RESUMO
BACKGROUND: Patients undergoing sleeve gastrectomy (SG) experience transformative changes in eating-related experiences that include eating-related symptoms, emotions, and habits. Long-term assessment of these endpoints with rigorous patient-reported outcome measures (PROMs) is limited. We assessed patients undergoing SG with the Body-Q Eating Module PROMs. METHODS: All patients evaluated at the Emory Bariatric Center were given the Body-Q Eating Modules questionnaire at preoperative/postoperative clinic visits. Rasch scores and prevalence of relevant endpoints were assessed across six time-points of interest: preoperatively, post-operative months 0-6, 7-12, 12-24, 24-36, and over 36. Student's t-test and Chi-square test were used for analysis. RESULTS: Overall, 1,352 questionnaires were completed pre-operatively and 493 postoperatively. Survey compliance was 81%. Compared to the pre-operative group, the post-operative group had lower BMI (39.7 vs. 46.4, p < 0.001) and higher age (46.3 vs. 44.9, p = 0.019). Beginning one year after SG, patients experience more frequent eating-related pain, nausea and constipation compared to pre-operative baseline (p < 0.05). They also more frequently experience eating-related regurgitation and dumping syndrome-related symptoms beginning post-operative year two (p < 0.05). In the first year after SG, patients more rarely feel eating-related embarrassment, guilt, and disappointment compared to pre-operative baseline (p < 0.05). These improvements disappear one year after SG, after which patients more frequently experience feeling out of control, unhappy, like a failure, disappointed, and guilty (p < 0.05). In the first year after SG, patients experience an increased frequency in positive eating behaviors (ate healthy foods, showed self-control, stopped before full; (p < 0.05). Only two eating-related behavior improvements persist long-term: feeling in control and eating the right amount (p < 0.05). CONCLUSIONS: Patients undergoing SG may experience more frequent eating-related symptoms, distress, and behavior in the long-term. These findings can enhance the pre-operative informed consent and guide development of a more tailored approach to postoperative clinical management such as more frequent visits with the dietician.
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Gastrectomia , Obesidade Mórbida , Medidas de Resultados Relatados pelo Paciente , Humanos , Gastrectomia/métodos , Gastrectomia/psicologia , Feminino , Masculino , Estudos Transversais , Adulto , Pessoa de Meia-Idade , Obesidade Mórbida/cirurgia , Obesidade Mórbida/psicologia , Comportamento Alimentar/psicologia , Inquéritos e Questionários , Cirurgia Bariátrica/psicologia , Transtornos da Alimentação e da Ingestão de Alimentos/psicologiaRESUMO
Background and Objectives: Attentional bias (AB) for addictive substances is a feature of attention found in individuals with substance misuse or diagnosed with substance use disorders. When AB exists, the attention of the addicted individual may be quickly oriented to cues related to the addictive substance or be maintained on these cues for a longer time. AB toward opioids was found in Western samples of smokers with chronic noncancer pain. The level of AB was dose-responsive. However, similar studies in the Taiwanese population are lacking. This study compared the patterns of AB for opioid analgesics in Taiwanese participants with chronic noncancer pain to that of individuals without pain. This study aimed to investigate if AB toward opioids is presented in Taiwanese heavy smokers who are on long-term opioid therapy for pain control. Materials and Methods: Participants were grouped into chronic noncancer pain smokers, chronic pain nonsmokers, and smokers without pain, according to smoking habits and whether or not on long-term opioid therapy for pain control. Each participant completed demographic questionnaires, mood scales, and the opioid-related visual probe task. Differences in AB among the groups were compared using a three-way analysis of covariance controlling for daily cigarette consumption. Results: Chronic noncancer pain smokers (n = 17) and chronic pain nonsmokers (n = 16) displayed more severe levels of depression, anxiety, and pain, compared to smokers without pain (n = 28). Only did chronic pain nonsmokers show significant AB for opioid cues that were displayed for a short time. Analysis on reaction time found that smokers without pain consistently responded faster to the tasks. No difference in reaction time was found between the pain groups. Conclusions: The current study did not fully replicate findings from studies that were based in Western countries. Formulary availability and regulatory limitations might have affected patient's perception of prescription opioids in Taiwan. However, chronic pain nonsmokers exhibited initial orientation toward opioid-related cues when daily cigarette consumption was accounted for. According to previous research, this AB for shortly displayed opioid cues can be associated with the expectation of pain relief. The current finding also indicated general psychomotor retardation in individuals who were on long-term use of opioids.
