The impact of procedure type on 30-day readmissions following metabolic and bariatric surgery: postoperative complications of bariatric surgery.

BACKGROUND: Hospital readmission (HR) rates following metabolic/bariatric surgery (MBS) are used as a surrogate for quality outcomes and are increasingly tied to reimbursement rates. There are limited data concerning predictors of HR rates with regard to type of bariatric procedure. METHODS: This study is a retrospective review of prospectively collected data from patients who underwent MBS from January 2014 to December 2019 at Brigham and Women's Hospital in Boston, Massachusetts. The causes of all HRs and reoperations within 30 days of the original discharge were analyzed. Statistical significance was determined using Chi Squared test and T test. RESULTS: 2815 patients underwent MBS. 2373 patients (84.3%) had primary procedures, while 442 patients (15.7%) had secondary or revisional procedures. The overall 30-day readmission rate was 5.7%, with no significant difference for patients who underwent primary vs. secondary MBS. Among primary procedures, the readmission rate was higher for Roux-en-Y Gastric Bypass (RYGB) than laparoscopic sleeve gastrectomy (SG) (10.32% vs. 4.77%). Readmissions were most often due to nontechnical causes. The overall reoperation rate was 1.14% and was higher for patients undergoing secondary vs. primary procedures (2.94% vs 0.80%). CONCLUSIONS: Readmission rate was similar to that in existing literature. Revisional/secondary surgery did not lead to increased readmissions, although was associated with a higher reoperation rate. Most HRs were due to nontechnical causes. Optimization of postoperative care, such as fluid status, may reduce the incidence of postoperative complications.

Polymer versus Titanium Clips in Laparoscopic Cholecystectomy.

BACKGROUND: Surgical clips are commonly used during laparoscopic cholecystectomy for cystic duct and artery ligation. Titanium and polymer clips are the two most common types used for this indication. Given the cost-saving potential, design advantages, and decreased incidence of complications associated with polymer clips, we sought to study whether there is a clinically significant difference in outcome between polymer and titanium clips in laparoscopic cholecystectomy. METHODS: Fifty consecutive cases using polymer clips followed by 50 consecutive cases using metal clips over a 6-month period by residents under the direction of a single surgeon were retrospectively reviewed. The following outcomes were evaluated: incidence of bile leak, postoperative bleeding, need for additional procedures, hospital length of stay, and cost. RESULTS: We found that significantly more misfires occurred with the use of the polymer clips (n=17) than with the titanium clips (n=2, p<.001). Eight cases (16%) required opening of an additional polymer clip cartridge to complete the operation. Despite this additional expense, the total cost as it pertained to clip usage ($30.32 USD) was still lower than that using titanium clips ($139.17 USD). While these numbers were not statistically significant, three cases had bile leaks and required additional procedures, all of which were performed with metal clips. No postoperative bleeds were identified and there was no difference in hospital length of stay; most patients were discharged on the day of the procedure. CONCLUSION: These findings demonstrate comparable clinical outcomes between laparoscopic cholecystectomies performed with polymer and titanium clips, though polymer clip usage carries a lower cost.

Fellowship training influences learning curves for laparoscopic sleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric surgical procedure. Little is known about how surgeon training background influences the learning curve of this procedure. We examined operating times (OT), weight loss outcomes, and 30-day complications between surgeons with and without fellowship training in LSG. We hypothesize that post-residency training specific to LSG influences learning curves. METHODS: Surgeons from a single institution were split into two groups: those who had not completed fellowship training in LSG (NF, n = 3), and those who had completed LSG specific training in fellowship (SGF, n = 3). OTs, BMI changes at 1 year, and 30-day readmissions, reoperations, and complications were extracted for the first 100 LSG cases of each surgeon. Data were analyzed in bins of 20 cases. Comparisons were made between cohorts within a bin and between adjacent bins of the same surgeon cohort. Logistic regression analyses were performed of OT and weight loss outcomes. RESULTS: SGF surgeons showed no difference in OTs over their first 100 cases. NF surgeons had statistically significant increased OTs compared to SGF surgeons during their first 60 cases and progressively shortened OTs during that interval (109 min to 78 min, p < 0.001 for NF surgeons vs. 73 min to 69 min, SGF surgeons). NF surgeons had a significantly steeper slope for improvement in OT over case number. There was no correlation between case number and weight loss outcomes in either group, and no differences in 30-day outcomes between groups. CONCLUSION: Surgeons who trained to perform LSG in fellowship demonstrate faster and consistent OR times on their initial independent LSG cases compared to surgeons who did not, with no correlation between case number and weight loss outcomes or safety profiles for either group. This suggests that learning curves for LSG are achieved during formal case-specific fellowship training.

