Outcome and Timing of Ostomy Reversal Surgery for Diverticular Disease in Veterans Administration Hospitals.

BACKGROUND: Veterans undergoing elective surgery for diverticular disease have an ostomy creation rate of 18%. The purpose of this study was to analyze the outcomes and timing of ostomy reversal surgery, perioperative complications, and differences between colostomy and ileostomy reversal outcomes. METHODS: A retrospective review of the Veterans Affairs Surgical Quality Improvement Project (VASQIP) database was performed. Patients undergoing elective colectomy for diverticular disease between 2004 and 2018 were identified. Demographics, comorbidities, ostomy type, time to reversal, and postoperative complications were analyzed. RESULTS: 4,198 patients underwent elective colectomy for diverticular disease, with 751 patients (17.9%) receiving an ostomy. Of patients who received an ostomy, 407 had ostomy reversal surgery within the Veterans Health Administration system (54.2%), with 243 colostomies, 149 ileostomies, and 15 unspecified. Median time to ostomy reversal was 5.0 months (interquartile range 3.2, 7.8). Complication rate after reversal was 23.1%; surgical site infection was most common (9.1%). Patients with American Society of Anesthesiologists classification >3 (adjusted odds ratio (aOR) = .40[.22-.72]), increasing age (aOR = .98[.97-.99]), laparoscopic index procedure (aOR = .42[.27-.63]), and hypertension (aOR = .63[.46-.87]) were less likely to have their ostomy reversed. There were no differences in postoperative complication rates after ostomy vs ileostomy reversals. Reversals after 4.6 months were associated with 3.4-times higher odds of complications. CONCLUSION: Ostomy creation and reversal rates are similar between the veteran and non-veteran populations in the United States. Delays in reversal surgery were associated with worse postoperative outcomes, which underscore the importance of close follow-up for patients with an ostomy after elective colectomy for diverticular disease.

Effects of Liver Pathology on Sleeve Gastrectomy Outcomes.

Introduction: Sleeve gastrectomy engenders weight loss and improves comorbidities at 1 year postoperatively. A relationship has not been established between liver pathology and diabetic outcomes and weight loss following a sleeve gastrectomy. This study evaluates the association between liver pathology and both diabetic remission and weight loss in morbidly obese veterans. Methods: A prospective database of all patients undergoing sleeve gastrectomy with simultaneous liver biopsy at a Veterans Affairs Medical Center was analyzed from 2018 through 2020. The database included patient demographics, liver biopsy pathology, laboratory values, and antihyperglycemic medications. Patient outcomes at 12 months postoperatively were analyzed specifically for diabetic resolution and weight loss. Chi-square test and Fisher's exact test were used for categorical comparisons, and one-way analysis of variance test and two-tailed t-test were used for continuous variable comparisons. Multivariate linear regression models were created to assess the association between liver pathology and changes in body mass index (BMI) and diabetic status. A two-sided P-value of 0.05 indicated significance. Results: Of the 77 patients included in the study, 70.1% of patients achieved diabetic remission at 12 months. After condensing steatosis and fibrosis scores into low- and high-grade categories, patients with no hepatic disease had significantly lower BMI at 12 months postoperatively than patients with low- or high-grade hepatic disease (29.2 ± 3.6 kg/m2 versus 35.1 ± 4.0 kg/m2 versus 34.5 ± 3.7 kg/m2, respectively, P = .009). On multivariate linear regression model, low-grade overall hepatic disease (ß = 3.1 ± 1.5; P = .043) and preoperative oral glycemic medications (ß = 2.4 ± 1.0; P = .026) were associated with a significantly increased 12-month BMI. Also, Black or African American race compared with White race was associated with a significant decrease in postoperative BMI (ß = -1.9 ± 0.8; P = .023). Conclusions: Regardless of preexisting liver disease, most diabetic patients who undergo sleeve gastrectomy experience diabetic remission at 12 months postoperatively. Additionally, patients with no underlying liver disease lose more weight than those with low- or high-grade liver disease.

Laparoscopic Intragastric Cystgastrostomy: A Technical Report.

Background: Management of symptomatic pancreatic pseudocysts poses a unique challenge to minimally invasive surgeons. Despite the predominance of endoscopic management of pancreatic pseudocysts, the laparoscopic approach remains a critical skill in the armamentarium of surgeons. Methods: This report details a laparoscopic intragastric approach to create a pancreatic cystgastrostomy using intraoperative ultrasound and endoscopy. Conclusion: Laparoendoscopic techniques for pancreatic pseudocysts are still required in selective cases when endoscopic management is not available or fails. Using this technique provides patients with same clinical benefits of an endoscopic approach.

Surgical Residents in the Battle Against COVID-19.

PERSPECTIVES: In times of public health crises, medical residency program leaders are responsible to maintain the wellbeing of their residents and ensure uninterrupted training. COVID-19 caused significant impact on healthcare industry, depleting resources and manpower, which led to disruption to graduate medical education and residency training. Surgical residents were affected by the pandemic both by reduced operative opportunities in most training centers and inducing stress and concerns about safety and wellbeing among residents. Spread of the SARS-Cov-2 was naturally accompanied with a gradual decrease in numbers of healthcare personnel which consequently increased the burden on residents. During these times of crisis and uncertainty, it is crucial that residency programs find alternative learning opportunities and deploy pre-designed, dynamic operational strategies to ensure high quality surgical services while optimizing resident safety and wellbeing. The COVID-19 crisis was a natural call for the essential need to add another dimension to residency competencies, which is Crisis-based learning and practice. Times of public health crisis are opportunities to reflect on the medical practice from an interdisciplinary and interprofessional perspective and train the residents to function as part of a larger, globally responsible team. It also calls upon adopting innovative instructional and learning strategies such as utilizing digital and online learning tools to complement learning. A holistic approach to the crisis was taken by the surgical residency program at the University of Illinois in Chicago, which addressed the issue from a resident, hospital, and public health standpoints. An operational strategy was introduced to optimize resident safety, maximize learning opportunities, support other non-surgical services, and promote online teaching and learning. This strategy is meant to serve as a dynamic reference for surgical residency programs and as an infrastructure for dealing with this and any upcoming healthcare crises in an efficient and resident-centered way.