Biomedical subjects

Volker R Jacobs

Publications and source records attributed to Volker R Jacobs.

At least 19 recordsLinked to original sources

PubMed2006

Critical appraisal of primary systemic endocrine therapy in receptor-positive postmenopausal breast cancer: an update.

Even in elderly patients, greater consideration is now being given to tumor volume reduction in locally advanced breast cancer, with increased subsequent breast-conserving surgery. Neoadjuvant endocrine therapy offers the possibility of testing therapeutic efficacy in vivo, which is of great importance for optimal adjuvant treatment. Resulting therapy modifications can be expected to increase disease-free as well as overall survival. Recent results indicate that remission rates with primary chemotherapy are significantly lower in receptor-positive than in receptor-negative breast cancer and that efficacy parameters in receptor-positive tumors tend to favor primary endocrine therapy, highlighting the increased importance of this type of treatment. Aromatase inhibitors are superior to tamoxifen in terms of clinical response as well as breast conservation rate. Results from a small number of studies suggest that prolonged preoperative aromatase inhibitor therapy for up to 12 months can increase the rate of clinical and pathological complete remissions. In conclusion, primary endocrine therapy is a valid therapeutic option for postmenopausal patients with locally advanced hormone receptor-positive breast cancer and significant comorbidity, increased risk of complications with regard to anesthesia and surgery, desire for breast-conserving surgery and/or reduced suitability for chemotherapy, as well as in very old patients.

Aromatase Inhibitors↗

PubMed2006

G-CSF in the prevention of febrile neutropenia in chemotherapy in breast cancer patients.

The most common chemotherapeutic agents in the treatment of breast cancer are anthracyclines and taxanes. The major dose-limiting toxicities associated with these agents are myelosuppression and associated febrile neutropenia (FN). FN can significantly impact the ability to deliver full-dose chemotherapy on schedule and as a result may increase the risk of disease recurrence and eventual disease-related mortality. The use of granulocyte colony stimulating factors (G-CSFs) significantly improves the management of FN, both in a therapeutic and in a prophylactic approach. Nevertheless, the high cost of these agents limits their widespread prophylactic use. Therefore, the identification of patients who are at a higher risk of developing FN and who will benefit from the prophylactic use of G-CSFs has become the subject of several clinical and cost-effectiveness studies. Recently, new data have been accumulated concerning the risk of FN in different chemotherapy regimens, and different risk models have been developed to assess the neutropenic risk with all its complications. This article reviews and summarizes cutting-edge, disease-specific data as well as national and international guidelines regarding the use of G-CSFs to prevent chemotherapy-induced FN, with focus on the treatment of breast cancer.

Antineoplastic Agents↗

PubMed2006

Maternal morbidity after maternal-fetal surgery.

OBJECTIVE: There is a paucity of published data on the maternal risks of fetal surgical interventions. We analyzed maternal morbidity and mortality that were associated with different types of fetal intervention (open hysterotomy, various endoscopic procedures and percutaneous techniques) to quantify this risk. STUDY DESIGN: We performed a retrospective evaluation of a continuous series of 187 cases that had been performed between July 1989 and May 2003 at the Fetal Treatment Center, a highly specialized interdisciplinary center for fetal surgery at the University of California, San Francisco. The primary outcome was the frequency of maternal morbidity for open, endoscopic, and percutaneous procedures to access the fetus. RESULTS: There were 187 pregnant women with confirmed major fetal malformations who were candidates for intrauterine fetal intervention. Maternal-fetal surgery was performed in 87 cases by open hysterotomy, in 69 cases by endoscopic procedures, and in 31 cases by percutaneous techniques. There were no maternal deaths, but significant short-term morbidity was observed. There were no significant differences in the incidence of premature rupture of membranes, pulmonary edema, placental abruption, postoperative vaginal bleeding, preterm delivery, or interval from maternal-fetal surgery to delivery between endoscopic procedures and open surgery. Complications were significantly less in the percutaneous ultrasound-guided procedures. Endoscopic procedures, even with a laparotomy, showed statistically significantly less morbidity compared with the open hysterotomy group regarding cesarean delivery as delivery mode (94.8% vs 58.8%; P < .001), requirement for intensive care unit stay (1.4% vs 26.4%; P < .001), length of hospital stay (7.9 vs 11.9 days; P = .001), and requirement for blood transfusions (2.9% vs 12.6%; P = .022). Chorion-amnion membrane separation (64.7% vs 20.3%; P < .001) was seen more often in the endoscopy group. CONCLUSION: Short-term morbidities include increased rates of cesarean birth, treatment in intensive care, prolonged hospitalization, and blood transfusion, all of which were more common with hysterotomy compared with other techniques. Maternal-fetal surgery can be performed without maternal death. Results from this study provide helpful data for counseling prospective patients.

