Critical pathways: a means of managing the operating room.

Critical pathways help institutions in efficient and appropriate resource use to increase the quality of health care and minimize health care costs. However, many opportunities for pathway development and implementation are unexplored. This article delineates the development process for critical pathways and discusses the outcomes realized from use of the total joint pathway at the Medical College of Georgia, Augusta, GA.

CT prior to second-look operation in ovarian cancer.

Second-look surgery is used in restaging patients with ovarian cancer to define sites of recurrence, plan therapy, and perform tumor debulking. We evaluated the role of CT in detecting residual or recurrent tumor in 55 patients in whom 64 abdominopelvic CT scans were obtained. Forty-eight patients underwent a second-look operation, and eight of these patients had an additional third-look operation. CT correctly identified 17 (85%) of 20 cases with residual or recurrent pelvic disease and three (75%) of four cases with bulky abdominal disease. CT failed to detect tumor in any of the five cases with minimal abdominopelvic disease and was able to detect carcinomatosis in only two (8%) of 24 cases. In four cases, CT detected pelvic disease not identified on clinical pelvic examination. On the 56 scans in 48 patients with surgical proof (280 surgical findings), CT had a sensitivity of 40% (22/55) and a specificity of 99% (224/225). In seven additional patients, second-look laparotomy was canceled because of CT findings of extensive, unresectable tumor. We conclude that CT provided valuable information regarding residual or recurrent tumor prior to second- and third-look surgery. In selective cases, CT findings obviated unnecessary surgery. However, the CT's lack of sensitivity in identifying minimal abdominopelvic disease and carcinomatosis precludes its use as a substitute for second-look surgery.

Total parenteral nutrition in poor prognosis gestational trophoblastic disease.

From 1978 through 1984, 35 women received therapy for poor prognosis gestational trophoblastic disease (GTD) at Duke University Medical Center. Total parenteral nutrition (TPN) was utilized in nine patients (26%) for reasons including inadequate oral intake, nutritional depletion, and/or bone marrow suppression. Overall survival with follow-up ranging from 12 to 78 months was 88% for the TPN group and 70% for the non-TPN group (P = 0.38). Median duration of TPN therapy was 4 weeks (2-46 weeks). Intensity of therapy was comparable between the groups. Median weight gain of 0.15 kg/week for the TPN group was significantly greater than the 0.18/kg/week weight loss in the non-TPN group (P less than 0.001). Severe nutritional depletion represented by both low serum albumin (less than or equal to 2.5 gm/dl) and weight loss greater than or equal to 10% had a higher mortality rate than when only one of these factors existed (P = 0.006). Future studies need to further define the proper role of TPN in patients with poor prognosis GTD especially in those with severe nutritional deficits.

Intraperitoneal chromic phosphate P 32 as salvage therapy for persistent carcinoma of the ovary after surgical restaging.

From 1977 through 1984, 23 patients with persistent epithelial carcinomas of the ovary received intraperitoneal instillation with chromic phosphate P 32 suspension as salvage therapy after second- or third-look laparotomy. Patients received a median 10 cycles of chemotherapy before chromic phosphate P 32. Disease consisted of microscopic residual only in 10 patients (43%), macroscopic residual that was completely resected in eight (35%), and macroscopic residual disease in which the largest diameter was less than 0.5 cm in five patients (22%). Ten patients are free of disease at 13 to 94 months after chromic phosphate P 32 salvage therapy. Life table survival is 75% at 2 years and 57% at 4 years, with a disease-free survival rate of 54% at 2 years and 27% at 4 years. Patients with no gross residual disease had median disease-free survival of 27 months versus 9 months for patients with macroscopic residual disease (p greater than 0.1). Only three patients (13%) developed surgical bowel complications related to chromic phosphate P 32. Compared with previous studies, intraperitoneal chromic phosphate P 32 as salvage therapy for patients with minimal residual ovarian carcinoma defined at secondary surgical evaluation results in comparable survival and fewer complications than does salvage abdominopelvic irradiation and should be considered as an option to further chemotherapy in selected patients.

Long-term effects on bladder function following radical hysterectomy with and without postoperative radiation.

Sixty-one patients with Stage IB cervical carcinoma treated initially by Type III radical hysterectomy underwent water cystometry 6 or more months after surgery. Adjunctive pelvic radiation in 10 patients was associated with significantly more contracted (P less than 0.001) and unstable (P less than 0.01) bladders than surgery alone. The necessity for bladder drainage 30 or more days after surgery alone in 17 patients was associated with significantly worse (P less than 0.05) long-term post-void residual and total bladder capacity as well as volume for first urge to void compared to 34 patients treated only with surgery who required short-term drainage. Management of bladder drainage following radical hysterectomy is discussed.

Role of computed axial tomography of the chest in staging patients with nonmetastatic gestational trophoblastic disease.

