The association between body mass index and severe biliary infections: a multivariate analysis.

Background: Obesity has been associated with worse infectious disease outcomes. It is a risk factor for cholesterol gallstones, but little is known about associations between body mass index (BMI) and biliary infections. We studied this using factors associated with biliary infections.

Predictors of long-term outcome after laparoscopic esophagomyotomy and Dor fundoplication for achalasia.

Objective: To identify predictors of long-term outcome of laparoscopic Heller myotomy for achalasia, including predictors of heartburn and recurrent dysphagia, which occasionally develop postoperatively.

Design: Retrospective review using interviews of patients.

Setting: Academic university hospital.

Operative reports: form and function.

Hypothesis: Little is known about how closely operative reports reflect what was actually performed during an operation, nor has the construction of operative reports been adequately studied with the aims of clarifying the objectives of those reports and improving their efficacy. We hypothesized that if more attention is paid to the objectives of operative reports, their content will more predictably contain the most relevant information, which might channel thinking in beneficial directions during performance of the operation.

Design: Multivariate analysis of 250 laparoscopic cholecystectomy operative reports (125 uncomplicated and 125 with bile duct injury).

The efficacy of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4863 cases.

Objectives: Medical team training (MTT) has been touted as a way to improve teamwork and patient safety in the operating room (OR).

Methods: OR personal completed a 1-day intensive MTT training. A standardized briefing/debriefing/perioperative routine was developed, including documentation of OR miscues, delays, and a case score (1-5) assigned by the OR team.

Excellent outcomes of laparoscopic esophagomyotomy for achalasia in patients older than 60 years of age.

Background: The effectiveness of an esophagomyotomy for dysphagia in elderly patients with achalasia has been questioned. This study was designed to provide an answer.

Methods: A total of 162 consecutive patients with achalasia who had a laparoscopic myotomy and Dor fundoplication and who were available for follow-up interview were divided by age: < 60 years (range, 14-59; 118 patients), and ≥ 60 years (range, 60-93; 44 patients).

Laparoscopic bile duct injuries: timing of surgical repair does not influence success rate. A multivariate analysis of factors influencing surgical outcomes.

Background: Many factors contribute to the success of biliary reconstructions following laparoscopic bile duct injury. We previously reported that control of intra-abdominal infection, complete preoperative cholangiography, surgical technique and surgical experience affected the results. There is no consensus, however, on whether the timing of the operation is important.

Has recognition of the relationship between mortality rates and hospital volume for major cancer surgery in California made a difference?: A follow-up analysis of another decade.

Background: Previous reports showed that in California during the early 1990s, operative mortality rates for esophageal, pancreatic, and hepatic cancers were inversely related to hospital volume. It is unknown whether this information has affected referral patterns or operative mortality rates.

Objectives: Data were analyzed for the 10 years that followed the period covered in the initial studies to determine if: (a) the operative mortality rates had decreased; and (b) a greater proportion of patients with esophageal, pancreatic, and hepatic cancers were treated at high-volume centers.

Neuroendocrine tumors of the ampulla of Vater: biological behavior and surgical management.

Objectives: To describe the biological behavior and surgical management of ampullary neuroendocrine tumors in 7 patients.

Design: Case series and literature review.

Setting: University hospital.

Evaluation of the biliary intestinal limb of a Roux-en-Y choledochojejunostomy using computed tomographic cholangiography.

Computed tomographic (CT) findings involving the biliary intestinal limb of a Roux-en-Y choledochojejunostomy may be ambiguous because oral agents frequently do not reflux into that limb. We describe 2 cases where antegrade biliary intestinal limb opacification by intravenous CT cholangiography in the left lateral decubitus position obviated the need for biopsy of an apparent enlarging mass in the biliary intestinal limb. We conclude that CT cholangiography may help clarify the status of a Roux-en-Y choledochojejunostomy.

Tumors of the ampulla of vater: histopathologic classification and predictors of survival.

Background: The histology and clinical behavior of ampullary tumors vary substantially. We speculated that this might reflect the presence of two kinds of ampullary adenocarcinoma: pancreaticobiliary and intestinal.

Study Design: We analyzed patient demographics, presentation, survival (mean followup 44 months), and tumor histology for 157 consecutive ampullary tumors resected from 1989 to 2006.

Elderly patients have more severe biliary infections: influence of complement-killing and induction of TNFalpha production.

Background: Biliary bacteria are more common in elderly patients and cause more serious illnesses. The reasons for this are unclear. We noted previously that bacterial serum-sensitivity and induction of TNFalpha production in sera (iTNFsera) were associated with severe biliary infections.

Laparoscopic enucleation of insulinomas.

Hypothesis: Laparoscopic enucleation of insulinomas is safe and effective and is associated with a short hospital stay.

Design: Case series identified through retrospective review of medical records.

Setting: University of California, San Francisco Medical Center, a tertiary care referral hospital.

Characterization of cystic pancreatic masses: relative accuracy of CT and MRI.

Objective: The objective of our study was to determine the role and relative accuracy of CT and MRI in the characterization of cystic pancreatic masses.

