ABSTRACT
BACKGROUND: A child's home and family environment plays a vital role in neuro-cognitive and emotional development. Assessment of a child's home environment and social circumstances is an crucial part of holistic Paediatric assessment. AIMS: Our aim is to achieve full compliance with comprehensive documentation of biopsychosocial history, for all children medically admitted to the children's inpatient unit in University Hospital Limerick. METHODS: We performed a retrospective chart review to audit documentation within our department. This was followed by teaching interventions and a survey on knowledge, attitudes and behaviour of paediatric non-consultant hospital doctors (NCHDs) towards the social history. We performed two subsequent re-audits to assess response to our interventions, and provided educational sessions to seek improvement in quality of care. RESULTS: Results showed a significant improvement in quality of documentation following interventions, demonstrated by a net increase of 53% in levels of documentation of some social history on first re-audit. Though this was not maintained at an optimum level throughout the course of the year with compliance reduced from 95% to 82.5% on second re-audit, there was nonetheless a sustained improvement from our baseline. Our qualitative survey suggested further initiatives and educational tools that may be helpful in supporting the ongoing optimisation of the quality of documentation of social history in our paediatric department. CONCLUSION: We hope this quality improvement initiative will ultimately lead to sustained improvements in the quality of patient-centred care, and early identification and intervention for children at risk in our community.
Subject(s)
Documentation , Quality Improvement , Child , Hospitalization , Hospitals, Pediatric , Humans , Retrospective StudiesABSTRACT
BACKGROUND: There is still some controversy over whether to use laparoscopic operative cholangiograms routinely (RLOC) or selectively (SLOC). Due to their high cost as well as other issues, in March 1997 we converted from RLOC to SLOC. The purpose of this study was to validate that decision. METHODS: The results of 2043 laparoscopic cholecystectomies (LC) were compiled and analyzed. The results of RLOC in 1556 patients undergoing LC from March 1990 through February 1997 were compared to the results of SLOC in 16 patients undergoing LC from March 1989 through February 1990 and 471 patients undergoing LC from March 1997 through December 1998. The literature was reviewed and data were compiled. Reasons that are typically given for operative cholangiograms (OC) were collected and scrutinized. Finally, cost surveys for RLOC and related procedures were obtained. RESULTS: Overall, laparoscopic operative cholangiogram (LOC) was attempted in 1661 patients and was successful in 1656 cases (99.7%). Bile duct stones (BDS) were evident in 166 patients. Laparoscopic bile duct exploration (LBDE) was attempted in all cases. None were referred for preoperative endoscopic retrograde cholangiopancreatography (ERCP). In the RLOC group, evidence of BDS was observed in 136 patients (9%). Forty-two were unsuspected (2.8%) and five were false positive (0.3%). In a collection of other RLOC studies, the average rate of unsuspected BDS was 2.9%, while the average rate of false positive cholangiograms was 1.6%. In the SLOC group, LOC was indicated in 139 of 487 patients (28.6%). None of the patients who did not have a LOC developed symptomatic residual BDS in < or = 11 years of follow-up. In a large collection of other SLOC studies, the rate of symptomatic residual BDS was 0.3%. A cost survey in February 1997 revealed that the average minimum global charge (MGC) for an OC was $1283.21; for a transcystic duct LBDE it was $1055.10, and for a transcholedochal LBDE it was $3263.61 [corrected]. The MGC for an ERCP with papillotomy was $4303.00. Thus, to avoid one patient with symptomatic residual BDS, 354 unnecessary procedures (333 RLOC, 18 LBDE, and three postoperative ERCP) costing $473,927.52 would be performed. There were no false negatives, bile duct injuries, or other complications attributable to RLOC or SLOC. CONCLUSIONS: The increased morbidity and cost of RLOC to avoid symptomatic residual BDS is not justified. All other reasons given for RLOC are either flawed or indicate that the procedure can be safely employed selectively. SLOC is an effective method of verifying suspected BDS and is safer and less expensive than RLOC.
