Factors Associated with Symptomology of Celiac Artery Compression and Outcomes following Median Arcuate Ligament Release.

BACKGROUND: This study aims to identify potential risk factors for becoming symptomatic in patients with radiographic celiac artery compression (CAC) as well as prognostic factors for patients with median arcuate ligament syndrome (MALS) who underwent surgical ligament release. METHODS: This is a retrospective cohort study of patients with findings of CAC on computed tomography or magnetic resonance angiography (CT/MRA) who were asymptomatic and who were diagnosed with MALS at a single university hospital between January 2001 and 2018. RESULTS: Following a review of 1,330 CT/MRA reports, a total of 109 patients were identified as having radiographically apparent CAC. Among these, 48 (44.0%) patients were symptomatic. Univariate comparison between those with and without symptoms showed that symptomatic patients were more commonly younger than 30 years old [17/48 (35.4%) vs. 8/61 (13.1%), P = 0.006], had a history of prior abdominal surgery [25/48 (52.1%) vs. 18/61 (29.5%), P = 0.017], and had high-grade stenosis [32/43 (74.4%) vs. 25/61 (41.0%), P = 0.001]. Among 41 included patients who underwent surgical release of the median arcuate ligament including open, laparoscopic, and robotic approaches, 82.9% reported overall clinical improvement, 5/41 (12.2%) reported persistent pain, and 13/36 (36.0%) experienced pain recurrence. The only identified risk factor associated with symptom recurrence was American Society of Anesthesiologists class III [7/13 (53.8%) vs. 4/23 (17.4%), P = 0.029]. CONCLUSIONS: The severity of stenosis and prior abdominal surgery both contributed to symptom development in patients with radiographically apparent CAC from the median arcuate ligament.

Impact of Approach and Hospital Volume on Cardiovascular Complications After Pulmonary Lobectomy.

BACKGROUND: Cardiovascular complications contribute significantly to the morbidity and resource utilization after pulmonary resections. Maturation of less-invasive technologies, such as video and robot-assisted thoracoscopic surgery, aims at improving postoperative outcomes by reducing the trauma of surgery. The present work aimed to evaluate changes in cardiovascular complications after open and minimally invasive lobectomies in the United States. METHODS: We performed a retrospective analysis of the Nationwide Inpatient Sample for patients having elective open, video-assisted, and robot-assisted thoracoscopic lobectomy during 2008-2014. Logistic regression was performed to determine predictors of in-hospital mortality, myocardial infarction (MI), cardiac arrest (CA), and postoperative pulmonary embolism (PE). RESULTS: A total of 201,226 patients underwent pulmonary lobectomy over the study period. Open thoracotomy (OPEN) approach has steadily decreased from 75%-52% (P < 0.0001), whereas minimally invasive surgery (MIS) utilization has increased from 25%-48% (P < 0.0001) of all lobectomies. MIS approach was independently associated with decreased odds of mortality (odds ratio [OR] 0.6, 95% confidence interval [CI] 0.50-0.73) and PE (OR 0.67, 95% CI 0.50-0.91). MIS patients at high volume institutions had the lowest odds of all-cause mortality (OR 0.27, 95% CI 0.26-0.53) and MI (OR 0.57, 95% CI 0.38-0.87). Operative approach and institutional lobectomy caseload reduced odds of mortality after MI, CA, or PE. Overall, the incidence of MI, CA, and PE increased. CONCLUSIONS: MIS lobectomies increased without a concurrent reduction in perioperative MI, CA, or PE incidence. High hospital lobectomy volume and MIS approach decrease odds of failure to rescue. Improved perioperative management of cardiovascular risk is warranted to reduce the morbidity, mortality, and resource utilization associated with these complications.

Impact of New-Onset Postoperative Depression on Readmission Outcomes After Surgical Coronary Revascularization.

