RESUMEN
BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is the most common surgical treatment for morbid obesity. While certain specialized ambulatory surgery centers offer LSG on an outpatient basis, patients undergoing LSG at most academic centers are admitted to hospital for initial postoperative convalescence and monitoring. Our institution has begun to offer LSG with same-day discharge (SDD) in select patients. We aimed to compare the perioperative outcomes and costs for patients undergoing LSG with inpatient admission versus SDD. METHODS: All patients enrolled in the SDD program from December 2020 through July 2022 were identified from a prospectively maintained database. Patients enrolled in this pathway were analyzed on an intention-to-treat basis even if ultimately admitted postoperatively. Propensity scoring was used to match these patients 1:1 to those with planned inpatient recovery based on age, BMI, and ASA classification. RESULTS: Seventy-five patients were enrolled in the LSG with SDD program during the study period. Among these, 62 patients (82.7%) had successful immediate postoperative discharge. Reasons for cancelation of planned SDD included anxiety (n = 5), pain (n = 3), nausea (n = 2), and one patient each with hypotension, urinary retention, and bleeding. After matching, there were no differences in age, BMI, or ASA classification in a comparison group of patients with planned inpatient recovery. There were no differences in perioperative complications. There were no readmissions or requirements for outpatient intravenous fluids among patients with SDD, compared to n = 3 (4.0%) and n = 2 (2.7%) in the inpatient cohort, respectively. The total perioperative cost for patients undergoing LSG with planned SDD was 6.8% less than those with inpatient recovery. CONCLUSION: With appropriate protocols, LSG with same-day discharge can safely be performed at large academic surgery centers without increased morbidity or need for additional services in the perioperative period. SDD may be associated with decreased costs and allows for more efficient hospital bed allocation.
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Laparoscopía , Obesidad Mórbida , Humanos , Laparoscopía/métodos , Alta del Paciente , Obesidad Mórbida/cirugía , Obesidad Mórbida/complicaciones , Hospitales , Gastrectomía/métodos , Estudios Retrospectivos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Resultado del TratamientoRESUMEN
BACKGROUND: Endoscopic per-oral pyloromyotomy (POP) has emerged as a safe and effective first line option in medically refractory gastroparesis. Determining the appropriate extent of the pyloromyotomy continues to present a challenge as there are no standardized tools for measuring changes in pyloric distensibility during the procedure. The objective of this study was to evaluate the utility of using impedance planimetry with endoscopic functional luminal imaging probe (FLIP) to measure changes in pyloric distensibility after POP, and to compare these changes with improvement in symptoms and objective gastric emptying. METHODS: Patients with medically refractory gastroparesis underwent POP with FLIP measurements of the pylorus (EndoFLIP®, Medtronic, Fridley MN). FLIP measurements, as well as changes in symptoms measured by the validated gastroparesis cardinal symptom index (GCSI) and scintigraphic gastric emptying studies (GES), were evaluated before and after POP. RESULTS: A total of 14 patients underwent measurement with FLIP during POP, 12 of whom had pre- and post-POP measurements. Mean pyloric diameter increased by 1.4 mm, from 13.9 mm to 15.3 mm (p = 0.0012). Mean distensibility index increased from 6.2 mm2/mmHg to 9.1 mm2/mmHg (p = 0.0074). Successful division of the pylorus was achieved in 100% of patients with a mean operative time of 36 min and no perioperative complications. The mean length of stay was 0.7 days (0-3 days). Post-POP mean GCSI score improved from 2.97 to 2.28 at a mean follow-up time of 27 days (p < 0.001). Objective improvement in gastric emptying was observed in 80% of patients with scintigraphic GES, with mean four-hour retention decreasing from 46.3% to 32.4% (p < 0.007). CONCLUSIONS: FLIP is a safe and feasible tool to provide objective measurements during POP. Larger cohorts with longer follow-up are required to determine if measured improvements in pyloric diameter and distensibility are predictive of sustained improvements in GCSI and GES.
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Gastroparesia , Piloromiotomia , Vaciamiento Gástrico , Gastroparesia/diagnóstico por imagen , Gastroparesia/etiología , Gastroparesia/cirugía , Humanos , Piloromiotomia/métodos , Píloro/diagnóstico por imagen , Píloro/cirugía , Resultado del TratamientoRESUMEN
BACKGROUND: In peroral endoscopic myotomy for Zenker's diverticulum (Z-POEM), the cricopharyngeus muscle is divided within a submucosal tunnel started in the hypopharynx. We aimed to evaluate the safety and preliminary outcomes in patients who underwent a modified version of the Z-POEM where the tunnel is made directly overlying the cricopharyngeus, the mucosal incision and muscular interruption (MIMI) approach, and to compare these with patients who underwent a non-tunneled flexible endoscopic approach. METHODS: All patients with ZD who were treated by flexible endoscopy at our institution between January 2015 and February 2020 were identified by a retrospective chart review. Dysphagia symptoms were assessed using a validated scoring system. RESULTS: Nineteen patients with ZD underwent MIMI (mean age 76.1 years, 68.1% male) and seven patients underwent non-tunneled flexible endoscopic approach (mean age 64.4 years, 85.7% male) during the study period. Mean ZD size was 2.8 cm in the MIMI group and 1.9 cm in the non-tunneled group (p = 0.03). Clinical success was achieved in 17/19(89.5%) MIMI patients and 7/7(100%) of non-tunneled flexible endoscopic patients (p = 0.101). Dysphagia scores improved in both groups, although this difference was only significant in the MIMI group (p ≤ 0.001). Recurrence occurred in 2/17(11.7%) MIMI patients and 3/7(42.9%) non-tunneled flexible endoscopic patients (p = 0.096). There were 4 complications, including one pharyngeal perforation requiring open surgical repair in a patient with a small ZD with an associated cricopharyngeal bar in the MIMI group. Median length of follow-up was 290 [142; 465] days in the MIMI group and 1056 [258; 1206] days in the non-tunneled group (p = 0.094). CONCLUSIONS: MIMI is a technically feasible and effective treatment for ZD. Care should be taken in patients with a cricopharyngeal bar and small ZD, as this may increase the risk of perforation. Larger studies with long-term follow-up are needed to determine if MIMI reduces the risk of symptom recurrence when compared to non-tunneled flexible endoscopic approaches.