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Analgésicos Opioides , Viés de Atenção , Dor Crônica , Humanos , Masculino , Taiwan/epidemiologia , Dor Crônica/tratamento farmacológico , Dor Crônica/psicologia , Analgésicos Opioides/uso terapêutico , Feminino , Pessoa de Meia-Idade , Adulto , Inquéritos e Questionários , Fumantes/psicologia , Fumantes/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides/psicologiaRESUMO
INTRODUCTION: Assessment of surgical resident technical performance is an integral component of any surgical training program. Timely assessment delivered in a structured format is a critical step to enhance technical skills, but residents often report that the quality and quantity of timely feedback received is lacking. Moreover, the absence of written feedback with specificity can allow residents to seemingly progress in their operative milestones as a junior resident, but struggle as they progress into their postgraduate year 3 and above. We therefore designed and implemented a web-based intraoperative assessment tool and corresponding summary "dashboard" to facilitate real-time assessment and documentation of technical performance. MATERIALS AND METHODS: A web form was designed leveraging a cloud computing platform and implementing a modified Ottawa Surgical Competency Operating Room Evaluation instrument; this included additional, procedure-specific criteria for select operations. A link to this was provided to residents via email and to all surgical faculty as a Quick Response code. Residents open and complete a portion of the form on a smartphone, then relinquish the device to an attending surgeon who then completes and submits the assessment. The data are then transferred to a secure web-based reporting interface; each resident (together with a faculty advisor) can then access and review all completed assessments. RESULTS: The Assessment form was activated in June 2021 and formally introduced to all residents in July 2021, with residents required to complete at least one assessment per month. Residents with less predictable access to operative procedures (night float or Intensive Care Unit) were exempted from the requirement on those months. To date a total of 559 assessments have been completed for operations performed by 56 trainees, supervised by 122 surgical faculty and senior trainees. The mean number of procedures assessed per resident was 10.0 and the mean number per assessor was 4.6. Resident initiation of Intraoperative Assessments has increased since the tool was introduced and scores for technical and nontechnical performance reliably differentiate residents by seniority. CONCLUSIONS: This novel system demonstrates that an online, resident-initiated technical assessment tool is feasible to implement and scale. This model's requirement that the attending enter performance ratings into the trainee's electronic device ensures that feedback is delivered directly to the trainee. Whether this aspect of our assessment ensures more direct and specific (and therefore potentially actionable) feedback is a focus for future study. Our use of commercial cloud computing services should permit cost-effective adoption of similar systems at other training programs.
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Cirurgia Geral , Internato e Residência , Competência Clínica , Educação de Pós-Graduação em Medicina/métodos , Retroalimentação , Avaliação Educacional/métodos , Cirurgia Geral/educaçãoRESUMO
BACKGROUND: Leukopenia in the early period following heart transplantation (HT) is not well-studied. The aim of this study was to evaluate risk factors for the development of post-transplant leukopenia and its consequences for HT recipients. METHODS: Adult patients at a large-volume transplant center who received HT between January 1, 2010 and December 31, 2020 were included. The incidence of leukopenia (WBC ≤3 × 103 /µL) in the first 90-days following HT, individual risk factors, and its effect on 1-year outcomes were evaluated. RESULTS: Of 506 HT recipients, 184 (36%) developed leukopenia within 90-days. Median duration of the first leukopenia episode was 15.5 days (IQR 8-42.5 days). Individuals who developed leukopenia had lower pre-transplant WBC counts compared to those who did not (6.1 × 103 /µL vs. 6.9 × 103 /µL, p = .02). Initial immunosuppressive and infectious chemoprophylactic regimens were not significantly different between groups. Early leukopenia was associated with a higher mortality at 1-year (6.6% vs. 2.1%, p = .008; adjusted HR 3.0) and an increased risk of recurrent episodes. Rates of infection and rejection were not significantly different between the two groups. CONCLUSIONS: Leukopenia in the early period following HT is common and associated with an increased risk of mortality. Further study is needed to identify individuals at highest risk for leukopenia prior to transplant and optimize immunosuppressive and infectious chemoprophylactic regimens for this subgroup.
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Transplante de Coração , Transplante de Rim , Leucopenia , Adulto , Humanos , Transplante de Rim/efeitos adversos , Leucopenia/epidemiologia , Leucopenia/etiologia , Imunossupressores/efeitos adversos , Fatores de Risco , Transplante de Coração/efeitos adversos , Transplantados , Rejeição de Enxerto/epidemiologia , Rejeição de Enxerto/etiologia , Rejeição de Enxerto/prevenção & controle , Estudos RetrospectivosRESUMO
INTRODUCTION: Monitoring for graft rejection is a fundamental tenet of post-transplant follow-up. In heart transplantation (HT) in particular, rejection has been traditionally assessed with endomyocardial biopsy (EMB). EMB has potential complications and noted limitations, including interobserver variability in interpretation. Additional tests, such as basic cardiac biomarkers, cardiac imaging, gene expression profiling (GEP) scores, donor-derived cell-free DNA (dd-cfDNA) and the novel molecular microscope diagnostic system (MMDx) have become critical tools in rejection surveillance beyond standard EMB. METHODS: This paper describes an illustrative case followed by a review of MMDx within the context of other noninvasive screening modalities for rejection. CONCLUSIONS: We suggest MMDx be used to assist with early detection of rejection in cases of discordance between EMB and other noninvasive studies.
