Trocar site recurrence is unlikely to result from aerosolization of tumor cells

PURPOSE: This study was undertaken to investigate the ability of a high-pressure CO₂ environment to aerosolize tumor cells in bothin vitroandin vivo models. (An aerosol is defined as a stable gaseous suspension of insoluble particles.) Also, this study was designed to determine if rapid desufflation is capable of transporting fluid laden with tumor cells. METHODS: The fourin vitro aerosol experiments were performed in an 18.9-l plastic vessel fitted with two 7-mm ports and a compliant latex balloon affixed to the top. After CO₂ insufflation, the vessel was desufflated through a sterile soluset containing 25 ml of culture media that was subsequently emptied into a culture dish, incubated for two weeks, and periodicallyassessed for growth. At the bottom of the vessel, one of the following was placed: Study 1 and 2, a suspension of B16 melanoma or colon 26 tumor cells in liquid culture media; Study 3, colon 26 cells in saline solution; Study 4, several pieces of solid colon 26 tumor. In Studies 1 to 3, cell preparations were subjected to the following high-pressure CO₂ conditions (pneumo): 1) static pneumo of 15 and 30 mmHg (10 minute dwell); 2) a continuous flow (CF) of CO₂ (10 l) while maintaining a pressure of 15 or 30 mmHg in the vessel. In Study 4, only the 30 mmHg static and CF conditions were tested. Between 6 and 12 determinations were performed for each condition and cell preparation.In vivo aerosol experiments consisted of Spraque Dawley rats that received intraperitoneal injections of 10-5 B16 cells in 0.1 ml of liquid media.Two laparoscopic ports were placed in the abdomen, one each for insufflation and desufflation. Study groups were: 1, static CO₂ pneumo of 15 mmHg; 2 and 3, continuous CO₂ flow (10 l) at a stable pneumo pressure of 5 and 10 mmHg. Desufflation was performedvia the same collecting device and handled in an identical manner to thein vitroexperiments described above. Thein vitro balloon experiment was designed to investigate the ability of desufflation to transport fluid-containing tumor cells; latex balloon model was used. To prevent complete loss of volume on desufflation, a wire coil was placed inside the balloon. Twenty ml of media containing 20×10^?6B16 cells was placed in the bottom of the balloon. The balloon was insufflated with 1 to 21 of gas. There were three study groups that differed in the degree to which the cell suspension was agitated before desufflation. Study conditions were as follows: 1) no agitation; 2) moderate agitation to coat the lower walls and coil; 3) maximum agitation to coat the entire balloon. To verify the viability of tumor cells,at the end of eachin vitroandin vivo study, a sample of tumor cells or peritoneal washing was incubated in sterile media. These samples served as positive controls. RESULTS:In vitro aerosol studies consisted of the following. At the end of two weeks of incubation, no tumor growth was noted in any of the 124 test dishes. The 14 control samples all demonstrated tumor growth.In vivo aerosol studies consisted of the following. Zero of 18 experimental dishes grew tumor. All three peritoneal washing samples demonstrated growth.In vitro balloon studies consisted of the following. Zero of 12 test dishes in Groups 1 and 2 demonstrated growth, whereas five of six dishes did so in Group 3 (maximally agitated before desufflation). Again, positive controls all grew tumor cells. SUMMARY: We were unable to demonstrate aerosol formation in any of thein vitroandin vivo studies performed. In the balloon experiment, desufflation-related transport of tumor cells was demonstrated but only when the entire balloon surface was coated with the tumor cell suspension before desufflation. CONCLUSION: Aerosols of tumor cells are not likely to form. Free intraperitoneal tumor cells are most likely found in liquid suspension. Desufflation is a potential means of transport of cell-laden fluid.     