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Trastornos de Deglución , Divertículo de Zenker , Anciano , Trastornos de Deglución/etiología , Endoscopía , Esofagoscopía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Músculos , Estudios Retrospectivos , Resultado del Tratamiento , Divertículo de Zenker/cirugíaRESUMEN
OBJECTIVE: The aim of this study was to determine characteristics of the most cited publications in the history of the American Surgical Association (ASA). SUMMARY BACKGROUND DATA: The Annals of Surgery has served as the journal of record for the ASA since 1928, with a special issue each year dedicated to papers presented before the ASA Annual Meeting. METHODS: The top 100 most cited ASA publications in the Annals of Surgery were identified from the Scopus database and evaluated for key characteristics. RESULTS: The 100 most cited papers from the ASA were published between 1955 and 2010 with an average of 609 citations (range: 333-2304) and are included among the 322 most cited papers in the Annals of Surgery. The most common subjects of study included clinical cancer (n = 43), gastrointestinal (n = 13), cardiothoracic/vascular (n = 9), and transplant (n = 9). Ninety-three institutions were included lead by Johns Hopkins University (n = 9), University of Pittsburgh (n = 8), Memorial Sloan-Kettering (n = 7), John Wayne Cancer Institute (n = 7), University of Texas (n = 7), and 5 each from Brigham and Women's Hospital, Mayo Clinic, and University of Chicago. The majority of manuscripts came from the United States (n = 85), followed by Canada (n = 7), Germany (n = 5), and Italy (n = 5). Study design included randomized controlled trials (n = 19), retrospective matched cohort studies (n = 11), retrospective nonmatched studies (n = 46), and other (n = 24). CONCLUSIONS: The top 100 most cited publications from the ASA are highly impactful, landmark studies representing a diverse array of subject matter, investigators, study design, institutions, and countries. These influential publications have immensely advanced surgical science over the decades and should serve as inspiration for all surgeons and surgical investigators.
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Bibliometría/historia , Cirugía General/historia , Publicaciones Periódicas como Asunto/historia , Edición/historia , Sociedades Médicas/historia , Historia del Siglo XX , Historia del Siglo XXI , Humanos , Estados UnidosRESUMEN
BACKGROUND: Conversion of Nissen fundoplication to Roux-en-Y (RnY) anatomy may be indicated in patients with post-surgical complications or who fail to achieve durable control of their disease. Herein we describe the largest series of patients at a single institution who underwent minimally invasive conversion of Nissen fundoplication to RnY reconstruction. METHODS: All patients with prior Nissen fundoplication which were converted to RnY anatomy at our institution from March 2009 through November 2017 were retrospectively reviewed and analyzed. Patients were identified based on CPT codes and the description of the operation performed. All cases with attempted minimally invasive approach were included for analysis. RESULTS: Fifty patients underwent conversion from prior Nissen fundoplication to RnY anatomy during the study period. The cohort was 84.0% female with a mean age of 53.5 years and a median body mass index of 36.7 kg/m2. Thirteen patients (26.0%) had multiple prior foregut operations. Complications from fundoplication that warranted revision included recurrent hiatal hernia (n = 16), post-surgical gastroparesis (n = 10), and mechanical complications from the wrap (n = 8). An additional fourteen patients underwent conversion to RnY for metabolic disease. The mean operative time and estimated blood loss were 266 min and 132 mL, respectively, with all but one (98.0%) completed with a minimally invasive approach. The median length of stay was 5 days. Complications included marginal ulcer (n = 2), superficial surgical site infection (n = 2), anastomotic leak (n = 2), and one case each of pulmonary embolism, small bowel obstruction, and gastrointestinal bleeding. There were no mortalities at a median follow-up of 12.4 months. CONCLUSIONS: Conversion of prior Nissen fundoplication to RnY anatomy is technically challenging, although it is safe and feasible even in the setting of multiple prior foregut operations. A minimally invasive approach should be offered to patients by surgeons with experience in revisional foregut and bariatric surgery.
