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PubMed2000

Financial analysis of anterior cruciate ligament reconstruction at Baylor University Medical Center.

Five hundred and twenty-five primary arthroscopic anterior cruciate ligament (ACL) reconstruction cases were retrospectively evaluated at our hospital with respect to operating room time, operating room cost, and hospital charges. Three main areas were financially analyzed: outpatient vs inpatient surgery, meniscus tears, and ACL grafting techniques. Patients who had their surgery done as an outpatient had, on average, a 21-minute faster operating room time, a dollar 477 lower operating room cost, and an dollar 840 lower hospital charge per case compared with patients who were admitted overnight (P = 0.001). Surprisingly, no statistically significant difference in operating room time or operating room cost was detected in ACL surgeries involving partial meniscectomy or meniscus repair compared with ACL surgeries without meniscus tears. When examining the 2 most popular ACL grafting techniques, 4-strand hamstring graft cases were, on average, 23 minutes faster, had dollar 565 lower operating room costs, and had dollar 1015 lower hospital charges compared with bone-patella tendon-bone cases (P = 0.001). Operating room time is a significant component of the overall cost of and charges for ACL surgery, and the 23-minute faster hamstring technique produced more savings than outpatient surgery.

Journal Article↗
PubMed2006

Modified endocystectomy versus pericystectomy in echinococcus granulosus liver cysts: a randomized controlled study, and the role of specific anti-hydatid IgG4 in detection of early recurrence.

The evidence based data of hydatid liver disease indicate that the level of evidence was too low to help decide between radical or conservative surgeries (level IV evidence, grade C recommendation). So, there is a need for accurately designed randomized trials with precise goals to compare pericystectomy versus a specific modified endocystectomy technique for the treatment of hepatic hydatid cysts 8 cm or less in diameter in Egyptian patients, regarding the operative time, intra-operative blood loss, complications and long-term recurrence and to test the role of anti-hydatid IgG4 in diagnosis and detection of early recurrence. 60 patients with 131 liver cysts of E. granulosus fulfilling the study criteria were randomly divided to two groups. GI: 32 patients with 69 cysts treated by modified endocystectomy and GII: 28 patients with 62 cysts treated by closed total pericystectomy. GIa included 40 cysts >5 cm in diameter (mean 6.86, SD+/-0.809) & GIb 29 cysts < or = 5 cm in diameter (mean 4.17 SD+/-0.83). GIIa included 37 cysts >5 cm in diameter (mean 7.01 SD+/+0.79) & GIIb 25 cysts < or = 5 cm in diameter (mean 4.04 SD+/-0.93). Preoperative evaluation included history taking, clinical examination, blood tests, specific anti-hydatid IgG4, abdominal sonography and CT scan. The operative time for dealing with each cyst was in minutes. Operative blood loss and need for blood transfusion were estimated for each patient. Specific anti-hydatid IgG4 by ELISA was used to diagnose and to detect early recurrence. Patients were followed up clinically and by ultrasonography every 3 months and for anti-hydatid IgG4 every 6 months for 24-90 months. The mean maximum operative time was in GIIa followed by GIa, GIb, then GIIb. The operative time was significantly lower in GIIb than Ib and in GIa than IIa. Seven patients (GII) had blood transfusion. The intraoperative bleeding in GI was <500 ml/ patient, and 18 patients (GII) each bled >500 ml. No intraperitoneal seedling during the follow up. 5 of 55 patients (9%) were serologically suspected of relapse or incomplete cure. One (GII) showed early recurrence at 3 months. High IgG4 antibodies were detected in patients which decreased gradually after surgery and normal after 18 months post-operation.

Adult↗
PubMed2003

How to release allocated operating room time to increase efficiency: predicting which surgical service will have the most underutilized operating room time.