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Transplante de Coração , Miocárdio , Humanos , Miocárdio/patologia , Transplante de Coração/efeitos adversos , Biópsia , Perfilação da Expressão Gênica , Rejeição de Enxerto/diagnóstico , Rejeição de Enxerto/etiologia , Rejeição de Enxerto/epidemiologiaRESUMO
INTRODUCTION: Surgery remains the cornerstone treatment for gastric cancer. Previous studies have reported better lymphadenectomy with minimally invasive approaches. There is a paucity of data comparing robotic and laparoscopic gastrectomy in the US. Herein, we examined whether oncological adequacy differs between laparoscopic and robotic approaches. METHODS: The National Cancer Database was utilized to identify patients who underwent gastrectomy for adenocarcinoma between 2010 and 2019. A propensity score-matching analysis between robotic gastrectomy (RG) versus laparoscopic gastrectomy (LG) was performed. The primary outcomes were lymphadenectomy ≥ 16 nodes and surgical margins. RESULTS: A total of 11,173 patients underwent minimally invasive surgery for gastric adenocarcinoma between 2010 and 2019. Of those 8320 underwent LG and 2853 RG. Comparing the unmatched cohorts, RG was associated with a higher rate of adequate lymphadenectomy (63.5% vs 57.1%, p < .0.0001), higher rate of negative margins (93.8% vs 91.9%, p < 0.001), lower rate of prolonged length of stay (26.0% vs 29.6%, p < .0.001), lower 90-day mortality (3.7% vs 5.0%, p < 0.0001), and a better 5-year overall survival (OS) (56% vs 54%, p = 0.03). A propensity score-matching cohort with a 1:1 ratio was created utilizing the variables associated with lymphadenectomy ≥ 16 nodes. The matched analysis revealed that the rate of adequate lymphadenectomy was significantly higher for RG compared to LG, 63.5% vs 60.4% (p = 0.01), respectively. There was no longer a significant difference between RG and LG regarding the rate of negative margins, prolonged length of stay, 90-day mortality, rate of receipt of postoperative chemotherapy, and OS. CONCLUSIONS: This propensity score-matching analysis with a large US cohort shows that RG was associated with a higher rate of adequate lymphadenectomy compared to LR. RG and LG had a similar rate of negative margins, prolonged length of stay, receipt of postoperative chemotherapy, 90-day mortality, and OS, suggesting that RG is a comparable surgical approach, if not superior to LG.
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Adenocarcinoma , Laparoscopia , Procedimentos Cirúrgicos Robóticos , Neoplasias Gástricas , Humanos , Resultado do Tratamento , Pontuação de Propensão , Adenocarcinoma/cirurgia , Neoplasias Gástricas/patologia , Gastrectomia , Estudos Retrospectivos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgiaRESUMO
INTRODUCTION: The COVID-19- pandemic significantly impacted metabolic and bariatric surgery (MBS) practices due to large-scale surgery cancellations along with staff and supply shortages. We analyzed sleeve gastrectomy (SG) hospital-level financial metrics before and after the COVID-19 pandemic. METHODS: Hospital cost-accounting software (MicroStrategy, Tysons, VA) was reviewed for revenues, costs, and profits per SG at an academic hospital (2017-2022). Actual figures were obtained, not insurance charge estimates or hospital projections. Fixed costs were obtained through surgery-specific allocation of inpatient hospital and operating-room costs. Direct variable costs were analyzed with sub-components including: (1) labor and benefits, (2) implants, (3) drug costs, and 4) medical/surgical supplies. The pre-COVID-19 period (10/2017-2/2020) and post-COVID-19 period (5/2020-9/2022) financial metrics were compared with student's t-test. Data from 3/2020 to 4/2020 were excluded due to COVID-19-related changes. RESULTS: A total of 739 SG patients were included. Average length of stay (LOS), Center for Medicaid and Medicare Case Mix Index (CMI), and percentage of patients with commercial insurance were similar pre vs. post-COVID-19 (p > 0.05). There were more SG performed per quarter pre-COVID-19 than post-COVID-19 (36 vs. 22; p = 0.0056). Pre-COVID-19 and post-COVID-19 financial metrics per SG differed significantly for, respectively, revenues ($19,134 vs. $20,983) total variable cost ($9457 vs. $11,235), total fixed cost ($2036 vs. $4018), total profit ($7571 vs. $5442), and labor and benefits cost ($2535 vs. $3734; p < 0.05). CONCLUSIONS: The post-COVID-19 period was characterized by significantly increased SG fixed cost (i.e., building maintenance, equipment, overhead) and labor costs (increased contract labor), resulting in precipitous profit decline that crosses the break-even in calendar year quarter (CQ) 3, 2022. Potential solutions include minimizing contract labor cost and decreasing LOS.
