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Implementation of a clinical pathway decreases length of stay and cost for bowel resection
GASTROENTEROLOGY Vol. 114, No. 4
A1418 SSAT ABSTRACTS
S0197 TECHNICAL ASPECTS OF LAPAROSCOPIC CARDIOMYOTOMY WITH PARTIAL FUNDOPLICATION IN THE MANAGEMENT OF ACHALASIA. HW Pinotti, CE Domene. MA Santo, P Volpe, P Onari. S Szachn0wicz, - Digestive Surgery Department. University of Sao Paulo Medical School, Sao Paulo, Brazil. We critically appraised 50 consecutive patients operated on according to our laparoscopic approach to achieve the same good results of open cardiomyotomy with partial fundoplication in the treatment of non-advanced achalasia. We performed the same operation as we have made in open surgery, with some variations in order to achieve a safer laparoscopic procedure: we began with the partial fundoplication, performing the first suture line between posterior esophagus and gastric fundus; the second line in the anterior surface of the esophagus, and thus the myotomy. The third suture line was made in the gastric fundus and right border or myotomy. There were no conversions to laparotomy. There were six (12%) intraoperative complications, all of them with good evolution. We had two immediate postoperative complications and one death. There were no late complications. LCPF in the management of achalasia provide the same functional results and brings to the patients the benefits of minimally invasive surgery with minimal morbidity and mortality. • S0198 VIDEOSURGERY ESOPHAGECTOMY. HW Pinotti. CE Domene, MA Santo. P Volpe, P Onari, F Atui - Digestive Surgery Department. University of S~o Paulo Medical School, Sao Paulo, Brazil. Controversial aspects remain surrounding the proper contribution of video surgery in staging and surgical treatment of esophageal diseases. Five patients with esophageal neoplasia were treated by thoracoscopy/laparoscopy/ cervicotomy, and five with advanced achalasia through laparoscopic/ cervicotomy approach, between 1995 and 1997; median age was 56 years. No complications were observed in the patients operated on for benign disorders. Two complications ocurred in the malignant group: one drainage of ascitis through the chest drain (patient with liver cirrhosis) and one partial dehiscence of the gastric tube (patient with malnutrition), treated in a conservative manner. The patients were discharged from the hospital after 7 to 10 days. One patient with advanced cancer died two months after operation with carcinomatosis. Those who underwent thoracoscopy and thoracic draining complained of pain and difficulty in locomotion. These patients benefited less from the relative advantages of the use of a minimally invasive surgical access. • S0199 RETROPERITONEAL AND MESENTERIC CYST: CHARACTERISTICS AND SURGICAL MANAGEMENT. B.K: Poul0se. M.F. Kutka. M.A. Talamini, K.D. Lillemoe. and J.L. Cameron. The Johns Hopkins University School of Medicine. Baltimore, Maryland. Retroperitoneal (RC) and mesenteric cysts (MC) are rare clinical entities, with only 300 cases reported in the English literature. Historically, their presentation includes nonspecific abdominal symptoms, and management strategies have included marsupialization, partial excision and drainage, or complete resection. Despite being of common origin, it is unclear whether these abdominal tumors have similar presentations and if similar surgical management is appropriate. To gain further experience with these tumors, we performed a retrospective study of the cases of RC and MC presenting to a tertiary care center for the past 49 years, representing the largest study to date of these lesions at a single institution. Patients with a diagnosis of RC or MC were identified from surgical and pathological records from 1949-1997. Thirty-one patients with cysts of congenital or neoplastic origin were entered into the review, including 14 cases of RC and 17 cases of MC. Cysts of traumatic or infectious etiology were excluded. Clinical, radiological, operative, and pathological factors were examined with total mean follow up of 65 months. Both RC and MC patients tended to be white (75%) females (75%) with mean ages of 40 (RC) and 31 (MC) years. The most common complaint for RC and MC was abdominal pain (29% and 65%, respectively). Twenty-nine percent of RC patients and 21% of MC patients were asymptomatic. The correct preoperative diagnosis was achieved in 8% of the RC group and 30% of the MC group. Diagnostic modalities for both groups included CT (53%), ultrasound (20%), MRI (13%), IVP (8%), and small bowel series (8%). Complete excision was performed on 71% of RC patients with no recurrence, while partially resected RC tumors recurred in 50% of cases. Patients undergoing partial excision had a significantly higher rate of major complications. Organs adherent to RC tumors included: pancreas, spleen, adrenal, kidney, IVC, aorta, and esophagus. All MC patients underwent complete cyst excision with no recurrence and no major complications, although 18% required bowel resection. RC and MC present similarly and are often asymptomatic. Despite current radiologic techniques, preoperative identification of these tumors can be difficult, and definitive diagnosis is usually made at the time of surgery. Complete resection is the procedure of choice for both RC and MC, even if bowel resection is required.