At many facilities, surgeons and patients choose the day of surgery, cases are not turned away, and staffing is adjusted to maximize operating room (OR) efficiency. If a surgical service has already filled its allocated OR time, but has an additional case to schedule, then OR efficiency is increased by scheduling the new case into the OR time of a different service with much underutilized OR time. The latter service is said to be "releasing" its allocated OR time. In this study, we analyzed 3 years of scheduling data from a medium-sized and a large surgical suite. Theoretically, the service that should have its OR time released is the service expected to have the most underutilized OR time on the day of surgery (i.e., any future cases that may be scheduled into that service's time also need to be factored in). However, we show that OR efficiency is only slightly less when the service whose time is released is the service that has the most allocated but unscheduled (i.e., unfilled) OR time at the moment the new case is scheduled. In contrast, compromising by releasing the OR time of a service other than the one with the most allocated but unscheduled OR time markedly reduces OR efficiency. OR managers can use these results when releasing allocated OR time.

Appointments and Schedules↗
PubMed1996

Laparoscopic cholecystectomy in acute cholecystitis. What is the optimal timing for operation?

OBJECTIVE: To review the results of laparoscopic cholecystectomy (LC) in patients with acute cholecystitis with attention to cost and clinical outcome. DESIGN: Retrospective study. SETTING: Large private metropolitan teaching hospital. PATIENTS: Four hundred forty-six patients had LCs at our institution between January 1993 and February 1995. Acute cholecystitis, confirmed by clinical, laboratory, operative, and histopathological findings, was present in 60 patients. MAIN OUTCOME MEASURES: The medical history, laboratory findings, gallbladder ultrasounds, timing of operation from the onset of symptoms, conversion rates to open procedures, operative times, intraoperative findings, complications, postoperative length of stay, cost of operative procedures and hospitalizations, and convalescence times were collected. RESULTS: Laparoscopic cholecystectomy was attempted in 16 patients within 72 hours of the onset of symptoms of acute cholecystitis (group 1), in 19 patients with symptoms between 4 and 7 days (group 2), and in 25 patients with symptoms lasting more than 7 days (group 3). The only factor (eg, preoperative laboratory and ultrasound findings) that affected the outcome of the operation was duration of symptoms prior to operation. Patients who had LC done within 72 hours of the onset of symptoms had lower rates of conversion to open procedures, less difficult operations, shorter operative times, less costly procedures, and a shorter convalescence than those with symptoms for longer than 72 hours prior to operation. The conversion rates in patients operated within and after 72 hours were 12% and 30%, respectively. There were no bile duct injuries and no mortalities. CONCLUSIONS: Laparoscopic cholecystectomy can be performed safely in most patients with acute cholelithiasis. However, we found that the duration of symptoms prior to LC affected the outcome; the conversion rates, hospital costs, and convalescence times increased in operated-on patients with symptoms for more than 72 hours. In our opinion, interval cholecystectomy may be a superior option in this latter group of patients.

Acute Disease↗
PubMed2006

Bladder recurrence of upper urinary tract cancer after laparoscopic surgery.

PURPOSE: We reviewed our cases to determine whether laparoscopic nephroureterectomy is a risk factor for the bladder recurrence. MATERIALS AND METHODS: From 1996 to 2003, 65 nephroureterectomies were performed: 47 by open and 18 by laparoscopic surgery. In 43 (28 by open, 15 by laparoscopic surgery), bladder cancer was not observed at the time of the operation. Two laparoscopic operations were converted to open surgery because of technical problems. The other 13 with laparoscopic and 28 with open surgery were enrolled into this study. RESULTS: Significantly higher recurrence rate was observed in laparoscopic cases (69.2%) than that in open cases (35.7%, P = 0.0484) by log rank test. However, the operation time required in laparoscopic surgery (371.5 +/- 90.8 min) was significantly longer than that in the open surgery (229.9 +/- 46.6 min, P < 0.0001). In multivariate analysis (Cox proportional hazards model), only the longer operation time (>250 min) was a significant variable (P = 0.0305), and laparoscopic surgery in itself was not a significant risk factor (P = 0.5011). CONCLUSIONS: Although frequent bladder recurrence was observed in laparoscopic cases, the most important risk factor was the longer operation time. Technical improvements including shortening of operation time and earlier ureteral ligation may decrease the bladder recurrence.

Aged↗
PubMed2001

Umbilical pyloromyotomy--an alternative to laparoscopy?

