Hepatic artery pseudoaneurysm: a report of seven cases and a review of the literature.

PURPOSE: To analyze seven cases of hepatic artery pseudoaneurysm (HAP) encountered at our hospital and review the relevant literature. METHODS: We searched the computerized medical record database from January 1, 1996, to September 1, 2003, to identify all cases of HAP, which we then reviewed in detail, examining etiology, findings, laboratory data, therapeutic intervention, complications, and outcome. We then compared these findings with those reported in the literature. RESULTS: There were five cases of HAP among 18,015 trauma and surgical admissions to the University of California Irvine Medical Center, representing an incidence of 0.03%. There were an additional two cases of HAP among 200 orthotopic liver transplants (OLT). The five HAPs not associated with OLT were preceded by blunt abdominal trauma, liver biopsy, pancreatic pseudocyst, and polyarteritis nodosa, in one patient each, and there was no apparent cause in one patient. Two patients were treated by ligation, and the patients with post-OLT HAP underwent resection and replacement with saphenous bypass grafts. Successful embolization was performed in the other three patients. CONCLUSION: Hepatic artery pseudoaneurysm is a rare but dangerous complication of both acute surgical and chronic injury to the hepatic artery. However, early diagnosis and intervention can result in an excellent long-term outcome.

Trends in utilization and outcomes of laparoscopic versus open appendectomy.

BACKGROUND: Although a number of trials have analyzed the outcomes of laparoscopic versus open appendectomy, the clinical advantages, and cost-effectiveness of laparoscopic appendectomy in the management of acute and perforated appendicitis are still not clearly defined. The aim of this study was to examine utilization and outcomes of laparoscopic versus open appendectomy using a national administrative database of academic medical centers and teaching hospitals. METHODS: Using ICD-9 diagnosis and procedure codes, we obtained data from the University HealthSystem Consortium Clinical Data Base for all patients who underwent appendectomy for acute and perforated appendicitis between 1999 and 2003 (n = 60,236). Trends in utilization of laparoscopic appendectomy were examined over the 5-year period. The outcomes of laparoscopic and open appendectomy were compared including length of hospital stay, 30-day readmission, complications, observed and expected (risk-adjusted) in-hospital mortality, and costs. RESULTS: Overall, 41,085 patients underwent open appendectomy and 19,151 patients underwent laparoscopic appendectomy. The percentage of appendectomy performed by laparoscopy increased from 20% in 1999 to 43% in 2003 (P <0.01). Compared with patients who underwent open appendectomy, patients who underwent laparoscopic appendectomy were more likely female, more likely white, had a lower severity of illness, and were less likely to have perforated appendicitis. Laparoscopic appendectomy was associated with a shorter length of hospital stay (2.5 days vs 3.4 days), lower rate of 30-day readmission (1.0% vs 1.3%), and lower rate of overall complications (6.1% vs 9.6%). There was no significant difference in the observed to expected mortality ratio between laparoscopic and open appendectomy (0.5 vs 0.6, respectively). The mean cost per case was similar between the two groups (US$ 6,242 vs US$ 6,260). CONCLUSIONS: Utilization of laparoscopic appendectomy at academic centers has increased more than two-fold between 1999 and 2003. Patients selected for laparoscopic appendectomy have less advanced appendicitis and have a shorter length of stay and fewer complications without increasing the inpatient care cost.

The efficacy of fibrin sealant in prevention of anastomotic leak after laparoscopic gastric bypass.

BACKGROUND: Anastomotic leak after laparoscopic gastric bypass (GBP) can result in significant morbidity, mortality, and consumption of healthcare resources. Fibrin sealant has been used clinically in the prevention of leak; however, its efficacy has not been clearly demonstrated. The aims of this study were to (1) develop an iatrogenic leak model in swine, (2) examine the efficacy of fibrin sealant in sealing iatrogenic anastomotic leak, and (3) review our experience with the use of fibrin sealant in 66 patients who underwent laparoscopic GBP. METHODS: This study was performed in three phases. In phase 1, laparoscopic gastrojejunostomy was performed in adult swine with iatrogenic disruption of the anastomotic staple line. The size of disruption was sequentially increased (6- to 12-F opening) until a leak model was developed. In phase 2, 16 animals underwent laparoscopic gastrojejunostomy with a 12-F disruption of the anastomosis; 10 animals (study group) had fibrin sealant (Tisseel VH) applied on the disrupted anastomosis and 6 animals (control group) did not receive fibrin sealant. Animals were sacrificed on postoperative day 5 or earlier if peritonitis developed and were examined for sealing of the anastomotic disruption and the presence of intraabdominal abscess. In phase 3, the outcome of 66 consecutive patients who underwent laparoscopic GBP with fibrin sealant applied at the gastrojejunostomy was reviewed. RESULTS: In phase 1, an anastomotic leak model was developed with a 12-F disruption of the staple line. In phase 2, two control animals required early sacrifice for bile peritonitis; three control animals had intraabdominal abscess discovered at sacrifice and one animal did not have any evidence of intraabdominal abscess or leak. Of the 10 animals in the study group, all survived until sacrifice and none of these animals had evidence of intraabdominal abscess or persistent leak. Therefore, 83% of animals in the control group developed either leak or abscess compared to 0% in the study group (P < 0.01, Fisher's exact test). Clinically, no leak or intraabdominal abscess developed in 66 patients who underwent laparoscopic GBP with the use of fibrin sealant. CONCLUSIONS: An anastomotic leak model was developed in swine with disruption of the stapled gastrojejunostomy to a 12-F opening. The use of fibrin sealant significantly reduces leak and abscess complication. Our results support the tissue sealing property of fibrin sealant and its use on high-risk gastrointestinal anastomosis.