Female↗

PubMed2005

Physician-based active cost management of oncological therapies reducing pharmaceutical costs by 83.4% in two years without leaving standard of care.

We report about the 2-year results of a physician-based active cost management model for oncological therapies in a German OB/GYN university clinic. Over 2 years more than 4,000 oncological cycles were prospectively and individually analyzed regarding costs and reimbursement mode. Main aim was reducing costs without lowering cycle number and standard of care. Within two years pharmaceutical costs were reduced by 83.4% or 785,976-EUR. All causes for a previous financial loss were identified and eliminated. Debts were paid back and employment of new staff and investments were possible. With this first active cost management model by and for physicians, oncological therapies can be performed cost covering even in a university clinic. Although developed for optimization of cost coverage of oncological therapies in Germany, this model is universally transferable.

Antineoplastic Agents↗

PubMed2005

Comparison of iron oxide labeling properties of hematopoietic progenitor cells from umbilical cord blood and from peripheral blood for subsequent in vivo tracking in a xenotransplant mouse model XXX.

RATIONALE AND OBJECTIVES: To compare and optimize ferumoxides labeling of human hematopoietic progenitor cells from umbilical cord blood and from peripheral blood for subsequent in vivo tracking with a clinical 1.5 T MR scanner. MATERIALS AND METHODS: Human hematopoietic progenitor cells, derived from umbilical cord blood or peripheral blood, were labeled with Ferumoxides by simple incubation or lipofection. Cellular iron uptake was quantified with spectrometry. Then, 3 x 10(7)-labeled cells were injected into the tail vein of 12 female nude Balb/c mice. The mice underwent magnetic resonance imaging before and 24 hours after injection. Precontrast and postcontrast signal intensities of liver, spleen, and bone marrow were measured and tested for significant differences with the t-test. Immunostains served as a histopathologic standard of reference. RESULTS: After labeling by simple incubation, only umbilical cord blood cells, but not peripheral blood cells, showed a significant iron uptake and could be tracked in vivo with magnetic resonance imaging. Using lipofection, both cell types could be tracked in vivo. A significant decline in signal intensity was observed in liver, spleen, and bone marrow at 24 hours after injection of efficiently labeled ferumoxides cells (P < .05). Histopathology proved the distribution of iron oxide-labeled cells to these organs. CONCLUSION: Hematopoietic progenitor cells from umbilical cord blood can be labeled by simple incubation with an Food and Drug Administration-approved magnetic resonance contrast agent with sufficient efficiency to provide an in vivo cell tracking at 1.5 T. Progenitor cells from peripheral blood need to be labeled with adjunctive transfection techniques to be depicted in vivo at 1.5 T.

Animals↗

PubMed2005

Cryopreservation of human endothelial cells for vascular tissue engineering.

