Impedance planimetry and panometry (EndoFLIP™) can replace manometry in preoperative anti-reflux surgery assessment.

BACKGROUND: Endoluminal functional impedance planimetry and panometry assesses secondary peristalsis in response to volumetric distention under sedation. We hypothesize that impedance planimetry and panometry can replace high-resolution manometry in the preoperative assessment prior to anti-reflux surgery. METHODS: Single institution prospective data were collected from patients undergoing anti-reflux surgery between 2021 and 2023. A 16-cm functional luminal imaging probe (FLIP) assessed planimetry and panometry prior to surgery under general anesthesia at the start of each case. Panometry was recorded and esophageal contractile response was classified as normal (NCR), diminished or disordered (DDCR), or absent (ACR) in real time by a single panometry rater, blinded to preoperative HRM results. FLIP results were then compared to preoperative HRM. RESULTS: Data were collected from 120 patients, 70.8% female, with mean age of 63 ± 3 years. There were 105 patients with intraoperative panometry, and 15 with panometry collected during preoperative endoscopy. There were 60 patients (50%) who had peristaltic dysfunction on HRM, of whom 57 had FLIP dysmotility (55 DDCR, 2 ACR) resulting in 95.0% sensitivity. There were 3 patients with normal secondary peristalsis on FLIP with abnormal HRM, all ineffective esophageal motility (IEM). No major motility disorder was missed by FLIP. A negative predictive value of 91.9% was calculated from 34/37 patients with normal FLIP panometry and normal HRM. Patients with normal HRM but abnormal FLIP had larger hernias compared to patients with concordant studies (7.5 ± 2.8 cm vs. 5.4 ± 3.2 cm, p = 0.043) and higher preoperative dysphagia scores (1.5 ± 0.7 vs. 1.1 ± 0.3, p = 0.021). CONCLUSION: Impedance planimetry and panometry can assess motility under general anesthesia or sedation and is highly sensitive to peristaltic dysfunction. Panometry is a novel tool that has potential to streamline and improve patient care and therefore should be considered as an alternative to HRM, especially in patients in which HRM would be inaccessible or poorly tolerated.

Subjective vs. objective assessment of simulation performance on laparoscopic cholecystectomy: are we evaluating the right things?

BACKGROUND: Simulation using virtual reality (VR) simulators is an important tool in surgical training. VR laparoscopic simulators can provide immediate objective performance assessment without observer evaluation. This study aims to explore the correlation between subjective observer evaluation and VR laparoscopic simulator performance metrics in a laparoscopic cholecystectomy (LC) simulation module. METHODS: A LC simulation module using a VR laparoscopic simulator was completed by PGY2-3 general surgery residents at a single institution. Simulation performance was recorded and evaluated by a trained evaluator using the validated Global Operative Assessment of Laparoscopic Skills (GOALS) form, the Objective Structured Assessment of Technical Skills (OSATS) form, and a LC-specific simulation assessment form (LC-SIM). Objective performance metrics were also obtained from the simulator system. Performance before the curriculum (pre-test) and after the curriculum (post-test) were compared. RESULTS: Fourteen residents were included in the study. There were significant improvements from pre-test to post-test on each component of GOALS, OSATS, and LC-SIM scores (all p values < 0.05). In terms of objective simulator metrics, significant improvements were noted in time to extract gallbladder (481 ± 221 vs 909 ± 366 min, p = 0.019), total number of movements (475 ± 264 vs 839 ± 324 min, p = 0.012), and total path length (955 ± 475 vs 1775 ± 632 cm, p = 0.012) from pre-test to post-test. While number of movements and total path lengths of both hands decreased, speed of right instrument also decreased from 4.1 + 2.7 to 3.0 ± 0.7 cm/sec (p = 0.007). Average speed of left instrument was associated with respect for tissue (r = 0.60, p < 0.05) and depth perception (r = 0.68, p < 0.05) on post-test evaluations. CONCLUSION: Our study demonstrated significant improvement in technical skills based on subjective evaluator assessment as well as objective simulator metrics after simulation. The few correlations identified between the subjective evaluator and the objective simulator assessments suggest the two evaluation modalities were measuring different aspects of the technical skills and should both be considered in the evaluation process.

