Ambulatory Basis Research Articles

Body mass index, alcohol, tobacco and symptomatic gallstone disease: a Swedish twin study

Both genetic and environmental factors are involved in the pathogenesis of gallstone disease (GD). We aimed to examine the association between symptomatic GD and overweight (body mass index, BMI, 25-30 kg m(-2)), obesity (BMI > 30 kg m(-2)), alcohol, smoking and smoke-free tobacco by analysing a large twin population. The Swedish Twin Registry (STR) was linked to the Swedish Hospital Discharge and Causes of Death Registries for GD and GD-surgery related diagnoses. Weight, height, use of alcohol, smoking and smoke-free tobacco were provided by STR and analysed for possible associations by conditional logistic regression. Overweight and obesity were associated with a significantly higher risk for symptomatic GD in the whole study population (OR 1.86 and OR 3.38; CI: 1.52-2.28 and 2.28-5.02 respectively). High alcohol consumption was associated with a lower risk for GD in the whole population (OR 0.62; CI: 0.51-0.74) with no difference between discordant monozygotic and dizygotic twins (OR 1.08 and OR 0.96; CI: 0.82-1.42 and 0.79-1.16). Smoking or smoke-free tobacco was not correlated with GD. Consistent with epidemiological studies, we found positive associations between BMI and the development of symptomatic GD. High alcohol consumption was associated with a decreased risk against GD. Tobacco use has no impact on GD.

Hospitalization Criteria in Imported Falciparum Malaria

Controversy exists about the management of patients with imported Plasmodium falciparum malaria. We postulated that rapid parasite clearance supports ambulatory care, or, conversely, that factors associated with longer parasite clearance time (PCT) could be used as hospitalization criteria. Hospitalized patients with imported falciparum malaria recruited through one single travel clinic between 1993 and 2000. We used a linear regression to identify factors independently associated with PCT defined as the time in hours from antimalarial drug administration until the first negative malaria smear. Among 400 patients hospitalized with falciparum malaria, mean (range) PCT was 58 (1-189) hours. In multivariate analysis, severe malaria, gastrointestinal signs, initial temperature greater than or equal to 40 degrees C, parasitemia greater than or equal to 1%, and platelet counts less than 50,000/microL were associated with longer PCT. Offering ambulatory care to patients aged 15 to 64 years with none of the factors associated with longer PCT in the study would have resulted in 147 (37%) patients receiving outpatient care. Factors identified in this model may help physicians determine which P falciparum malaria patients can be treated on an ambulatory basis, and contribute to revisions of national guidelines for imported malaria management.

1112 Consecutive Bilateral Neck Explorations for Primary Hyperparathyroidism

Bilateral neck exploration has been the standard approach for patients with primary hyperparathyroidism. Improved localization studies and the availability of intraoperative parathyroid hormone monitoring have challenged the necessity of four-gland exploration. In this series we report a single surgeon's experience with bilateral neck exploration for primary hyperparathyroidism in an effort to establish benchmark outcomes from which to evaluate minimally invasive protocols. The charts of 1112 consecutive patients who underwent neck exploration for primary hyperparathyroidism by a single surgeon over a 17-year period were reviewed. All patients underwent bilateral neck exploration under either general (n = 264) or local (n = 848) anesthesia. The overall cure rate was 97.4% with a complication rate of 3.4%. Morbidity included recurrent laryngeal nerve injury (0.2%), postoperative bleeding (0.8%), and transient hypocalcemia (1.8%). There was no mortality. Overall mean operating time was 52.5 +/- 30.2 minutes. A single gland was removed in 78.4% of patients, and 22.3% of patients underwent concomitant thyroidectomy. The cure rate was lower for patients undergoing reexploration (89.2% vs. 97.9%, p < 0.05). Choice of anesthetic approach did not affect the cure or complication rate. The overall conversion rate from local to general anesthesia was 1.5%. Patients undergoing general anesthesia were operated on earlier in the series and were less likely to be managed on an ambulatory basis (local 87.5% vs. general 38.4%, p < 0.05). During the last 5 years of the series, more than 90% of patients underwent exploration under local anesthesia. This large modern series of neck explorations for primary hyperparathyroidism confirms the safety, feasibility, and efficacy of the bilateral approach. It further demonstrates that individual surgeons can achieve outcomes equivalent to those with four-gland explorations under local anesthesia.

