Negative workup? Laparoscopic cholecystectomy Still alleviates symptoms.

BACKGROUND: Studies have shown that patients with abdominal pain and biliary dyskinesia (low ejection fraction <35 â€‹%) have significant improvement of symptoms following laparoscopic cholecystectomy, but there is lack of evidence that demonstrates whether patients with biliary symptoms and a normal ejection fraction (>35 â€‹%) will have similar results. METHODS: Retrospective, single center study of patients with biliary pain and negative workup, including HIDA with EF>35 â€‹%, who were treated with laparoscopic cholecystectomy from 2017 to 2022. RESULTS: There were 117 total patients. The mean age was 45.49 â€‹± â€‹15.5 years and 101 (86 â€‹%) were female. 101 (86 â€‹%) of patients underwent a right upper quadrant ultrasound, 91 had normal findings, 9 difficult to visualize anatomy and 1 had adenomyomatosis. All patients had a normal HIDA scan and ejection fraction 104 (89 â€‹%) of patients followed up in clinic within 30 days of surgical intervention. 87 (84 â€‹%) reported resolution of pre-operative symptomatology after surgical intervention. There was no statistically significant correlation between pain with CCK administration during HIDA (p â€‹= â€‹0.803) scan or ejection fraction (p â€‹= â€‹0.0977) with resolution of symptoms. CONCLUSIONS: Laparoscopic cholecystectomy appears to be a beneficial intervention for patients with abdominal pain and normokinetic biliary disease. Offering surgical intervention early on can potentially save patients from exhaustive diagnostic investigations and possibly misdiagnosis.

The robot can break bars with the best of them: a novel approach to treating cricopharyngeal bars with myotomy.

INTRODUCTION: Failure of the cricopharyngeus to relax results in oropharyngeal dysphagia, which over time results in hypertrophy and increased risk for aspiration. Open myotomy is one definitive treatment option, however there are several drawbacks attributable to the long neck incision, ± drain placement, and invasiveness of the procedure. We aim to share our experience using the DaVinci robotic platform to perform a minimally invasive cricopharyngeal myotomy, which has never been described before in the literature. METHODS: All robotic cricopharyngeal myotomies performed in adult patients by a single surgeon from 2021 to 2022 were retrospectively reviewed. No patients were excluded. Outcomes of interest included length of procedure, time to diet resumption, hospital length of stay, complications, symptom improvement at follow-up, and symptom recurrence. RESULTS: Eight robotic cricopharyngeal myotomies were performed. The median age was 65 years old (62-91) and mostly female (n = 5, 56%) with a median BMI of 28.9 kg/m2 (21.7-39.5). The median procedure length was 113 min (94-141) and there were no intraoperative complications. All patients underwent a post-procedural esophagram with no leaks were identified. All patients were started on clear liquids in recovery and transitioned to full liquids prior to discharge. All but one patient was subsequently discharged home on the same day as procedure. All patients had routine 2-week post-operative follow-up in addition to phone follow-up at a later date (6-11 months post-operative). All patients reported resolution of symptoms. There were no complications or readmissions. No instances of recurrence were reported. On cost analysis, the minimally invasive robotic approach allows for an outpatient procedure with similar cost to an open approach with a one-night stay. CONCLUSION: Our experience with the novel technique of minimally invasive robotic cricopharyngeal myotomy for cricopharyngeal bars with cervical dysphagia is safe, efficacious, less invasive, and cost saving, with excellent patient outcomes.

Who drops the beat? Effects of music on residents in laparoscopic surgery.

BACKGROUND: Music is played in the operating room and commonly chosen by the surgeon or circulating nurse. The aim of this study is to measure the effect of different genres of music on resident performance in laparoscopic surgery. METHODS: This is a prospective observational study including residents from a university-affiliated general surgery program who performed standardized laparoscopic skills while listening to music. RESULTS: 64% of residents ranked pop music as their favorite genre followed by classic rock, country, and classical at 17%, 11% and 8% respectively. For peg transfer and intracorporeal knot tying, the task completion time was fastest with pop music (57.4 s p < 0.49, 109.6 s p < 0.47) and slowest with classical (61.4 s p < 0.49, 148.1 s p < 0.47). CONCLUSIONS: Pop music was ranked the most favored genre and found to have the fastest task completion times however, no genre of music was statistically significant in improving resident performance.

A fast tract to foregut surgery: Pandemic-driven protocol development.