Comparing cost and outcomes between peroral endoscopic myotomy and laparoscopic heller myotomy.

BACKGROUND: Peroral endoscopic myotomy (POEM) has previously been shown to be equally if not more expensive than laparoscopic Heller myotomy (LHM). We compare perioperative outcomes and charges between POEM and LHM at a single institution. METHODS: Outcomes and charge data of 33 patients who underwent LHM and 126 patients who underwent POEM were analyzed. Patients who did not present electively were excluded. RESULTS: There were no demographic differences between groups. Patients who underwent POEM had a significantly shorter mean operative time and median length of stay (both p < 0.001). Patients who underwent POEM stopped narcotics earlier and had faster return to activities of daily living (both p < 0.05). When adjusted for inflation, POEM incurred less in hospital charges than LHM (35.5 ± 12.8 vs 30.7 ± 10.3 in thousands of US dollars, p = 0.006). CONCLUSIONS: Patients who underwent POEM compared to LHM had significantly better perioperative outcomes. Our results suggest POEM may be the more cost-effective option.

Predicting Progression in Barrett's Esophagus: Development and Validation of the Barrett's Esophagus Assessment of Risk Score (BEAR Score).

OBJECTIVE: To develop and validate a scoring tool capable of accurately predicting which patients with Barrett's esophagus (BE) will progress to dysplasia and/or esophageal adenocarcinoma. BACKGROUND: Endoscopic therapies have emerged capable of eradicating BE with high efficacy and low complication rates, but which patients should receive treatment is still debated. Current knowledge of risk factors is insufficient to allow for the accurate prediction of which patients will progress to dysplasia or adenocarcinoma. METHODS: We retrospectively collected data from a cohort of BE patients over a 13-year period. A multivariable logistic regression model was constructed to predict progression. A simplified risk of progression (ROP) score was developed from weighted beta coefficients. Internal validation was performed using bootstrap analysis, and model discrimination was assessed using k-fold cross-validation. RESULTS: The cohort included 2591 BE patients of which 133 progressed to dysplasia/adenocarcinoma. Multivariable analysis with bootstrap internal validation resulted in 5 variables associated with an increased ROP (age ≥70 years, male sex, lack of proton-pump inhibitor use, segment greater than 3 cm, and history of esophageal candidiasis). Using this model, we developed a simple ROP score between 0 and 8. Receiver operating characteristic analysis showed a cutoff of 3 or higher to have a sensitivity and specificity of 70% and 79%, respectively. Patients with a score of 3 or higher had an odds ratio of 9.04 (95% confidence interval 6.06-13.46). The c-statistic obtained from 10-fold cross-validation was 0.76 (95% confidence interval 0.72-0.79), indicating good overall discrimination. CONCLUSIONS: Our data show the development and internal validation of the Barrett's Esophagus Assessment of Risk Score as capable of quantifying the likelihood of progression to dysplasia/adenocarcinoma. The Barrett's Esophagus Assessment of Risk Score can be used clinically to guide treatment decisions in nondysplastic BE patients.

Passing the fundamentals of endoscopic surgery (FES) exam: linking specialty choice and attitudes about endoscopic surgery to success.

INTRODUCTION: Previous work has shown that up to 30% of graduating surgery residents fail the fundamentals of endoscopic surgery (FES) exam. This study investigated the extent to which FES pass rates differ in a specific sample of individuals who have chosen a career in GI surgery and to examine the relationships between FES performance and confidence in performing flexible endoscopy. METHODS: Fellows attending the 2016 SAGES Flexible Endoscopy Course were invited to complete the FES manual skills examination. Participants also provided survey responses examining demographics, fellowship type, endoscopy curricula in residency, previous endoscopic case volume, confidence in performing endoscopy, and future practice plans. RESULTS: Twenty-nine (age: 32.24 ± 3.24; 72% men) fellows completed the FES skills examination. Reported fellowships were MIS/Bariatric (41.4%), MIS (24.1%), bariatric (13.8%), flexible endoscopy (6.9%), Advanced GI (6.9%), and MIS/bariatric/flexible endoscopy (6.9%). Almost half (41.4%) had previously participated in a simulation curricula, with 20.7% completing a didactic endoscopy curriculum. Fellows reported performing an average of 110 ± 109.48 EGDs and 77.44 ± 58.80 colonoscopies. The majority (96.4%) indicated that they will perform endoscopy at least occasionally in practice. Overall pass rate was 60%. Previous endoscopy experience did not correlate with overall FES examination scores. However, confidence performing EGDs (r = 0.57, p < 0.01), colonoscopies (r = 0.45, p < 0.05), polypectomy (r = 0.52, p < 0.01), and PEGs (r = 0.46, p < 0.05) did. CONCLUSIONS: These data support existing research suggesting that current flexible endoscopy training in residency may be insufficient for trainees to pass the FES examination, and that failure rates hold true even for this select group of trainees who have chosen a profession in GI surgery and intend to use endoscopy in practice.