A randomized trial of the Tubulcus multilayer bandaging system in the treatment of extensive venous ulcers

Venous ulcers are a major health problem because of their high prevalence and associated high cost of care. Compression therapy is the most widely used treatment for this condition. The vast majority of published articles on compression therapy present the results in the treatment of venous ulcers usually up to 15 to 20 cm(2). However, there are no published data in English medical literature on the efficacy of compression therapy in the treatment of extensive venous ulcers (ulcers >20 cm(2) of more than 6 months' duration) with regard to healing rate, time to healing, and recurrence rate at 12 months after healing. A total of 138 patients with extensive venous ulceration (ulceration surface, 20-210 cm(2); duration, 7 months to 28 years) were randomized into 2 groups: (1) a treatment group (72 patients who were treated by using a multilayer bandaging system with the Tubulcus (a heelless open-toed elastic compression device knitted in tubular form) and elastic bandages and (2) a control group (66 patients treated with a multilayer bandaging system with elastic bandages only). The patients were treated on an ambulatory basis; the primary end point of the study was complete ulcer healing at 500 days. The secondary end point was to assess the ulcer recurrence rate during continuation of below-knee compression of different degrees of compression. In the treatment group, patients were instructed to continue to wear the Tubulcus (35 mm Hg), and patients in the control group were instructed to wear compression stockings with compression of 20 to 25 mm Hg. The exclusion criteria from the study were heart insufficiency with an ejection fraction <35, an ankle-brachial pressure index less than 0.8, and pregnancy. The cumulative healing rate was 93% in the treatment group and was 51% in the control group (P < .001). The median healing time in the treatment group was 133 days (range, 28 to 464 days), and in the control group it was 211 days (range, 61 to 438 days). The recurrence rate at 12 months in the treatment group was 24% (16/67) and was 53% (18/34) in the control group (P < .05). After additional compression treatment with the same treatment protocol, all 16 recurrent ulcers in the treatment group healed. In the control group, the healing rate of recurrent ulcers was 89% (16/18). This study suggests that for extensive venous ulceration, multilayer compression therapy with the Tubulcus provides an extremely high healing rate. Compression of more than 30 mm Hg results in decreased ulcer recurrence. However, recurrence cannot be completely avoided.

Laser Resection of the Prostate: Implications for Anesthesia

Holmium:yttrium-aluminum-garnet and potassium-titanyl-phosphate lasers make it possible to perform transurethral prostate resection with almost no absorption of irrigant and minimal blood loss. Subarachnoid block is usually administered for classical transurethral resection of the prostate, so that the patient can be monitored for the onset of transurethral resection of the prostate syndrome secondary to irrigant absorption. New laser resection techniques may allow the patient and anesthesiologist to choose options most appropriate for the patient's medical conditions and preference. In this study, we review the urologic literature to provide an overview of current laser technology for prostate reduction surgery. We also screened this literature for evidence of potential effects on anesthesia care for special patient groups as well as for overall perioperative management. Our findings suggest that the anesthesiologist may now safely offer general anesthesia for endourologic laser surgery, even on an ambulatory basis. This includes patients with cardiovascular disease or receiving continuous anticoagulation therapy. We found no studies specifically aimed at evaluating best anesthetic practices for patients undergoing laser procedures. Therefore, clinical research is needed to better define the risks and benefits of the various anesthetic alternatives.