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Anastomosis en-Y de Roux/métodos , Fundoplicación/efectos adversos , Laparoscopía/métodos , Complicaciones Posoperatorias/etiología , Adulto , Anastomosis en-Y de Roux/efectos adversos , Índice de Masa Corporal , Femenino , Gastroparesia/etiología , Gastroparesia/cirugía , Hernia Hiatal/etiología , Hernia Hiatal/cirugía , Humanos , Laparoscopía/efectos adversos , Masculino , Persona de Mediana Edad , Tempo Operativo , Complicaciones Posoperatorias/cirugía , Reoperación , Estudios Retrospectivos , Terapia Recuperativa , Infección de la Herida Quirúrgica/etiología , Insuficiencia del TratamientoRESUMEN
BACKGROUND: Gastroparesis is a debilitating functional disorder of the stomach marked by delayed gastric emptying in the absence of mechanical obstruction. Patients with severe, refractory symptoms may ultimately be managed with Roux-en-Y reconstruction; however, it is unclear whether the stomach should be left in situ, similar to a conventional gastric bypass, or resected as in gastrectomy. METHODS: All patients undergoing Roux-en-Y for the treatment of gastroparesis (GP) at our institution from September 2010 through March 2018 were retrospectively reviewed. Patients with prior gastric resection or whose primary operative indication was not gastroparesis were excluded from analysis. RESULTS: Twenty-six patients underwent Roux-en-Y with stomach left in situ (RY-SIS) and twenty-seven patients underwent gastrectomy with Roux-en-Y reconstruction during the study period. The mean age was 49.7 years in the RY-SIS cohort and 48.5 years in the gastrectomy cohort. Etiology of GP was similar between the two cohorts. Patients undergoing gastrectomy were more likely to have previous interventions for GP (63.0% vs. 26.9%). RY-SIS was associated with a shorter operative time (155 vs. 223 min), less blood loss (24 vs. 130 mL), and shorter length of stay (4.0 vs. 7.2 days). Twelve patients (44.4%) had complications within 30 days following gastrectomy compared to two patients (7.7%) following RY-SIS (p = 0.001). Patients in the RY-SIS cohort were more likely to require further subsequent surgical intervention for GP (23.1% vs. 3.7%, p = 0.04). At last follow-up, there were no differences in reported GP symptoms or symptom scoring. CONCLUSIONS: Gastrectomy was associated with greater perioperative morbidity compared to leaving the stomach in situ. Symptomatic improvement at intermediate follow-up was equivalent following either procedure. However, patients undergoing RY-SIS were more likely to require subsequent surgical intervention, suggesting that gastrectomy may be a more definitive operation for the management of medically refractory gastroparesis.
Asunto(s)
Anastomosis en-Y de Roux/métodos , Gastrectomía/métodos , Gastroparesia/cirugía , Estómago/cirugía , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
BACKGROUND: While per-oral pyloromyotomy (POP) has shown promise as a novel endoscopic procedure to treat medically refractory gastroparesis, standardized care pathways are not well-defined. We aimed to compare the safety and cost of same-day discharge (SDD) after POP with inpatient stay overnight or longer. METHODS: All patients with SDD after POP between January 2016 and May 2018 were retrospectively identified from a prospectively maintained registry. Propensity scores considering gender, age, gastroparesis etiology, and American Society of Anesthesiologists (ASA) class were used to match a comparison group which stayed overnight or longer. Statistical tests included two-sample t tests for continuous variables, Fisher's exact test for categorical variables, and paired sample t tests for within-group comparisons with repeated measures. RESULTS: Fifty-four patients who underwent POP with SDD during the study period were propensity-matched with 54 patients with inpatient recovery. The SDD cohort was 85.2% female with a mean age of 44.8 years and median ASA class 3. The etiology of gastroparesis was idiopathic in 53.7% (n = 29), diabetic in 29.6% (n = 16), and post-surgical in 11.1% (n = 6). Operative time was shorter in the SDD cohort (25.4 vs. 31.3 min, p = 0.02). The mean post-procedure recovery time was 4 h in patients with SDD and 29.3 h in the inpatient cohort (p < 0.001). There was a trend towards less readmissions with SDD (7.4% vs. 18.5%, p = 0.08). There was no increased risk of complications with SDD (1.9% vs. 3.7%, p = 0.57). Compared to inpatient recovery, the average total cost for the procedure, recovery, and all subsequent care within 30 days was 26.0% less with SDD (p < 0.001). CONCLUSIONS: Following POP, patients can be safely discharged the same day with low risk of both complications and readmission. Total costs in the complete perioperative period are significantly less with SDD compared to inpatient recovery.
