Second surgical opinion programs: dead or alive?

BACKGROUND: In the 1970s, second surgical opinion programs were established in an effort to improve medical care and to control health care costs. The cost-effectiveness of these programs has been questioned recently. STUDY DESIGN: A retrospective review was conducted of elective second-opinion surgical consultations for members of Local 32B-J of the International Service Employees Union for the years 1993-1994. Nonconfirmed consultations were reviewed against claims history data for the subsequent 2 years. Data were analyzed for rates of nonconfirmation by diagnosis and surgical specialty and for cost-effectiveness benefit. RESULTS: Of the 5,601 second surgical consultations performed, 490 procedures were not confirmed as medically necessary (9%). Claims history survey for these 490 patients for the 2 years following the consultation revealed that no operation was performed in 62%. The highest nonconfirmation rate (41%) was in plastic and reconstructive surgery, followed by gynecology (22%). The cost-benefit ratio for the program was calculated to be 1.34. CONCLUSIONS: A second surgical opinion program confers both cognitive and psychologic beneficial effects on Joint Trust Fund members and their dependents who are advised to undergo elective operations. Our current second surgical opinion nonconfirmation rate is 9%, with hysterectomy, prostatectomy, and bunionectomy among the procedures most frequently nonconfirmed. The cost-benefit ratio was estimated at 1.34.

Spermatic granuloma. An uncommon complication of the tension-free hernia repair.

A patient with a sperm granuloma following a tension-free hernia repair utilizing Marlex mesh 4 years prior to presentation is described. The mechanism of granuloma formation is believed to be secondary to vas deferens injury due to erosion by the cut edges of the mesh at the medial end of the slit used to recreate the internal inguinal ring. Spermatic granuloma has been rarely described in hernia surgery and requires a previous vas deferens injury. While the more common and clinically significant events of hernia recurrence and wound infection should be considered first, the occurrence of spermatic granuloma as a cause of postoperative pain or a mass should be included in the differential diagnosis.

Asymptomatic metachronous metastatic renal cell adenocarcinoma to the gallbladder. Report of a case and guidelines for evaluation of intraluminal polypoid gallbladder masses.

A case of asymptomatic metachronous metastatic unilateral renal cell adenocarcinoma to the gallbladder detected five years after resection of the primary renal neoplasm is reported here. The lesion was diagnosed by contrast enhancement of a gallbladder mass on abdominal computerized tomography scan and by color Doppler sonographic study of the gallbladder, both of which demonstrated the vascular supply to the intraluminal gallbladder mass. The biological behavior of renal cell adenocarcinoma is reviewed. Guidelines for the evaluation of intraluminal gallbladder masses are suggested.

Pneumothorax associated with laparoscopic cholecystectomy.

Pneumothorax is an uncommon but potentially serious complication that can occur during laparoscopic procedures. A patient under-going laparoscopic cholecystectomy developed an 80% pneumothorax during the course of the procedure and required chest tube insertion. She then underwent an uneventful recovery. The etiology of this complication as well as methods for avoiding this problem have been reviewed. Because of the potential serious nature of this complication, it is imperative that the surgeon be aware of the possibility and implement appropriate immediate therapy.

Metabolism of beta-muricholic acid in the hamster and prairie dog.

The metabolism of beta-muricholic acid was investigated in the prairie dog and the hamster. Intravenous infusion into bile fistula hamsters showed that beta-muricholic acid was extracted by the liver and secreted into the bile (> 85% in 1 h). Hepatic extraction of this compound and cholic acid in the prairie dog was not as rapid as in the hamster. In the bile of the prairie dog, most (93%) of the administered beta-muricholic acid was present as the taurine conjugate. In the hamster, 28% of infused beta-muricholic acid was secreted in unconjugated form, 43% as the taurine conjugate, and 22% as the glycine conjugate. In both species, the administered compound underwent little biotransformation. After intraduodenal injection of [6 alpha-3H]-labeled beta-muricholic acid into bile fistula hamsters, the bile acid was rapidly secreted into the bile; more than 80% of the administered radioactivity was recovered in 3 h. In the prairie dog, biliary recovery after intraduodenal administration of either beta-muricholic acid (43% in 3 h) or cholic acid (22% in 3 h) was slower than in the hamster. After intragastric administration, more than 80% of beta-muricholic acid was recovered unchanged in feces of both animal species.

