The effect of diabetes on major robotic hepatectomy.

Studies regarding the influence of diabetes on perioperative outcomes after major hepatectomy are conflicting. The objective of this study is to analyze the effects of diabetes on patients undergoing robotic major hepatectomy. With Institutional Review Board (IRB) approval, 94 patients undergoing major hepatectomy were prospectively followed. Demographic data and postoperative outcomes were analyzed and compared between diabetic and non-diabetic patients. Data were presented as median (mean ± SD). Patients were of age 62 (61 ± 13.0) years, BMI of 29 (29 ± 5.9) kg/m2, and ASA class of 3 (3 ± 0.55). The mass size was 5 (5 ± 3.0) cm. Operative duration was 252 (277 ± 106.6) min with estimated blood loss (EBL) was 175 (249 ± 275.9) mL. One operation was converted to 'open' due to bleeding, accounting for one intraoperative complication. Postoperatively, nine patients required ICU admission, with a duration of 1 (4 ± 5.9) day. Seven patients had postoperative complications. Length of stay (LOS) was 4 (4 ± 2.6) days. Fourteen patients were readmitted within 30 days. There were no deaths in-hospital or within 30 days. Of the 94 patients, 22 were diabetic and 72 were nondiabetic. Diabetic patients were older (70 (69 ± 11.3) years versus 58 (58 ± 12.4) years (p = 0.004)). Intraoperatively, operative duration, EBL, and complications were not significantly different. Postoperatively, LOS, ICU admission, ICU duration, complications, in-hospital mortality, readmission in 30 days, and death after 30 days showed no significant difference between diabetics and nondiabetics. In our experience, diabetes has no significant effect on perioperative outcomes after a robotic major hepatectomy.

Robot Application for Hepatopancreatic Disorders, Gastroesophageal Reflux Disease, and Achalasia.

INTRODUCTION: We undertook this study to describe the number and variety of robotic operations undertaken for hepatopancreatic and esophageal disorders. METHODS: Data from 2015 through March of 2018 were analyzed for da Vinci™ robot application for hepatopancreatic disorders, gastroesophageal reflux disease (GERD), and achalasia. RESULTS: From 2015 through 2017, robotic hepatopancreatic operations increased 49%, robotic hepatic operations increased 107%, and robotic pancreatic operations increased 26%. Quarter after quarter, robotic application increased for hepatopancreatic operations, hepatic operations, and pancreatic operations (P < .001 for each) with acceleration over the most recent months. The application of the Xi robot platform increased from 12% of robotic hepatopancreatic operations in 2015-71% in 2018 (1075% increase in numbers). From 2015 through 2017, robotic fundoplications and myotomies increased by 55%, robotic fundoplications increased by 59%, and robotic Heller myotomies increased by 211%. Quarter after quarter, robotic application increased for fundoplications and Heller myotomies (P < .001 for each) with acceleration over the most recent months. The application of the Xi robot platform increased from 13% of these robotic operations in 2015-64% in 2018 (935% increase in numbers). Less than 10% of hepatopancreatic operations, fundoplications, and myotomies are undertaken robotically. CONCLUSIONS: There has been an accelerating increase in the number of robotic operations for hepatopancreatic disorders, GERD, and achalasia over the past 3 » years. Application of the Xi robot has dramatically increased, both absolutely and relatively. Still only a small proportion of operations for hepatopancreatic disorders, GERD, and achalasia use the robotic platform; this is changing fast.

Eleventh International Women in Surgery Career Symposium, February 14-16, 2020 Sand Key Resort, Clearwater Florida.

