SAGES Foregut Surgery Masters Program: a surgeon's social media resource for collaboration, education, and professional development.

BACKGROUND: Facebook is a popular online social networking platform increasingly used for professional collaboration. Literature regarding use of Facebook for surgeon professional development and education is limited. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has established a Facebook group dedicated to discussion of surgery of the esophagus, stomach, and small intestine-the "SAGES Foregut Surgery Masters Program." The aim of this study is to examine how this forum is used for professional development, education, and quality improvement. METHODS: Member and post statistics were obtained from https://grytics.com , a Facebook group analytics service. All posts added to the Foregut forum since its creation in April 2015 through December 2016 were reviewed and categorized for content and topic. Posts were reviewed for potential identifiable protected health information. RESULTS: As of December 2016, there were 649 total members in the group. There have been a total of 411 posts and 4116 comments with a median of 10.1 comments/post (range 0-72). Posts were categorized as operative technique (64%), patient management (52%), continuing education (10%), networking (10%), or other (6%). Video and/or photos were included in 53% of posts with 4% of posts depicting radiologic studies and 13% with intraoperative photos or videos. An additional 40 posts included links to other pages, such as YouTube, journal articles, or the SAGES website. One post (0.2%) contained identifiable protected health information and was deleted once recognized by the moderators of the group. CONCLUSION: Social media is a unique, real-time platform where surgeons can learn, discuss, and collaborate towards the goal of optimal treatment of surgical disease. Active online surgical communities such as the SAGES Foregut Surgery Masters Program have the potential to enhance communication between surgeons and are a potential innovative adjunct to traditional methods of continuing surgical education. Surgical societies should adopt and promote professional and responsible use of social media.

Viewer discretion advised: is YouTube a friend or foe in surgical education?

BACKGROUND: In the current era, trainees frequently use unvetted online resources for their own education, including viewing surgical videos on YouTube. While operative videos are an important resource in surgical education, YouTube content is not selected or organized by quality but instead is ranked by popularity and other factors. This creates a potential for videos that feature poor technique or critical safety violations to become the most viewed for a given procedure. METHODS: A YouTube search for "Laparoscopic cholecystectomy" was performed. Search results were screened to exclude animations and lectures; the top ten operative videos were evaluated. Three reviewers independently analyzed each of the 10 videos. Technical skill was rated using the GOALS score. Establishment of a critical view of safety (CVS) was scored according to CVS "doublet view" score, where a score of ≥5 points (out of 6) is considered satisfactory. Videos were also screened for safety concerns not listed by the previous tools. RESULTS: Median competence score was 8 (±1.76) and difficulty was 2 (±1.8). GOALS score median was 18 (±3.4). Only one video achieved adequate critical view of safety; median CVS score was 2 (range 0-6). Five videos were noted to have other potentially dangerous safety violations, including placing hot ultrasonic shears on the duodenum, non-clipping of the cystic artery, blind dissection in the hepatocystic triangle, and damage to the liver capsule. CONCLUSIONS: Top ranked laparoscopic cholecystectomy videos on YouTube show suboptimal technique with half of videos demonstrating concerning maneuvers and only one in ten having an adequate critical view of safety. While observing operative videos can be an important learning tool, surgical educators should be aware of the low quality of popular videos on YouTube. Dissemination of high-quality content on video sharing platforms should be a priority for surgical societies.

Outcomes of laparoscopic feeding jejunostomy tube placement in 299 patients.

