Early Diagnosis and Treatment of Chylous Mesenteric Cysts.

Mesenteric cysts are benign congenital cysts typically discovered incidentally during abdominal explorations for other reasons. When feasible, they should be excised to prevent recurrence, bowel obstruction or volvulus, and resulting complications. We present a unique case of an infant, diagnosed prenatally by ultrasound with possible bowel obstruction, found to have micro and macro chylous mesenteric cysts. Although initially asymptomatic with normal abdominal x-ray and discharged on day of life 2, the parents were taught how to recognize symptoms of bowel obstruction. He presented at 1 month with obstructive symptoms, was confirmed to have large mesenteric cystic structures on ultrasound, and was immediately taken to the operating room. Due to the extensive number of cysts and intimate involvement of the largest cyst with the superior mesenteric artery, he was treated with partial excision and observation since resection may have resulted in short gut syndrome. Given a prenatal ultrasound suggestive of mesenteric cysts, we recommend abdominal imaging at birth with close follow-up until the appropriate time for elective resection. When disease is extensive precluding full enucleation and resection, we advocate for enucleation in combination with unroofing of as many cysts as possible followed by postoperative surveillance ultrasounds and family counseling.

Outcomes in complex ventral hernia repair with anterior component separation in class III obesity patients.

BACKGROUND: Consensus guidelines recommend against elective ventral hernia repair (VHR) in patients with BMI >30 kg/m2 without preoperative weight loss intervention. We aim to compare hernia recurrence and perioperative complications in VHR utilizing anterior component separation (CS) in patients with class III obesity (BMI >40 kg/m2). METHODS: A retrospective review of patients undergoing VHR with CS was performed. The primary endpoint was hernia recurrence; secondary endpoints were wound complications, postoperative medical complications, mortality and length of stay. RESULTS: 185 consecutive patients were identified from 2008 to 2016. There were no significant differences between groups: hernia recurrence (6.9% BMI >40 kg/m2, 2.4% BMI <39.9 kg/m2, p = 0.21), wound complications (58.6% BMI >40 kg/m2, 47.2% BMI <39.9 kg/m2, p = 0.16), postoperative complications (39.7% BMI >40 kg/m2, 26% BMI <39.9 kg/m2, p = 0.08), mortality (1.6% BMI >40 kg/m2, 3.4% BMI <39.9 kg/m2, p = 0.59), and length of stay (10.6 days BMI >40 kg/m2, 11.2 days BMI <39.9 kg/m2, p = 0.5). CONCLUSION: This study demonstrates similar outcomes in class III obesity patients undergoing elective VHR compared to patients with BMI <39.9 kg/m2.

The effect of tobacco use on outcomes of laparoscopic and open inguinal hernia repairs: a review of the NSQIP dataset.

BACKGROUND: As the effort to reduce postoperative morbidity and mortality continues, the search for modifiable patient risk factors to reduce complications is ongoing. Tobacco use is associated with impaired wound healing, but its effect on inguinal hernia repair has not been studied in a large population. An ACS-NSQIP dataset was used to evaluate the effect of tobacco use on outcomes of inguinal hernia repairs. METHODS: The ACS-NSQIP dataset was queried for patients who underwent open or laparoscopic inguinal hernia repairs, by primary procedure CPT codes, between years 2009-2012. Tobacco use was registered, as defined by the ACS-NSQIP, in two ways: current smoking (within the past 12 months), or history of smoking (having ever smoked). Univariate and multivariate analyses were used to investigate outcome variables for 30-day morbidity by type of smoking status, while adjusting for preoperative risk factors. RESULTS: During the study period, 90,162 patients underwent inguinal hernia repair. 76 % of the cases were open compared to 24 % laparoscopic. The population was overwhelmingly male, 91 %, compared to 9 % female. The average age of patients was 42.5 years. Of the available data (69 % of patients), 38.5 % had a history of smoking. 18 % had smoked within the 12 months prior to surgery (current smokers). Their average number of pack years was 27.2 (SD 24.0) compared to 4.5 pack years (SD 14.7) for those who had not smoked 12 months prior to surgery (historical smokers). Using Fisher's exact test, having ever smoked was found to be significantly associated with pneumonia (p = 0.0008) and return to the operating room (p = 0.010). This relationship held when preoperative variables were controlled for using logistic regression (pneumonia, p = 0.002; return to the operating room, p = 0.002). When preoperative variables were controlled for and logistic regression was performed for current smokers, there was also a significant association with pneumonia (p = 0.005) and return to the operating room (p = 0.01). CONCLUSION: Current smoking status is a modifiable risk of patients undergoing laparoscopic and open inguinal hernia repair. Failure to quit smoking prior to surgical repair is associated with complications like pneumonia and return to the operating room.

