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BACKGROUND: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) uses the Laparoscopic colectomy Train the Trainer (Lapco TT) framework for standardization of instructor training for Hands-On surgical skills courses. The curriculum focuses on teaching structure, skills deconstruction, trainer intervention framework, and performance enhancing feedback. A halt in the in-person Lapco TT courses due to the Coronavirus Disease 2019 (COVID-19) pandemic necessitated creation of a virtual alternative. We investigated the effectiveness of this virtual course. METHODS: Adaptation of the in-person Lapco TT course to the virtual format retained the majority of content as well as the 4:6 instructor-to-participant ratio. The virtual platform and simulators chosen allowed maximal interactivity and ease of use. After participating in the day and one half course, participants completed an 8-item post-course survey using a 5-point Likert scale related to the training experience. In addition, they had the opportunity to provide answers to several open-ended questions regarding the course. For the survey, frequency counts provided an assessment of each item. For the open questions, qualitative analysis included determination of themes for each question. Frequency counts of each theme provided quantitative analysis. RESULTS: Thirty-six total participants completed a Lapco TT virtual course (six sessions of six participants). Of this number, 32 participants completed post-course surveys and questions. All the participants completing the survey would very likely or definitely (Likert scale 4, 5) recommend the course to a colleague and incorporate the teaching in their practice. The majority of participants completing open-ended questions felt the virtual course format was effective; half thought that post-course follow-up would be useful. Technical concerns were an issue using the virtual format. CONCLUSION: A virtual Lapco TT course is feasible and well received by participants. It presents a potentially more cost effective option to faculty development.
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COVID-19 , Cirurgiões , Humanos , Estados Unidos , Endoscopia/educação , Cirurgiões/educação , Currículo , DocentesRESUMO
INTRODUCTION: Inguinal complete lymph node dissection (CLND) for metastatic melanoma exposes the femoral vein and artery. To protect femoral vessels while preserving the sartorius muscle, we developed a novel sartorius and adductor fascial flap (SAFF) technique for coverage. METHODS: The SAFF technique includes dissection of fascia off sartorius and/or adductor muscles, rotation over femoral vasculature, and suturing into place. Patients who underwent inguinal CLND with SAFF for melanoma at our institution were identified retrospectively from a prospectively-collected database. Patient characteristics and post-operative outcomes were obtained. Multivariate logistic regression assessed associations of palpable and non-palpable disease with wound complications. RESULTS: From 2008 to 2019, 51 patients underwent CLND with SAFF. Median age was 62 years, and 59% were female. Thirty-one (61%) patients were presented with palpable disease and 20 (39%) had non-palpable disease. Fifty-five percent (95% confidence interval CI: 40%-69%) experienced at least one wound complication: wound infection was most common (45%; 95% CI: 31%-60%), while bleeding was the least (2%; 95% CI: 0.05%-11%). Complications were similar, with and without palpable disease. CONCLUSIONS: The SAFF procedure covers femoral vessels, minimizes bleeding, preserves the sartorius muscle, and uses standard surgical techniques easily adoptable by surgeons who perform inguinal CLND.
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Melanoma , Neoplasias Cutâneas , Feminino , Virilha/patologia , Virilha/cirurgia , Humanos , Excisão de Linfonodo/efeitos adversos , Excisão de Linfonodo/métodos , Masculino , Melanoma/patologia , Pessoa de Meia-Idade , Estudos Retrospectivos , Biópsia de Linfonodo Sentinela , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/cirurgia , Retalhos Cirúrgicos/patologiaRESUMO
BACKGROUND: Laryngopharyngeal reflux (LPR) symptoms are often present in patients with Gastroesophageal reflux disease (GERD). Whereas antireflux surgery (ARS) provides predictably excellent results in patients with typical GERD, those with atypical symptoms have variable outcomes. The goal of this study was to characterize the response of LPR symptoms to antireflux surgery. METHODS: Patients who underwent ARS between January 2009 and May 2020 were prospectively identified from a single institutional database. Patient-reported information on LPR symptoms was collected at standardized time points (preoperative and 2 weeks, 8 weeks, and 1 year postoperatively) using a validated Reflux Symptom Index (RSI) questionnaire. Patients were grouped by preoperative RSI score: ≤ 13 (normal) and > 13 (abnormal). Baseline characteristics were compared between groups using chi-square test or t-test. A mixed effects model was used to evaluate improvement in RSI scores. RESULTS: One hundred and seventy-six patients fulfilled inclusion criteria (mean age 57.8 years, 70% female, mean BMI 29.4). Patients with a preoperative RSI ≤ 13 (n = 61) and RSI > 13 (n = 115) were similar in age, BMI, primary reason for evaluation, DeMeester score, presence of esophagitis, and hiatal hernia (p > 0.05). The RSI > 13 group had more female patients (80 vs 52%, p = < 0.001), higher mean GERD-HRQL score, lower rates of PPI use, and normal esophageal motility. The RSI of all patients improved from a mean preoperative value of 19.2 to 7.8 (2 weeks), 6.1 (8 weeks), and 10.9 (1 year). Those with the highest preoperative scores (RSI > 30) had the best response to ARS. When analyzing individual symptoms, the most likely to improve included heartburn, hoarseness, and choking. CONCLUSIONS: In our study population, patients with LPR symptoms achieved a rapid and durable response to antireflux surgery. Those with higher preoperative RSI scores experienced the greatest improvement. Our data suggest that antireflux surgery is a viable treatment option for this patient population.