Materials And Methods: We retrospectively identified 58 patients with histopathologically proven cystic pancreatic masses at our institution who underwent preoperative CT (n = 40), MRI (n = 6), or both (n = 12). Two radiologists independently recorded their leading diagnoses with levels of diagnostic certainty (0-100%), their estimates of overall likelihood of malignancy (0-100%), and the morphologic characteristics of the tumors.

The outcome of laparoscopic Heller myotomy for achalasia is not influenced by the degree of esophageal dilatation.

In the past, a Heller myotomy was considered to be ineffective in patients with achalasia and a markedly dilated or sigmoid-shaped esophagus. Esophagectomy was the standard treatment. The aims of this study were (a) to evaluate the results of laparoscopic Heller myotomy and Dor fundoplication in patients with achalasia and various degrees of esophageal dilatation; and (b) to assess the role of endoscopic dilatation in patients with postoperative dysphagia.

Bacteria entombed in the center of cholesterol gallstones induce fewer infectious manifestations than bacteria in the matrix of pigment stones.

Purpose: The clinical significance of bacteria in the pigment centers of cholesterol stones is unknown. We compared the infectious manifestations and characteristics of bacteria from pigment stones and predominantly cholesterol stones.

Methods: Three hundred forty patients were studied.

Gallstones containing bacteria are biofilms: bacterial slime production and ability to form pigment solids determines infection severity and bacteremia.

Objective: Gallstone bacteria provide a reservoir for biliary infections. Slime production facilitates adherence, whereas beta-glucuronidase and phospholipase generate colonization surface. These factors facilitate gallstone formation, but their influence on infection severity is unknown.

Biliary bacterial factors determine the path of gallstone formation.

Background: Bacteria cause pigment gallstones and can act as a nidus for cholesterol gallstone formation. Bacterial factors that facilitate gallstone formation include beta-glucuronidase (bG), phospholipase (PhL), and slime. The current study sought to determine whether bacterial factors influence the path of gallstone formation.

Bipolar pulse coagulation for resection of the cirrhotic liver.

Background: The major technical challenge of liver surgery is controlling bleeding during transection of the parenchyma. The Gyrus hand piece (GHP) is a bipolar diathermy pulsation instrument that is similar in design to a large hemostat (Péan) clamp that divides tissue while the clamp remains closed.

Materials And Methods: We retrospectively analyzed the peri-operative data from 10 patients with early cirrhosis (stage 1-4) who underwent liver resection for hepatocellular cancer between February 2004 and July 2005.

Laparoscopic fundoplication in elderly patients with gastroesophageal reflux disease.

Hypothesis: It is unclear if age should be considered a factor in the choice of treatment for gastroesophageal reflux disease (GERD) and if fundoplication in elderly patients is as safe and effective as it is in younger patients. We hypothesized that the outcome of laparoscopic antireflux operations in patients younger than 65 years is similar to that of patients 65 years and older.

Design: Retrospective review of findings from a prospectively acquired database.

Local resection of ampullary tumors.

There is no consensus on the appropriateness of local resection for ampullary tumors, because malignant recurrence of what were thought to be benign tumors has been reported. This study examined the role of local resection in the management of ampullary tumors. Thirty patients (mean age 66 years) had transduodenal local resections performed at UCSF-Moffitt Hospital or the San Francisco VA Medical Center (February, 1992 to March, 2004).

Cause and treatment of epiphrenic diverticula.

Background: Epiphrenic diverticula of the esophagus are often associated with a concomitant esophageal motor disorder, which is thought to be the cause of the diverticulum and some of the patient's symptoms. At one time diverticula were best removed via a left thoracotomy, but now the operation can be performed laparoscopically in most cases. We hypothesized that: (1) a motor disorder is the underlying cause of the diverticulum; and (2) optimal treatment consists of laparoscopic resection of the diverticulum, a Heller myotomy, and Dor fundoplication.

Idiopathic pulmonary fibrosis: how often is it really idiopathic?

The cause of idiopathic pulmonary fibrosis (IPF) is unknown. The pathology suggests that IPF results from serial lung injury. It has been suggested that gastroesophageal reflux disease (GERD) may relate to the cause or the progression of the disease.

Spectrum of gallstone disease in the veterans population.

Background: Elderly male patients are thought to have a higher incidence of biliary infections. This demographic is common among veterans, so we analyzed the spectrum of gallstone disease in a large veteran population.

Methods: A total of 285 patients with gallstone disease were studied.

Spectrum of esophageal motility disorders: implications for diagnosis and treatment.

Background: The named primary esophageal motility disorders (PEMDs) are achalasia, diffuse esophageal spasm (DES), nutcracker esophagus (NE), and hypertensive lower esophageal sphincter (HTN-LES). Although the diagnosis and treatment of achalasia are well defined, such is not the case with the other disorders.

Hypothesis: (1) Symptoms do not reliably distinguish PEMDs from gastroesophageal reflux disease; (2) esophageal function tests are essential to this distinction and to identifying the type of PEMD; (3) minimally invasive surgery is effective for each condition; and (4) the laparoscopic approach is better than the thoracoscopic approach.

Congenital choledochal cysts in adults.

Hypothesis: Excision of the extrahepatic portion of congenital choledochal cysts (CCs) avoids the risk of cancer. The standard classification scheme is out of date.

Design: Retrospective case series and literature review.