A nutrition support team led by general surgeons decreases inappropriate use of total parenteral nutrition on a surgical service.

The purpose of this study was to decrease the number of inappropriate orders for total parenteral nutrition (TPN) in surgical patients. From February 1999 through November 2000 and between July 2001 and June 2002, the surgeon-guided adult nutrition support team (NST) at a university hospital monitored new TPN orders for appropriateness and specific indication. In April 1999, the NST was given authority to discontinue inappropriate TPN orders. Indications, based on the American Society for Parenteral and Enteral Nutrition (ASPEN) standards, included short gut, severe pancreatitis, severe malnutrition/catabolism with inability to enterally feed > or =5 days, inability to enterally feed >50 per cent of nutritional needs > or =9 days, enterocutaneous fistula, intra-abdominal leak, bowel obstruction, chylothorax, ischemic bowel, hemodynamic instability, massive gastrointestinal bleed, and lack of abdominal wall integrity. The number of inappropriate TPN orders declined from 62/194 (32.0%) in the first 11 months of the study to 22/168 (13.1%) in the second 11 months (P < 0.0001). This number further declined to 17/215 (7.9%) in the final 12 months of data collection, but compared to the second 11 months, this decrease was not statistically significant (P = 0.1347). The involvement of a surgical NST was associated with a reduction in inappropriate TPN orders without a change in overall use.

Outpatient laparoscopic cholecystectomy: patient outcomes after implementation of a clinical pathway.

OBJECTIVE: To determine the success of a clinical pathway for outpatient laparoscopic cholecystectomy (LC) in an academic health center, and to assess the impact of pathway implementation on same-day discharge rates, safety, patient satisfaction, and resource utilization. SUMMARY BACKGROUND DATA: Laparoscopic cholecystectomy is reported to be safe for patients and acceptable as an outpatient procedure. Whether this experience can be translated to an academic health center or larger hospital is uncertain. Clinical pathways guide the care of specific patient populations with the goal of enhancing patient care while optimizing resource utilization. The effectiveness of these pathways in achieving their goals is not well studied. METHODS: During a 12-month period beginning April 1, 1999, all patients eligible for an elective LC (n = 177) participated in a clinical pathway developed to transition LC to an outpatient procedure. These were compared with all patients undergoing elective LC (n = 208) in the 15 months immediately before pathway implementation. Successful same-day discharges, reasons for postoperative admission, readmission rates, complications, deaths, and patient satisfaction were compared. Average length of stay and total hospital costs were calculated and compared. RESULTS: After pathway implementation, the proportion of same-day discharges increased significantly, from 21% to 72%. Unplanned postoperative admissions decreased as experience with the pathway increased. Patient characteristics, need for readmission, complications, and deaths were not different between the groups. Patients surveyed were highly satisfied with their care. Resource utilization declined, resulting in more available inpatient beds and substantial cost savings. CONCLUSIONS: Implementation of a clinical pathway for outpatient LC was successful, safe, and satisfying for patients. Converting LC to an outpatient procedure resulted in a significant reduction in medical resource use, including a decreased length of stay and total cost of care.

Laparoscopic bariatric surgery.

At present, laparoscopic bariatric surgery is a controversial topic among bariatric and laparoscopic surgeons. Although difficult to perform, the traditional procedures used for treating severe obesity are now being performed successfully using a laparoscopic approach. In addition, a new procedure, adjustable gastric banding, has been used in Europe; however, it lacks US Food and Drug Administration approval and adequate scientific follow-up data about long-term effectiveness. Appropriate patient selection and adherence to the principles that have been learned by experience through open bariatric surgery remain of paramount importance for the success of laparoscopic bariatric operations.

Postprandial response of gastric slow waves: correlation of serosal recordings with the electrogastrogram.

Controversial interpretations have been given to the postprandial increase in the dominant power (amplitude) of the electrogastrogram (EGG). The aim of this study was to find an appropriate interpretation of the postprandial EGG power changes. Simultaneous serosal and cutaneous recordings of gastric myoelectrical activity were made in 11 patients with gastroparesis in the fasting state and after the ingestion of 8 oz of water. The dominant frequency and corresponding power of the recording before and after water were computed using the power spectral analysis method. It was found that the dominant frequency of the EGG was the same as that of the serosal recording in 10 patients. One patient showed a substantial amount of dysrhythmia and no obvious dominant frequency was noted. A decrease in the dominant frequency was found in these 10 patients after the ingestion of water. Tachygastria of higher than 4 cycles/min was observed in one of 11 patients both in the prewater and postwater states. Consistent changes in amplitude after a drink of water were noted in both serosal recording and EGG. Statistical analysis demonstrated that the dominant power change after water computed from the EGG was correlated with that observed in the serosal recording (r = 0.757, P = 0.007). In conclusion, exogenous stimulation, such as ingestion of water, may change the amplitude of the gastric slow wave and this change is reflected in the EGG, suggesting that the change of the slow-wave amplitude is an important contributing factor to the postprandial change in the EGG dominant power.

