[Comparative study of health care costs for patients using home oxygen therapy or those in waiting lists]. / Estudio comparativo de costos anuales en salud entre usuarios de oxígeno domiciliario y pacientes en lista de espera.

BACKGROUND: Home oxygen therapy is the only intervention that significantly prolongs survival of patients with chronic obstructive pulmonary disease. Since this therapy is expensive, it is imperative to calculate its cost-benefit ratio. AIM: To compare health care costs for patients in a home oxygen therapy program, with those of a similar group of patients in a waiting list for this therapy. MATERIAL AND METHODS: A retrospective analysis of 21 patients on home oxygen therapy for 36 months or less and a group of 13 patients in the waiting list during a similar lapse. Medical consultations, drugs delivered and the cost of oxygen therapy were considered among ambulatory costs. Hospitalization costs included the number of days on regular or intermediary care beds, laboratory tests and drugs delivered. RESULTS: The annual health care costs for patients on home oxygen therapy were 709,656 Chilean pesos and the costs for patients in the waiting list were 797,320 Chilean pesos. CONCLUSIONS: The overall health care costs of home oxygen therapy are similar to the cost required by patients with chronic obstructive pulmonary disease remaining in waiting lists.

Gallbladder carcinoma during laparoscopic cholecystectomy: is it associated with bad prognosis?

Laparoscopic cholecystectomy is the treatment of choice for gallstone disease. The ultrasonogram has failed for the early detection of gallbladder cancer, especially if inflammation (chronic or acute) is present. Incidental gallbladder could be an important cancer finding during laparoscopic cholecystectomy, due to the potential cancer cell dissemination during the procedure. In our Department, 6500 laparoscopic cholecystectomies have been performed in the last 5 years and in 15 cases (0.23%) gallbladder cancer was found during surgery or after histological examination of the resected gallbladder. In none of these 15 patients was pre-operative diagnosis of gallbladder carcinoma postulated. When re-evaluation of the pre-operative ultrasonograms was done, it was possible to observe signs suggesting the presence of neoplastic infiltration in 4 of them (28.6%). During videoscopic exploration, also in 4 patients, the suspicion of gallbladder cancer was noted. Laparoscopic cholecystectomy was completed in 9 patients. In 2 of them, in situ or mucosal invasion was demonstrated with a long survival. One patient presented recurrence at the biliary hilum 2,5 years after surgery. Six patients were re-operated and in 4 of them peritoneal or port site metastasis was found; all died early (4.5 month median survival). The other 2 patients were submitted to liver bed resection and lymph node dissection. These patients are free of cancer recurrence after 15 months of follow-up. Six patients were converted to open surgery, performing palliative procedures and died before the 12 month follow-up. The suspicion of pre-operative gallbladder cancer is generally unlikely to be confirmed based on ultrasonographic signs; but, in some cases with high suspicion, further investigation (TAC, tumor markers, etc.) must be indicated in order to avoid poor results. Laparoscopic cholecystectomy could be associated with bad prognosis, and then, when gallbladder cancer is suspected during the laparoscopic procedure, conversion to open surgery could be the best choice.

Gallstone ileus.

A retrospective analysis of 74 patients with gallstone ileus detected during the period between 1975 and 1987 was performed at the Surgical Department. The group comprised 55 females and 19 males, with a mean age of 64.8 years. Previous biliary symptoms had been observed in 76% of the cases and in 58% there had been concomitant disease. The main duration of symptoms previous to admission was 3.4 days. In 85% of the cases complementary diagnostic procedures were performed. The triad of air in the biliary tract, air-fluid levels and ectopic stone was found in only 9.5% of the cases. The preoperative diagnosis of gallstone ileus was made in 31% of the patients. The preoperative period was 2.2 days. The main surgical procedure was enterolithotomy in 92% of the cases, the site of impaction being the terminal ileum in 65%. Only in 1 case was simultaneous biliary tract surgery and enterolithotomy performed. Overall, the 30-day postoperative mortality rate was 13.5%, with intra-abdominal sepsis as the main cause of death. Sixteen patients were submitted to biliary surgery 2 to 6 months later, and no deaths occurred.

[Dieulafoy's vascular malformation as a cause of massive and recurrent gastric hemorrhage]. / Malformación vascular de Dieulafoy como causa de hemorragia gástrica masiva y recurrente.

We demonstrated a Dieulafoy-type vascular malformation in 10 patients with upper gastrointestinal bleeding. Most patients had a history of prior bleeding and were older than 60 years of age. A mean of 2.6 endoscopic examinations had been performed, and a mean of 2500 ml of blood transfused per patient. A localized resection of the lesion was performed in 9 patients and a partial gastrectomy in the remaining. Surgery was performed as an emergency in 5 patients. The lesion was a small, 2 to 5 mm, erosion localized in the subcardial region. The vascular nature of the lesion was confirmed by histologic study in all cases. Postoperative course was uneventful in all patients and no recurrences have been observed.

Treatment of residual common bile duct stones after cholecystectomy.

This study was conducted to determine the occurrence of "open" residual common bile duct stones after cholecystectomy to establish predisposing factors and possible alternative treatments. Correct diagnosis of choledocholithiasis before or during surgery, adequate exploration of the common bile duct, and suitable selection of technical procedures are the most important points in preventing retained CBD stones. If these occur, an adequate alternative treatment may prove helpful. Classical "clysis" of the bile duct is least recommended because of its high failure rate. The best method of chemical dissolution seems to be the use of mono-octanoin with 60% good results and a no-response rate of 30-40%. Instrumental extraction has been reported to be very successful (80-98%). Endoscopic sphincterotomy is currently the most frequently employed procedure for retained CBD stones, especially in poor risk patients. The reported success rate is 82-93% according to literature, with an extremely low mortality (0.2%). Reoperation should be resorted to only if all the other methods fail. Sphincteroplasty or choledochoduodenostomy, whenever indicated, are good alternative operations, with a mortality rate of approx. 3.5%.

Results of surgical treatment in patients with "western" intrahepatic lithiasis.

The results of the surgical treatment in 251 patients with intrahepatic stones are discussed. The mean age of the group was 48 years, with a predominance of females. Gallstones were observed in 72% of the cases, because 28% had had previous cholecystectomy. Associated common bile duct stones were present in 222 (88%) cases, while primary intrahepatic stones were seen in 29 patients. The intrahepatic stones were usually bilateral. Three main operations were employed. Choledochostomy with or without cholecystectomy was performed in 166 (66%) cases with 6 deaths (3.6%). Bilioenteric anastomosis such as sphincteroplasty or choledochoduodenostomy were used in the rest with similar results. However, residual stones were documented in 32% after choledochostomy, while only 4% were seen after choledochoduodenostomy. In our groups, intrahepatic stones originated from migrated stones from the gallbladder, and surgical treatment should be orientated towards complete extraction of the stones and prevention of their further appearance.

Indications and results of sphincteroplasty in benign biliary diseases.

A retrospective analysis of 143 patients submitted to sphincteroplasty at the Department of Surgery, University of Chile Clinical Hospital was performed. A significant percentage of these patients (90%) were admitted due to acute biliary tract disease with or without cholangitis. The standard operative procedure was anterior transduodenal sphincteroplasty with supraduodenal choledochal exploration leaving a choledochostomy. A high number of our cases presented with intrahepatic lithiasis (23.8%). The morbidity was 15.4% and the 30 days post operative mortality rate was 4.9%, similar to other reports. Residual stones were observed in 10 patients (7%), and were successfully removed by other procedures. Three patients showed recurrent stenosis of the papilla and were operated on again with good results.