A Comparative Assessment of Novel Mini-Laparoscopic Tools.

BACKGROUND: Mini-laparoscopy, or needlescopy, is an emerging minimally invasive technique that aims to improve on standard laparoscopy in the areas of tissue trauma, pain, and cosmesis. The objective of this study was to determine if there was a difference in functionality between 2 novel mini-laparoscopic instruments when compared to standard laparoscopic tools. Differences were assessed in a simulated surgical environment. METHODS: Twenty participants (5 novices, 10 intermediate, 5 expert) were recruited for this institutional review board-approved study in a surgical simulation training center. Group A tools were assembled intracorporeally, and Group B tools were assembled extracorporeally. Using standard laparoscopic graspers, mini-laparoscopic graspers, or a combination of both, each participant performed 3 basic laparoscopic training tasks: a Peg Transfer, Rubber Band Stretch, and Tootsie Roll Unwrapping. Following each round of tasks, participants completed a survey evaluating the mini-laparoscopic graspers with respect to standard laparoscopic graspers. Data were analyzed using Kruskal-Wallis test with Dunn's test for post hoc comparisons. RESULTS: When comparing task times, both mini tools performed at the level of standard laparoscopic graspers in all participant groups. Group A tools were quicker to assemble and disassemble versus Group B tools. According to posttask surveys, all participant groups indicated that both sets of mini-laparoscopic graspers were comparable to the standard graspers. CONCLUSION: In a nonclinical setting, mini-laparoscopic instruments perform at the level of standard laparoscopic tools. Based on these results, clinical trials would be a reasonable next step in assessing feasibility and safety.

A Model of Cost Reduction and Standardization: Improved Cost Savings While Maintaining the Quality of Care.

BACKGROUND: Surgeon instrument choices are influenced by training, previous experience, and established preferences. This causes variability in the cost of common operations, such as laparoscopic appendectomy. Many surgeons are unaware of the impact that this has on healthcare spending. OBJECTIVE: We sought to educate surgeons on their instrument use and develop standardized strategies for operating room cost reduction. DESIGN: We collected the individual surgeon instrument cost for performing a laparoscopic appendectomy. Sixteen surgeons were educated about these costs and provided with cost-effective instruments and techniques. SETTINGS: This study was conducted in a university-affiliated hospital system. PATIENTS: Patients included those undergoing a laparoscopic appendectomy within the hospital system. MAIN OUTCOME MEASURES: Patient demographics, operating room costs, and short-term outcomes for the fiscal year before and after the education program were then compared. RESULTS: During fiscal year 2013, a total of 336 laparoscopic appendectomies were performed compared with 357 in 2014. Twelve surgeons had a ≥5% reduction in average cost per case. Overall, the average cost per case was reduced by 17% (p < 0.001). Switching from an energy device to a stapler load or reusable plastic clip applier resulted in the largest savings per case at $321 or $442 per case. There were no differences in length of stay, 30-day readmissions, postoperative infections, operating time, or reoperations. LIMITATIONS: This retrospective study is subject to the accuracy of the medical chart system. In addition, specific instrument costs are based on our institution contracts and vary compared with other institutions. CONCLUSIONS: In this study we demonstrate that operative instrument costs for laparoscopic appendectomy can be significantly reduced by informing the surgeons of their operating room costs compared with their peers and providing a low-cost standardized instrument tray. Importantly, this can be realized without any incentive or punitive measures and does not negatively impact outcomes. Additional work is needed to expand these results to more operations, hospital systems, and training programs.