Prospective comparison of open<Emphasis Type="Italic">vs</Emphasis>. laparoscopic colon surgery for carcinoma

Laparoscopy for colonic diseases began in 1990 and has established a role in benign disease. Early observations and experiences demonstrated feasibility of laparoscopic surgery for a variety of colonic disease processes, but the applicability to colonic carcinoma was unclear. METHODS: In 1990, we began a comparative study of open (OCR)vs.laparoscopic (LCR) approach to colon cancer. The study progressed 65 months, with 224 patients in OCR group and 191 patients in LCR group. Parameters studied are stage, location, length of specimen, number of lymph nodes resected, margins, postoperative course, wound complications, recurrence rates, and immediate and long-term survival. OCR were standardized by one group, and LCR were standardized by a second group. All patients undergoing LCR were given freedom to choose either OCR or LCR, and informed consent was obtained. RESULTS: Equal or greater lymph node retrieval, resections, and distal margins were evident with LCR. Benefits with LCR were shown with shorter hospitalization (5.7vs.9.7 days), less blood loss, less wound problems (1vs.14), and quicker return of bowel function. Survival, recurrence, and death rates were essentially the same. There were no trocar implants in the LCR group. CONCLUSION: After five years, this study shows that laparoscopy does no harm to the patient, offers comparable oncologic resections, and seems to be patient-friendly, with less pain, quicker return of bowel functions, shortened hospitalization, and quicker return to full activity.     

Effect of fibrin sealant on perianastomotic tumor growth in an experimental model of colorectal cancer surgery

Viable intraluminal tumor cells can penetrate a clinically intact rodent colonic anastomosis and give rise to perianastomotic tumor growth. The aim of this study was to determine whether transanastomotic cell migration can be prevented by fibrin-based tissue sealant. Following distal colonic transection and reanastomosis with 5/0 silk sutures, Fischer F344 rats were randomly allocated to three experimental groups. In Group A, a circumferential ring of tissue sealant was placed around the serosal surface of the anastomosis; in Group B, sealant was limited to 50 percent of the anastomotic circumference; and, in Group C, no sealant was applied. All rats then had 10 ⁵ Mtln ₃ carcinoma cells injected into the proximal colonic lumen via a rectal catheter. The incidence of perianastomotic tumor at 21 days was significantly lower in Group A (3 of 14 animals) than in Group B (11 of 16 rats) (P =0.012; Fisher's exact test) or Group C (10 of 14 rats;P=0.011). A further experiment demonstrated that sealant did not protect the anastomosis when tumor cells were instilled directly into the peritoneal cavity. A topical carcinocidal action therefore appears unlikely, but our results suggest that a circumferential anastomotic ring of fibrin sealant forms an effective mechanical barrier preventing intraluminal tumor cells from reaching the peritoneal cavity.     

Laparoscopic resection for diverticular disease

PURPOSE: The role of laparoscopic surgery in treatment of patients with diverticulitis is unclear. A retrospective comparison of laparoscopic with conventional surgery for patients with chronic diverticulitis was performed to assess morbidity, recovery from surgery, and cost. METHODS: Records of patients undergoing elective resection for uncomplicated diverticulitis from 1992 to 1994 at a single institution were reviewed. Laparoscopic resection involved complete intracorporeal dissection, bowel division, and anastomosis with extracorporeal placement of an anvil. RESULTS: Sigmoid and left colon resections were performed laparoscopically in 25 patients and by open technique in 17 patients by two independent operating teams. No significant differences existed in age, gender, weight, comorbidities, or operations performed. In the laparoscopic group, three operations were converted to open laparotomy (12 percent) because of unclear anatomy. Major complications occurred in two patients who underwent laparoscopic resection, both requiring laparotomy, and in one patient in the conventional surgery group who underwent computed tomographic-guided drainage of an abscess. Patients who underwent laparoscopic resection tolerated a regular diet sooner than patients who underwent conventional surgery (3.2±0.9vs.5.7±1.1 days;P<0.001) and were discharged from the hospital earlier (4.2±1.1vs.6.8±1.1 days;P<0.001). Overall costs were higher in the laparoscopic group than the open surgery group ($10,230±49.1vs.$7,068±37.1;P<0.001) because of a significantly longer total operating room time (397±9.1vs.115±5.1 min;P<0.001). Follow-up studies with a mean of one year revealed two port site infections in the laparoscopic group and one wound infection in the open group. Of patients undergoing conventional resection, one patient experienced a postoperative bowel obstruction that was managed nonoperatively, and, in one patient, an incarcerated incisional hernia developed that required urgent laparotomy. CONCLUSIONS: Laparoscopic resection in patients with chronic diverticulitis is safe, with faster recovery and shorter hospital stay compared with conventional open surgery. Higher cost of operating room usage time makes the laparoscopic technique difficult to justify economically. Simplification of operating room use and better case selection may improve cost-effectiveness of the laparoscopic approach.     