To investigate the influence of cryopreservation on endothelial cell growth, morphology, and function human umbilical vein endothelial cells (HUVECs) were frozen following a standard protocol. Cell suspensions were exposed to 10% dimethyl sulfoxide in a high-potassium solution, cooled to -80 degrees C at 1 degrees C/min and stored in liquid nitrogen for 7-36 days. Samples were thawed in a 37 degrees C water bath and the cryoprotectant was removed by serial dilution. The growth of cell suspensions was assayed by culturing 7300 cells/cm2 for 3-5 days in order to determine the cell multiplication factor. Fresh and cryopreserved/thawed cells were analyzed for their growth, and their anti-inflammatory and anti-coagulant function by using cellular ELISA. Cryopreservation resulted in a retrieval of 66 +/- 5% and a viability of 79 +/- 3%. Cryopreserved/thawed and fresh cells showed identical doubling times and identical cell counts in the confluent monolayers. However, the lag phase of thawed HUVECs was approximately 36 h longer, resulting in significant differences in the cell multiplication factor at 3 and 5 days after seeding. After expansion to a sufficient cell count the lag phases were identical. Fresh and cryopreserved/thawed cells showed comparable anti-inflammatory and anti-coagulant activity, as judged by the basal and TNF-induced VCAM-1, ICAM-1, E-selectin, and thrombomodulin expression. Cryopreserved/thawed and recultivated endothelial cells are suitable for endothelialization of autologous allograft veins. Such tissue-engineered grafts will offer the necessary clinical safety for those patients who lack autologous material.

Cell Adhesion Molecules↗

PubMed2005

Effect of pregnancy on long-term kidney function in renal transplant recipients treated with cyclosporine and with azathioprine.

In order to investigate the effect of different immunosuppressive regimens and the time interval between transplantation and pregnancy on long-term outcome, we performed a case-control study in pregnant renal allograft recipients. Eighty-one pregnancies of kidney transplanted recipients were identified [cyclosporine (CYA): n = 40; azathioprine (AZA): n = 41]. Controls were matched with respect to important prognostic factors. Posttransplant follow-up was 91.3 +/- 5 months. Graft and patient survival were similar in both groups and there was no apparent effect of immunosuppression. A total of 28 recipients (33%) delivered within 2 years and 6 (8%) subjects within 1 year after transplantation, but these short transplantation-to-pregnancy intervals had no apparent adverse effect on long-term outcome. In contrast to AZA-treated patients, CYA-treated patients experienced an increase in serum creatinine postpartum (1.15 +/- 0.2 mg/dL vs. 1.61 +/- 0.1 mg/dL; p < 0.05). Whole blood CYA levels decreased transiently during pregnancy from 115.9 +/- 8 ng/mL to 80.7 +/- 7 ng/mL leading to a gradual increase in drug dose from 240 +/- 14 mg/day to 324 +/- 21 mg/day (p < 0.05). Following delivery, there was an increase in CYA concentrations to 173 +/- 5.4 ng/mL, requiring rapid dose tapering to baseline of 246 +/- 15 mg/day. Pregnancies in renal recipients do not affect long-term patient and graft survival, independent of the immunosuppression. No detrimental effect of short transplantation-to-pregnancy intervals on long-term graft function was detected.

Adult↗

PubMed2004

A randomized, prospective, controlled, multicenter clinical trial of a sprayable, site-specific adhesion barrier system in patients undergoing myomectomy.

OBJECTIVE: To assess the safety and effectiveness of a sprayable, site-specific adhesion barrier system (SprayGel; Confluent Surgical, Waltham, MA) for reduction of adhesion formation. DESIGN: Prospective, randomized, controlled phase III trial. SETTING: University clinic (Kiel, Germany) and private clinic (Bordeaux, France). PATIENT(S): Sixty-six women aged 34.9 years (range, 23-52 years) undergoing laparoscopic or open uterine myomectomy, enrolled over a 15-month period. INTERVENTION(S): Patients were randomized to receive either optimal surgical treatment plus adhesion barrier or optimal surgical treatment alone, followed by second-look laparoscopy. MAIN OUTCOME MEASURE(S): Initial and second-look laparoscopy procedures were assessed for incidence, extent, and severity of adhesions; all patients were followed for safety analysis. RESULT(S): When compared with initial surgery, the mean adhesion tenacity score of adhesions seen at second-look laparoscopy was significantly reduced in treatment patients compared with control patients (0.6 vs. 1.7, a 64.7% reduction). Mean adhesion extent score at second-look laparoscopy compared with initial surgery was 4.5 cm(2) vs. 7.2 cm(2), mean adhesion incidence score was 0.64 vs. 1.22. Of 64 patients, 40 (62.5%) returned for second-look laparoscopy. CONCLUSION(S): This adhesion barrier was safe, well tolerated, and demonstrated efficacy in a population of patients known to be at risk for adhesion formation. There were no adverse effects attributable to the product and no patients in whom it could not be applied.

