Hidden Port Site Incision for Robotic Foregut and Hepatopancreatobiliary Operation: A Cosmetically Superior Approach.

While the widespread adoption of minimally invasive surgery has led to improved cosmesis for abdominal operations, visible scars on the abdomen may still have a negative psychosocial impact on patients, especially for those with poor healing. We have developed a cosmetically favorable, safe, and easily adaptable robotic technique for common foregut and hepatopancreatobiliary procedures with hidden incisions at the level of the pubic hairline to minimize visibility. This technique monopolizes on the unique advantages of the robotic platform to maximize cosmetic outcome while maintaining clinical outcomes and technical ease. Herein we describe how to accomplish this technique for three different procedures: anti-reflux operation, distal pancreatectomy, and small bowel resection. In our experience, this technique of hiding port site incisions at the level of the pubic hairline can be easily adopted for improved patient quality of life and cosmesis. We especially recommend this technique in patients with a history of hypertrophic or keloid scars.

IDEAL Phase 2a Results: Posterior Rectus Sheath Flap for Hiatal Augmentation in Complex Paraesophageal Hernias.

OBJECTIVE: To report the developmental phase results of posterior rectus sheath hiatal flap augmentation (PoRSHA), a promising surgical innovation for large and recurrent paraesophageal hernias. BACKGROUND: Durable hernia repair for large paraesophageal hernias continues to be a surgical challenge. PoRSHA addresses the challenges of current and historical approaches to complex paraesophageal hernias and demonstrates significant promise as a successful alternative approach. METHODS: Using the IDEAL framework, we outline the technical modifications made over the first 27 consecutive cases using PoRSHA. Outcomes measured included hernia recurrence on routine imaging at 6 months and 2 years, development of a postoperative abdominal wall eventration and incidence of solid food dysphagia. RESULTS: Twenty-seven patients at our single institution with type III (n=12), type IV (n=7), or recurrent (n=8) paraesophageal hernias underwent PoRSHA. Surgery was safely and successfully carried out in all cases. Stability of the technique was reached after 16 cases, resulting in 4 main repair types. At an average follow-up of 11 months, we observed no radiologic recurrences, no abdominal eventrations or hernias at the donor site, and 1 patient with occasional solid food dysphagia that resolved with dilation. CONCLUSIONS: PoRSHA can not only be safely added to conventional hiatal hernia repair with appropriate training but also demonstrates excellent short-term outcomes. While the long-term durability with 5-year follow-up is still needed, here we provide cautious optimism that PoRSHA may represent a novel solution to the long-standing high recurrence rates observed with current complex PEH repair.

Supervised weight loss requirements disproportionately affect Black patients seeking weight loss surgery.

BACKGROUND: We use our high-volume institutional experience with a majority Black population to examine the role of supervised weight loss (SWL) requirements perpetuating disparities in bariatric surgery. OBJECTIVE: To determine if there are racial disparities in the required amount of supervised weight loss prior to approval for bariatric surgery. SETTING: University hospital. METHODS: A retrospective review was conducted of all patients seen at our institution's bariatric surgery clinic in 2018. Odds of undergoing surgery within 1 year and mean number of SWL requirements were determined using descriptive statistics for Black patients as compared with non-Hispanic White patients. Finally, a logistic model was constructed to examine likelihood of undergoing an operation within 1 year for patients of varying SWL requirements. RESULTS: A total of 335 patients were included (75% Black, 25% White). Within 1 year, 37% of Black patients compared with 53% of White patients had undergone an operation (relative risk .7, P = .01). Mean insurance-mandated SWL sessions were significantly higher for Black patients (3.6 ± 2.8) versus non-Hispanic White patients (2.2 ± 2.7) (P < .01). Mean program-mandated SWL sessions were also significantly higher for Black patients (2.5 ± 2.6) versus non-Hispanic White patients (.8 ± 1.8) (P < .01). Increasing SWL requirements significantly reduced the odds of undergoing surgery at 1 year within the entire cohort (odds ratio .86, P < .01). CONCLUSIONS: Black patients are disproportionally affected by SWL requirements, which strongly correlate with decreased likelihood of undergoing a bariatric operation as compared with their White counterparts. Even after overcoming barriers to see a bariatric surgery provider, Black patients still face disproportionally more barriers to surgery. Bariatric centers must be sensitive to the effect of SWL requirements, as it is negatively associated with the likelihood of a patient receiving a bariatric operation.