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COVID-19 , Obesidade Mórbida , Idoso , Humanos , Estados Unidos/epidemiologia , Pandemias , Medicare , COVID-19/epidemiologia , Tempo de Internação , Gastrectomia , Estudos Retrospectivos , Obesidade Mórbida/cirurgiaRESUMO
BACKGROUND: It is critical to ensure appropriate and consistent sleeve size and orientation during laparoscopic sleeve gastrectomy (LSG). Various devices are used to achieve this, including weighted rubber bougies, esophagogastroduodenoscopy (EGD), and suction calibration systems (SCS). Prior reports suggest that SCSs may decrease operative time and stapler load firings but are limited by single-surgeon experience and retrospective design. We performed the first randomized controlled trial comparing SCS against EGD in patients undergoing LSG to investigate whether the SCS decreases the number of stapler load firings. METHODS: This was a randomized, non-blinded study from a single MBSAQIP-accredited academic center. Appropriate LSG candidates ≥ 18 years of age were randomized to EGD or SCS calibration. Exclusion criteria included prior gastric or bariatric surgery, detection of hiatal hernia before surgery, and intraoperative hiatal hernia repair. A randomized block design was employed controlling for body mass index, gender, and race. Seven surgeons employed a standardized LSG operative technique. The primary endpoint was the number of stapler load firings. Secondary endpoints were operative duration, reflux symptoms, and change in total body weight (TBW). Endpoints were analyzed via t-test. RESULTS: A total of 125 LSG patients (84% female) underwent study enrollment, with an average age of 44 ± 12 years and average BMI of 49 ± 8 kg/m2. Overall, 117 patients were randomized to receive EGD (n = 59) or SCS (n = 58) calibration. No significant differences in baseline characteristics were identified. The mean number of stapler load firings for EGD and SCS groups were 5.43 ± 0.89 and 5.31 ± 0.81, respectively (p = 0.463). The mean operative times for EGD and SCS groups were 94.4 ± 36.5 and 93.1 ± 27.9 min, respectively (p = 0.83). There were no significant differences in post-operative reflux, TBW loss, or complications. CONCLUSION: Use of EGD and SCS resulted in a similar number of LSG stapler load firings and operative duration. Additional research is needed to compare LSG calibration devices in different patients and settings to optimize surgical technique.
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Laparoscopia , Obesidade Mórbida , Humanos , Feminino , Adulto , Pessoa de Meia-Idade , Masculino , Obesidade Mórbida/cirurgia , Duração da Cirurgia , Calibragem , Estudos Retrospectivos , Sucção , Laparoscopia/métodos , Gastrectomia/métodos , Resultado do TratamentoRESUMO
BACKGROUND: Enhanced recovery protocols (ERPs) after metabolic and bariatric surgery (MBS) may help decrease length of stay (LOS) and postoperative nausea/vomiting but implementation is often fraught with challenges. The primary aim of this pilot study was to standardize a MBS ERP with a real-time data support dashboard and checklist and assess impact on global and individual element compliance. The secondary aim was to evaluate 30 day outcomes including LOS, hospital readmissions, and re-operations. METHODS AND PROCEDURES: An ERP, paper checklist, and virtual dashboard aligned on MBS patient care elements for pre-, intra-, and post-operative phases of care were developed and sequentially deployed. The dashboard includes surgical volumes, operative times, ERP compliance, and 30 day outcomes over a rolling 18 month period. Overall and individual element ERP compliance and outcomes were compared pre- and post-implementation via two-tailed Student's t-tests. RESULTS: Overall, 471 patients were identified (pre-implementation: 193; post-implementation: 278). Baseline monthly average compliance rates for all patient care elements were 1.7%, 3.7%, and 6.2% for pre-, intra-, and post-operative phases, respectively. Following ERP integration with dashboard and checklist, the intra-operative phase achieved the highest overall monthly average compliance at 31.3% (P < 0.01). Following the intervention, pre-operative acetaminophen administration had the highest monthly mean compliance at ≥ 99.1%. Overall TAP block use increased 3.2-fold from a baseline mean rate of 25.4-80.8% post-implementation (P < 0.01). A significant decrease in average intra-operative monthly morphine milligram equivalents use was noted with a 56% drop pre- vs. post-implementation. Average LOS decreased from 2.0 to 1.7 days post-implementation with no impact on post-operative outcomes. CONCLUSION: Implementation of a checklist and dashboard facilitated ERP integration and adoption of process measures with many improvements in compliance but no impact on 30 day outcomes. Further research is required to understand how clinical support tools can impact ERP adoption among MBS patients.