Adult↗

PubMed2004

Outpatient laparoscopic hysterectomy in a rural ambulatory surgery center.

STUDY OBJECTIVE: To evaluate a cost-optimized operative technique for outpatient laparoscopic hysterectomy in a rural ambulatory surgery center focusing on shortening hospital stay and substitution of expensive disposable laparoscopic instruments with standard surgical techniques. DESIGN: Prospective feasibility and observational study (Canadian Task Force classification II-3). SETTING: Rural ambulatory surgery center in Lamar, Alabama. PATIENTS: Fifty-two women. INTERVENTION: Outpatient laparoscopic hysterectomy. MEASUREMENTS AND MAIN RESULTS: From September 2001 through September 2003, 52 consecutive procedures with a modified classical intrafascial supracervical hysterectomy (CISH) technique without disposable instruments have been performed on patients with an average age of 42.2 years (range 25-62 years) and a follow-up of 12.5 months (range 0.4-23.6 months). Mean postoperative length of stay was 6 hours, 79 minutes (range 3 hours, 10 minutes-17 hours, 30 minutes), and overall length of stay was 11 hours, 37 minutes (range 6 hours, 45 minutes-22 hours, 50 minutes). Five patients (9.6%) stayed overnight, three for medical and two for social reasons. With an average of 2 hours, 14 minutes, the operating room time was about 1 hour longer than with disposable instruments. Health insurance reimbursement for the ambulatory surgery center was on average $1814.11. No complications occurred, and no readmission to the hospital was necessary. CONCLUSION: Outpatient laparoscopic hysterectomy is feasible and safe and can be performed cost effectively in ambulatory surgery centers, even in rural areas. Development of a protocol with patient selection, preoperative and postoperative patient teaching, caring family environment, and round-the-clock medical telephone backup is necessary.

Adult↗

PubMed2004

Twenty-five simple ways to increase insufflation performance and patient safety in laparoscopy.

Technical aspects of laparoscopic insufflation technique and interaction among patient, technique, and physician can affect the performance of laparoscopy and patient safety. A variety of laparoscopic equipment was evaluated regarding insufflation performance in laboratory measurements and/or in an intraoperative computer-based data-acquisition model for intraabdominal pressure, gas flow, and temperature. In this article, we present 25 suggestions for improving insufflation performance and increasing patient safety. These tips may help avoid and solve insufflation problems and malfunction, over- and under-pressure peaks, laparoscopic hypothermia, and gas embolism, and shorten operation room and anesthesia time, thereby saving time, money, and physician stress.

Female↗

PubMed2004

Body piercing affecting laparoscopy: perioperative precautions.