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Alta del Paciente , Piloromiotomia/efectos adversos , Piloromiotomia/economía , Adulto , Estudios de Cohortes , Femenino , Gastroparesia/cirugía , Costos de la Atención en Salud , Humanos , Pacientes Internos , Masculino , Persona de Mediana Edad , Tempo Operativo , Alta del Paciente/economía , Readmisión del Paciente , Complicaciones Posoperatorias/etiología , Piloromiotomia/métodos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Gastroparesis is a debilitating functional disorder of the stomach characterized by delayed gastric emptying absent an obstructive etiology. Surgical or endoscopic disruption of the pylorus has been utilized to treat this disease, but there is little evidence comparing laparoscopic pyloroplasty (LP) with endoscopic per-oral pyloromyotomy (POP). Herein we describe our experience at our institution using a propensity-matched cohort study to compare outcomes between these procedures. METHODS: All patients who underwent LP for the treatment of gastroparesis from October 2014 through September 2017 at our institution were retrospectively reviewed. Propensity scoring was used to match these patients 1:1 to patients undergoing POP during this time period based on gender, age, and etiology of gastroparesis. Symptom scores using the Gastroparesis Cardinal Symptom Index (GCSI), scintigraphic gastric emptying studies (GES), and perioperative outcomes were compared between matched cohorts. Thirty patients underwent LP for gastroparesis during the study period which were matched 1:1 with patients undergoing POP. The etiology of gastroparesis was 63.3% idiopathic (n = 19), 20.0% post-surgical (n = 6), and 16.7% diabetic (n = 5) in both cohorts. RESULTS: Patients who underwent LP had a longer average length of stay (4.6 vs. 1.4 days, p = 0.003), operative time (99.3 vs. 33.9 min, p < 0.001), and estimated blood loss (12.9 vs. 0.4 mL, p < 0.001). There were more complications in the LP cohort (16.7 vs. 3.3%, p = 0.086), which included surgical site infection (6.7 vs. 0%, p = 0.153), pneumonia (6.7 vs. 0.0%, p = 0.153), and unplanned ICU admission (10.0 vs. 0.0%, p = 0.078). LP and POP both resulted in similar, significant improvements in both in GCSI scores and objective gastric emptying. CONCLUSIONS: Per-oral endoscopic pyloromyotomy (POP) is safe and effective for the treatment of medical refractory gastroparesis. POP has less perioperative morbidity compared to LP with comparative functional outcomes.
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Gastroparesia/cirugía , Laparoscopía , Cirugía Endoscópica por Orificios Naturales , Piloromiotomia/métodos , Píloro/cirugía , Adulto , Anciano , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Píloro/diagnóstico por imagen , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVE: For patients with gastroparesis, temporary pyloric disruption has been shown to improve symptoms and gastric emptying. Per-oral pyloromyotomy (POP) is an innovative endoscopic procedure to divide the pylorus from within a submucosal tunnel, as a corollary to surgical pyloromyotomy. Here we evaluate subjective and objective outcomes 12-weeks after POP at a high volume center. METHODS: The first 100 consecutive patients undergoing POP were included, with procedure dates between January 2016 and October 2017. Patients were evaluated using the Gastroparesis Cardinal Symptom Index (GCSI), and 4-hour solid-phase scintigraphic gastric emptying studies (GES) prior to procedure and at 90 days post-POP RESULTS:: The study cohort was 85% female with a mean age of 45.0â±â14.6 years. Gastroparesis etiologies were divided among idiopathic (56%), diabetic (21%), postsurgical (19%), and other in 4%. There were 67% of the patients who had previous endoscopic or surgical interventions for gastroparesis. Most POP procedures were performed in the operating room (97%) and were completed in an average of 33 minutes. Ten patients incurred complications (10%), which included 1 diagnostic laparoscopy and 2 cases of gastrointestinal bleeding. Overall GCSI improved from a preoperative mean of 3.82â±â0.86 to 2.54â±â1.2 (P < 0.001). The improvement in each GCSI subscore was also highly statistically significant. Among the patients with postoperative GES available, 78% had objectively better 4-hour emptying with a mean improvement in retention by 23.6% (P < 0.001). This included 57% of patients with normal gastric emptying post-POP. CONCLUSION: For patients with medically refractory gastroparesis, POP results in both subjective and objective improvement in the majority of patients. Prior intervention does not obviate POP as a therapeutic option. POP should be included along the treatment algorithm for patients with gastroparesis as an organ-sparing procedure.
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Gastroparesia/cirugía , Piloromiotomia/métodos , Adulto , Femenino , Vaciamiento Gástrico , Gastroparesia/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Estudios Prospectivos , Cintigrafía , Resultado del TratamientoRESUMEN
BACKGROUND: Central lung cancers with pulmonary hilar involvement can pose a technical challenge when a lateral thoracotomy is used. Proximal vascular control and pulmonary vascular dissection from this approach can be challenging and potentially dangerous. We describe the use of a Chamberlain anterior minithoracotomy as an alternative approach for safe and reliable access to the pulmonary hilum. METHODS: One hundred two consecutive patients undergoing the Chamberlain approach were identified through retrospective chart review from 2002 to 2009. The supine position was used, thus reducing the likelihood of down-lung syndrome. An 8-cm anterior thoracotomy was performed over the second interspace along the line of the pectoral fibers, with preservation of the mammary artery medially and the thoracoacromial neurovascular bundle laterally. Primary outcome variables included hospital course, complications, and mortality rate. RESULTS: The mean age was 64.8 years (range, 20-89 years). Sex ratio (female:male) was 44:58. Neoadjuvant therapy was used in 43 patients (42.2%). Proposed resections were successful in 101 (99%) of 102 patients. Conversion to hemiclamshell was required in 1 patient for vascular control. Three perioperative deaths (2.9%; two pneumonectomies, one lobectomy) occurred. CONCLUSIONS: The Chamberlain mini anterior thoracotomy provides direct access to the pulmonary hilum, facilitating dissection and vascular control for large and central tumors. Reduced perioperative pain and down-lung syndrome compared to lateral approaches can be achieved. Muscle function is preserved, and intrapericardial/hilar access is expeditious. This approach enhances hilar access and avoids the vascular control and hilar exposure challenges inherent with lateral thoracotomy.
