Endoscopic management of colonic perforations: clips versus suturing closure (with videos).

BACKGROUND AND AIMS: Perforation during colonoscopy remains the most worrisome adverse event and usually requires urgent surgical rescue. The aim of this study was to evaluate the feasibility and effectiveness of endoscopic closure of full-thickness colonic perforations. METHODS: We performed a retrospective analysis of all consecutive patients with endoscopically closed colonic perforations over the past 6 years (2009-2014). Colonic perforations were closed by using endoscopic clips or an endoscopic suturing device. Most patients were admitted for treatment with intravenous antibiotics and kept on bowel rest. If their clinical condition deteriorated, urgent surgery was performed. If patients remained stable, oral feeding was resumed, and patients were discharged with subsequent clinical and endoscopic follow-up. RESULTS: Twenty-one patients had iatrogenic colonic perforations closed with an endoscopic suturing device or endoscopic clips during the study period. Primary closure of a colonic perforation was performed with endoscopic clips in 5 patients and sutured with an endoscopic suturing device in 16 patients. All 5 patients after clip closure had worsening of abdominal pain and required laparoscopy (4 patients) or rescue colonoscopy with endoscopic suturing closure (1 patient). Two patients had abdominal pain after endoscopic suturing closure, but diagnostic laparoscopy confirmed complete and adequate endoscopic closure of the perforations. The other 15 patients did not require any rescue surgery or laparoscopy after endoscopic suturing. The main limitation of our study is its retrospective, single-center design and relatively small number of patients. CONCLUSION: Endoscopic suturing closure of colonic perforations is technically feasible, eliminates the need for rescue surgery, and appears more effective than closure with hemostatic endoscopic clips.

Gaze disruptions experienced by the laparoscopic operating surgeon.

BACKGROUND: Disruptions to surgical workflow have been correlated with an increase in surgical errors and suboptimal outcomes in patient safety measures. Yet, our ability to quantify such threats to patient safety remains inadequate. Data are needed to gauge how the laparoscopic operating room work environment, where the visual and motor axes are no longer aligned, contributes to such disruptions. We used time motion analysis techniques to measure surgeon attention during laparoscopic cholecystectomy in order to characterize disruptive events imposed by the work environment of the OR. In this investigation we identify attention disruptions as they occur in terms of the operating surgeon's gaze. We then quantify such disruptions and also seek to establish what occasioned them. METHODS: Ten laparoscopic cholecystectomy procedures were recorded with both intra- and extracorporeal cameras. The views were synchronized to produce a video that was subsequently analyzed by a single independent observer. Each time the surgeon's gaze was diverted from the operation's video display, the event was recorded via time-stamp. The reason for looking away (e.g., instrument exchange), when discernable, was also recorded and categorized. Disruptions were then reviewed and analyzed by an interdisciplinary team of surgeons and human factors experts. RESULTS: Gaze disruptions were classified into one of four causal categories: instrument exchange, extracorporeal work, equipment troubleshooting, and communication. On average, 40 breaks occurred in operating surgeon attention per 15 min of operating time. The most frequent reasons for these disruptions involved instrument exchange (38%) and downward gaze for extracorporeal work (28%). CONCLUSIONS: This study of laparoscopic cholecystectomy performance reveals a high gaze disruption rate in the current operating room work environment. Improvements aimed at reducing such disruptions-and thus potentially surgical error-should center on better instrument design and realigning the axis between surgeon's eye and visual display.

Ergonomic risk associated with assisting in minimally invasive surgery.