Surgery, society, and the world are ever changing. The role of women in surgery is changing too and changing fast. For many women, this change is too slow, too fast, too disruptive, too confusing, and too dependent on others. A symposium such as this helps direct our discussions and thoughts, but many answers will evolve only with and after thoughtful consideration, debate, and action. The symposium is not a "gripe session," but a call to arms for all stakeholders, including surgery. Surgery must evolve commensurate with the times and recognize the huge and unique talent pool women represent. Herein is the summary of the plenary session of the symposium. Hopefully, it will stir emotions and initiate debate which will lead to enlightenment and benefit to surgery, our patients, our employers, and all surgeons, both current and future. For those who want to be part of the dialogue, please take advantage of this opportunity. This symposium will continue to be held annually as we build our awareness and develop impactful ideologies to further the beneficial impact of the surgical community. Lead, follow, or get out of the way; your choice. We encourage all to be part of the process.

Robotic resection of extrahepatic cholangiocarcinoma: Institutional outcomes of bile duct cancer surgery using a minimally invasive technique.

BACKGROUND AND OBJECTIVES: The purpose of this study is to report our early experience and outcomes, the first in North America, of Extrahepatic Cholangiocarcinoma (EHC) resection with Roux-en Y Hepaticojejunostomy reconstruction via the robotic approach. METHODS: With Institutional Review Board approval, 15 patients who underwent robotic resection of EHC were studied. RESULTS: Patients were 74 (73 ± 8.9) years of age. There were 9 men and 6 women. Average body mass index was 24 (27 ± 6.3) kg·m-2 . Mean & Median ASA class was 3. Median Tumor size was 2 (2 ± 1.3) cm. There were no intraoperative complications. Operative duration was 453 (443 ± 85.0) minutes and the estimated blood loss was 150 (182 ± 138.4) ml. No patient required admission to the intensive care unit. Hospital length of stay was 4 (6 ± 3.2) days. There was one patient with Clavien-Dindo Class 3 or greater complication. No mortality was seen in this series. DISCUSSION: Robotic resection of EHC is safe, feasible, and reproducible with excellent clinical outcomes. Consequently, the robotic technique should be considered in some patients requiring EHC resection.

Robotic Complex Fundoplication in Patients at High-Risk to Fail.

BACKGROUND: This study was undertaken to analyze our outcomes after robotic fundoplication for GERD in patients with failed antireflux procedures, with type IV (i.e., giant) hiatal hernias, or after extensive intra-abdominal surgery with mesh, and to compare our results to outcomes predicted by the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Surgical Risk Calculator and to national outcomes reported by NSQIP. METHODS: 100 patients undergoing robotic fundoplication for the aforementioned factors were prospectively followed. RESULTS: 100 patients, aged 67 (67 ± 10.3) years with body mass index (BMI) of 26 (25 ± 2.9) kg/m2 underwent robotic fundoplication for failed antireflux fundoplications (43%), type IV hiatal hernias (31%), or after extensive intra-abdominal surgery with mesh (26%). Operative duration was 184 (196 ± 74.3) min with an estimated blood loss of 24 (51 ± 82.9) mL. Length of stay was 1 (2 ± 3.6) day. Two patients developed postoperative ileus. Two patients were readmitted within 30 days for nausea.Nationally reported outcomes and those predicted by NSQIP were similar. When comparing our actual outcomes to predicted and national NSQIP outcomes, actual outcomes were superior for serious complications, any complications, pneumonia, surgical site infection, deep vein thrombosis, readmission, return to OR, and sepsis (P < 0.05); our actual outcomes were not worse for renal failure, deaths, cardiac complications, and discharge to a nursing facility. CONCLUSIONS: Our patients were not a selective group; rather they were more complex than reported in NSQIP. Most of our results after robotic fundoplication were superior to predicted and national outcomes. The utilization of the robotic platform for complex operations and fundoplications to treat patients with GERD is safe and efficacious.

Cost Analysis of Pancreaticoduodenectomy at a High-Volume Robotic Hepatopancreaticobiliary Surgery Program.