BACKGROUND: Jejunostomy catheters for jejunal feeding are an effective method to improve nutritional status in malnourish patients. However, this procedure is commonly being performed using an open approach, which can be associated with more postoperative pain and prolonged recovery. The objective of this study was to assess the outcomes of patients who underwent placement of feeding jejunostomy using a laparoscopic approach. METHODS: A retrospective review was performed of patients who underwent laparoscopic jejunostomy tube placement between 1998 and 2014. Main outcome measures included indication for catheter placement, rate of conversion rate to open surgery, perioperative and late morbidity and in-hospital mortality. RESULTS: Two hundred and ninety-nine consecutive patients underwent laparoscopic jejunostomy during the study period. The mean age was 64 years, and 81% of patients were male. The mean BMI was 26.2 kg/m(2). The most common indications for catheter placement were resectable esophageal cancer (78%), unresectable esophageal cancer (10%) and gastric cancer (6%). There were no conversions to open surgery. The 30-day complication rate was 4.0% and included catheter dislodgement (1%), intraperitoneal catheter displacement (0.7%), catheter blockage (1%) or breakage (0.3%), site infection requiring catheter removal (0.7%) and abdominal wall hematoma (0.3%). The late complication rate was 8.7% and included jejuno-cutaneous fistula (3.7%), jejunostomy tube dislodgement (3.3%), broken or clogged J-tube (1.3%) and small bowel obstruction (0.3%). The 30-day mortality was 0.3% for a patient with stage IV esophageal cancer who died in the postoperative period secondary to respiratory failure. CONCLUSION: In this large consecutive series of feeding jejunostomy, the laparoscopic approach is feasible and safe and associated with a low rate of small bowel obstruction and no intraabdominal catheter-related infection.

Colorectal surgery in Parkinson's disease--outcomes and predictors of mortality.

PURPOSE: Although diseases of the lower gastrointestinal tract are common in patients with Parkinson's disease, there is a paucity of data regarding postoperative outcomes after colorectal surgery. METHODS: The Nationwide Inpatient Sample database (2007-2011) was utilized to analyze outcomes in patients with Parkinson's disease (PD) undergoing colorectal surgery. Main outcomes were risk-adjusted inpatient morbidity, mortality, hospital charge, and length of hospital stay. RESULTS: A total of 6490 patients were identified. Utilization of laparoscopic surgery in Parkinson's patients has progressively increased in frequency over the latest 5 years analyzed. The most common diagnoses were colorectal malignancy (39 %) and intestinal obstruction (20 %). Right hemicolectomy (37 %) and sigmoidectomy (30 %) were the most common operations. Laparoscopy was used in 18 % of Parkinson's patients and most commonly in the elective setting. 54.3 % of Parkinson's patients had emergency surgery compared to 38.6 % in non-Parkinson's. Overall morbidity and mortality were significantly lower after laparoscopic surgery compared to open (20 vs. 25 % and 2.1 vs. 6.6 %, respectively). Length of stay was significantly shorter (OR -1.86; p < 0.01) for laparoscopic operations, but there were no significant differences in risk-adjusted outcomes between laparoscopic and open groups. CONCLUSION: PD patients have high rates of morbidity and mortality after colorectal surgery; this may be because more than half of all patients in this population undergo emergent surgery. The laparoscopic approach appears to have short-term benefits in this patient population.

Surgical treatments for rectal prolapse: how does a perineal approach compare in the laparoscopic era?

BACKGROUND: Patients with rectal prolapse often have significant comorbidities that lead surgeons to select a perineal resection for treatment despite a reported higher recurrence rate over abdominal approaches. There is a lack of data to support this practice in the laparoscopic era. The objective of this study was to evaluate if risk-adjusted morbidity of perineal surgery for rectal prolapse is actually lower than laparoscopic surgery. DESIGN: A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database as performed for patients undergoing surgical treatment of rectal prolapse between 2005 and 2011. Outcomes were analyzed according to procedure-type: laparoscopic rectopexy (LR), laparoscopic resection/rectopexy (LRR), open rectopexy (OR), open resection/rectopexy (ORR), and perineal resection (PR). A multivariate logistic regression was used to compare risk-adjusted morbidity and mortality between each procedure. Main outcome measures were 30-day morbidity and mortality. RESULTS: Among 3,254 cases sampled, a laparoscopic approach was used in 22 %, an open abdominal approach in 30 %, and PR in 48 %. Patients undergoing PR were older (76) and had a higher ASA (3) compared to laparoscopic (58, 2) and open abdominal procedures (58, 2). Risk-adjusted mortality could not be assessed due to a low overall incidence of mortality (0.01 %). Overall morbidity was 9.3 %. ORR was associated with a higher risk-adjusted morbidity compared to PR (OR: 1.89 CI (1.19-2.99), p = 0.03). There were no significant differences in risk-adjusted morbidity found between LR and LRR compared to PR (OR 0.44 CI (0.19-1.03), p = 0.18; OR 1.55 CI (0.86-2.77), p = 0.18). Laparoscopic cases averaged 27 min longer than open cases (p < 0.001). CONCLUSION: Laparoscopic rectal prolapse surgery has comparable morbidity and mortality to perineal surgery. A randomized trial is indicated to validate these findings and to assess recurrence rates and functional outcomes.

