Also, within 1 year, 23 of 28 (82%) patients requiring lipid-lowering medications preoperatively were able to discontinue their medications. CONCLUSIONS: Weight loss after laparoscopic gastric bypass substantially improves lipid profiles in morbidly obese patients who have hyperlipidemia. Improvement in lipid profiles was observed as early as 3 months postoperatively and was sustained at 1 year. Improvement of lipid profiles after laparoscopic gastric bypass can reduce health risks associated with high levels of atherogenic lipoproteins.

Adult↗
PubMed2006

Transluminal stenting for femoropopliteal occlusive disease: analysis of restenosis by serial arteriography.

Our objective was to evaluate restenosis after stenting of femoropopliteal occlusions and the impact of percutaneous transluminal angioplasty (PTA) on recurrent stenosis. We used a retrospective analysis of contrast angiograms obtained during follow-up of stented limbs. Subjects included 27 claudicants (34 limbs) who had complete superficial femoral artery occlusion treated with PTA and Wallstents at the Veterans Adminstration Medical Center. During follow-up, 31 PTAs, three thrombolytic treatments, and one additional stenting were performed. Outcome was measured by contrast angiography. Primary patency at 1 and 3 years was 38% and 8% after stenting, and secondary patency (PTA required at least once in 21/34 limbs) was 89% and 55%, respectively. PTA performed during follow-up reduced within-stent restenosis on average from 48.3 +/- 13.6% to 22.8 +/- 18.0%. Recurrent stenosis after PTA measured 14.9 +/- 10.9 months later was 46.8 +/- 16.7%, showing little permanent impact of PTA on stenosis. Severe within-stent stenosis develops commonly after initial stenting of complete femoropopliteal occlusions. Supplemental PTA performed during follow-up provides immediate improvement in lumen diameter, but severe restenosis is still likely to recur.

Angiography↗
PubMed2006

Result of a national audit of bariatric surgery performed at academic centers: a 2004 University HealthSystem Consortium Benchmarking Project.

HYPOTHESIS: Bariatric surgery performed at US academic centers is safe and associated with low mortality. DESIGN: Multi-institutional consecutive cohort study. SETTING: Academic medical centers. PATIENTS AND INTERVENTIONS: We audited the medical records from 40 consecutive bariatric surgery cases performed between October 1, 2003, and March 31, 2004, at each of the 29 institutions participating in the University HealthSystem Consortium Bariatric Surgery Benchmarking Project. All medical records that met inclusion criteria (patient age, >17 and <65 years; and body mass index [calculated as weight in kilograms divided by the square of height in meters], 35-70) and exclusion criteria (previous bariatric surgery) were reviewed and data were collected on a standardized form. MAIN OUTCOME MEASURES: Demographic data, operative time, blood loss, transfusion requirement, complications, readmission, reoperation, and in-hospital and 30-day mortality. RESULTS: Data from 1144 bariatric surgery cases were reviewed from 29 University HealthSystem Consortium institutions. The specific bariatric procedures included gastric bypass (91.7%), gastroplasty or gastric banding (8.2%), and biliopancreatic diversion (0.1%). For gastric bypass procedures (n = 1049), the mean patient age was 43 years and mean body mass index was 49; 76% of procedures were performed laparoscopically, with a conversion rate of 2.2%; the overall complication rate was 16%, with an anastomotic leakage rate of 1.6%; the 30-day readmission rate was 6.6%; and the 30-day mortality rate was 0.4%. For restrictive procedures (n = 94), the mean patient age was 45 years and mean body mass index was 45; 92% of procedures were performed laparoscopically with no conversion; the overall complication rate was 3.2%; the 30-day readmission rate was 4.3%; and the 30-day mortality rate was 0%. CONCLUSIONS: Within the context of the 2004 University HealthSystem Consortium Bariatric Surgery Benchmarking Project, the risk for death within 30 days after bariatric surgery at academic centers is less than 1%. In addition, the practice of bariatric surgery at these centers has shifted from open surgery to predominately laparoscopic surgery. These quality-controlled outcome data can be used as a benchmark for the practice of bariatric surgery at most US hospitals.

Adult↗
PubMed2006

Clinical significance of type II endoleak after endovascular repair of abdominal aortic aneurysm.