AIMS: To evaluate the utility of umbilical pyloromyotomy for infantile hypertrophic pyloric stenosis (IHPS) compared to published series promoting laparoscopy. METHODS: Eighty-six babies with IHPS had pyloromyotomy using an umbilical skin fold incision. Operating times, post-operative hospital stay and cosmetic appearance of the umbilical wound were studied. Data extracted from recent series promoting laparoscopy were identified using a MEDLINE search strategy and used for comparative analysis. RESULTS: Mean operating time for umbilical pyloromyotomy was 30 min (range 15-50 min). All patients went home at an average period of 58 h (range 48-72 h) following surgery. The umbilical scar was barely visible in the post-operative period. Laparoscopic pyloromyotomy operating times ranging from 18-41 min (mean overall 30 min) are recorded in the literature. Post-operative stay following laparoscopy has been variable (23-91 h), where reported. In contrast with umbilical pyloromyotomy, "pox" marks observed following port insertions for laparoscopy can give an unsightly scar. CONCLUSIONS: This study has found that umbilical pyloromyotomy can be performed with minimal morbidity and equivalent operating times to laparoscopy. The shorter hospital stay reported in some series promoting laparoscopy must be balanced against local practice influencing hospital stay, the financial implications of offering a laparoscopic service, the skills needed for laparoscopy, and the short learning curve required by paediatric surgical trainees to become proficient at umbilical pyloromyotomy. The cosmesis of the umbilical incision is excellent. These findings suggest that umbilical pyloromyotomy is a reliable alternative to laparoscopy.

Humans↗
PubMed1988

Use of ultrasonographic risk score in the timing of operative intervention for acute cholecystitis.

Timing of operative intervention for acute cholecystitis has long been a subject of debate. However, actual or impending perforation constitutes an absolute indication for prompt operative intervention. To discriminate these cases from those undergoing observation with conservative treatment, clinical and ultrasonographic findings were reviewed and analyzed in 17 patients with acute cholecystitis. Specificity, sensitivity, and accuracy of ultrasonography in discriminating cases of acute cholecystitis, in terms of timing of operative intervention, were calculated retrospectively based on the operative findings. The risk score for each ultrasonographic finding was determined, and the total risk score was calculated for each patient. The calculated total risk score was found to be well correlated with the macroscopic appearance of the gallbladder at operation in cases of acute cholecystitis. Therefore, this score should be useful in determining the timing of operative intervention for acute cholecystitis. However, the usefulness of the variables should further be established prospectively in other patient populations.

Acute Disease↗
PubMed2004

Radiofrequency ablation versus electrocautery in tonsillectomy.

OBJECTIVES: The objective of this study was to compare the safety, difficulty of removal, and postoperative pain profile of radiofrequency ablation versus standard electrocautery removal of tonsils. STUDY DESIGN AND SETTING: A prospective, blinded study was designed to remove 1 tonsil with each of the 2 methods. Time of operation, estimated blood loss, difficulty of operation, postoperative pain, rate of postoperative hemorrhage, and the patient's preferred technique were evaluated. RESULTS: The operating time was significantly longer (P < 0.007) and the patients reported significantly less pain (P < 0.001) with radiofrequency ablation. There were no differences in blood loss, difficulty of operation, or postoperative hemorrhage rates. The patients preferred the radiofrequency ablation technique (P < 0.001). CONCLUSION: Radiofrequency ablation is a viable method to remove tonsillar tissue. Operating time for this procedure will likely decrease with experience. There was significantly less pain reported with radiofrequency ablation compared with standard electrocautery.

Adult↗
PubMed1996

Vaginal hysterectomy for the large uterus.

OBJECTIVE: To assess the feasibility and safety of performing vaginal hysterectomy on enlarged uteri the equivalent of 14 to 20 weeks of gestation in size. DESIGN: A prospective observational study. SETTING: The Royal Free Hospital, London. PARTICIPANTS: Fourteen consecutive women undergoing vaginal hysterectomy for uterine fibroids up to 20 weeks in size. INTERVENTIONS: Vaginal hysterectomy with or without bilateral salpingo-oophorectomy or oophorectomy. MAIN OUTCOME MEASURES: Uterine size and weight, techniques used to reduce uterine size, surgical outcome, operative time, estimated operative blood loss, intra- and post-operative complications, duration of hospitalisation. RESULTS: The mean uterine size was 16.3 weeks (range 14 to 20 weeks). All hysterectomies were completed successfully by the vaginal route. The uteri weighed 380 to 1100 g, with a mean of 638.7 g. Bisection combined with myomectomy and morcellation were used in most cases to obtain reduction in uterine size, whereas coring was only utilised in two cases. The mean operating time was 84.3 min with a range of 30 to 150 min. The only complications were transient haematuria (n = 6) and superficial vaginal grazes (n = 5). One of the women required a blood transfusion. The mean post-operative hospital stay was 3.7 days (range 2 to 9 days). CONCLUSION: Enlargement of the uterus to a size equivalent to 20 weeks of gestation should no longer be considered a contraindication to vaginal hysterectomy. Many more hysterectomies should be carried out vaginally without resorting to abdominal or laparoscopic surgery.