Laparoscopic Versus Open Loop Ileostomy Reversal: Is there an Advantage to a Minimally Invasive Approach?

BACKGROUND: Ileostomy reversals are commonly performed procedures after colon and rectal operations. Laparoscopic ileostomy reversal (LIR) with lysis of adhesions has potential benefits over conventional open surgery. The aim of this study was to compare outcomes of laparoscopic and open ileostomy reversal. METHODS: 133 consecutive patients undergoing ileostomy reversal at our institution between June 2009 and August 2013 were analyzed using a retrospective database. The group comprised 53 laparoscopic cases and 80 open cases, performed by four surgeons at a single center. The data were analyzed for patient demographics, operative characteristics, postoperative outcomes, and 30-day morbidity and mortality. RESULTS: The two groups had comparable mean age, gender distribution, ASA scores, and BMI. The laparoscopic group had a significantly longer duration of surgery compared to the open reversal group (109 versus 93 min, p < 0.05). However, this group underwent more lysis of adhesions (60.4 % versus 26.3 %, p < 0.01) as well as concurrent stoma site mesh reinforcement (32.1 % versus 6.3 %, p < 0.01). In the laparoscopy group, 20.7 % of patients underwent intra-corporeal ileo-ileal anastomosis. There were no significant differences between the laparoscopic and open groups with regard to estimated blood loss (31 versus 40 ml, respectively) or mean length of stay (5.3 vs. 5.7 days, respectively). The rates of overall 30-day morbidity (16.9 % for laparoscopic vs. 21.3 % for open) as well as rates of specific complications were equivalent between groups. 30-day mortalities were not noted in either group. CONCLUSION: LIR is safe and effective with low perioperative morbidity and mortality. The use of laparoscopy as an option in terms of concomitant hernia repair and lysis of adhesions may be considered in selected patients.

Incisional reinforcement in high-risk patients.

Hernia formation after surgical procedures continues to be an important cause of surgical morbidity. Incisional reinforcement at the time of the initial operation has been used in some patient populations to reduce the risk of subsequent hernia formation. In this article, reinforcement techniques in different surgical wounds are examined to identify situations in which hernia formation may be prevented. Mesh use for midline closure, pelvic floor reconstruction, and stoma site reinforcement is discussed. Additionally, the use of retention sutures, closure of the open abdomen, and reinforcement after component separation are examined using current literature. Although existing studies do not support the routine use of mesh reinforcement for all surgical incisions, certain patient populations appear to benefit from reinforcement with lower rates of subsequent hernia formation. The identification and characterization of these groups will guide the future use of mesh reinforcement in surgical incisions.

Volume and outcome relationship in bariatric surgery in the laparoscopic era.

