Laparoscopic cholecystectomy for biliary dyskinesia in children provides durable symptom relief

Purpose

The purpose of this study was to determine the effectiveness of laparoscopic cholecystectomy in children with biliary dyskinesia.

Methods

Reports of children with an abnormal cholecystokinin (CCK)-stimulated HIDA scan between January 2001 and July 2006 who underwent laparoscopic cholecystectomy were reviewed. Postoperatively, a 23-item Likert scale, symptom questionnaire was administered to parents.

Results

Sixty-four children with chronic abdominal pain and no gallstones on ultrasound had an abnormal CCK-HIDA scan. Twenty-three children (median age, 14 years; 16 girls), with mean (SD) ejection fraction of 17% (8), underwent laparoscopic cholecystectomy and were further analyzed. Preoperatively, these children had right upper quadrant/epigastric pain (78%), nausea (52%), vomiting (43%), and generalized abdominal pain (22%) lasting for a median of 3 months (range, 1 month to 2.5 years). Median postoperative follow-up was 2.7 years. Sixteen (70%) parents completed the questionnaire. Of those who responded, 63% indicated that their children had no abdominal pain, 87% had no vomiting, and 69% had no nausea in the month preceding the questionnaire. Overall, 67% of parents indicated that their children's symptoms were completely relieved after cholecystectomy, whereas 7% indicated that the symptoms were not relieved.

Conclusion

Laparoscopic cholecystectomy is effective in providing both short-term and long-term improvement of symptoms in children with biliary dyskinesia.     

Older age at diagnosis of Hirschsprung disease decreases risk of postoperative enterocolitis, but resection of additional ganglionated bowel does not

Purpose

This study was conducted to determine the effect of age at diagnosis and length of ganglionated bowel resected on postoperative Hirschsprung-associated enterocolitis (HAEC).

Methods

Children who underwent endorectal pull-through (ERPT) between January 1993 and December 2004 were retrospectively reviewed. t Test, analysis of variance, Kaplan-Meier, and Cox's proportional hazards analyses were performed.

Results

Fifty-two children with Hirschsprung disease (median age, 25 days; range, 2 days-16 years) were included. Nineteen (37%) had admissions for HAEC. Proportional hazards regression showed that HAEC admissions decreased by 30% with each doubling of age at diagnosis (P = .03) and increased 9-fold when postoperative stricture was present (P < .01), after controlling for type of ERPT, trisomy 21, transition zone level, and preoperative enterocolitis. Thirty-six children, with age at initial operation less than 6 months, were grouped based on length of ganglionated bowel excised (A [5 cm] and B [>5 cm]). No significant difference in the number of HAEC admissions during initial 2 years post-ERPT was seen between groups A (n = 18) and B (n = 18). The study had a power of 0.8 to detect a difference of 1 admission over 2 years.

Conclusions

Children diagnosed with Hirschsprung disease at younger ages are at a greater risk for postoperative enterocolitis. Excising a longer margin of ganglionated bowel (>5 cm) does not seem to be beneficial in decreasing HAEC admissions.     

Smaller scars--what is the big deal: a survey of the perceived value of laparoscopic pyloromyotomy

Purpose

Laparoscopic and open pyloromyotomies are equally safe and effective, with the principal benefit of laparoscopy being better cosmesis. The goal of this study was to measure the perceived value of laparoscopic pyloromyotomy.

Methods

Four hundred sixteen subjects (177 college freshmen, 126 first-year medical students, and 101 parents) were asked to complete a questionnaire after photographs of mature pyloromyotomy (open and laparoscopic) scars were shown to them. To measure the perceived value, subjects' willingness to pay hypothetical additional out-of-pocket expenses for their preferred operation was assessed. Data were analyzed using Cochran-Mantel-Haenszel test, t test and multivariable regression.

Results

Four hundred four surveys were complete. Overall, 74% preferred the appearance after laparoscopy. Eighty-eight percent would pay an additional out-of-pocket amount for their daughter and 85% for their son to have the cosmetic outcome after laparoscopy. Respondents were willing to pay more for their daughters (P < .0001) and sons (P < .0001) than themselves. As expected, income level (P < .0001) influenced the willingness to pay, whereas ethnicity, education, number of children, and sex did not.