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Esofagite Péptica , Hérnia Hiatal , Refluxo Laringofaríngeo , Feminino , Fundoplicatura/métodos , Hérnia Hiatal/cirurgia , Humanos , Refluxo Laringofaríngeo/diagnóstico , Refluxo Laringofaríngeo/etiologia , Refluxo Laringofaríngeo/cirurgia , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
BACKGROUND: Typically, in-person follow-up in clinic is utilized after outpatient inguinal hernia repair. Studies have shown that phone follow-up may be successfully used for the detection of postoperative hernia recurrences. However, no studies have evaluated the detection rates of other postoperative complications, such as emergency department visits and readmissions, with the utilization of phone follow-up after inguinal hernia repair. The objective of our study was to investigate the safety of a phone follow-up care pathway following elective, outpatient inguinal hernia repair. METHODS: In this retrospective cohort study, adult patients who underwent elective, outpatient inguinal hernia repair between 2013 and 2019 at a large academic health system in the Midwest United States were identified from the electronic health record. Patients were categorized by type of postoperative follow-up: in-person or phone follow-up. Baseline demographics, operative, and postoperative data were compared between follow-up groups. Multivariable logistic regression was performed to investigate predictors of having any related emergency department (ED) visit/readmission/reoperation within 90 days. RESULTS: We included 2009 patients who underwent elective inguinal hernia repair during the study period. 321 patients had in-person follow-up only, while 1,688 patients had phone follow-up. There was a higher rate of laparoscopic repair in the phone follow-up group (85.4% vs. 53.0% for in-person follow-up). There were no differences in rates of related 90-day ED visits, readmissions, and reoperations between the phone and in-person follow-up groups. On multivariable logistic regression, receipt of phone follow-up was not a predictor of having 90-day ED visits, readmissions, or reoperations (OR 1.30, 95% CI [0.83, 2.05]). CONCLUSIONS: Patients who underwent phone follow-up had similarly low rates of adverse outcomes to those with in-person follow-up. Phone follow-up protocols may be implemented as an alternative for patients and provide a means to decrease healthcare utilization following inguinal hernia repair.
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Hérnia Inguinal , Laparoscopia , Adulto , Seguimentos , Hérnia Inguinal/cirurgia , Herniorrafia , Humanos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Recidiva , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Gastroparesis (GP) is hallmarked by nausea, vomiting, and early satiety. While dietary and medical therapy are the mainstay of treatment, surgery has been used to palliate symptoms. Two established first-line surgical options are gastric electrostimulation (GES) and pyloric procedures (PP) including pyloroplasty or pyloromyotomy. We sought to compare these modalities' improvement in Gastroparesis cardinal symptom index (GCSI) subscores and potential predictors of therapy failure. METHODS: All patients undergoing surgery at a single institution were prospectively identified and separated by surgery: GES, PP, or combined GESPP. GCSI was collected preoperatively, at 6 weeks and 1 year. Postoperative GCSI score over 2.5 or receipt of another gastroparesis operation were considered treatment failures. Groups were compared using Pearson's chi-squared and Kruskal-Wallis one-way ANOVA. RESULTS: Eighty-two patients were included: 18 GES, 51 PP, and 13 GESPP. Mean age was 44, BMI was 26.7, and 80% were female. Preoperative GCSI was 3.7. The PP group was older with more postsurgical gastroparesis. More patients with diabetes underwent GESPP. Preoperative symptom scores and gastric emptying were similar among all groups. All surgical therapies resulted in a significantly improved GCSI and nausea/vomiting subscore at 6 weeks and 1 year. Bloating improved initially, but relapsed in the GES and GESPP group. Satiety improved initially, but relapsed in the PP group. Fifty-nine (72%) had surgical success. Ten underwent additional surgery (7 crossed into the GESPP group, 3 underwent gastric resection). Treatment failures had higher preoperative GCSI, bloating, and satiety scores. Treatment failures and successes had similar preoperative gastric emptying. CONCLUSIONS: Both gastric electrical stimulation and pyloric surgery are successful gastroparesis treatments, with durable improvement in nausea and vomiting. Choice of operation should be guided by patient characteristics and discussion of surgical risks and benefits. Combination GESPP does not appear to confer an advantage over GES or PP alone.