In vivo real-time analysis of intraperitoneal radiolabeled tumor cell movement during laparoscopy

PURPOSE: A porcine model has been developed to allow the real-time imaging of radiolabeled tumor cell movement throughout the peritoneal cavity, both at rest and during carbon dioxide insufflation. METHODS: Fifteen 30-kg domestic white female pigs were used. Under anesthesia, 15 to 20 million radiolabeled human colorectal tumor cells (LIM1215) were introduced into the peritoneal cavity under laparoscopic vision into the pelvis. Radiolabeled tumor cell movement was examined by using a 25-cm-diameter, low-energy mobile gamma camera with high resolution collimator. Tumor cell movement and distribution during two hours without insufflation was examined in four pigs. Then tumor cell movement and distribution during two hours with CO₂ insufflation was examined in four pigs. In a further four pigs, tumor cells were then mixed with blood and injected into the peritoneal cavity and the effect of no insufflationvs. insufflation was noted. A further three pigs were examined with manipulation of the intra-abdominal contents after injection of LIM1215 cells into the peritoneal cavity. Venting insufflating CO₂ was filtered for tumor cells. RESULTS: Widespread intraperitoneal distribution of tumor cells from the pelvis was identified both with CO₂ insufflation of the peritoneal cavity and without insufflation. Tumor cells dispersed throughout the peritoneal cavity at a slower rate without carbon dioxide insufflation. There was a differential rate of tumor cell movement to the left upper quadrant and right upper quadrant with insufflation and without insufflation. Blood within the peritoneal cavity and an extended contact of the laparoscopic trocars with the peritoneal cavity in this setting increased contamination of the trocars and trocar sites with tumor cells. Tumor cells were identified on laparoscopic instruments in all experiments. No evidence of aerosolization of tumor cells was found. CONCLUSION: Tumor cells move throughout the peritoneal cavity both at rest and during CO₂ insufflation. The pattern of tumor cell dispersion differs with CO₂ insufflation. The presence of blood and extended contact of trocars with peritoneal contents are a major factor in trocar and trocar site tumor cell contamination.This work was performed at The Queen Elizabeth Hospital and the Institute of Medical and Veterinary Sciences, South Australia.Supported by the National Health and Medical Research Council of Australia and the Alfred and Ferrers Scammel Scholarship, Faculty of Medicine, University of Adelaide.Material supplies provided by Johnson and Johnson Australia.Read at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio, Texas, May 2 to 7, 1998.     

Intraoperative laparoscopic complications

PURPOSE: The aim of this study was to assess various intraoperative and postoperative complications associated with laparoscopic colorectal surgery. Specifically, the impact of surgical experience and procedure type on complications was analyzed. METHODS: All patients who underwent laparoscopic surgery were analyzed by age, sex, surgical indications, procedure performed, procedure length, intraoperative and postoperative complications, incidence and causes for conversion, duration of postoperative ileus, and length of hospital stay. Patients were classified for type of procedure and chronologically into four consecutive groups. Procedures were also categorized into four different groups: GI, total abdominal colectomies; GII, segmental resections; GIII, diverting procedures; GIV, others (abdominoperineal resection, Hartmann's creation or closure, anterior resection, and rectopexy). RESULTS: Between August 1991 and October 1995, 167 patients of a mean age of 49.6 (15–88) years underwent laparoscopic colorectal procedures. All procedures were electively performed. Common indications for surgery included inflammatory disease in 70 (42 percent), neoplasia in 56 (33 percent), functional bowel disorders in 30 (18 percent), and other forms of colorectal disorders in 11 (7 percent) patients. The most significant variable affecting intraoperative laparoscopic complication rate was surgical experience measured as the time interval during which surgery was performed (P=0.02). Total complication rate decreased from 29 percent during the first period to 11 percent by the second period (P<0.04) and 7 percent during the third period (P<0.005). Thus, the learning curve appeared to have required more than 50 cases to achieve. Moreover, even after performance of 94 (1991–1993) procedures in GI and GIV, these procedures were associated with higher complication rates than were those procedures in GII and GIII (P=0.04). CONCLUSION: Surgical experience and case selection are the most critical variables by which the surgeon can decrease the intraoperative laparoscopic complication rate.     