Conclusions

The cosmetic benefit of laparoscopic pyloromyotomy was valued by a wide demographic with 85% being willing to pay additional expenses for their children to have smaller scars.     

Splenectomy reduces packed red cell transfusion requirement in children with sickle cell disease

Purpose

The purpose of the study was to measure the effect of splenectomy on packed-cell transfusion requirement in children with sickle cell disease.

Methods

Thirty-seven sickle cell children who underwent splenectomies between January 2000 and May 2006 at a children's hospital were reviewed. Data were collected 6 months preoperatively to 12 months postsplenectomy. Paired t test, analysis of variance, and multivariable regression analyses were performed.

Results

Of 37 children with median age 11 years (range, 2-18 years), 34 (21 males) had data that allowed analyses. Twenty-six had Hgb-SS, 5 had Hgb-SC, and 3 had Hgb S-Thal. Laparoscopic splenectomy was attempted in 36 and completed successfully in 34 (94% success). The number of units transfused decreased by 38% for 0 to 6 months and by 45% for 6 to 12 months postsplenectomy. Postoperatively, hematocrit levels increased and reticulocytes concurrently decreased with a reduction in transfusion clinic visits. The decrease in transfusion was not influenced by spleen weight, age, or hemoglobin type. Two children had acute chest syndrome (6%), and 1 had severe pneumonia (3%).

Conclusion

Laparoscopic splenectomy can be successfully completed in sickle cell children. Splenectomy significantly reduces the packed red cell transfusion requirement and frequency of clinic visits, in sickle cell children for at least 12 months postoperatively.     

Prospective study of adiposity and weight change in relation to prostate cancer incidence and mortality

BACKGROUND.

Adiposity has been linked inconsistently with prostate cancer, and few studies have evaluated whether such associations vary by disease aggressiveness.

METHODS.

The authors prospectively examined body mass index (BMI) and adult weight change in relation to prostate cancer incidence and mortality in 287,760 men ages 50 years to 71 years at enrollment (1995–1996) in the National Institutes of Health‐AARP Diet and Health Study. At baseline, participants completed questionnaires regarding height, weight, and cancer screening practices, including digital rectal examinations and prostate‐specific antigen tests. Cox regression analysis was used to calculate relative risks (RR) and 95% confidence intervals (95% CIs).

RESULTS.

In total, 9986 incident prostate cancers were identified during 5 years of follow‐up, and 173 prostate cancer deaths were ascertained during 6 years of follow‐up. In multivariate models, higher baseline BMI was associated with significantly reduced total prostate cancer incidence, largely because of the relationship with localized tumors (for men in the highest BMI category [≥40 kg/m²] vs men in the lowest BMI category [<25 kg/m²]: RR, 0.67; 95% CI, 0.50–0.89; P = .0006). Conversely, a significant elevation in prostate cancer mortality was observed at higher BMI levels (BMI <25 kg/m²: RR, 1.0 [referent group]; BMI 25–29.9 kg/m²: RR, 1.25; 95% CI, 0.87–1.80; BMI 30–34.9 kg/m²: RR, 1.46; 95% CI, 0.92–2.33; and BMI ≥35 kg/m²: RR, 2.12; 95% CI, 1.08–4.15; P = .02). Adult weight gain from age 18 years to baseline also was associated positively with fatal prostate cancer (P = .009), but not with incident disease.

CONCLUSIONS.

Although adiposity was not related positively to prostate cancer incidence, higher BMI and adult weight gain increased the risk of dying from prostate cancer. Cancer 2007. Published 2007 by the American Cancer Society.     

Does body mass index affect infection-related outcomes in the intensive care unit?