"Mirror, Mirror on the Wall" Pediatric liver transplantation in the case of situs inversus totalis with a disrupted inferior vena cava.

We present the unique case of a 15-month-old male born with biliary atresia and situs inversus totalis and disrupted inferior vena cava who underwent a successful liver transplantation. The patient had previously undergone a failed Kasai procedure and presented with persistent hyperbilirubinemia. The patient was transplanted with a left lateral segment donor having standard arterial anatomy. Technical considerations included identifying completely replaced arterial anatomy in the recipient from the superior mesenteric artery and creating a branch patch between the gastroduodenal artery and HA, anastomosing the donor left hepatic vein to confluences of the donor left, middle, and right hepatic veins, using a "lazy-S" configuration of portal vein anastomosis, and suspending the allograft to the abdominal wall. Post-operatively, his liver function tests and total bilirubin normalized and he progressed to tolerating an oral diet with tube-feed supplementation.

Anatomic findings and outcomes associated with upper extremity arteriography and selective thrombolysis for acute finger ischemia.

OBJECTIVE: Limited evidence exists to guide clinical management of acute finger ischemia (AFI). To further inform diagnostic evaluation and decision making, we evaluated anatomic findings, procedural management, and amputation-free survival in an institutional cohort of patients with AFI. METHODS: Consecutive patients undergoing transfemoral upper extremity angiography for AFI were identified. Clinical, laboratory, and procedural data were collected retrospectively from medical records, and arteriograms were reviewed to characterize anatomic findings. Telephone interviews were used to determine long-term outcomes, and additional symptomatic assessments (Symptom Severity and Functional Status scale, the Cold Sensitivity Severity scale, and the McGill Pain Severity Scale) were available in a subgroup of patients. Outcomes included anatomic findings, use of thrombolysis, complications, and amputation-free survival. Descriptive statistics and survival analysis were used to evaluate results. RESULTS: Thirty-five patients (54% women) were analyzed with a median follow-up of 13.7 months. Symptom duration at time of presentation ranged from 1 to 28 days, and seven patients had tissue loss or gangrene, or both. Mean age was 47.7 ± 12.2 years. Baseline characteristics included smoking in 22 (65%), connective tissue disorder in 11 (31%), and history of repetitive hand trauma in 10 (29%). The most frequent anatomic location of arterial pathology identified during angiography was distal to the wrist (n = 32), including eight ulnar/radial aneurysms; upper arm (n = 3) and forearm (n = 8) lesions were less common. Sixteen patients were treated with catheter-directed thrombolysis, of which eight (50%) had interval anatomic improvement on repeat angiography. Procedure-related adverse events associated with angiography included bleeding (n = 3) and pseudoaneurysm (n = 1). Eleven of 35 patients had subsequent surgical revascularization at a median of 15 days after angiography. Estimated (standard error) amputation-free survival was 0.88 (0.07) at 1 month and 0.84 (0.08) at 6 months among patients without tissue loss or gangrene. Estimated 60-day amputation-free survival was 0.84 (standard error, 0.08). Overall amputation-free survival was similar between patients managed with vs without thrombolysis (P = .61), but subgroup analysis of those patients without tissue loss or gangrene at the time of presentation revealed a trend toward improved amputation-free survival with use of thrombolysis, with 60-day amputation-free survival of 0.92 vs 0.75 (P = .12). Persistent late symptoms were present in 17 patients (48.6%) at the last follow-up and were generally characterized as mild by functional and pain scale assessments. CONCLUSIONS: Angiography performed for AFI frequently identifies distal occlusive disease, and catheter-directed thrombolysis may expand revascularization options in select patients.

Primary Uncomplicated Ventral Hernia Repair: Guidelines and Practice Patterns for Routine Hernia Repairs.

Surgical repair of primary umbilical and epigastric hernias are among the most common abdominal operations in the world. The hernia defects range from small (<1 cm) to large and complex even in the absence of prior incision or repair. Mesh has generally been shown to decrease recurrence rates, and its use and location of placement should be individualized for each patient. Open, laparoscopic, and robotic approaches provide unique considerations for the technical aspects of primary repair with or without mesh augmentation.

