Intracolonic vancomycin for severe Clostridium difficile colitis.

BACKGROUND: Clostridium difficile colitis is associated with increased age, antibiotic usage, and hospitalization. Severe C. difficile colitis refractory to medical therapy may require surgical intervention including subtotal colectomy. We initiated an adjuvant intracolonic vancomycin (ICV) enema protocol for inpatients with severe C. difficile colitis and compared the response to this therapy in patients from the community and nursing homes. METHODS: A single-hospital, retrospective chart review was done on 47 consecutive patients with C. difficile colitis treated with ICV (1 g/500 mL normal saline q6h) from January 2007 through October 2009. The proportions of patients with the outcomes of response to the ICV protocol, need for subtotal colectomy, and death were described. Associations of patient characteristics with these outcomes were examined with bivariate tests and multivariable logistic models with adjustment for age, hypoalbuminemia, acidosis, and nursing-home status. RESULTS: Thirty-three of 47 patients (70%) with severe C. difficile colitis responded to adjunct ICV with complete resolution without surgery. Incomplete responders who had surgery were more likely to survive than those patients who did not undergo subtotal colectomy (p<0.01). Seven of nine patients who underwent surgery survived >90 d, and overall, 37 of 47 patients (79%) survived after ICV therapy. Nursing-home residence, acidosis, and hypoalbuminemia were significantly associated with the non-resolution of colitis in bivariate analyses (all p<0.01), whereas nursing-home residence and hypoalbuminemia showed non-significant trends toward association with death (p=0.07 and p=0.06, respectively). Multivariate logistic-regression models showed significant associations of acidosis with an incomplete response to ICV (p=0.02), of older age with death (p=0.04), and of hypoalbuminemia with both an incomplete response to ICV and death (both p=0.04). No complications were attributable to ICV. CONCLUSION: Complete resolution without surgery was achieved in 70% in this series of patients with severe C. difficile colitis who received adjunct ICV therapy. A clinical trial will be needed to determine whether ICV as compared with standard therapy alone can reduce the need for surgery with non-inferior or superior outcomes.

Single-incision laparoscopic cholecystectomy learning curve experience seen in a single institution.

INTRODUCTION: Single-incision laparoscopic surgery (SILS) is laparoscopic surgery done by one incision through the umbilicus. Cholecystectomy lends itself well to a SILS approach. As these procedures have become more widely adapted, it is important to determine the approximate learning curve to decrease two surgical endpoints: (1) time to completion of the procedure; and (2) decreased incidence of conversion. METHODS: We prospectively reviewed our series of 50 cholecystectomies done using the SILS approach between May 2008 to September 2008. All cases were performed by two advanced laparoscopic surgeons at a single institution. Data was collected immediately after the case and entered into an Excel database. Cases were performed by insufflating the abdomen with a Veress needle through the umbilicus followed by placement of 5-mm ports at the umbilicus. RESULTS: Patient ages ranged between 21 and 82 years with a median age of 45 years. Body mass index (BMI) range was 21 to 42 kg/m with a mean of 30 kg/m. Average length of time for cases was 1 hour 9 minutes with a range between 55 minutes and 120 minutes. The average length of time for the first 25 cases was 80 minutes. When compared with cases 26 to 50 the average length of time was 60 minutes (P<0.05). The conversion rate to conventional laparoscopic cholecystectomy was 10%. Conversion was accomplished through the addition of a 5-mm port elsewhere on the abdominal cavity. After the tenth case, the incidence of conversion went down to zero. When conversions were further stratified, they occurred within each individual surgeon's first ten cases. CONCLUSIONS: The learning curve for successful consistent completion of SILS cholecystectomy cases appears to be after 25 cases. In addition, conversion rates drop dramatically after the first ten cases.

Pneumoperitoneum after sexual assault in a patient who had hysterectomy 30 years ago: case report.

