Intraoperative and early postoperative gastric intramucosal pH predicts morbidity and mortality after major abdominal surgery.

The present study was undertaken to investigate the correlation between the intraoperative and postoperative gastric intramucosal pH (pHi) with important perioperative variables and to explore any potential relationship of the measured pHi with the patients' postoperative course. A prospective study was carried out in a group of 48 patients who underwent major abdominal operations over an 8-month period at St. John Hospital and Medical Center. An automated air tonometer was used for gastric pHi monitoring. Twenty-eight elective and 20 emergency abdominal operations were performed in 23 men and 25 women. Twenty-six patients (54%) required postoperative hospitalization in the Intensive Care Unit (ICU). Seventeen patients (35%) developed early postoperative complications. The non-ICU and ICU mortality rates were 4.5 and 19.2 per cent respectively. The mean intraoperative pHi (pHiOR) and postoperative pHi (pHiPO) ranged between 7.03 and 7.58 (7.38+/-0.12) and 6.89 and 7.56 (7.35+/-0.12) respectively (mean +/- standard deviation). There was a significant decrease of the gastric pHi at the first hour intraoperatively compared with the pHi after induction to anesthesia (7.44 vs 7.38+/-0.14, P < 0.001). Patients who underwent emergent abdominal procedures were characterized by lower pHiOR and pHiPO values (7.43+/-0.08 vs 7.30+/-0.13 and 7.39+/-0.84 vs 7.30+/-0.15, P < 0.001 and P < 0.05). Similarly patients who required surgical ICU admission had significantly lower pHiOR and pHiPO measurements (7.3+/-0.12 and 7.28+/-0.12) compared with the rest (7.46+/-0.06 and 7.43+/-0.06; P < 0.001). Overall, lower pHiOR and pHiPO values were associated with the occurrence of postoperative complications (P < 0.001), the postoperative mortality (P < 0.001), the requirement for postoperative mechanical ventilator (P < 0.001) and its duration (P < 0.001), longer ICU stay (P < 0.001), and prolonged hospitalization (P < 0.05). Evidence of intraoperative and early postoperative gastric mucosal ischemia (pHiOR and pHiPO < or = 7.32) was observed in 12 (25%) and 15 (31%) patients respectively. The incidence of postoperative complications and the mortality rate were higher in this group of patients (P < 0.001). At a cutoff point of 7.32 gastric pHiOR gave a sensitivity of 69 per cent and specificity of 97 per cent for predicting postoperative complications as well as a sensitivity and specificity of 67 per cent and 81 per cent for predicting death. Intraoperative and early postoperative gastric pHi is a reliable predictor of patient outcome after major abdominal operations. Splanchnic ischemia may play an important role in determining early complications and survival; therapy guided by the gastric pHi might improve outcome.

The advanced breast biopsy instrumentation (ABBI) experience at a community hospital.

The Advanced Breast Biopsy Instrumentation (ABBI; U.S. Surgical Corp., Norwalk, CT) system is the newest technology available for the evaluation and diagnosis of nonpalpable breast lesions. It requires the breast imaging specialist, often a radiologist, to localize the suspicious lesion to x, y, and z coordinates in a digital mammogram unit. The coordinates are then used by the surgeon to operate and direct the ABBI biopsy device around the lesion to obtain an excisional biopsy. Mammographic confirmation of the specimen is then immediately obtained. First introduced in the United States in April 1996, the ABBI system is aimed at rivaling the previously relied upon methods of needle-localized and core needle breast biopsies. In this study, we analyzed the first 15 months of use of the ABBI system in a community hospital to evaluate its applicability and efficacy in the diagnosis of nonpalpable breast lesions. Eighteen surgeons and three radiologists performed a total of 230 cases on 223 patients (seven patients had bilateral breast biopsies). The lesions biopsied included 114 clustered microcalcifications, 115 masses, and 1 retained guidewire from a previous needle-localized breast biopsy. The average time for the complete procedure was 65 minutes. Breast cancer was identified in 36 patients (36 of 230, 15.7%) and 1 additional patient had an incidental finding of lobular carcinoma in situ. The malignancies included 20 cases of invasive ductal carcinoma, 12 cases of ductal carcinoma in situ, and four cases of invasive lobular carcinoma. Overall, 84 per cent of the patients had a definitive benign diagnosis and required no further surgical treatment of their mammographic finding. There have been no known missed lesions after use of the ABBI procedure. In conclusion, our experience has shown the ABBI system to be a valuable option in the management of selected patients with nonpalpable breast lesions.