Stapled Hemorrhoidopexy: Outcome Assessment

Since its introduction as a new procedure for the surgical management of hemorrhoidal disease in 1993, stapled hemorrhoidopexy has become increasingly popular. This has been mostly the result of the reported reduction in postoperative pain. This study was designed to review retrospectively 152 patients combined from a 3-year period in a three-surgeon private colorectal practice and a 1-year period from an academic colon and rectal surgery training program. All patients had either grade II or III hemorrhoidal prolapse. There were 78 male (mean age, 52 years) and 74 female patients (mean age, 54 years). A total of 133 patients (87.5%) were treated on an ambulatory basis, with 131 patients (86%) given monitored sedation with local anesthesia. Postoperative complications were seen in 49 patients (32%); 33 were for bleeding, with four requiring operative control. Subsequent associated anorectal procedures were performed on 14 patients (9.2%). Of the original 152 patients, 78 participated in a postoperative survey. Of these patients, 67.9 per cent stated that their postoperative pain was less than expected. Seventy-one patients (91%) stated significant improvement or complete resolution of their symptoms, and 73.1 per cent returned to normal activity in less than 2 weeks. Eighty-nine per cent of patients surveyed stated they would recommend hemorrhoidopexy to others.

Intraarticular Morphine after Knee Arthroscopy. A Prospective, Randomized and Double-blind Study

Knee arthroscopy is a usual procedure in orthopedic surgery, which currently tends to be performed on an ambulatory basis. This underscores the need to provide the patient with efficient and safe analgesia. To assess the analgesic effect of intraarticular morphine after knee arthroscopy, as well as whether this effect is dose-dependent or whether, on the contrary, it is influenced by the patient's body mass index (BMI) or the duration of the procedure. The study analyzed 45 patients subjected to a knee arthroscopy at the Castelló General Hospital. They were randomly distributed across 3 groups (saline solution, 1 mg morphine chloride, 4 mg morphine chloride). For pain control, the visual analog scale (VAS) and the demand of rescue analgesia (metamizole 2 gr i.v.).In addition, a note was made of the time at which side effects occurred that could be attributed to the morphine chloride. Significant differences were found between the two morphine chloride groups and the control group regarding VAS scores at 24 hours. There were no significant differences in the remaining AVS measurements or in the demand of rescue analgesia. We did not observe a dose-dependent effect. There were no side effects that could be attributed to the intraarticular morphine chloride. The use of morphine chloride as an analgesic for patients undergoing knee arthroscopy is an effective and safe method. Larger study groups are necessary to find other statistically significant differences. La artroscopia de rodilla es una intervención frecuente en cirugía ortopédica, y últimamente se realiza sin ingreso, debiéndose proporcionar una analgesia eficaz y segura. Valorar el efecto analgésico de la morfina intraarticular tras artroscopia de rodilla, así como si este efecto es dosis dependiente o está influenciado por el índice de masa corporal del paciente o por la duración de la intervención. Se han incluido 45 pacientes intervenidos por artroscopia de rodilla en un hospital general. Se distribuyeron aleatoriamente en 3 grupos (suero fisiológico, 1 mg de cloruro mórfico, 4 mg de cloruro mórfico). Para el control del dolor se empleó la escala visual analógica (EVA) y la demanda de analgesia de rescate (metamizol 2 g intravenosos). También se recogió la hora a la que se presentaron efectos secundarios que podrían deberse al cloruro mórfico. Se encontraron diferencias significativas entre los dos grupos con cloruro mórfico respecto al grupo control en las puntuaciones de la EVA a las 24 horas. No se apreciaron diferencias significativas en el resto de las mediciones de la EVA ni en la demanda de analgesia de rescate. No observamos efecto dosis dependiente. No aparecieron efectos secundarios que puedan asociarse al cloruro mórfico intraarticular. El uso del cloruro mórfico como analgesia en pacientes sometidos a artroscopia de rodilla es un método eficaz y seguro. Hacen falta grupos de estudio más numerosos para encontrar otras diferencias estadísticas.

