Short-term surgical mission to the Dominican Republic: a cost-benefit analysis.

OBJECTIVE: This study determines the cost-effectiveness of a recurring short-term surgical mission trip to the Dominican Republic. BACKGROUND: The global burden of surgical disease is significant. Recent investigations have shown surgical treatment to be cost-effective at established hospitals within low- or middle-income countries (LMIC), drawing attention to surgical diseases world-wide. Another method of providing general surgical care in LMIC is short-term mission trips, but no studies have examined their cost-effectiveness. METHODS: Consecutive week-long trips by the Midwest Medical Missions Michigan Chapter to the Dominican Republic were studied in 2010 and 2012. All costs were recorded, and operative logs were maintained. Costs of identical procedures carried out at the authors' host institution were estimated. Direct comparisons were made between the cost of surgeries performed in the USA and the estimated amount of money spent on the mission trips attributable to each procedure. Disability-adjusted life years (DALYs) averted were calculated for both trips. RESULTS: The cost for all cases in 2010 would have been $255,187 if performed at the United States hospital and $398,177 in 2012. The amount actually spent on the trips was $61,924 in 2010 and $82,368 in 2012 - a relative cost-reduction of 79%. 473 DALYs were averted. An average of 6.9 DALYs were averted per patient, and the cost per DALY averted was $304.88. CONCLUSIONS: The procedures on a surgical mission trip to the Dominican Republic were less expensive than similar care provided in the United States. The cost per DALY averted is low, demonstrating the cost-effectiveness of the trips.

Surgery for diverticulitis: a re-evaluation of the changing trends.

The surgical management of diverticulitis continues to evolve but recent literature has not qualified just how different current practice is compared with the previous era. This study aims to update the seminal paper by Rodkey and Welch regarding indications and operation types performed for diverticulitis by comparing their findings with present practice at a community based institution. The charts of 407 patients admitted with "diverticular disease" between 2005 and 2010 were identified. For each admission, patients' demographics, presentations and management were recorded. Direct comparisons were made with results from the study by Rodkey and Welch. Of the 407 admissions studied, the distribution was 335 emergency and 72 elective. Medical management alone treated 90% of emergency admissions, while 4% required additional radiologic intervention. Emergency surgery was necessary in only 6% of cases with Hartmann's procedure being the most common procedure. Recurrent diverticulitis was a prime indication for elective surgery with 96% of cases undergoing a 1-staged procedure. Compared with the previous era, the nonoperative approach to managing acute diverticulitis is now applied for the vast majority of admissions. Improved success in medically temporizing patients in the present era has allowed for a higher percentage of successful single-staged elective surgeries.

Clinicopathological significance of the expression of estrogen receptor-beta and vascular endothelial growth factor-A in colorectal cancer.

Estrogen-receptor-beta (ERß), progesterone receptor (PR) and vascular endothelial growth factor (VEGF-A) have been implicated in colorectal cancer. However, the clinicopathological significance of any expression of these markers remains unclear. Immunohistochemical assays of ERα, ERß, PR, and VEGF-A were performed on 72 colorectal cancer cases. Normal mucosa from the same cases was assessed as a control. The correlation of presence of these markers with clinicopathological features and survival was determined. ERα and PR were not expressed in tumors. Forty-one of 53 (77.4%) cases of normal mucosa showed strong ERß expression compared with weak expression in 32 of 72 (44.4%) of malignant cells. A significant decrease in ERß expression from normal mucosa to tumor was found in females (P = 0.007) but not in males (P = 0.149). VEGF-A was expressed strongly in malignant cells in 64 of 72 (89%) cases. No association was found between ERß or VEGF-A expression and tumor grade, angiolymphatic involvement, stage, disease-free survival, or overall survival. Colorectal cancers do not express ERα or PR. ERß may have a protective role, especially in females. VEGF-A may have a role in tumorigenesis. Nevertheless, ERß and VEGF-A cannot be used as prognostic markers.