BACKGROUND: Depression affects between 10% and 40% of cardiac surgery patients and is associated with significantly worse outcomes. The incidence and impact of new-onset depression beyond acute follow-up remain ill-defined. The present study aimed to evaluate the incidence, risk factors, and prognostic implication of depression on 90-d readmission rates after coronary artery bypass grafting (CABG) surgery. METHODS: A retrospective cohort study was performed identifying adult patients without prior depression who underwent CABG surgery using the 2010-2014 National Readmissions Database. CABG patients who were readmitted more than 2 wk but within 90 d of discharge were categorized based on the presence of new-onset depression. Association between the development of new-onset depression and rehospitalization were morbidity, mortality, costs, and length of stay (LOS) and were examined using multivariable regression. RESULTS: During the study period, 1,001,945 patients underwent CABG. Of these, 11.7% of patients were readmitted after 14 d but within 90 d of discharge with 5.1% of these patients having a diagnosis of new-onset depression. Postoperative new-onset depression was not associated with increased readmission morbidity, costs, or LOS. Mortality in new-onset depression readmissions was 1.2%, compared with 2.3% in all readmitted patients (P = 0.014). Depression was associated with lower odds of mortality (OR = 0.56, P = 0.02). CONCLUSIONS: New-onset depression following CABG discharge was not associated with increased odds of mortality, morbidity, costs, or increased LOS on readmission. Rather, new-onset depression is associated with decreased odds of readmission mortality. Overall, CABG readmissions are decreasing, whereas the rate of new-onset depression is slightly increasing. Implementation of routine depression screening tools in postoperative CABG care may aid in early detection and management of depression to enhance postoperative recovery and quality of life.

Artificial palpation in robotic surgery using haptic feedback.

BACKGROUND: The loss of tactile feedback in minimally invasive robotic surgery remains a major challenge to the expanding field. With visual cue compensation alone, tissue characterization via palpation proves to be immensely difficult. This work evaluates a bimodal vibrotactile system as a means of conveying applied forces to simulate haptic feedback in two sets of studies simulating an artificial palpation task using the da Vinci surgical robot. METHODS: Subjects in the first study were tasked with localizing an embedded vessel in a soft tissue phantom using a single-sensor unit. In the second study, subjects localized tumor-like structures using a three-sensor array. In both sets of studies, subjects completed the task under three trial conditions: no feedback, normal force tactile feedback, and hybrid vibrotactile feedback. Recordings of correct localization, incorrect localization, and time-to-completion were used to evaluate performance outcomes. RESULTS: With the addition of vibrotactile and pneumatic feedback, significant improvements in the percentage of correct localization attempts were detected (p = 0.0001 and p = 0.0459, respectively) during the first experiment with phantom vessels. Similarly, significant improvements in correct localization were found with the addition of vibrotactile (p = 2.57E-5) and pneumatic significance (p = 8.54E-5) were observed in the second experiment involving tumor phantoms. CONCLUSIONS: This work demonstrates not only the superior benefits of a multi-modal feedback over traditional single-modality feedback, but also the effectiveness of vibration in providing haptic feedback to artificial palpation systems.

Application of a newly designed microfork probe for robotic-guided pelvic intraoperative neuromapping.

Introduction: Robotic-assisted total mesorectal excision (TME) with pelvic intraoperative neuromapping was recently accomplished. However, neuromapping is conventionally conducted by a hand-guided laparoscopic probe. We introduce a prototype microfork probe to make robotic-guided neuromapping feasible. Experiments and Technical Setup: Two porcine experiments with nerve-sparing TME surgery were performed. A newly designed prototype bipolar microfork probe was inserted intraabdominally and guided with the robotic forceps. Intermittent neuromapping was then conducted and neuromonitoring data integrated in the surgeon console viewer. Conclusion: Robotic-guided neuromapping is shown to be feasible and fully controllable from the surgeon console.

Diffusion of robotic-assisted laparoscopic technology across specialties: a national study from 2008 to 2013.