BACKGROUND: The robotic approach to pancreaticoduodenectomy is thought by many to be associated with increased financial burden for hospitals. We undertook this study to analyze and compare the cost of "open" pancreaticoduodenectomy with that associated with the application of the robotic surgical system to pancreaticoduodenectomy in our hepatobiliary program. STUDY DESIGN: With IRB approval, all patients undergoing pancreaticoduodenectomy at our institution, from August 2012 to November 2019, were prospectively followed. Cost, including total, variable, fixed-direct, fixed-indirect, and profitability for robotic and "open" pancreaticoduodenectomy were analyzed and compared. Data are presented as median (mean ± SD). RESULTS: There were 386 patients who underwent pancreaticoduodenectomy; 205 patients underwent robotic pancreaticoduodenectomy and 181 underwent "open" pancreaticoduodenectomy. Costs are presented as mean ± SD. Overall, the cost of care for robotic pancreaticoduodenectomy was $31,389 ($36,611 ± $20,545.40) vs $23,132 ($31,323 ± $28,885.50) for "open" pancreaticoduodenectomy (p = 0.04); total variable cost was $20,355 ($22,747 ± $11,127.60) vs $11,680 ($16,032 ± $14,817.20) (p = 0.01), total fixed direct cost was $1,999 ($2,330 ± $1,363.10) vs $2,073 ($2,983 ± $3,209.00) (p = 0.01), and total indirect cost was $7,217 ($9,354 ± $6,802.40) vs $6,802 ($9,505 ± $9,307.20) (p = 0.86), for robotic vs "open" pancreaticoduodenectomy, respectively. Since 2016, profitability was achieved in 29% of patients undergoing robotic pancreaticoduodenectomy. CONCLUSIONS: Robotic pancreaticoduodenectomy had lower estimated blood loss and shorter length of stay. Cost of care for robotic pancreaticoduodenectomy was greater across all categories, except for total indirect cost, than "open" pancreaticoduodenectomy. For our institution, profitability was accomplished in less than one-third of patients undergoing robotic pancreaticoduodenectomy. The role of the robotic platform for pancreaticoduodenectomy needs to be discussed among all stakeholders.

Laparo-Endoscopic Single Site (LESS) cosmesis: Patients perception of body image distortion after LESS surgery.

BACKGROUND: Relative to conventional laparoscopy, Laparo-Endoscopic Single Site (LESS) surgery has been associated with improved cosmesis. This study investigated preoperative and postoperative patient perceptions of LESS surgery and what factors may affect those perceptions. METHODS: Patients undergoing LESS Surgery were queried before and after their operations. Body image and other factors were assessed preoperatively and postoperatively in 881unselected patients undergoing LESS surgery utilizing Likert scale questionnaires. Responses were collated and analyzed. Data are reported as median (mean ± SD), where appropriate. RESULTS: 881 patients studied had a median age of 59 (57 ± 15.3) years and had a median Body Mass Index of 27 (28 ± 6.2) kg/m2. 65% were women. 343 (39%) had undergone a previous abdominal operation(s). Prior to LESS surgery, patients reported neutral body image scores and rated their overall appearance satisfaction as 40% (37% ± 30.7) on a Visual Analog Scale (VAS). 68% were unwilling to undergo LESS surgery if it involved more risk relative to traditional laparoscopy as safety was their number one concern. Postoperatively, patients reported a significant improvement in body image perception and safety was no longer their foremost concern. CONCLUSION: Preoperatively, patients are most concerned with safety (e.g. risk) with secondary concerns of cost and pain but they were less concerned with their appearance. Postoperatively, safety is much, much less of an issue (because it has been achieved) and appearance is more paramount with significant improvements in their self-assessed appearance. With LESS surgery patients indicate a high level of satisfaction with cosmesis.

Robotic Major Hepatectomy: Influence of Age on Clinical Outcomes.