The effect of tobacco use on outcomes of laparoscopic and open ventral hernia repairs: a review of the NSQIP dataset.

INTRODUCTION: Tobacco smoking is a known risk factor for complications after major surgical procedures. The full effect of tobacco use on these complications has not been studied over large populations for ventral hernia repairs. This effect is more important as the preoperative conditioning, and optimization of patients is adopted. We sought to use the prospectively collected ACS-NSQIP dataset to evaluate respiratory and infectious complications for patients undergoing both laparoscopic and open ventral hernia repairs. METHODS: The ACS-NSQIP dataset was queried for patients who underwent open or laparoscopic ventral hernia repairs, by primary procedure CPT codes, between years 2009-2012. Smoking use was registered as defined by the ACS-NSQIP, as both a current smoker (within the prior 12 months) or as a history of smoking (having ever smoked). Univariate and multivariate analyses were used to investigate postoperative complications for 30-day morbidity and mortality by smoking status while adjusting for preoperative risk factors. RESULTS: The majority of cases were open, 82 %, compared to laparoscopic 18 %. Sex was evenly distributed with 58 % female and 42 % male; however, there was a difference in the distribution of current smokers (p = 0.03). On analysis there were significantly more respiratory complications (p = 0.0003) and infectious complications (p < 0.0001). When controlling for sex, age, and type of surgery, using logistic regression, there were associations between smoking in the prior 12 months and respiratory complications, including pneumonia (p < 0.0001), and re-intubation (p < 0.0001). Similar associations were seen on logistic regression if a patient ever smoked; including pneumonia (p < 0.0001), re-intubation (p < 0.0001), and failure to wean (p < 0.0001). CONCLUSION: Smoking tobacco, both current and historical use, leads to an increase in both respiratory and infectious complications. As more centers try to preoperatively condition patients for elective hernia repairs, it is important to note that patients may never return to the baseline outcomes of patients who never smoked.

Primary Anastomosis versus Ostomy after Colon Resection during Debulking of Ovarian Carcinomatosis: A NSQIP Analysis.

Ovarian carcinomatosis poses a dilemma for the surgeon. When resecting colon for tumor invasion, one must decide between diversion and primary anastomosis (PA). We examined the National Surgical Quality Improvement Program to determine whether PA associated with more complications than ostomy. The National Surgical Quality Improvement Program dataset was queried for patients with ovarian carcinomatosis between 2007 and 2012. Current Procedural Terminology codes were used to further identify patients undergoing colectomy with PA or ostomy. Logistic regression was used to evaluate 30-day morbidity and mortality. The 1013 ovarian carcinomatosis patients who underwent elective colon surgery were divided into primary repair (n = 453, 43.5%) or ostomy (n = 586, 56.5%) groups. Preoperative demographics were similar; however, ostomy patients had more severe preoperative laboratory derangements. The 30-day mortality and postoperative transfusion requirements were higher in the ostomy group. On multivariate analysis controlling for confounders, the differences were no longer significant. In conclusion, 30-day mortality and postoperative complications were increased in the ostomy group. Given the laboratory derangements in this group, this may reflect tendency to allocate ostomies to more ill patients. Primary repair in a selected population does not worsen outcomes. Prospective evaluation would help determine the impact of PA in the ovarian carcinomatosis population.

Current practices in biliary surgery: Do we practice what we teach?

