Nonsteroidal anti-inflammatory drug-induced small bowel strictures (diaphragm disease) - an under-recognized cause of small bowel obstruction.

BACKGROUND: Small bowel obstruction is a major source of morbidity and mortality that carries a significant economic burden. Recurrent small bowel obstruction may be secondary to circumferential strictures (small bowel diaphragm disease), an under-recognized entity secondary to long-term nonsteroidal anti-inflammatory drug (NSAID) use. We aimed to describe the sensitivity of preoperative computed tomography (CT) enterography in patients with surgically treated small bowel diaphragm disease. METHODS: We retrospectively reviewed adult patients who underwent elective small bowel resection for small bowel obstruction performed by a single minimally invasive surgeon between 2010 and 2023. Patient history, radiographic, endoscopic, operative, and pathology reports were reviewed for reference to NSAID use, small bowel strictures, diaphragms, and enteropathy. Exclusion criteria were prior radiation, inflammatory bowel disease, malignancy, adhesive disease, and anastomotic strictures. RESULTS: A total of 225 patients were identified, 22 (10%) of whom met the inclusion criteria. The mean age was 60.7 years (range 29-78), with 15 women (68%). All patients underwent minimally invasive small bowel resection for obstruction with histopathologic evidence of stricture without evidence of transmural inflammation, granuloma, or dysplasia and confirmed NSAID use (n = 22, 100%). Anemia was present in 36% (n = 8). Preoperative CT or magnetic resonance (MR) enterography was performed in 18 patients (82%), of which stricturing was reported in 13 (72%). Intraoperatively, palpation identified strictures in all patients. CONCLUSION: NSAID-induced small bowel injury is an under-recognized condition that, in severe cases, can present as small bowel obstruction. Surgeons should consider diaphragm disease in patients with obstruction and NSAID use, in which preoperative CT or MR enterography may be useful but cannot rule out disease.

Failed recovery after pancreatoduodenectomy: A significant problem even without surgical complications.

BACKGROUND: The absence of surgical complications has traditionally been used to define successful recovery after pancreas surgery. However, patient-reported outcome measures as metrics of a challenging recovery may be superior to objective morbidity. This study aims to evaluate the use of patient-reported outcomes in assessing recovery after pancreas surgery. METHODS: Patients scheduled for pancreatoduodenectomy were prospectively enrolled between 2016 to 2018. Patient-reported outcomes were collected using the linear analog self-assessment questionnaire preoperatively and on postoperative days 2, 7, 14, 30, and monthly until 6 months. Patients were also asked if they felt fully recovered at 30 days and 6 months. Thirty-day surgical morbidity was prospectively assessed, and the comprehensive complication index at 30 days was used to categorize morbidity as major or multiple minor complications (comprehensive complication index ≥26.2) vs uncomplicated (comprehensive complication index <26.2). Clinically significant International Study Group Pancreas Surgery Grade B and C pancreatic fistulas and delayed gastric emptying were reported. χ2 and Kruskal-Wallis tests were used to assess associations with recovery by 6 months and quality of life throughout the postoperative period. RESULTS: Of 116 patients who met inclusion criteria and were enrolled, 32 (28%) had major or multiple minor complications (comprehensive complication index ≥26.2). Overall, fewer than 1 in 10 patients (7%) reported feeling fully recovered at 30 days postoperatively, whereas 55% reported feeling fully recovered at 6 months. Of patients suffering major morbidity, 62% did not recover by 6 months, whereas 38% of those in the uncomplicated group reported not being recovered at 6 months (P = .03). Patients who experienced delayed gastric emptying reported low quality-of-life scores at 1 month (P = .04) compared to those with no delayed gastric emptying, but this did not persist at 6 months (P = .80). Postoperative pancreatic fistula was not associated with quality of life at 1 or 6 months (both P > .05). In the uncomplicated patients, age, sex, surgical approach, and cancer status were not associated with failed recovery at 6 months (all P > .05), and healthier patients (American Society of Anesthesiologists 1-2) were less likely to report complete recovery (42% vs 69% American Society of Anesthesiologists 3-4, P = .04). With the exception of higher preoperative pain scores (mean 2.3 [standard deviation 2.4] among patients not fully recovered at 6 months vs 1.6 [2.2] among those fully recovered, P = .04), preoperative patient-reported outcomes were not associated with failed recovery at 6 months (all P > .05). However, lower 30-day quality of life, social activity, pain, and fatigue scores were associated with incomplete recovery at 6 months. CONCLUSION: More than 1 in 3 patients with an uncomplicated course do not feel fully recovered from pancreas surgery at 6 months; the presence of surgical complications did not universally correspond with recovery failure. In patients with complications, delayed gastric emptying appears to drive quality of life more significantly than postoperative pancreatic fistula. In patients with uncomplicated recovery, healthier patients were less likely to report full recovery at 6 months. Thirty-day patient-reported outcomes may be able to identify patients who are at risk of incomplete long-term recovery.