BACKGROUND: This study was undertaken to determine if age influences postoperative outcomes for patients undergoing robotic major hepatectomy. METHODS: Ninety-four patients undergoing robotic major hepatectomy were prospectively followed. With regression analysis, demographic data and postoperative outcomes were compared to age. Data are presented as median (mean ± SD). RESULTS: Overall, the patients were of age 62 (61 ± 13) years, body mass index (BMI) of 29 (29 ± 5.9) kg/m2, and American Society of Anesthesiologists (ASA) class of 3 (3 ± 0.5). The mass size was 5 (5 ± 3.0) cm. The operative duration was 252 (276 ± 106) minutes with an estimated blood loss (EBL) of 175 (249 ± 275.9) mL. One operation was converted to "open" due to bleeding, accounting for the only intraoperative complication. Nine patients required intensive care unit (ICU) admission. Postoperatively, 7 patients had complications with no in-hospital mortalities, and a length of stay (LOS) of 4 (5 ± 2.6) days. Thirteen patients were readmitted within 30 days with 0 deaths within 30 days.A significant relationship was found between age and ASA class (P = .001) and LOS (P = .03). No correlation was found when comparing age to operative duration, EBL, ICU admission, ICU duration, complications, and readmission within 30 days. CONCLUSION: For patients undergoing robotic major hepatectomy, there was no significant correlation between age and perioperative outcomes, with the exception of LOS. Increasing age is not associated with increased morbidity or perioperative mortality. With the application of innovative technology, that is, the robotic approach, surgeons should be encouraged to undertake major hepatectomy in elderly patients deemed candidates for surgery.

Applying IWATE criteria to robotic hepatectomy: is there a "robotic effect"?

BACKGROUND: The objective of this study is to apply this criteria to determine its applicability to robotic hepatectomy. METHODS: We prospectively followed 105 patients undergoing robotic hepatectomy. Operations were categorized into Low (0-3), Intermediate (4-6), Advanced (7-9), and Expert (10-12). RESULTS: Patients had a median age of 62 (61 ± 13.1) years, with a BMI of 28 (29 ± 6.1) kg/m2; 38% were women. ASA class was 3 (3 ± 0.6). Of the 105 operations, 2 were categorized as Low, 31 as Intermediate, 49 as Advanced, and 23 as Expert. EBL and operative duration were found to be significantly greater as the operative difficulty level increased (p < 0.03 and p < 0.01, respectively). Intraoperatively, when comparing Expert and Intermediate, EBL and operative duration were significantly greater (p = 0.0001 and p = 0.0031, respectively). In the comparison of Expert with Advanced, operative duration was significantly longer (p = 0.0001). Postoperatively, comparisons between Expert and Intermediate, Expert and Advanced, and Advanced and Intermediate showed no differences. CONCLUSION: EBL and operative duration increased with IWATE scores reflecting more difficult robotic hepatectomies. However, with the robotic approach, our postoperative outcomes were similar irrespective of IWATE difficulty scores. Perhaps, the robotic approach potentially has a mitigating effect on postoperative outcomes regardless of difficulty level.

100 Robotic Distal Pancreatectomies: The Future at Hand.

INTRODUCTION: This study was undertaken to examine 100 consecutive robotic distal pancreatectomies with splenectomies, and to compare our outcomes to predicted outcomes as calculated using the American college of surgeons national surgical quality improvement program (ACS NSQIP) Surgical Risk Calculator and to the outcomes contained within NSQIP. METHODS: Outcomes were compared with predicted outcomes, calculated using the ACS NSQIP Surgical Risk Calculator, and with outcomes documented in NSQIP for distal pancreatectomy. For illustrative purposes, data are presented as median (mean ± SD). RESULTS: Patients who underwent robotic distal pancreatectomy were of age 67 (63 ± 13.4) years with a BMI of 29 (29 ± 6.3) kg/m2, with 49% being women. Operative duration was 242 (265 ± 112.2) minutes and estimated blood loss was 110 (211 ± 233.9) mL. Predicted outcomes were similar to those reported in NSQIP. Our actual outcomes were significantly superior to the predicted outcomes for serious complication, any complication, surgical site infection, sepsis, and length of stay. Compared to NSQIP outcomes, our actual outcomes for serious complication, any complication, surgical site infection, sepsis, and delayed gastric emptying were significantly superior. Twelve percent of operations were converted to "open." There were 3 deaths within 30 days, similar to predicted outcomes. Deaths were due to sepsis (2) and respiratory failure (1). CONCLUSION: Our patients' predicted outcomes were the same as national outcomes; our patients were not a select group. However, their actual outcomes were like or significantly superior than those predicted by NSQIP or reported in NSQIP. We believe that the robot has the future of distal pancreatectomy with or without splenectomy.