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Terapia por Estimulação Elétrica , Gastroparesia , Piloromiotomia , Adulto , Estimulação Elétrica , Feminino , Esvaziamento Gástrico , Gastroparesia/etiologia , Gastroparesia/cirurgia , Humanos , Piloro/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: The diagnosis of inguinal hernias is predominantly based on physical exam, although imaging may be used in select cases. The objective of this study was to determine the frequency of unnecessary imaging used in the diagnosis of inguinal hernias. METHODS: Patients who underwent elective inguinal hernia repair at a large academic health system in the U.S. from 2010 to 2017 were included. Within this cohort, we identified patients who received imaging 6 months prior to surgery. Through chart review of physical exam findings and imaging indications, we categorized patients into four imaging categories: unrelated, necessary, unnecessary, and borderline. Multivariable logistic regression analysis was used to identify factors associated with receipt of unnecessary imaging. RESULTS: Of 2162 patients who underwent inguinal hernia surgery, 249 patients had related imaging studies 6 months prior to surgery. 47.0% of patients received unnecessary imaging. 66.9% and 33.1% of unnecessary studies were ultrasounds and CT scans, respectively. 24.5% of patients had necessary studies, while 28.5% had studies with borderline indications. On multivariable analysis, having a BMI between 25.0 and 29.9 kg/m2 was associated with receipt of unnecessary studies. Primary care providers and ED physicians were more likely to order unnecessary imaging. CONCLUSIONS: Nearly 50% of all patients who receive any related imaging prior to surgery had potentially unnecessary diagnostic radiology studies. This not only exposes patients to avoidable risks, but also places a significant economic burden on patients and our already-strained health system.
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Hérnia Inguinal , Radiologia , Estudos de Coortes , Hérnia Inguinal/diagnóstico por imagem , Hérnia Inguinal/cirurgia , Herniorrafia , Humanos , Estudos RetrospectivosRESUMO
BACKGROUND: Heller myotomy (HM) has historically been considered the gold standard treatment for achalasia. Peroral endoscopic myotomy (POEM) is a less-invasive procedure and offers a quicker recovery. Although some studies have compared short-term outcomes of HM and POEM, predictors of long-term dysphagia resolution remain unclear. The objective of this study was to evaluate patient-reported outcomes for achalasia patients who underwent either POEM or HM over a 9-year period. METHODS: Data from our single academic institutional foregut database were used to identify achalasia patients who underwent HM or POEM from 2009 to 2018. Electronic health record data were reviewed to obtain patient characteristics and operative data. Achalasia severity stages were established for each patient using esophagram findings from an attending radiologist blinded to the procedure type. Postoperative outcomes were assessed via telephone for patients with at least 9 months of follow-up using Eckardt dysphagia scores. Patient age, sex, type of operation, and duration of follow-up were included in a multivariable linear regression model with Eckardt score as the outcome. RESULTS: Our cohort included 141 patients (97 HM and 44 POEM). Eighty-two patients completed a phone survey at the 9 months or greater time interval (response rate = 58%). Mean Eckardt scores were 2.98 and 2.53 at a median follow-up of 3 years and 1 year for HM and POEM patients, respectively (an Eckardt score ≤ 3 is considered a successful myotomy). Lower stages of achalasia on esophagram (e.g., Stage 0 vs. Stage 4) were associated with greater dysphagia improvement. On multivariable analysis, operative approach was not associated with a statistically significant difference in dysphagia outcomes. CONCLUSIONS: POEM and HM were associated with similar rates of dysphagia resolution for achalasia patients at a median of 2 years of follow-up. Both procedures appear to be durable options for achalasia treatment.
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Transtornos de Deglutição/cirurgia , Acalasia Esofágica/cirurgia , Miotomia de Heller/métodos , Piloromiotomia/métodos , Adulto , Idoso , Bases de Dados Factuais , Transtornos de Deglutição/etiologia , Acalasia Esofágica/complicações , Esfíncter Esofágico Inferior/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medidas de Resultados Relatados pelo Paciente , Período Pós-Operatório , Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Roux-en-Y gastric bypass (RYGB) consistently produces the most sustainable weight loss among common interventions for morbid obesity. Anastomotic leaks at the gastrojejunal (GJ) connection result in severe morbidity. We apply endoluminal negative pressure vacuum devices (EVD) to heal anastomotic leaks in a swine model. METHODS: RYGB was performed in 10 pigs (3 control, 7 experimental). GJ anastomoses were fashioned, and a 2-cm defect was made across the staple line. In controls, the defects remained open. In experimental pigs, the EVD was placed across the defect and kept at continuous 50 mmHg suction. All pigs were euthanized on postoperative day seven unless they displayed signs of peritonitis or sepsis. Fluoroscopy and necropsy were performed to assess a persistent leak, and tissue specimens were sent to histology to evaluate for degree of inflammation and ischemia. RESULTS: All three control pigs' GJ anastomoses demonstrated evidence of a persistent leak. All seven experimental pigs with the EVD in place showed evidence that their leak had sealed at time of fluoroscopy (p value 0.008). CONCLUSIONS: Endoluminal vacuum therapy is well tolerated in a swine model. GJ anastomotic leaks were consistently sealed with our device in place compared to controls. This therapy shows promise as a method to address GJ leaks in the bariatric population, and thus, we believe additional evaluation is warranted.