Adult↗
PubMed2004

Long-term follow-up of percutaneous transhepatic balloon cholangioplasty in the management of biliary strictures after liver transplantation.

BACKGROUND: This study evaluated the efficacy of a protocol of initial balloon dilation for biliary strictures after liver transplantation. METHODS: Complete records from 96 patients with biliary strictures were retrospectively reviewed. Seventy-six patients received percutaneous transhepatic balloon cholangioplasty (PTBC) after initial placement of biliary drainage (percutaneous transluminal cholangiography [PTC]) tube. In most cases, three dilations were performed with a 4 to 8 week interval between procedures. Follow-up ranged from 6 months to 10 years. RESULTS: PTBC successfully treated strictures in 39 of 76 (51.3%) cases. Factors favoring successful PTBC included older age at transplant, shorter cold ischemic time, and single strictures. There were nine recurrent strictures after PTBC, all of which were successfully treated by nonoperative measures. The number of dilations performed affected both the likelihood of success and the long-term risk of stricture recurrence. Of the 37 PTBC failures, 14 underwent subsequent surgical revision. When both angiographic and surgical modalities were considered, treatment success was associated with first transplants, shorter cold ischemic time and operative time, and less intraoperative transfusion requirements. Factors associated with treatment failure included multiple, central hepatic duct, and intrahepatic strictures. PTC-tube independence was achieved in 51 of 76 (67%) patients using the combined approach of PTBC and surgery for PTBC failures. CONCLUSIONS: PTBC is an effective initial modality for treating posttransplant biliary strictures. Prolonged cold ischemic and operative times and multiple or peripheral strictures predispose to treatment failure. Solitary extrahepatic strictures that fail PTBC are salvageable with surgical revision with excellent results.

Adult↗
PubMed1999

Surgical management of renal trauma: is vascular control necessary?

OBJECTIVE: To assess in a randomized prospective manner nephrectomy rate, transfusion rate, blood loss, and time of operation in penetrating renal trauma patients randomized to vascular control or no vascular control before opening Gerota's fascia. METHOD: During a 53-month period from January of 1994 to May of 1998, 56 patients with penetrating renal injuries were entered into a randomized prospective study at an urban Level I trauma center. The patients were randomized to a preliminary vascular control group or no vascular control group. Randomization was performed intraoperatively before opening Gerota's fascia. All renal injuries were identified and diagnosed intraoperatively. Intravenous pyelography was not performed preoperatively. If the patient was randomized to the no control group and significant bleeding ensued after opening of Gerota's fascia, the renal hilum was cross-clamped. All injuries were included regardless of patient age, associated injuries, blood loss, severity of renal injury, or other abdominal organs injured. All injuries that required renorrhaphy or partial nephrectomy underwent drainage with closed Jackson-Pratt drainage. RESULTS: Twenty-nine patients were randomized to the preliminary vascular control group, and 27 patients were randomized to the no vascular control group. The average age in the vascular control group was 25.3 years (SD, 10.9) and 23.4 years (SD, 8.2) in the no control group. The average penetrating abdominal trauma index in the vascular control group was 22.9 (SD, 10.9) and in the no control group 23.7 (SD, 13.7). Nine nephrectomies (31%) were performed in the vascular control group, and eight nephrectomies (30%) were performed in the no vascular control group (p > 0.05). The average operative time for the vascular control group was 127 minutes and for the no control group was 113 minutes (p > 0.05). Eleven patients (38%) required intraoperative blood transfusion in the vascular control group (average, 5.5 U/patient transfused) versus eight patients (30%) in the no vascular control group (average, 5.2 U/patient transfused) (p > 0.05). The average blood loss in the vascular control group was 1.06 liters versus 0.91 liters in the no control (p > 0.05). There was one mortality in the study population. CONCLUSION: Vascular control of the renal hilum before opening Gerota's fascia has no impact on nephrectomy rate, transfusion requirements, or blood loss. Operative time may be increased with the vascular control technique.

