Outpatient laparoscopic cholecystectomy: safe and cost effective?

Among the many advantages of laparoscopic cholecystectomy (LC), which has become the standard of care for symptomatic gallbladder disease, is the decrease in hospital stay. Although some studies of outpatient LC are starting to appear, few compare return visits to the hospital up to 30 days after surgery as well as cost of hospitalization between a group of outpatients and overnight admission patients. From January through December 1994, 415 LCs were attempted at Good Samaritan Hospital. Total hospitalization charges were obtained for a comparable subset of the outpatient and 24-h observation patients. There were 229 LCs performed without difficulty on an outpatient basis and 90 performed with a 24-h hold. Of the 229 outpatient LCs, only 1.3% had minor problems related to LC. Of the 90 LCs performed with 24-h hold, only 2.2% had problems related to the LC. The average charge for LC with overnight admission $4,890.37; the average charge for outpatient surgery was $3,669.54 (p < 0.0001). There was no increase in patient morbidity or mortality associated with outpatient LC. The cost savings for outpatient surgery compared with surgery with 24-h admission was 25%.

Delayed presentation of pericardial rupture with luxation of the heart following blunt trauma: a case report.

OBJECTIVE: To present an unusual case of delayed presentation of pericardial rupture with luxation of the heart 6 months after the initial injury. DESIGN: Diagnosis, outcome, associated injuries, and treatment are discussed. METHODS: A high index of suspicion is required to make the diagnosis; no single diagnostic test can be used as a screening tool. CONCLUSION: Once recognized, treatment of pericardial rupture is relatively simple.

Selective use of pelvic roentgenograms in blunt trauma patients.

This study was initiated to investigate the need for routine pelvic roentgenograms for all blunt trauma victims. Over a 2-year period, we prospectively studied patients referred to the trauma service in the level I trauma center at our institution who met the inclusion criteria. The patients were evaluated by physical examination and, if mentally alert and reliable, were included in the study. After inclusion into the study, a routine pelvic roentgenogram was performed to substantiate the results of our physical examination. All 125 patients included in the study were found to have normal results on pelvic roentgenograms. We conclude that alert, oriented and reliable patients involved in blunt trauma do not need a routine pelvic roentgenogram if the findings on physical examination are negative.

Non-operative management of blunt splenic trauma: a 10-year experience.

There is growing awareness that the majority of traumatic splenic injuries should be managed non-operatively. This review of all traumatic spleen injuries at a large community teaching hospital over a 10-year period (1978-1988) confirms that principle. The study generated selection criteria and principles of non-operative management. Of a total of 91 patients, 23 were initially treated non-operatively. The average age was 27 years and all but two were adults. Splenic injury was confirmed by computed tomography scan in 20 patients (87 per cent) and by liver/spleen scan in three patients (13 per cent). Of the 23 patients, 21 (91 per cent) were successfully treated non-operatively. Of these, 14 had intraparenchymal or subcapsular haematomas and seven had splenic lacerations with haemoperitoneum. Two patients (9 per cent) initially treated non-operatively required splenectomy. Haemodynamically stable adult patients with blunt splenic injuries can be managed non-operatively if monitored in a setting where immediate operative intervention is available. Operative intervention is indicated not only in haemodynamically unstable patients, but also in patients who require more than four units of blood during a 48-h period.

Intestinal dysfunction associated with acute thoracolumbar fractures.

The frequency of intestinal dysfunction, particularly intestinal ileus, among patients with acute thoracolumbar fractures and no neurologic compromise was assessed. We reviewed the medical records of 70 patients who met specific criteria. Only four (6%) of these patients developed intestinal dysfunction, manifested by vomiting, abdominal distention, diminished bowel sounds, or an intestinal ileus documented by an abdominal roentgenogram. Conservative initial nutritional management of the patients did not reduce the incidence of intestinal dysfunction. This study suggests that patients with acute thoracolumbar fractures and no neurologic compromise are not at substantial risk of intestinal dysfunction and that nasogastric suction and restriction of oral intake are unnecessary in the initial management of these patients.