Piercing is an increasingly popular fashion trend mainly among adolescents. Umbilical piercing in particular can cause perioperative problems during laparoscopic procedures. We describe how to deal with this fashion trend in our institutions. First, any piercing needs to be documented during preoperative physical examination. During preoperative informed consent, patients are told that all pierced jewelry needs to be removed, preferably by the patient before the procedure. For the operation, patients may be offered the use of sterile "sleepers," which are substitutes made of plastic to avoid closure of the wound canal perioperatively. Postoperatively, most pierced jewelry can be put back into position after anesthesia has completely worn off. Only jewelry for piercings close to wounds (e. g., navel piercings) should not be reinserted until the skin is closed. Careful observation and increased hygienic effort to prevent local infection is necessary. To date, we have not seen any severe umbilical infection after laparoscopy. However, in several patients the umbilical pierced jewelry was back in the navel on the same day of surgery, sometimes immediately after waking from anesthesia. Hospital staff should know how to remove and substitute piercing jewelry as well as how to optimize hygienic care perioperatively to prevent umbilical wound infections. Time and effort for patient teaching and hygienic care are slightly increased.

Body Piercing↗

PubMedDate not supplied

Breast ductoscopy with a 0.55-mm mini-endoscope for direct visualization of intraductal lesions.

Standard radiologic examinations of breast duct lesions can give only indirect information. Mini-endoscopy with a breast ductoscope of only 0.55 mm offers direct visualization of the lesion and helps in the decision to perform or avoid exploratory breast tissue resection. We used a LaDuScope (PolyDiagnost, Pfaffenhofen, Germany) with a 0.55- or 0.95-mm outer diameter and a 75-mm working length from October 2003 through July 2004 on 11 women (average age of 48.3 years [range 36-69 years]) with suspicious nipple discharge. The optics have zero-degree direct view, 70-degree field vision, and 3000 or 6000 pixel resolution. Breast ducts and walls could be easily inspected; and irrigation of breast ducts, aspiration, and use of cytology brush were possible under visual control. We had no intraoperative or postoperative complications. The new procedure of mini-ductoscopy is feasible, safe, and helpful as an additional ambulatory diagnostic method for visual inspection of breast ducts. This instrument demonstrates the latest advances of technology and a trend toward less-invasive diagnostics for breast duct lesions.

Adult↗

PubMedDate not supplied

Development of a thinner and more flexible type of minihysteroscope with a controlled 90-degree bendable tip for vision-guided endometrium biopsy.

STUDY OBJECTIVE: Evaluation of the uterine cavity is limited with rigid 5-mm hysteroscopes because of the need for cervical dilatation, reduced movements inside the uterus, and no option for vision-guided biopsy. In cooperation with PolyDiagnost GmbH, Pfaffenhofen, Germany, a new type of flexible minihysteroscope with bendable tip was developed and evaluated. DESIGN: Prospective and parallel observational interindividual evaluation of flexible minihysteroscope and standard hysteroscope for diagnostic hysteroscopy (Canadian Task Force classification II-3). SETTING: Obstetrics and gynecology department of a university clinic. PATIENTS: Nine women, average age 65.0 years (range 46-89 years), with indications for diagnostic hysteroscopy. INTERVENTIONS: After defining requirements, a novel, thinner, and more flexible minihysteroscope, 18-cm long with a 2.67-mm outer diameter, was developed with straight zero-degree scope, 70-degree vision field, and 6000-pixel resolution. Two working channels, 1.2 mm and 0.55 mm, allow suction-irrigation and introduction of a 1.0-mm biopsy forceps or cytology brush. The tip of the instrument is 90-degree stageless bendable to both sides. Diagnostic hysteroscopy was performed with flexible minihysteroscope followed by standard rigid hysteroscopy to verify results. MEASUREMENTS AND MAIN RESULTS: From July 2003 through March 2004, both procedures were performed in nine patients with identical visual and histologic results. No complications occurred. No cervix-dilating instruments were necessary for introduction of the flexible minihysteroscope. Visualization of the entire uterine cavity is improved with the flexible scope because a bendable tip allows better peripheral vision (e.g., of the openings of the tubes). However, movement of the tip should be performed carefully due to potential risk of uterine perforation. CONCLUSION: This new flexible minihysteroscope is less invasive compared with standard rigid hysteroscopy, which supports performance of ambulatory hysteroscopy and makes increased movements and vision-guided biopsy inside the uterine cavity possible.