Thirty-nine women with nonmetastatic gestational trophoblastic disease as determined by conventional staging studies were prospectively evaluated with computed axial tomography (CAT) of the lungs. Sixteen patients (41%) had pulmonary micrometastases detected by CAT, which were not detected by routine chest x-ray. Eight patients (20.5%) had indeterminate scans, and only 15 patients (38%) had negative scans. Eight of 16 patients (50%) with pulmonary micrometastases failed initial therapy with methotrexate-folinic acid rescue while one of eight (12.5%) patients in the indeterminate group and one of 15 (6.7%) patients in the true nonmetastatic group failed initial therapy (P less than .006). All patients who failed methotrexate-folinic acid rescue ultimately achieved prolonged remission with actinomycin D. Time to remission was significantly decreased in patients without evidence of pulmonary micrometastases (P = .03), but the total number of courses of chemotherapy was not significantly different (P = .06). No life-threatening toxicity occurred. Pulmonary micrometastases detected by CAT but not chest x-ray are predictive of an increased risk of methotrexate-folinic acid therapy failure. Computed axial tomography of the lungs identifies a group of patients at high risk for failure of methotrexate-folinic acid rescue, and, therefore, may be indicated for routine staging of patients with otherwise nonmetastatic gestational trophoblastic disease.

Computed tomography in evaluation of patients with ovarian carcinoma in complete clinical remission. Correlation with surgical-pathologic findings.

Computed tomography (CT) of the abdomen and pelvis was performed in 47 patients who were in complete clinical remission from ovarian carcinoma. Results of CT were correlated with surgical-pathologic findings at surgical reexploration. Overall, CT had a sensitivity of 0.32, specificity of 0.77, positive predictive value of 0.79, and negative predictive value of 0.30. Accuracy of CT did not vary by intraperitoneal or retroperitoneal site studied. Computed tomography detected only 7% of tumor nodules 1 cm or less in diameter and only 37% of nodules over 1 cm in diameter. The utility of CT in this clinical setting was limited to approximately 20% of patients with true-positive CT findings who might have been saved surgical reexploration. Due to a high false-negative rate, a normal CT cannot replace a second-look laparotomy for accurate assessment of disease status.

Pseudoobstruction of the colon complicating choriocarcinoma.

Colonic pseudoobstruction is an enigmatic condition which can mimic mechanical obstruction clinically and lead to spontaneous cecal perforation. A patient who was treated for choriocarcinoma developed colonic pseudoobstruction and appropriate evaluation permitted nonsurgical management. The etiologies, diagnosis, and management of colonic pseudoobstruction are discussed.

Computed tomography in evaluation of extrapelvic lymphadenopathy in carcinoma of the cervix.

The diagnostic value of computed tomography for detecting metastatic tumor in common iliac and/or paraaortic lymph nodes among 44 patients with cervical carcinoma was analyzed. Pathologic confirmation of nodal status was obtained in 33 patients with primary disease and 11 patients with recurrent disease, either by staging laparotomy (82%) or fine needle aspiration (18%). Nodal metastases were detected in 12 patients. Fine needle aspiration of nodes 1.5 cm or greater in size detected 67% of metastatic nodes. The sensitivity of computed tomography for detection of metastatic nodes was 75%, specificity 91%, negative predictive value 91%, and positive predictive value 75%. There appears to be a role for computed tomography and fine needle aspiration of enlarged nodes in patients with advanced or recurrent cervical carcinoma.

Malignant potential of gestational trophoblastic disease at the extreme ages of reproductive life.

The effect of maternal age on the incidence and significance of hydatidiform mole in 2202 patients studied at the Southeastern Regional Trophoblastic Disease Center during 1978 to 1982 is analyzed. Results are compared with a contemporary control group that comprised all types of pregnancy events. A significant increase (P less than .001) in the incidence of hydatidiform mole was seen in women 15 years of age or less and 40 years of age or more. A significant decrease (P less than .001) in the incidence of hydatidiform mole was seen in women in the 20 to 29-year age group. The greatest relative risk of hydatidiform mole occurred in women 50 years of age and older (relative risk = 519). The malignant sequelae rate from hydatidiform mole was 21.7% for the entire group. The relative risk of malignant gestational trophoblastic disease was lowest among patients 15 years of age and less (13.9%) and highest in patients 50 years of age and more (37.5%), but the differences were not significant (P greater than .05). The findings of the present study are compared with the previous literature and management recommendations are made.

Acute renal failure in pregnancy associated with solitary kidney, congenital ureteropelvic junction obstruction, and renal cortical cyst.

We have described a patient with acute renal insufficiency during pregnancy related to unilateral renal agenesis and congenital obstruction of the ureteropelvic junction. Optimism for a good outcome in both the mother and fetus seems justified if therapeutic measures in such cases can maintain renal homeostasis.

Vitamin-B12 deficiency following therapy in gynecologic oncology.

Vitamin-B12 deficiency results from inadequate absorption of the vitamin by the distal ileum and depletion of available stores. Both radiotherapy and intestinal resection can contribute to development of this condition. The significance of this problem in gynecologic oncology is discussed and two patients are described.

Surgical management of rectovaginal fistulas in Crohn's disease.

An analysis of 15 patients with rectovaginal fistulas complicating Crohn's disease, who were managed at Duke Medical Center between 1966 and 1979, is presented. The experience reported suggests that, in carefully selected patients, and with proper timing of operative intervention, the role of primary repair of these fistulas may be more important and yield greater success than is generally maintained in the literature. Selection of the patients, perioperative management, and surgical technique are discussed.