INTRODUCTION: Robotic-assisted procedures were frequently found to have similar outcomes and indications to their laparoscopic counterparts, yet significant variation existed in the acceptance of robotic-assisted technology between surgical specialties and procedures. We performed a retrospective cohort study investigating factors associated with the adoption of robotic assistance across the United States from 2008 to 2013. METHODS: Using the Nationwide Inpatient Sample database, patient- and hospital-level variables were examined for differential distribution between robotic-assisted and conventional laparoscopic procedures. Multilevel logistic regression models were constructed to identify independent factors associated with robotic adoption. Furthermore, cases were stratified by procedure and specialty before being ranked according to proportion of robotic-assistance adoption. Correlation was examined between robotic-assistance adoption and relative outcome in comparison with conventional laparoscopic procedures. RESULTS: The national robotic case volume doubled over the five-year period while a gradual decline in laparoscopic case volume was observed, resulting in an increase in the proportion of procedures performed with robotic assistance from 6.8 to 17%. Patients receiving robotic procedures were more likely to be younger, males, white, privately insured, more affluent, and with less comorbidities. These differences have been decreasing over the study period. The three specialties with the highest proportion of robotic-assisted laparoscopic procedures were urology (34.1%), gynecology (11.0%), and endocrine surgery (9.4%). However, no significant association existed between the frequency of robotic-assistance usage and relative outcome statistics such as mortality, charge, or length of stay. CONCLUSION: The variation in robotic-assistance adoption between specialties and procedures could not be attributable to clinical outcomes alone. Cultural readiness toward adopting new technology within specialty and target anatomic areas appear to be major determining factors influencing its adoption.

Robotic-assisted laparoscopic median arcuate ligament release: 7-year experience from a single tertiary care center.

BACKGROUND: Despite previous reports of robotic-assisted laparoscopic release for median arcuate ligament syndrome (MALS), the safety and efficacy profile of this approach has been difficult to establish due to the rarity of this diagnostic entity. We aim to present our experience from a tertiary minimally invasive surgery referral center. METHODS: A case series was performed whereby all patients who underwent robotic-assisted MAL release from July 2010 to July 2017 at our institution were included. Diagnosis of MALS was made based on consideration of symptom presentation, celiac artery duplex ultrasound, and corresponding findings on Computed Tomography (CT) or Magnetic Resonance Angiography (MRA). Outcomes up until the most recent clinic follow-up were reviewed. RESULTS: A total of 13 patients underwent robotic-assisted MAL release. Patients' age ranged from 16 to 71 years (mean 38 years) and consisted primarily of females (76.9%). Most common presenting symptoms included postprandial pain (76.9%), weight loss (76.9%), nausea and vomiting (76.9%). Mean symptom duration was 3 years (range 1-10 years). No intraoperative complications. None required conversion to open surgery. One case required a conversion back to laparoscopy due to anatomical complexity. The mean operative time for successfully completed robotic cases was 94.6 min (range 52-120 min), and for all cases including converted case was 103.5 min (52-210 min). Mean follow-up duration was 19.7 months (range 1-77 months). During subsequent follow-up, a 30-day readmission rate of 23.1% was observed. All but one of the patients experienced prompt symptom improvement. Four patients had symptom recurrence during follow-up. CONCLUSIONS: Our experience demonstrates that the robotic-assisted approach to MAL release may be safe and efficacious in selected patients. Prospective comparative studies are required to further evaluate its outcomes against conventional laparoscopic approach, the current gold standard.

Are nonemergent cardiac operations performed during off-time associated with worse outcome?

