Benefits of laparoscopy in middle-aged patients.

BACKGROUND: The introduction of laparoscopic techniques in biliary, adrenal and thoracic surgery has shortened the patient's hospital stay and lowered costs. However, in colorectal surgery, only a limited number of patients obtain these benefits, and these controversial results have been achieved in laparoscopic appendectomy (LA). The objective of this study was to compare the results of LA performed in young patients (<50 years) to those obtained with older counterparts. METHODS: All patients who underwent LA and open appendectomy (OA) between January 1996 and December 2000 were analyzed retrospectively. The data included age, gender, American Society of Anesthesiologists (ASA) score, emergent procedure, length of procedure, operating room and hospitalization costs as well as length of stay. For analysis purposes, the patients were divided into two chronological groups: age <50 and age >50 years. RESULTS: A total of 405 patients were available for analysis. Average age was 35 years and 42% were females. Thirty-nine patients underwent LA. The rate of LA was 14% in women and 6% in men (p<0.05). For young patients, there was no difference between LA and OA in ASA score, length of procedure, operating room costs, and total cost. Length of stay was 2.7 days in both the LA and the OA groups (P>0.05). However, patients >50 years in the LA group had a significantly shorter length of stay (2.5 days) than those in compared to the OA group (6 days) (p<0.05). Furthermore, total hospitalization cost was significantly lower for the LA group (13,448 dollars) than for the OA group (21,730 dollars) (p<0.05). No difference was found for length of operation, ASA score, or operating room costs. CONCLUSIONS: We found no benefits in terms of cost containment or reduced length of stay for LA patients aged 50 years old. We attribute this diminution of the benefits of LA in younger patients probably diminished due to their lower rate of comorbid conditions and better tolerance of surgical stress.

Nitric oxide synthase as a marker in colorectal carcinoma.

Elevated inducible nitric oxide synthase (iNOS) activity has been found in 60 per cent of colon adenomas and 20 to 50 per cent of adenocarcinomas. We postulated that high levels of iNOS may increase the invasive and metastatic potential of colon carcinoma and could be indicative of survival potential. Data were reviewed for 52 patients with colorectal carcinoma diagnosed in 1991 and 1992. Specimens were stained for iNOS and catalogued as low-activity staining (LAS) or high-activity staining (HAS) on the basis of visual evaluation by three pathologists. Thirty patients were LAS and 22 HAS. Age, sex, preoperative carcinoembryonic antigen, tumor and nodal status, and American Joint Committee on Cancer staging were not different between groups. Forty-six per cent of the HAS group remained alive after 5 years versus 71 per cent in the LAS group. Survival was significantly lower and metastatic status significantly higher in the HAS group. Results indicated that iNOS activity may be a prognostic indicator of long-term survival potential after treatment for colon cancer. In addition results suggested that metastasis was greater in colon carcinoma specimens that maintain an activated iNOS and that these cells clinically react more aggressively. Conclusions are tempered by the fact that results were based on a limited sample size.

Organ donation: a statewide survey of trauma surgeons.

PURPOSE: Organ procurement organizations (OPOs) operate under the premise that Americans would donate organs and/or tissue if placed in appropriate circumstances. This study evaluated opinions of Pennsylvania trauma surgeons regarding OPOs and organ donation. METHODS: Ninety-six Pennsylvania trauma surgeons were surveyed and descriptive results calculated. RESULTS: Ninety percent were familiar with criteria for organ donation, and about 76% would invoke their institution's brain death policy even if families did not desire to donate organs. A small portion did not routinely pronounce patients brain dead that met criteria. One fourth indicated trauma surgeons should have no role in requesting organs. A majority believed trauma surgeons should have a role in organ donation requests, either alone or with an OPO representative, and most indicated that they could influence a family's decision. CONCLUSION: Requestor attitude is important, and our results show an overall positive attitude toward donation and a solid level of knowledge regarding donor eligibility. Hospital development programs to improve donation consent should emphasize decoupling of brain death discussion and donation request, work to improve staff attitudes about approaching patients, and address donor eligibility criteria.