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Cirurgia Bariátrica , Recuperação Pós-Cirúrgica Melhorada , Humanos , Projetos Piloto , Assistência Perioperatória/métodos , Tempo de Internação , Estudos RetrospectivosRESUMO
BACKGROUND: Multiple medication changes are common after bariatric surgery, but pharmacist assistance in this setting is not well described. This study evaluated the feasibility and effectiveness of a pharmacy-led initiative for facilitating discharge medicine reconciliation after bariatric surgery. METHODS: A standardized post-operative pharmacy consult evaluation was conducted on bariatric surgery inpatients at a single academic center starting 1/2/2019. Retrospective chart review evaluated patient characteristics, medication changes, and 30-day outcomes pre-intervention (7/2018-12/2018) and post-intervention (1/2019-12/2019). Two-sample t tests or binomial tests were used for continuous or categorical variables, respectively; a p-value of < 0.05 was deemed statistically significant. RESULTS: A total of 353 patients were identified for study inclusion (n = 158 pre-intervention, n = 195 post-intervention) with a mean age of 45 years, 87% female, and 71% sleeve gastrectomy. Overall pharmacy consultation compliance was 94% with 77.0% of home medication recommendations followed. Non-narcotic pain medication prescription use significantly increased (39% pre- vs. 54% post-intervention; p < 0.001). At discharge, the average number of changed or new medications significantly increased (3.7 ± 1.2 pre- vs. 4.2 ± 1.8 post-intervention; p = 0.003) while the average number of stopped medications was similar (1.2 ± 1.5 pre- vs. 1.5 ± 1.9 post-intervention; p = 0.09). Anti-hypertensive medications were decreased or stopped substantially more often with pharmacist input (44.7% pre- vs. 85.4% post-intervention; p < 0.001). Three medication-related readmissions happened pre-intervention with none post-intervention. Outpatient medication-related phone calls did considerably increase (31% pre- vs. 39% post-intervention; p = 0.04), while overall 30-day readmissions significantly decreased (7.6% pre- vs. 1.5% post-intervention; p = 0.04). CONCLUSIONS: Inpatient pharmacy consultation facilitated rapid alteration to more appropriate therapy for hypertension management and significantly increased use of non-narcotic pain medications upon discharge among bariatric surgery patients. Improved protocol adherence is anticipated with program maturity and patient education interventions will be deployed to address outpatient phone calls.
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Cirurgia Bariátrica , Farmácia , Feminino , Humanos , Masculino , Reconciliação de Medicamentos/métodos , Pessoa de Meia-Idade , Alta do Paciente , Farmacêuticos , Estudos RetrospectivosRESUMO
INTRODUCTION: Surgical procedures in patients with cirrhosis and associated ascites carry significant morbidity and mortality. However, these patients often undergo non-emergent but necessary procedures such as laparoscopic cholecystectomy. The purpose of this study is to determine the impact of cirrhosis with ascites on non-emergent laparoscopic cholecystectomy. METHODS: The ACS-NSQIP database was queried from 2005 to 2017 for patients undergoing non-emergent laparoscopic cholecystectomy with or without intra-operative cholangiogram. Groups were propensity score matched for age, sex, BMI, smoking, inpatient status, ASA Class, presence of pre-operative SIRS/sepsis, and the individual components of the 5-item modified frailty index. RESULTS: 346,105 patients were identified, 591 of which who had liver-related ascites. Patients without ascites were matched at a 5:1 ratio, producing 2955 controls. Patients with ascites had significantly higher rates of overall morbidity (15.6% vs. 11.3%, p = 0.0039), mortality (3.6% vs. 1.5%, p = 0.0020), and longer hospitalizations (7.4 vs. 4.4 days, p < 0.0001). Patients with ascites and a MELD score less than or equal to 9 had no difference in morbidity (p = 0.1124) or mortality (p = 0.6021) when compared to patients without ascites. Patients with ascites and a MELD score greater than 9 had significantly higher rates of both morbidity (25.8%, p = 0.0056) and mortality (7.1%, p = 0.0333). CONCLUSION: Patients with cirrhosis and ascites have many comorbidities in addition to their liver disease. These patients are at significant risk for both morbidity and mortality related to non-emergent laparoscopic cholecystectomy. Surgeons should proceed with caution for patients with ascites and MELD scores greater than 9. These cases should only be performed by surgeons comfortable with difficult gallbladders at facilities equipped to take care of cirrhotic patients.
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Ascite/cirurgia , Colecistectomia Laparoscópica/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Colecistectomia Laparoscópica/mortalidade , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Esophagogastric junction obstruction (EGJO) post-fundoplication (PF) is difficult to identify with currently available tests. We aimed to assess the diagnostic accuracy of EGJ opening on functional lumen imaging probe (FLIP) and dilation outcome in FLIP-detected EGJO in PF dysphagia. METHODS: We prospectively collected data on PF patients referred to Esophageal Clinic over 18 months. EGJO diagnosis was made by (a) endoscopist's description of a narrow EGJ/wrap area, (b) appearance of wrap obstruction or contrast/tablet retention on esophagram, or (c) EGJ-distensibility index (DI) < 2.8 mm2/mmHg on real-time FLIP. In patients with EGJO and dysphagia, EGJ dilation was performed to 20 mm, 30 mm, or 35 mm in a stepwise fashion. Outcome was assessed as % dysphagia improvement during phone call or on brief esophageal dysphagia questionnaire (BEDQ) score. RESULTS: Twenty-six patients were included, of whom 17 (65%) had a low EGJ-DI. No patients had a hiatal hernia greater than 3 cm. Dysphagia was the primary symptom in 17/26 (65%). In 85% (κ = 0.677) of cases, EGJ assessment (tight vs. open) was congruent between the combination of endoscopy (n = 26) and esophagram (n = 21) vs. EGJ-DI (n = 26) on FLIP. Follow-up data were available in 11 patients who had dilation based on a low EGJ-DI (4 with 20 mm balloon and 7 with ≥ 30 mm balloon). Overall, the mean % improvement in dysphagia was 60% (95% CI 37.7-82.3%, p = 0.0001). Nine out of 11 patients, including 6 out of 7 undergoing pneumatic dilation, had improvement ≥ 50% in dysphagia (mean % improvement 72.2%; 95% CI 56.1-88.4%, p = 0.0001). CONCLUSIONS AND INFERENCES: Functional lumen imaging probe is an accurate modality for evaluating for EGJ obstruction PF. FLIP may be used to select patients who may benefit from larger diameter dilation.
