Incidental rectal carcinoid discovered after stapled hemorrhoidopexy: importance of histopathologic examination.

AIM: Haemorrhoids are the most common surgically-treated gastrointestinal disorder. Complications of this surgery are generally non-neoplastic. Because rectal tumours usually present demonstratively during endoscopic examination, it is perhaps tempting to omit histopathologic examination after haemorrhoidectomy, especially in younger patients. METHODS: The AA present a case of an early rectal carcinoid discovered after surgical treatment of haemorrhoids in a 27 years old man as an example of why it is essential to send all such specimens in the pathologist. RESULTS: The detection of early lesions permits the adequate follow-up necessary to preclude more extensive surgery and eventually to prevent recurrence of tumour. CONCLUSION: All tissue resected by haemorrhoidopexy must be sent to the pathology laboratory to protect the life and health of the patient .

Bariatric surgery costs and implications for hospital margins: comparing laparoscopic gastric bypass and laparoscopic gastric banding.

BACKGROUND: Effective cost reduction strategies require effective analyses of charges. METHODS: Costs and charges for laparoscopic gastric bypass and laparoscopic gastric banding were compared. Equipment costs, both disposable and reusable, were obtained. Data on the total charges, anesthesiology charges, and hospital charges were obtained; univariate and multivariate analyses were performed. RESULTS: Disposable equipment costs for laparoscopic gastric bypass totaled $3516.23, for laparoscopic gastric banding they were $4363; the difference stemmed from the $3195 laparoscopic band. Median total charges for the procedures differed by less than $100 (P=0.81). Hospital charges for gastric bypass were about $275 (P=0.087) more for bypass than for banding. CONCLUSIONS: Effective cost reduction strategies require cost analyses of each individual procedure; results for one procedure cannot necessarily be generalized to another procedure even if overall costs do not differ.

Practicing medicine in a new environment: what can we learn from the business managers?

Physicians, once only responsible for patient care, now are responsible for their organization's management. Although this paradigm shift occasioned much opposition, most aspects of this change are improving as the rules are reevaluated and reconsidered. Physician managers have difficult tasks for which medical school provides no preparation. Employees must be individually evaluated, so their unique talents can be properly exploited and appropriately compensated. Each person's weaknesses must be improved upon with delicacy, while his or her strengths are given greater and greater focus. This is especially true with regards to billing and coding because the financial health of all healthcare businesses requires organizational competence in this arena. It is vital to have an understanding of each staff member's skills, talents, and knowledge, and a proper deployment of each person into the appropriate job. The goal of any manager is a group of satisfied employees who enjoy their work and make appropriately recognized contributions.

A proposed canine model of laparoscopic nonanatomic liver resection.

INTRODUCTION: An animal model would be of great use to establish the safety and efficacy of laparoscopic hepatectomy. MATERIALS AND METHODS: A canine model of nonanatomic resection, using low pressure pneumoperitoneum, a variety of dissection and hemostatic techniques, and laparoscopic ultrasonographic vessel identification, was used. We used 20 female dogs: the first 10 were the training group, and the remaining 10 were the evaluation group. RESULTS: In the training group of 10 dogs, 3 of the first 4 developed pneumothorax; this was averted in subsequent cases by disconnecting the ventilator during establishment of pneumoperitoneum. During 2 weeks of postoperative evaluation, intraoperative bleeding required an extended procedure in 1 dog. No other dogs experienced massive intraoperative bleeding. Postoperatively, vital signs and blood hematocrit values showed no bleeding in any dog. Postoperatively, only 2 dogs, as measured by Jackson-Pratt drainage and serum total bilirubin levels, developed bile duct leakage; 1 died due to bacterial peritonitis. Serum aspartate aminotransferase levels corrected within 2 weeks. No emboli were observed in any of the dogs. CONCLUSION: A canine model of laparoscopic hepatectomy is feasible and has readily available monitors for major postoperative complications. Many patients with primary or secondary liver tumors would benefit from limited nonanatomic resection, which seems feasible as less-invasive techniques are improved.

Impact of a warm gas insufflation on operating-room ergonometrics during laparoscopic gastric bypass: a pilot study.

BACKGROUND: With the use of various laparoscopic instruments, the work of operating-room (OR) personnel has increased significantly. The impact of warm gas insufflation on the ergonometrics of the OR was studied, using one of the most involved laparoscopic surgical procedures, Roux-en-Y gastric bypass (RYGBP) for morbid obesity, to assess if use of warm gas insufflation decreases the work of the OR personnel. METHODS: 20 patients between August 2003 and January 2004 (6 months) were divided into 2 groups. 10 patients with age 50+/-10 years and BMI 48+/-8 underwent laparoscopic RYGBP using a warmed CO2 insufflator (WI). These results were compared to 10 patients with age 53+/-15 years and BMI 51+/-7 using a non-warmed CO2) insufflator (NWI). Total time of surgery (TOS), time spent cleaning the laparoscope (TCS), time spent changing warm saline (TWS), time spent using anti-fog (TAF), and time the circulating nurse was involved in these activities (TN) were compared. Statistical analysis used a two-sample, Student t-test with unequal variances. RESULTS: The 2 bariatric populations were almost similar in age and BMI. TCS (P<0.0003), TWS (P<0.0001) and TN (P<0.0002) took significantly less time in the WI group, while TOS and TAF were similar. CONCLUSION: Use of warmed CO2 insufflation had a significant impact on TCS, TWS and TN. This impacts the ergonometrics of the OR, allowing more time for the personnel and surgeons to concentrate on the surgery.

Bariatric and associated operations in private and academic practices.

BACKGROUND: The types of bariatric and the associated operations performed by academic and private surgeons were surveyed. METHODS: A survey containing 8 questions regarding type of practice, type of surgery, associated procedures during bariatric surgery, years in practice and bariatric training was e-mailed to all members of the American Society for Bariatric Surgery. RESULTS: 46% of the members responded and were divided between those who performed their procedures laparoscopically and those who performed open procedures. Laparoscopic adjustable gastric banding was almost exclusively performed in academic centers and encompassed 20% of their bariatric operations, while the gastric bypass was the most common operation performed (65%), followed by vertical banded gastroplasty and duodenal switch. Operations performed simultaneously indicated that cholecystectomies were performed equally in private practice (92.5%) and the academic sector (95%), with higher incidence in open procedures (95%) compared to laparoscopic (40%). Of the surgeons performing appendectomies, 20% were in private practice and 10% in academic. Liver biopsy was performed with the same incidence in private and academic practices (60%). A minority of responders had formal fellowship training (17%), and many had learned from a partner (40%). The approach was dictated by the surgical training (85%) and background. CONCLUSION: No significant difference was found between the private and academic surgeons in performing operations. Appendectomy is rarely performed academically, and cholecystectomy is mostly performed in the open procedure.

Therapeutic management algorithm in cirrhotic and noncirrhotic patients in primary or secondary liver masses.

The treatment of hepatic tumors in cirrhotic and noncirrhotic patients still represents a major issue in decision making for oncologists and surgeons. The high mortality of open liver surgery, particularly in cirrhotic patients, has pushed physicians to research new modalities. In this review paper we summarize the available and alternative methods for the treatment of liver masses using new modalities and a minimally invasive approach, which will benefit the quality of life of the patients. We also outline therapeutic plan options.