• S0200 IMPLEMENTATION OF A CLINICAL PATHWAY DECREASES LENGTH OF STAY AND COST FOR BOWEL RESECTION. TA Pritts, MS Nussbaum. LV Flesch. EJ Fevelman. AJ Parikh. and JE Fischer. Department of Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio. Clinical Pathways are designed to streamline patient care delivery and maximize efficiency while minimizing cost. Despite the growing utilization of these pathways in medicine, their impact has not been extensively investigated. In this study, we examined the effect of a clinical pathway for small and large bowel resection on cost and length of stay. Methods: A clinical pathway to serve patients undergoing bowel resection was developed by a multidisciplinary team and implemented in January 1996. All patients undergoing bowel resection were eligible for inclusion at the discretion of the attending surgeon. Data concerning length of stay and cost was collected retrospectively for all patients undergoing bowel resection in 1995 and prospectively for one year after pathway implementation. The following groups were compared: (1) prepathway implementation, (2) postpathway implementation but not enrolled in pathway, and (3) participating in pathway. Results: Length of stay (LOS) and cost in the three groups were analyzed by ANOVA with multiple comparisons done by Tukey's test when overall differences were significant. Patient demographics, results, and statistical analyses are summarized in the table below. Values represent means + SEM where applicable. Costs from 1996 were converted to 1995 dollars by linking 1996 charges to the appropriate 1995 cost. Group
prepathway nonpathway pathway * p value vs. other groups
N 167 69 101
M:F 78:89 30:39 44:57
Age (years) 57.1-+ 1.3 50.0 +- 2.3* 59.6 -+ 1.6 < 0.05
LOS (davs) 12.5-+0.79 1.6 -+ 1.07 9.4 -+0.61" 0.0207
Cost $20376-+ 1276 $21841 -+ 2386 $14720 -+ 1105" 0.0049
Conclusions: Implementation of the pathway produced significant decreases in length of stay and cost in participating patients. We conclude that a clinical pathway is effective in lowering cost and length of stay even in an operation in which there is a great deal of experience. These results support the further development of clinical pathways for surgical procedures. S0201 SELECTIVE DECREASES IN LEVELS OF mRNA ENCODING A WATER CHANNEL (AQP3) IN ILEAL MUCOSA AFTER ILEOSTOMY. J. Purdy, R.R. Cima, M. A. DoNe, MJ. Zinner, and D.I. Soybel. Dept. of Surgery, Brigham and Women's Hospital and West Roxbury V.A.M.C., Boston, MA.