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Transtornos de Deglutição , Acalasia Esofágica , Transtornos de Deglutição/etiologia , Junção Esofagogástrica/diagnóstico por imagem , Fundoplicatura , Humanos , ManometriaRESUMO
BACKGROUND: Minimally invasive approaches to major liver resection have been limited by presumed difficulty of the operation. While some concerns arise from mastering the techniques, factors such as tumor size and liver parenchymal features have anecdotally been described as surrogates for operative difficulty. These factors have not been systematically studied for minimally invasive right hepatectomy (MIRH). METHODS: Seventy-five patients who underwent MIRH during 2007-2016 by the senior author were evaluated; these were compared to control group of open right hepatectomy. Demographics, operative, and post-operative variables were collected. Operative times and estimated blood loss, two objective parameters of operative difficulty were correlated to volume of hepatic resection, parenchymal transection diameter and liver parenchymal features using regression analysis. RESULTS: Thirty-eight (50.6%) resections were performed for malignant indications. Average tumor size was 5.7 cm (±3.6), mean operative time was 196 min (±74), and mean EBL was 220 mL (±170). Average transection diameter was 10.1 cm (±1.7). There was no correlation between operative difficulty with parenchymal transection diameter or presence of steatosis. Blood loss was higher with increased right hepatic lobe volume and body mass index. CONCLUSIONS: This analysis of a very defined anatomical resection suggests that the often quoted radiographic and pathologic features indicative of a challenging procedure were not significant in determining operative difficulty.
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Laparoscopia , Neoplasias Hepáticas , Hepatectomia , Humanos , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/cirurgia , Duração da Cirurgia , Resultado do TratamentoRESUMO
BACKGROUND : Gastric peroral endoscopic pyloromyotomy (G-POEM) and gastric electrical stimulation (GES) have been reported as treatment options for refractory gastroparesis. In this study, we compared the long term clinical outcomes of G-POEM versus GES in the treatment of such patients. METHODS : We retrospectively evaluated 111 consecutive patients with refractory gastroparesis between January 2009 and August 2018. To overcome selection bias, we used propensity score matching (1:1) between G-POEM and GES treatment. The primary outcome was the duration of clinical response. RESULTS : After propensity score matching, 23 patients were included in each group.âAfter a median follow-up of 27.7 months, G-POEM had a significantly better and longer clinical response than GES (hazard ratio [HR] for clinical recurrence 0.39, 95â% confidence interval [CI] 0.16â-â0.95; Pâ=â0.04). The median duration of response was 25.4 months (95â%CI 8.7â-â42.0) in the GES group and was not reached in the G-POEM group. The Kaplanâ-âMeier estimate of 24-month clinical response rate was 76.6â% with G-POEM vs. 53.7â% with GES. GES appeared to have little effect on idiopathic gastroparesis (HR for recurrence with G-POEM vs. GES 0.35, 95â%CI 0.13â-â0.95; Pâ=â0.05). The incidence of adverse events was higher in the GES group (26.1â% vs. 4.3â%; Pâ=â0.10). CONCLUSION : Among patients with refractory gastroparesis, clinical response was better and lasted longer with G-POEM than with GES.âThe positive outcomes with G-POEM are likely to derive from the superior clinical response in patients with idiopathic gastroparesis. Further studies are needed to confirm these findings.