Evidence for a peripheral mechanism of esophagocrural diaphragm inhibitory reflex in cats.

The esophagogastric junction (EGJ) is guarded by two sphincters, a smooth muscle lower esophageal sphincter (LES) and a skeletal muscle crural diaphragm. These two sphincters relax simultaneously under certain physiological conditions, i.e., swallowing, belching, vomiting, transient LES relaxation, and esophageal distension. Esophageal distension-induced crural diaphragm relaxation is mediated through vagal afferents that are thought to exert inhibitory influence on the central mechanism (brain stem) of crural diaphragm contraction. We conducted studies in 10 cats to determine whether a mechanism of crural diaphragm relaxation was located at the level of the neuromuscular junction and/or muscle. Stimulation of the crural diaphragm neuromuscular junction through 1) the electrodes implanted in the muscle and 2) the bilateral phrenic nerve resulted in an increase in EGJ pressure. Nicotinic receptor blockade (pancuronium, 0.2 mg/kg) abolished the EGJ pressure increase caused by electrical stimulation of the neuromuscular junction. Esophageal distension and bolus-induced secondary esophageal peristalsis caused relaxation of the EGJ during the stimulation of the neuromuscular junction. Bilateral phrenicotomy and vagotomy had no influence on this relaxation. These data suggest the existence of a peripheral mechanism of crural diaphragm inhibition. This peripheral inhibitory mechanism may reside at the level of either the neuromuscular junction or the skeletal muscle.

The accuracy of laparoscopic ultrasound in the detection of colorectal cancer liver metastases.

BACKGROUND: The most sensitive and specific method of detecting colorectal cancer hepatic metastases has been shown to be a combination of careful intraoperative palpation and intraoperative ultrasound. Although there has been growing interest in laparoscopic surgical therapy for colorectal cancer, the ability of this technique to adequately evaluate the liver for small metastases has been unknown. This study was undertaken to compare laparoscopic liver ultrasound to the gold standard of open palpation and intraoperative ultrasound in detecting hepatic metastases from colorectal cancer. METHODS: A preliminary animal model was first performed in adult pigs. Eighteen liver "lesions" were created with chlorhexidine gluconate under laparoscopic guidance. A blinded surgeon then performed laparoscopic liver ultrasound followed by open ultrasound and palpation, comparing the accuracy of these techniques in detecting the lesions. In a second study, 15 patients undergoing laparotomy for colorectal cancer underwent preliminary laparoscopic liver ultrasound followed by open palpation and intraoperative ultrasound to compare these methods of liver evaluation. RESULTS: Laparoscopic liver ultrasound detected 17 of 18 lesions created in the pig livers, for a sensitivity of 94.4%. There were two false negatives, for a specificity of 77.7%. Laparoscopic liver ultrasound detected 4 of the 5 liver metastases in the human study, for a sensitivity of 80%. There was a single false negative, for a specificity of 90.9%. Several technical difficulties and their solutions are discussed. CONCLUSIONS: With several technical modifications guided by our initial experience, we believe laparoscopic liver ultrasound can be an effective way of evaluating the liver for metastases during laparoscopic colorectal resection for cancer.

Gastric pacing improves emptying and symptoms in patients with gastroparesis.

BACKGROUND & AIMS: No effective treatment is available for patients with gastroparesis refractory to standard medical therapy. The aim of this study was to investigate the effects of gastric pacing on gastric electrical activity, gastric emptying, and symptoms in patients with gastroparesis. METHODS: Nine patients with gastroparesis participated in this study. Four pairs of cardiac pacing wires were implanted on the serosa of the stomach. The protocol consisted of two portions: a temporary inpatient study period and an outpatient study for a period of 1 month or more. RESULTS: Gastric pacing entrained the gastric slow wave in all subjects and converted tachygastria in 2 patients into regular 3-cpm slow waves. Gastric emptying was significantly improved after the outpatient treatment with gastric pacing. The gastric retention at 2 hours was reduced from 77.0% +/- 3.3% to 56.6% +/- 8.6% (P < 0.05). Symptoms of gastroparesis were substantially reduced at the end of the outpatient treatment (1.51 +/- 0.46 vs. 2.84 +/- 0.61; P < 0.04). Eight of 9 patients no longer relied on jejunostomy tube feeding, and no adverse events were noted related to the pacing unit. CONCLUSIONS: Gastric pacing seems to be able to improve symptoms of gastroparesis and to accelerate gastric emptying in patients with gastroparesis. More controlled studies are necessary to further investigate the role of gastric pacing in clinical practice.