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Fístula Anastomótica/etiologia , Fístula Anastomótica/terapia , Derivação Gástrica/efeitos adversos , Tratamento de Ferimentos com Pressão Negativa , Animais , Modelos Animais , Projetos Piloto , SuínosRESUMO
INTRODUCTION: Surgical options for symptomatic delayed gastric emptying include gastric stimulator implantation, subtotal gastrectomy, and pyloroplasty. Pyloroplasty has been shown to improve gastric emptying yet is seldom described as a primary treatment for gastroparesis. We present a single-institution experience of laparoscopic Heineke-Mikulicz pyloroplasty (LP) as treatment for gastroparesis. METHODS AND PROCEDURES: A prospective foregut surgery database was queried for LP over a 5-year period. Charts were reviewed for indications, complications, symptom score, and outcomes. Gastroparesis was defined by (1) abnormal gastric emptying study, (2) endoscopic visualization of retained food after prolonged NPO status, or (3) clinical symptoms suspicious of vagal nerve injury following complex re-operative foregut surgery. Results were analyzed using a paired T test and single-factor ANOVA. RESULTS: One hundred and seventy-seven LP patients were identified and reviewed. One hundred and five had a concurrent fundoplication for objective reflux. There were no intraoperative complications or conversions to laparotomy. Overall morbidity rate was 6.8% with four return to OR and two confirmed leaks (1.1% leak rate). Average length of stay was 3.5 days, and readmission rate was 7%. Eighty-six percent had improvement in GES with normalization in 77%. Gastric emptying half-time decreased from 175 ± 94 to 91 ± 45 min. Nineteen patients (10.7%) had subsequent surgical interventions: gastric stimulator implantation (12), feeding jejunostomy and/or gastrostomy tube (6), or subtotal gastrectomy (4). Symptom severity scores for nausea, vomiting, bloating, abdominal pain, and early satiety decreased significantly at 3 months. CONCLUSION: Laparoscopic pyloroplasty improves or normalizes gastric emptying in nearly 90% of gastroparesis patients with very low morbidity. It significantly improves symptoms of nausea, vomiting, bloating, and abdominal pain. Some patients may go on to another surgical treatment for GP, but it remains a safe and less invasive alternative to a subtotal gastrectomy in these clinically challenging patients.
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Gastroparesia/cirurgia , Laparoscopia , Piloro/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Esvaziamento Gástrico , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Adulto JovemRESUMO
BACKGROUND: Differentiating melanoma metastasis from benign cutaneous lesions currently requires biopsy or costly imaging, such as positron emission tomography scans. Melanoma metastases have been observed to be subjectively warmer than similarly appearing benign lesions. We hypothesized that infrared (IR) thermography would be sensitive and specific in differentiating palpable melanoma metastases from benign lesions. MATERIALS AND METHODS: Seventy-four patients (36 females and 38 males) had 251 palpable lesions imaged for this pilot study. Diagnosis was determined using pathologic confirmation or clinical diagnosis. Lesions were divided into size strata for analysis: 0-5, >5-15, >15-30, and >30 mm. Images were scored on a scale from -1 (colder than the surrounding tissue) to +3 (significantly hotter than the surrounding tissue). Sensitivity and specificity were calculated for each stratum. Logistical challenges were scored. RESULTS: IR imaging was able to determine the malignancy of small (0-5 mm) lesions with a sensitivity of 39% and specificity of 100%. For lesions >5-15 mm, sensitivity was 58% and specificity 98%. For lesions >15-30 mm, sensitivity was 95% and specificity 100%, and for lesions >30 mm, sensitivity was 78% and specificity 89%. The positive predictive value was 88%-100% across all strata, and the negative predictive value was 95% for >15-30 mm lesions and 80% for >30 mm lesions. CONCLUSIONS: Malignant lesions >15 mm were differentiated from benign lesions with excellent sensitivity and specificity. IR imaging was well tolerated and feasible in a clinic setting. This pilot study shows promise in the use of thermography for the diagnosis of malignant melanoma with further potential as a noninvasive tool to follow tumor responses to systemic therapies.