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Acalasia Esofágica , Gastroparesia , Piloromiotomia , Estimulação Elétrica , Esfíncter Esofágico Inferior , Esvaziamento Gástrico , Gastroparesia/cirurgia , Gastroparesia/terapia , Humanos , Pontuação de Propensão , Piloromiotomia/efeitos adversos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Light-chain (AL) cardiac amyloidosis (CA) has a worse prognosis than transthyretin (ATTR) CA. In this single-center study, we compared post-heart transplant (OHT, orthotopic heart transplantation) survival for AL and ATTR amyloidosis, hypothesizing that these differences would persist post-OHT. Thirty-nine patients with CA (AL, n = 18; ATTR, n = 21) and 1023 non-amyloidosis subjects undergoing OHT were included. Cox proportional hazards modeling was used to evaluate the impact of amyloid subtype and era (early era: from 2001 to 2007; late era: from 2008 to 2018) on survival post-OHT. Survival for non-amyloid patients was greater than ATTR (P = .034) and AL (P < .001) patients in the early era. One, 3-, and 5-year survival rates were higher for ATTR patients than AL patients in the early era (100% vs 75%, 67% vs 50%, and 67% vs 33%, respectively, for ATTR and AL patients). Survival in the non-amyloid cohort was 87% at 1 year, 81% at 3 years, and 76% at 5 years post-OHT. In the late era, AL and ATTR patients had unadjusted 1-year, 3-year, and 5-year survival rates of 100%, which was comparable to non-amyloid patients (90% vs 84% vs 81%). Overall, these findings demonstrate that in the current era, differences in post-OHT survival for AL compared to ATTR are diminishing; OHT outcomes for selected patients with CA do not differ from non-amyloidosis patients.
Assuntos
Neuropatias Amiloides Familiares , Amiloidose , Cardiomiopatias , Transplante de Coração , Neuropatias Amiloides Familiares/cirurgia , Cardiomiopatias/etiologia , Humanos , Pré-Albumina , Prognóstico , Taxa de SobrevidaRESUMO
Nrf2 is a transcription factor regulating expression of the Phase II Antioxidant Response and plays an important role in neuroprotection and detoxification. Nrf2 activation is inhibited by interaction with Keap1. Covalent Keap1 inhibitors such as dimethyl fumarate (DMF) and RTA-408 are either on the market or in late stage clinical trials which implies potential benefit of Nrf2 activation. Activation of Nrf2 by disrupting Nrf2-Keap1 interaction through a non-covalent small molecule is an attractive approach with the promise of greater selectivity. However, there are no known non-covalent Nrf2 activators with acceptable pharmacokinetic properties to test the hypothesis in vivo. Based on our early reported work, using structural-based design, followed by extensive SAR exploration, we have identified a novel series of non-covalent Nrf2 activators, with sub-nanomolar binding affinity on Keap1 and single digit nanomolar activity in an astrocyte assay. A representative analog shows excellent oral PK and good Nrf2-dependent gene inductions in kidney. These results provide a peripheral in vivo tool compound to validate the biology of non-covalent activation of Nrf2.
Assuntos
Desenho de Fármacos , Fator 2 Relacionado a NF-E2/agonistas , Administração Oral , Animais , Astrócitos/citologia , Astrócitos/efeitos dos fármacos , Astrócitos/metabolismo , Encéfalo/metabolismo , Meia-Vida , Humanos , Proteína 1 Associada a ECH Semelhante a Kelch/química , Proteína 1 Associada a ECH Semelhante a Kelch/metabolismo , Rim/metabolismo , Camundongos , Fator 2 Relacionado a NF-E2/metabolismo , Domínios e Motivos de Interação entre Proteínas , Ratos , Bibliotecas de Moléculas Pequenas/química , Bibliotecas de Moléculas Pequenas/farmacocinética , Bibliotecas de Moléculas Pequenas/farmacologia , Relação Estrutura-AtividadeRESUMO
INTRODUCTION: Percutaneous Endoscopic Gastrostomy (PEG) is an infrequent adjunct in elective paraesophageal hernia repair (PEHR). Guidelines denote that PEG "may facilitate postoperative care in selected patients." Though there is sparse literature defining which patients may benefit. The purpose of this study is to determine factors associated with simultaneous PEG placement during PEHR and their subsequent outcomes. METHODS: The NSQIP database was queried from 2011 to 2016 for patients undergoing elective laparoscopic PEHR. Cases were excluded if PEHR or fundoplasty was not the primary procedure, a concomitant bariatric procedure was performed, or if the primary surgeon was not a general or cardiothoracic surgeon. Groups were Propensity Score Matched for age, BMI, and ASA Class. RESULTS: 15700 patients were identified, 371 who underwent simultaneous PEG placement (2.4%). Non-PEG patients were matched at a 5:1 ratio, producing 1855 controls. PEG patients had higher rates of pre-operative dyspnea (OR 1.45, p = 0.0110), pre-operative weight loss (OR 2.87, p = 0.0001), and lower pre-operative albumin (3.92 vs. 4.01, p = 0.0129). PEG patients had more intra-operative contamination (mean Wound Classification 1.54 vs. 1.38, p < 0.0001) and longer case durations (170 vs. 148 min, p < 0.0001). PEG patients had longer lengths of stay (3.4 vs. 2.5 days, p = 0.0001), rates of superficial SSI (OR 5.82, p = 0.0012), peri-operative transfusions (OR 2.68, p = 0.0197), and pulmonary emboli (OR 3.61, p = 0.0359). CONCLUSION: Patients undergoing simultaneous PEG during PEHR are more likely to have respiratory symptoms, markers of malnutrition, and intra-operative factors indicative of more technically challenging cases. These patients have longer hospitalizations, higher rates of superficial SSI, and more pulmonary emboli.