Effects of pacing parameters on entrainment of gastric slow waves in patients with gastroparesis.

The aim of this study was to investigate the effect of pacing parameters on the entrainment of gastric slow waves in patients with gastroparesis. Four pairs of cardiac pacing wires were placed on the serosal surface of the stomach in 13 patients with gastroparesis. After a baseline recording for 30 min, gastric pacing was performed in a number of sessions with different effective parameters, each lasting for 30 min. The following parameters were found to be effective for the entrainment of the gastric slow wave: a pacing frequency 10% higher than the intrinsic gastric slow wave frequency (IGF), 300 ms pulse width, and 4 mA pacing amplitude. A reduction of pacing amplitude from 4 to 2 mA and 1 mA reduced the percentage of entrainment of the gastric slow wave to 79 +/- 10% and 50 +/- 11%, respectively. Pacing with a pulse width of 30 or 3 ms was not able to entrain the gastric slow wave in any of the patients. An ectopic pacemaker of tachygastria found in three patients was reversed with gastric pacing. It was concluded that gastric pacing at a frequency up to 10% higher than the IGF and with an amplitude of 4 mA and a pulse width of 300 ms is able to completely entrain the gastric slow wave and normalize gastric dysrhythmias in patients with gastroparesis.

Recovery of gastrointestinal tract motility and myoelectric activity change after abdominal surgery.

OBJECTIVE: To investigate the relationship between fedstate gastrointestinal tract (GI) function and upper GI myoelectric changes seen after abdominal surgery. DESIGN: Twenty-one adult female mongrel dogs underwent either an open cholecystectomy, a laparoscopic cholecystectomy alone, or a laparoscopic cholecystectomy with peritoneal injury (n = 7 for each group). Bipolar recording electrodes were placed on the antrum and 3 sites of the proximal small intestine to record fasting myoelectric data each morning postoperatively. Solid-phase, technetium Tc 99m gastric emptying studies were performed on postoperative days 1 and 2. Radiopaque markers were ingested just before operation, and the excreted markers were counted using x-ray films of the feces. MAIN OUTCOME MEASURES: Postoperative fasting GI myoelectric activity, gastric emptying, and intestinal transit time. RESULTS: Migrating motor complexes (MMCs) in the small intestine were observed in 33.3% and 75.0% of the dogs on postoperative days 1 and 2, respectively. Gastric dysrhythmias were observed in 23.8% and 45.0% of the dogs on postoperative days 1 and 2, respectively. No relationship between type of surgery and the presence of MMCs or gastric dysrhythmias was noted. Gastric emptying was delayed on postoperative day 1 and was unrelated to the presence of MMCs. Transit time was not significantly delayed in dogs without MMCs on postoperative day 1 compared with that in dogs with MMCs on that day. The presence of gastric dysrhythmias did not affect transit time studies. CONCLUSION: Fasting GI myoelectric activity, including the return of MMCs and the presence of gastric dysrhythmias, does not accurately predict fed-state gastrointestinal GI function following abdominal surgery.

Laparoscopic percutaneous jejunostomy for long term enteral access.

BACKGROUND: Patients suffering from upper gastrointestinal pathology may require jejunal feeding for adequate nutrition. A laparoscopically guided percutaneous jejunostomy offers a minimally invasive means of obtaining such feeding access. METHODS: Laparoscopic jejunostomy was performed in 32 patients. The most common indications were gastroparesis (n = 16), neurological deficits (n = 7), and proximal obstruction (n = 5). The proximal jejunum was affixed to the abdominal wall using intracorporeal and extracorporeal transabdominal sutures, allowing safe insertion of an 18-Fr Silastic dual-lumen tube. RESULTS: Laparoscopic jejunostomy was successfully completed for 28 patients; the procedure was converted to an open operation in four cases. Three of these four were among 14 patients undergoing the procedure who had a history of previous abdominal surgery. Major complications were observed in seven patients, including one reoperation and one death from aspiration pneumonia. Tube feeding was accomplished in all patients; progression to full enteral feeding proceeded without interruption in 20 patients. CONCLUSION: Laparoscopic jejunostomy can be performed with relative safety. Morbidity, though high, is usually related to preexisting disease. Previous abdominal surgery is not necessarily a contraindication to laparoscopic jejunostomy.