Adult↗
PubMed1985

Inguinal hernias in premature infants operated on before discharge from the neonatal intensive care unit.

Sixteen premature infants were operated on during the two-year period from 1981 through 1982 for inguinal hernia prior to discharge from the hospital. There were no complications from the hernias before surgery and during administration of anesthesia and postoperative recovery, and no recurrences, would infections, or testicular atrophy was noted in long-term follow-up. In contrast to a controlled group of 11 full-term patients of this same age who were operated on as outpatients, the operating room time, operation time, and time in the recovery room were significantly increased for the premature infants. This resulted in a 22% increase in cost for the correction of the premature inguinal hernias. Analysis of the factors in repair of these hernias indicates that this increased cost will have to be accepted as part of the care of premature infants in neonatal intensive care units.

Hernia, Inguinal↗
PubMed1996

Laparoscopy through the open ipsilateral sac to evaluate presence of contralateral hernia.

PURPOSE: Laparoscopic evaluation of the contralateral side (LECS) in children with unilateral inguinal hernia (UIH) has been criticized because of the abdominal trocar risk and costs. LECS was modified to avoid abdominal trocar insertion by using the open hernia sac for instrumentation (OHLECS). This study was performed to determine the utility, safety, and effectiveness of this technique. METHODS: During a 15-month period, 80 children with unilateral hernia underwent attempted OHLECS. All ordinarily would have undergone open contralateral exploration. The indications were UIH in boys < or = 2 years of age and girls < or = 4 years of age (n = 53) or high clinical suspicion (but not certainty) of contralateral hernia in older children with UIH (n = 27). Endotracheal intubation was not used unless otherwise indicated. Reusable 3-mm blunt trocars and 3-mm 30 degrees or 70 degrees laparoscopes were employed, with and 6 to 8 mm of insufflation pressure. No urethral catheter was used. The ipsilateral hernia sac was dissected, opened, and instrumented, and the contralateral side was evaluated for patency. Concurrent external palpation of the contralateral inguinal canal is an important diagnostic adjunct. Positive results were visible patency of processus vaginalis or bubbles or fluid and/or gas expressed from the processus by palpation. Only if the evaluation was positive was contralateral incision and repair performed. OHLECS added no more than 2 minutes of operating time. The operating room cost is similar to that of opening the contralateral side. Only reusable laparoscopic instruments are used, and less operating time, anesthetic time, suture material, and dressings are required if the contralateral side is not opened. RESULTS: In 10 patients (all < 6 months old) OHLECS was aborted because the hernia sac was smaller than 3 mm at the internal ring. OHLECS was successful in 70 (88%) patients-56 boys and 14 girls, aged 2 mo to 12 years (mean, 2.6 years). The presenting hernia was right-sided in 46 (66%) and left-sided in 24 (34%). Overall, 43 (61%) OHLECS results were negative and 27 (39%) were positive. The OHLECS results were positive for 22 (39%) boys and 5 (36%) girls. Their mean age was 1.9 years (range, 2 months to 10 years). There were no false-positives and one false-negative. There have been no complications during follow-up (mean, 1.14 years; range, 6 months to 2 years). No additional costs were incurred because nondisposable equipment was used. CONCLUSION: Laparoscopic evaluation of the contralateral side via the open ipsilateral hernia sac is feasible, quick, safe, cost effective, and requires no additional incisions. The rate of positive findings is comparable with that of open exploration. Long-term follow-up is required to determine the ultimate effectiveness of the technique.

Child↗
PubMed2001

Reduction in operator supervision time using a modified malfunction detection system with fuzzy inference in an industrial-scale fermentation of alkaline cellulase.