Assuntos
Gastrostomia , Hérnia Hiatal/cirurgia , Herniorrafia , Laparoscopia , Complicações Pós-Operatórias , Bases de Dados Factuais , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Gastrostomia/efeitos adversos , Gastrostomia/métodos , Herniorrafia/efeitos adversos , Herniorrafia/métodos , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/classificação , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Medição de Risco , Fatores de TempoRESUMO
BACKGROUND: Basal cell cancer is the most common cutaneous malignancy. It rarely presents with locally advanced or metastatic disease. Rare presentations such as intraorbital invasion remain a difficult clinical problem with significant potential morbidity. There is no review of sonic hedgehog pathway inhibitors (HPIs) for intraorbital basal cell cancer, and evidence regarding optimal management is limited. OBJECTIVE: To evaluate the evidence for the management of intraorbital basal cell cancer with HPIs. METHODS: A search to identify evidence for treatment intraorbital basal cell cancers with HPIs to date was performed in PubMed database and OVID using the phrases "basal cell cancer/carcinoma/BCC," "intraorbital," "orbital," "ocular," "periocular," "vismodegib," "GDC-0449," "sonidegib," and "LDE224," in various combinations with Boolean operators "AND" and "OR." RESULTS: Rigorous clinical trials have previously reported the use of vismodegib and sonidegib in locally advanced and metastatic basal cell carcinoma (BCC). However, specific descriptions of treatment of intraorbital tumors are rarely presented in detail adequate for analysis. Twenty-two cases of intraorbital BCC treated with vismodegib have been described in the literature, and no cases using sonidegib were identified. These vary in quality, but highlight important questions regarding optimal treatment duration, follow-up, and adjunctive therapies. Reports describing locally advanced BCC in various facial and periocular locations, but without specific mention of intraorbital invasion, were excluded. CONCLUSION: Vismodegib is an attractive eye and vision-sparing option in patients with locally advanced intraorbital basal cell cancer whose other options often include exenteration, radiation, or other radical surgery.
Assuntos
Anilidas/uso terapêutico , Antineoplásicos/uso terapêutico , Carcinoma Basocelular/tratamento farmacológico , Carcinoma Basocelular/cirurgia , Proteínas Hedgehog/antagonistas & inibidores , Recidiva Local de Neoplasia/tratamento farmacológico , Neoplasias Orbitárias/tratamento farmacológico , Piridinas/uso terapêutico , Neoplasias Cutâneas/cirurgia , Administração Oral , Anilidas/administração & dosagem , Antineoplásicos/administração & dosagem , Humanos , Aparelho Lacrimal , Masculino , Pessoa de Meia-Idade , Piridinas/administração & dosagem , Terapia de SalvaçãoRESUMO
BACKGROUND: With current emphasis on improving cost-quality relationship in medicine, it is imperative to evaluate cost-value relationships for surgical procedures. Previously the authors demonstrated comparable clinical outcomes for minimally invasive right hepatectomy (MIRH) and open right hepatectomy (ORH). MIRH had significantly higher intraoperative cost, though overall costs were similar. METHODS: MIRH was decoded into its component critical steps using value stream mapping, analyzing each associated cost. MIRH technique was prospectively modified, targeting high cost steps and outcomes were re-examined. Records were reviewed for elective MIRH before (pre-MIRH n = 50), after (post MIRH n = 25) intervention and ORH (n = 98), between January 1, 2008 and November 30, 2016. RESULTS: Average overall cost was significantly lower for post-standardization MIRH (post-MIRH $21 768, pre-MIRH $28 066, ORH $33 020; p < 0.001). Average intraoperative blood loss was reduced with MIRH (167, 292 and 509 mL p < 0.001). Operative times were shorter (147, 190 and 229 min p < 0.001) and LOS was reduced for MIRH (3, 4, 7 days p < 0.002). CONCLUSIONS: Using a common quality improvement tool, the authors established a model for cost effective clinical care. These tools allow surgeons to overcome personal or traditional biases such as stapler choices, but most importantly eliminate non-value added interventions for patients.
Assuntos
Hepatectomia/economia , Hepatectomia/normas , Hepatopatias/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/economia , Procedimentos Cirúrgicos Minimamente Invasivos/normas , Idoso , Biomarcadores/análise , Comorbidade , Custos e Análise de Custo , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Testes de Função Hepática , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias , Resultado do TratamentoRESUMO
The differential of a newly discovered solitary intracranial mass is a primary intracranial neoplasm and metastatic disease. Differentiating between the two entities on imaging is difficult, though there are clues on conventional imaging that suggest one over the other. The purpose of this article is to describe a new imaging finding on T2-weighted imaging, the "pool sign," that may be specific for metastatic adenocarcinomas and can help differentiate a solitary metastasis from a primary CNS neoplasm. We present a series of four patients with initial magnetic resonance imaging of a solitary intracranial mass demonstrating the "pool sign," and therefore predicted to be metastatic adenocarcinoma. All of these cases were confirmed to be metastatic adenocarcinoma on pathology.