Management of enterocutaneous fistulae: A 10 years experience.

AIM: To compare the outcomes of conservative vs surgical treatment of enterocutaneous fistulae (ECF) in a community teaching hospital over a decade. METHODS: All cases of ECF between 1997 and 2007 were reviewed for management strategy. RESULTS: Of the 83 patients with ECF, 60 (72%) were postoperative. Sixty-six patients (79.5%) were treated initially with conservative measures. Eighteen patients failed to respond to conservative treatment and required later (secondary) exploration; this group consisted of an equal number of low vs high output fistulae. Seventeen (20.5%) patients underwent initial (primary) definitive-surgery secondary to anastomotic leak and peritonitis. Surgical procedures included resection of ECF with anastomosis (24), exclusion (6) and direct-drainage (4). No significant difference was seen in the recurrence rate for conservative (10%) vs operative-treatment (20%). CONCLUSION: Conservative treatment plays a pivotal role as an initial management in both low and high output fistulae. In selective cases only, early primary exploration is recommended.

Gastrointestinal carcinoids: an increasing incidence of rectal distribution.

Carcinoid tumors are slow-growing and usually become symptomatic late in the course of the disease. We evaluated our 10-year experience in the management of GI carcinoid tumors. The records of 133 patients with GI carcinoids were reviewed. The rectum was the most common site for carcinoid tumors with an incidence of 30 per cent followed by jejunoileal at 29.3 per cent. Other sites of carcinoid tumors were the appendix (8.3%), colon (8.3%), and duodenum (3.8%). Endoscopy was the most helpful modality in diagnosing GI carcinoids. CT was not helpful in preoperative diagnosis of carcinoid tumor. Fifteen patients died in follow-up with eight deaths related to carcinoid tumors, in the small bowel (6), rectum (1), and colon (1). Overall survival was 68.7 per cent and mortality rate was 19.5 per cent from carcinoid tumors. Most of the deaths occurred in patients with carcinoid syndrome, synchronous malignancy, and malignant carcinoid tumors. The mean disease-free survival was 51 months (range, 15 to 138 months). Screening colonoscopy, in addition to decreasing colorectal adenocarcinoma mortality, is useful in diagnosing carcinoid tumors at an earlier stage and in decreasing mortality from malignant colorectal carcinoid tumors.

Oral vitamin A enhances the effectiveness of formalin 8% in treating chronic hemorrhagic radiation proctopathy.

PURPOSE: Chronic radiation proctopathy occurs in 5 to 20% of patients receiving radiation therapy, with rectal bleeding as its most common presentation. Although formalin treatment for rectal bleeding is promising, improvement is possible. Given the success of vitamin A in other radiation-induced treatments, we studied the efficacy of combining formalin with vitamin A in controlling bleeding symptoms of chronic radiation proctopathy. METHODS: A retrospective review (1993-2007) was performed of patients presenting with features of chronic radiation proctopathy. Formalin 8% in a buffered solution was applied to the affected mucosa with use a tip applicator, and 10,000 units of vitamin A were given orally on a daily basis. Formalin treatments were repeated at three-week to four-week intervals until symptoms resolved. RESULTS: A comparison was made between patients who received formalin alone (n = 30) and those who received formalin in combination with vitamin A (n = 34). The 64 patients had a mean age of 79 years (range, 54-90 years). The combination group required fewer treatments (mean, 1.9) and a shorter time (11 weeks) for resolution of symptoms compared with the formalin-alone group (mean, 5.2 and 31 weeks, respectively) (P < 0.001). The overall success rate in controlling bleeding was only 64% in the formalin-alone group when compared with 94% in the combination group. CONCLUSIONS: When vitamin A was added to the regimen, a significant reduction was observed in the number of treatments and the time needed for resolution of symptoms, and there was an increased overall success rate. This combination represents a simple, effective, and well tolerated method of controlling hemorrhagic chronic radiation proctopathy.