BACKGROUND: With the implementation of value-based health care, it is of increasing interest to understand whether performing elective surgeries during off-time impacts surgical outcomes. The objective of this study was to evaluate the impact of start times on nonemergent cardiac operations. METHODS: The institutional Society of Thoracic Surgeons was used to identify all adult nonemergent cardiac operations performed between January 2008 and December 2015 at our institution. "Off-time" is defined as either operation "late starts," that is, an incision time after 3 PM and before 7 AM, or procedures occurring during the weekends. Univariate and multivariate logistic regression analyses were performed to examine its impact on in-hospital mortality and major adverse events. Available cost data were directly obtained from the departmental BIOME database. RESULTS: Of the 3406 cardiac operations included in the study, 2933 (86.1%) were normal-start and 473 (13.9%) were off-time-start operations. After adjusting for patient and operative characteristics, late operating room start times were not associated with increased in-hospital mortality (P = 0.28, confidence interval [CI] 95% = 0.99-1.03), readmissions (P = 0.21, CI 95% = 0.99-1.07), or major adverse events (P = 0.07, CI 95% = 1.00-1.12). In addition, there was no significant impact on total hospital cost (9.0% increase, P = 0.07). CONCLUSIONS: These findings suggest that late operating room start times are not associated with increased mortality or other complications in a tertiary-care academic medical center. Our findings should be considered during operative scheduling to optimize resource distribution and patient care strategies.

Robotic-assisted colorectal surgery in obese patients: a case-matched series.

BACKGROUND: Reports demonstrate laparoscopic colorectal surgery in obese patients is associated with higher conversion to laparotomy and complication rates. While several advantages of robotic-assisted surgery have been reported, outcomes in obese patients have not been adequately studied. Therefore, this study compares outcomes of robotic-assisted surgery in non-obese and obese patients. METHODS: A retrospective review of 331 consecutive robotic procedures performed at a single institution between 2009 and 2015 was performed. Patients were divided into non-obese (BMI <30 kg/m2) and obese (BMI ≥30 kg/m2) groups, and were clinically matched by gender, age, and procedure performed. Intraoperative and postoperative complications, operative time, estimated blood loss, and length of stay were examined. RESULTS: Following matching, each group included 108 patients comprised of 50 men and 58 women. Mean BMI was 24.6 ± 3.15 and 36.2 ± 5.67 kg/m2 (p < 0.0001), and the mean age was 59.2 ± 11.28 years for non-obese patients and 57.1 ± 12.44 for obese patients (p = 0.18). Surgeries included low anterior resection, right colectomy, left colectomy, sigmoid colectomy, excision of rectal endometriosis, total proctocolectomy, APR, subtotal colectomy, ileocecectomy, proctectomy, rectopexy, transanal excision of rectal mass, and colostomy site hernia repair. The mean operative time was 272.69 ± 115.43 and 282.42 ± 120.51 min (p = 0.55), estimated blood loss 195.23 ± 230.37 and 289.19 ± 509.27 mL (p = 0.08), conversion to laparotomy 6.48 and 9.26 % (p = 0.45), and length of stay 5.38 ± 4.94 and 4.56 ± 4.04 days (p = 0.18) for the non-obese and obese groups, respectively. Twenty of the non-obese patients had postoperative complications as compared to 27 of the obese patients (p = 0.30). However, the prevalence of wound complications was higher in obese patients (1.9 vs 9.3 %; p = 0.03). CONCLUSION: There is no difference in conversion to laparotomy and overall complication rates in non-obese and obese patients undergoing robotic-assisted colorectal surgery. However, obesity is associated with a higher prevalence of wound complications. Robotic-assisted surgery may minimize conversion to laparotomy and complications typically seen in obese patients due to improved visualization, instrumentation, and ergonomics.

Laparoscopic versus open ventral hernia repair in patients with chronic liver disease.