Robotic Major Hepatectomy: An Institutional Experience and Clinical Outcomes.

INTRODUCTION: Most of the literature has only reported outcomes on robotic minor non-anatomical hepatectomy. This study was undertaken to analyze and examine the safety, feasibly, and perioperative outcomes of robotic major hepatectomy at our institution. METHODS: All patients undergoing robotic major hepatectomy were prospectively followed. Major hepatectomy was defined as a resection of 3 or more segments. Data are expressed as median (mean ± SD). RESULTS: A total of 170 consecutive patients underwent robotic hepatectomies, of which 100 were major resections involving at least 3 segments. The 100 patients were of median 62 (61 ± 13.0) years, and 46% were women. Median BMI was 29 (29 ± 5.9) kg/m2 and median ASA class was 3 (3 ± 0.5). Thirty percent of robotic major hepatectomies were for hepatocellular carcinoma, 28% were for metastatic adenocarcinoma, 9% were for cholangiocarcinoma, and 5% were for metastatic neuroendocrine tumor. Prep time (in the room until incision) was a median 58 min (62 ± 18.4), extraction time (incision until specimen extraction) was 124 min (146 ± 99.5), console time was 198 min (210 ± 123.9), closure time (extraction until dressing placement) was 109 min (131 ± 93.8), operative duration was 246 min (269 ± 123.2), and time under anesthesia was 330 min (353 ± 109.6). Estimated blood loss was 175 ml (249 ± 275.9) and length of stay was 4 days (5 ± 4.3). Seven patients experienced postoperative complications. Thirteen patients were readmitted within 30 days, and one patient died within 30 days. CONCLUSION: Application of the robotic platform to major hepatectomy is safe and feasible. Our early experience shows that this minimally invasive approach results in excellent short-term outcomes.

Robotic Pancreatic Surgery for Solid, Cystic, and Mixed Lesions.

Robotic surgery is flourishing worldwide. Pancreatic cancer is the fourth leading cause of cancer death in the United States. Most pancreatic operations are undertaken for the management of pancreatic adenocarcinoma. Therefore, it is essential for all physicians caring for patients with cancer to understand the role and importance of molecular tumor markers. This article details our technique and application of the robotic platform to robotic pancreatectomy. The use of the robot does not change the nature of pancreatic operations, but it is our belief that it will improve patient outcomes and, possibly, survival by reducing perioperative complications.

Laparoscopic Heller Myotomy with Anterior Fundoplication Improves Frequency and Severity of Symptoms of Achalasia, Regardless of Preoperative Severity Determined by Esophagography.

This study was undertaken to determine whether postoperative outcomes after laparoscopic Heller myotomy with anterior fundoplication could be predicted by preoperative findings on esophagography. Preoperative barium esophagograms of 135 patients undergoing laparoscopic Heller myotomy with anterior fundoplication were reviewed. The number of esophageal curves, esophageal width, and angulation of the gastroesophageal junction (GEJ) were determined; correlations between these determined parameters and symptoms were assessed using linear regression analysis. The number of esophageal curves correlated with the preoperative frequency of dysphagia, vomiting, chest pain, regurgitation, and heartburn. The width of the esophagus negatively correlated with the preoperative frequency of regurgitation. The angulation of the GEJ did not correlate with preoperative symptoms. Laparoscopic Heller myotomy with anterior fundoplication significantly reduced the frequency and severity of all symptoms, regardless of the number of esophageal curves, esophageal width, or angulation of the GEJ. Laparoscopic Heller myotomy with anterior fundoplication provides dramatic palliation for achalasia. More esophageal curves on preoperative esophagography correlate well with the frequency of a broad range of preoperative symptoms, including the frequency of dysphagia and regurgitation. Patients experience dramatically improved frequency and severity of symptoms after laparoscopic Heller myotomy with anterior fundoplication for achalasia regardless of the number of esophageal curves, esophageal width, or the angulation of the GEJ. Findings on barium esophagogram, in evaluating achalasia, should not deter the application of laparosocopic Heller myotomy with anterior fundoplication.