BACKGROUND: COVID-19 has overwhelmed many health care systems which has affected the landscape of elective surgery. A pandemic driven protocol was developed to perform foregut surgeries as a Same Day Surgery (SDS) discharge for all comers to reduce resource utilization. METHODS: Retrospective review of all patients who underwent elective laparoscopic foregut surgery (hiatal hernia, paraesophageal hernia, heller myotomy, and fundoplication) from 8/1/2020-1/31/2022 by a single surgeon after the implementation of a SDS protocol. Patients were compared to a pre-pandemic cohort, from 8/1/2019-4/30/2020, when overnight admission was standard practice. RESULTS: There were 36 pre-pandemic patients, and 41 pandemic patients successfully discharged the same day of surgery. We failed to detect a statistically significant difference between the two groups regarding 30-day ED visit rate (p-value of 0.4557) and 30-day readmission rate (p-value of 0.6790). CONCLUSION: The creation of a SDS protocol for foregut surgery is a safe way to deliver much needed care to the community while decreasing resource utilization.

Peroral cricopharyngeal myotomy for the management of Zenker's diverticulum in the hands of a general surgeon.

BACKGROUND: The treatment of Zenker's diverticulum has been shifted from open cricopharyngeal myotomy and rigid endoscopy to the use of flexible endoscopy. Few studies evaluate general surgeon's performance of flexible endoscopic management of Zenker's diverticulum as the majority are performed by gastroenterologists. The objective of our case series is to show that general surgeons trained in surgical endoscopy can perform this procedure with favorable outcomes. METHODS: A retrospective review of peroral cricopharyngeal myotomies performed at Spectrum Health hospital in Grand Rapids, Michigan by a single surgical endoscopist between the 2018 and 2021 was conducted. The primary outcome was the improvement of dysphagia. Intra-procedural complications, post-procedural complications, hospital length of stay, time to oral intake, and recurrence were also evaluated. Age, sex, body mass index, diverticulum size, and procedure time were abstracted. Median (ranges) and frequencies (percentages) are used to describe the patient population and outcomes. RESULTS: Forty patients were included in the study. Median age was 74 years old (60-95) with a male predominance (n = 27, 67.5%). Median BMI was 28 kg/m2 (18-43), average procedure length of 64 min (41-119), diverticulum size of 28 mm (19-90), and average length of stay of 0.9 days (0-8). There were no intra-procedural complications. All patients had a post-procedural esophagram prior to initiation of diet. Esophageal leak was the only complication that occurred, which was found on post-procedural esophagram (n = 5). Only two patients had clinical sequelae. All leaks closed without additional surgical intervention. The majority of patients had their diet resumed and discharged the same day of the procedure. Frequency of recurrence was 17.5% (n = 7). CONCLUSION: Our study demonstrates that general surgeons trained in endoscopy can perform endoscopic myotomies for Zenker's diverticula on a wide range of sizes, with favorable patient outcomes, and few complications.

Comparison of Robotic, Laparoscopic, and Open Unilateral Repair of Non-recurrent Inguinal Hernia.

BACKGROUND: There is a paucity of data comparing open, robotic, and laparoscopic approaches on unilateral, non-recurrent inguinal hernias. Our study presents a large, retrospective triple-arm outcome analysis between robotic, laparoscopic, and open unilateral, non-recurrent inguinal hernia repairs at a single institution. METHODS: 706 patients who underwent elective, non-recurrent inguinal hernia repair performed by 8 general surgeons at a single institution from 2016 to 2019 were reviewed retrospectively. Patient baseline characteristics, operative times, resident involvement, and postoperative outcomes were analyzed for all repair types. A cost analysis of the different procedures was performed. RESULTS: There were 305 laparoscopic repairs, 207 robotic repairs, and 194 open repairs. Open and laparoscopic repairs were performed on patients who were older (p =< .001) and with a higher Charlson Comorbidity Index (p =< .001). Patient BMI was higher in minimally invasive repair than open repair (P = .021). There were no significant differences in complication rates on pairwise analysis. Robotic and open repairs had significantly longer operative times than laparoscopic repairs (P < .001). There was less resident involvement in robotic repair than with the other approaches (P < .001). Resident involvement was associated with shorter OR times (P = .001) and no significant difference in postoperative complications. There was a trend over the study period toward faster operative times and more robotic repair. Robotic repair is the most expensive repair, followed by laparoscopic and open repairs. CONCLUSION: All 3 repair techniques can be performed without significant differences in outcomes. The technique utilized should be based on surgeon preference and patient characteristics.

Outcomes of partial fundoplication for GERD-related allograft decline after lung transplantation.