BACKGROUND: The relationship between volume and outcomes in bariatric surgery is well established in the literature. However, the analyses were performed primarily in the open surgery era and in the absence of national accreditation. The recent Metabolic Bariatric Surgery Accreditation and Quality Improvement Program proposed an annual threshold volume of 50 stapling cases. This study aimed to examine the effect of volume and accreditation on surgical outcomes for bariatric surgery in this laparoscopic era. METHODS: The Nationwide Inpatient Sample was used for analysis of the outcomes experienced by morbidly obese patients who underwent an elective laparoscopic stapling bariatric surgical procedure between 2006 and 2010. In this analysis, low-volume centers (LVC < 50 stapling cases/year) were compared with high-volume centers (HVC ≥ 50 stapling cases/year). Multivariate analysis was performed to examine risk-adjusted serious morbidity and in-hospital mortality between the LVCs and HVCs. Additionally, within the HVC group, risk-adjusted outcomes of accredited versus nonaccredited centers were examined. RESULTS: Between 2006 and 2010, 277,760 laparoscopic stapling bariatric procedures were performed, with 85% of the cases managed at HVCs. The mean number of laparoscopic stapling cases managed per year was 17 ± 14 at LVCs and 144 ± 117 at HVCs. The in-hospital mortality was higher at LVCs (0.17%) than at HVCs (0.07%). Multivariate analysis showed that laparoscopic stapling procedures performed at LVCs had higher rates of mortality than those performed at HVCs [odds ratio (OR) 2.5; 95% confidence interval (CI) 1.3-4.8; p < 0.01] as well as higher rates of serious morbidity (OR 1.2; 95% CI 1.1-1.4; p < 0.01). The in-hospital mortality rate at nonaccredited HVCs was 0.22% compared with 0.06% at accredited HVCs. Multivariate analysis showed that nonaccredited centers had higher rates of mortality than accredited centers (OR 3.6; 95% CI 1.5-8.3; p < 0.01) but lower rates of serious morbidity (OR 0.8; 95% CI 0.7-0.9; p < 0.01). CONCLUSION: In this era of laparoscopy, hospitals managing more than 50 laparoscopic stapling cases per year have improved outcomes. However, nonaccredited HVCs have outcomes similar to those of LVCs. Therefore, the impact of accreditation on outcomes may be greater than that of volume.

A Decade Analysis of Trends and Outcomes of Male vs Female Patients Who Underwent Bariatric Surgery.

BACKGROUND: Male obesity rates are now estimated to be equal to female obesity rates. Despite this, men constitute a minority of patients undergoing bariatric surgery. The aim of this study was to examine the national trends and outcomes of bariatric surgery in male patients compared with female patients. STUDY DESIGN: The Nationwide Inpatient Sample database was reviewed for obese patients undergoing bariatric surgery between 2002 and 2011. Outcomes were analyzed according to sex. Main outcomes measures were patient demographics, length of stay, risk-adjusted inpatient morbidity and mortality, and hospital charge. RESULTS: During the 10-year period, 810,999 patients underwent bariatric surgery; 19.3% were male and 80.7% were female. The percentage of male patients increased from 15.4% in 2002 to 21.7% in 2011. Mean age was significantly older for males (46 ± 11 years vs 43 ± 11 years; p < 0.01, respectively). Male patients had a higher proportion of moderate, major, and extreme severity of illness classifications and higher rates of comorbid conditions. Serious morbidity was significantly higher in male patients compared with female patients (7.58% vs 5.42%; p < 0.01). Mean hospital length of stay was longer for male patients (2.75 vs 2.61 days; p < 0.01) with a higher mean hospital charge ($38,682 vs $34,294; p < 0.01). Compared with the female group, the male group had higher risk-adjusted in-hospital mortality (odds ratio = 2.16; 95% CI, 1.62-2.88; p < 0.01) and serious morbidity (odds ratio = 1.23; 95% CI, 1.17-1.29; p < 0.01). CONCLUSIONS: The number of male patients undergoing bariatric surgery in the past decade continues to be a small fraction compared with the number of female patients. Men undergoing bariatric surgery tend to have higher severity of illness, with higher risk-adjusted serious morbidity and mortality rates. Additional studies are necessary to examine barriers in obtaining treatment for obese men.

Effect of Resident Involvement on Patient Outcomes in Complex Laparoscopic Gastrointestinal Operations.