Subject(s)
Cholangiography , Cholecystectomy, Laparoscopic , Cholelithiasis/diagnostic imaging , Cholelithiasis/surgery , Female , Humans , Intraoperative Period , Male , Middle Aged , Retrospective StudiesABSTRACT
Laparoscopic transperitoneal fusion of the L5-S1 spinal interspace has become a common procedure. Retroperitoneal retraction and laparoscopic instrumentation without insufflation also allows visualization of the upper lumbar spaces, but this procedure is much more difficult to accomplish. We review and compare our results using each of these techniques for the treatment of mechanical instability and chronic back pain. A total of 35 selected patients underwent intervertebral fusion between February 1996 and August 1998. Their mean age was 48 years. There were 22 female and 13 male patients. Standard CO2 insufflation was used in 10 patients with L5-S1 fusions. Retractional gasless technique was used in nine patients with fusions at L5-S1, 16 patients at L4-L5, one patient at L3-L4, three patients at L2-3, and one patient at L1-L2. Thus, we performed a total of 40 lumbar fusions in 35 patients. In the 19 patients with the gasless technique, a balloon dissector and retractor facilitated the retroperitoneal exposure. Seven of these 19 patients were converted to open procedures, most commonly due to lacerations of the peritoneal lining that prohibited visualization. None of the L5-S1 patients with insufflation were converted to open. Mean operative time in the insufflated patients was 152 min vs. 181 min for the retractional technique. There were seven complications in the transperitoneal group: one fusion device migration, one postoperative UTI, one intracerebral hemorrhage, one severe postoperative pancreatitis, and three iliac vein lacerations. There were 16 complications in the retroperitoneal group: one deep vein thromboses, one serosal bowel injury, one small tear in the spleen, one cage migration, one postoperative pulmonary atelectasis, one postoperative hydrocele, four postoperative ileus, and six peritoneal tears. The mean postoperative stay was three days for both groups. There were no deaths. The L5-S1 interspace is best approached transperitoneally for anterior fusion. Although the retroperitoneal retractional technique is much more difficult and has a longer and steeper learning curve, it does allow laparoscopic anterior fusion of the upper lumbar spine.
Subject(s)
Intervertebral Disc Displacement/surgery , Laparoscopy/methods , Lumbar Vertebrae/surgery , Spinal Fusion/methods , Female , Humans , Male , Middle Aged , Postoperative Complications , Retroperitoneal Space/surgery , Retrospective Studies , Treatment OutcomeABSTRACT
BACKGROUND: Percutaneous balloon-tipped laparoscopic cannulas designed for preperitoneal hernia repair can be readily used to treat gastric bleeding laparoscopically. METHODS: Between 1995 and 1997, we successfully used balloon-tipped cannulas to visualize, biopsy, and suture acutely bleeding gastric lesions in five patients. These case histories are reviewed for this study. RESULTS: Patients received an average of six units of blood preoperatively (range, 0-15). Operative time averaged 207 min (range, 149-270). At surgery, gastrotomies were made for cannula placement under laparoscopic visualization. Operative findings included: lesser curve gastric ulcer, Mallory-Weiss tear, prepyloric ulcer, duodenal ulcer, and angiosarcoma. Three patients had successful percutaneous suture of bleeding gastric lesions. One patient was converted to open surgery. One patient had local resection of an angiosarcoma. CONCLUSION: The laparoscopic use of balloon-tipped cannulas allows the expeditious diagnosis and treatment of acute gastric hemorrhage.
Subject(s)
Catheterization , Gastrointestinal Hemorrhage/diagnosis , Gastrointestinal Hemorrhage/therapy , Laparoscopes , Laparoscopy , Adult , Aged , Female , Humans , Male , Middle AgedABSTRACT
Laparoscopic transperitoneal fusion of the L5-S1 spinal interspace has become a common procedure. Retroperitoneal retraction and laparoscopic instrumentation without insufflation also allows visualization of the upper lumbar spaces, but this procedure is much more difficult to accomplish. We review and compare our results using each of these techniques for the treatment of mechanical instability and chronic back pain. A total of 35 selected patients underwent intervertebral fusion between February 1996 and August 1998. Their mean age was 48 years. There were 22 female and 13 male patients. Standard CO2 insufflation was used in 10 patients with L5-S1 fusions. Retractional gasless technique was used in nine patients with fusions at L5-S1, 16 patients at L4-L5, one patient at L3-L4, three patients at L2-3, and one patient at L1-L2. Thus, we performed a total of 40 lumbar fusions in 35 patients. In the 19 patients with the gasless technique, a balloon dissector and retractor facilitated the retroperitoneal exposure. Seven of these 19 patients were converted to open procedures, most commonly due to lacerations of the peritoneal lining that prohibited visualization. None of the L5-S1 patients with insufflation were converted to open. Mean operative time in the insufflated patients was 152 min vs 181 min for the retractional technique. There were seven complications in the transperitoneal group: one fusion device migration, one postoperative UTI, one intracerebral hemorrhage, one severe postoperative pancreatitis, and three iliac vein lacerations. There were 16 complications in the retroperitoneal group: one deep vein thromboses, one serosal bowel injury, one small tear in the spleen, one cage migration, one postoperative pulmonary atelectasis, one postoperative hydrocele, four postoperative ileus, and six peritoneal tears. The mean postoperative stay was three days for both groups. There were no deaths. The L5-S1 interspace is best approached transperitoneally for anterior fusion. Although the retroperitoneal retractional technique is much more difficult and has a longer and steeper learning curve, it does allow laparoscopic anterior fusion of the upper lumbar spine.
