Changing patterns of care for occult breast lesions in a community teaching hospital.

We performed a retrospective analysis of 384 consecutive stereotactic breast biopsies (SBBs) from March 1995 through January 1999 and compared it with our historical breast biopsy experience. Two hundred forty-four patients underwent biopsies for microcalcifications and 135 patients for abnormal mammographic densities. Pathology diagnoses included 302 patients with benign disease, 35 patients with atypical ductal hyperplasia, 4 patients with lobular carcinoma in situ, 29 patients with ductal carcinoma in situ, and 9 patients with invasive breast cancer. These diagnostic rates were compared with our prior needle-localized pathology findings. For the study period, the number of mammograms, open biopsies, and needle-localized biopsies remained stable. The number of SBBs, however, increased progressively in every year. Medicare reimbursement for SBB was $921.19, and for breast biopsy after needle localization, $1566.22. Our study strongly suggests that the availability of SBB has significantly lowered the threshold for recommending biopsy of abnormal mammograms. The increased utilization of SBB almost certainly indicates an increase in the overall cost of breast care. This cost must be balanced against substantial potential benefits of this minimally invasive technique: possible earlier diagnosis of atypical and precancerous lesions, patient reassurance in cases of uncertain mammographic interpretation, and a reduced need for follow-up of indeterminate mammograms.

Laparoscopic transcystic management of choledocholithiasis.

Our objective was to review our community hospital experience with laparoscopic management of choledocholithiasis from 1991 to 1997. We performed a retrospective review of all case records of patients with choledocholithiasis managed surgically at St. Francis Hospital during the study period. Data regarding the history, presentation, investigations, operative details, and follow-up were recorded. Procedures were performed by multiple attending surgeons supervising surgical residents. All common bile duct explorations (CBDEs) were performed by a transcystic approach and followed routine cholangiography. In most cases, cystic duct dilatation over a guide wire was followed by transcystic CBDE with choledochoscopy. Stone extraction was accomplished through a combination of flushing, basket manipulation, fragmentation, retrieval, or advancement of stones through the ampulla. Data were analyzed using SPSS computer software, and P < 0.05 was considered statistically significant. During the period of study there were 1053 laparoscopic cholecystectomies with and without cholangiography and 100 total CBDE performed. Of these, 54/100 had an attempt at laparoscopic CBDE. There were 39 females and 15 males, with a median age of 52 years (range 14-88). Presentation included acute cholecystitis or biliary colic (63%), gallstone pancreatitis (20%), and jaundice or cholangitis (17%). Successful laparoscopic stone removal was achieved in 36 of 54 (67%) cases. Eighteen of the remainder (33%) were converted to an open procedure. Size, number, position of stones, technical difficulties in accessing the common bile duct, and patient factors contributed to open conversion. The rate of successful laparoscopic CBDE improved for each individual surgeon from an average of 22 per cent in the first half of the study period (1991-1994) to 87 per cent in the second half (1995-1997). There was no operative mortality. Significant morbidity in the laparoscopic group included one retained stone and two cases of postoperative pancreatitis. There were three false negative preoperative endoscopic retrograde cholangiopancreatography examinations. Multivariate analysis showed that experience of the individual surgeon was the only significant factor predicting successful laparoscopic CBDE. Low initial success rate in the early phase of the study period improved dramatically to reach an overall success rate of 87 per cent in the second half. Laparoscopic management of common bile duct stones is possible in a community setting with a high success rate and minimal morbidity. It precludes excessive use of endoscopic retrograde cholangiopancreatography with its own set of complications but is associated with a significant learning curve. It is currently our preferred therapeutic approach for choledocholithiasis discovered pre- or intraoperatively.

Colonoscopy: the initial test for acute lower gastrointestinal bleeding.