Detection of free malignant cells in the peritoneal cavity before and after resection of colorectal cancer

PURPOSE: This study was designed to select the best monoclonal antibody to stain malignant cells in peritoneal wash fluid, and to investigate the incidence of free malignant cells in preresection and postresection colorectal cancer peritoneal washings using a combination of conventional cytology and immunocytochemistry. METHODS: Peritoneal washings were taken from 35 consecutive patients undergoing colorectal cancer resection. RESULTS: Malignant cells were isolated on a density gradient and identified by conventional cytology and an indirect immunoperoxidase stain. Malignant cells were identified in peritoneal washings from 15 patients (preresection only n=3, postresection only n=4, both n= 8). The origin of free malignant peritoneal cells in 11 preresection-positive washings must be the serosa. The origin of these cells in the four postresection-positive patients is uncertain: serosal and luminal spillage were considered unlikely and no circulating cells were found in the mesenteric vessels near the tumor. CONCLUSION: Tumor cells may have leaked out from lymphatics cut during the dissection.     

Barriers to veterans health administration care in a nationally representative sample of women veterans

BACKGROUND: Women veterans are generally less healthy than their nonveteran female counterparts or male veterans. Accumulating evidence suggests there may be barriers to women veterans’ access to and use of Veterans Health Administration (VHA) care. OBJECTIVE: To document perceived and/or actual barriers to care in a nationally representative sample of women veterans and examine associations with VHA use. DESIGN: Cross-sectional telephone survey. PARTICIPANTS: Women who are current and former users of VHA from VA’s National Registry of Women Veterans. MEASUREMENTS: Assessments of perceptions of VHA care, background characteristics, and health service use. RESULTS: Perceptions of VHA care were most positive regarding facility/physical environment characteristics and physician skill and sensitivity and least positive regarding the availability of needed services and logistics of receiving VHA care (M=0.05 and M=?0.10; M=?0.23 and M=?0.25, respectively). The most salient barrier to the use of VHA care was problems related to ease of use. Moreover, each of the barriers constructs contributed unique variance in VHA health care use above and beyond background characteristics known to differentiate current users from former VHA users (Odds ratio [OR]=4.03 for availability of services; OR=2.63 for physician sensitivity and skill: OR=2.70 for logistics of care; OR=2.30 for facility/physical environment). Few differences in barriers to care and their association with VHA health care use emerged for women with and without service-connected disabilities. CONCLUSIONS: Findings highlight several domains in which VHA decisionmakers can intervene to enhance the care available to women veterans and point to a number of areas for further investigation.     

Improved experimental radioimmunotherapy of colon xenografts by combining<Superscript>131</Superscript>I-CC49 and Interferon-γ

PURPOSE: This study was designed to determine whether the ability of interferon-γ to upregulate the expression of a human tumor antigen improved the therapeutic efficacy of a radionuclide-conjugated monoclonal antibody. METHODS: Tumor xenografts of the moderately differentiated human colon tumor cell line HT-29 were grown in athymic mice. Constitutive levels of the human tumor antigen, tumor-associated glycoprotein-72, were measured before and after treatment with interferon-γ. Antitumor effects of an¹³¹I-labeled antitumor-associated glycoprotein-72 monoclonal antibody, CC49, were determined by measuring changes in tumor volumes in the respective groups of athymic mice. RESULTS: Interferon-γ induced a time-dependent and dose-dependent increase in tumor-associated glycoprotein-72 expression in the HT-29 tumors. Immunohistochemical staining revealed a more homogeneous tumor-associated glycoprotein-72-positive tumor cell population in tumors isolated from mice treated for eight days with interferon-γ, which accounted for the enhanced tumor localization of¹³¹I-CC49 in mice. That experimental model was used to examine the antitumor effects of combining interferon-γ with¹³¹I-CC49. Administration of 300 μCi of¹³¹I-CC49 to mice bearing HT-29 tumors induced a transient suppression of tumor growth. Conversely, a long-term, sustained HT-29 tumor growth suppression was achieved in mice given 300μCi of¹³¹I-CC49 and interferon-γ. In fact, the cytokine/radioimmunoconjugate combination eradicated any evidence of tumor in approximately 30 percent of the mice. CONCLUSION: The ability of interferon-γ to enhance tumor-associated glycoprotein-72 expression substantially augmented the antitumor effects of the radioimmunoconjugate. Those observations provide additional argument for use of a radioimmunoconjugate in combination with a cytokine to improve tumor diagnosis and therapy.     