Autologous Posterior Rectus Sheath as a Vascularized Onlay Flap: a Novel Approach to Hiatal Hernia Repair.

INTRODUCTION: Complex and recurrent paraesophageal hernia repairs are a challenge for surgeons due to their high recurrence rates despite the use of various prosthetic and suturing techniques. METHODS: Here we describe the use of vascularized fascia harvested from the posterior rectus sheath with peritoneum during robotic hiatal hernia repair in two patients with large complex diaphragmatic defects. RESULTS: Successful harvesting and onlay of the right posterior rectus sheath based on a falciform vascular pedicle was achieved robotically by rotating and securing the flap to the diaphragmatic hiatus as an onlay flap following cruroplasty of the hiatal defect. CONCLUSIONS: In patients with difficult to repair large paraesophageal hernias, we demonstrate a promising new technique to restore the dynamic hiatal complex with the tensile strength of autologous vascularized fascia and peritoneum.

What Is the Appropriate Use of Laparoscopy over Open Procedures in the Current COVID-19 Climate?

INTRODUCTION: Among surgeons worldwide, a concern with the use of minimally invasive techniques has been raised due to a proposed risk of viral transmission of the coronavirus disease of 2019 (COVID-19) with the creation of pneumoperitoneum. Due to this proposed concern, we sought to collect the available data and evaluate the use of laparoscopy and the risk of COVID-19 transmission. METHODS: A literature review of viral transmission in surgery and of the available literature regarding the transmission of the COVID-19 virus was performed. We additionally reviewed surgical society guidelines and recommendations regarding surgery during this pandemic. RESULTS: Few studies have been performed on viral transmission during surgery, but to date there is no study that demonstrates or can suggest the ability for a virus to be transmitted during surgical treatment whether open or laparoscopic. There is no societal consensus on limiting or restricting laparoscopic or robotic surgery; however, there is expert consensus on the modification of standard practices to minimize any risk of transmission. CONCLUSIONS: Despite very little evidence to support viral transmission through laparoscopic or open approaches, we recommend making modifications to surgical practice such as the use of smoke evacuation and minimizing energy device use among other measures to minimize operative staff exposure to aerosolized particles.

Weight loss and co-morbidity resolution between different races and ethnicities after gastric bypass.

BACKGROUND: Several studies have demonstrated that minorities and Hispanic ethnicities have disproportionally greater burden of morbid obesity in the United States. However, the majority of bariatric procedures are performed in the non-Hispanic white population. OBJECTIVES: The objective of this study was to investigate the weight loss and remission of obesity-related co-morbidities based on race and ethnicity. SETTING: The Longitudinal Assessment of Bariatric Surgery prospective, multicenter, observational study was used to collect patients from 10 different health centers across the United States. METHODS: Retrospective analysis of a prospective, multicenter, observational study over a 5-year follow-up. RESULTS: All patients who underwent primary gastric bypass and provided racial/ethnic information were included in the study (n = 1695). Regardless of race or ethnicity, total weight loss was maintained over a 5-year follow-up, which included 87% of the original cohort. However, whites had on average 1.94% higher adjusted total weight loss compared with blacks (P < .0001). After adjusting for confounders there were no significant differences in resolution of co-morbidities, including diabetes. CONCLUSION: All patients regardless of race or ethnicity have significant and sustained total weight loss and resolution of co-morbidities after gastric bypass at 5-year follow-up.

Laparoscopic procedures in patients with cardiac ventricular assist devices.