BACKGROUND: Given the physical risks associated with performing laparoscopic surgery, ergonomics to date has focused on the primary minimally invasive surgeon. Similar studies have not extended to other operating room staff. Simulation of the assistant's role as camera holder and retractor during a Nissen fundoplication allowed investigation of the ergonomic risks involved in these tasks. METHODS: Seven subjects performed camera navigation and retraction tasks using a box trainer on an operating room table that simulated an adult patient in low lithotomy position. Each subject stood on force plates at the simulated patient's left side. A laparoscope was introduced through a port into the training box with four 2-cm circles as rear-panel targets located in relation to the assistant as distal superior, proximal superior, distal inferior, and proximal inferior target effects. The subjects held the camera with their left hand, pointing it at a target. The task was to match the target to a circle overlaid on the monitor. Simultaneously, a grasper in the right hand grasped and pulled a panel-attached band. A minute signal moved the subject to the next target. Each trial had three four-target repetitions (phase effect). The subjects performed two separate trials: one while holding the camera from the top and one while holding it from the bottom (grip effect). A 4 x 3 x 2 (target x phase x grip) repeated-measures design provided statistics. Dividing the left force-plate vertical ground reaction forces (VGRF) by the total VGRF from both plates provided a weight-loading ratio (WLR). RESULTS: The WLR significantly increased (p < 0.005) with proximal targets (2 by 80% and 4 by 79%). The WLR decreased 75%, 74%, and 71% over time. No difference existed between the grip strategies (grip effect, p > 0.5). CONCLUSIONS: A high-risk ergonomic situation is created by the assistant's left or caudal leg disproportionately bearing 70-80% of body weight over time. A distance increase between the camera head location and the camera holder increases ergonomic risk. The phase effect was interpreted as a compensatory rebalancing to reduce ergonomic risk. Ergonomic solutions minimizing ergonomic risks associated with laparoscopic assistance should be considered.

Patients benefit while surgeons suffer: an impending epidemic.

BACKGROUND: The widely held belief that laparoscopy causes greater strain on surgeons' bodies than open surgery is not well documented in scope or magnitude. In the largest North American survey to date, we investigated the association of demographics, ergonomics, and environment and equipment with physical symptoms reported by laparoscopic surgeons. STUDY DESIGN: There were 317 surgeons identified as involved in laparoscopic practices who completed the online survey. Data collected from this comprehensive 23-question survey were analyzed using chi-square. RESULTS: There were 272 laparoscopic surgeons (86.9%) who reported physical symptoms or discomfort. The strongest predictor of symptoms was high case volume, with the surprising exceptions of eye and back symptoms, which were consistently reported even with low case volumes. High rates of neck, hand, and lower extremity symptoms correlated with fellowship training, which is strongly associated with high case volume. Surprisingly, symptoms were little related to age, height, or practice length. The level of surgeons' awareness of ergonomic guidelines proved to be somewhere between slightly and somewhat aware. A substantial number of respondents requested improvements in regard to both the positioning and resolution of the monitor. CONCLUSIONS: Far beyond previous reports of 20% to 30% incidence of occupational injury, we present evidence that 87% of surgeons who regularly perform minimally invasive surgery suffer such symptoms or injuries, primarily high case load-associated. Additional data accrual and analysis are necessary, as laparoscopic procedures become more prevalent, for improvement of surgeon-patient and surgeon-technology interfaces to reverse this trend and halt the epidemic before it is upon us.

Percutaneous endoscopic gastrostomy tube placement is safe in patients undergoing corticosteroid therapy.

BACKGROUND: Percutaneous endoscopic gastrostomy tube placement is performed commonly in patients unable to eat. Corticosteroids have been shown to increase the incidence of infections in patients undergoing surgical gastrostomy. The safety of percutaneous endoscopic gastrostomy in patients receiving corticosteroids has not been demonstrated. METHODS: A retrospective review of 746 patients undergoing percutaneous endoscopic gastrostomy at a single institution between January 2002 and June 2007 was performed. Patients receiving corticosteroid therapy either acutely or chronically were identified. Charts were reviewed for demographic information, diagnoses, comorbidities, complications, and death. RESULTS: Seven hundred forty-six patients underwent percutaneous endoscopic gastrostomy tube placement of which only 745 charts were complete and available for review. Ninety-four patients (12.6%) were receiving steroids at the time of the procedure. Fifty-nine patients (7.9%) received steroids for two or less weeks (acute), and 35 patients (4.5%) received steroids for more than 2 weeks (chronic). The overall incidence of complications was 98/745 (13.3%). No significant difference in post-procedural complications occurred in patients not receiving steroids 83/651 (12.7%) and steroid recipients 15/94 (16.0%). There was no difference in complications between the acute steroid group 10/59 (16.9%) and the chronic steroid group 5/35 (14.3%). CONCLUSIONS: Percutaneous endoscopic gastrostomy tube placement may be safely performed in patients receiving corticosteroids both acutely and chronically with complication rates comparable to those patients not receiving steroid medications.