A malfunction detection system based on fuzzy inference, in which a fermentation process is categorized into three states (normal, intermediate and abnormal) according to the computation of malfunction degree, was modified to reduce the supervision tasks required for an industrial-scale production of alkaline cellulase. The time lag of the culture, tau, was determined from the difference in the cumulated amount of CO2 evolved between the actual and standard values. By employing tau, the deviations of the actual values of process data (pH of broth and the amount of antifoaming agent supplied) from the standard values could be compensated for in terms of a delayed or forward effect in fermentation time. In the detection tests conducted for a series of 200 runs using the modified method, two runs and a single run were categorized as belonging to the abnormal and intermediate states, respectively, and all of the other runs were recognized to be in a normal state. As a result, the total supervision time for operators was reduced by the modification.

Journal Article↗
PubMed2005

Effect of water-soluble contrast in colorectal surgery: a prospective randomized trial.

AIM: Postoperative gastrointestinal-tract motility is normally delayed. Early feeding after colorectal surgery has been reported recently, but late feeding is common. Gastrografin not only enhances bowel peristalsis, but also decreases bowel-wall edema. Whether contrast medium allows early oral feeding and reduces the duration of hospitalization requires clarification. METHODS: Fifty patients underwent elective colorectal surgery in a regional medical center. Patients were prospectively randomized into a Gastrografin group or control group (n = 25 each). Patients in the Gastrografin group began their feeding schedule with 100 mL of 5% dextrose water with 100 mL of Gastrografin on postoperative d 3 and were advanced to a full liquid diet when the contrast reached the colon in 4 h. Patients in the control group began their feeding schedule with 200 mL of 5% dextrose water on postoperative d 3 and were advanced to a full liquid diet after the passage of flatus and stool. Nasogastric tubes were inserted for persistent postoperative vomiting. Fullness, nausea, vomiting, complications, time of anesthesia, time of operation, time of mobilization, time of oral feeding, and duration of hospital stay were recorded and analyzed with Student's t-test. RESULTS: In the Gastrografin group, one patient had aspiration pneumonia and one patient had anastomotic leakage resulting in sepsis and eventual death. This mortality was excluded from the subsequent statistical analysis. In the control group, two patients had wound infections. There was no significant difference between the two groups at the time of anesthesia, time of operation, or time of mobilization. There were significant differences between the two groups in the time of oral feeding (3.3+/-0.3 d in the Gastrografin group vs 4.8+/-0.4 d in the control group; P = odds ratio--, 95%CI [-0.5 to +0.7 d]) and in the length of hospital stay (7.6+/-1.1 d in the Gastrografin group vs 10.2+/-1.3 d in the control group; P = odds ratio--, 95% CI [-1.2 to +1.4 d]). CONCLUSION: Gastrografin not only allowed early oral feeding but also reduced the duration of hospitalization after elective colorectal surgery.

Aged↗
PubMed2003

Interstitial laser photocoagulation for treatment of benign prostatic hypertrophy: outcomes and cost effectiveness.

BACKGROUND: We examined the efficiency and cost effectiveness of a temperature feedback diode-laser system in the treatment of benign prostatic hypertrophy (BPH). METHODS: One hundred twenty patients with symptomatic BPH were included in this study between October 1997 and January 1998. Sixty of them were treated by transurethral resection of the prostate (TUR-P), and 60 patients were treated by temperature feedback interstitial laser coagulation (ILC). Direct and indirect cost parameters, such as operative time, operation-related consumables, duration of hospitalization, and amount of medication used were compared between the 2 groups. RESULTS: All subjective and objective urinary parameters exhibited significant improvement 12 months after ILC. A reduction of 26.8% (46.6 to 34.1 ml) of the pretreatment prostate volume was observed at 12 months following ILC. The duration of hospital stay, operative time, and postoperative medications were significantly lower for those receiving ILC (5.9 to 2.5 days, p < 0.001) than for those who underwent TUR-P. The variety of laboratory tests needed for preoperative evaluation was no less when ILC was chosen for treating BPH (p = 0.849). Indirect costs, such as investment in laser equipment and laser accessories were higher in the ILC group (p < 0.001). CONCLUSION: The low morbidity profile, particularly the absence of retrograde ejaculation, makes ILC a valuable and attractive option for treatment of BPH patients who wish to retain their ejaculation ability, who have serious underlying diseases, or who have surgical risks for TUR-P or other invasive modalities.

Adult↗