Aged↗

PubMedDate not supplied

Three-dimensional model for gas flow, resistance, and leakage-dependent nominal pressure maintenance of different laparoscopic insufflators.

STUDY OBJECTIVE: To compare laparoscopic insufflators with different insufflation characteristics and evaluate the effects of resistance and leakage on maintenance of nominal pressure. DESIGN: Prospective study (Canadian Task Force classification II-2). SETTING: Laboratory of university clinic. INTERVENTIONS: Measurement in an abdomen box model of insufflator response to different resistance and leakage combinations during steady state while attempting to maintain a nominal set pressure of 12 mm Hg. MEASUREMENTS AND MAIN RESULTS: An abdomen box model for laboratory measurements was designed with differing entrance and exit diameters simulated by hole disks of 0.5 mm to 7.6 mm. With a computer-based data-acquisition model, five insufflators (Olympus 9L and 16L, Storz 10L and 30L, HiTec 16L) were evaluated with 150 disk combinations. Average abdominal box pressures were recorded in three-dimensional (3-D) profiles showing different nominal pressure maintenance response for all insufflators regarding the resistance and leakage combination, maximum flow performance, and insufflation principle of the device. Average abdomen model box pressure can increase up to 26.57 mm Hg at 12 mm Hg nominal pressure setting (+121.4%). Insufflators with high flow rates (Storz 30L) tend to compensate leakage better but with the risk of higher intraabdominal pressure peaks. Insufflators with low-pressure principle (HiTec 16L) have limited pressure compensation but are safer for the patient. CONCLUSIONS: Nominal pressure maintenance of insufflators is mainly dependent on flow resistance and leakage rate and less on potential insufflator flow capacity. With this 3-D model, the nominal pressure maintenance of different insufflators can be described for the first time regarding these main factors.

Abdominal Cavity↗

PubMedDate not supplied

The real intraabdominal pressure during laparoscopy: comparison of different insufflators.

STUDY OBJECTIVE: To compare 5 laparoscopic insufflators with different gas flow rates with regard to accuracy of preset pressure setting versus real intraoperative intraabdominal pressure. DESIGN: Prospective study (Canadian Task Force classification II-2). SETTING: Fayette Medical Center, Alabama. PATIENTS: Five patients undergoing laparoscopic cholecystectomy. INTERVENTIONS: Intraoperative intraabdominal and system pressure measurements during comparable laparoscopic procedures. MEASUREMENTS AND MAIN RESULTS: Actual intraabdominal pressure was measured and compared between 5 different 10 to 20 L/min insufflators (Storz Laparoflator and Endoflator, Richard Wolf, BEI Medical and Snowden & Pencer) with a computer-based online data acquisition system. At a nominal pressure of 10 mm Hg, the mean intraabdominal pressure during the entire procedure was measured to be between 9.68 and 11.45 mm Hg. The mean intraabdominal pressure during laparoscopy for the insufflators showed a margin of error of 14.5%, with maximum intraabdominal pressure peaks measured between 14.65 and 17.87 mm Hg. CONCLUSIONS: Within an error margin of <15% of the preset intraabdominal pressure setting, the insufflators evaluated can be considered pressure reliable. Although intraabdominal pressure peaks exceeding the nominal pressure temporarily reached up to 78.7% of the setting, no apparent complications were observed. Excessive pressure peaks seen in the previous reported laboratory model could not be confirmed during in vivo application.

Abdominal Cavity↗

PubMedDate not supplied

Mastitis nonpuerperalis after nipple piercing: time to act.