Water channels (aquaporins) provide pathways for water permeation in a variety of epithelia. Aquaporin-3 (AQP3), has been localized to the small intestine but mechanisms that regulate its expression and function have not been explored. To determine whether the presence or absence of luminal contents may influence intestinal AQP3 expression, adult Sprague-Dawley rats underwent sham laparotomy (SHAM, n=5) or loop ileostomy (ILEO, n=5). Loop ileostomies were constructed proximal to the cecum, leaving 5 cm of ileum deprived of luminal content. Animals were fed ad libitum. Animals were sacrificed 8 days after procedures. Mucosa was harvested for isolation of total mRNA from jejunum, ileum proximal to the stoma, and ileum distal to the stoma. Northem analysis was used to measure mRNA levels for AQP3 and the Na+/K+ ATPase, a housekeepingtransporter that regulates cellular levels of Na÷ and K+. Results (mRNA measured by densitometry, normalized to GAPDH mRNA levels, and expressed as means + SE, *p<0.05 compared to SHAM):
AQP3 Na/K
JEJUNUM SHAM ILEO 104--.12 116-+15 94 -+4 94 -+ 5
ILEUM-PROX SHAM ILEO 101-+5 98-+15 106 -+4 127 -+ 2*
ILEUM-DIST SHAM ILEO 269-+17 I21-+16 ~ 129 -+7 125 -+7
Through the 8 day period before sacrifice, weights were stable in all SHAM animals and declined by -25% in all ILEO animals (p<0.001). At sacrifice, all regions of mucosa in SHAM animals were normal. In all ILEO animals, the jejunal and proximal ileal mucosa had not yet hypertrophied but the diverted distal ileum was already visibly atrophied. Little variation in Na/K mRNA levels was observed among different regions of the small intestine, in SHAM or ILEO animals. In ILEO animals, these levels were mildly elevated in the proximal ileal segment, consistent with increases in Na÷ transport in this region that might be expected in the early response to loss of the colon. In contrast, levels of AQP3 mRNA were similar in jejunum and proximal ileal regions, but 2-fold higher in the distal ileum (P<0.0001). Ileostomy decreased AQP3 mRNA levels in this region markedly. These findings indicate regional variations in expression of water channels in mucosa of the small intestine. In addition, they suggest that AQP3 gene expression may be altered in response to luminal contents. • S0202 GENERATION OF A TISSUE SPECIFIC TRANSGENIC MOUSE MODEL USING CRE RECOMBINASE LINKED TO AN INSULIN PROMOTER. M.K. Ray, F.J. DeMayo, F.C. Brunicardi. Departments of Surgery and Cell Biology, Baylor College of Medicine, Houston, TX.
The rat insulin promoter has been characterized at Baylor College of Medicine enabling targeted gene expression in the beta cells. The purpose of this study was to express in vivo Cre recombinase specifically in beta cells of the mouse.
A1418 SSAT ABSTRACTS
S0197 TECHNICAL ASPECTS OF LAPAROSCOPIC CARDIOMYOTOMY WITH PARTIAL FUNDOPLICATION IN THE MANAGEMENT OF ACHALASIA. HW Pinotti, CE Domene. MA Santo, P Volpe, P Onari. S Szachn0wicz, - Digestive Surgery Department. University of Sao Paulo Medical School, Sao Paulo, Brazil. We critically appraised 50 consecutive patients operated on according to our laparoscopic approach to achieve the same good results of open cardiomyotomy with partial fundoplication in the treatment of non-advanced achalasia. We performed the same operation as we have made in open surgery, with some variations in order to achieve a safer laparoscopic procedure: we began with the partial fundoplication, performing the first suture line between posterior esophagus and gastric fundus; the second line in the anterior surface of the esophagus, and thus the myotomy. The third suture line was made in the gastric fundus and right border or myotomy. There were no conversions to laparotomy. There were six (12%) intraoperative complications, all of them with good evolution. We had two immediate postoperative complications and one death. There were no late complications. LCPF in the management of achalasia provide the same functional results and brings to the patients the benefits of minimally invasive surgery with minimal morbidity and mortality. • S0198 VIDEOSURGERY ESOPHAGECTOMY. HW Pinotti. CE Domene, MA Santo. P Volpe, P Onari, F Atui - Digestive Surgery Department. University of S~o Paulo Medical School, Sao Paulo, Brazil. Controversial aspects remain surrounding the proper contribution of video surgery in staging and surgical treatment of esophageal diseases. Five patients with esophageal neoplasia were treated by thoracoscopy/laparoscopy/ cervicotomy, and five with advanced achalasia through laparoscopic/ cervicotomy approach, between 1995 and 1997; median age was 56 years. No complications were observed in the patients operated on for benign disorders. Two complications ocurred in the malignant group: one drainage of ascitis through the chest drain (patient with liver cirrhosis) and one partial dehiscence of the gastric tube (patient with malnutrition), treated in a conservative manner. The patients were discharged from the hospital after 7 to 10 days. One patient with advanced cancer died two months after operation with carcinomatosis. Those who underwent thoracoscopy and thoracic draining complained of pain and difficulty in locomotion. These patients benefited