Open cholecystectomy.

The experience with "open" biliary tract surgery is documented in this report in an effort to provide a basis for comparison with the more recent experience with laparoscopic cholecystectomy. During the years 1932 through 1984, 14,232 patients were surgically treated for nonmalignant biliary tract disease at The New York Hospital-Cornell Medical Center. Among these patients, the mortality rate was 1.7% (237 postoperative deaths). Cholecystectomy was performed in 10,749 patients, and the mortality rate was 0.6% (60 postoperative deaths). Of this group of patients, chronic cholecystitis was present in 8,910 patients, and the mortality rate was 0.4% (38 postoperative deaths). Acute cholecystitis was present in 1,839 patients, and the mortality rate was 1.2% (22 postoperative deaths). Choledochotomy as a component of the primary biliary tract operation was performed in 2,226 patients (15.6%), and there were 89 postoperative deaths (4%). In the last 6 years of this study (1978 through 1984), 1,693 patients underwent cholecystectomy alone, and the mortality rate was 0.2% (3 postoperative deaths).

Sulfonate analogues of chenodeoxycholic acid: metabolism of sodium 3 alpha, 7 alpha-dihydroxy-25-homo-5 beta-cholane-25-sulfonate and sodium 3 alpha, 7 alpha-dihydroxy-24-nor-5 beta-cholane-23-sulfonate in the hamster.

This report describes the chemical synthesis of a new bile acid analogue, namely, sodium 3 alpha, 7 alpha-dihydroxy-25-homo-5 beta-cholane-25-sulfonate from homochenodeoxycholic acid. The structure of the new compound was assigned by proton magnetic resonance and infrared spectrometry. Its metabolism was studied in the hamster in comparison with sodium 3 alpha, 7 alpha-dihydroxy-24-nor-5 beta-cholane-23-sulfonate and sodium taurochenodeoxycholate. After intraduodenal administration of the 3H-labeled analogues into bile fistula hamsters, both sulfonates were absorbed from the intestine and nearly 80% of the radioactivity was secreted into bile within 8 h. Intra-ileal administration revealed that these compounds resembled taurochenodeoxycholate in that they were much more rapidly absorbed from the ileum than from the proximal small intestine: more than 85% of the radioactivity was recovered in bile within 1 h. After intravenous infusion the sulfonates were efficiently extracted by the liver at rates similar to that of sodium taurochenodeoxycholate. Chromatographic analysis of the bile showed that, regardless of the route of administration, most (> 95%) of the sulfonates were not biotransformed and they became major biliary bile acids. Sodium 3 alpha, 7 alpha-dihydroxy-25-homo-5 beta-cholane-25-sulfonate and, to a lesser extent, sodium 3 alpha, 7 alpha-dihydroxy-24-nor-5 beta-cholane-23-sulfonate induced cholestasis at infusion rates at which sodium taurochenodeoxycholate produced choleresis.

Dietary fat and fatty acids modulate cholesterol cholelithiasis in the hamster.