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Melanoma/diagnóstico , Melanoma/secundário , Neoplasias Cutâneas/diagnóstico , Neoplasias Cutâneas/secundário , Termografia , Adulto , Idoso , Idoso de 80 Anos ou mais , Diagnóstico Diferencial , Estudos de Viabilidade , Feminino , Humanos , Raios Infravermelhos , Masculino , Pessoa de Meia-Idade , Neoplasias/diagnóstico , Segurança do Paciente , Projetos Piloto , Sensibilidade e EspecificidadeRESUMO
INTRODUCTION: Metastatic melanoma has few FDA approved treatments, and aggressive surgical resection has to be considered for management of bulky axillary metastases. We hypothesized that axillary resection in this setting is well tolerated and improves symptoms in the majority of patients. METHODS: We reviewed a prospectively collected database and identified 47 stage IIIC and IV patients with axillary nodal disease greater than 5 cm (68%), recurrent disease (36%), or disease adherent to axillary neurovascular structures (45%). Paresthesias, pain, and bleeding were present in 40% of patients, and were stable or improved after surgery in 75%. Most patients were asymptomatic prior to resection, and underwent resection for prevention of potential symptoms. RESULTS: Most patients underwent outpatient surgery. Postoperative complications included lymphedema (34%), range of motion limitation (23%), wound infection (17%), and neuropathic pain (17%). Among symptomatic patients, average time to progression was 3 months, compared to 9.5 months in asymptomatic patients (P = 0.08). Five-year survival was lower (16%) in symptomatic patients than in asymptomatic patients (35%, P = 0.001). DISCUSSION: Surgery for bulky axillary melanoma metastases is well tolerated, and should be considered in the management of Stage III or IV melanoma. Resection prior to symptoms may improve quality of life and is associated with longer survival.
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Linfonodos/cirurgia , Melanoma/cirurgia , Recidiva Local de Neoplasia/cirurgia , Neoplasias Cutâneas/cirurgia , Axila , Feminino , Seguimentos , Humanos , Linfonodos/patologia , Metástase Linfática , Masculino , Melanoma/mortalidade , Melanoma/patologia , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/patologia , Estadiamento de Neoplasias , Prognóstico , Estudos Prospectivos , Estudos Retrospectivos , Neoplasias Cutâneas/mortalidade , Neoplasias Cutâneas/secundário , Taxa de SobrevidaRESUMO
BACKGROUND: There is no consensus about the optimal extent of surgery for patients with melanoma metastases to inguinal nodes, and this is further complicated by variations in terminology for these dissections. In patients without clinical evidence of iliac metastases, we routinely perform a superficial groin dissection (SGD), which clears node-bearing tissue superficial to the fascia lata. We hypothesized that SGD provides regional tumor control comparable to published experience with deep groin dissection (DGD) and iliac and obturator dissection (IOD), but with less morbidity. MATERIALS AND METHODS: A retrospective review of a prospectively collected database evaluated patients undergoing SGD April 1994 through May 2008. Patients with clinical evidence of iliac metastases were excluded. Clinical and pathologic data regarding recurrence and survival were evaluated. RESULTS: We identified 53 primary SGD: 27 for clinically palpable disease, and 25 for microscopic disease. Number and percentage of positive nodes were similar between groups. Median follow-up was 39 months, and 2 patients had primary recurrence in the groin (1 in each group). Two additional patients had concurrent groin and systemic recurrence. Ipsilateral groin recurrence rate prior to systemic disease was similar at 4% and 3.7% for microscopic and palpable disease, respectively. Similarly, survival was comparable between groups (82% and 73%). Toxicities were comparable to previously published data. CONCLUSION: SGD provides regional control rates similar to DGD and IOD, for lymph node metastases clinically limited to the groin, whether occult or clinically evident.
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Virilha/cirurgia , Artéria Ilíaca/cirurgia , Melanoma/cirurgia , Morbidade/tendências , Recidiva Local de Neoplasia/cirurgia , Neoplasias Cutâneas/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Feminino , Virilha/patologia , Humanos , Artéria Ilíaca/patologia , Lactente , Excisão de Linfonodo , Linfonodos , Metástase Linfática , Masculino , Melanoma/patologia , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia , Estadiamento de Neoplasias , Prognóstico , Estudos Prospectivos , Estudos Retrospectivos , Neoplasias Cutâneas/secundário , Adulto JovemRESUMO
INTRODUCTION: pH impedance testing is the most sensitive diagnostic test for detecting gastroesophageal reflux disease (GERD). The literature remains inconclusive on which preoperative pH impedance testing parameters are associated with an improvement in heartburn symptoms after anti-reflux surgery. The objective of this study was to evaluate which parameters on preoperative pH impedance testing were associated with improved GERD health-related quality of life (GERD-HRQL) following surgery. METHODS: Data from a single-institution foregut database were used to identify patients with reflux symptoms who underwent anti-reflux surgery between 2014 and 2020. Acid and impedance parameters were extracted from preoperative pH impedance studies. GERD-HRQL was assessed pre- and postoperatively with a questionnaire that evaluated heartburn, dysphagia, and the impact of acid-blocking medications on daily life. Patient characteristics, fundoplication type, and four pH impedance parameters were included in a multivariable linear regression model with improvement in GERD-HRQL as the outcome. RESULTS: We included 108 patients (59 Nissen and 49 Toupet fundoplications), with a median follow-up time of 1 year. GERD-HRQL scores improved from 22.4 (SD ± 10.1) preoperatively to 4.2 (± 6.2) postoperatively. In multivariable analysis, a normal preoperative acid exposure time (p = 0.01) and Toupet fundoplication (vs. Nissen; p = 0.03) were independently associated with greater improvement in GERD-HRQL. CONCLUSIONS: Of the four pH impedance parameters that were investigated, a normal preoperative acid exposure time was associated with greater improvement in quality of life after anti-reflux surgery. Further investigation into the critical parameters on preoperative pH impedance testing using a multi-institutional cohort is warranted.