less from the relative advantages of the use of a minimally invasive surgical access. • S0199 RETROPERITONEAL AND MESENTERIC CYST: CHARACTERISTICS AND SURGICAL MANAGEMENT. B.K: Poul0se. M.F. Kutka. M.A. Talamini, K.D. Lillemoe. and J.L. Cameron. The Johns Hopkins University School of Medicine. Baltimore, Maryland. Retroperitoneal (RC) and mesenteric cysts (MC) are rare clinical entities, with only 300 cases reported in the English literature. Historically, their presentation includes nonspecific abdominal symptoms, and management strategies have included marsupialization, partial excision and drainage, or complete resection. Despite being of common origin, it is unclear whether these abdominal tumors have similar presentations and if similar surgical management is appropriate. To gain further experience with these tumors, we performed a retrospective study of the cases of RC and MC presenting to a tertiary care center for the past 49 years, representing the largest study to date of these lesions at a single institution. Patients with a diagnosis of RC or MC were identified from surgical and pathological records from 1949-1997. Thirty-one patients with cysts of congenital or neoplastic origin were entered into the review, including 14 cases of RC and 17 cases of MC. Cysts of traumatic or infectious etiology were excluded. Clinical, radiological, operative, and pathological factors were examined with total mean follow up of 65 months. Both RC and MC patients tended to be white (75%) females (75%) with mean ages of 40 (RC) and 31 (MC) years. The most common complaint for RC and MC was abdominal pain (29% and 65%, respectively). Twenty-nine percent of RC patients and 21% of MC patients were asymptomatic. The correct preoperative diagnosis was achieved in 8% of the RC group and 30% of the MC group. Diagnostic modalities for both groups included CT (53%), ultrasound (20%), MRI (13%), IVP (8%), and small bowel series (8%). Complete excision was performed on 71% of RC patients with no recurrence, while partially resected RC tumors recurred in 50% of cases. Patients undergoing partial excision had a significantly higher rate of major complications. Organs adherent to RC tumors included: pancreas, spleen, adrenal, kidney, IVC, aorta, and esophagus. All MC patients underwent complete cyst excision with no recurrence and no major complications, although 18% required bowel resection. RC and MC present similarly and are often asymptomatic. Despite current radiologic techniques, preoperative identification of these tumors can be difficult, and definitive diagnosis is usually made at the time of surgery. Complete resection is the procedure of choice for both RC and MC, even if bowel resection is required.
• S0200 IMPLEMENTATION OF A CLINICAL PATHWAY DECREASES LENGTH OF STAY AND COST FOR BOWEL RESECTION. TA Pritts, MS Nussbaum. LV Flesch. EJ Fevelman. AJ Parikh. and JE Fischer. Department of Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio. Clinical Pathways are designed to streamline patient care delivery and maximize efficiency while minimizing cost. Despite the growing utilization of these pathways in medicine, their impact has not been extensively investigated. In this study, we examined the effect of a clinical pathway for small and large bowel resection on cost and length of stay. Methods: A clinical pathway to serve patients undergoing bowel resection was developed by a multidisciplinary team and implemented in January 1996. All patients undergoing bowel resection were eligible for inclusion at the discretion of the attending surgeon. Data concerning length of stay and cost was collected retrospectively for all patients undergoing bowel resection in 1995 and prospectively for one year after pathway implementation. The following groups were compared: (1) prepathway implementation, (2) postpathway implementation but not enrolled in pathway, and (3) participating in pathway. Results: Length of stay (LOS) and cost in the three groups were analyzed by ANOVA with multiple comparisons done by Tukey's test when overall differences were significant. Patient demographics, results, and statistical analyses are summarized in the table below. Values represent means + SEM where applicable. Costs from 1996 were converted to 1995 dollars by linking 1996 charges to the appropriate 1995 cost. Group
prepathway nonpathway pathway * p value vs. other groups
N 167 69 101
M:F 78:89 30:39 44:57
Age (years) 57.1-+ 1.3 50.0 +- 2.3* 59.6 -+ 1.6 < 0.05
LOS (davs) 12.5-+0.79 1.6 -+ 1.07 9.4 -+0.61" 0.0207
Cost $20376-+ 1276 $21841 -+ 2386 $14720 -+ 1105" 0.0049
Conclusions: Implementation of the pathway produced significant decreases in length of stay and cost in participating patients. We conclude that a clinical pathway is effective in lowering cost and length of stay even in an operation in which there is a great deal of experience. These results support the further development of clinical pathways for surgical procedures. S0201 SELECTIVE DECREASES IN LEVELS OF mRNA ENCODING A WATER CHANNEL (AQP3) IN ILEAL MUCOSA AFTER ILEOSTOMY. J. Purdy, R.R. Cima, M. A. DoNe, MJ. Zinner, and D.I. Soybel. Dept. of Surgery, Brigham and Women's Hospital and West Roxbury V.A.M.C., Boston, MA.