Elective conventional colectomy in the era of laparoscopic surgery.

Laparoscopic surgery, since its introduction into the general surgery, has reduced hospital stay. Can lessons learned from laparoscopic surgery about aggressive postoperative care be applied to elective conventional colectomy? Between August 1994 and February 1995, a prospective study was conducted on 24 consecutive patients undergoing elective conventional colectomy with primary anastomosis. A comparison of 30 consecutive patients in the 7 months immediately before this study were used as a historical control group. Both groups were comparable in age, indications for operation, type of operation, and operative time. The protocol consisted of an outpatient bowel prep, hospital admission on day of surgery, and intravenous metoclopramide starting before the operation and continued every 6 hours with diet started at 24 hours. Patients were discharged on regular diet after a bowel movement and were continued on oral metoclopramide for a total of 7 days. Hospital stay was reduced from 8 days (range 4-19 days) to 4 days (range 2-7 days) on the protocol P < 0.001). Hospital charges were also reduced by 20 per cent (from $18,450 to $14,586) (P = 0.066). Complication rate and postoperative emergency room visits as a measure of quality of care did not differ between the two groups. By implementing this protocol, hospital costs and length of stay for elective conventional colectomy were reduced without compromising patient care.

Laparoscopic appendectomy for acute appendicitis: is there really any benefit?

Laparoscopic appendectomy is emerging as a popular treatment modality for acute appendicitis. Although claims have been made to potential superiority over traditional appendectomy, comparisons of operative difficulty, hospital stay, hospital costs, complication rates, postoperative pain, and convalescence have not been well studied. Two hundred consecutive patients presenting with signs and symptoms of acute appendicitis underwent appendectomy. Traditional appendectomy was employed in 101 patients, while 99 underwent laparoscopy. Successful laparoscopic appendectomy was possible in 89 patients who were compared with the 101 patients with traditional appendectomy. There were two pregnant patients with appendicitis in each group. The incidence of acute appendicitis was 72 per cent for traditional appendectomy and 74 per cent for laparoscopic appendectomy. Operating time was significantly longer with laparoscopic appendectomy (60.1 vs 45.4 minutes, P = 0.0001). This was reflected in higher (although not significant) hospital costs ($8,683 vs $6,213). Post-op hospital stay was shorter for laparoscopic appendectomy (2.7 vs 3.8 days, P = 0.001). Complication rates were no different between the two groups. Post-op pain, as evaluated by a patient grading scale, was less for laparoscopic appendectomies up to the third post-op week (P = 0.003). The amount of IM pain medication was greater with traditional appendectomy (P = 0.009). Convalescence was significantly shorter with laparoscopic appendectomy as measured by: 1) return to normal household activity (7.8 vs 13.2 days, P = 0.016), 2) returned ability to exercise (19.7 vs 29.0 days, P = 0.009), 3) patient feeling well enough to return to work (14.1 vs 19.2 days, P = 0.032), and 4) actual return to work (15.4 vs 20.5 days, P = 0.038).(ABSTRACT TRUNCATED AT 250 WORDS)

Open breast biopsy. A critical analysis.