Comparison of short- and long-term postoperative occurrences after robotic single-incision cholecystectomy versus multiport laparoscopic cholecystectomy.

BACKGROUND: Long-term outcomes of SIRC are not well established. Furthermore, SIRC is only now being considered more frequently for patients with independent risk factors for PSH, such as obesity. As such, the paucity of data on longer-term post-surgical outcomes of SIRC is particularly notable as it pertains to obese patients. METHODS: All patients undergoing cholecystectomy performed by two surgeons at our institution from 2008-2018 were reviewed. Our inclusion criteria were patients who underwent SIRC or multiport laparoscopic cholecystectomy (MPLC) and had at least one month of postoperative follow-up. Patients who underwent additional procedures at the time of cholecystectomy were excluded. Our outcomes of interest were the 30-day POC rate and the long-term PSH rate. Analysis was conducted on an intention-to-treat basis, using logistic regression analysis for POC and time-to-event analysis for PSH. RESULTS: We examined 584 patients who underwent either SIRC (51%) or MPLC (49%). Of the 296 patients who underwent SIRC, 15 (5%) developed a POC and 23 (8%) developed a PSH. Of the 288 patients who underwent MPLC, 11 (4%) developed a POC, and 28 (10%) developed a PSH. Procedure group and obesity was not associated with the risk of POC (p = 0.29, p = 0.21, respectively). Procedure group was not associated with an increased risk of PSH (p = 0.29). Obese patients, however, were 1.94 times more likely to develop PSH compared to non-obese patients overall (p = 0.02). CONCLUSIONS: There is no statistically significant difference in POC and PSH rate following SIRC when compared with MPLC in patients in the same BMI group. Male gender and prior abdominal surgery are risk factors for POC, while advancing age and obesity are risk factors for PSH.

The effect of pre-operative diagnosis on patient reported outcomes in patients undergoing colorectal operations: A prospective study.

INTRODUCTION: Patient Reported Outcomes (PROs) capture peri-operative fatigue, pain, and quality of life and influence outcomes in gastrointestinal surgery. We compared peri-operative PROs in patients undergoing colorectal operations for neoplastic versus non-neoplastic processes. METHODS: Patients undergoing colectomy were enrolled prospectively. Demographics and PROs were gathered preoperatively and on post-operative day (POD) 2, 7, 14, and 30 using the validated Linear Analog Self-Assessment (LASA). Severe pain was defined as pain ≥5, severe fatigue as ≥7, a quality of life deficit as QOL ≤5. RESULTS: We included 192 patients, median age 54 years, 44% female, 88 (46%) for neoplasia. Morbidity was 38%, mortality 3%. Pre-operatively, non-neoplasia patients reported significantly more pain, fatigue, and QOL deficits than neoplasia patients. Severe pain at POD 2 was a positive predictor for complications (p-value< 0.05). CONCLUSION: In patients undergoing colorectal surgery, diagnosis influences peri-operative PROs; early severe pain and fatigue may predict complications.

Faculty Diversity at Academic Surgical Meetings-Opportunity for Action?

BACKGROUND: The American Surgical Association delineated deficiencies of diversity, equity, and inclusion within academic surgery. Opportunities to increase diversity are membership in surgical societies and leadership development. We hypothesized that surgical society meetings represent additional opportunities, using gender diversity as an example. METHODS: Published programs from annual meetings of three large surgical societies were reviewed. Participants' gender was classified by first name. Online search was used for equivocal names. We used JMP Pro 14.1.0 for univariate and multivariate logistic regression. RESULTS: During six meetings (2016-2018), 415 sessions with 4078 participants were included, 61% educational panels with invited faculty and 39% abstract sessions. Across all meetings, 32% of abstracts were presented by women, 22% of panel chairs or invited faculty were women. Fifty-four percent of male meeting participants were invited by their societies as moderator or speaker, and 41% of female participants were invited faculty. Fifty-nine percent of all panel chairs had no woman participant. In both univariate and multivariate regression, women had more than threefold the odds of presenting an abstract than presenting on a panel (p < 0.0001). Women were three times more likely to present in a session that was co-chaired by a woman (< 0.0001). CONCLUSIONS: One in three abstract presenters in national surgery meetings was a woman, demonstrating engagement in the societies. Historically, men are more likely invited as faculty than women. The presence of a woman co-chair on a panel correlated with increased female participation. Similar scenarios may apply to other underrepresented groups.