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Neoplasias Pulmonares/cirugía , Neumonectomía , Arteria Pulmonar/cirugía , Grapado Quirúrgico , Toracotomía/métodos , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Tasa de Supervivencia , Cirugía Torácica Asistida por Video , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Preservation of esophageal and gastric function is a hallmark principle in ensuring optimal surgical outcomes after gastric fundoplication. In this study, we evaluated the impact of fundoplication on esophageal transit and gastric emptying using scintigraphy studies and related these functional findings to symptomatic outcomes. METHODS: A total of 106 consecutive patients (37 women, 69 men) with both preoperative and 6-month postoperative nuclear scintigraphy studies undergoing partial (Toupet) fundoplication at a single institution were analyzed. Primary variables included alterations in esophageal transit and gastric emptying times after fundoplication (1 = rapid; 2 = normal; 3 = mild delay; 4 = severe delay). Symptomatic variables included heartburn, regurgitation, dysphagia, pulmonary symptoms, and bloating. RESULTS: Mean age was 57.2 years. Symptomatic improvement was achieved in 91.5% of patients. Significant reduction of all symptoms (heartburn, regurgitation, pulmonary symptoms, and dysphagia) was noted after fundoplication, except gas bloating (4.7 vs. 20.8%). There were no significant differences in preoperative and postoperative esophageal transit (2.53 vs. 2.52) and gastric emptying (2.13 vs. 2.06) scores after fundoplication. Interestingly, 17% of esophageal transit times and 18% of gastric emptying times improved after fundoplication. However, worsening scores were seen in 16 and 12%, respectively. There was no significant postoperative dysphagia, even in patients with impaired transit times. CONCLUSIONS: Nuclear scintigraphic assessment of esophageal transit and gastric emptying are valuable, user-friendly tools to identify and avoid functional motility problems in the setting of fundoplication. These studies seem to be a reasonable alternative to manometry in assessing esophageal function before surgery in this setting. Postoperative symptoms may be related to objective changes in esophageal transit or gastric emptying. The causes may be iatrogenic in nature or related to vagal denervation with associated changes in esophagogastric compliance. Awareness of these physiologic changes may prompt further technical precautions at the time of surgery to avoid vagal injury and also may facilitate postoperative medical management.
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Esófago/fisiopatología , Fundoplicación/métodos , Vaciamiento Gástrico , Reflujo Gastroesofágico/diagnóstico por imagen , Reflujo Gastroesofágico/fisiopatología , Tránsito Gastrointestinal , Hernia Hiatal/diagnóstico por imagen , Hernia Hiatal/fisiopatología , Laparoscopía , Adulto , Anciano , Anciano de 80 o más Años , Técnicas de Diagnóstico del Sistema Digestivo , Femenino , Reflujo Gastroesofágico/cirugía , Hernia Hiatal/cirugía , Humanos , Masculino , Persona de Mediana Edad , Cintigrafía , Estudios RetrospectivosRESUMEN
BACKGROUND: Many patients considering bariatric surgery will obtain medical information through the Internet. The type and quality of information patients access may vary significantly by geographic region. METHODS: Searches were performed using commercial search engines in both the United States of America (USA) and United Arab Emirates (UAE) using search terms "bariatric surgery" and "weight loss surgery." Quality was assessed using the scoring systems previously published by DISCERN (United Kingdom (UK)), the Journal of the American Medical Association Benchmark (JAMA; USA), and Expanded Ensuring Quality Information for Patients (EQIP) (UK). RESULTS: Website types were more evenly distributed in UAE, though physician websites were also the most common (n = 25, 25%). Within the USA, most websites analyzed were from physicians (n = 32, 32%), followed by academic sources (n = 26, 26%). Academic websites were the highest average quality in the USA (p < .00001). The overall mean DISCERN scores for all websites in the UAE group and US group had no statistically significance differences (p = .950). The overall mean JAMA Benchmark for all websites in the UAE group and USA had no statistically significance differences (p = 0.202). There were no major differences between the USA and UAE in Expanded EQIP scores. CONCLUSIONS: The overall quality of information regarding bariatric surgery is poor to fair in both the USA and UAE. Additionally, there are differences in the types of sites retrieved by the most commonly used search engines in each region. The lack of high-quality, evidence-based, information regarding bariatric surgery online is a potential target to improve public education.