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Refluxo Gastroesofágico , Laparoscopia , Impedância Elétrica , Fundoplicatura , Refluxo Gastroesofágico/diagnóstico , Refluxo Gastroesofágico/cirurgia , Humanos , Concentração de Íons de Hidrogênio , Qualidade de Vida , Resultado do TratamentoRESUMO
BACKGROUND: Paraesophageal hernia (PEH) is a common condition that bariatric surgeons encounter. Expert opinion is split on whether bariatric surgery and PEH repair should be completed concurrently or sequentially. We hypothesized that concurrent bariatric surgery and PEH repair is safe. OBJECTIVES: We examined 30-day outcomes after concomitant PEH repair and bariatric surgery. SETTING: National database, United States. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database (2011-2014), we identified patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) with or without PEH repair. A propensity score-matching algorithm was used to compare patients who underwent either LRYGB or LSG with PEH repair. The primary outcome was overall morbidity. Secondary outcomes included mortality, serious morbidity, readmission, and reoperation. RESULTS: Of the 76,343 patients in this study, 5958 (7.80%) underwent PEH repair concurrently with bariatric surgery. The frequency of bariatric operations that included PEH repair increased over time (2.14% in 2010 versus 12.17% in 2014, P<.001). The rate of PEH/LSG was higher than PEH/LRYGB in 2014 (8.9 % versus 3.2%). There were no significant differences in outcomes between the matched cohort of PEH and non-PEH patients. Subgroup analysis showed significantly greater rates of morbidity (6.20% versus 2.69%, P<.001), readmission (6.33% versus 3.06%, P<.001), and reoperation (3.00% versus 1.05%, P<.001) for PEH/LRYGB versus PEH/LSG. CONCLUSIONS: A PEH repair at the time of bariatric surgery does not appear to be associated with increased morbidity or mortality. A concurrent approach to treat patients with severe obesity and PEH appears safe.
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Gastrectomia/métodos , Derivação Gástrica/métodos , Hérnia Hiatal/cirurgia , Herniorrafia/métodos , Adulto , Idoso , Feminino , Hérnia Hiatal/complicações , Humanos , Laparoscopia/métodos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/complicações , Obesidade Mórbida/cirurgia , Resultado do TratamentoRESUMO
INTRODUCTION: Laparoscopic fundoplication is the gold standard treatment for gastroesophageal reflux disease (GERD) refractory to medical management. Although many studies have compared Nissen fundoplication (NF) to Toupet fundoplication (TF), it is unclear which operation provides the best long-term reflux control. The objective of this study was to evaluate long-term quality-of-life (QoL) outcomes after NF versus TF. METHODS: Clinical data from our single academic institutional foregut database were used to identify patients who underwent NF or TF (June 2010 to May 2016). Postoperative QoL was assessed through telephone at 1, 3, or 5 years postsurgery, using GERD-health related quality of life (GERD-HRQL), Gastroparesis Cardinal Symptom Index (GCSI), and Eckardt Dysphagia scores. Proton pump inhibitor (PPI) use and satisfaction with surgery were also obtained. Trends in outcomes over time were analyzed by logistic regression or Cochran-Armitage trend test. RESULTS: Our cohort included 155 TF and 161 NF patients. TF patients reported baseline dysphagia at higher rates (42.6% versus 19.9%; P < .001) and had worse preoperative esophageal dysmotility than NF patients. There were no significant differences in GERD-HRQL or GCSI scores between TF and NF patients at any time point postoperatively. Long-term satisfaction was equivalent between TF and NF patients 5 years postoperatively (70.0% versus 77.4%; P = .67). NF patients had higher Eckardt dysphagia scores 1 year after surgery compared to TF patients, but this difference was not present at 3 or 5 years postoperatively. Over time, PPI use increased and there was a trend toward increased GERD-HRQL scores in the TF group. CONCLUSIONS: Both TF and NF provide excellent long-term satisfaction for patients with GERD. NF and TF patients reported similar postoperative QoL scores. Our finding of increasing PPI use and a trend toward worsening GERD scores following TF warrants additional investigation regarding the long-term durability of TF.