Using the six sigma process to implement the centers for disease control and prevention guideline for hand hygiene in 4 intensive care units

BACKGROUND: The Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene in Health Care Settings was issued in 2002. In 2003, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established complying with the CDC Guideline as a National Patient Safety Goal for 2004. This goal has been maintained through 2006. The CDC’s emphasis on the use of alcohol-based hand rubs (ABHRs) rather than soap and water was an opportunity to improve compliance, but the Guideline contained over 40 specific recommendations to implement.OBJECTIVE: To use the Six Sigma process to examine hand hygiene practices and increase compliance with the CDC hand hygiene recommendations required by JCAHO.DESIGN: Six Sigma Project with pre-post design.PARTICIPANTS: Physicians, nurses, and other staff working in 4 intensive care units at 3 hospitals.MEASUREMENTS: Observed compliance with 10 required hand hygiene practices, mass of ABHR used per month per 100 patient-days, and staff attitudes and perceptions regarding hand hygiene reported by questionnaire.RESULTS: Observed compliance increased from 47% to 80%, based on over 4,000 total observations. The mass of ABHR used per 100 patient-days in 3 intensive care units (ICUs) increased by 97%, 94%, and 70%; increases were sustained for 9 months. Self-reported compliance using the questionnaire did not change. Staff reported increased use of ABHR and increased satisfaction with hand hygiene practices and products.CONCLUSIONS: The Six Sigma process was effective for organizing the knowledge, opinions, and actions of a group of professionals to implement the CDC’s evidence-based hand hygiene practices in 4 ICUs. Several tools were developed for widespread use.     

<Emphasis Type="Italic">Per Anum</Emphasis> intersphincteric rectal dissection with direct coloanal anastomosis for lower rectal cancer

PURPOSE: The most important goal of sphincter-preserving operations for rectal cancer is to secure a distal surgical margin of safety and the anal sphincter. However, it is not always easy to transect the rectum and to secure a distal surgical margin of safety through the abdominal approach for tumors situated extremely low in the rectum. The aim of this study was to describe and to evaluate a new technique ofper anumintersphincteric rectal dissection and coloanal anastomosis. METHODS: The rectum, including the entire width of the internal anal sphincter, is transected circum ferentiallyviathe anal route to secure the surgical margin of safety under direct vision and is mobilized proximally as far as possible through the intersphincteric plane.Per anumcoloanal anastomosis is performed following transabdominal resection of the rectum. RESULTS: This technique has been used in 12 patients. There have been no instances of short-term or long-term anastomotic complications. CONCLUSIONS: This technique is safe when anastomosis must be performed at the dentate line. It is the best sphincter-preserving operation for lower rectal cancer and does not result in serious postoperative anal dysfunction.     

Morbidity and mortality following laparoscopic-assisted right hemicolectomy for cancer

PURPOSE: This study was undertaken to compare morbidity, mortality, and pathology after laparoscopically assisted right hemicolectomy (LARHC) or open right hemicolectomy (ORHC) for cancer of the right colon. METHODS: Patients undergoing either LARHC or ORHC for invasive carcinoma of the right colon during a 30-month period were studied. Data were collected from two sources. All morbidity, mortality, and pathology data were collected prospectively in a form suitable for computer storage and analysis as part of the ongoing Concord Hospital Colorectal Cancer Registry. Data concerning in hospital course were obtained by casenote review. RESULTS: Twenty-eight patients underwent LARHC, and 33 had an ORHC during the study period. The two groups were well matched with respect to age, sex, weight, associated comorbidities, and tumor stage. Mean operating room use time was significantly higher for LARHC (LARHC=261 minutes; ORHC=203 minutes;P<0.001). Mean hospital stay from date of resection was the same in both groups (LARHC=12 days; ORHC=12.2 days). There was no significant difference between procedures with respect to postoperative complications, return of gastrointestinal function, or narcotic analgesic requirements. There was a significant shorter distal margin of resection in the LARHC group (ORHC=13.4 cm; LARHC=10 cm;P=0.03.). Total cost was significantly greater for LARHC ($9,064vs.$7,881 (Australian);P<0.001). Median follow-up was 23.4 months for the LARHC group and 23.9 months for the ORHC group. To date, there have been no local or port site recurrences. CONCLUSION: Although there is no difference in morbidity and mortality following LARHC or ORHC, there is no apparent benefit for LARHC.     