INTRODUCTION: Gastroesophageal reflux disease contributes to allograft decline secondary to bronchiolitis obliterans after lung transplantation. Antireflux surgery (ARS) slows the decline in lung function related to GERD. ARS operations range from Nissen fundoplications to partial fundoplications, such as the Toupet and Dor. Research in the general population has indicated that partial fundoplication is effective at controlling reflux. We explored lung function and reflux outcomes in a cohort of lung transplant patients who received partial fundoplications. METHODS: Data from an institutional lung transplant registry was reviewed for patients between 2009 and 2020 who underwent fundoplication after transplant. Lung transplant patients underwent routine pulmonary function testing. Patients with FEV1 values within 180 days pre-fundoplication and two years post-fundoplication were included in the analysis. All patients referred for fundoplication underwent esophageal pH testing, manometry, UGI, and EGD. Most patients underwent Toupet fundoplication, but those with severe dysmotility underwent Dor fundoplication. RESULTS: 53 patients were included in the analysis. Median time to fundoplication after transplant was 403 days. 48 patients underwent Toupet fundoplication. Five underwent Dor fundoplication. 40% of patients had abnormal high-resolution manometry. A linear mixed-effects model tested for a change in FEV1 trajectory up to two years post-fundoplication with an auto-regressive correlation structure. Post-fundoplication FEV1 values decreased by 7 mL per month, and suggested a slow in the decline by 2 mL per month, but this was not significant (p = 0.8). In patients for whom postoperative DeMeester scores were available (19), there was a decline in acid exposure from a median of 45.8 to 1.8 after ARS (p = 0.0003). CONCLUSION: Although our results did not reach statistical significance, there was a trend towards a decrease in the rate of decline of allograft function before and after partial fundoplication. In the patients whom results were available, a partial fundoplication appropriately controlled acid exposure.

Is barium esophagram enough? Comparison of esophageal motility found on barium esophagram to high resolution manometry.

BACKGROUND: The aim of the study is to determine if barium esophagram (BE) alone is sufficient to diagnose esophageal dysmotility when compared to the gold standard, high-resolution manometry (HRM). METHODS: This is a retrospective review of patients that underwent laparoscopic fundoplication by two surgeons at a single institution from 10/1/2015-6/29/2019. Patients with large paraesophageal hernias and patients without both BE and HRM were excluded. RESULTS: Forty-six patients met the inclusion criteria. BE was found to be concordant with HRM for esophageal motility in only 21 patients (46%). Setting HRM as the gold standard, BE had a sensitivity of 14% (95% CI: 5%-35%), specificity of 72% (95% CI: 52%-86%), PPV of 30% (95% CI: 11%-60%), and NPV of 50% (95% CI: 35%-66%). The accuracy was 46%, while a McNemar test showed p = 0.028. CONCLUSION: Traditional BE should not be used in place of HRM for assessing pre-operative motility in patients undergoing anti-reflux surgery.

Transient Secondary Hypothyroidism and Thyroid Hormone Replacement Therapy in Pediatric Postoperative Cardiopulmonary Bypass.

BACKGROUND: To develop an understanding of current practices in the management of transient secondary hypothyroidism in pediatric postoperative cardiopulmonary bypass (CPB) patients. METHODS: Electronic survey comprising a 10-item questionnaire was sent to sixty-four high volume pediatric heart centers in the United States and United Kingdom. Survey participants included cardiologists, intensivists, cardiothoracic surgeons, and advanced practice providers. A retrospective chart review was also performed at a large regional referral center in the Midwest on subjects 0-18 years old who underwent CPB from 2005-2015. Information obtained included a unique identifier, date of birth, age, procedure performed, CPB time, date of surgery and date and type of Thyroid Function Test (TFT) ordered. RESULTS: 1,153 individuals from 64 congenital heart centers were contacted via email to participate in the electronic survey. In the 3-month response window, 129 completed surveys were received from cardiologists (55%), intensivists (17%), surgeons (15%), "other" (8%), and advanced practice providers (5%). This yielded a response rate of 11.2%. Of the 129 respondents, only 10 providers routinely order TFTs prior to (n=7) and after (n=1) CPB or when clinically indicated (n=2). All 10 providers order thyroid stimulating hormone test, 7 order thyroxine, and 3 order triiodothyronine. Only 1 provider routinely treats children with prophylactic thyroid hormone replacement therapy after CPB. Our retrospective review included 502 CPB events with 442 unique patients. Of the events, 20 patients received preoperative TFT testing while 11 received postoperative testing. CONCLUSIONS: There is a general lack of uniformity in the evaluation, diagnosis, and treatment of transient secondary hypothyroidism in pediatric postoperative CPB patients.