Despite literature showing safety, accuracy, and therapeutic capability of emergency colonoscopy for acute lower gastrointestinal (LGI) bleeding, surgical literature suggests that this examination is difficult to perform in the acute setting. In contrast to currently accepted protocols, we believe that unprepared colonoscopy within 24 hours of presentation can be performed safely with a high rate of success in localizing and often treating the specific cause of LGI bleeding. We report results over a 7-year period in our institution using early colonoscopy as the primary investigative method for the diagnosis and treatment of LGI bleeding. We analyzed 85 consecutive patients suspected of LGI bleeding referred to the surgical service between 1989 and 1996. LGI bleeding was defined as the passage of blood per rectum, distal to the ligament if Trietz. We excluded patients who were only hemoccult positive or had an upper gastrointestinal source by nasogastric aspirate or upper gastrointestinal endoscopy. All patients underwent urgent unprepped colonoscopy by surgical endoscopists relying on the cathartic effect of blood and liberal suction/irrigation to cleanse the colon. Therapeutic maneuvers included Nd:YAG laser or BICAP coagulation. Studies in which active bleeding was found or lesions with endoscopic evidence of recent hemorrhage were considered positive. A total of 126 colonoscopies were performed in 85 patients, 44 males and 41 females, with a median age of 75 years (range, 12-91 years). Fifty-three patients (62%) had hematocrit drops of greater than 5 per cent. Thirty-four patients were transfused an average of 4.5 units of blood per patient. The source of bleeding was correctly identified in 82 of 85 (97%) patients. Ninety-one per cent of sources were colonic, and 9 per cent were small bowel. Fecal residue prevented initial adequate examination in only two patients. Diverticulosis (20%), ischemic colitis (18%), hemorrhoids (14%), and arteriovenous malformations (11%) were the predominant sources of bleeding. Spontaneous cessation of bleeding occurred in 58 (68%) patients. Control of active hemorrhage was achieved endoscopically in 17 of 27 acutely bleeding patients. Significant therapeutic interventions were performed in 26 additional patients, including fulgration, polypectomy, relief of obstruction, and removal of foreign body. One patient with asymptomatic free air was observed nonoperatively, for a complication rate of 0.8 per cent. In-hospital mortality was 3.5 per cent (three patients), all secondary to multisystem organ failure and underlying disease. In-hospital rebleeding rate was 3.5 per cent (three). We conclude that, using colonoscopy, it is possible to identify the source of acute LGI bleeding in more than 95 per cent of cases. Diagnostic and therapeutic capability with colonoscopic intervention to control active hemorrhage is especially appealing. Additionally, the pattern, amount, and location of blood in the unprepared colon all give clues as to source and rate of bleeding. In experienced hands, morbidity and mortality of emergent colonoscopy is very low. High accuracy, safety, and therapeutic capability makes colonoscopy the initial diagnostic test of choice for acute LGI hemorrhage.

Endoscopic Nd:YAG laser therapy for villous adenomas of the colon and rectum.

We reviewed 34 villous tumors of the colon and rectum treated endoscopically with neodymium:YAG laser therapy from 1983 to the present. Twenty-three tumors were benign, and 11 contained carcinoma in situ. Invasive carcinomas were excluded. Treatment locations included cecum (6), descending colon (1), sigmoid colon (2), and rectum (25). Fourteen males and 20 females with a mean age of 70 years (31-93) completed an average of 3.3 total treatments per patient under no sedation (9), intravenous demerol (24), or general anesthesia (1). Treated tumors ranged between 2-12 cm in greatest dimension, and one fourth were 50 to 100 per cent circumferential. Four patients presented with recurrent tumors subsequent to transanal excisions, done elsewhere. Five patients suffered complications of mild stricture (2), self-limited bleeding (2), and one pinhole colovaginal fistula. There was one incomplete treatment and one recurrence in the cecum that was carcinoma in situ at resection. There were no missed cancers during follow up that ranged from 1-120 months (average 32 months). The average total cost for the entire treatment per patient was $3627. Endoscopic neodymium:YAG laser therapy of villous tumors of the colon and rectum is a safe and effective outpatient procedure. The complication rate is lower than most reported series of operatively treated patients, and sphincter dysfunction, incontinence, or fecal fistula is avoided. With close follow up and repeated biopsy, invasive carcinoma can be ruled out. We believe this is the procedure of choice for management of these tumors.

Laparoscopic cholecystectomy in the obese patient.

The authors' experience with laparoscopic cholecystectomy (LC) in obese (O, n = 96) and morbidly obese (MO, n = 27) patient groups was compared with that in the normal weight (NW, n = 174) group of patients as well as the whole group (WG). There were no operative deaths. There were no significant differences between groups for any of the following: successful intraoperative cholangiography (WG, 52.2%; NW, 52.9%; O, 51.1%; MO, 55.6%), conversion to open cholecystectomy (WG, 9.6%; NW, 9.2%; O, 10.4%; MO, 11.1%), incidence of major complications (WG, 4.1%; NW, 3.4%, O, 5.2%; MO, 0%), incidence of minor complications (WG, 7.4%, NW, 7.5%; O, 6.3%; MO, 3.7%), and length of hospitalization after successful LC (WG, 1.25 days; NW, 1.31 days; O, 1.16 days; MO, 1.13 days). Duration of operation did not differ except LC in the MO group (136.4 +/- 6.9 minutes) was longer when compared with NW patients (123.0 +/- 2.9 minutes, p less than 0.05). The authors conclude LC is a safe and effective treatment for obese patients with symptomatic cholelithiasis.