We tested two hypotheses, i) whether the type and the amount of fat in the diet will affect the formation of cholesterol gallstones in the hamsters, and ii) whether palmitic acid, a major fatty acid component of butterfat, can act as a potentiator of cholesterol cholelithiasis in the hamster. Young, male golden Syrian hamsters (Sasco) were fed a semipurified diet containing casein, corn starch, cellulose and cholesterol (0.3%) to which various types and amounts of fat (butterfat, olive oil, menhaden oil, corn oil) were added. All diets contained 2% corn oil to supply essential fatty acids to the growing hamsters. No deaths or illness occurred during the experiment. Animals fed the semipurified diet plus 4% butterfat (group 1) had a gallstone incidence of 63%. Replacement of butterfat with either olive oil, corn oil or menhaden oil prevented the formation of cholesterol gallstones entirely (groups 2-4). When total butterfat was increased from 4% to 8% (group 8), the incidence of cholesterol gallstones increased to 80%. Substitution of 4% olive oil (group 5), corn oil (group 6), or menhaden oil (group 7) for the additional 4% butterfat significantly reduced gallstones to 35%, 45% and 30%, respectively. The replacement of 4% butterfat with 1.2% palmitic acid gave the highest incidence of cholesterol gallstones (95%). These results suggest that butterfat (and one of its components, palmitic acid) intensifies gallstone formation in this model whereas mono- and polyunsaturated fats act as inhibitors of cholesterol cholelithiasis. A fatty acid, possibly palmitic acid, appears to act as lithogen in our model.

Carcinoma of the gallbladder: review of the literature and report on 56 cases at the Beth Israel Medical Center.

Fifty-six patients with carcinoma of the gallbladder were treated at the Beth Israel Medical Center, New York City, during the 17-year period 1969-1987. The disease was most common among elderly women with cholelithiasis. Of the 56, 42 patients (75%) had liver metastases at operation; therefore, the majority underwent only exploratory laparotomy and biopsy. In 50 patients (89%), the tissue diagnosis was adenocarcinoma. Cholecystectomy was performed in 19 patients. Long-term survival occurred in patients with an incidental diagnosis of carcinoma of the gallbladder. The average survival in 44 patients for whom data were available, including long-term survivors, was 20 months. Of this group, 5 patients (11.3%) were still alive 5 years after diagnosis. Excluding those with an incidental diagnosis of gallbladder cancer, 1 patient (2.2%) survived longer than 5 years after diagnosis. Survival data in 3 of 4 patients who underwent extensive surgical treatment, such as liver wedge resection or hepatic lobectomy, averaged 23 months. Although no defined protocols were used, the addition of adjuvant chemotherapy or radiation therapy in patients treated surgically appeared to improve survival. Five patients survived more than 5 years after diagnosis, and 2 patients were alive after 17 years.

The results of the EDAP multicenter trial of biliary lithotripsy in the United States. The EDAP Investigators Group.

The results of the EDAP International Corporation multicenter trial to test the efficacy and safety of its piezoelectric lithotripter in conjunction with ursodeoxycholic acid therapy for the treatment of gallstones are reported. Three hundred and sixty-two patients with one to three radiolucent calculi in a functioning gallbladder were studied. The mean stone size burden was 19 millimeters and was less than 30 millimeters in all patients. Lithotripsy treatment sessions were performed without analgesia or sedation in 72 per cent of the patients. Post-treatment complications were minimal. There were six patients with pancreatitis; two of whom had obstruction of the common bile duct by stone fragments. Three of these patients required endoscopic papillotomy. At the present time 120 of the patients (33.0 per cent) are stone-free and 197 (54.4 per cent) have residual fragments. Of the 163 patients in the study for at least six months, the stone-free rate is 44 per cent and for those individuals with a solitary stone less than 20 millimeters in size, the stone-free rate is 56 per cent. Biliary lithotripsy using piezoelectric techniques followed by adjuvant ursodeoxycholic acid is effective and is performed without significant pain or morbidity in the majority of patients.

Chemical synthesis and hepatic biotransformation of 3 alpha,7 alpha-dihydroxy-7 beta-methyl-24-nor-5 beta-cholan-23-oic acid, a 7-methyl derivative of norchenodeoxycholic acid: studies in the hamster.