Prospective longitudinal cohort study of patient recovery after major gastrointestinal surgery: is there a difference between minimally invasive and open approaches?

BACKGROUND: Surgeons use the absence of post-operative complications to define recovery while patients define recovery as return to normal function. We aimed to better define the recovery process after minimally invasive surgery (MIS) and open gastrointestinal surgery. METHODS: Patients scheduled for open or MIS pancreaticoduodenectomy, esophagectomy, colectomy, and proctectomy were prospectively enrolled. Patient-reported outcomes (PROs) were collected using validated PROMIS and LASA scales pre-operatively, on post-operative days 2, 7, 14, 30, and monthly until 6 months. Patients were also asked if they felt fully recovered. Descriptive statistics and area under the curve (AUC) were used to compare approaches. Multivariable mixed-effects repeated measures models and logistic regression were used to control for covariates. RESULTS: 340 patients met inclusion criteria (158 open and 182 MIS). Median age was 60 years with 44% women. The PRO showed improved post-operative QOL scores in MIS compared to open on all measures by AUC. None of these difference persisted at 6-months. After adjusting for covariates, MIS had higher overall QOL scores at day 14 (Estimate + 0.58, p = 0.02) and 30 (+ 0.56, p = 0.03). Differences did not persist at 3 and 6 months (both p > 0.05). At 1, 3, and 6 months, 20%, 47%, and 61% of patients reported feeling completely recovered. On adjusted analysis there was no difference in odds of complete recovery in MIS at 1 (OR 1.07 [95% CI 0.53-2.14] and 3 months (1.12 [0.63-2.01]) compared to open. MIS patients were more likely to report complete recovery at 6 months (1.87 [1.05-3.33]). CONCLUSION: MIS patients reported improved PRO on selected QOL measures early in the recovery period compared to open. There was no difference in long-term QOL data between MIS and open patients. Two-thirds (61%) of patients reported being fully recovered at 6 months with MIS patients being more likely to report a complete recovery.

Laparoscopic celiac plexus ganglioneuroma resection: A video case report.

BACKGROUND: Ganglioneuromas are mature, benign neurogenic tumors that arise from neural crest-derived cells. Given the rarity of these tumors and their often close proximity to major vessels, there is a paucity of reports in the literature of minimally invasive resections of ganglioneuromas near the celiac plexus. We report a case of laparoscopic resection of a retroperitoneal ganglioneuroma adhering to the portal vein and celiac axis. CASE SUMMARY: A 27-year-old female was referred to our medical center with a symptomatic retroperitoneal mass. Using high quality preoperative imaging and biopsies, we confirmed the diagnosis of a 4 cm ganglioneuroma abutting the celiac axis, portal vein, and the caudate lobe of the liver. We elected for laparoscopic resection after careful preoperative planning and discussions with the patient. Laparoscopy enhanced visualization of the tumor and its relationships to surrounding vital structures for optimal dissection. Ultrasonic energy devices and adjusting liver retraction to allow for manipulation of the mass facilitated a safe and effective resection in a tight space. There were no operative complications and the patient was discharged home on postoperative day 1 with no residual symptoms upon follow-up. With sufficient experience in laparoscopic surgery and preoperative imaging and diagnostics, a minimally invasive approach for removing this celiac plexus ganglioneuroma was successful. CONCLUSION: In carefully selected patients, laparoscopic ganglioneuroma resection is appropriate, reducing postoperative morbidity, hospital length of stay, and recovery time.

Is functional gallbladder disease truly increasing? Results from the Rochester Epidemiology Project.