BACKGROUND: Cardiac left ventricular assist device (LVAD) placement is a common therapy for heart failure. Non-cardiac surgical care of these patients can be complex given the need for anticoagulation, perioperative monitoring, comorbidities, and anatomical considerations due to the device itself. There are no guidelines or significant patient series reported to date for laparoscopic procedures in this population. We herein report the techniques and outcomes for commonly performed laparoscopic procedures in patients with LVADs at a high volume center. METHODS: From our database of patients with ventricular assist devices, we retrospectively identified patients who underwent laparoscopic abdominal surgery. Intraoperative and perioperative data were collected, including anticoagulation management, transfusions and complications. Techniques and preoperative considerations from the surgeons were also compiled and described. RESULTS: Of 374 patients that had placement of LVADs, 17 had an elective laparoscopic procedure: enteral access placement (n = 7), cholecystectomy (n = 6), hernia repair (n = 2), small bowel resection (n = 1) and splenectomy (n = 1). Preoperative evaluation routinely included radiologic imaging to evaluate driveline location. The most common abdominal entry technique was a periumbilical open Hasson technique (11/17). No cases were converted to open. Overall, the average blood loss was 132 ± 64 mL and the average operative time was 1.8 ± 0.3 h. Five of the 17 patients required intraoperative blood transfusion. No patients suffered perioperative thrombotic events or LVAD complications secondary to holding anticoagulation. No patients required interventions or reoperation for bleeding complications. There were no mortalities related to these procedures. CONCLUSIONS: Laparoscopic abdominal procedures are safe and feasible in patients with LVADs. Although special consideration for bleeding and thrombotic risks, placement of ports and perioperative management is required, the presence of a LVAD itself should not be considered a contraindication for laparoscopic surgery and may in fact be the preferred method for access in these patients.

Video review program enhances resident training in laparoscopic inguinal hernia: a randomized blinded controlled trial.

BACKGROUND: The purpose was to determine if a standardized video review program for residents improves operative performance. METHODS: Participation was offered to surgical residents rotating on a minimally invasive service. Residents were randomized to either the video review group or no video review group. Every participant in the video review group underwent video reviews with an attending surgeon for 30 min once weekly during their 1-month rotation. A blinded surgeon evaluated performance in the operating room using validated assessment tools. The amount of time the resident spent as primary surgeon was recorded. One-way analysis of variance was used to compare the video and no video review groups. Differences were considered statistically significant for p values < 0.05. RESULTS: Sixteen residents were randomized to the video review group (n = 8) or the no video review group (n = 8). Residents in the video review cohort significantly improved in creating a working space (p = 0.04), hernia sac reduction (p = 0.01), mesh placement (p = 0.01), knowledge of the procedure (p = 0.01), and overall competence (p = 0.02). Residents in the no video review group did not significantly improve in five of seven categories. The video review group significantly increased the time spent as primary surgeon (p = 0.02). CONCLUSION: Video review with a coach proved to be beneficial for residents when learning laparoscopic inguinal hernia repairs. We conclude that systematic video review is a good supplemental tool in resident surgical training.

Laparoscopic Antireflux Surgery: Importance of Patient's Selection and Preoperative Workup.

BACKGROUND: Laparoscopic antireflux surgery (LARS) is an excellent option for patients with symptoms refractory to medical treatment, for patients who have complications secondary to the use of proton pump inhibitors, and for those who do not want to take medications for a long period of time. HYPOTHESIS: We hypothesized that (1) LARS has excellent outcomes if a complete preoperative workup and proper patient selection are performed and (2) recurrent symptoms often are not due to failure of the fundoplication to control the pathologic reflux. PATIENTS AND METHODS: Every patient referred for antireflux surgery underwent a detailed symptomatic evaluation, barium swallow, esophagogastroduodenoscopy (EGD), high-resolution manometry (HRM), and pH monitoring. A fundoplication was performed in all of them. Data were analyzed to determine outcomes across 8 years. RESULTS: From 2008 to 2016, 176 patients with gastroesophageal reflux disease (GERD) underwent LARS. One hundred and thirty-four patients (76.1%) had a total fundoplication, 31 (17.6%) had an anterior partial fundoplication, and 11 (6.3%) had a posterior partial fundoplication. Thirty-nine patients (22.2%) referred persistent or recurrent symptoms after the procedure and underwent EGD, HRM, and pH monitoring. Abnormal reflux was documented in 5 patients (2.8%). Among these failures, 3 patients had a body mass index (BMI) ≥30 and 2 had ≥35. CONCLUSIONS: The results of this study showed that (1) laparoscopic fundoplication is an effective procedure for GERD; (2) patient's BMI can affect the outcome of a fundoplication; and (3) pH monitoring is important to establish if recurrent symptoms are secondary to failure of the operation.