The Prevalence of Postoperative Pain in a Cross-sectional Group of Patients After Day-case Surgery in a University Hospital

Although a great variety of surgical procedures are performed on an ambulatory basis, little is known about postoperative pain experience at home after ambulatory surgery. This study was performed to assess the prevalence and course of postoperative pain in the early postoperative period after ambulatory surgery. Over a period of 4 months, 648 patients who underwent day-case surgery were included in our study. Data were collected with interviews and questionnaires. Pain intensity was measured using a visual analog scale (VAS) during 4 days after surgery. Side effects of anesthesia and analgesia techniques were also recorded. On the day of the operation, 26% of the patients had moderate to severe pain (defined as mean VAS >40 mm). Mean VAS-scores were greater than 40 mm in 21% on postoperative day (POD) 1, in 13% on POD 2, in 10% on POD 3, and in 9% on POD 4. Operations of nose and pharynx, abdominal operations, plastic surgery of the breasts, and orthopedic operations were the most painful procedures during the first 48 hours. This study showed that an important number of patients still experience moderate to severe pain in the postoperative period after day-case surgery even after a 4-day period. Furthermore, the type of operation should be considered when planning postoperative analgesia for ambulatory surgery.

Diagnostik bei ambulant erworbener Pneumonie

The diagnosis of community acquired pneumonia (CAP) is based on a patient history with respiratory symptoms and additional symptoms and signs such as fever over more than 4 days, dyspnea and tachypnea and/or a positive lung auscultation. Despite recently developed tests, radiology is a key diagnostic procedure for confirming CAP. Importantly, the first treating physician must judge whether to hospitalize a patient or not. Two major scoring systems allow judgement of severity and short-term prognosis. In general, in patients with mild or moderate pneumonia who can be treated on an ambulatory basis, no specific microbiological diagnosis must be performed. If, for clinical or epidemiological reasons a gram stain is done, it must be obtained from purulent sputum. Recent tests may help in discriminating between viral and bacterial pneumonia (procalcitonin test) or determine the bacteria responsible for acute disease (pneumococcal antigen test using urine).

Fluxión funiculotesticular, una complicación frecuente en la herniorrafia inguinal

SUMMARY Background: A complication of inguinal hernia repair that is seldom mentioned is spermatic cord and testicular swelling. Aim: To study the frequency of this complication, its clinical manifestations and to analyze its pathogenesis. Material and Methods: A descriptive observational, prospective study in 304 men (aged 15 to 89 years), subjected to an inguinal hernia repair. Operation was performed under local anesthesia in an ambulatory basis, with standard surgical techniques. The postoperative assessment was done by a member of the surgical staff one week and one month after surgery. Results: A mild or moderate swelling

Can spontaneous pneumothorax patients be treated by ambulatory care management?

In the Emergency Department, it would be worthwhile to treat pneumothorax patients on an outpatient basis by utilizing a small-calibre catheter and Heimlich valve insertion. We evaluated this treatment and compared it with the closed thoracostomy. In this comparative study, the success rate, complications and recurrence rate of treating spontaneous pneumothorax patients by using a small-calibre catheter and Heimlch valve were compared with those of a similar-sized group treated by closed thoracostomy. Pneumothorax was successfully treated on an ambulatory basis by using the small-calibre catheter and Heimlch valve in 20 patients (47%); this was less than the 42 patients (89%) who were successfully treated by closed thoracostomy. While no complications were encountered in the group treated using the small-calibre catheter and Heimlich valve, 11 patients in the group treated by closed thoracostomy developed complications. The medical expenses for the treatment involving the small-calibre catheter and Heimlich valve were less than those for closed thoracostomy. Prior to the treatment, the patients should be fully informed of the success rate of this treatment and the possibility of requiring closed thoracostomy in the event of treatment failure.