ABSTRACT
Evidence of bile duct stones (BDSs) was identified on routine cholangiogram in 136 (8.7%) of 1572 patients undergoing laparoscopic cholecystectomy from March 1989 through March 1997. Forty-two (30.9%) were unsuspected. All patients with evidence of BDSs underwent laparoscopic bile duct exploration (LBDE). Initially, a standard choledochotomy with T-tube drainage as in the open approach was used. Later, transcystic duct exploration was added to the algorithm. The algorithm evolved into an ongoing treatment protocol study that was initiated in March 1992. Through March 1997, 100 patients underwent LBDE based on the protocol. The study is divided into two groups. Group A comprises the total 136 patients undergoing LBDE, including those in the protocol study. A subgroup, Group B, comprises only the 100 patients in the protocol study. In Group A, LBDE was successful in 114 patients (83.8%). Stones were missed in seven patients and left behind for spontaneous passage or later retrieval in six patients. Eleven patients (8.1%) were converted to open. There were 13 major complications (9.6%), including the seven missed stones and two deaths. In Group B, LBDE was successful in 94 per cent. Stones were missed in one patient and intentionally left behind in four patients. One patient was converted to open. There were seven major complications (7%), including one of the missed stones and one death. Using the protocol algorithm and the techniques described, BDSs can be effectively managed laparoscopically at the time of cholecystectomy in approximately 94 per cent of cases.
Subject(s)
Bile Duct Diseases/complications , Bile Duct Diseases/surgery , Bile Ducts/surgery , Cholecystectomy, Laparoscopic , Cholelithiasis/complications , Cholelithiasis/surgery , Laparoscopy , Adolescent , Adult , Aged , Aged, 80 and over , Algorithms , Cholangiography , Female , Humans , Intraoperative Period , Male , Middle Aged , Treatment OutcomeABSTRACT
This paper presents the technique and results of an operation that restores normal anatomical and physiological antireflux mechanisms for the treatment of gastroesophageal reflux disease (GERD). The Hill procedure was modified beginning in 1973, evolving into an operation that has been standard in our practice since 1987. Major changes included total fixation of the abdominal esophagus and elimination of phrenoesophageal bundle plication. We began performing the procedure laparoscopically in 1991 and simultaneously began a study to look at our results. This is the first report of the first 44 patients operated on from October 1991 through March 1994. There was one operative complication. Mean follow-up was 14 months. One patient was lost to follow-up and one patient died. There were no long-term side effects. A Visick grading scale was designed to categorize results. Forty graded satisfactory (95%) and two unsatisfactory.
Subject(s)
Gastroesophageal Reflux/surgery , Laparoscopy/methods , Adolescent , Adult , Aged , Aged, 80 and over , Female , Hernia, Hiatal/surgery , Humans , Life Style , Male , Middle AgedABSTRACT
A technique of anterior highly selective vagotomy is described that uses an endoscopic stapling device to facilitate and speed the procedure. Further study is necessary to ascertain the long-term recurrence rate for this new procedure, but it shows great promise as a simplified procedure for laparoscopic application in peptic ulcer disease.
Subject(s)
Gastrectomy/methods , Laparoscopy/methods , Peptic Ulcer/surgery , Surgical Stapling/methods , Vagotomy, Proximal Gastric/methods , Vagotomy, Truncal/methods , Female , Humans , Middle AgedABSTRACT
Laparoscopic cholecystectomy is a new method of removing diseased gallbladders. It has the advantage of being an outpatient procedure with rapid full recovery. Morbidity and complications are decreased, and patient satisfaction has been excellent. This is a report of our first 42 patients selected to undergo this procedure.