Outcomes in patients with over 1-year follow-up after peroral endoscopic myotomy (POEM).

BACKGROUND: Peroral endoscopic myotomy (POEM) is a promising therapy in the treatment of achalasia. The study was designed to report outcomes, including quality of life, in patients with at least 1-year follow-up. METHODS: Patients from an institutional review board-approved protocol underwent POEM and were followed prospectively. Health-related quality of life was measured preoperatively and 1 year post-operatively using Short Form-36 Health Survey version 2 (SF-36v2). Comparisons were made with patients from a prospective database who underwent laparoscopic Heller myotomy (LHM) over the same period. Paired t tests were used to analyze all normally distributed data, while Wilcoxon signed-rank tests were used to analyze SF-36 data, as it does not follow a normal distribution. RESULTS: We analyzed 41 consecutive POEM patients with at least 1-year follow-up. Significant improvements in quality of life between baseline and 1 year were found in role limitations due to physical health (81.8 ± 25.8 vs. 65.9 ± 31.6, p = 0.01) and social functioning (83 ± 19.1 vs. 64.6 ± 31.3, p = 0.01). When compared to 24 patients who underwent LHM, there was no difference in average Eckardt scores (0.9 ± 1.6 vs. 1.0 ± 1.3, p > 0.05) or incidence of PPI use (43.5 vs. 47.5 %, p = 0.71). However, when looking at just type III patients, POEM patients had a higher remission rate (100 vs. 62.5 %) and significantly lower post-operative Eckardt scores at 1 year (1.1 vs. 3.1, p < 0.05). The average myotomy length of type III achalasia patients undergoing POEM was 18.6 cm (±6.9) compared to 10.3 cm (±1.0) in LHM patients (p < 0.01), which may have contributed to this difference. CONCLUSION: POEM provides a significant quality of life benefit at 1 year while having similar relief of dysphagia and post-operative PPI use compared to LHM. Type III achalasia patients may have better outcomes with POEM compared to LHM.

Importance of esophageal manometry and pH monitoring for the evaluation of otorhinolaryngologic (ENT) manifestations of GERD. A multicenter study.

BACKGROUND/AIMS: Patients with otorhinolaryngologic (ear, nose, and throat-ENT) symptoms attributed to gastroesophageal reflux disease (GERD) are usually treated with medication based on the findings of nasal endoscopy and laryngoscopy only. This study aims to determine sensitivity and specificity of symptoms, nasal endoscopy, and laryngoscopy for the diagnosis of GERD as compared to pH monitoring. METHODS: We studied 79 patients (mean age 53 years, 38 % males) in whom ENT symptoms were assumed to be secondary to GERD. All patients underwent a transnasal laryngoscopy by the ENT team and upper endoscopy and esophageal function tests by the surgical team. GERD was defined by a pathological pH monitoring. RESULTS: Pathologic reflux by pH monitoring was documented in 36 of the 79 patients (46 %), with a mean DeMeester score of 44. In 25 of the 36 patients (69 %), distal and proximal reflux was present. Among patients with negative pH monitoring, one patient was diagnosed with achalasia. ENT symptom sensitivity for globus, hoarseness and throat clearing was respectively 11, 58, and 33 %; specificity was respectively 77, 42, and 58 %. Positive predictive value for nasal endoscopy and laryngoscopy was 46 %. Among patients with positive pH monitoring, 13 (36 %) had a hypotensive lower esophageal sphincter (p < 0.01) and 27 (34 %) had abnormal peristalsis (p < 0.01). CONCLUSIONS: In conclusion, the results of this study showed that (a) ENT symptoms were unreliable for the diagnosis of GERD and (b) laryngoscopy had a low positive predictive value for the diagnosis of GERD. These data confirm the importance of esophageal manometry and pH monitoring in any patient with suspected ENT manifestations of GERD before starting empiric therapy with acid-reducing medications since pathologic reflux by pH monitoring was confirmed in less than half of the patients with suspected GERD.