BACKGROUND: Previous studies demonstrated laparoscopic ventral hernia repair (LVHR) to be associated with fewer short-term complications than open ventral hernia repair (OVHR). Little literature is available comparing LVHR and OVHR in chronic liver disease (CLD) patients. METHODS: Patients with model for end-stage liver disease score ≥9 who underwent elective ventral hernia repair in the National Surgical Quality Improvement Program Database were included. 30-day outcomes were compared between LVHR and OVHR after adjusting for hernia disease severity, baseline comorbidities and demographic factors. RESULTS: A total of 3594 ventral hernia repairs were included, 536 (14.9 %) of which were LVHR. After adjusting for other confounders, LVHR was associated with a lower incidence of wound-related complications (0.23, 95 % CI 0.07-0.74, p = 0.01), shorter length of stay (mean 3.7 vs. 5.0 days, p < 0.01) than OVHR, but similar systemic complications (p = 0.77), bleeding complications (p = 0.69), unplanned reoperation (p = 0.74) or readmission (p = 0.40). Propensity score-matched comparison showed similar conclusions. Five hundred and sixty-two patients had ascites, among whom 35 (6.2 %) underwent LVHR. In this subcohort, LVHR was associated with higher mortality (OR 5.36, 95 % CI 1.00-28.60, p = 0.05), systemic complications (OR 7.03, 95 % CI 2.06-24.00, p < 0.01), and unplanned reoperation (OR 6.03, 95 % CI 1.51-24.12, p = 0.01) than OVHR. CONCLUSIONS: In comparison with OVHR, LVHR is associated with similar short-term outcomes except for lower wound-related complications and shorter length of stay in CLD patients. However, when patients have ascites, LVHR is associated with higher mortality, systemic complications, and unplanned reoperation.

Efficacy of Distal Perfusion Cannulae in Preventing Limb Ischemia During Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis.

To date, no consensus exists regarding indication, technique, or efficacy of distal perfusion cannulae (DPC) in preventing limb ischemia among patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO). We aim to examine the available literature and report association between DPC and risk of limb ischemia. PubMed/Medline, Scopus, Cochrane Central Register of Controlled Trials, Google Scholar, and bibliographies of included studies were searched from database inception until August 2016. Original studies describing the DPC placement technique and incidence of limb ischemia following DPC placement among VA-ECMO patients were included for systematic review. Studies with a comparison group of patients without DPC were included for meta-analysis. Two authors independently screened title/abstracts, reviewed full texts, and extracted data from the eligible studies. Meta-analysis was performed using the Mantel-Haenszel method under a random-effects model. Statistical heterogeneity was examined with the I2 statistic (RevMan Version 5.3). Of 542 title/abstracts screened, 62 full text articles were selected for review, yielding 22 retrospective observational studies, for a total of 779 patients with 132 limb ischemia events. There was significant variation in DPC indication, cannula type, and placement technique among the studies. Compared to no DPC, the presence of a DPC was associated with at least a 15.7% absolute reduction in the incidence of limb ischemia (9.74 vs. 25.42%; risk ratio 0.41; 95% confidence interval 0.26-0.65, P < 0.01; heterogeneity statistic I2 = 28%). There was no statistically significant difference in mortality in the pooled dataset comparing DPC versus no DPC. In adults treated with VA-ECMO, DPC placement was associated with a lower incidence of limb ischemia. Currently no consensus guidelines exist regarding indication for DPC placement. Given the association described in this analysis, future prospective trials are warranted to establish a causal relationship and optimal technique for the use of DPC in patients treated with VA-ECMO.

Incisional and port-site hernias following robotic colorectal surgery.

BACKGROUND: The association between extraction site location, robotic trocar size, and the incidence of incisional hernias in robotic colorectal surgery remain unclear. Laparoscopic literature reports variable rates of incisional hernias versus open surgery, and variable rates of trocar site hernias. However, conclusions from these studies are confusing due to heterogeneity in closure techniques and may not be generalized to robotic cases. This study evaluates the effect of extraction site location on incisional hernia rates, as well as trocar hernia rates in robotic colorectal surgery. MATERIALS AND METHODS: A retrospective review of multiport and single incision robotic colorectal surgeries from a single institution was performed. Patients underwent subtotal, segmental, or proctocolectomies, and were compared based on the extraction site through either a muscle-splitting (MS) or midline (ML) incision. Hernias were identified by imaging and/or physical exam. Demographics and risk factors for hernias were assessed. Groups were compared using a multivariate logistic regression analysis. RESULTS: The study included 259 colorectal surgery patients comprising 146 with MS and 113 with ML extraction sites. Postoperative computed tomograms were performed on 155 patients (59.8 %) with a mean follow-up of 16.5 months. The overall incisional hernia rate was 5.8 %. A significantly higher hernia rate was found among the ML group compared to the MS group (12.4 vs. 0.68 %, p < 0.0001). Of the known risk factors assessed, only increased BMI was associated with incisional hernias (OR 1.18). No trocar site hernias were found. CONCLUSION: Midline extraction sites are associated with a significantly increased rate of incisional hernias compared to muscle-splitting extraction sites. There is little evidence to recommend fascia closure of 8-mm trocar sites.