BACKGROUND: Multiple studies examining the impact of resident involvement on patient outcomes in general surgical operations have shown an associated increase in morbidity and operative time. However, these studies included basic and advanced laparoscopic and open operations. The aim of this study was to examine the impact of resident involvement on outcomes specifically in patients who underwent complex minimally invasive gastrointestinal operations. STUDY DESIGN: The American College of Surgeons NSQIP database was reviewed for patients who underwent laparoscopic colectomy and laparoscopic paraesophageal hernia and anti-reflux procedures between 2002 and 2010. Data were analyzed based on operations performed with a resident involved compared with those performed by an attending surgeon without resident involvement. Primary end points included risk-adjusted 30-day mortality, 30-day reoperation, and 30-day serious morbidity. Secondary end points were operative time, hospital length of stay, and 30-day overall morbidity. RESULTS: A total of 31,736 cases were analyzed; 63.3% of cases had a resident involved in the operation and 36.7% were performed by an attending without resident involvement. Operative time was significantly longer in cases performed with a resident (162 vs 138 minutes in attending-only cases; p < 0.01), however, there were no significant differences between groups with regard to hospital length of stay (4.5 vs 4.5 days, respectively). Compared with cases without resident involvement, risk-adjusted outcomes for cases with resident involvement showed no significant differences in 30-day serious morbidity (odds ratio = 1.03; 95% CI, 0.94-1.14; p = 1.0), 30-day mortality (odds ratio = 0.83; 95% CI, 0.60-1.15; p = 1.0), or 30-day reoperation (odds ratio = 0.93; 95% CI, 0.81-1.06; p = 1.0). CONCLUSIONS: Resident involvement in complex laparoscopic gastrointestinal procedures is associated with an increase in operative time with no impact on postoperative outcomes.

Bariatric surgery in the elderly: 2009-2013.

BACKGROUND: Ample evidence supports the safety and effectiveness of bariatric surgery in the general adult population but more information is needed in patients age 60 years and older (elderly). We previously examined the outcome of bariatric surgery performed in the elderly between 1999 and 2005 using the University HealthSystem Consortium (UHC) Clinical Database. The aim of this study was to analyze contemporary outcomes of bariatric surgery in the elderly and to compare them to previous data from 1999-2005. METHODS: Using International Classification of Diseases, 9(th) Revision diagnosis and procedure codes, we obtained data from the UHC database for all elderly (age >60 yr) and adult nonelderly (age 19-60 yr) patients who underwent bariatric surgery for the treatment of morbid obesity between 2009 and 2013. Outcome measures, such as patient characteristics, LOS, morbidity, and observed-to-expected (risk-adjusted) mortality ratio were compared between elderly and nonelderly patients. RESULTS: Bariatric surgery in the elderly made up 2.7% of all bariatric operations in 1999-2005. This represents an increase to 10.1% of all bariatric operations in 2009-2013. In-hospital mortality was .30% for the nonelderly and .70% for the elderly in 1999-2005, whereas contemporary in-hospital mortality has decreased to .11% for the nonelderly and .05% for the elderly. CONCLUSION: Our results show that the number of bariatric procedures performed in the elderly is increasing and now represents 10% of all bariatric operations performed at academic centers. In-hospital mortality in bariatric surgery in the elderly has improved so much that it is now even better than in-hospital mortality in the nonelderly in 1999-2005.

Use and Outcomes of Laparoscopic Sleeve Gastrectomy vs Laparoscopic Gastric Bypass: Analysis of the American College of Surgeons NSQIP.