This paper is the winner of an SFB Award in the Hospital Intern, Residency category: Peptide biomaterials raising adaptive immune responses in wound healing contexts.

Biomaterials used in the context of tissue engineering or wound repair are commonly designed to be "nonimmunogenic." However, previously it has been observed that self-assembled peptide nanofiber materials are noninflammatory despite their immunogenicity, suggesting that they may be appropriate for use in wound-healing contexts. To test this hypothesis, mice were immunized with epitope-containing peptide self-assemblies until they maintained high antibody titers against the material, then gels of the same peptide assemblies were applied within full-thickness dermal wounds. In three different murine dermal-wounding models with different baseline healing rates, even significantly immunogenic peptide assemblies did not delay healing. Conversely, adjuvanted peptide assemblies, while raising similar antibody titers to unadjuvanted assemblies, did delay wound healing. Analysis of the healing wounds indicated that compared to adjuvanted peptide assemblies, the unadjuvanted assemblies exhibited a progression of the dominant T-cell subset from CD4(+) to CD8(+) cells in the wound, and CD4(+) cell populations displayed a more Th2-slanted response. These findings illustrate an example of a significant antibiomaterial adaptive immune response that does not adversely affect wound healing despite ongoing antibody production. This material would thus be considered "immunologically compatible" in this specific context rather than "nonimmunogenic," a designation that is expected to apply to a range of other protein- and peptide-based biomaterials in wound-healing and tissue-engineering applications. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 104A: 1853-1862, 2016.

Elderly and octogenarian cohort: Comparable outcomes with nonelderly cohort after open or laparoscopic inguinal hernia repairs.

PURPOSE: To understand whether the elderly (>65 years of age) or octogenarian cohort is at greater risk for poor clinical outcomes after open or laparoscopic inguinal hernia repairs. METHODS: Beginning in June 2009, all patients presenting to our institution for inguinal hernia repair were asked to participate in a prospective database. Demographics, presenting symptoms, preoperative findings on examination, intraoperative variables, postoperative outcomes, and readmission data were collected. Additionally, patient-centered outcomes were evaluated with the Short Form-36 and Carolina Comfort Score questionnaires at follow-up visits (3 weeks, 6 months, 1 year, and for the Short Form-36 preoperatively as well). RESULTS: A total of 471 patients were included in the study; 285 were nonelderly, 155 patients were aged 65-80 years, and 31 patients were older than 80 years of age. Of these patients, the percent who underwent laparoscopic repair was 86% for the nonelderly, 79% for the elderly, and 41.9% for the octogenarian cohorts (P < .001). After laparoscopic repairs, the older cohorts had greater rates of minor postoperative complications than the nonelderly cohort (38% and 58% vs 15%; P < .001) attributable to greater rates of seroma and urinary retention. Intraoperative complications and recurrence rates were not different among the cohorts; however, the octogenarian cohort was more likely to be readmitted compared with both the nonelderly and elderly cohorts (17% vs 2% and 2%, respectively, P < .001) and to have a greater duration of stay (P < .001). For laparoscopic repairs over all the cohorts, the Carolina Comfort Scale improved over time (P < .001). Laparoscopic repairs in the octogenarians (P = .07) but not in the elderly (P = .6) had better scores over time (8.1 and 1.0 and points less/better, respectively) than the nonelderly cohort. CONCLUSION: Laparoscopic inguinal hernia repair is safe and effective in elderly and octogenarian patients with no major morbidities or mortalities. Although these patients are at greater risk for postoperative seroma and urinary retention, and octogenarians are at greater risk for readmission, patient-centered outcomes may be better after laparoscopic repairs with the proper patient selection in the older population.

Evaluation of Vessel Sealing Performance Among Ultrasonic Devices in a Porcine Model.

