Prospective randomized trial of LC+LCBDE vs ERCP/S+LC for common bile duct stone disease.

OBJECTIVE: To compare outcome parameters for good-risk patients with classic signs, symptoms, and laboratory and abdominal imaging features of cholecystolithiasis and choledocholithiasis randomized to either laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC+LCBDE) or endoscopic retrograde cholangiopancreatography sphincterotomy plus laparoscopic cholecystectomy (ERCP/S+LC). DESIGN: Our study was a prospective trial conducted following written informed consent, with randomization by the serially numbered, opaque envelope technique. SETTING: Our institution is an academic teaching hospital and the central receiving and trauma center for the City and County of San Francisco, California. PATIENTS: We randomized 122 patients (American Society of Anesthesiologists grade 1 or 2) meeting entry criteria. Ten of these patients, excluded from outcome analysis, were protocol violators having signed out of the hospital against medical advice before 1 or both procedures were completed. INTERVENTIONS: Treatment was preoperative ERCP/S followed by LC, or LC+LCBDE. MAIN OUTCOME MEASURES: The primary outcome measure was efficacy of stone clearance from the common bile duct. Secondary end points were length of hospital stay, cost of index hospitalization, professional fees, hospital charges, morbidity and mortality, and patient acceptance and quality of life scores. RESULTS: The baseline characteristics of the 2 randomized groups were similar. Efficacy of stone clearance was likewise equivalent for both groups. The time from first procedure to discharge was significantly shorter for LC+LCBDE (mean [SD], 55 [45] hours vs 98 [83] hours; P < .001). Hospital service and total charges for index hospitalization were likewise lower for LC+LCBDE, but the differences were not statistically significant. The professional fee charges for LC+LCBDE were significantly lower than those for ERCP/S+LC (median [SD], $4820 [1637] vs $6139 [1583]; P < .001). Patient acceptance and quality of life scores were equivalent for both groups. CONCLUSIONS: Both ERCP/S+LC and LC+LCBDE were highly effective in detecting and removing common bile duct stones and were equivalent in overall cost and patient acceptance. However, the overall duration of hospitalization was shorter and physician fees lower for LC+LCBDE. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00807729.

Case managers in mass casualty incidents.

OBJECTIVE: To examine whether case managers affect patient evaluation/treatment/outcome and staffing requirements during Multiple Casualty Incidents (MCIs). SUMMARY BACKGROUND DATA: Multiple patient relocations during MCIs may contribute to chaos. One hospital changed its MCI patient relocation policy during a wave of MCIs; rather than transfer patients from one medical team to another in each location, patients were assigned case-managers +/- teams who accompanied them throughout the diagnostic/treatment cascade until definitive placement. METHODS: MCI data (n = 17, 2001-2006) were taken from the hospital database which is updated by registrars in real-time. ISSs were calculated retrospectively. Matched events before (n = 5)/after (n = 3) the change yielded data on staff utilization. Semi-structured interviews were conducted with 26 experienced staff members regarding the effect of the change on patient care. RESULTS: Twelve events occurred before (n = 379 casualties) and 5 occurred after (n = 152 casualties) the change. Event extent/severity, manpower demands and patient mortality remained similar before/after the change. Reductions were observed in: the number of x-rays/patient/1st 24-hour (P < 0.001), time to performance of first chest x-ray (P = 0.015), time from first chest x-ray to arrival at the next diagnostic/treatment location (P = 0.016), time from ED arrival to surgery (P = 0.022) and hospital lengths of stay for critically injured casualties (37.1 +/- 24.7 versus 12 +/- 4.4 days, P = 0.016 for ISS > or = 25). Most interviewees (62%, n = 16) noted improved patient care, communication and documentation. CONCLUSIONS: During an MCI, case managers increase surge capacity by improving efficacy (workup/treatment times and use of resources) and may improve patient care via increased personal accountability, continuity of care, and involvement in treatment decisions.

Endovascular repair of an actively hemorrhaging gunshot injury to the abdominal aorta.

Endovascular stents have had a limited role in the management of trauma and vascular emergencies involving active hemorrhage. We describe a patient with delayed rupture of the infrarenal aorta after intra-abdominal sepsis caused the breakdown of a primary aortic repair. A stent-graft repair was performed, as concomitant injuries did not allow anterior access to the aorta. This report describes the successful endovascular repair of an actively hemorrhaging penetrating abdominal aortic injury. Endovascular approaches to aortic injuries may be valuable in settings where a hostile abdomen precludes traditional open repair.

Bacterial agents used for bioterrorism.

BACKGROUND: Bacterial pathogens and their products are potential agents of biological terrorism and biological warfare. These agents can be deployed through simple aerosol delivery systems and thereby cause widespread disease and death. METHODS: This report is a review of bacterial species that have been employed for development of biological terrorism, relying on a system for classification of their threat developed by the Centers for Disease Control. RESULTS: Physicians must understand how to recognize early signs and symptoms caused by bacterial agents. Clinical findings often seen on presentation are emphasized along with a summary of therapeutic approaches. CONCLUSIONS: Initiation of immediate therapy and supportive care provides the best chance for survival from these potentially lethal and devastating infections. A high index of suspicion must be maintained, especially in the setting of a sudden influx of cases with what are often relatively nonspecific symptoms.

Congenital cleft spleen with CT scan appearance of high-grade splenic laceration after blunt abdominal trauma.

The spiral computed tomography (CT) scan has made the diagnosis of traumatic injury increasingly rapid and accurate, especially in cases of solid parenchymal organ injury that follows blunt abdominal trauma. Nonetheless, this valuable method of diagnosis can be confounded when anatomical variances are encountered in the setting of concomitant associated injuries. We present here a case where a congenitally bi-lobed spleen was diagnosed by CT scan as an apparent high-grade splenic laceration, prompting emergent laparotomy.

Laparoscopic adrenalectomy for pheochromocytoma.

aparoscopic adrenalectomy is the standard for most surgical adrenal diseases. The aim of this study was to evaluate the safety and effectiveness of laparoscopic adrenalectomy for patients with pheochromocytoma. The medical records of 39 consecutive patients who underwent laparoscopic adrenalectomy for pheochromocytomas from 1994 to 2000 at the University of California-San Francisco were reviewed. Three groups of patients were identified. The first group comprised 17 patients with classic symptoms and signs of pheochromocytoma. The second group comprised 17 patients who had minimal symptoms and incidentally discovered pheochromocytoma (i.e., "incidentaloma"), almost half of whom inappropriately underwent fine-needle biopsies before diagnosis. The third group consisted of 5 patients who had acute hypertensive crises and required intensive preoperative preparation. The mean age of the 22 men and 17 women was 46 years (range 20-84 years), and the mean adrenal tumor size was 4.8 cm (range 2-12 cm). A total of 43 laparoscopic adrenalectomies were performed for 35 patients with unilateral tumors and 4 patients with bilateral tumors. The retroperitoneal approach was used in four patients and the lateral transabdominal approach in the remaining patients without conversion to an open operation. There were no intraoperative complications or mortality. The mean duration of hospitalization was 1.7 days. In conclusion, patients with pheochromocytoma have a wide spectrum of presentations, from minimal symptoms to hypertensive crises. When evaluating an incidentaloma, pheochromocytoma should be excluded by metabolic testing, not by needle biopsy. Laparoscopic adrenalectomy is the preferred surgical approach for patients with pheochromocytoma because it is safe and efficacious.