INTRODUCTION: Since the widespread adoption of laparoscopic techniques in biliary surgery, the incidence of bile duct injures (BDI) has not significantly declined despite increased operative experience and recognition of the critical view of safety (CVS) method for anatomic identification. We hypothesized that operative approaches in clinical practice may vary from well-described technical recommendations. The objective of this study was to access how practicing surgeons commonly identify anatomy during laparoscopic cholecystectomy (LC). METHODS: We performed a cohort study assessing practices in biliary surgery among current practicing surgeons. Surgeons belonging to the Midwest Surgical Association and the Society of American Gastrointestinal and Endoscopic Surgeons were surveyed. Items surveyed include preferred methods for cystic duct identification, recognition of the CVS, and use of intraoperative imaging. RESULTS: In total, 374 of 849 surgeons responded. The CVS was not correctly identified by 75 % of surgeons descriptively and by 21 % of surgeons visually. 56 % of surgeons practiced the infundibular method for identification of the cystic duct; 27 % practiced the CVS method. Intraoperative cholangiography was used by 16 % and laparoscopic ultrasound by <1 %. CONCLUSION: A majority of surgeons preferably do not use the CVS method of identification during LC. A large percentage of practicing surgeons are unable to describe or visually identify the CVS. These results suggest an urgent need to reexamine the tenets of how LC is being taught and disseminated and present a clear target for improvement to reduce BDI.

The utility of mock oral examinations in preparation for the American Board of Surgery certifying examination.

BACKGROUND: Determine the utility of mock oral examinations in preparation for the American Board of Surgery certifying examination (ABS CE). METHODS: Between 2002 and 2012, blinded data were collected on 63 general surgery residents: 4th and 5th-year mock oral examination scores, first-time pass rates on ABS CE, and an online survey. RESULTS: Fifty-seven residents took the 4th-year mock oral examination: 30 (52.6%) passed and 27 (47.4%) failed, with first-time ABS CE pass rates 93.3% and 81.5% (P = .238). Fifty-nine residents took the 5th-year mock oral examination: 28 (47.5%) passed and 31 (52.5%) failed, with first-time ABS CE pass rates 82.1% and 93.5% (P = .240). Thirty-eight responded to the online survey, 77.1% ranked mock oral examinations as very or extremely helpful with ABS CE preparation. CONCLUSIONS: Although mock oral examinations and ABS CE passing rates do not directly correlate, residents perceive the mock oral examinations to be helpful.

Retroperitoneal sarcoma (RPS) high risk gross tumor volume boost (HR GTV boost) contour delineation agreement among NRG sarcoma radiation and surgical oncologists.

PURPOSE: Curative intent management of retroperitoneal sarcoma (RPS) requires gross total resection. Preoperative radiotherapy (RT) often is used as an adjuvant to surgery, but recurrence rates remain high. To enhance RT efficacy with acceptable tolerance, there is interest in delivering "boost doses" of RT to high-risk areas of gross tumor volume (HR GTV) judged to be at risk for positive resection margins. We sought to evaluate variability in HR GTV boost target volume delineation among collaborating sarcoma radiation and surgical oncologist teams. METHODS: Radiation planning CT scans for three cases of RPS were distributed to seven paired radiation and surgical oncologist teams at six institutions. Teams contoured HR GTV boost volumes for each case. Analysis of contour agreement was performed using the simultaneous truth and performance level estimation (STAPLE) algorithm and kappa statistics. RESULTS: HRGTV boost volume contour agreement between the seven teams was "substantial" or "moderate" for all cases. Agreement was best on the torso wall posteriorly (abutting posterior chest abdominal wall) and medially (abutting ipsilateral para-vertebral space and great vessels). Contours varied more significantly abutting visceral organs due to differing surgical opinions regarding planned partial organ resection. CONCLUSIONS: Agreement of RPS HRGTV boost volumes between sarcoma radiation and surgical oncologist teams was substantial to moderate. Differences were most striking in regions abutting visceral organs, highlighting the importance of collaboration between the radiation and surgical oncologist for "individualized" target delineation on the basis of areas deemed at risk and planned resection.

The impact of operative timing on outcomes of appendicitis: a National Surgical Quality Improvement Project analysis.