Educating Residents in Abdominal Wall Closure: An Overview.

Background and Aims: Incisional hernia prevention has become an important concept for surgeons operating on the abdominal wall. Several techniques have been proposed to help decrease incisional hernia formation with suture closure of the abdominal wall being one of the cornerstones. Technical details that have been reported to decrease incisional hernia rates include achieving a 4:1 Suture to Wound length ratio and the use of a small bites technique. Despite evidence to support many of these techniques there appears to be a gap in practice patterns amongst practicing surgeons. Introducing and promoting these principles in surgical residency may help to close this gap. This paper reviews our experience with surgical training for abdominal wall closures at our institution. Materials and Methods: Programs and projects related to abdominal wall closure were reviewed from our institution from 2010-Present. Type of project, intervention, and impact on education was evaluated and summarized. Results: Seven projects were identified relating to surgical training and abdominal wall closure. Three projects dealt with skills training using an abdominal wall simulation model and related to suturing techniques. Two projects were clinical studies focused on suture to wound length ratios and improving outcomes with this variable in a residency training program. Two projects dealt with models relating to abdominal wall closure and education. Conclusion: Implementation of educational programs in surgical residency programs can lead to improvements in technique and knowledge around abdominal wall closure and help in research endeavors.

Teaching Small Bite Fascial Closure Technique: Improved Accuracy and Consistency Through Simulation.

Despite evidence that small bite closure is beneficial, it is not well documented how accurately and consistently surgeons employ this technique. We created a felt model to simulate fascial closure and educate residents regarding small bites. This study aims to gauge accuracy and consistency of bite size in fascial closure and assess if utilizing a templated model could improve technique. Two 10 cm incisions were made in different pieces of felt. Residents were instructed to suture the incisions to simulate fascial closure by running the incisions closed with 1 cm and 5 mm bites respectively. The process was repeated with templated pieces of felt marking 1 and 0.5 cm to guide bite size. Residents were timed for each closure. The travel and distance from the midline for each bite was measured and analysis performed. 14 residents participated. Paired T-test compared means and standard deviations of bite size. Taking 5 mm bites took more time. Standard deviation of travel and right sided distance from midline were significantly smaller when a template was utilized. Standard deviation of travel as well as right sided distance was also improved when instructed to take 5 mm bites. This study demonstrates that a small bite technique results more closure and that when residents are instructed to take smaller bites. The adage, "aim small, miss small," holds true in fascial closure and may be one reason why small bites improve hernia rates. This study also suggests that the use of a template improves accuracy and consistency of closure regardless of bite size intention.

Patterns of Weight Loss Medication Utilization and Outcomes Following Bariatric Surgery.

BACKGROUND: Bariatric surgery is the most effective treatment for obesity; however, some patients experience significant weight regain. Weight loss medications (WLM) are being increasingly used in surgery patients with limited evidence. We examine weight loss outcomes in patients using WLM after bariatric surgery. METHODS: In a retrospective study, 197 bariatric surgery patients who started WLM between 2016 and 2019 at a single center were analyzed. Patients were categorized into 3 groups based on outcomes of the initial surgery: (1) Weight regainers (WR) = achieved goal weight loss after surgery (15% total body weight loss (TBWL) for sleeve gastrectomy (SG) and 25% TBWL for Roux-en-Y gastric bypass (RYGB)) with subsequent regain of > 20% of weight lost; (2) Adequate weight loss (AWL) = achieved goal weight loss without > 20% weight regain; (3) Non-responders (NR) = never achieved goal weight loss. Weight loss and medication use patterns were analyzed. RESULTS: Among the three categories, there was no significant difference in duration of medical therapy or %TBWL with medications. RYGB patients lost more weight than SG patients using WLM (p = 0.03). Of the medications used, patients treated with phentermine + topiramate had the highest likelihood of achieving 5%, 10%, and 15% weight loss. Compared to other 2 groups, AWL group initiated WLM earlier and experienced more weight loss when compared to their pre-operative weight or post-operative nadir. CONCLUSIONS: RYGB patients respond better to WLM than SG patients. Those who had started WLM before regaining weight (AWL) experienced greater overall weight loss, suggesting that proactive medical therapy at the time of weight plateau can help with greater total weight loss. Phentermine + topiramate is the most effective WLM in post-bariatric surgery patients.

Airway pressure release ventilation does not increase intracranial pressure in patients with traumatic brain injury with poor lung compliance.