Television viewing practices and obesity among women veterans

BACKGROUND: Obesity is epidemic in the U.S. and has been associated with television viewing. OBJECTIVE: To describe the association between obesity and television viewing practices among women veterans. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional, mailed survey completed by 1,555 female veterans enrolled at the VA Puget Sound Health Care System in 2000. MEASUREMENTS AND METHODS: We used bivariate and multivariate analyses to assess the association of obesity (body mass index >30 kg/m² based on self-reported height and weight) with self-reported number of hours of television or videos viewed per day, and frequency of eating meals or snacking while watching television, controlling for other covariates. RESULTS: Watching television >2 hours per typical day on week days and/or weekends was associated with obesity (P<.001), as was eating or snacking while watching television (P=.003). In multivariate logistic regression analyses, watching television >2 hours per day and eating or snacking while watching television were each associated with obesity (odds ratio [OR] 1.4, 95% confidence interval [CI] 1.1 to 1.8; and OR 1.3, 95% CI 1.0 to 1.7, respectively), after adjusting for demographic variables, smoking, physical activity, and depression. Results were similar when posttraumatic stress disorder was included in the model instead of depression. Women who both watched >2 hours of television per day and ate or snacked while viewing were almost twice as likely to be obese (OR 1.9, 95% CI 1.4 to 2.6). CONCLUSION: Watching television over 2 hours per day and eating while watching television were each associated with obesity among female VA patients and may be modifiable risk factors for obesity.     

Are there gender differences in diabetes care among elderly medicare enrolled veterans?

OBJECTIVE: To examine gender differences in diabetes care process measures and intermediate outcomes among veteran clinic users. DESIGN: A retrospective cohort study using Veterans Health Administration (VHA) and Medicare files of VHA clinic users with diabetes. Diabetes care process measures were tests for hemoglobin A1c (HbA1c), low-density lipoprotein (LDL-C) values, and eye exams. Intermediate outcomes were HbA1c and LDL-C values below recommended thresholds. Chi-square tests and logistic regressions were used to assess gender differences. PARTICIPANTS: Study population included 3,225 women and 231,922 men veterans with diabetes, enrolled in Medicare fee-for-service and alive at the end of fiscal year 2000. RESULTS: Overall, there were no significant gender differences in HbA1c or LDL-C testing. However, women had higher rates in these process measures than men among the non-African American minorities. Women were more likely to have completed eye exams (odds ratio [OR]=1.11; 99% confidence interval [CI]=1.10, 1.23) but were less likely to have LDL-C under 130 mg/dL (OR=0.77; 99% CI=0.69, 0.87). CONCLUSIONS: Among VHA patients with diabetes, clinically significant gender inequality was not apparent in most of diabetes care measures. However, there was evidence of better care among nonwhite and non-African American women than their male counterparts. Further research on interaction of race and gender on diabetes care is needed. This includes evaluation of integrated VHA women’s health programs as well as cultural issues. Lower LDL-C control among women suggests areas of unmet needs for women and opportunities for future targeted quality improvement interventions at system and provider levels.     

Better preservation of immune function after laparoscopic-assisted<Emphasis Type="Italic">vs</Emphasis>. open bowel resection in a murine model

PURPOSE: We evaluated cell-mediated immune function after laparoscopic-assisted and open bowel resection in rats by measuring delayed-type hypersensitivity responses to keyhole limpet hemocyanin (KLH) and phytohemagglutinin (PHA). METHODS: Male Sprague-Dawley rats (n=120) were sensitized to 1 mg of KLH ten days before investigations. Rats were challenged preoperatively, immediately postoperatively, and on postoperative day (POD) 2 with an intradermal injection of 0.3 mg of KLH and 0.2 mg of PHA (at different sites). Averages of two measures of perpendicular diameters (taken 24 and 48 hours postchallenge) were used to calculate the area of induration using the formula for the area of an ellipse, A=(D₁/2×D₂/2)×π. Anesthesia control animals underwent no procedure (n=40). Open resection group underwent ligation and resection of the cecum (length=2 cm) through a 7 cm midline incision (n=40). In the laparoscopic-assisted resection group, under CO₂ pneumoperitoneum (4–6 mmHg), the cecum was identified, dissected free, and exteriorized through a 4 mm port. The cecum was then ligated and resected extracorporeally (n=40). RESULTS: Preoperative responses to both KLH and PHA were the same in all three groups. Furthermore, within each group, postoperative responses were similar. When groups were compared, the anesthesia group responses were significantly greater than the open resection group responses at all time points (P<0.05 for all comparisons). Laparoscopic-assisted resection group responses differed from control at only two of eight postoperative measures. Laparoscopic resection group responses were significantly greater than open resection group responses to challenge with both KLH and PHA on POD1 (P<0.02, for both comparisons) and POD 4 (P<0.05, for both comparisons). CONCLUSIONS: Postoperative cell-mediated immune function is better preserved after laparoscopic-assisted bowel resection than after open resection as assessed by skin antigen testing.     