OBJECTIVE: To review the literature and discuss problems related to post-piercing breast abscesses. MATERIALS AND METHODS: Retrospective analysis of 10 case reports after Medline and internet search regarding breast abscess after nipple piercing. RESULTS: Nine case reports are published in Medline so far, the first in 1982, but eight within the last 3 years. One abstract of a case report presented at a meeting was found on the internet. Average patient age was 31.2 (15-60) years; 7 female and 3 male. Side of breast infection was 5 right, 4 left, and one both. The interval between piercing and treatment was on the average 20.8 (2-52) weeks, duration of symptoms 1 week to several months. Therapy in 9 patients was antibiotics and in 7 operation. The following major complications were seen: endocarditis, heart valve operation, prosthesis infection, metal foreign body in breast tissue, one reoperation because of recurrent infection, psychological stress because of primary diagnosis of breast cancer in 2 cases. CONCLUSION: The risks in nipple piercing are obviously under-documented and may be as high as 10-20% in the months after the procedure. Healing of the wound channel can take 6-12 months.

Abscess↗

PubMedDate not supplied

Axillary Dissection with Access Minimized (ADAM): a new technique for lymph node dissection in conservative surgery for breast cancer.

OBJECTIVE: Standard axillary lymph node dissection causes postoperative morbidity with pain, reduced arm mobility and axillary seromas. Endoscopy-supported axillary dissection using the same incision as was used for the breast tumor excision eliminates the necessity for a second axillary incision and potentially reduces operative trauma. This new technique is described and evaluated in a feasibility study. METHODS: Parallel observational study of a non-selected patient group with breast cancer (FIGO I-III) operated on with this less invasive technique from 11/2002 to 03/2003 in an oncological unit at the university level. RESULTS: 18 patients were operated on, with an average age of 74.7 (49-88) years, and a follow-up of 8.3 (5-10) months. Breast tumors could be removed in all quadrants. The single incision was 2.5-8.0 cm in length; operation time was 17-45 minutes and on the average, 14.2 (7-28) lymph nodes were removed. Only one patient was below the oncological standard of a minimum retrieval of 10 lymph nodes. There were no intra- or postoperative complications. Laparoscopic dissection was combined with sentinel lymph node biopsy, segment and quadrant resection as well as immediate breast reconstruction with latissimus dorsi flap or implant. Axillary pain and sensitivity effects were minimal. Advantages of this new technique are elimination of a second axillary incision and a remarkable increase of postoperative recovery regarding arm mobility and morbidity. CONCLUSIONS: The technique of endoscopy-supported axillary dissection with access minimized (ADAM) is feasible and safe and can be performed according to oncological standards.

Aged↗

PubMedDate not supplied

Replacement of expensive, disposable instruments with old-fashioned surgical techniques for improved cost-effectiveness in laparoscopic hysterectomy.

OBJECTIVE: Patients demand that health care and procedures in rural areas be provided by ambulatory surgery centers close to home. However, the reimbursement rate for such procedures in ambulatory centers is extremely low, so a standard classic intrafascial supracervical hysterectomy procedure needs to be more cost effective to be performed there. Instruments and disposable devices can make up > or = 50% of hospital costs for this procedure, so any cost reduction has to focus on this aspect. METHODS: We identified the 3 most expensive disposable devices: (1) an Endostapler, 498 US dollars and 3 staple reloads, 179 US dollars each; (2) a calibrated uterine resection tool 15 mm for encoring of the endocervical canal, 853 US dollars; and (3) a serrated edged macro morcellator for intraabdominal uterus morcellation, 321 US dollars, and substituted them using classic conservative surgical techniques. RESULTS: From September 2001 to September 2002, we performed 26 procedures with this modified technique at an ambulatory surgery center with a follow-up of 6.7 (2 to 14) months. This modified operative technique was feasible; no conversions were necessary, and no complications occurred. Cost savings were 2209 US dollars per procedure; additional costs were 266.33 US dollars for suture material and an Endopouch, resulting in an overall savings of 50 509.42 US dollars. The disadvantage was an increase in operating room time of about 1 hour 20 minutes per case. CONCLUSION: These modifications in the classic intrafascial supracervical hysterectomy technique have proven to be feasible, safe, and highly cost effective, especially for a rural ambulatory surgery center. Long-term follow-up is necessary to further evaluate these operative modifications.

Adult↗