A Cost-Benefit Analysis of Reducing Surgical Site Infections.

Surgical Site Infections (SSI) represent an onerous burden on our health-care system. This study was undertaken to determine the impact of a protocol aimed at reducing SSIs on the frequency and cost of SSIs after abdominal surgery. Beginning in 2013, 811 patients undergoing gastrointestinal operations were prospectively followed. In 2014, we initiated a protocol to reduce SSIs. SSIs were monitored before and after protocol implementation, and differences in SSI incidence and associated costs were determined. Before protocol initiation, standardized operative preparation cost was $40.85 to $126.94 per patient depending on the results of methicillin-resistant Staphylococcus aureus screen; after protocol initiation, the cost was $43.85 per patient, saving up to $83.09 per patient. With the protocol in place, SSI rate was reduced from 4.9 to 3.4 per cent (13 of 379) representing a potential prevention of eight infections that would have cost payers $166,280 ($20,785 per infection). Notably, the SSI rate after pancreatectomy was reduced by 63 per cent (P = 0.04). With preparation and diligence, SSI rate can be meaningfully reduced and potential cost savings can be achieved. In particular, SSI rate reduction for major abdominal operations and especially pancreatic resections can be achieved. A protocol to reduce SSI is a "win-win" for all stakeholders and should be encouraged with thoughtful and active participation from all hospital disciplines.

Sulfonylureas (not metformin) improve survival of patients with diabetes and resectable pancreatic adenocarcinoma.

Patients with pancreatic adenocarcinoma have an increased propensity for diabetes. Recent studies suggest patients with diabetes and pancreatic adenocarcinoma treated with metformin have increased survival. This study was undertaken to determine whether metformin use is associated with increased survival in patients with pancreatic adenocarcinoma. METHODS: Patients who underwent pancreaticoduodenectomy for pancreatic adenocarcinoma from 1991 to 2013 were included in this study. Survival was evaluated by Kaplan-Meier analysis. Median data are reported. Significance was accepted with 95% probability. RESULTS: Of 414 patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma, 132 (32%) were diabetic. Of patients with diabetes, 35 (27%) were diet-controlled, 34 (26%) were treated with insulin alone, 18 (14%) were treated with metformin alone, 14 (10%) were treated with sulfonylureas alone, 7 (5%) were taking sulfonylureas with insulin, and 24 (18%) patients were taking metformin with sulfonylureas and/or insulin. Patients with/without diabetes not taking sulfonylureas had survival of 16.4 months compared with patients taking sulfonylureas who achieved survival of 27.5 months after undergoing pancreaticoduodenectomy (P<0.05). CONCLUSIONS: Patients taking sulfonylureas with or without other therapy had improved survival compared with patients not taking sulfonylureas after pancreaticoduodenectomy. Metformin does not seem to be beneficial for patients with resectable disease, but may be beneficial for patients with unresectable and/or metastatic disease as shown in prior studies. The use of sulfonylureas is associated with a survival benefit for patients undergoing resection for pancreatic adenocarcinoma. Tumor staging and margin status continue to be the overriding predictors of survival in patients with resectable pancreatic adenocarcinoma, not metformin therapy.

Has survival improved following resection for pancreatic adenocarcinoma?