Peritoneal adhesions after laparoscopic gastrointestinal surgery

Although laparoscopy has the potential to reduce peritoneal trauma and post-operative peritoneal adhesion formation,only one randomized controlled trial and a few comparative retrospective clinical studies have addressed this issue.Laparoscopy reduces de novo adhesion formation but has no efficacy in reducing adhesion reformation after adhesiolysis.Moreover,several studies have suggested that the reduction of de novo post-operative adhesions does not seem to have a significant clinical impact.Experimental data in animal models have suggested that CO2 pneumoperitoneum can cause acute peritoneal inflammation during laparoscopy depending on the insufflation pressure and the surgery duration.Broad peritoneal cavity protection by the insufflation of a low-temperature humidified gas mixture of CO2,N2O and O2 seems to represent the best approach for reducing peritoneal inflammation due to pneumoperitoneum.However,these experimental data have not had a significant impact on the modification of laparoscopic instrumentation.In contrast,surgeons should train themselves to perform laparoscopy quickly,and they should complete their learning curves before testing chemical anti-adhesive agents and antiadhesion barriers.Chemical anti-adhesive agents have the potential to exert broad peritoneal cavity protection against adhesion formation,but when these agents are used alone,the concentrations needed to prevent adhesions are too high and could cause major postoperative side effects.Anti-adhesion barriers have been used mainly in open surgery,but some clinical data from laparoscopic surgeries are already available.Sprays,gels,and fluid barriers are easier to apply in laparoscopic surgery than solid barriers.Results have been encouraging with solid barriers,spray barriers,and gel barriers,but they have been ambiguous with fluid barriers.Moreover,when barriers have been used alone,the maximum protection against adhesion formation has been no greater than 60%.A recent small,randomized clinical trial suggested that the combination of broad peritoneal cavity protection with local application of a barrier could be almost 100%effective in preventing post-operative adhesion formation.Future studies should confirm the efficacy of this global strategy in preventing adhesion formation after laparoscopy by focusing on clinical end points,such as reduced incidences of bowel obstruction and abdominal pain and increased fertility.     

Toward evidence-based quality improvement

OBJECTIVES: To determine effectiveness and costs of different guideline dissemination and implementation strategies. DATA SOURCES: MEDLINE (1966 to 1998), HEALTH-STAR (1975 to 1998), Cochrane Controlled Trial Register (4th edn 1998), EMBASE (1980 to 1998), SIGLE (1980 to 1988), and the specialized register of the Cochrane Effective Practice and Organisation of Care group. REVIEW METHODS: INCLUSION CRITERIA: Randomized-controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series evaluating guideline dissemination and implementation strategies targeting medically qualified health care professionals that reported objective measures of provider behavior and/or patient outcome. Two reviewers independently abstracted data on the methodologic quality of the studies, characteristics of study setting, participants, targeted behaviors, and interventions. We derived single estimates of dichotomous process variables (e.g., proportion of patients receiving appropriate treatment) for each study comparison and reported the median and range of effect sizes observed by study group and other quality criteria. RESULTS: We included 309 comparisons derived from 235 studies. The overall quality of the studies was poor. Seventy-three percent of comparisons evaluated multi-faceted interventions. Overall, the majority of comparisons (86.6%) observed improvements in care; for example, the median absolute improvement in performance across interventions ranged from 14.1% in 14 cluster-randomized comparisons of reminders, 8.1% in 4 cluster-randomized comparisons of dissemination of educational materials, 7.0% in 5 cluster-randomized comparisons of audit and feedback, and 6.0% in 13 cluster-randomized comparisons of multifaceted interventions involving educational outreach. We found no relationship between the number of components and the effects of multifaceted interventions. Only 29.4% of comparisons reported any economic data. CONCLUSIONS: Current guideline dissemination and implementation strategies can lead to improvements in care within the context of rigorous evaluative studies. However, there is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances. Decision makers need to use considerable judgment about how best to use the limited resources they have for quality improvement activities.     