BACKGROUND: A non-surgical etiology accounts for approximately 10% of cases of pneumoperitoneum. However, in the patient with pneumoperitoneum, one must be suspicious of the less common non-surgical etiologies, including coitus, to avoid unnecessary laparotomy. OBJECTIVES: To report a case of pneumoperitoneum caused by coitus during sexual assault in a patient who had a hysterectomy 30 years ago. CASE REPORT: The authors present a case of non-surgical pneumoperitoneum after sexual assault occurring over 30 years after abdominal hysterectomy. CONCLUSION: This case is an important reminder that a thorough sexual and gynecologic/obstetrical history is an essential tool in identifying the patient who does not require laparotomy.

Is the length of follow-up evaluation in published reports on the treatment of infrainguinal occlusive disease decreasing?

BACKGROUND: There is increasing pressure for the rapid development and implementation of new techniques and procedures. This study examined whether or not there has been a trend toward increasingly short follow-up times for studies evaluating the treatment of lower-extremity occlusive disease. METHODS: A search was performed of PubMed using the term "femoropopliteal occlusive disease" from 1976 to 2006. Reports describing the open and/or endovascular treatment of femoropopliteal occlusive disease were classified according to the number of patients, method of treatment, and follow-up time. RESULTS: A total of 103 of the 435 reports met the inclusion criteria. Average follow-up times from 1976 to 1986 were a mean of 43.3 months and a median of 38.8 months, from 1986 to 1996 were a mean of 32.4 months and a median of 16.9 months, from 1996 to 2006 were a mean of 22.6 months and a median of 16.5 months. CONCLUSIONS: The number of reports on femoropopliteal occlusive disease treatment has increased. The length of follow-up period was 2- to 3-fold longer for reports on open procedures compared with those on endovascular procedures. Whether length of follow-up evaluation and reporting intervals should be standardized warrants further investigation.

Single-incision laparoscopic appendectomy: an early experience.

Acute appendicitis is one of the most common causes of abdominal pain that a general surgeon will encounter. We describe our modification to the laparoscopic appendectomy: a single-incision laparoscopic (SILS) appendectomy completed entirely intracorporeally. From September 2008 to September 2009, a retrospective review of the electronic medical record was performed in all patients who underwent a SILS appendectomy to specifically analyze the demographic characteristics, time in the operating room to perform SILS appendectomy, length of postoperative hospital stay, and postoperative complications. Twenty-five patients underwent SILS appendectomy in the study period. There were 18 males and seven females with a mean age of 41 ± 15 years and mean body mass index of 26.5 ± 5 kg/m². Single-incision laparoscopic appendectomy was performed successfully in all of our cases (100%). Mean operative time was 56 ± 16 minutes. Blood loss in all cases was minimal and there were no intraoperative complications. We successfully completed 25 appendectomies using the SILS method. Operative times were similar compared with the traditional laparoscopic technique. We believe that the SILS appendectomy is a safe and effective method that leaves a virtually invisible scar.

Single-incision laparoscopic-assisted right colon resection for cancer.

INTRODUCTION: We present an approach to laparoscopic right colon resection utilizing a single port placed through the umbilicus. The technique described is performed through a single small umbilical incision with a virtually scar-free result. METHODS: A 77-year-old woman with a tubulovillous adenoma in her cecum underwent a laparoscopic right colectomy using a single port placed through the umbilicus. Straight and reticulating laparoscopic instruments were utilized. RESULTS: The total operative time was 112 minutes. No intraoperative or postoperative complications occurred. The patient was discharged home on day 5 postoperatively with normal bowel function and tolerance of a solid diet. CONCLUSIONS: Laparoscopic right colectomy can be safely performed through a single incision through the umbilicus with an excellent cosmetic result.

Elevated childhood cancer incidence proximate to U.S. nuclear power plants.

Numerous reports document elevated cancer rates among children living near nuclear facilities in various nations. Little research has examined U.S. rates near the nation's 103 operating reactors. This study determined that cancer incidence for children < 10 yr of age who live within 30 mi (48 km) of each of 14 nuclear plants in the eastern United States (49 counties with a population > 16.8 million) exceeds the national average. The excess 12.4% risk suggests that 1 in 9 cancers among children who reside near nuclear reactors is linked to radioactive emissions. If cancer incidence in 5 western states is used as a baseline, the ratio is closer to 1 in 5. Incidence is particularly elevated for leukemia. Childhood cancer mortality exceeds the national average in 7 of the 14 study areas.