BACKGROUND: Surgery is indicated for acute uncomplicated appendicitis but the optimal timing is controversial. Recent literature is conflicting on the effect of time to intervention. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Project dataset for patients undergoing laparoscopic and open appendectomy between 2007 and 2012. Logistic regression was used to evaluate 30-day morbidity and mortality of intervention at different time periods, adjusting for preoperative risk factors. RESULTS: A total of 69,926 patients undergoing appendectomy were identified. Groups were divided by time to intervention: group 1, less than 24 hours (n = 55,839; 79.9%); group 2, 24 to 48 hours (n = 13,409; 18.6%); and group 3, greater than 48 hours (n = 1,038; 1.5%). After adjustment, the risk of complication remained increased for group 3 versus group 1 or 2 (odds ratio 1.66, 95% confidence interval 1.34 to 2.07). CONCLUSIONS: These data demonstrate equivalent outcomes between time to appendectomy of less than 24 and 24 to 48 hours. There was a 2-fold increase in complication rate for patients delayed longer than 48 hours.

Outcomes and Use of Laparoscopic Versus Open Gastric Resection.

BACKGROUND AND OBJECTIVES: The advantages of laparoscopy over open surgery are well established. Laparoscopic resection for gastric cancer is safe and results in equivalent oncologic outcomes when compared with open resection. The purpose of this study was to assess the use of laparoscopy to treat gastric cancer and the associated outcomes. METHODS: The American College of Surgeons National Surgical Quality Improvement Project (NSQIP) dataset was queried for patients with gastric cancer (ICD-9 Code 151.0-151.9) from January 2005 through December 2012. Logistic regression was used to evaluate the 30-day morbidity and mortality of open gastrectomy (CPT code 43620-2, 43631-4) versus that of the laparoscopic procedure on the stomach (CPT code 43650), while adjusting for preoperative risk factors. RESULTS: A total of 4116 patients with gastric cancer were identified and divided by surgical approach into 2 groups: open gastrectomy (n = 3725; 90.5%) and laparoscopic procedure on the stomach (n = 391; 9.5%). After adjustment for preoperative risk factors, complications were significantly fewer in laparoscopic versus open gastric resection (odds ratio [OR] 0.61, 95% confidence interval [CI] = 0.45-0.82; P = .001). After adjusting for preoperative risk factors, there was no statistically significant difference in mortality with laparoscopic compared to open gastric resection (OR 0.74; 95% CI = 0.32-1.72; P = .481). CONCLUSIONS: Laparoscopy is underused in the treatment of gastric cancer. Given that laparoscopic gastric resection has a lower morbidity in comparison to open resection, steps should be made toward advancing the use of laparoscopy for gastric cancer.

The utilization of laparoscopy in ventral hernia repair: an update of outcomes analysis using ACS-NSQIP data.

BACKGROUND: Numerous prospective studies and randomized controlled trials have demonstrated shorter length of stay, lower morbidity rates, and similar recurrence rates with laparoscopic ventral hernia repair (VHR) when compared to open VHR. Despite these promising results, previous data showed low utilization of laparoscopic VHR. The aim of our study was to evaluate the utilization of laparoscopic VHR using the most updated information from the American College of Surgeons-National Surgical Quality Improvement Project (NSQIP) dataset. The secondary aim was to evaluate the outcomes from NSQIP for patients undergoing open versus laparoscopic VHR for the outcome of 30-day mortality and the peri-operative morbidities listed in the NSQIP dataset. METHODS: We performed this study using 2009-2012 data from the ACS-NSQIP database. The study population included patients who had undergone an open or laparoscopic ventral hernia repair as their primary procedure based on CPT codes. Demographic characteristics, overall morbidity, and complications were compared using Chi-square tests for categorical variables and two-sided t tests for continuous variables. Secondary outcomes (mortality and any complications) were further analyzed using logistic regression. RESULTS: Utilization of laparoscopic VHR was 22%. While adjusted mortality was similar, overall morbidity was increased in the open VHR group (OR 1.63; CI 95% 1.38-1.92). The open group had a higher rate of return to the OR, pneumonia, re-intubation, ventilator requirement, renal failure/insufficiency, transfusion, DVT, sepsis, and superficial and deep incisional wound infections. CONCLUSIONS: The utilization of laparoscopic VHR remained low from 2009 to 2012 and continued to lag behind the use of laparoscopy in other complex surgical procedures. The mortality rate between laparoscopic and open VHR was similar, but laparoscopic repair was associated with lower overall complication rates.