INTRODUCTION: Reports from US administrative databases showed an increase in cholecystectomy rate for functional gallbladder disorder (FGBD), a disease is not well recognized elsewhere. We aimed to identify the incidence and cholecystectomy rate for FGBD in an epidemiologically well-defined and prospectively studied population and compare results to published data. METHODS: After IRB approval, we extracted data from the NIH funded Rochester Epidemiology Project. We used ICD-9 codes (575.8) and (575.9) to identify patients with FGBD from 2000 to 2014. RESULTS: Between 2000 and 2014 we identified 253 patients with specified ICD-9 codes and no stones among a population of 135,000. Based on their medical records, 24 patients had confirmed FGBD, the incidence was 1.77/10,000 and cholecystectomy rate was for these patients was 70%. CONCLUSION: The incidence of FGBD was much lower than State data with similar cholecystectomy rate. Additional investigation may be needed to understand if cholecystectomy rate is truly increasing.

How much pain relief do patients expect after cholecystectomy?

BACKGROUND: Cholecystectomy is a common operation, increasingly performed, in the USA, for "functional gall bladder disorder" (FGBD). Outcomes of these surgeries are uncertain. In planning a study of FGBD, we needed to define the best outcome measures. METHODS: We sought the opinions of patients (52 with FGBD and 100 with stones for comparison) coming to cholecystectomy. They were asked to respond in four ways about the minimum benefit they would count as "success." RESULTS: We found that most patients do not expect cholecystectomy to relieve their pain-related disability completely, regardless of the presence or absence of stones. CONCLUSIONS: Future studies of the success of surgery should use patient-centered outcome assessments, such as PGIC (patient's global impression of change), in addition to objective measures of the impact of treatment on key symptoms, such as pain.

Validation of a Novel Inverted Peg Transfer Task: Advancing Beyond the Regular Peg Transfer Task for Surgical Simulation-Based Assessment.

OBJECTIVE: To evaluate the validity of a novel inverted peg transfer (iPT) task for assessing laparoscopic skills of novices and experts and compare iPT to the regular PT (rPT) task to ensure surgical trainee acquisition of an adequate advanced laparoscopic skills level for safe laparoscopic practice in the operating room. DESIGN: Prospective crossover study. SETTING: Multidisciplinary simulation center and motion analysis laboratory, Mayo Clinic. PARTICIPANTS: Novices were medical students and surgical interns without laparoscopic experience. Experts were surgeons with at least 3 years of experience in laparoscopic surgery. METHODS: This was the first exposure to iPT for both groups. Completion time and performance metrics were recorded. A scoring rubric was used to calculate a normalized performance score between 0 and 100. Wilcoxon rank sum and Mann-Whitney tests were performed with α = 0.05. Receiver-operating characteristic curves were graphed for the 2 task scores to assess the tasks' sensitivity and specificity in differentiating laparoscopic experience level. MAIN OUTCOME MEASURES: Performance measures of completion time, transferred triangles, dropped triangles (errors), and the overall performance score on both tasks between- and within-subjects (i.e., novices and experts). RESULTS: Thirty-six novices and eight experts participated. Both experts and novices had longer completion time and lower scores during iPT than rPT (p < 0.05). Within iPT, novice completion times were 144 seconds longer (p = 0.04), and performance score was 35 points lower than experts (p < 0.01). No differences between novices and experts were observed for completion time or performance scores (p > 0.05) for rPT. The iPT scores had a higher sensitivity and specificity than the rPT (area under the receiver-operating characteristic curve: iPT = 0.91; rPT = 0.69). CONCLUSIONS: iPT is a valid assessment of advanced laparoscopic skills for surgical trainees with higher specificity and sensitivity than rPT. As advanced minimally invasive surgery becomes more common, it is important that tasks such as iPT be included in surgical simulation curricula and training assessment.

Gender disparities in the utilization of laparoscopic groin hernia repair.

BACKGROUND: Clinical treatment guidelines have suggested that laparoscopic hernia repair should be the preferred approach in both men and women with bilateral or recurrent elective groin hernias. Anecdotal evidence suggests, however, that women are less likely to undergo a laparoscopic repair than men, and therefore, we aimed to delineate if these disparities persisted after controlling for patient factors and comorbidities. MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Project data were abstracted for all elective groin hernia repairs between 2005 and 2014. Univariate analysis was used to compare rates of laparoscopic surgery between men and women. Multivariable analysis was performed, controlling for patient demographics, preoperative comorbidities, and year of surgery. RESULTS: Over the 10-y period, 141,490 patients underwent elective groin hernia repair, of which 13,325 were women (9.4%). The rate of general anesthesia utilization was high in both men (81.3%) and women (77.2%) with 75.1% of open repairs being performed under general anesthesia. Overall, 20.2% of women underwent laparoscopic repair compared with 28.0% of men (P < 0.01). Women tended to be older, had a lesser body mass index, and slightly greater American Anesthesia Association (all P < 0.05). On multivariable regression, women had decreased odds of undergoing a laparoscopic approach compared with men (odds ratio: 0.70; 95% confidence interval, 0.67-0.73, P < 0.01). CONCLUSIONS: In the elective setting, women were less likely to undergo laparoscopic repair of groin hernias than men. Although we are unable to ascertain underlying causes for these gender disparities, these data suggest that there remains a disparity in the management of groin hernias in women.