Water channels (aquaporins) provide pathways for water permeation in a variety of epithelia. Aquaporin-3 (AQP3), has been localized to the small intestine but mechanisms that regulate its expression and function have not been explored. To determine whether the presence or absence of luminal contents may influence intestinal AQP3 expression, adult Sprague-Dawley rats underwent sham laparotomy (SHAM, n=5) or loop ileostomy (ILEO, n=5). Loop ileostomies were constructed proximal to the cecum, leaving 5 cm of ileum deprived of luminal content. Animals were fed ad libitum. Animals were sacrificed 8 days after procedures. Mucosa was harvested for isolation of total mRNA from jejunum, ileum proximal to the stoma, and ileum distal to the stoma. Northem analysis was used to measure mRNA levels for AQP3 and the Na+/K+ ATPase, a housekeepingtransporter that regulates cellular levels of Na÷ and K+. Results (mRNA measured by densitometry, normalized to GAPDH mRNA levels, and expressed as means + SE, *p<0.05 compared to SHAM):
AQP3 Na/K
JEJUNUM SHAM ILEO 104--.12 116-+15 94 -+4 94 -+ 5
ILEUM-PROX SHAM ILEO 101-+5 98-+15 106 -+4 127 -+ 2*
ILEUM-DIST SHAM ILEO 269-+17 I21-+16 ~ 129 -+7 125 -+7
Through the 8 day period before sacrifice, weights were stable in all SHAM animals and declined by -25% in all ILEO animals (p<0.001). At sacrifice, all regions of mucosa in SHAM animals were normal. In all ILEO animals, the jejunal and proximal ileal mucosa had not yet hypertrophied but the diverted distal ileum was already visibly atrophied. Little variation in Na/K mRNA levels was observed among different regions of the small intestine, in SHAM or ILEO animals. In ILEO animals, these levels were mildly elevated in the proximal ileal segment, consistent with increases in Na÷ transport in this region that might be expected in the early response to loss of the colon. In contrast, levels of AQP3 mRNA were similar in jejunum and proximal ileal regions, but 2-fold higher in the distal ileum (P<0.0001). Ileostomy decreased AQP3 mRNA levels in this region markedly. These findings indicate regional variations in expression of water channels in mucosa of the small intestine. In addition, they suggest that AQP3 gene expression may be altered in response to luminal contents. • S0202 GENERATION OF A TISSUE SPECIFIC TRANSGENIC MOUSE MODEL USING CRE RECOMBINASE LINKED TO AN INSULIN PROMOTER. M.K. Ray, F.J. DeMayo, F.C. Brunicardi. Departments of Surgery and Cell Biology, Baylor College of Medicine, Houston, TX.
The rat insulin promoter has been characterized at Baylor College of Medicine enabling targeted gene expression in the beta cells. The purpose of this study was to express in vivo Cre recombinase specifically in beta cells of the mouse.