Postoperative pain relief using regional anaesthesia

Summary Fear of severe pain after surgery is one of the main concerns of many patients who undergo surgery. There seems to be some justification for this fear. Several recent publications show that the management of postoperative pain is still suboptimal in many institutions. Undertreated postoperative pain may delay discharge and recovery and result in poor rehabilitation and outcomes. Currently, a variety of opioid and non-opioid-based analgesic techniques are used to treat pain. Opioid analgesics, regardless of the route of administration, are associated with a high incidence of adverse effects. In recent years, there has been a great increase in the use of regional anaesthesia techniques for surgery and postoperative pain management. Catheter techniques are increasingly used in in-patients and ambulatory surgery patients to achieve prolonged pain relief lasting several days. The techniques available for postoperative analgesia include neuraxial (central) blocks, peripheral nerve blocks, wound infiltration techniques, intraperitoneal, intra-articular, and intrabursal techniques. There is overwhelming evidence that epidural technique provides superior analgesic efficacy; however, its effects on reducing morbidity and mortality are controversial. Perineural catheter techniques provide better analgesia and fewer side effects when compared with opioid analgesia and are a good alternative to the more invasive epidural technique, particularly for major orthopaedic extremity surgery. There is good evidence that a simple technique of wound catheter infusion of local anaesthetic provides effective analgesia after a variety of surgical procedures with reduced side effects and high patient satisfaction. With the availability of portable pumps, the technique can be used on ambulatory basis.

Preprocedure Administration of Oral Vitamin K1: Lessons Learned from 2 Experiences in the Same Patient

INTRODUCTION The management of patients undergoing invasive procedures while taking oral anticoagulant therapy can be complex and requires careful evaluation of several risk factors, including the urgency of the surgery, the risk of thrombosis in the absence of warfarin, and the risk of procedure-related bleeding. Lowering the international normalized ratio (INR) before an invasive procedure may involve the following steps: withholding warfarin for about 4 days before the procedure,1 administering vitamin K1 (phytonadione) either orally or intravenously 24–48 h before the procedure,1-3 and infusing fresh frozen plasma or clotting factor concentrate for patients with life-threatening bleeding or an urgent need for surgery.3,4 For ambulatory patients, vitamin K1 by oral administration is commonly used to rapidly reduce critical INR values (defined as INR above 5.0) to therapeutic values (2.0–3.5).1 Small doses (1.0–2.5 mg) of oral vitamin K1 are suggested if INR is between 5.0 and 9.0, whereas 5–10 mg of oral vitamin K1 is recommended if INR is 10.0 or above.1 IV administration of vitamin K1 is also efficacious for this indication, but use of this route for outpatients is limited, because the drug must be administered slowly. The use of oral vitamin K1 to completely reverse a therapeutic INR in ambulatory patients in preparation for elective invasive procedures is not routine, and to our knowledge has not been reported. We proposed that the use of oral vitamin K1 might reduce the number of preprocedure days over which a patient would require subtherapeutic anticoagulation. Current practice for periprocedural management of ambulatory patients who are receiving oral anticoagulant therapy and who have an INR range of 2.0–3.0 is to discontinue warfarin 4 or 5 days before the procedure and then to reintroduce it after the procedure.1 Patients at greater risk of thromboembolism are often given “bridging therapy” with heparin while oral anticoagulation is temporarily reversed.1 In patients with elevated INR (above 3.0) withholding warfarin for a longer period before an invasive procedure is recommended5,6; this implies, for patients at high risk of a thromboembolic event, an extended period before the procedure when full-dose heparin or full-dose low-molecular-weight heparin (LMWH) must be administered.2 We describe a patient at high risk of thrombosis (INR range 3.5–4.0) who was treated with oral vitamin K1 before each of 2 invasive procedures. Despite the abundant literature evaluating the use of oral vitamin K1 for critical INR management, to our knowledge this is the first report of the use of this drug to normalize the INR on an ambulatory basis before an elective procedure.

Hospitalization Costs of Total Knee Arthroplasty With a Continuous Femoral Nerve Block Provided Only in the Hospital Versus on an Ambulatory Basis

Hospitalization Costs of Total Knee Arthroplasty With a Continuous Femoral Nerve Block Provided Only in the Hospital Versus on an Ambulatory Basis

Admission is not Always Necessary for Patients with Community-Acquired Pneumonia in Risk Classes IV and V Diagnosed in the Emergency Room