Intraoperative "Micro Breaks" With Targeted Stretching Enhance Surgeon Physical Function and Mental Focus: A Multicenter Cohort Study.

OBJECTIVE: The aim of this study was to investigate the effect of intraoperative targeted stretching micro breaks (TSMBs) on the experienced pain and fatigue, physical functions, and mental focus of surgeons. BACKGROUND: Surgeons are routinely subject to mental and physical stresses through the course of their work in the operating room. One of the factors most contributory to the shortening of a surgeon's career is work-related pain and its effects on patient safety and personal relationships. METHODS: Surgeons and operating room staff from 4 medical centers rated pain/fatigue, physical, and mental performance using validated scales during 2 operative days: 1 day without implementing TSMB, the other including standardized (1.5 to 2 minutes) guided TSMB at appropriate 20 to 40-minute intervals throughout each case. Case type and duration were recorded as were surgeon pain data before and after each procedure and at the end of the surgical day. Individual body part pre/postdiscomfort difference was modeled, controlling for clinical center. Random coefficient mixed models accounted for surgeon variability. RESULTS: Sixty-six participants (69% men, 31% women; mean 47 years) completed 193 "non-TSMB" and 148 "TSMB" procedures. Forty-seven percent of surgeons were concerned that musculoskeletal pain may shorten their career. TSMB improved surgeon postprocedure pain scores in the neck, lower back, shoulders, upper back, wrists/hands, knees, and ankles. Operative duration did not differ (P> 0.05). Improved pain scores with TSMB were statistically equivalent (P > 0.05) for laparoscopic and open procedures. Surgeons perceived improvements in physical performance (57%) and mental focus (38%); 87% of respondents planned to continue TSMB. CONCLUSIONS: Many surgeons are concerned about career-ending or limiting musculoskeletal pain. Intraoperative TSMB may represent a practical, effective means to reduce surgeon pain, enhance performance, and increase mental focus without extending operative time.

Effects of carbon dioxide insufflation during direct cholangioscopy on biliary pressures and vital parameters: a pilot study in porcine models.

BACKGROUND AND AIMS: Direct per-oral cholangioscopy allows endoscopic visualization of the biliary tract. Insufflation with carbon dioxide (CO2) is an alternative to saline solution irrigation during direct cholangioscopy. There are no data on maximal CO2 insufflation in direct cholangioscopy without causing biliary barotrauma or fatal gas embolism. We aimed to evaluate the safety of increasing CO2 insufflation in direct cholangioscopy without causing biliary barotrauma or fatal gas embolism. METHODS: This was an in vivo animal study. Four domestic pigs, under general endotracheal anesthesia, were used. The first animal was used to validate the feasibility of direct cholangioscopy and biliary pressure measurements, after which all animals underwent laparotomy, insertion of a pressure transducer in the cystic duct, and direct transpapillary placement of the cholangioscope. The common bile duct (CBD) and cystic duct were ligated to contain the instilled gas and exclusively expose the biliary tree. Insufflation of CO2 started at 200 mL/min and was continuously increased until there was evidence of bile duct rupture (as measured by a drop in intraductal pressures) or instability of vital signs (hypotension, bradycardia, bradypnea, O2 desaturation). Necropsy was performed on all animals to assess the liver and biliary system for evidence of barotrauma. RESULTS: CO2 was insufflated up to 8 L/min without causing bile duct rupture or instability in vital signs despite increasing CBD pressure with insufflation. There was significant correlation between CO2 flow with partial pressure of CO2 in arterial blood (PaCO2) (coefficient, 0.96-1.00; P < .01) and end tidal expired CO2 (EtCO2) (coefficient, 0.94-1.00; P < .01). However, the pulse rate, respiratory rate, arterial blood pressure, and O2 did not correlate with the amount of CO2 flow. There was no evidence of hepatic or biliary barotrauma on necropsy. CONCLUSIONS: This pilot experience in porcine models suggests that CO2 insufflation is safe for direct cholangioscopy and does not result in biliary barotrauma or vital signs instability.