INTRODUCTION: This study was undertaken to determine if survival after resection of pancreatic adenocarcinoma has improved over the past two decades. METHODS: The SEER database was queried for patients who underwent pancreatectomy for pancreatic adenocarcinoma from 1992 to 2010. AJCC Stage and survival were determined for patients. Data were analyzed using Mantel-Cox test and linear regression. RESULTS: 15,604 patients underwent pancreatectomy from 1992 to 2010. Survival improved from 1992 to 2010 (p < 0.0001); specifically, median survival increased 1992-2010 (p < 0.0001). However, 5-year survival rates did not change 1992-2010. More patients (p = 0.007) underwent resections of Stage I and relatively more patients (p = 0.004) underwent resections of Stage II cancers 2004-2010 with commensurately smaller tumors (p = 0.01). CONCLUSIONS: From 1992 to 2010, progressively more patients underwent pancreatectomy for pancreatic adenocarcinoma with progressively smaller tumors and earlier stages. These patients lived more years (e.g., improved survival curves and median survival) but without improved 5-year survival, denoting better early and intermediate survival. Early detection, better perioperative care, more efficacious noncurative chemotherapy undoubtedly play a role, but better solutions for long-term survival must be sought.

Dissatisfaction after laparoscopic Heller myotomy: The truth is easy to swallow.

BACKGROUND: Although laparoscopic Heller myotomy has been shown to well palliate symptoms of achalasia, we have observed a small subset of patients who are "Dissatisfied". This study was undertaken to identify the causes of their dissatisfaction. STUDY DESIGN: Patients undergoing laparoscopic Heller myotomy from 1992 to 2015 were prospectively followed. Using a Likert scale, patients rated their symptom frequency/severity before and after the procedure. Patients graded their experience from "Very Satisfying" to "Very Unsatisfying." RESULTS: 647 patients underwent laparoscopic Heller myotomy. Fifty (8%) patients, median age 57 years and BMI 24 kg/m2 reported dissatisfaction at follow-up subsequent to myotomy. "Dissatisfied" patients were more likely to have undergone prior abdominal operations (p = 0.01) or previous myotomies (p = 0.02). "Dissatisfied" patients had a greater incidence of diverticulectomy (p = 0.03) and had longer postoperative LOS (p = 0.01). Symptom frequency/severity persisted after myotomy for dissatisfied patients (p > 0.05). CONCLUSION: Dissatisfaction after laparoscopic Heller myotomy is directly related to persistent/recurrent symptoms. Previous abdominal operations/myotomies, diverticulectomies, and longer LOS are predictors of dissatisfaction. With this understanding, we can identify patients who might be more prone to dissatisfaction.

Portal Hypertension Over the Last 25 Years: Where Did It Go?

BACKGROUND: Portal hypertension has seemingly vanished from surgery; this study was undertaken to determine where it has gone. STUDY DESIGN: Data from the Agency for Health Care Administration for 33,166,201 hospital inpatients in Florida for the periods 1988 to 1992, 1998 to 2002, and 2008 to 2012 were analyzed. RESULTS: Admissions with a diagnosis of portal hypertension dramatically increased: 5,473 patients from 1988 to 1992, 7,366 patients from 1998 to 2002, and 36,554 patients from 2008 to 2012. Endoscopic treatment of esophageal varices also dramatically increased. The number of decompressive shunts placed nominally increased, but application of endoscopic therapy increased significantly faster than the application of decompressive shunts (p < 0.0001). The percentage of patients who underwent shunting dramatically and significantly decreased (p < 0.0001), and surgeons undertook proportionally fewer shunts (42% in 1992 to 4% in 2012; p < 0.0001). For patients with a diagnosis of portal hypertension, in-hospital mortality progressively decreased, from 9% in 1988 to 1992 to 3% in 2008 to 2012 (p < 0.0001). CONCLUSIONS: In the state of Florida, over 25 years, there has been a 7-fold increase in the number of patients admitted with a diagnosis of portal hypertension, with a 65% reduction of in-hospital mortality. Application of endoscopic treatment of varices has increased dramatically. Decompressive shunts are applied to an ever-decreasing percentage of patients, and when applied, are now routinely undertaken by nonsurgeons. Therefore, portal hypertension has disappeared from the purview of surgery and has migrated toward the world of medical and endoscopic therapy, probably never to return.