BACKGROUND: Obesity is a worldwide healthcare concern, but its impact on critical care (intensive care unit; ICU) outcomes is not well understood. The general hypothesis is that obesity worsens ICU outcomes, but published reports fail to demonstrate this effect consistently. We hypothesized that increasing BMI would be an independent predictor of higher mortality rates in the surgical/trauma ICU. METHODS: Data on patients with infections, defined by U.S. Centers for Disease Control and Prevention criteria, were collected prospectively from a single university surgical/trauma ICU. From 1996 to 2003, 807 such patients had measurable BMIs on admission to the ICU and were divided into underweight (<18.5 kg/m(2)), normal weight (18.5-24.9 kg/m(2)), overweight (25.0-29.9 kg/m(2)), obese (30.0-39.9 kg/m(2)), and morbidly obese (> or =40.0 kg/m(2)). The primary outcome was in-hospital death. Bivariate and multivariate analyses were performed. RESULTS: In-hospital death was associated with increasing age, increasing average Acute Physiology and Chronic Health Evaluation (APACHE) II score, history of diabetes (p = 0.001), cardiac disease (p = 0.001), hypertension (p = 0.044), history of cerebrovascular disease (p = 0.021), renal insufficiency (p = 0.007), need for hemodialysis (p < 0.001), history of pulmonary disease (p = 0.012), requirement for mechanical ventilation while in the ICU (p = 0.107), history of malignant disease (p < 0.001), and history of liver disease (p < 0.001). The multivariate analysis selected age (odds ratio [OR] 1.03 per integer; confidence interval [CI] 1.0, 1.05), APACHE II score (OR 1.17 per integer; CI 1.12, 1.74), diabetes (OR 2.20; CI 1.32, 3.65), mechanical ventilation (OR 1.88; CI 1.21, 2.94), malignancy (OR 2.54; CI 1.43, 4.47), and liver disease (OR 5.01; CI 2.69, 9.32) as significant risk factors. When controlling for these variables, none of the BMI groups had an independent association with death compared with the normal weight group. CONCLUSION: Contrary to the hypothesis, the data suggest no discernable independent association of increasing BMI with heightened mortality rate in the surgical/trauma ICU patient with infection.     

Duration of antibiotic therapy for ventilator-associated pneumonia caused by non-fermentative gram-negative bacilli

BACKGROUND AND PURPOSE: Chastre et al. compared eight and 15 days of antibiotic therapy for ventilator-associated pneumonia (VAP), finding no difference in outcome with the exception of VAP caused by non-fermentative gram-negative bacilli (NFGNB), for which a higher recurrence rate was seen in the shorter-duration group (JAMA 2003;290:2588-2598). We recently examined our institutional experience with VAP caused by NFGNB to determine whether shorter courses of antibiotic therapy were associated with higher rates of recurrence. METHODS: Data collected on all patients completing treatment for VAP in a surgical/trauma intensive care unit from December 1996 to October 2004 were analyzed retrospectively for the relations between the duration of antibiotic therapy and recurrence and in-hospital mortality rates. RESULTS: Of the 452 episodes of VAP, 154 were associated with NFGNB. Twenty-seven patients were treated with 3-8 days (mean 6.4 +/- 0.3 days) of antibiotics, whereas 127 received nine or more days (mean 17.1 +/- 0.7 days) of therapy. The recurrence rate for infections treated with the shorter course was 22% vs. 34% for patients receiving nine or more days of antibiotics (p = 0.27). The mortality rates were 22% and 14%, respectively (p = 0.38). Similar trends were demonstrated for infections caused by other organisms. CONCLUSIONS: We did not find a higher recurrence rate in patients with VAP caused by NFGNB who received shorter courses of antibiotic therapy. On the contrary, those patients receiving shorter courses trended toward lower rates of recurrence. Pending further prospective trials addressing the duration of antibiotic treatment for patients with VAP caused by NFGNB, shorter courses of treatment, perhaps based on improvement in clinical parameters, may be warranted.     

Single-institutional experience with the surgical infection prevention project in intra-abdominal surgery

BACKGROUND: The incidence of surgical site infection (SSI) is becoming a key component of standard measures of quality of performance. We hypothesized that institutional implementation of a protocol targeting known risk factors would reduce the incidence of SSI associated with intra-abdominal surgery. METHODS: Beginning in June 2004, a quality control initiative was implemented to prevent SSI in patients undergoing intra-abdominal surgical procedures at an academic medical center. This protocol included administration of the proper prophylactic antibiotic 0-60 minutes before incision, continued antibiotic administration for or=36 degrees C), along with good glycemic control (goal<200 mg/dL 48 h postoperatively) in diabetic patients. Baseline data collected during the initial four months of protocol development (379 patients) were compared with data collected during the last four months of the 11-month study period (390 patients). RESULTS: Compliance with antibiotic selection increased from 89 percent to 97 percent (p 相似文献