Asunto(s)
Cirugía Bariátrica , Obesidad Mórbida , Humanos , Internet , Obesidad Mórbida/cirugía , Emiratos Árabes Unidos , Reino UnidoRESUMEN
BACKGROUND: Complications after sleeve gastrectomy (SG) unfortunately lead a subset of patients to require revisional surgery, including conversion to Roux-en-Y gastric bypass (RYGB). OBJECTIVES: We aimed to describe the indications for conversion and perioperative outcomes in this subset of patients. SETTING: Academic hospital, Abu Dhabi, United Arab Emirates. METHODS: All patients undergoing conversion from SG to RYGB from September 2015 to December 2018 were retrospectively reviewed. Patients who underwent conversion solely for weight recidivism were excluded from analysis. RESULTS: Forty-seven patients underwent conversion to RYGB due to complications from SG. The cohort was 76.5% female with a mean age of 39 years and median body mass index of 34 kg/m2. The median time between SG and RYGB was 36 months. Indications warranting conversion included mechanical complications (n = 24, 51.1%), intractable reflux (n = 21, 44.7%), and fistula (n = 2, 4.2%). Preoperative mechanical abnormalities included hiatal hernia (n = 13, 27.7%), helical twist (n = 10, 21.3%), sleeve stenosis/stricture (n = 5, 10.6%), fistula (n = 2, 4.2%), and leak (n = 1, 2.1%). Each conversion was completed with a laparoscopic approach, with a median length of stay of 3 days. Four patients (8.5%) experienced complications within 30 days, including 2 patients (4.2%) with superficial surgical site infection, 1 patient each (2.1%) with gastrointestinal hemorrhage and anastomotic leak. There were no mortalities at a median follow-up of 17 months. CONCLUSION: In this series, representing the largest reported single-center experience in the Middle East, conversion of SG to RYGB was safe and effective for the treatment of symptoms and mechanical complications after SG.
Asunto(s)
Gastrectomía/efectos adversos , Derivación Gástrica , Complicaciones Posoperatorias , Reoperación , Adulto , Femenino , Derivación Gástrica/efectos adversos , Derivación Gástrica/métodos , Derivación Gástrica/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/cirugía , Reoperación/efectos adversos , Reoperación/métodos , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Centros de Atención Terciaria , Emiratos Árabes UnidosRESUMEN
BACKGROUND: One-anastomosis gastric bypass (OAGB), also known as minigastric bypass, is an increasingly popular bariatric surgery option worldwide. While OAGB offers advantage in terms of procedure time and technical ease, revisional operations to correct complications may be necessary. OBJECTIVES: We aimed to describe the indications and perioperative outcomes for OAGB conversions to Roux-en-Y gastric bypass (RYGB) at a single-referral center. SETTING: Academic hospital, Abu Dhabi, United Arab Emirates. METHODS: All patients undergoing conversion from OAGB to RYGB from February 2016 through September 2018 were retrospectively identified from a prospectively maintained database of revisional bariatric surgeries. RESULTS: Sixteen patients underwent conversion from previous OAGB to RYGB during the study period. The cohort was 62.5% female (n = 10) with a mean age of 40.2 years and median body mass index of 30.7 kg/m2. Indications for conversion included intractable nausea/vomiting (n = 8, 50.0%), biliary reflux (n = 3, 18.8%), weight recidivism (n = 3, 18.8%), and protein-calorie malnutrition (n = 2, 12.5%). Twelve cases (75.0%) were successfully completed with a laparoscopic approach, with 4 cases (25.0%) converted to open. The median length of stay was 5.5 days. Six patients (37.5%) experienced minor and major complications within 30 days of discharge. Fourteen patients (87.5%) were available for follow-up at 6 months, with 100% of these patients reporting resolution of their preoperative symptoms. There were no mortalities. CONCLUSIONS: Data from this largest reported single-center experience demonstrates that conversion of OAGB to RYGB is safe and technically feasible. Further studies and longer-term follow-up are needed to definitively describe outcomes after this revisional bariatric surgery.
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Índice de Masa Corporal , Derivación Gástrica/métodos , Tiempo de Internación , Obesidad Mórbida/cirugía , Complicaciones Posoperatorias/cirugía , Centros Médicos Académicos , Adulto , Anastomosis Quirúrgica/métodos , Bases de Datos Factuales , Femenino , Estudios de Seguimiento , Derivación Gástrica/efectos adversos , Humanos , Laparoscopía/métodos , Masculino , Persona de Mediana Edad , Obesidad Mórbida/diagnóstico , Complicaciones Posoperatorias/fisiopatología , Reoperación/métodos , Estudios Retrospectivos , Medición de Riesgo , Centros de Atención Terciaria , Factores de Tiempo , Emiratos Árabes Unidos , Pérdida de PesoRESUMEN
BACKGROUND: Post-surgical gastroparesis (psGP) is putatively related to vagal denervation from either therapeutic transection or inadvertent injury. Here, we present a series of patients undergoing endoscopic per-oral pyloromyotomy (POP) as a treatment for medically refractory psGP. METHODS: Patients identified from a prospectively maintained database of patients undergoing POP procedures at our institution from January 2016 to January 2018 were included. Surgical history, symptom scores, and gastric emptying studies before and 3 months after POP were additionally recorded. RESULTS: During the study period, 177 POP procedures were performed, of which 38 (21.5%) were for psGP. The study cohort was 84.2% female with a mean body mass index of 27.6 kg/m2 and mean age of 55.2 years. Common comorbidities included hypertension (34.2%), depression (31.6%), and gastroesophageal reflux disease (28.9%). Hiatal/paraesophageal hernia repair (39.5%) or fundoplication (36.8%) preceded psGP diagnosis most often. The mean operative time was 30 ± 20 min. There were no intraoperative complications. Mean postoperative length of stay was 1.2 days. There were two readmissions within 30 days, one for melena and one for dehydration. The mean improvement in total Gastroparesis Symptom Index Score was 1.29 (p = 0.0002). The mean 4-h gastric retention improved from a pre-POP mean of 46.4 to 17.9% post-POP. Normal gastric emptying was noted in 50% of subjects with available follow-up imaging. CONCLUSION: POP is a safe and effective endoscopic therapy for patients with psGP. POP should be considered a reasonable first-line option for patients with medically refractory psGP and may allow stomach preservation.