Application of robotics in general surgery: initial experience.

Robotic surgery was recently approved for clinical use in general abdominal surgery. The aim of this study was to review our experience with the da Vinci surgical system during laparoscopic general surgical procedures. Eighteen patients underwent robotically assisted laparoscopic abdominal surgery between June 2002 and March 2003. Main outcome measures were operative time, room setup time, robotic arm-positioning and surgical time, blood loss, conversion to laparoscopy, length of stay, and morbidity. The types of robotically assisted laparoscopic procedures were excision of gastric leiomyoma (n = 1), Heller myotomy (n = 1), cholecystectomy (n = 2), gastric banding (n = 2), Nissen fundoplication (n = 4), and gastric bypass (n = 8). The mean room setup time was 63 +/- 14 minutes, and the mean robotic arm-positioning time was 16 +/- 7 minutes. Conversion to laparoscopy occurred in two (11%) of 18 cases because of equipment difficulty (n = 1) and technical difficulty (n = 1). Estimated blood loss was 91 +/- 71 mL. The mean operative time was 156 +/- 42 minutes, and the robotic operative time was 27% of the total operative time. The mean length of hospital stay was 2.2 +/- 1.5 days. There was one postoperative wound infection and one anastomotic stricture. Robotically assisted laparoscopic abdominal surgery is feasible and safe; however, the theoretical advantages of the da Vinci surgical system were not clinically apparent.

The relationship between hospital volume and outcome in bariatric surgery at academic medical centers.

OBJECTIVE: To examine the effect of hospital volume of bariatric surgery on morbidity, mortality, and costs at academic centers. SUMMARY BACKGROUND DATA: The American Society for Bariatric Surgery recently proposed categorization of certain bariatric surgery centers as "Centers of Excellence." Some of the proposed inclusion criteria were hospital volume and operative outcomes. The volume-outcome relationship has been well established in several complex abdominal operations; however, few studies have examined this relationship in patients undergoing bariatric surgery. METHODS: Using the International Classification of Diseases, 9th edition, diagnosis and procedure codes, we obtained data from the University HealthSystem Consortium Clinical Data Base for all patients who underwent Roux-en-Y gastric bypass for the treatment of morbid obesity between 1999 and 2002 (n = 24,166). Outcomes of bariatric surgery, including length of hospital stay, 30-day readmission, morbidity, observed and expected (risk-adjusted) mortality, and costs were compared between high-volume (>100 cases/year), medium-volume (50-100 cases/year), and low-volume hospitals (<50 cases/year). RESULTS: There were 22 high-volume (n = 13,810), 27 medium-volume (n = 7634), and 44 low-volume (n = 2722) hospitals included in our study. Compared with low-volume hospitals, patients who underwent gastric bypass at high-volume hospitals had a shorter length of hospital stay (3.8 versus 5.1 days, P < 0.01), lower overall complications (10.2% versus 14.5%, P < 0.01), lower complications of medical care (7.8% versus 10.8%, P < 0.01), and lower costs ($10,292 versus $13,908, P < 0.01). The expected mortality rate was similar between high- and low-volume hospitals (0.6% versus 0.6%), demonstrating similarities in characteristics and severity of illness between groups. The observed mortality, however, was significantly lower at high-volume hospitals (0.3% versus 1.2%, P < 0.01). In a subset of patients older than 55 years, the observed mortality was 0.9% at high-volume centers compared with 3.1% at low-volume centers (P < 0.01). CONCLUSIONS: Bariatric surgery performed at hospitals with more than 100 cases annually is associated with a shorter length of stay, lower morbidity and mortality, and decreased costs. This volume-outcome relationship is even more pronounced for a subset of patients older than 55 years, for whom in-hospital mortality was 3-fold higher at low-volume compared with high-volume hospitals. High-volume hospitals also have a lower rate of overall postoperative and medical care complications, which may be related in part to formalization of the structures and processes of care.