A new bile acid analogue, 3 alpha,7 alpha-dihydroxy-7 beta-methyl-24-nor-5 beta-cholan-23-oic acid (7-Me-norCDCA) was synthesized from the methyl ester of norursodeoxycholic acid, and its hepatic biotransformation was defined in the hamster. To synthesize 7-Me-norCDCA, the 3 alpha-hydroxyl group of methyl norursodeoxycholate was protected as the hemisuccinate, and the 7 beta-hydroxyl group was oxidized with CrO3 to form the 7-ketone. A Grigard reaction with methyl magnesium iodide followed by alkaline hydrolysis gave 7-Me-norCDCA (greater than 70% yield). The structure of the new compound was confirmed by proton magnetic resonance and mass spectrometry. After intraduodenal administration of the 14C-labeled compound into the anesthetized biliary fistula hamster, it was rapidly and efficiently secreted into the bile; 80% of radioactivity was recovered in 2 h. After intravenous infusion, the compound was efficiently extracted by the liver and secreted into the bile (greater than 75% in 3 h). Most (93%) of the biliary radioactivity was present in biotransformation products. The major biotransformation product (48.7 +/- 6.0%) was a new compound, assigned the structure of 3 alpha,5 beta,7 alpha- trihydroxy-7 beta-methyl-24-nor-5 beta-cholan-23-oic acid (5 beta-hydroxy-7- Me-norCDCA). In addition, conjugates of 7-Me-norCDCA with taurine (13.7 +/- 5.0%), sulfate (10.3 +/- 3.0%), or glucuronide (5.1 +/- 1.7%) were formed. 7-Me-norCDCA was strongly choleretic in the hamster; during its intravenous infusion, bile flow increased 2 to 3 times above the basal level, and the calculated choleretic activity of the compound (and its metabolic products) was much greater than that of many natural bile acids, indicating that the compound induced hypercholeresis. It is concluded that the biotransformation and physiological properties of 7-Me-norCDCA closely resemble those of norCDCA. Based on previous studies, the major biological effect of the 7-methyl group in 7-Me-norCDCA is to prevent its bacterial 7-dehydroxylation in the distal intestine.

Aspirin does not inhibit cholesterol cholelithiasis in two established animal models.

The effect of aspirin on cholesterol cholelithiasis was examined in the hamster and the prairie dog. In the prairie dog, diets were composed of semipurified components of chow, plus cholesterol (1.2%), with and without aspirin. Animals were studied for either 2 weeks or 4 weeks. Cholesterol gallstones were present in all groups at the end of each period; aspirin did not alter the incidence of cholelithiasis. All animals studied had cholesterol crystals in the bile when they were killed. Liver cholesterol levels in prairie dogs with and without aspirin tended to be lower in animals fed chow than in animals fed semipurified diets. There were no significant differences in cholesterol levels in the plasma or bile. The cholesterol saturation index of all biles approached unity when animals were fed chow with aspirin; animals fed the semipurified diets had cholesterol saturation indices of less than 1.0. The prairie dogs fed aspirin plus cholesterol in the semipurified diet showed increased levels of biliary chenodeoxycholic acid amidates and concomitant decreased levels of cholic acid amidates compared with animals fed the same diet without aspirin. Hamsters fed aspirin plus cholesterol in a semipurified diet tended to have a greater incidence of gallstones than animals given no aspirin (80% vs. 55%). Liver and bile cholesterol levels were similar with and without aspirin; plasma cholesterol levels increased significantly with aspirin [14.20 vs. 7.80 mmol/L (549 vs. 301 mg/dL)]. Lithogenic indices in all hamsters were above unity; biliary lipids, total lipid concentration, and biliary bile acid composition were similar. These results show that the addition of aspirin to a lithogenic diet does not reduce the incidence of cholelithiasis.

Replacement of cholesterol gallstones by murideoxycholyl taurine gallstones in prairie dogs fed murideoxycholic acid.