Type II endoleaks after endovascular repair of abdominal aortic aneurysm (EVAR) are a result of retrograde flow from arterial branches (e.g., lumbar and inferior mesenteric) refilling the aneurysm sac, which has been excluded by the stent graft. Controversy continues with regard to the clinical significance and treatment of type II endoleaks. To develop recommendations for management, we analyzed outcome data from 10 EVAR trials completed over the last 5 years involving a total of 2,617 cases. The incidence of type II endoleak at discharge or 30 days was 6-17%, at 6 months 4.5-8%, and at 1 year 1-5%. Successful resolution of endoleak following secondary interventions was observed in 11-100% of cases. There were 10 conversions to open repair and no ruptures related to type II endoleak. In patients observed for 12 months with computed tomography and/or ultrasound, approximately one-half of type II endoleaks disappeared spontaneously. In the absence of a type I endoleak, our analysis of the current literature suggests that intervention for type II endoleak should be undertaken for abdominal aortic aneurysm sac enlargement occurring after 6 months, persistence for >12 months without abdominal aortic aneurysm sac enlargement, or an aneurysm sac pressure >20% of systolic blood pressure; translumbar aneurysm sac thrombosis and intra-arterial feeding vessel occlusion appear to be prudent management options.

Adult↗
PubMed2006

Esophagectomy for Barrett's esophagus: indications, techniques, and outcome.

Barrett's esophagus describes metaplastic changes from squamous mucosa to specialized columnar epithelium that can progress from low-grade dysplasia to high-grade dysplasia and even invasive carcinoma. The treatment of Barrett's esophagus with low-grade dysplasia or Barrett's adenocarcinoma is relatively standardized; however, controversy remains regarding appropriate therapy for Barrett's esophagus with high-grade dysplasia. Treatment recommendations for high-grade dysplasia vary widely, from periodic endoscopic surveillance to endoscopic ablative therapies and esophagectomy. Selected studies have shown that a relatively high percentage (41% to 47%) of patients with high-grade dysplasia have occult carcinoma. In these patients, surgery is indicated, as esophagectomy can be curative for early stage adenocarcinoma in Barrett's esophagus. A major criticism of esophagectomy is the significant morbidity and mortality. Minimally invasive esophagectomy was developed in an effort to reduce the morbidity associated with open esophagectomy. In minimally invasive esophagectomy, the abdominal laparotomy is replaced with laparoscopy, and the conventional right thoracotomy is replaced with thoracoscopy to reduce the operative trauma. In experienced centers, minimally invasive esophagectomy is now an attractive alternative for the treatment of Barrett's esophagus with high-grade dysplasia.

Journal Article↗
PubMed2006

Comparison of laparoscopic and open gastrectomy for gastric cancer.

BACKGROUND: The role of minimally invasive gastrectomy in the treatment of gastric cancer is not well defined. The aim of the current study was to compare the operative outcomes and adequacy of resection of laparoscopic gastrectomy compared to open gastrectomy for gastric cancer. METHODS: The clinical course of 15 consecutive patients who underwent minimally invasive gastrectomy or esophagogastrectomy for gastric cancer were compared with that of 21 patients who underwent open gastrectomy. Main outcome measures included operative time, blood loss, length of stay, morbidity, 30-day mortality, and adequacy of lymphadenectomy and resection margins. RESULTS: There was no conversion to laparotomy in the laparoscopic group. Intraoperative blood loss was significantly lower in the laparoscopic group (138 mL vs. 357 mL). There was no significant differences in the mean operative time (244 vs. 241 min.), transfusion rate (6% vs. 29%), median length of stay (6 vs. 7 days), morbidity (7% vs. 24%), or number of lymph nodes harvested (15 vs. 14 nodes) between the 2 groups. Resection margins were negative in all patients. There were no leaks and the 30-day mortality was 0 in both groups. Anastomotic strictures were higher in the laparoscopic patients. CONCLUSION: Laparoscopic gastrectomy is feasible and can be performed safely with adequate lymphadenectomy compared with open gastrectomy.

Aged↗
PubMed2006

Preoperative laparoscopic ligation of the left gastric vessels in preparation for esophagectomy.

Anastomotic leak is a major cause for morbidity after esophagectomy. The cause is believed to be ischemia of the gastric conduit. Preoperative embolization of the left gastric vessels in preparation for esophagectomy has been shown to improve collateral blood flow of the gastric conduit and may reduce the frequency of anastomotic dehiscence after esophagectomy. This report describes the technique of laparoscopic division of the left gastric vessels in 9 patients who underwent pre-esophagectomy staging laparoscopy. Our initial experience demonstrates that laparoscopic ligation of the left gastric artery is a safe alternative to embolization and can be performed in conjunction with staging laparoscopy for patients with esophageal cancer.

Adenocarcinoma↗
PubMed2006

Laparoscopic and thoracoscopic Ivor Lewis esophagectomy after Roux-en-Y gastric bypass.

Roux-en-Y gastric bypass is a commonly performed procedure for the treatment of morbid obesity. Esophagectomy in patients with a history of Roux-en-Y gastric bypass presents a difficult technical challenge for the surgeon. In this report we describe a technique of minimally invasive Ivor Lewis esophagogastrectomy in a patient who had had an open Roux-en-Y gastric bypass. Minimally invasive esophagectomy was performed with resection of the Roux limb using the gastric remnant as the conduit for gastrointestinal reconstruction.