The use of Airway Pressure Release Ventilation (APRV) in patients with traumatic brain injury (TBI) remains controversial. Some believe that elevated mean airway pressures transmitted to the thorax may cause clinically significant increases in Central Venous Pressure (CVP) and intracranial pressure (ICP) from venous congestion. We perform a retrospective review from 2009 to 2015 of traumatically injured patients who were transitioned from traditional ventilator modes to APRV and also had an ICP monitor in place. Fifteen patients undergoing 19 transitions to APRV were identified. Prior to transitioning to APRV the average static and dynamic compliance was 22.9 +/- 5.6 and 16.5 +/- 4.12 mL/cm H2O. There was no statistical difference in ICP, MAP, and CPP prior to and after transition to APRV. There was a statistically significant increase in CVP, PaO2, and P:F ratio. Individually, only 4 patients had ICP values >20 in the first hour after transitioning to APRV and the rate of ICP elevations was similar between the two modes of ventilation. These data show that APRV is a viable mode of ventilation in patients with TBI who have low lung compliance. The increased CVP of this mode of ventilation did not affect ICP or hemodynamic parameters.

Orthopedic resident work-shift analysis: are we making the best use of resident work hours?

BACKGROUND: Surgery programs have been tasked to meet rising demands in patient surgical care while simultaneously providing adequate resident training in the midst of increasing resident work-hour restrictions. The purpose of this study was to quantify orthopedic surgery resident workflow and identify areas needing improved resident efficiency. We hypothesize that residents spend a disproportionate amount of time involved in activities that do not relate directly to patient care or maximize resident education. METHODS: We observed 4 orthopedic surgery residents on the orthopedic consult service at a major tertiary care center for 72 consecutive hours (6 consecutive shifts). We collected minute-by-minute data using predefined work-task criteria: direct new patient contact, direct existing patient contact, communications with other providers, documentation/administrative time, transit time, and basic human needs. A seventh category comprised remaining less-productive work was termed as standby. RESULTS: In a 720-minute shift, residents spent on an average: 191 minutes (26.5%) performing documentation/administrative duties, 167.0 minutes (23.2%) in direct contact with new patient consults, 129.6 minutes (17.1%) in communication with other providers regarding patients, 116.2 (16.1%) minutes in standby, 63.7 minutes (8.8%) in transit, 32.6 minutes (4.5%) with existing patients, and 20 minutes (2.7%) attending to basic human needs. Residents performed an additional 130 minutes of administrative work off duty. Secondary analysis revealed residents were more likely to perform administrative work rather than directly interact with existing patients (p = 0.006) or attend to basic human needs (p = 0.003). CONCLUSIONS: Orthopedic surgery residents spend a large proportion of their time performing documentation/administrative-type work and their workday can be operationally optimized to minimize nonvalue-adding tasks. Formal workflow analysis may aid program directors in systematic process improvements to better align resident skills with tasks. LEVEL OF EVIDENCE: III.

Motor vehicle crash-related subdural hematoma from real-world head impact data.

Abstract Approximately 1,700,000 people sustain a traumatic brain injury (TBI) each year and motor vehicle crashes (MVCs) are a leading cause of hospitalization from TBI. Acute subdural hematoma (SDH) is a common intracranial injury that occurs in MVCs associated with high mortality and morbidity rates. In this study, SDH volume and midline shift have been analyzed in order to better understand occupant injury by correlating them to crash and occupant parameters. Fifty-seven head computed tomography (CT) scans were selected from the Crash Injury Research Engineering Network (CIREN) with Abbreviated Injury Scale (AIS) level 3+ SDH. Semi-automated methods were used to isolate the intracranial volume. SDH and additional occupant intracranial injuries were segmented across axial CT images, providing a total SDH injury volume. SDH volume was correlated to crash parameters and occupant characteristics. Results show a positive correlation between SDH volume and crash severity in near-side and frontal crashes. Additionally, the location of the resulting hemorrhage varied by crash type. Those with greater SDH volumes had significantly lower Glasgow Coma Scale (GCS) scores at the crash site in near-side crashes. Age and fracture type were found to be significant contributors to SDH volume. This study is a volumetric analysis of real world brain injuries and known MVC impacts. The results of this study demonstrate a relationship among SDH volume, crash mechanics, and occupant characteristics that provide a better understanding of the injury mechanisms of MVC-associated TBI.