Asunto(s)
Gastroparesia/cirugía , Piloromiotomia/métodos , Adulto , Anciano , Endoscopía Gastrointestinal , Femenino , Fundoplicación/efectos adversos , Vaciamiento Gástrico , Reflujo Gastroesofágico/cirugía , Gastroparesia/tratamiento farmacológico , Gastroparesia/etiología , Hernia Hiatal/cirugía , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Tempo Operativo , Complicaciones Posoperatorias/tratamiento farmacológico , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Retratamiento , Resultado del TratamientoRESUMEN
OBJECTIVE: Hospitalized patients are exposed to more than 1 medication error per day, but there are limited data concerning the factors associated with medication order errors made by general surgery residents. The objective of this study was to identify patterns in medication order errors amongst general surgery residents, which may provide educational targets to reduce medication errors by this population of providers. DESIGN: This study used a retrospective cohort design to review inpatient medication orders placed via a computerized physician order entry system by general surgery residents at a single academic medical center from July 2011 to February 2018. SETTING: A single large academic medical center located in the Midwest, United States. PARTICIPANTS: General surgery residents completing residency between July 2011 and February 2018 and their respective inpatient medication orders. RESULTS: Of 571,811 included medication orders placed by 169 unique general surgery residents, 4.2% (nâ¯=â¯24,177) triggered pharmacist intervention, and 11 (0.001%) resulted in significant near-miss events. Of orders requiring pharmacist intervention, most were either duplicate therapies (nâ¯=â¯8703, 36.1%) or errors in renal dosing (nâ¯=â¯7576, 31.3%). Error rates were higher within pharmaceutical classes ordered less frequently, with the notable exception of antimicrobials and anticoagulants, which accounted for 20.1% (nâ¯=â¯5280) and 13.5% (nâ¯=â¯3270) of all order errors, respectively. In a multivariable model, errors were more likely to occur in the intensive care unit versus other units (ORâ¯=â¯1.21, 95%CIâ¯=â¯1.14-1.29) and in August versus other months (ORâ¯=â¯1.09, 95%CIâ¯=â¯1.01-1.17), but were independent of other resident and order characteristics. CONCLUSIONS: This study identified that resident medication order errors are common and are associated with specific therapeutic classes, the beginning of academic years, and intensive care unit patients. These findings represent potential targets for educational interventions and highlight the role of interdisciplinary teams in providing quality surgical care.
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Cirugía General/educación , Internado y Residencia/métodos , Errores de Medicación/prevención & control , Estudios de Cohortes , Humanos , Estudios RetrospectivosRESUMEN
INTRODUCTION: A subset of patients undergoing laparoscopic sleeve gastrectomy (SG) require eventual conversion to Roux-en-Y gastric bypass (RYGB) due to complications from SG or to enhance weight loss. The aim of this study is to characterize the indications for conversion and perioperative outcomes in a large cohort of these patients at a single institution. METHODS: Patients who underwent revisional surgery to convert SG to RYGB at our institution from January 2008 through January 2017 were retrospectively reviewed. RESULTS: Eighty-nine patients with previous SG underwent conversion to RYGB as part of a planned two-stage approach to gastric bypass (n = 36), for weight recidivism (n = 11), or for complications related to SG (n = 42). Complications from SG that warranted conversion included refractory GERD (40.5%), sleeve stenosis (31.0%), gastrocutaneous (16.7%), or gastropleural (7.1%) fistula, and gastric torsion (4.1%). The mean (SD) age was 47.2 years (11.4 years) and median BMI at the time of revision was 43.2 kg/m2. A laparoscopic approach was successfully completed in 76 patients (85.4%), with an additional of four completed robotically (4.5%). The median length of stay was 3 days. Twenty-eight patients (31.5%) had complications which included surgical site infection (20.2%), re-operation (6.7%), anastomotic stricture (3.4%), and one pulmonary embolism. There were no mortalities with a median follow-up of 15 months. CONCLUSIONS: Conversion of SG to RYGB is safe and technically feasible when performed for complications of SG or to enhance weight loss. This operation can be successfully performed laparoscopically with a low rate of conversion and reasonable complication profile.
