Litigious consequences of open and laparoscopic biliary surgical mishaps.

Three hundred six injuries or complications coincident to 296 laparoscopic cholecystectomies were analyzed for the nature and extent of injuries and litigious outcomes that followed. The data were drawn from 31 member companies of the Physician Insurers Association of America, a trade association that initiated the study. The outcomes were compared to 261 contemporaneous open cholecystectomy claims. Biliary tract injuries were the most common, accounting for almost two thirds of all injuries. The spectrum of cases, originally selected for indemnity potential, reflected relative incidences in the medical literature. Laparoscopic injuries were significantly more severe, more likely to result in indemnity, and more apt to involve higher mean +/- standard deviation dollar values (160 dollars +/- 154 x 10(3)) to surviving claimants than injuries resulting from open procedures (106 dollars +/- 122 x 10(3), P = 0.01). Injury recognition at the time of the original procedure had no discernible mitigating effect because 80% of recognized injuries required an additional operative procedure. Risk-aversive behavior should include paying particular attention to placement of the first port, more liberal use of the Hasson technique, placement of all other ports under direct vision, elimination of intraoperative anatomic uncertainty, programmed inspection of the abdomen before withdrawing the laparoscope, and acquiring sufficient knowledge of electrosurgical principles to ensure the safe use of this potentially dangerous modality.

Postprandial serum glucose, insulin, and lipoprotein responses to high- and low-fiber diets.

The effects of high-fiber (HF) and low-fiber (LF) meals on postprandial serum glucose, insulin, lipid, lipoprotein, and apolipoprotein concentrations of 10 hypercholesterolemic men were examined using a random-order, cross over design. HF and LF meals provided 15% of energy as protein, 40% as carbohydrate, and 45% as fat, 200 mg cholesterol/1,000 kcal, and 25 g fiber/1,000 kcal for HF or 3 g fiber/1,000 kcal for LF. Responses over a 15-hour period after multiple meals (MM) and over a 10-hour period after a single meal (SM) were compared. HF meals were associated with a significant reduction in postprandial serum glucose (P < .0005 after SM) and insulin (P < .0005 after SM). Serum free fatty acid (FFA) levels decreased significantly after MM and SM, but differences between HF and LF meals were insignificant. Although serum triglyceride responses did not differ significantly (ANOVA) between HF and LF meals, values were higher at 2 and 3 hours after a HF SM than after a LF SM and at 16 hours after HF MM than after LF MM. Although serum cholesterol values did not differ significantly (ANOVA) between HF and LF meals, values were higher after a HF SM than after a LF SM. Other subtle differences in responses of high-density lipoprotein (HDL) cholesterol, HDL2, and HDL3 concentrations were noted. These studies indicate that large increases in dietary fiber intake are accompanied by small changes in postprandial serum lipoprotein concentrations.

Metabolic effects of high-carbohydrate, high-fiber diets for insulin-dependent diabetic individuals.

The metabolic effects of high-carbohydrate (70%), high-fiber (70 g) (HCHF) and low-carbohydrate (39%), low-fiber (10 g) (LCLF) diets were examined for 10 subjects with insulin-dependent diabetes mellitus (IDDM). After a 1-wk control period subjects on a metabolic ward were randomly allocated to HCHF or LCLF diets for 4 wk. After a 6-wk washout period subjects re-entered the metabolic ward for 4 wk on the alternate diet. Artificial-pancreas studies were performed on each diet for measurement of insulin requirements. Compared with the LCLF diet, the HCHF diet reduced basal insulin requirements (P less than 0.025), increased carbohydrate disposed of per unit insulin (P less than 0.0008), and lowered total (P less than 0.0004) and high-density-lipoprotein cholesterol (P less than 0.0013). Glycemic control and other lipid fractions did not differ significantly. These results suggest that in IDDM patients, HCHF diets enhance peripheral glucose disposal, decrease basal insulin requirements, and lower total cholesterol without altering glycemic control or triglycerides.

Hypocholesterolemic effects of different bulk-forming hydrophilic fibers as adjuncts to dietary therapy in mild to moderate hypercholesterolemia.

Hypercholesterolemia is a significant risk factor for coronary heart disease, and the hypocholesterolemic effects of psyllium are well established. This placebo-controlled, parallel study compared psyllium with methylcellulose, calcium polycarbophil, and placebo as dietary adjuncts in treating mild to moderate hypercholesterolemia. Of 163 men and women recruited with serum cholesterol levels above 5.17 mmol/L (200 mg/dL), 105 completed 8 weeks of an American Heart Association step I diet and then augmented the diet with one of the fiber supplements for 8 additional weeks. Incremental differences from placebo for low-density lipoprotein cholesterol were -8.8% for psyllium, -3.2% for methylcellulose (not significant), and +8.7% for calcium polycarbophil; and for total cholesterol the differences were -4.3% for psyllium (not significant), -1.4% for methylcellulose (not significant), and +5.9% for calcium polycarbophil. Compliance was 94% to 96%, and only mild gastrointestinal side effects were observed. In managing mild to moderate hypercholesterolemia, methylcellulose and calcium polycarbophil provide little or no additional benefit, while psyllium significantly enhances the American Heart Association diet effects.