Adenocarcinoma↗
PubMed2006

Three-year follow-up of a prospective randomized trial comparing laparoscopic versus open gastric bypass.

OBJECTIVE: To analyze long-term weight loss, changes in comorbidities and quality of life, and late complications after laparoscopic and open gastric bypass. SUMMARY BACKGROUND DATA: Early results from our prospective randomized trial comparing the outcome of laparoscopic versus open gastric bypass demonstrated less postoperative pain, shorter length of hospital stay, fewer wound-related complications, and faster convalescence for patients who underwent laparoscopic gastric bypass. METHODS: Between May 1999 and March 2001, 155 morbidly obese patients were enrolled in this prospective trial, in which 79 patients were randomized to laparoscopic gastric bypass and 76 to open gastric bypass. Two patients in the laparoscopic group required conversion to open surgery; their data were analyzed within the laparoscopic group on an intention-to-treat basis. The 2 groups were well matched for body mass index, age, and gender. Outcome evaluation included weight loss, changes in comorbidities and quality of life, and late complications. RESULTS: The mean follow-up was 39+/-8 months. There were no significant differences in the percent of excess body weight loss between the 2 groups at the 3-year follow-up (77% for laparoscopic versus 67% for open). The rate of improvement or resolution of comorbidities was similar between groups. Improvement in quality of life, measured by the Moorehead-Ardelt Quality of Life Questionnaire, was observed in both groups without significant differences between groups. Late complications were similar between groups except for the rate of incisional hernia, which was significantly greater after open gastric bypass (39% versus 5%, P<0.01), and the rate of cholecystectomy, which was greater after laparoscopic gastric bypass (28% versus 5%, P=0.03). CONCLUSIONS: In this randomized trial with a 3-year follow-up, we found that laparoscopic gastric bypass was equally effective as open gastric bypass with respect to weight loss and improvement in comorbidities and quality of life. A major advantage at long-term follow-up for patients who underwent laparoscopic gastric bypass was the reduction in the rate of incisional hernia.

Adult↗
PubMed2006

Continuous infraclavicular brachial plexus block in a child.

Continuous regional anesthesia for both intra- and postoperative use in adults is becoming more common. As with many new anesthesia techniques, however, there is often a lag time before the same techniques are utilized in children. Our patient was a 10-year-old child requiring reoperation on her fifth digit with planned 48-h admission for range of motion exercises. We wanted to have a continuous regional blockade to control the patient's pain during the postoperative manipulations of the digit. A search of the literature from the last 10 years did not show any reports of the placements of a continuous brachial plexus block in children. In this case report, we present the successful placement and use of a continuous infraclavicular catheter in a child undergoing upper extremity surgery.

Amides↗
PubMed2006

Outcomes of bariatric surgery in the elderly.

The Medicare Coverage Advisory Committee recently concluded that evidence supports the safety and effectiveness of bariatric surgery in the general adult population. However, more information is needed on the role of bariatric surgery in the elderly. The aim of this study was to examine the outcome of bariatric surgery in the elderly performed at academic centers. Using International Classification of Diseases, 9th Revision diagnosis and procedure codes, we obtained data from the University HealthSystem Consortium Clinical Data Base for all elderly (>60 years) and nonelderly (19-60 years) patients who underwent bariatric surgery for the treatment of morbid obesity between 1999 and 2005. Outcome measures, including patient characteristics, length of stay, 30-day readmission, morbidity, and observed and expected (risk-adjusted) mortality, were compared between groups. Bariatric surgery in the elderly represents 2.7 per cent (n = 1,339) of all bariatric operations being performed at academic centers. Of the 99 University HealthSystem Consortium centers performing bariatric surgery, 78 centers (79%) perform bariatric surgery in the elderly. Compared with nonelderly patients, elderly patients who underwent bariatric surgery had more comorbidities, longer lengths of stay (4.9 days vs 3.8 days, P < 0.01), more overall complications (18.9% vs 10.9%, P < 0.01), pulmonary complications (4.3% vs 2.3%, P < 0.01), hemorrhagic complications (2.5% vs 1.5%, P < 0.01), and wound complications (1.7% vs 1.0%). The in-hospital mortality rate was also higher in the elderly group (0.7% vs 0.3%, P = 0.03). When risk adjusted, the observed-to-expected mortality ratio for the elderly group was 0.9. In a subset of elderly patients with a pre-existing cardiac condition (n = 236), the in-hospital mortality was 4.7 per cent. Bariatric surgery in the elderly represents only a small fraction of the number of bariatric operations performed at academic centers. Although the morbidity and mortality is higher in the elderly, bariatric surgery in the elderly is considered as safe as other gastrointestinal procedures because the observed mortality is better than the expected (risk-adjusted) mortality.

Adult↗
PubMed2006

Quality of life assessment in the morbidly obese.