Patient satisfaction of female and male users of veterans health administration services

OBJECTIVE: To compare patient satisfaction of male and female users of Veterans Health Administration (VHA) services. DESIGN: Cross-sectional study based on secondary analysis of data from VHA’s Survey of Healthcare Experiences of Patients (SHEP). PATIENTS: National random sample of 107,995 outpatients and 112,817 inpatients in FY2004. MEASURES: Patient’s ratings of overall quality (OQ) and unique dimensions of satisfaction. Sociodemographic and health-related patient attributes. ANALYSIS: Bivariate unadjusted analyses of the association between gender and other patient attributes and the outcomes of OQ and dimensions of satisfaction were conducted followed by multivariate analyses for each outcome, adjusting for demographic and health variables. RESULTS: Significant differences between female and male reporting of satisfaction were found in the unadjusted analyses with males showing greater levels of satisfaction than females (P<.05). These differences disappeared or became smaller for both outpatient and inpatient services, after adjusting for covariates. For 6 of the inpatient dimensions (Transitions, Physical Comfort, Involvement Family and Friends, Courtesy, Coordination, and Access) males had higher satisfaction than females after statistical adjustment. CONCLUSIONS: After adjustment for patient attributes, female VHA outpatients report similar OQ with VHA services as male patients. The fact that some inpatient dimensions of satisfaction continued to show effects favoring males even after adjustment suggests areas for continued focus in improving health care quality. Covariate adjustment is essential for evaluating satisfaction with health care services. Breaking down overall satisfaction into independent aspects of services is useful. The SHEP survey has provided a useful tool for evaluating and improving satisfaction among its VHA veteran users.     

Interleukin-6 and stress hormone responses after uncomplicated gasless laparoscopic-assisted and open sigmoid colectomy

PURPOSE: Laparoscopic colectomy has increasingly been advocated as an option for treatment of colonic disease. The purpose of this study was to compare effects of laparoscopicassisted sigmoid colectomy (LAS) and conventional open colectomy (OPEN) on postoperative cytokine and stress hormone responses. METHODS: Fourteen patients with sigmoid colon cancer, apparently free of preoperative complications, were analyzed. Patients in both groups underwent sigmoid colectomy with lymphadenectomy. LAS was performed by the gasless abdominal wall-lifting method. A 5 cm incision was placed at the beginning of the operation. Blood samples were taken preoperatively and postoperatively for measurement of interleukin-6, glucagon and C-reactive protein. Urinary catecholamine excretions were also determined postoperatively. RESULTS: The two groups of patients were similar with respect to age (61±7 for LASvs.64±9 for OPEN) and sex. Intraoperative blood loss did not differ significantly between groups (112±97 ml for LASvs.366±380 ml for OPEN). Operative times for LAS tended to be longer than those for OPEN (231±67vs.169±45 minutes;P=0.08). Similar time courses of postoperative interleukin-6, C-reactive protein, and stress hormone responses were observed in both groups. No significant differences were observed in the magnitude of changes except that the serum interleukin-6 level on day of surgery (postoperative day 0) was significantly higher in LAS patients than in those receiving OPEN. In addition, interleukin-6 levels showed a significant positive correlation with operative duration (r=0.582;P<0.05). CONCLUSIONS: Data suggest that stress responses after sigmoid colectomy, in patients undergoing LAS, are comparable with those of patients receiving OPEN and that the early interleukin-6 response after surgery appears to be associated with operative time.     

Strategies for promoting organizational and practice change by advancing implementation research

BACKGROUND: The persistence of a large quality gap between what we know about how to produce high quality clinical care and what the public receives has prompted interest in developing more effective methods to get evidence into practice. Implementation research aims to supply such methods. PURPOSE: This article proposes a set of recommendations aimed at establishing a common understanding of what implementation research is, and how to foster its development. METHODS: We developed the recommendations in the context of a translation research conference hosted by the VA for VA and non-VA health services researchers. IMPACTS: Health care organizations, journals, researchers and academic institutions can use these recommendations to advance the field of implementation science and thus increase the impact of clinical and health services research on the health and health care of the public.