To determine the factors that allow patients with community-acquired pneumonia who are at high risk of mortality (risk classes IV and V) to be treated at home. A prospective, observational study. Six hospitals and one free-standing emergency room in Edmonton, Alberta. The present study included 2354 patients in risk classes IV and V who had a diagnosis of pneumonia made by an emergency room physician or an internist. Symptoms, signs and laboratory findings, as well as outcome measures of length of stay and mortality. Of the total study group, 319 of the patients (13.5%) were treated on an ambulatory basis. Factors predictive of admission were definite or possible pneumonia on chest radiograph as read by a radiologist, functional impairment, altered mental status, substance abuse, psychiatric disorder, abnormal white blood cell count, abnormal lymphocyte count, oxygen saturation less than 90% and antibiotic administration in the week before admission. If chest pain was present, admission was less likely. Only two of the 319 patients required subsequent admission (both had positive blood cultures) and only two died. A substantial number of patients in risk classes IV and V can be safely treated at home. Factors that help clinicians to select this subset of patients are discussed.

Interscalene brachial plexus block for outpatient shoulder arthroplasty: Postoperative analgesia, patient satisfaction and complications

Background:Shoulder arthroplasty procedures are seldom performed on an ambulatory basis. Our objective was to examine postoperative analgesia, nausea and vomiting, patient satisfaction and complications of ambulatory shoulder arthroplasty performed using interscalene brachial plexus block (ISB).Materials and Methods:We prospectively examined 82 consecutive patients undergoing total and hemi-shoulder arthroplasty under ISB. Eighty-nine per cent (n=73) of patients received a continuous ISB; 11% (n=9) received a single-injection ISB. The blocks were performed using a nerve stimulator technique. Thirty to 40 mL of 0.5% ropivacaine with 1:400,000 epinephrine was injected perineurally after appropriate muscle twitches were elicited at a current of less than 0.5% mA. Data were collected in the preoperative holding area, intraoperatively and postoperatively including the postanesthesia care unit (PACU), at 24h and at seven days.Results:Mean postoperative pain scores at rest were 0.8 ± 2.3 in PACU (with movement, 0.9 ± 2.5), 2.5 ± 3.1 at 24h and 2.8 ± 2.1 at seven days. Mean postoperative nausea and vomiting (PONV) scores were 0.2 ± 1.2 in the PACU and 0.4 ± 1.4 at 24h. Satisfaction scores were 4.8 ± 0.6 and 4.8 ± 0.7, respectively, at 24h and seven days. Minimal complications were noted postoperatively at 30 days.Conclusions:Regional anesthesia offers sufficient analgesia during the hospital stay for shoulder arthroplasty procedures while adhering to high patient comfort and satisfaction, with low complications.

Hospitalization Costs of Total Knee Arthroplasty With a Continuous Femoral Nerve Block Provided Only in the Hospital Versus on an Ambulatory Basis: A Retrospective, Case-Control, Cost-Minimization Analysis

After total knee arthroplasty (TKA), hospitalization may be shortened by allowing patients to return home with a continuous femoral nerve block (CFNB). This study quantified the hospitalization costs for 10 TKA patients receiving ambulatory CFNB versus a matched cohort of 10 patients who received CFNB only during hospitalization. We examined the medical records (n = 125) of patients who underwent a unilateral, primary, tricompartment TKA with a postoperative CFNB by 1 surgeon at one institution in an 18-month period beginning January 2004. Each of the 10 patients discharged home with an ambulatory CFNB (cases) was matched with a patient with a hospital-only CFNB (controls) for age, gender, body mass index, and health status. Financial data were extracted from the hospital microcosting database. Nine patients with ambulatory CFNB (cases) were discharged home on postoperative day (POD) 1 and 1 on POD 4. Of the controls, 3 were discharged home on POD 3, 6 on POD 4, and 1 on POD 5. The median (range) costs of hospitalization (excluding implant and professional fees) was US dollars 5,292 (US dollars 4,326-US dollars 7,929) for ambulatory cases compared with US dollars 7,974 (US dollars 6,931-US dollars 9,979) for inpatient controls (difference = US dollars 2,682, 34% decrease, P < .001). The total charges for hospitalization, the implant, and professional fees was US dollars 33,646 (US dollars 31,816-US dollars 38,468) for cases compared with US dollars 39,100 (US dollars 36,096-US dollars 44,098) for controls (difference = US dollars 5,454, 14% decrease, P < .001). This study provides evidence that ambulatory CFNB for selected patients undergoing TKA has the potential to reduce hospital length of stay and associated costs and charges. However, the current study has significant inherent limitations based on the study design. Additional research is required to replicate these results in a prospective, randomized, controlled trial and to determine whether any savings exceed additional CFNB costs such as from complications, having caregivers provide care at home, and additional hospital/health care provider visits.