BACKGROUND: As new technologies emerge, it is imperative to define which new devices are most likely to provide a reproducible, effective result for the patient and surgeon. The purpose of our study was to analyze 3 commercially available ultrasonic energy devices; the Sonicision (SC), the Harmonic ACE (HA), and the THUNDERBEAT (TB). MATERIAL AND METHODS: Eight female Yorkshire pigs were used for data collection and vessel harvest. Three devices were evaluated and compared with each other with respect to seal failure and cutting speed in vivo. After vessel harvest, one end of the fragment was sent for histological evaluation, and the other was used for burst pressure measurement testing in a blinded fashion. The coagulation and cut levels of all the generators were set up at a similar and constant level. RESULTS: Eighty-four vessels (47 arteries and 37 veins) were tested. Mean vessel diameter was equal among the groups. Cutting speed was significantly faster with TB (3.4 ± 0.7 seconds) than SC or HA (5.8 ± 2.4 and 6.1 ± 3.1 seconds; P < .0001). Burst pressure trended higher after ligation with TB (505.4 ± 349.4 mm Hg) than SC and HA (435.8 ± 403.0 and 437.6 ± 291.3 mm Hg). There were 2 seal failures in the SC group and HA group and none in the TB group. Histologically, the perpendicular width of tissue seal with TB (1.250 ± 0.55 mm) was significantly longer than that of the SC and the HA (0.772 ± 0.23 and 0.686 ± 0.23 mm; P < .0001). CONCLUSIONS: TB has proven to provide the most rapid and reliable seal. Therefore, TB may be safer and may decrease time during surgical procedures.

Educating surgeons may allow for reduced intraoperative costs for inguinal herniorrhaphy.

BACKGROUND: Our aim was to determine the impact of surgeon education regarding disposable supply costs to reduce intraoperative costs for a common procedure such as inguinal hernia repair. STUDY DESIGN: At the end of the 2013 fiscal year (FY 13), surgeons in our department were provided with information about the cost of disposable equipment and implants used in common general surgery operations. Surgeons who historically had lower supply costs demonstrated individual techniques to their colleagues. No financial incentive or punitive measures were used to encourage behavior change. Surgical supply costs for laparoscopic and open inguinal hernia repair in FY13 were then compared with costs during fiscal year 2014 (FY14) using Mann-Whitney U tests. RESULTS: The average cost of laparoscopic inguinal hernia repairs decreased from an average $1,088±473 (±SD) in FY13 (n=258) to $860±441 (n=274) in FY14 after surgeon education, representing a 21.0% reduction in intraoperative costs (p<0.001). The most impactful adjustments to reduce costs included selective use of mesh fixation devices (22.9%) and balloon dissecting trocars (27.6%), reduction in use of disposable scissors (13.8%), and reduction in use of disposable clip appliers (3.7%). Open inguinal hernia costs were reduced from an average (±SD) of $315±$253 in FY13 (n=366) to $288±$130 in FY14 (n=286), an 8.6% reduction in cost (p<0.01). In these cases, both avoiding the use of fixation devices and using less expensive mesh implants were identified as significant factors. CONCLUSIONS: Surgeon education and empowerment may significantly reduce the cost of disposable equipment in laparoscopic and open inguinal hernia repair. This simple educational technique could prove financially beneficial throughout various procedures and disciplines.

Educating surgeons on intraoperative disposable supply costs during laparoscopic cholecystectomy: a regional health system's experience.

BACKGROUND: Surgeons play a crucial role in the cost efficiency of the operating room through total operative time, use of supplies, and patient outcomes. This study aimed to examine the effect of surgeon education on disposable supply usage during laparoscopic cholecystectomy. METHODS: Surgeons were educated about the cost of disposable equipments without incentives for achieved cost reductions. Surgical supply costs for laparoscopic cholecystectomy in fiscal year (FY) 2013 were compared with FY 2014. RESULTS: The average disposable supply cost per laparoscopic cholecystectomy was reduced from $589 (n = 586) in FY 2013 to $531 (n = 428) in FY 2014, representing a 10% reduction in supply costs (P < .001). Adjustments included reduction in the use of expensive fascial closure devices, clip appliers, suction irrigators, and specimen retrieval bags. CONCLUSIONS: Disposable equipment cost for laparoscopic cholecystectomy can be reduced by surgeon education. These techniques can likely be used to reduce costs in an array of specialties and procedures.

Quality of life assessment after peroral endoscopic myotomy.