A retrospective study of open breast biopsies performed from January 1, 1988 to December 31, 1988 was undertaken to compare the malignancy rate of the authors with that generally reported in the literature. This was done to determine if biopsy of mammographically demonstrated nonpalpable lesions had a favorable impact on outcome, and to identify factors with high relative risk or predictive value for malignancy. Office records of 518 patients who underwent breast biopsies were reviewed, 122 of which (23.6%) proved to be malignant. The malignancy rate for needle localized excisions of nonpalpable lesions was 17.5 per cent. Of these, 28 per cent were stage tumor in situ (TIS), 60 per cent stage 1, and 12 per cent stage 2. A higher percentage of palpable lesions were malignant than were nonpalpable lesions (29.0%). Of the palpable malignancies, 28 per cent were stage 1, 51 per cent stage 2, 13 per cent stage 3, and 8 per cent stage 4. Those who were older than 40 years of age yielded a significantly higher malignancy rate when compared with the less than 40 age group (28.6% versus 6.7%, P less than 0.001). Lesions that appeared on mammogram as nodules, calcium, or both had a higher malignancy rate than those where no lesion was identified (25.3% versus 14.2%, P less than 0.001). None of these factors alone or in combination ruled out malignancy. Biopsy of nonpalpable mammographically demonstrated lesions lead to detection of breast cancer at an earlier stage. Age greater than forty years, demonstrable lesion by mammogram, and palpable lesion were significant predictors of malignancy.(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopic cholecystectomy. The learning curve: report of 50 patients.

Laparoscopic cholecystectomy was first performed at Saint John Hospital in November 1989. This is a study of the first 50 patients operated on between November 1989 and March 1990. This new technique, which requires different eye-hand coordination and deals with new instruments, prompted an analysis of the first 25 patients (Group 1) vs the second 25 patients (Group 2) for complications, hospital stay, and operating time. All patients were candidates for elective cholecystectomy. There were 32 women and 18 men with an average age of 51 years (range of 20-72 years). There was an average weight of 174 lb (range of 107-265 lb). Group 1 had three minor complications: bile drainage (1), nausea (1), and pain (1). Group 2 only had one minor complication: nausea. Group 1 had four major complications: bile leak from the cystic duct (1), conversion to open cholecystectomy for bleeding (1), reoperation for control of liver oozing in an unsuspected cirrhotic (1), and common duct injury (1). Group 2 had no major complications. The hospital stay was 2.33 days (range of 1-13 days) and 1.04 days (range of 1-3 days) and the operating time was 134 minutes (range of 75-200 min) and 78 minutes (range of 50-150 min) for Group 1 and Group 2, respectively. Sixteen Group 1 patients (64%) and 24 Group 2 patients (96%) were outpatients. Significantly fewer complications, shorter hospital stay, and decreased operating time in Group 2 emphasize the importance of the learning experience.

Axillary dissection for breast carcinoma. The myth of skip metastasis.

The question of what constitutes an adequate axillary dissection for breast cancer remains open for debate. Central to this controversy is whether axillary nodal metastasis occurs in a stepwise fashion or spreads sporadically, creating skip metastases. The therapeutic aim of axillary dissection also must be considered. To resolve this controversy, a prospective study involving 129 patients who underwent complete axillary dissection for breast carcinoma was performed. The tissue from the axillary dissections was divided intraoperatively and sent to the pathologist as two specimens. The first specimen contained all nodes lateral to the pectoralis minor muscle (Level I), whereas the second contained all nodes beneath and medial to the pectoralis minor (Levels II and III). The tissue was analyzed to determine the frequency of skip metastasis. Only two patients, 1.6 per cent of the total group or 3.2 per cent of the positive node group, were found to have a positive node in Level II-III with no metastasis in Level I. A thorough dissection of Level I alone is sufficient to detect more than 98 per cent of all axillary lymph node metastases from breast cancer. Thus, proper staging of the disease can be obtained. When Level I contained positive nodes, the probability of metastatic disease to higher levels was significant (45%), indicating further treatment is necessary in incomplete axillary dissections.

A totally implanted venous access system for the delivery of chemotherapy.

The use of an Ommaya Capsule-Catheter System for the delivery of chemotherapy in cancer patients with inadequate peripheral veins has been studied over a 6-year period. Between 1978 and 1984, 76 Ommaya capsules were implanted in 68 patients, providing a collective experience of over 28,000 venous access days. Two patients were lost to follow-up. The results of the capsule-catheter system performance indicates a functional rate of over 90%. The complications included a 6.7% catheter occlusion rate, and a 2.7% capsule leakage rate. This accounts for an overall catheter related complication rate of 9.4%.