Evaluation of the Use of BioGlue® in the Treatment of High Anal Fistulas: Preliminary Results of a Pilot Study

Treatment of anal fistulas by use of adhesives is an attractive method because of its simplicity and it can be performed on an ambulatory basis. Furthermore, if the treatment is unsuccessful, adhesive use does not subsequently prevent the surgeon from utilizing alternative surgical techniques and/or products. BioGlue Surgical Adhesive is a two-component surgical adhesive composed of bovine serum albumin and glutaraldehyde. We evaluated the usefulness of BioGlue for the treatment of high transsphincter anal fistulas. Patients diagnosed with high transsphincter anal fistulas of cryptoglandular origin, whether relapsed or not, were included in this study. A seton was placed before the injection of BioGlue into the fistula track of high transsphincter anal fistulas in patients with secondary tracts and/or purulent collections. Clinical charts, operative reports, and endoanal echography results obtained for each patient were reviewed. Fourteen patients (13 males; mean age, 39.9 (range, 24-66) years) with high transsphincter anal fistulas of cryptoglandular origin were recruited into the study. The average time of symptom evolution was 35.6 (range, 2-96) months. Ten of 14 cases were for relapsed fistulas. Six patients required the placement of a seton 37 (range, 32-42) days before the BioGlue injection. Patients were followed for a mean length of 13.92 (range, 3-21) months, and the fistula healed completely in only seven patients (50 percent). These preliminary results demonstrate that BioGlue may be useful for treating patients with high transsphincter anal fistulas. Further prospective long-term studies are needed.

Editorial Commentary:The Pneumonia Severity Index Score: Time to Move to a Prospective Study of Patients with Community‐Acquired Pneumonia who are Discharged from Emergency Departments to be Managed on an Ambulatory Basis

<i>Editorial Commentary:</i>The Pneumonia Severity Index Score: Time to Move to a Prospective Study of Patients with Community‐Acquired Pneumonia who are Discharged from Emergency Departments to be Managed on an Ambulatory Basis

Laparoscopic Splenectomy for Hematologic Disorders: A Safe Procedure.

Background : Splenectomy for hematological diseases remains controversial in many circumstances due to a high morbidity and mortality after a classical surgery. Laparoscopic surgery becoming more popular, spleen removal by this approach was more widely used and we retrospectively reviewed the outcome of 33 patients who underwent laparoscopic splenectomy in our institution.Population : Between 1998 and 2006, laparoscopic splenectomy was performed in 33 patients (F=6, M=27) by an anterior approach. Median age was 62 (40–90) y.o. Indications for splenectomy was hemolytic anemia or discomfort in malignant hemopathies (CML, MF, NHL, CLL, HD) and autoimmune cytopenia or peripheral cytopenia in non malignant hemopathies (AIHA, ITP,.). Spleen weights ranged from 100g to 5000g. All the patients received anti-pneumococcal vaccination 2 weeks before surgery. After surgery, all patients were covered by penicillin and LMWH until discharge from the hospital.Results : Perioperative mortality was 0% and major postoperative complications were observed in 3 patients (Pulmonary Embolism, DVT, Hemorrhage). Conversion was required in one patient. One patient died 4 years after splenectomy from extended deep portal thrombosis.Improvement in hematological parameters and/or performans status was observed in 95% of the patients. Mean duration of hospital stay was 5 days.Conclusion : Anterior laparoscopic splenectomy for splenomegaly is a safe and minimally invasive procedure in the hands of experienced surgeons. Howerer, a closed monitoring of the platelets count should be performed, even on an ambulatory basis, because of the risk of thrombotic complications.