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.

Single-incision surgery has higher cost with equivalent pain and quality-of-life scores compared with multiple-incision laparoscopic cholecystectomy: a prospective randomized blinded comparison.

BACKGROUND: Since the development of single-incision surgery, several retrospective studies have demonstrated its feasibility; however, randomized prospective trials are still lacking. We report a prospective randomized single-blinded trial with a cost analysis of single-incision (SI) to multi-incision (MI) laparoscopic cholecystectomy. STUDY DESIGN: After obtaining IRB approval, patients with chronic cholecystitis, acute cholecystitis, or biliary dyskinesia were offered participation in this multihospital, multisurgeon trial. Consenting patients were computer randomized into either a transumbilical SI or standard MI group; patient data were then entered into a prospective database. RESULTS: We report 79 patients that were prospectively enrolled and analyzed. Total hospital charges were found to be significantly different between SI and MI groups (MI $15,717 ± $14,231 vs SI $17,817 ± $5,358; p < 0.0001). Broken down further, the following subcharges were found to also be significant: operating room charges (MI $4,445 ± $1,078 vs SI $5,358 ± 893; p < 0.0001); medical/surgical supplies (MI $3,312 ± $6,526 vs SI $5,102 ± $1,529; p < 0.0001); and anesthesia costs (MI $579 ± $7,616 vs SI $820 ± $23,957; p < 0.0001). A validated survey (ie, Surgical Outcomes Measurement System) was used to evaluate various patient quality-of-life parameters at set visits after surgery; scores were statistically equivalent for fatigue, physical function, and satisfaction with results. No difference was found between visual analogue scale scores or inpatient and outpatient pain-medication use. CONCLUSIONS: We show SI surgery to have higher costs than MI surgery with equivalent quality-of-life scores, pain analogue scores, and pain-medication use.

Computed tomography (CT)-guided versus laparoscopic radiofrequency ablation: a single-institution comparison of morbidity rates and hospital costs.

BACKGROUND: Computed tomography (CT)-guided radiofrequency ablation (RFA) is presumed to be less morbid and less costly than laparoscopic RFA. This analysis investigates the 30-day morbidity, hospital cost, and reimbursement for CT-guided RFA versus laparoscopic RFA used to manage hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM). METHODS: A retrospective review was performed for all patients with CRLM or HCC who underwent CT-guided RFA or laparoscopic RFA between January 2002 and August 2008. Demographics, risk stratification, and procedural data were analyzed. Hospital financial data were queried for total cost, reimbursement, and itemized departmental charges. The CRLM and HCC patients were evaluated separately. RESULTS: The study analyzed 18 RFA procedures for the treatment of HCC (8 CT-guided RFA; 10 laparoscopic RFA) and 25 RFA procedures for the treatment of CRLM (6 CT-guided RFA; 19 laparoscopic RFA). Immediate local failures were reported for 33.3% and 12.5% of the CT-guided RFA procedures for CRLM and HCC and for 5.2% and 0.0% of the laparoscopic RFA procedures for CRLM and HCC, respectively. The mean hospital cost was higher for the patients who underwent laparoscopic RFA ($11,808.70 ± $7,238.90 for HCC vs $9,882.40 ± $1,926.90 for CRLM) than for those who underwent CT-guided RFA ($7,186.10 ± $3,899.60 for HCC vs $5,767.50 ± $2,869.00 for CRLM). The mean reimbursement was lower than the mean hospital cost for the patients who underwent CT-guided RFA for CRLM ($4,329.10 vs $5,767.50). CONCLUSION: Although CT-guided RFA is less expensive, it is poorly reimbursed. Also, CT-guided RFA is associated with a higher immediate local failure rate for both CRLM and HCC and a higher complication rate for patients with CRLM. For patients with HCC, CT-guided RFA is associated with a lower complication rate. Our data suggest that laparoscopic RFA should be used for most patients with CRLM and only selectively for patients with HCC.