The effect of two hydrophilic bile acids, murideoxycholic acid (3 alpha,6 beta-dihydroxy-5 beta-cholanoic acid) and ursodeoxycholic acid, on cholesterol and bile acid metabolism and hepatic pathology and gallstone composition was studied in the prairie dog. Cholesterol gallstones were induced by feeding a diet containing 1.2% cholesterol for 75 days. The animals were divided into six groups, and gallstone regression was studied as follows: groups 2 and 5, chow plus 0.2% cholesterol; groups 3 and 6, chow plus 0.2% cholesterol plus 0.15% ursodeoxycholic acid; groups 4 and 7, chow plus 0.2% cholesterol plus 0.15% murideoxycholic acid. Animals in groups 2 to 4 were killed after an additional 6 wk; animals in groups 5 to 7 were killed after an additional 12 wk. Gallstone dissolution did not occur in any group. The gallstones in groups 2, 3, 5 and 6 were typical cholesterol aggregates, as determined by polarized light microscopy and Fourier transform infrared spectrometry. The gallstones of the murideoxycholic acid group were large, solitary, dark stones that appeared radiopaque under 22 kVp x-ray examination. Scanning electron microscopy showed that in these stones the cholesterol crystals had been replaced by an amorphous material, both within the stone and on the stone surface. Chemical analysis indicated that at the end of 12 wk the calcium/sodium salt of the taurine conjugate of murideoxycholic acid (murideoxycholyl taurine) comprised 70% of the stones; protein, cholesterol and small amounts of other bile salts were also present. In vitro studies confirmed the insolubility of the sodium and calcium salts of murideoxycholyl taurine. These studies indicate that the hydrophilic bile acids, murideoxycholic acid and ursodeoxycholic acid, did not achieve gallstone dissolution under the conditions used. In the animals fed murideoxycholic acid, an insoluble calcium salt of murideoxycholyl taurine replaced cholesterol as the major constituent of gallbladder stones. This is the first example of an insoluble dihydroxy taurine-conjugated bile acid; administration of the unconjugated bile acid induced precipitation of a kind of gallstone not previously reported. The final result was transformation of cholesterol stones to bile salt stones.

The effect of alfalfa-corn diets on cholesterol metabolism and gallstones in prairie dogs.

Cholesterol gallstones were present in prairie dogs fed alfalfa plus corn with and without exogenous cholesterol (0.4%). The diets fed to the animals for eight weeks contained alfalfa plus corn in fixed proportions of 50:50, 85:15 and 15:85 (w/w). At sacrifice, all animals were healthy but had not gained weight; no deaths occurred during the experiment. Cholesterol gallstones were present in all groups. In the absence of exogenous cholesterol, the highest stone incidence was found in the animals which received the lowest fiber (highest corn) diets (alfalfa plus corn, 50:50, 67%; alfalfa plus corn, 15:85, 83%). Cholesterol gallstone incidence was 100% when exogenous cholesterol was added to the alfalfa plus corn diets (50:50 and 15:85). No pigment gallstones were detected in any animal. Liver and plasma cholesterol concentrations were highest in the animals receiving alfalfa plus corn (15:85) plus 0.4% cholesterol (4.29 mg/g, and 356 mg/dl, respectively). These values were lowest in animals receiving 85% alfalfa plus 15% corn without cholesterol (2.19 mg/g and 88 mg/dl, respectively). Lithogenic indices were below 1.00 in all groups. Biliary bile acids were mainly amidates of cholic acid and chenodeoxycholic acid, with the former predominating. Thus, gallstones can be formed in prairie dogs in the absence of exogenous cholesterol; gallstone incidence is reduced by dietary fiber.

Bile acids substituted in the 6 position prevent cholesterol gallstone formation in the hamster.