Single-incision robotic colectomy (SIRC): Current status and future directions.

By combining laparo-endoscopic single-site surgery (LESS) techniques with the da Vinci robotic platform, single-incision robotic colectomy (SIRC) aims to further minimize incision-related complications and improve cosmetic outcomes from the current standard of care, laparoscopic colectomy. While there is limited literature on SIRC, all available reports suggest SIRC to be a safe and feasible procedure in terms of perioperative outcomes. Future research should focus on further clarification of proposed benefits of SIRC such as cosmetics, ergonomics, incidence of incision-related complications, and long-term oncologic outcomes.

Single-Incision Robotic Colectomy (SIRC) case series: initial experience at a single center.

BACKGROUND: Laparoscopic colectomy has been associated with favorable outcomes when compared to open colectomy. Single-Incision Robotic Colectomy (SIRC) is a novel procedure hypothesized to improve upon conventional three-port laparoscopic colectomy. We hereby present and analyze our institution's initial experience with SIRC. METHODS: We performed a retrospective review of 59 patients who underwent SIRC between May 2010 and September 2013, attempting to identify factors associated with conversion rate and postoperative complication rate. RESULTS: Our study included 34 males (57.6%) and 25 females (42.4%). The mean age was 60.3 years (range 29-92 years), and the mean BMI was 26.6 kg/m(2) (range 14.9-39.7 kg/m(2)). We identified 31 right hemicolectomies (53.4%), 20 sigmoid colectomies (34.5%), 5 left hemicolectomies (1.7%), 2 low anterior resections (3.5%), and 1 total colectomy (1.7%). The overall median operative time was 188 min with an interquartile range of 79 min. Surgical indications included diverticulitis (n = 23, 39.0%), benign colonic mass (n = 18, 30.5%), colon cancer (n = 16, 27.1%), familial adenomatous polyposis (n = 1, 1.7%), and Crohn's disease (n = 1, 1.7%). There were four conversions to open procedure (6.8%), three conversions to multiport robotic procedure (5.1%), and one conversion to single-port laparoscopic procedure (1.7%). Reasons for conversions include difficulty mobilizing the colon and robotic equipment malfunction. Conversions were associated with both higher complication rates (62.5 vs 25.5%, p = 0.035) and longer LOS (7.4 vs 4.0 days, p = 0.0003). Postoperative complications occurred in 16 of the 59 cases (27.1%). Higher BMI was the only significant risk factor for postoperative complications. The overall median LOS was 4 ± 2 days, while the median estimated blood loss was 100 ± 90 ml. CONCLUSIONS: Our experience has shown that SIRC can be a safe and feasible procedure for both benign and malignant disease. Patient selection is the key to improving surgical outcomes in SIRC.

Reducing retraction forces with tactile feedback during robotic total mesorectal excision in a porcine model.