BACKGROUND: Laparoscopic sleeve gastrectomy is gaining popularity in the United States. However, few studies have examined outcomes of sleeve gastrectomy compared with those of the "gold standard" bariatric operation: Roux-en-Y gastric bypass. STUDY DESIGN: Using the American College of Surgeons National Surgical Quality Improvement Program database, clinical data were obtained for all patients who underwent laparoscopic sleeve gastrectomy or laparoscopic gastric bypass between 2010 and 2011. Main outcomes measures were risk-adjusted 30-day serious morbidity and mortality. RESULTS: We analyzed 24,117 patients who underwent laparoscopic sleeve gastrectomy or laparoscopic gastric bypass for the treatment of morbid obesity. Gastric bypass comprised 79.5% of cases and sleeve gastrectomy comprised 20.5%; the proportion of sleeve gastrectomy cases increased from 14.6% in 2010 to 25.8% in 2011. On univariate analysis, sleeve gastrectomy had a shorter mean operative time (101 vs 133 minutes, p < 0.01), a lower rate of blood loss requiring transfusion (0.6% vs 1.5%, p < 0.01), a lower rate of deep wound infections (0.06% vs 0.20%, p = 0.05), lower serious morbidity rate (3.8% vs 5.8%, p < 0.01), and 30-day reoperation rate (1.6% vs 2.5%, p < 0.01), but a higher rate of deep venous thrombosis (0.47% vs 0.21%, p < 0.01). Compared with sleeve gastrectomy, gastric bypass patients had higher risk-adjusted 30-day serious morbidity (odds ratio [OR] 1.32; 95% CI1.11 to 1.56, p < 0.01). Patients who were older, had higher BMI, smoked, or had hypertension were at significantly greater risk of serious morbidity. The 30-day mortality was similar between groups (0.10% for sleeve vs 0.15% for bypass). CONCLUSIONS: Use of laparoscopic sleeve gastrectomy is increasing on a national level. Compared with laparoscopic gastric bypass, laparoscopic sleeve gastrectomy is associated with lower 30-day risk-adjusted serious morbidity and equivalent 30-day mortality.

One-year outcomes of laparoscopic sleeve gastrectomy versus laparoscopic adjustable gastric banding for the treatment of morbid obesity.

Sleeve gastrectomy is emerging to be the procedure of choice in the management of severe obesity. The aim of this study was to analyze outcomes between patients who underwent laparoscopic sleeve gastrectomy (LSG) versus laparoscopic adjustable gastric banding (LAGB). A retrospective matched cohort analysis was performed between 150 patients who underwent LSG versus 150 patients who underwent LAGB. The cohorts were matched for age, gender, body mass index (BMI), and preoperative comorbidities. Length of hospital stay (1.6 vs 1.1 days, P < 0.01) was longer in the LSG group. Perioperative complications were similar between groups (4.6% for LSG vs 2.0% for LAGB) but the late complication rate was significantly lower in the LSG group (1.3 vs 8.0%). The 30-day reoperation (0 vs 0.7%) and readmission (1.3 vs 1.3%) rates were similar between groups. There were no 90-day mortalities in the study. The mean reduction in BMI was significantly higher for LSG (-11.9 kg/m(2) for LSG vs -6.2 kg/m(2) for LAGB, P < 0.01) at 1-year follow-up. The number of medications used to control all comorbidities was significantly lower at follow-up compared with baseline for both groups. The mean reduction in the number medications used to control hypertension was greater in the LSG group (-1.00 ± 0.70 vs -0.35 ± 0.70 medications, P < 0.01). LSG has a perioperative safety profile comparable to that of LAGB but achieved significantly better weight loss and control of hypertension with a lower rate of late complications.

A decade analysis of trends and outcomes of bariatric surgery in Medicare beneficiaries.

BACKGROUND: In 2006, the Centers for Medicare and Medicaid Services issued a National Coverage Determination (NCD), which mandates that bariatric procedures be performed only at accredited centers. The aim of this study was to analyze outcomes of Medicare beneficiaries who underwent bariatric surgery before (2001 through 2005) vs after (2006 through 2010) implementation of the NCD. STUDY DESIGN: The Nationwide Inpatient Sample database was used to analyze data on patients who underwent bariatric surgery between 2001 and 2010. Main outcomes measures were demographics, length of stay, risk-adjusted inpatient morbidity and mortality, and cost. RESULTS: There were 775,040 patients who underwent bariatric surgery, with 16% of the patients Medicare beneficiaries. There was an overall trend for improved in-hospital mortality during the decade (0.35% in 2001 to 0.10% in 2010). Medicare patients who underwent bariatric surgery had higher rates of comorbidities and a higher rate of in-hospital mortality than non-Medicare patients. After the NCD, there was a significant reduction of the in-hospital mortality (0.56% vs 0.23%; p < 0.01) and serious morbidity (9.92% vs 6.98%; p < 0.01) for Medicare patients and a similar reduction of the in-hospital mortality (0.18% vs 0.08%; p < 0.01) and serious morbidity (6.84% vs 5.08%; p < 0.01) for non-Medicare patients. Compared with patients who underwent stapling bariatric procedures at accredited centers, patients at nonaccredited centers had higher risk-adjusted in-hospital mortality (odds ratio = 3.53; 95% CI, 1.01-6.52) and serious morbidity (odds ratio = 1.18; 95% CI, 1.07-1.30). After the NCD, use of bariatric surgery within Medicare beneficiaries increased by 71%. CONCLUSIONS: Outcomes of bariatric surgery in Medicare beneficiaries have improved substantially since the 2006 NCD. Facility accreditation appears to be a contributing factor to the observed improvement in outcomes.