Colonoscopy in octogenarians and older patients.

INTRODUCTION: Colonoscopy in the elderly has been considered by many to be risky because of mechanical bowel preparation and dehydration, electrolyte disturbances, conscious sedation, and hypoxic complications. We hypothesized that colonoscopy in octogenarians and older patients is a safe procedure. MATERIALS AND METHODS: A retrospective review of 803 patients who underwent colonoscopy from January 1997 to October 1997 was performed. The patients were grouped by age: group A (17-49 years) had 166 patients (20%); group B (50-79 years) had 534 patients (67%); and group C (80 years and older) had 103 patients (13%). Results were considered significant at p value less than 0.05 unless otherwise noted. RESULTS: Blood in the stool (84%) and history of colonic vascular disease (5.8%) were the most common indication in group C (84%). Colonoscopy was used in group A (18%) more often than in the other groups to rule out inflammatory bowel disease. History of colon polyps was a more common indication in group B (20%) than in the other groups. Group A had a significantly higher incidence of normal examinations (84%) and diagnosis of inflammatory bowel disease (14%). Group B had a higher incidence of polyps than the other groups. Group C had the highest incidence of vascular disease (15%). Diverticular disease and carcinoma were more common in groups B (37%) and C (52%). The amount of sedation in the groups did not significantly differ. Completion of the colonoscopy to the cecum or anastomotic sites did not differ among the groups (p > 0.05), nor did complication rates among groups (p > 0.05). CONCLUSIONS: Colonoscopy is safe in octogenarians and older patients. Age does not, by itself, confer an increased risk to the procedure.

Axillary lymph node dissection in breast cancer: an evolving question?

Axillary lymph node dissection (ALND) is performed for staging purposes. Sentinel lymph node biopsy may decrease the cost and morbidity of ALND. Are there patients that the procedure is not indicated avoiding cost and morbidity? We retrospectively studied the incidence of lymph node metastasis in 423 patients with T1 breast cancer. Thirty-one T1a, 146 T1b, and 246 T1c tumors were seen. The mean age was 61 years. Ten per cent were premenopausal, and 84 per cent were postmenopausal. Tumor size averaged 1.29 cm. Eighty-one per cent of the tumors were node negative and 19 per cent were node positive. One T1a patient (3 per cent) had an axillary metastasis, 19 T1b patients (13%), and 61 T1c patients (25%) were node positive, respectively. Seventy-three per cent were ER positive. Thirty-three patients (8%) died from cancer. Eighty-seven per cent received surgery with axillary lymph node dissection (ALND), and three per cent had surgery without ALND. Younger age, increased tumor size, premenopausal status, and ER negativity affected node positivity rates (P < 0.05). Death from breast cancer was more common among node-positive patients (P < 0.05). No difference was found regarding the performance of ALND and survival (P > 0.05). We feel that ALND can be safely omitted in T1a to reduce the morbidity and the expense of breast cancer treatment. In T1b and T1c tumors, the use of ALND is necessary, but morbidity and cost can be reduced by the use of sentinel lymph node biopsy.

Managing intractable pain with an intrathecal catheter and injection port: technique and guidelines.

The objective of our study was to describe an effective technique for the management of chronic intractable pain in patients with intermediate life expectancy or as a long-term screening device prior to implantable pump therapy. In the study, an InDura intraspinal catheter is connected to a BardPort, which is accessed transdermally. We describe our surgical technique, recommended dosage calculations, cost comparison to an implantable infusion pump, and our experience with 13 cases. In our series of 13 patients, there was one seroma and one dural leak. There were no infections, and all were functioning well in the 12 cancer patients until their deaths. One case was converted to an implantable pump. There were no malfunctions or infections of the intrathecal infusion system in the 12 cancer patients. This intrathecal drug infusion system should be considered in the treatment armamentarium for chronic intractable pain and cancer pain.