Excessive tissue-instrument interaction forces during robotic surgery have the potential for causing iatrogenic tissue damages. The current in vivo study seeks to assess whether tactile feedback could reduce intraoperative tissue-instrument interaction forces during robotic-assisted total mesorectal excision. Five subjects, including three experts and two novices, used the da Vinci robot to perform total mesorectum excision in four pigs. The grip force in the left arm, used for retraction, and the pushing force in the right arm, used for blunt pelvic dissection around the rectum, were recorded. Tissue-instrument interaction forces were compared between trials done with and without tactile feedback. The mean force exerted on the tissue was consistently higher in the retracting arm than the dissecting arm (3.72 ± 1.19 vs 0.32 ± 0.36 N, p < 0.01). Tactile feedback brought about significant reductions in average retraction forces (3.69 ± 1.08 N vs 4.16 ± 1.12 N, p = 0.02), but dissection forces appeared unaffected (0.43 ± 0.42 vs 0.37 ± 0.28 N, p = 0.71). No significant differences were found between retraction and dissection forces exerted by novice and expert robotic surgeons. This in vivo animal study demonstrated the efficacy of tactile feedback in reducing retraction forces during total mesorectal excision. Further research is required to quantify the clinical impact of such force reduction.

Risk factors for readmission for early small bowel obstruction following laparoscopic Roux-en-Y gastric bypass: an MBSAQIP analysis.

BACKGROUND: Small bowel obstruction (SBO) following laparoscopic Roux-en-Y gastric bypass (LRYGB) is associated with significant morbidity. OBJECTIVES: To evaluate the rate of and risk factors for readmission for SBO within 30 days of LRYGB. SETTING: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)-accredited centers. METHODS: This is a retrospective study using the MBSAQIP database. A query was performed from 2015-2018 for patients who underwent LRYGB and required readmission for SBO. Those who had a reoperation, intervention, readmission, or expired from causes other than SBO were excluded. Descriptive, bivariate, and binary logistic regression analyses were performed. RESULTS: Among 184,660 patients undergoing LRYGB, 1189 (.64%) required readmission due to SBO. Among the readmission cases, 978 (82.5%) were identified as having intestinal obstruction (unspecified), 108 (9.1%) incisional hernia, and 100 (8.4%) internal hernia. Among these cases, 69% had a reoperation and 1.3% expired during the 30-day period. From a logistic regression model, parameters independently associated with an increased risk for readmission for early SBO include being female (adjusted odds ratio [AOR], 1.53) or black (AOR, 1.41) and having gastroesophageal reflux (AOR, 1.35), a history of myocardial infarction (AOR, 1.76), a history of deep vein thrombosis (AOR, 1.73), previous obesity surgery/foregut surgery (AOR, 1.79), a robotic-assisted procedure (AOR, 1.23), concurrent hiatal hernia repair (AOR, 1.66) and adhesiolysis (AOR, 1.42). CONCLUSION: The rate of readmission for early SBO following LRYGB was less than 1%. The majority of these cases required reoperation. The increased intraoperative complexity of LRYGB is associated with an increased risk of readmission due to early SBO.

Technical Feasibility, Outcomes, and Patient Satisfaction After Needlescopic and Laparoscopic Bariatric Surgery: a Randomized Study.

BACKGROUND: Needlescopic instruments create a 3-mm incision and may result in less pain and superior cosmesis. There is limited understanding of the effectiveness of needlescopic instruments in patients with a body mass index (BMI) > 35 kg/m2. We report perioperative outcomes and perception of body image with use of needlescopic instruments after bariatric surgery. METHODS: Laparoscopic bariatric procedures were performed on 30 adults at a single academic medical center from January to December 2017. Patients were randomized to conventional laparoscopy (LAP) or needlescopic (NEED) surgery. The Multidimensional Body-Self Relations Questionnaire (MBSRQ) and Patient Scar Assessment Questionnaire (PSAQ) were completed at 6 months and 1 year. Univariate analysis was performed on perioperative outcomes and survey scores. RESULTS: Surgery was completed on patients in the LAP group (N = 13) and compared to the NEED group (N = 17). The mean BMI was 41.4 kg/m2 LAP and 41.1 kg/m2 NEED. The most common procedure was Roux-en-Y gastric bypass (RYGB), with 13 RYGB in LAP and 12 RYGB in NEED (P = 0.76).The operative time was not significantly different between the LAP and the NEED group (209.5 ± 66.1 vs 181.9 ± 58.1 min, P = 0.48). There was no leak or mortality in the 30-day follow-up period. Within MBSRQ, the patient's appearance self-evaluation score was similar between LAP and NEED (2.5 ± 0.6 vs 2.4 ± 0.6, P = 0.61). Within PSAQ, the mean satisfaction score for incision appearance was also similar between LAP and NEED (16.1± 2.9 vs 15.4 ± 4.6, P = 0.85). Incision-related perceptions remained consistent at 6 months and 1 year after bariatric surgery. CONCLUSIONS: Needlescopic instruments are safe and a viable alternative to use during bariatric surgery. Appearance and perception of scar were similar between groups. Further studies with needlescopic instruments should include patients with a BMI > 35 kg/m2 and compare additional factors associated with body image.