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Fundoplicatura/métodos , Refluxo Gastroesofágico/cirurgia , Qualidade de Vida , Adulto , Idoso , Estudos de Coortes , Transtornos de Deglutição/etiologia , Transtornos da Motilidade Esofágica/cirurgia , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Inibidores da Bomba de Prótons/administração & dosagemRESUMO
BACKGROUND: Laparoscopic antireflux surgery (LARS) is the gold standard treatment for refractory gastroesophageal reflux disease (GERD). Traditional surgical outcomes following LARS are well described, but limited data exist regarding patient-reported outcomes. We aimed to identify preoperative characteristics that were independently associated with a high GERD health-related quality of life (GERD-HRQL) following LARS. METHODS: Clinical data from our single institution foregut surgery database were used to identify all patients with GERD who underwent primary LARS from June 2010 to November 2015. Electronic health record data were reviewed to extract patient characteristics, diagnostic study characteristics, and operative data. Postoperative GERD-HRQL data were obtained through telephone follow-up. Variables hypothesized a priori to be associated with high GERD-HRQL after LARS, which were significant at P ≤ .2 on bivariate analysis, were entered into a multivariable linear regression model with GERD-HRQL as the outcome. RESULTS: The study included 248 patients; 69.0% were female, 56.9% were married, and 58.1% had concurrent atypical symptoms. The most commonly performed fundoplications were Nissen (44.8%), Toupet (41.3%), and Dor (14.1%), respectively. The median follow-up interval was 3.4 years. The telephone response rate was 60.1%. GERD-HRQL scores improved from 24.8 (SD ±11.4) preoperatively to 3.0 (SD ±5.9) postoperatively. 79.9% of patients were satisfied with their condition at follow-up. On multivariable analysis, being married (P = .04) and absence of depression (P = .02) were independently associated with a higher postoperative QoL. CONCLUSIONS: Strong social support and psychiatric well-being appear to be important predictors of a higher QoL following LARS. Optimizing social support and treating depression preoperatively and postoperatively may improve QoL outcomes for LARS patients.
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Fundoplicatura , Refluxo Gastroesofágico/psicologia , Refluxo Gastroesofágico/cirurgia , Laparoscopia , Qualidade de Vida , Adulto , Idoso , Idoso de 80 Anos ou mais , Transtorno Depressivo/complicações , Feminino , Seguimentos , Humanos , Masculino , Estado Civil , Pessoa de Meia-Idade , Satisfação do Paciente , Estudos Prospectivos , Análise de Regressão , Resultado do Tratamento , Adulto JovemRESUMO
INTRODUCTION: Feeding jejunostomies (J tubes) provide enteral nutrition when oral and gastric routes are not options. Despite their prevalence, there is a paucity of literature regarding their efficacy and clinical burden. METHODS: All laparoscopic J tubes placed over a 5-year period were retrospectively reviewed. Clinical burden was measured by number of clinical contact events (tube-related clinic visits, phone calls, ED visits) and morbidity (dislodgement, clogging, tube fracture, infection, other). Tube replacements were also recorded. RESULTS: One hundred fifty-one patients were included. Fifty-nine percent had associated malignancy, and 35 % were placed for nutritional prophylaxis. Mean time to J tube removal was 146 days. J tubes were expected to be temporary in >90 % but only 50 % had sufficient oral intake for removal. Tubes were removed prematurely due to patient intolerance in 8 %. Mortality was 0 %. Morbidity was 51 % and included clogging (12 %), tube fracture (16 %), dislodgement (25 %), infection (18 %) and "other" (leaking, erosion, etc.) in 17 %. The median number of adverse events per J tube was 2(0-8). Mean number of clinic phone calls was 2.5(0-22), ED visits 0.5(0-7), and clinic visits 1.4(0-13), with 82 % requiring more than one J tube-related clinic visit. Unplanned replacements occurred in 40 %. CONCLUSION: While necessary for some patients, J tubes are associated with high clinical burden.
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Nutrição Enteral/métodos , Intubação Gastrointestinal/instrumentação , Jejunostomia/instrumentação , Laparoscopia , Complicações Pós-Operatórias/epidemiologia , Nutrição Enteral/efeitos adversos , Feminino , Seguimentos , Humanos , Intubação Gastrointestinal/efeitos adversos , Jejunostomia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Morbidade/tendências , Estudos Retrospectivos , Falha de Tratamento , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Four-dimensional computed tomography is being used increasingly for localization of abnormal glands in primary hyperparathyroidism. We hypothesized that compared with traditional 4-phase imaging, 2-phase imaging would halve the radiation dose without compromising parathyroid localization and clinical outcomes. METHODS: A transition from 4-phase to 2-phase imaging was instituted between 2009 and 2010. A pre-post analysis was performed on patients undergoing operative treatment with a parathyroid protocol computed tomography, and relevant data were correlated with operative findings. Sensitivity, positive predictive value, technical success, and cure rates were calculated. The Fisher exact test or χ(2) test assessed the significance of 2-phase and 4-phase imaging and operative findings. RESULTS: Twenty-seven patients had traditional four-dimensional computed tomography and 35 had modified 2-phase computed tomography. Effective radiation doses were 6.8 mSy for 2-phase and 14 mSv for 4-phase. Four-phase computed tomography had a sensitivity and positive predictive value of 93% and 96%, respectively. Two-phase computed tomography had a comparable sensitivity and positive predictive value of 97% and 94%, respectively. Eight patients with discordant imaging had an average parathyroid weight of 240 g compared with 1,300 g for all patients. Technical surgical success (90% for 4-phase computed tomography versus 91% 2-phase computed tomography) and normocalcemia rates at 6 months (88% for both) did not differ between computed tomography protocols. Computed tomography correctly predicted multiglandular disease and localization for reoperations in 88% and 90% of cases, respectively, with no difference by computed tomography protocol. CONCLUSION: With regard to surgical outcomes and localization, 2-phase parathyroid computed tomography is equivalent to 4-phase for parathyroid localization, including small adenomas, reoperative cases, and multiglandular disease. Two-phase parathyroid computed tomography for operative planning should be considered to avoid unnecessary radiation exposure.