Laparoscopy has a superior diagnostic yield than percutaneous image-guided biopsy for suspected intra-abdominal lymphoma.

INTRODUCTION: To date, no study has compared laparoscopy (LB) to percutaneous (PB) biopsy for the diagnosis of abdominal lymphoma. The objective of this study is to compare the success rate and safety profile of laparoscopic lymph node biopsy to the percutaneous approach in patients with intra-abdominal lymphadenopathy concerning for lymphoma. MATERIALS AND METHODS: We performed a multi-institution, retrospective review of patients undergoing lymph node biopsy for suspected intra-abdominal lymphoma between 2005 and 2013. Our primary outcome was adequate tissue yield between the two techniques, both for histologic diagnosis and for ancillary studies such as flow cytometry. Secondary outcomes included 30-day morbidity, 30-day readmission rates, the need for additional lymph node biopsy procedures, and length of stay. RESULTS: All 34 of the LB patients had adequate specimen for histologic diagnosis compared to 92.3% of patients with a PB (p = 0.18). Significantly more patients in the LB group had sufficient tissue for ancillary studies when needed than in the PB group, 95.5 and 68.2%, respectively (p = 0.04). A second biopsy was pursued in 23.1% of failed PB patients, 0% with success on second attempt. DISCUSSION: When index of suspicion is high or when biopsy is performed for patient previously diagnosed with lymphoma and recurrence/transformation is suspected, LB safely and consistently provides adequate tissue for initial diagnosis and for ancillary studies. In contrast, image-guided PB may be more appropriate for patients for whom ancillary studies are unlikely to add to planned treatments or when there is a high risk of complications from either general anesthesia or patient comorbidities.

Improved patient outcomes in paraesophageal hernia repair using a laparoscopic approach: a study of the national surgical quality improvement program data.

A consensus on the optimal surgical approach for repair of a paraesophageal hernia has not been reached. The aim of this study was to examine the outcomes of open and laparoscopic paraesophageal hernia repairs (PHR), both with and without mesh. A review of the National Surgical Quality Improvement Program (NSQIP) database from 2007 to 2011 was conducted. Patients who underwent an open or laparoscopic PHR were included. The primary outcome was 30-day mortality. Secondary outcomes included infections, respiratory and cardiac complications, intraoperative or perioperative transfusions, sepsis, and septic shock. Statistical analyses using odds ratios were performed comparing the open and laparoscopic approaches. A total of 4470 patients were identified using NSQIP; 2834 patients had a laparoscopic repair and the remaining 1636 patients underwent an open PHR. Compared with the laparoscopic approach, the open repair group had significantly higher 30-day mortality (odds ratio, 4.75; 95% confidence interval, 2.67 to 8.47; P < 0.0001). The laparoscopic approach had a statistically significant decrease in infections, respiratory and cardiac events/complications, transfusion requirements, episodes of sepsis, and septic shock (P < 0.05). Our data suggest increased perioperative morbidity associated with an open PHR compared with laparoscopic. There was no statistically significant difference in any of the primary or secondary outcomes in patients repaired with mesh compared with those without. The overall use of mesh in paraesophageal hernia repairs has increased. The NSQIP data show significantly increased 30-day mortality in open repair compared with laparoscopic as well as a significantly higher perioperative complication rate.

Minimally invasive technique leads to decreased morbidity and mortality in small bowel resections compared to an open technique: an ACS-NSQIP identified target for improvement.