BACKGROUND: Peroral Endoscopic Myotomy (POEM) is a promising treatment option for motor disorders of the esophagus. The purpose of this study was to assess quality of life (QOL) postoperatively. METHODS: All patients who presented to our institution for surgical treatment of achalasia after 2011 were asked to complete QOL (SF-36), dysphagia, reflux severity index, and GERD questionnaires in clinic preoperatively and postoperatively at approximately 3 weeks, 6 months, and 1 year. RESULTS: Those patients who underwent a POEM procedure (n = 37) demonstrated a significant improvement in dysphagia scores, reflux severity scores, and GERD scores (p < 0.05) at each time point. SF-36 questionnaires specifically demonstrated a significant improvement in several concepts. At 3 weeks, emotional well-being scores were significantly higher (p = 0.006). At 6 months, the following concepts were significantly higher: emotional well-being (p = 0.039), social functioning (p = 0.038), and general health (p = 0.029). At 1 year, the following concepts were significantly higher: role limitations due to physical health (p = 0.001) and social functioning (p = 0.002). CONCLUSION: There is a significant improvement in several measures of QOL after POEM, which is comparable to that seen after laparoscopic Heller myotomy.

Laparoscopy has a superior diagnostic yield than percutaneous image-guided biopsy for suspected intra-abdominal lymphoma.

INTRODUCTION: To date, no study has compared laparoscopy (LB) to percutaneous (PB) biopsy for the diagnosis of abdominal lymphoma. The objective of this study is to compare the success rate and safety profile of laparoscopic lymph node biopsy to the percutaneous approach in patients with intra-abdominal lymphadenopathy concerning for lymphoma. MATERIALS AND METHODS: We performed a multi-institution, retrospective review of patients undergoing lymph node biopsy for suspected intra-abdominal lymphoma between 2005 and 2013. Our primary outcome was adequate tissue yield between the two techniques, both for histologic diagnosis and for ancillary studies such as flow cytometry. Secondary outcomes included 30-day morbidity, 30-day readmission rates, the need for additional lymph node biopsy procedures, and length of stay. RESULTS: All 34 of the LB patients had adequate specimen for histologic diagnosis compared to 92.3% of patients with a PB (p = 0.18). Significantly more patients in the LB group had sufficient tissue for ancillary studies when needed than in the PB group, 95.5 and 68.2%, respectively (p = 0.04). A second biopsy was pursued in 23.1% of failed PB patients, 0% with success on second attempt. DISCUSSION: When index of suspicion is high or when biopsy is performed for patient previously diagnosed with lymphoma and recurrence/transformation is suspected, LB safely and consistently provides adequate tissue for initial diagnosis and for ancillary studies. In contrast, image-guided PB may be more appropriate for patients for whom ancillary studies are unlikely to add to planned treatments or when there is a high risk of complications from either general anesthesia or patient comorbidities.

NBME subject examination in surgery scores correlate with surgery clerkship clinical experience.

OBJECTIVE: Most medical schools in the United States use the National Board of Medical Examiners Subject Examinations as a method of at least partial assessment of student performance, yet there is still uncertainty of how well these examination scores correlate with clinical proficiency. Thus, we investigated which factors in a surgery clerkship curriculum have a positive effect on academic achievement on the National Board of Medical Examiners Subject Examination in Surgery. DESIGN: A retrospective analysis of 83 third-year medical students at our institution with 4 unique clinical experiences on the general surgery clerkship for the 2007-2008 academic year was conducted. Records of the United States Medical Licensing Examination Step 1 scores, National Board of Medical Examiners Subject Examination in Surgery scores, and essay examination scores for the groups were compared using 1-way analysis of variance testing. SETTING: Rush University Medical Center, Chicago IL, an academic institution and tertiary care center. RESULTS: Our data demonstrated National Board of Medical Examiners Subject Examination in Surgery scores from the group with the heavier clinical loads and least time for self-study were statistically higher than the group with lighter clinical services and higher rated self-study time (p = 0.036). However, there was no statistical difference of National Board of Medical Examiners Subject Examination in Surgery scores between the groups with equal clinical loads (p = 0.751). CONCLUSIONS: Students experiencing higher clinical volumes on surgical services, but less self-study time demonstrated statistically higher academic performance on objective evaluation, suggesting clinical experience may be of higher value than self-study and reading.