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Tomografia Computadorizada Quadridimensional , Hiperparatireoidismo Primário/diagnóstico por imagem , Tomografia Computadorizada Multidetectores , Idoso , Estudos Controlados Antes e Depois , Feminino , Humanos , Hiperparatireoidismo Primário/cirurgia , Masculino , Pessoa de Meia-Idade , Paratireoidectomia , Seleção de Pacientes , Valor Preditivo dos TestesRESUMO
OBJECTIVES: Delayed gastric emptying (DGE) after pancreaticoduodenectomy (PD) is associated with increased hospital length of stay (LOS) and health care costs. We hypothesized that a long gastrojejunostomy for PD (LGPD) is associated with decreased incidence of DGE. METHODS: Data were reviewed from patients who underwent standard PD (SPD), pylorus-preserving PD (PPPD), or LGPD with a 9-cm-long anastomosis between August 2000 and July 2010. Primary outcomes included presence and grade of DGE and LOS. The International Study Group of Pancreatic Surgery definition was used to define DGE. RESULTS: A total of 194 PDs (28 SPDs, 82 PPPDs, and 84 LGPDs) were performed. The rates of DGE were 46.4%, 37.8%, and 16.7%, respectively (P = 0.001). The LGPD was associated with fewer grades B/C DGE (2.4%) compared to SPD (10.7%) and PPPD (17.5%). Rates of postoperative abdominal fluid collection and abscess were similar among the groups. Patients with DGE had significantly longer LOS (14.0 vs 7.0 days, P < 0.001). CONCLUSIONS: This is the first study evaluating the effect of a long gastrojejunostomy on the incidence of DGE after PD. The LGPD is associated with significantly decreased DGE compared to SPD and PPPD and warrants further exploration as a means to improve outcome for patients who undergo PD.
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Derivação Gástrica/métodos , Esvaziamento Gástrico , Gastroparesia/fisiopatologia , Pancreaticoduodenectomia/métodos , Complicações Pós-Operatórias/fisiopatologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Gastroparesia/epidemiologia , Gastroparesia/etiologia , Humanos , Incidência , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pancreaticoduodenectomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Índice de Gravidade de Doença , Fatores de Tempo , Virginia/epidemiologiaRESUMO
Adrenal-mediated hypertension (AMH) has been increasingly treated by laparoscopic adrenalectomy (LA). Metabolic derangements in patients with AMH could result in perioperative complications and mortality. Long-term operative and clinical outcomes after laparoscopic treatment of AMH have not been evaluated using large clinical databases. The institutional National Surgical Quality Improvement Program (NSQIP) data for patients undergoing adrenalectomy for AMH between 2002 and 2012 were reviewed. Patient demographics, perioperative variables, and outcomes were analyzed and compared with national NSQIP adrenalectomy data. Improvement in AMH was recorded when discontinuation or reduction of antihypertensive medication occurred or with a decrease of blood pressure on the preoperative antihypertensive regimen. Ninety-four patients underwent adrenalectomy. There were 48 patients with pheochromocytoma (PHE) and 46 patients with aldosterone-producing adenoma (APA). Eighty-five patients (90%) were taking antihypertensive medications preoperatively compared with 36 patients (38%) postoperatively (P < 0.0001). Patients with PHE were more likely to discontinue all medications compared with the patients with APA (80 vs 20%, respectively, P < 0.0001). Patients with PHE and APA, respectively, took an average of 2.0 and 3.2 antihypertensive medications preoperatively compared with 0.3 and 1.2 postoperatively. There were no conversions to open procedures or 30-day mortality. Our results were 0 per cent for cerebral vascular accident, 0 per cent for myocardial infarction, and 0.5 per cent for transfusions compared with the national NSQIP data of 0.2, 0, and 6.7 per cent, respectively. Patients presenting with significant AMH including PHE and APA can be effectively and safely treated with LA with minimal complications and with a significant number of patients eliminating or decreasing their need for antihypertensive medications.