Laparoscopic versus robotic-assisted rectal surgery: a comparison of postoperative outcomes.

Rectal surgery continues to be an area of advancement for minimally invasive techniques. However, there is controversy regarding whether a robotic approach imparts any advantages over established laparoscopic procedures. The aim of this study was to analyze and compare outcomes of laparoscopic and robotic rectal resection operations. A single-institution retrospective review was performed identifying 83 consecutive patients undergoing low rectal resection requiring proximal diversion between 2009 and 2013. The cohort was comprised of 38 laparoscopic and 45 robotic cases. Data were analyzed for postoperative outcomes as well as 30-day morbidity and mortality. Male gender frequency, body mass index, and American Society of Anesthesiologists class were higher in the robotic group (71%, 28.6 kg/m(2), and 2.6, respectively) compared with the laparoscopic group (42%, 23.7 kg/m(2), and 2.2, respectively; P < 0.01). Length of stay was significantly longer for patients undergoing laparoscopic (7.5 days) compared with robotic procedures (5.7 days, P < 0.01). This difference was even greater when comparing patients who underwent a hybrid laparoscopic-assisted open total mesorectal excision (TME) with robotic TME (8.2 vs 5.7 days, respectively, P < 0.01). Conversion rate was 7.9 per cent for the laparoscopic group and zero per cent for the robotic (P = 0.09). There were no mortalities in either group. A pure laparoscopic or robotic rectal surgery may be associated with a shorter hospital stay compared with a laparoscopic-assisted approach.

Delineation of cardiac twist by a sonographically based 2-dimensional strain analysis method: an in vitro validation study.

OBJECTIVE: Normal left ventricular contraction involves a twisting component that helps augment stroke volume, the unwinding of which also very usefully contributes to early diastolic filling. Abnormalities of cardiac twist have been related to abnormal cardiac function. We sought to quantify the twisting action using a new sonographically based angle-independent motion-detecting echo method. METHODS: A twist model was developed with a variable-speed motor to rotate a wheel in water bath. A freshly harvested pig heart was mounted on it as a twist phantom. Short axis views were acquired with a GE/VingMed Vivid 7 system (GE Healthcare, Milwaukee, WI) at 3.5 MHz and more than 100 frames/s. Eight different speeds (30-100 cycles/min of winding and unwinding) were studied at 5 degrees of rotation (10 degrees , 20 degrees , 30 degrees , 40 degrees , and 50 degrees ). Data were analyzed off-line for twist analysis with a new 2-dimensional speckle-tracking-based program (2-dimensional strain rate method [2DSR]) embedded in EchoPac software (GE Healthcare). Ten freshly harvested pig hearts were studied in this model. RESULTS: The 2DSR program tracked the twist well (mean determination at 10 degrees = 16.88 degrees +/- 1.81 degrees [SD]; at 20 degrees = 26.5 degrees +/- 1.05 degrees ; at 30 degrees = 36.47 degrees +/- 1.31 degrees ; at 40 degrees = 44.03 degrees +/- 1.39 degrees ; and at 50 degrees = 54.1 degrees +/- 1.96 degrees ). CONCLUSIONS: The 2DSR program can be used to study twisting action of the heart.