Analysis of Early Job Market Experiences and Perceptions Among Bariatric Surgery Fellowship Graduates and Bariatric Surgery Program Directors.

PURPOSE: Over the past decade, an increasing number of bariatric surgeons are trained in fellowships annually despite only a modest increase in nationwide bariatric surgery volume. The study surveys the bariatric surgery job market trend in order to inform better career-choice decisions for trainees interested in this field. MATERIALS AND METHODS: A national retrospective cohort survey over an 11-year period was conducted. Bariatric surgery fellowship graduates from 2008 to 2019 and program directors (PDs) were surveyed electronically. Univariate analysis was performed comparing responses between earlier (2008-2016) and recent graduates (2017-2019). RESULTS: We identified a total of 996 graduates and 143 PDs. Response rates were 9% and 20% respectively (n = 88, 29). Sixty-eight percent of graduates felt there are not enough bariatric jobs for new graduates. Seventy-nine percent of PDs felt that it is more difficult to find a bariatric job for their fellows now than 5-10 years ago. Forty-eight percent of PDs felt that we are training too many bariatric fellows. Seventy-seven percent of all graduates want the majority of their practice to be comprised bariatric cases; however, only 42% of them reported achieving this. In the univariate analysis, recent graduates were less likely to be currently employed as a bariatric surgeon (64% vs. 86%, p = 0.02) and were less satisfied with their current case volume (42% vs. 66%, p = 0.01). CONCLUSIONS: The temporal increase in bariatric fellowship graduates over the past decade has resulted in a significant decline in the likelihood of employment in a full-time bariatric surgical practice and a decline in surgeons' bariatric case volumes.

Screen-Based Simulation for Training and Automated Assessment of Teamwork Skills: Comparing 2 Modes With Different Interactivity.

INTRODUCTION: The need for teamwork training is well documented; however, teaching these skills is challenging given the logistics of assembling individual team members together to train in person. We designed 2 modes of screen-based simulation for training teamwork skills to assess whether interactivity with nonplayer characters was necessary for in-game performance gains or for player satisfaction with the experience. METHODS: Mixed, randomized, repeated measures study with licensed healthcare providers block-stratified and randomized to evaluation-participant observes and evaluates the team player in 3 scenarios-and game play-participant is immersed as the leader in the same 3 scenarios. Teamwork construct scores (leadership, communication, situation monitoring, mutual support) from an ontology-based, Bayesian network assessment model were analyzed using mixed randomized repeated measures analyses of variance to compare performance, across scenarios and modes. Learning was measured by pretest and posttest quiz scores. User experience was evaluated using χ2 analyses. RESULTS: Among 166 recruited and randomized participants, 120 enrolled in the study and 109 had complete data for analysis. Mean composite teamwork Bayesian network scores improved for successive scenarios in both modes, with evaluation scores statistically higher than game play for every teamwork construct and scenario (r = 0.73, P = 0.000). Quiz scores improved from pretest to posttest (P = 0.004), but differences between modes were not significant. CONCLUSIONS: For training teamwork skills using screen-based simulation, interactivity of the player with the nonplayer characters is not necessary for in-game performance gains or for player satisfaction with the experience.