Laparoscopic cholecystectomy. Treatment of choice for symptomatic cholelithiasis.

Our initial experience with laparoscopic cholecystectomy (LC) for symptomatic cholelithiasis has involved 152 patients. Patient age ranged from 17 to 83 years; most were female (78%). Their average weight was 170 pounds (range, 75 to 365 lbs.). Twenty-two per cent had a single gallstone, while 9% had two to three stones and 64% had more than three stones. Exclusion criteria initially included upper abdominal scarring, severe acute cholecystitis, choledocholithiasis, and inability to tolerate general anesthesia. The first two of these are now only relative contraindications with increased experience. Thirteen of the one hundred fifty-two procedures (8.5%) required conversion to an open operation. Average time of operation was 138 minutes. Intraoperative cholangiography was attempted in 78% of cases and was completed successfully in 66% of those attempted. There have been no deaths. The complication rate has been low: 4% major, 0% life-threatening, and 7.2% minor complications. Postoperative analgesic requirements are remarkably low: 36% of patients required no narcotics after leaving the recovery room. Eighty-seven per cent of patients successfully undergoing LC were discharged by the first postoperative day. Most patients resumed normal activities within 1 week after discharge. Laparoscopic cholecystectomy offers the majority of patients with symptomatic cholelithiasis an improved treatment option, resulting in significantly less postoperative pain, hospitalization, and recuperation time.

Major abdominal operations in acquired immunodeficiency syndrome.

Twenty-one major abdominal operations performed on 20 patients with Acquired Immunodeficiency Syndrome (AIDS) were reviewed. Fourteen operations were for therapeutic indications, eight were emergent. The array of pathology encountered included opportunistic infection with Mycobacterium avium intracellulare, Cytomegalovirus, Cryptosporidium, abdominal tuberculosis, lymphoma, Kaposi's sarcoma, AIDS-related immune thrombocytopenia, perforated appendicitis and colonic pseudo-obstruction. Hospital mortality was 20 per cent. Major morbidity occurred in 15 per cent of patients and was more common following emergency operations. Preoperative demographic, hematologic, or nutritional parameters examined or the presence of single-organ system dysfunction did not predict outcome. Fifty-three per cent of hospital survivors are alive with a nine-month median postoperative follow-up. It is concluded that major abdominal procedures in patients with AIDS should not be withheld due to fear of excessive morbidity or mortality. General surgeons are involved in the evaluation and treatment of increasing numbers of patients with HIV infection. Appropriate management requires recognition of a wide range of surgical pathology and attention to details of safe intraoperative conduct.

An immunohistochemical analysis of ras oncogene expression in epithelial neoplasms of the colon.

Colonic epithelial tumors (101) including villoglandular adenomas, carcinomas in situ, adenocarcinomas, and neuroendocrine (NE) carcinomas were studied immunohistochemically with monoclonal antibodies (MoAb) RAP-5 and RAS-10 recognizing altered and unaltered ras oncogene products. In addition, 20 samples from multiple polyposis including adenomas with and without dysplasia, carcinomas in situ, and invasive carcinomas were studied. Using immunostaining techniques, normal mucosa was weakly stained, whereas the mucosa in the vicinity of tumors or inflammation showed enhanced staining. More tumors stained intensely with MoAb RAP-5 than with MoAb RAS-10. With MoAb RAP-5, most benign and malignant tumors showed enhanced staining. No significant differences in staining were noted in relation to superficial versus deeply invasive carcinomas or clinical staging. Immunostaining was also noted in some metastases. No significant differences in enhanced staining were found in carcinomas. Interestingly, the most extensive and enhanced immunostaining was noted in the villoglandular adenomas, dysplastic adenomas, and carcinomas in situ. The authors conclude that (1) ras protein expression is detectable in most benign, borderline, and malignant epithelial tumors of the colon as determined with MoAb RAP-5 and RAS-10, whereas enhanced expression is more often detected with RAP-5; (2) enhanced ras product expression in colon carcinomas does not seem to correlate with advanced tumor stages or with exocrine, NE, or phenotypically mixed tumors; and (3) the finding of the most intensely enhanced ras products expression in villoglandular polyps and carcinomas in situ suggests a possibly significant role for the oncogene in the early phases of transformation.