The aim of the present study is to examine the efficacy of 6-hydroxy substituted bile acids on the prevention of cholesterol gallstones in a new hamster model of cholesterol cholelithiasis. Male golden Syrian hamsters were fed a nutritionally adequate semipurified lithogenic diet consisting of casein, cornstarch, soluble starch, butterfat, corn oil, and cellulose plus 0.3% cholesterol. Six different bile acids were added to this diet at the 0.05% level: chenodeoxycholic acid, ursodeoxycholic acid, hyodeoxycholic acid, murideoxycholic acid, 6 beta-methyl-hyodeoxycholic acid, and 6 alpha-methyl-murideoxycholic acid. At the end of the 6-wk feeding period, the control group receiving the lithogenic diet had a 55% incidence of gallstones. It was found that all bile acids had inhibited the formation of cholesterol gallstones; complete prevention of gallstones was observed with all 4 3,6-dihydroxy bile acids, whereas chenodeoxycholic acid and ursodeoxycholic acid were somewhat less effective (80% and 75% prevention, respectively). The accumulation of cholesterol in serum and liver induced by the lithogenic diet was inhibited to some extent by all of the bile acids; hyodeoxycholic acid, murideoxycholic acid, and 6 beta-methyl hyodeoxycholic acid were most effective in this respect. The administered bile acids tended to predominate in bile in the case of chenodeoxycholic acid, hyodeoxycholic acid, and 6 beta-methyl-hyodeoxycholic acid. In contrast, ursodeoxycholic acid seemed to be converted to chenodeoxycholic acid and murideoxycholic acid to hyodeoxycholic acid. Only 4% of the 6-methyl analogue of murideoxycholic acid, 6 alpha-methyl-murideoxycholic acid, was recovered in gallbladder bile. These experiments show that the new hamster model of cholesterol cholelithiasis is suitable for gallstone-prevention studies. It was not possible to draw definite conclusions concerning the mechanism of action of the administered bile acids on the basis of cholesterol saturation or the presence of liquid crystals. The detailed mechanism of gallstone prevention by hydrophilic bile acids in this model remains to be elucidated.

Effects of calcium and bile acid feeding on colon tumors in the rat.

The hypothesis that dietary calcium alters the incidence of colorectal neoplasms was examined in an established model of carcinogenesis. Male Fischer 344 rats (28 days old) were quarantined for 2 weeks. All animals were fed the basal diet (AIN-76) supplemented with cholic acid (0.2%) and/or calcium (1.6%, corresponding to a 3-fold increase above that of the basal diet). N-Methyl-N-nitrosourea (MNU) (2 mg/dose) or saline (control) was given intrarectally to all animals on days 1 and 4 of the experiment. Groups 1-8 were fed the experimental diets concurrently with the first dose of MNU, while groups 9 and 10 were fed the diets 2 weeks prior to MNU (or saline). All animals were sacrificed after 28 weeks. No tumors were observed in the groups given saline (groups 1, 3, 5, 7, and 9). In groups receiving MNU, the addition of cholic acid to the diet (group 4) caused a significant increase in tumors (80% versus 55%), tumors/animal ratio (2.24 versus 0.75), and tumors/tumor-bearing animal ratio (2.80 versus 1.36), group 4 versus group 2, respectively. Increased dietary calcium did not inhibit tumor formation; 68% of animals in groups 6 and 10 had tumors. The combination of dietary cholic acid and calcium (group 8) gave a tumor incidence similar to cholic acid (group 4) alone (72% versus 80%, 2.00 versus 2.24 tumors/animal; 2.77 versus 2.80 tumors/tumor-bearing animal). Most tumors were adenomatous polyps but carcinomas in situ and invasive carcinomas were also present; dietary calcium reduced the number of invasive carcinomas (group 6 versus group 2, P less than 0.04).

Advantages of elective surgical treatment of gallstones.

The author presents the mortality and morbidity of the surgical treatment of calculous disease of the biliary tract, especially cholecystectomy for chronic cholecystitis and cholelithiasis. Between 1932 and 1984, 10,749 patients underwent cholecystectomy, with an operative mortality of 0.4%. The most frequent cause of death in these patients was advanced age and cardiovascular diseases. Comparatively few patients with gallstones have been treated with bile acids alone or in combination with shock wave lithotripsy or by contact dissolution with MTBE. Although success with the non-operative techniques is improving, the high recurrence of biliary calculi imposes serious limitations on their effectiveness.