PubMed · 8128682
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E H Phillips. 1993. Laparoscopic biliary operation.. https://pubmed.ncbi.nlm.nih.gov/8128682/
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We investigated the usefulness of hepatobiliary scintigraphy (HBS) for diagnosing biliary obstruction after curative hepatic resection with biliary-enteric anastomosis. The study population consisted of 54 patients who underwent surgery for benign (n=18) or malignant (n=36) biliary disease. We analysed 68 technetium-99m DISIDA scintigrams which were performed at least 1 month after the surgery (median: 9 months). Final diagnosis was made by operative exploration, other invasive radiological studies or clinical and radiological follow-up for at least 6 months after the surgery. Diagnostic accuracy was analysed according to the pretest likelihood of biliary obstruction. There were two total and 15 segmental biliary obstructions. In patients with symptoms of biliary obstruction and abnormal liver function, HBS always allowed correct diagnosis (two instances of total obstruction, seven of segmental obstruction and seven of non-obstruction). Among the patients with nonspecific symptoms or isolated elevation of serum alkaline phosphatase, HBS diagnosed segmental biliary obstruction in seven of the eight instances, and non-obstruction in 22 of 23 instances. There were no cases of biliary obstruction and no false-positive results of HBS in 21 instances with no clinical signs or symptoms of biliary obstruction. The diagnostic sensitivity and specificity of HBS for biliary obstruction were 94% (16/17) and 97% (50/51), respectively. In conclusion, HBS is a highly accurate modality for the diagnosis of segmental biliary obstruction during long-term follow-up after hepatic resection with biliary-enteric anastomosis.
BACKGROUND: Reports of better results at national referral centers than at low-volume community hospitals have prompted calls for regionalizing pancreaticoduodenectomy (the Whipple procedure). We examined the relationship between hospital volume and mortality with this procedure across all US hospitals. METHODS: Using information from the Medicare claims database, we performed a national cohort study of 7,229 Medicare patients more than 65 years old undergoing pancreaticoduodenectomy between 1992 and 1995. We divided the study population into approximate quartiles according to the hospital's average annual volume of pancreaticoduodenectomies in Medicare patients: very low (<1/y), low (1-2/y), medium (2-5/y), and high (5+/y). Using multivariate logistic regression to account for potentially confounding patient characteristics, we examined the association between institutional volume and in-hospital mortality, our primary outcome measure. RESULTS: More than 50% of Medicare patients undergoing pancreaticoduodenectomy received care at hospitals performing fewer than 2 such procedures per year. In-hospital mortality rates at these low- and very-low-volume hospitals were 3- to 4-fold higher than at high-volume hospitals (12% and 16%, respectively, vs. 4%, P<.001). Within the high-volume quartile, the 10 hospitals with the nation's highest volumes had lower mortality rates than the remaining high-volume centers (2.1% vs. 6.2%, P<.01). The strong association between institutional volume and mortality could not be attributed to patient case-mix differences or referral bias. CONCLUSIONS: Although volume-outcome relationships have been reported for many complex surgical procedures, hospital experience is particularly important with pancreaticoduodenectomy. Patients considering this procedure should be given the option of care at a high-volume referral center.
During my stay in France I had the unique opportunity to meet surgical professors from all over the world and made many friends and contacts in the field of hepatobiliary surgery. Brittany is a beautiful province of France, having unique way of life and approach to social and societal problems. The cultural enrichment that I received from my year there will last a lifetime, as well the many fond memories of the people, the culinary delights and the spectacular seashore.