BACKGROUND: We hypothesize that currently minimally invasive techniques are underutilized, leading to unnecessary morbidity and mortality. The objective of the study was to compare morbidity and mortality rates in patients receiving a minimally invasive (MIS) small bowel resection to patients receiving an open (OP) small bowel resection. METHODS: Patients in the National Surgical Quality Improvement Program (NSQIP) database who underwent a small bowel resection between 2007 and 2011 were enrolled in the study and grouped whether they received a MIS procedure (n = 1,780) or an OP procedure (n = 17,701). The primary endpoint of the study was to evaluate the difference in morbidity (excluding mortality) and mortality in patients undergoing a minimally invasive procedure compared to an open procedure. RESULTS: The MIS technique is utilized in 9.0 % of patients undergoing a small bowel resection. Significantly lower mortality rate (2.9 vs. 8.2 %; p < 0.001) and mean morbidity rate (1.7 vs. 4.3 %; p < 0.001) were demonstrated in the MIS group. Significantly lower mean major morbidity rate (1.4 vs. 3.9 %; p < 0.001) and mean minor morbidity rate (2.6 vs. 5.5 %; p < 0.001) were demonstrated in the MIS group. CONCLUSION: The MIS technique in small bowel resections appears to be underutilized, with only 9.0 % of patients in need of a small bowel resection undergo the minimally invasive approach. Wider utilization of the MIS technique could lead to significantly decreased morbidity and mortality.

Long-term efficacy of laparoscopic cholecystectomy for the treatment of biliary dyskinesia.

BACKGROUND: Laparoscopic cholecystectomy is the treatment of choice for biliary dyskinesia; however, long-term outcomes remain unclear. METHODS: A retrospective review of patients diagnosed with biliary dyskinesia and treated with laparoscopic cholecystectomy at a single institution between 2001 and 2012 was conducted. Long-term outcome data were obtained by telephonic interview using a modified Likert scale. RESULTS: Sixty-seven patients met inclusion criteria, of which 34 patients (51%) had long-term follow-up data. Mean time of follow-up was 65 (range: 6 to 134) months. Long-term follow-up demonstrated symptom response in 88% (n = 30) of patients (responders), compared to no response in 12% (n = 4) of patients (nonresponders). Responders underwent a mean of 1.56 preoperative diagnostic procedures, compared to 2.5 for nonresponders (P = .01). CONCLUSION: This represents the longest mean time of follow-up study demonstrating the success of laparoscopic cholecystectomy to improve symptoms in patients with biliary dyskinesia.

Permanent mesh results in long-term symptom improvement and patient satisfaction without increasing adverse outcomes in hiatal hernia repair.

BACKGROUND: The purpose of this study is to evaluate symptom relief, patient satisfaction, and safety of permanent mesh following Nissen fundoplication and hiatal hernia repair. METHODS: Patients who underwent Nissen fundoplication and hiatal hernia repair with permanent mesh (Crurasoft; Davol, Inc, Bard, Warwick, RI) between 2005 and 2011 were identified. A retrospective chart review was conducted. Long-term follow-up data were obtained via telephone interviews using a modified 5-point Likert scale. RESULTS: Forty-one patients were identified. Twenty-six patients (63%) had complete follow-up data. Mean follow-up period was 65 months (14 to 96 months). Symptomatic improvement occurred in 23 patients (88%). Twenty-three patients (88%) reported overall satisfaction with the procedure as either excellent or good, and 23 of 26 patients (89%) would undergo surgery again. Three patients (12%) reported hernia recurrence. There were no mesh erosions. CONCLUSION: The use of permanent (Crurasoft; Davol, Inc) mesh resulted in symptom improvement as well as patient satisfaction, and no mesh erosions were seen.

Higher clinical performance during a surgical clerkship is independently associated with matriculation of medical students into general surgery.

BACKGROUND: The purpose of our study was to determine the predictive impact of individual academic measures for the matriculation of senior medical students into a general surgery residency. METHODS: Academic records were evaluated for third-year medical students (n = 781) at a single institution between 2004 and 2011. Cohorts were defined by student matriculation into either a general surgery residency program (n = 58) or a non-general surgery residency program (n = 723). Multivariate logistic regression was performed to evaluate independently significant academic measures. RESULTS: Clinical evaluation raw scores were predictive of general surgery matriculation (P = .014). In addition, multivariate modeling showed lower United States Medical Licensing Examination Step 1 scores to be independently associated with matriculation into general surgery (P = .007). CONCLUSIONS: Superior clinical aptitude is independently associated with general surgical matriculation. This is in contrast to the negative correlation United States Medical Licensing Examination Step 1 scores have on general surgery matriculation. Recognizing this, surgical clerkship directors can offer opportunities for continued surgical education to students showing high clinical aptitude, increasing their likelihood of surgical matriculation.