Health-related quality of life and appropriateness of cholecystectomy

OBJECTIVE: To evaluate the relationship among appropriateness of the use of cholecystectomy and outcomes. SUMMARY BACKGROUND DATA: The use of cholecystectomy varies widely across regions and countries. Explicit appropriateness criteria may help identify suitable candidates for this commonly performed procedure. This study evaluates the relationship among appropriateness of the use of cholecystectomy and outcomes. METHODS: Prospective observational study in 6 public hospitals in Spain of all consecutive patients on waiting lists to undergo cholecystectomy for nonmalignant disease. Explicit appropriateness criteria for the use of cholecystectomy were developed by a panel of experts using the RAND appropriateness methodology and applied to recruited patients. Patients were asked to complete 2 questionnaires that measure health-related quality of life-the Short Form 36 (SF-36) and the Gastrointestinal Quality of Life Index (GIQLI)-before the intervention and 3 months after it. RESULTS: Patients judged as being appropriate candidates for cholecystectomy, using the panel's explicit appropriateness criteria, had greater improvements in the bodily pain, vitality, and social function domains of the SF-36 than those judged to be inappropriate candidates. They also demonstrated improvements in the GIQLI's physical impairment domain. Interventions judged as inappropriate were performed primarily among patients without symptoms of cholelithiasis. Those asymptomatic had a lower improvement in the bodily pain, social functioning, and physical summary scale of the SF-36 and in the symptomatology, physical impairment, and total score domains of the GIQLI. CONCLUSIONS: These results suggest a direct relationship between the application of explicit appropriateness criteria and better outcomes, as measured by health-related quality of life. They also indicate that patients without symptoms are not good candidates for cholecystectomy.     

Managing bariatric patients in a children's hospital: radiologic considerations and limitations

As the increasing prevalence of pediatric obesity and its associated risks gain national attention, adolescent bariatric surgery is gradually gaining acceptance as a viable weight loss tool for some severely obese adolescents. Obese patients often exceed the capacity limits of most radiological devices used for imaging. Because the radiological evaluation often plays a crucial role in the management of these patients, it is important for pediatric surgeons and radiologists to be aware of the special challenges and alternative algorithms for radiological evaluation. This review outlines and illustrates these considerations and limitations. Herein the authors discuss these topics within the context of characteristic bariatric patient profiles and the Roux-en-Y gastric bypass procedure, currently the authors' standard operative approach.     

Continent Urinary Diversion in Patients with Pelvic Irradiation: An Alternative Utilizing Transverse Colon Reservoir

The use of radiation therapy in pelvic malignancies increases the risk of urinary complications, sometimes being necessary urinary diversion. The risk of utilizing previously irradiated bowel should be avoided. The use of transverse colon is a safe and effective alternative. We present a heterotopic continent colonic reservoir with an easily catheterizable conduit.     

Kinematics of posterior cruciate ligament-retaining and -substituting total knee arthroplasty: a prospective randomised outcome study

We performed a prospective, randomised trial of 44 patients to compare the functional outcomes of a posterior-cruciate-ligament-retaining and posterior-cruciate-ligament-substituting total knee arthroplasty, and to gain a better understanding of the in vivo kinematic behaviour of both devices. At follow-up at five years, no statistically significant differences were found in the clinical outcome measurements for either design. The prevalence of radiolucent lines and the survivorship were the same. In a subgroup of 15 knees, additional image-intensifier analysis in the horizontal and sagittal planes was performed during step-up and lunge activity. Our analysis revealed striking differences. Lunge activity showed a mean posterior displacement of both medial and lateral tibiofemoral contact areas (roll-back) which was greater and more consistent in the cruciate-substituting than in the cruciate-retaining group (medial p < 0.0001, lateral p = 0.011). The amount of posterior displacement could predict the maximum flexion which could be achieved (p = 0.018). Forward displacement of the tibiofemoral contact area in flexion during stair activity was seen more in the cruciate-retaining than in the cruciate-substituting group. This was attributed mainly to insufficiency of the posterior cruciate ligament and partially to that of the anterior cruciate ligament. We concluded that, despite similar clinical outcomes, there are significant kinematic differences between cruciate-retaining and cruciate-substituting arthroplasties.     

Endovascular native vessel recanalization to maintain limb perfusion after infected prosthetic vascular graft excision

Prosthetic vascular graft infection is an uncommon yet serious condition. Traditional management has included debridement, excision of the infected graft, and revascularization as needed. We report on two cases in which limb viability was maintained by using endovascular native vessel recanalization after excision of infected prosthetic grafts. This approach was successful in maintaining adequate limb perfusion in both cases. Endovascular native vessel recanalization should be considered as an option to maintain limb viability after excision of infected prosthetic vascular grafts, especially when autogenous conduit is lacking or limitation of the extent of surgery is desirable.