Laparoscopic colon resection.

Laparoscopic colectomy, usually performed in a laparoscopy-assisted fashion, is a technically difficult operation not easily mastered by the average surgeon and requiring a skilled team for its successful completion. There is a significant learning curve for the procedure, and conversion to open colectomy has been necessary in about 25% of cases in collected series. As such, its popularity has increased only slowly, and currently it is appropriate for treatment of benign colonic disease and as a palliative approach for unresectable carcinoma. Although the procedure produces an adequate tissue resection, concern about trocar site tumor recurrences has led to the general consensus that the procedure should currently be done only in a prospective investigational protocol setting for the treatment of curable colorectal carcinoma. These studies are expected to yield the data critically needed to assess its role in treating this disease. Experience to date suggests that laparoscopic colectomy can be performed with morbidity and mortality lower than or comparable to those of open colectomy. It likely is associated with less postoperative pain and a shorter hospitalization and has the potential for modestly more rapid recovery of gastro-intestinal function than open colectomy.

Gastric myoelectric activity changes following open abdominal surgery in humans.

We examined the postoperative changes in fasting gastric myoelectric activity in 11 patients undergoing nongastric surgery (colon surgery) via celiotomy. Recordings were performed on postoperative days (POD) 1, 2, 3, 5, and 7+ (7-35) for 1-1.5 hr after overnight fasting. Patients had placement of bipolar seromuscular recording electrodes on the proximal (N = 9) and distal (N = 11) antrum at the time of surgery. Data were analyzed visually and analysis of variance or tests of proportion were used for statistical analysis. Although there was a trend of decreasing slow wave frequency from POD 1 to 7+ in the proximal and distal antrum, no significant differences were observed in slow wave amplitude or in the percentage of slow waves with spike activity between postoperative day. In a few of the patients, several types of gastric dysrhythmias were infrequently observed. We conclude that certain parameters of fasting gastric myoelectric activity do not change sufficiently following open abdominal surgery to adequately reflect clinical recovery from postoperative ileus.

Gastrointestinal recovery following laparoscopic vs open colon surgery.

BACKGROUND: We prospectively studied the recovery of gastrointestinal motility in patients undergoing laparoscopic (LAP, n = 7) or open (OPEN, n = 7) colon resections. METHODS: At operation, bipolar recording electrodes were placed on the proximal and distal antrum, the proximal site of the colonic anastomosis, and the rectosigmoid for postoperative myoelectric recordings. RESULTS: Shorter postoperative hospitalization and earlier resumption of a regular diet of the LAP group just barely failed to achieve significant differences when compared with the OPEN group (p = 0.091, p = 0.050, respectively). There were no differences between groups for slow wave frequency, amplitude, or dysrhythmias in the antrum, nor for return of discrete (DERA) and continuous (CERA) electrical response activity in the colon. Percentage of slow waves with spike activity tended to increase with passage of time postoperatively in both groups. There was a significant difference between POD 3 and 7+ in the LAP group (p < 0.05). However, there were no significant differences in the percentage of slow waves with spike activities between groups on any postoperative day. CONCLUSIONS: The potential benefits of using a laparoscopic approach to colon resection are not clearly confirmed by these data. While such an approach may possibly result in shorter hospitalization, it appears to offer at best only modest increases in the rapidity of recovery of gastrointestinal function.

Recovery of gastrointestinal motility following open versus laparoscopic colon resection in dogs.

The recovery of gastrointestinal motility was compared in dogs undergoing either laparoscopic or open sigmoidectomy. During surgery, bipolar recording electrodes were placed on the proximal and distal antrum, mid- and distal colon, and the rectum. Fasting myoelectric data were recorded postoperatively. Scintigraphic gastric emptying studies employing a solid test meal were performed before and after [postoperative day (POD) 2] operation. Ten radiopaque markers were given just before operation and retained markers were counted daily by abdominal x-ray. Gastric emptying on POD 2 was significantly delayed in the open group at 120 min compared with preoperative studies for the open group and compared with the laparoscopic group on POD 2 (P < 0.05 and P < 0.01, respectively). A significant difference in the number of retained markers was observed between the groups on POD 4 (P < 0.05). There were no significant differences in slow-wave frequency, presence of dysrhythmias in the proximal and distal antrum, or presence of either discrete or continuous electrical response activity in the colon and rectum between groups on any days. We conclude that using a laparoscopic approach results in more rapid recovery of fed-state gastrointestinal motility following colon resection. These data also suggest that myoelectric activity alone is not a sensitive enough parameter to detect these differences in recovery in this animal model.