The use of patient factors to improve the prediction of operative duration using laparoscopic cholecystectomy.

BACKGROUND: Reliable prediction of operative duration is essential for improving patient and care team satisfaction, optimizing resource utilization and reducing cost. Current operative scheduling systems are unreliable and contribute to costly over- and underestimation of operative time. We hypothesized that the inclusion of patient-specific factors would improve the accuracy in predicting operative duration. METHODS: We reviewed all elective laparoscopic cholecystectomies performed at a single institution between 01/2007 and 06/2013. Concurrent procedures were excluded. Univariate analysis evaluated the effect of age, gender, BMI, ASA, laboratory values, smoking, and comorbidities on operative duration. Multivariable linear regression models were constructed using the significant factors (p < 0.05). The patient factors model was compared to the traditional surgical scheduling system estimates, which uses historical surgeon-specific and procedure-specific operative duration. External validation was done using the ACS-NSQIP database (n = 11,842). RESULTS: A total of 1801 laparoscopic cholecystectomy patients met inclusion criteria. Female sex was associated with reduced operative duration (-7.5 min, p < 0.001 vs. male sex) while increasing BMI (+5.1 min BMI 25-29.9, +6.9 min BMI 30-34.9, +10.4 min BMI 35-39.9, +17.0 min BMI 40 + , all p < 0.05 vs. normal BMI), increasing ASA (+7.4 min ASA III, +38.3 min ASA IV, all p < 0.01 vs. ASA I), and elevated liver function tests (+7.9 min, p < 0.01 vs. normal) were predictive of increased operative duration on univariate analysis. A model was then constructed using these predictive factors. The traditional surgical scheduling system was poorly predictive of actual operative duration (R 2 = 0.001) compared to the patient factors model (R 2 = 0.08). The model remained predictive on external validation (R 2 = 0.14).The addition of surgeon as a variable in the institutional model further improved predictive ability of the model (R 2 = 0.18). CONCLUSION: The use of routinely available pre-operative patient factors improves the prediction of operative duration during cholecystectomy.

Single-incision laparoscopic resection of small bowel tumours: Making it easier for patient and surgeon.

BACKGROUND: Patients with small bowel tumours frequently require surgical intervention. Minimally invasive techniques require advanced skills and may not be offered to many patients. We present a laparoscopic single-incision technique that is minimally invasive without requiring intracorporeal anastomosis. MATERIALS AND METHODS: The cases of all patients with laparoscopic small bowel resections performed by one surgeon from 2008 to 2012 were reviewed. A single-port technique was introduced after it became available at our institution in 2009. Before that, conventional laparoscopy (LAP) was performed with extension of the periumbilical incision to allow externalisation of the bowel. RESULTS: Totally, 10 patients were identified who underwent laparoscopic resection of small bowel tumours: 9 in the small bowel and 1 in the terminal ileum near the cecum. Three tumours were resected before 2009 using LAP, and 7 were resected using the single-port technique. Median length of stay was 3 days, median follow-up was 16.5 months, and no patients had a recurrence. Operative time, post-operative complications, hospital length of stay, and narcotic utilisation were similar between the single-port and traditional laparoscopic groups. CONCLUSION: Laparoscopic removal of small bowel tumours with a small, periumbilical trocar incision is both effective and feasible without advanced technical skill.

Patient-Reported Outcomes after Laparoscopic Ventral Hernia Repair.

Approximately 350,000 ventral hernia repairs are performed in the United States each year. Patients expect fast recovery after laparoscopic ventral hernia repair (LVHR) and undisturbed postoperative quality of life (QOL). We examined the utility of a brief, validated 10-point Linear Analog Self-Assessment coupled with the Visual Analog Scale pain scale to discern risk factors for decreased postoperative QOL. Between January 2011 and May 2013, we prospectively assessed patient-reported outcomes for patients who underwent LVHR. Visual Analog Scale pain scale and Linear Analog Self-Assessment items were recorded preoperatively and postoperatively at four hours, one day, and seven days. Eighteen patients were included, 11 were female (61%) and 8 > 60 years old (44%). Patient-reported fatigue increased clinically and statistically from baseline over time (P = 0.007) as did pain (P < 0.001). There was a statistically significant difference in QOL scores over time by gender with women reporting worse scores than men (P = 0.001). In conclusion, our study detected significant changes from baseline in both fatigue and pain over the seven days after LVHR. Age is associated with postoperative differences in physical well-being. Gender is associated with differences in postoperative course in QOL and physical well-being.