Quality of life (QoL) is an important measure of outcome after bariatric surgery. Impairment in QoL has been well documented in morbidly obese patients before undergoing bariatric surgery and has been shown to improve significantly within 3 months after the operative intervention. Improvement in QoL should be recognized as one of the benefits of bariatric surgery that can be quantified.

Bariatric Surgery↗
PubMed2006

Reduction in prescription medication costs after laparoscopic gastric bypass.

Morbidly obese patients undergoing bariatric surgery commonly have multiple obesity-related comorbidities, including hypertension (HTN), diabetes mellitus (DM), hyperlipidemia (HLP), and gastroesophageal reflux (GERD). Medical management of these conditions can be costly. The aim of this study was to determine changes in the monthly prescription medication costs in morbidly obese patients who underwent laparoscopic gastric bypass. We examined the data on 77 morbidly obese patients receiving medications prescribed for GERD, DM, HTN, and/or HLP before and after laparoscopic gastric bypass. Changes in medication usage were recorded at 3-month intervals. The retail cost for these medications was obtained from drugstore.com. There were 55 women with a mean age of 45 +/- 11 years. The mean body mass index was 47 +/- 6. The mean excess body weight loss was 67 +/- 14 per cent at 1 year. The mean number of prescription medication per patient was reduced from 2.4 preoperatively to 0.2 at 12 months after surgery. The mean monthly medication cost decreased from dollars 196 preoperatively to dollars 54 one month after surgery, representing a 72 per cent cost savings. One month postoperatively, medication cost saving for GERD was 81 per cent; for DM was 69 per cent; for HLP was 53 per cent; and for HTN was 43 per cent. The mean monthly medication cost savings for the first year after surgery was dollars 168, with a yearly savings of dollars 2016 per patient. Improvement of GERD, DM, HLP, and HTN occur as early as 1 month after laparoscopic gastric bypass results in substantial monthly medication cost savings.

Adolescent↗
PubMed2006

Transmetatarsal amputation: predictors of healing.

The objective of this study is to determine the predictors of healing after transmetatarsal amputations (TMA) and factors leading to a higher level of amputation. A total of 33 TMA was performed in 31 patients during the 5 years between January 2000 and Jul 2005. All patients were men between the ages of 44 and 82 years (mean, 68 years). The mean follow-up period was 36 months (range, 1-65 months). Twelve (40%) TMA required a subsequent higher level of amputation. Seventeen (57%) TMA were successful. The average time until further proximal amputation after TMA was 3.5 months. Risk factors for subsequent higher amputation by univariate analysis included infrapopliteal arterial occlusion (P < 0.05), tobacco smoking greater than 20 years (P < 0.05), and further TMA debridement (P < 0.05). Upon multivariate analysis, only patients undergoing further TMA debridement were at risk for TMA failure (P = 0.01). The difference in ankle-to-brachial pressure ratio (ABI) between the higher amputation group (ABI = 0.51) and the successful TMA group (ABI = 0.54) was not significant. There were no perioperative deaths after TMA. Five (18%) deaths occurred at a mean of 8.2 months after the TMA. In patients who are walking preoperatively, aggressive TMA is warranted in an attempt to maintain ambulation, recognizing that requirement for further debridement, smoking history, and infrapopliteal occlusion may be predictors of nonhealing and subsequent higher amputation.

Adult↗
PubMed2005

The surgeon and AIDS: twenty years later.

BACKGROUND: Since the first reports on indications and outcome for abdominal procedures in the HIV/AIDS patient were published 20 years ago, the epidemiology and presentation of surgical illness have changed remarkably with the advent of new antiviral regimens. A review of the now occasional, but still important, role of the surgeon in contemporary treatment of HIV/AIDS is presented. DATA SOURCES: Information was obtained by PubMed searches of medical journals, examination of reference lists, and Web resources. STUDY SELECTION: Articles on operative indications, outcomes, precautions, source of transmission, and pathophysiology of HIV/AIDS were selected. DATA EXTRACTION: Data was obtained from peer-reviewed articles and references. DATA SYNTHESIS: The last 2 decades have seen a decrease in operative mortality from as high as 85% to approximately 15% with a corresponding improvement in morbidity. Surgical emergencies such as appendicitis occur in HIV patients with the same frequency as non-HIV patients and are treated with equivalent results. Concern about transmission of HIV in the operating room has lessened somewhat. Although still a hazard, the probability of HIV transmission with accidental exposure is low, with risks below 0.5% for percutaneous hollow-bore needles and less than 0.1% risk for mucus membrane exposure. CONCLUSIONS: Improved surgical outcomes together with of accurate data on the modes and likelihood of accidental transmission of HIV to members of the surgery team have resulted in the treatment of HIV/AIDS patients becoming an accepted part of routine surgical practice.

Abdomen, Acute↗