Recovery of fasted and fed gastrointestinal motility after open versus laparoscopic cholecystectomy in dogs.

OBJECTIVE: The authors investigate the recovery of gastrointestinal motility in the fed and fasted state after laparoscopic and open cholecystectomy. SUMMARY BACKGROUND DATA: Clinical recovery after laparoscopic cholecystectomy is known to be more rapid than after conventional open cholecystectomy. However, the actual effect of a laparoscopic approach on gastrointestinal motility, particularly fed-state motility, is not well investigated. METHODS: Laparoscopic (LAP, n=6) or open (OPEN, n=6) cholecystectomy was performed in 12 dogs. Bipolar recording electrodes were placed on the antrum, small intestine, and the transverse and descending colon, and fasting myoelectric data were recorded after operation. Solid meal gastric emptying studies were performed before surgery and on postoperative days 1 and 2. Transit time studies were performed using 10 radiopaque markers. RESULTS: Gastric emptying was significantly delayed in the OPEN group at 120 minutes on postoperative day 1 compared with pre-operative emptying (p<0.05), but was not delayed on postoperative day 2. Gastric emptying was not delayed in the LAP group after operation. Transit time was the same between groups. Gastric dysrhythmias were more frequent on postoperative day 3 (p<0.05) in the OPEN group. There were no significant differences in the presence, cycle length, or propagation velocity of the migrating motor complex on any postoperative day. Discrete or continuous electrical response activity in the colon was observed by postoperative day 1 in both groups. CONCLUSIONS: Fed-state motility is the only parameter for which laparoscopic cholecystectomy showed an improvement in postoperative recovery. Recovery of fasted gastrointestinal motility in dogs is equally rapid after either operation.

The impact of previous abdominal surgery on outcome following laparoscopic cholecystectomy.

The first 1000 patients undergoing laparoscopic cholecystectomy (LC) at our institution were reviewed to investigate the impact of previous abdominal surgery on LC. The 454 patients having no previous abdominal surgery (NS) were compared to the 541 patients who had previous surgery (PS). PS patients were older, more likely to be female, and had a higher ASA risk category. PS patients had a higher incidence of wound infection, but in all other parameters of outcome, including operative duration and completion, length of hospitalization, and morbidity, there were no significant differences between PS and NS. When PS patients with previous upper abdominal surgery (PUAS, n = 59) were separately compared to the remainder of the entire patient group (NUAS, n = 936), the PUAS group was found to be older, to be more likely to be male, and to have a higher ASA risk category. PUAS patients had a longer postoperative hospitalization, and an increased incidence of intraoperative, postoperative, and total complications, readmissions to the hospital, and unrelated deaths. We conclude previous lower abdominal surgery has little impact on the outcome of patients undergoing LC while previous upper abdominal surgery is associated with increased morbidity.

A retrospective analysis of 6,387 cholecystectomies.

This is the largest retrospective analysis of biliary tract surgery ever reported involving 6,378 patients operated on during a three year period, 1990-1992. During this time interval, the frequency of laparoscopic procedures has increased dramatically. The use of laparoscopic procedures was associated with a significant decrease in the total length of hospital stay and total charges as compared to the open procedures. Because of laparoscopic surgery's increased acceptance, we propose that the frequency of laparoscopic surgery of the biliary tract should be used as a quality control measure.

Gastric atony and the Roux syndrome.

The Roux limb syndrome is a symptom complex characterized by chronic postprandial epigastric pain, fullness, and vomiting observed in approximately one third of patients after gastric reconstructive surgery for reflux gastritis and other conditions in which vagotomy and Roux-en-Y gastroenterostomy have been preformed. The etiology of the symptom complex is controversial, with experimental evidence in animal and human studies suggesting dysfunction of both the gastric remnant and the Roux limb itself. Medical treatment is successful in only about half of cases, but surgical treatment to remove most or all of the gastric remnant is usually successful. These observations suggest that most of the symptoms of the Roux limb syndrome arise from postvagotomy gastric atony.