Impact of patient factors on operative duration during laparoscopic cholecystectomy: evaluation from the National Surgical Quality Improvement Program database.

BACKGROUND: Patient factors impact laparoscopic cholecystectomy (LC) difficulty, specifically operative duration. This study quantifies the impact of patient factors on LC duration. METHODS: The national surgery database (American College of Surgeons National Surgical Quality Improvement Program) was reviewed for all elective LC for biliary colic from 2005 to 2013. Multivariate general linear model and logistic regression were used to evaluate patient factors as predictors of operative duration greater than 60 minutes, adjusted for resident involvement and cholangiography. RESULTS: A total of 24,099 LC met inclusion criteria. Regression analysis found procedure duration greater than 60 minutes was less likely for patients age greater than 40 and less than 30 (P < .001) and more likely for men (P < .05), body mass index (BMI) greater than 30 compared with BMI 18.5 to 24.9 (P < .05), abnormal liver function test (LFT) (P < .05), and higher ASA class (P < .05). Smoking, cardiovascular disease, chronic obstructive pulmonary disease, diabetes, and abnormal white blood cell count were not significant predictors. CONCLUSIONS: Higher BMI, younger age, male gender, higher ASA, and abnormal LFTs are possible predictors of prolonged LC duration and can aid in operating room scheduling and utilization.

Innovative gastric endoscopic muscle biopsy to identify all cell types, including myenteric neurons and interstitial cells of Cajal in patients with idiopathic gastroparesis: a feasibility study (with video).

BACKGROUND AND AIMS: The pathophysiology of some GI neuromuscular diseases remains largely unknown. This is in part due to the inability to obtain ample deep gastric wall biopsies that include the intermuscular layer of the muscularis propria (MP) to evaluate the enteric nervous system, interstitial cells of Cajal (ICCs), and related cells. We report on a novel technique for gastric endoscopic muscle biopsy (gEMB). METHODS: Patients with idiopathic gastroparesis were prospectively enrolled in a feasibility study by using a novel "no hole" gEMB. Main outcome measures were technical success, adverse events, and histologic confirmation of the intermuscular layer, including myenteric neurons and ICC. The gEMB was a double resection clip-assist technique. A site was identified on the anterior wall of the gastric body as recommended by the International Working Group on histologic techniques. EMR was performed to unroof and expose the underlying MP. The exposed MP was then retracted into the cap of an over-the-scope clip. The clip was deployed, and the pseudopolyp of MP created was resected. This resulted in a no-hole gEMB. RESULTS: Three patients with idiopathic gastroparesis underwent gEMB. Patients had severe delayed gastric emptying with a mean (± standard deviation [SD]) of 49 ± 16.8% of retained gastric contents at 4 hours. They had no history of gastric or small-bowel surgery and did not use steroids or other immunosuppressive drugs. The gEMB procedure was successfully performed, with no procedural adverse events. Postprocedural abdominal pain was controlled with nonsteroidal anti-inflammatory agents and opioid analgesics. Mean length of resected MP was 10.3 ± 1.5 mm. Mean procedure time was 25.7 ± 6 minutes. Hematoxylin and eosin (H&E) staining of tissue samples confirmed the presence of both inner circular and outer longitudinal muscle, as well as the intermuscular layer. H&E staining showed reduced myenteric ganglia in 1 patient. In 2 patients, specialized immunohistochemistry was performed, which showed a marked decrease in myenteric neurons as delineated by an antibody to protein gene product 9.5 and a severe decrease in ICC levels across the muscle layers. At 1 month follow-up, upper endoscopy showed a well-healed scar in 2 patients and minimal ulceration with a retained clip in 1 patient. CT of the abdomen confirmed the integrity of the gastric wall in all patients. Because of lack of an immune infiltrate in the resected samples, patients were not considered suitable for immunosuppressive or steroid therapy. CONCLUSIONS: gEMB is feasible and easy to perform, with acquisition of tissue close to surgical samples to identify myenteric ganglia, ICCs, and multiple cell types. The ability to perform gEMB represents a paradigm shift in endoscopic tissue diagnosis of gastric neuromuscular pathologies.