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Gastrectomía , Derivación Gástrica , Obesidad Mórbida , Reoperación , Adulto , Gastrectomía/efectos adversos , Gastrectomía/estadística & datos numéricos , Derivación Gástrica/efectos adversos , Derivación Gástrica/métodos , Derivación Gástrica/estadística & datos numéricos , Humanos , Persona de Mediana Edad , Obesidad Mórbida/epidemiología , Obesidad Mórbida/cirugía , Reoperación/efectos adversos , Reoperación/métodos , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Traditionally, anticancer chemotherapy has been generally considered to be strongly immunosuppressive. However, increasing evidence suggests that certain chemotherapeutic agents rely on the induction of antitumor immune responses, in both experimental animal models and patients with cancer. Many of these chemotherapeutic agents exert immunogenic effects via the induction and release of immunostimulatory "danger" signals from dying cancerous cells when used in low doses. New data suggests that several common chemotherapeutic agents may also display direct stimulating effects on immune cells even when applied in ultra-low concentrations (chemoimmunomodulation). Importantly, it is becoming clear that both immune effector cells and immune regulatory cells can be targeted by various chemotherapeutic agents to produce favorable antitumor immune responses. Therefore, utilizing cancer drugs to enhance host antitumor immunity should be considered a feasible therapeutic approach; and recent characterization of the immunomodulatory mechanisms of anticancer chemotherapy using both new and traditional cytotoxic agents suggests that combinations of these approaches with "classical" immunomodulatory agents could lead to a viable new therapeutic paradigm for the treatment of cancer.
RESUMEN
BACKGROUND: Sublobar wedge resection is associated with an increased risk of locoregional recurrence (15-20%) compared with lobectomy for early non-small cell lung cancer (NSCLC). We have previously shown that the addition of brachytherapy mesh at the time of sublobar resection might decrease the risk of local recurrence in this setting, equivalent to that of lobectomy [Santos et al. Surgery 2003;134:691-7]. In the current study, we evaluated the impact of brachytherapy mesh implantation after formal anatomic segmentectomy on local recurrence rates in the management of clinical stage I NSCLC. METHODS: We undertook a retrospective review of 369 patients undergoing anatomic segmentectomy for clinical stage I NSCLC from 2002 to 2010 with (n = 155) or without (n = 214) the use of I(131) brachytherapy mesh applied over the staple line. The primary end point was local recurrence. Secondary end points included morbidity, mortality, and recurrence-free survival. RESULTS: Patients undergoing brachytherapy mesh implantation were older (71.0 vs 69.0 years, P = .03) and had larger tumors (2.3 cm vs 2.0 cm, P = .001) compared with those treated without mesh. There were no differences noted in sex, histology, or tumor stage. Overall mortality was 1.1% (mesh, 0.6%; no mesh 1.4%). Perioperative morbidity was similar in patients receiving mesh (45.8% vs 37.4%, P = .11). At a mean follow-up of 32.9 months, the overall local recurrence rate was 5.4% (mesh: 6.4% vs no mesh: 4.6%, P = .49). Five-year actuarial freedom from local recurrence was 92% in the mesh group, and 90% in patients undergoing segmentectomy without mesh (P = .24). CONCLUSION: It appears that the local recurrence noted with non-anatomic wedge resection is not an equivalent concern when anatomic segmentectomy with adequate margins are obtained. This implies that adjuvant brachytherapy after anatomic segmentectomy is not required for local control, thus avoiding the costs of radiation therapy and its associated potential toxicity. These data also suggest that proper anatomic segmentectomy alone may be associated with local recurrence rates similar to those of anatomic lobectomy in the setting of clinical stage I NSCLC.
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Braquiterapia/métodos , Carcinoma de Pulmón de Células no Pequeñas/radioterapia , Radioisótopos de Yodo/administración & dosificación , Neoplasias Pulmonares/radioterapia , Recurrencia Local de Neoplasia/epidemiología , Anciano , Carcinoma de Pulmón de Células no Pequeñas/mortalidad , Carcinoma de Pulmón de Células no Pequeñas/cirugía , Femenino , Humanos , Neoplasias Pulmonares/mortalidad , Neoplasias Pulmonares/cirugía , Masculino , Análisis Multivariante , Pennsylvania/epidemiología , Estudios Retrospectivos , Mallas QuirúrgicasRESUMEN
BACKGROUND: Thoracic surgeons are commonly consulted to provide anterior thoracic exposure for infection and malignant neoplasms involving the thoracolumbar spine. These cases can present significant technical and management challenges secondary to the underlying pathology, associated anatomic inflammation, and impaired functional status. In this study, we review the perioperative outcomes in patients undergoing anterior spinal exposure for infection and neoplasm. METHODS: 130 consecutive patients (61 women, 69 men) undergoing corpectomy, debridement, or debulking for osteomyelitis (n=50) or neoplasms (n=80) with decompression/stabilization at a single institution were analyzed. Primary endpoints included morbidity, mortality, and perioperative neurologic outcomes. RESULTS: The mean age was 61.1 years. A cervical/sternotomy (n=8) approach was used for levels C7 to T2, thoracotomy (n=79) for levels T3 to T10, and thoracoabdominal (n=43) for T11 to L2 involvement. Primary spinal neoplasms (n=22, 16.9 %) and metastases (n=58, 44.6%) were treated with corpectomy and prosthetic stabilization and were associated with increased operative time (310 vs 243 minutes, p=0.02) and blood loss (825 vs 500 mL, p=0.002). Osteomyelitis was associated with longer hospital stays (12 vs 7 days, p<0.001). The 30-day and 90-day mortality was 9.2% and 20.8%, respectively. The major complication rate was 27.7%. The median length of stay was 9 days. Surgical intervention resulted in significant improvement in pain, numbness, weakness, and bowel and bladder dysfunction. CONCLUSIONS: Anterior spinal exposure represents an important modality in facilitating the treatment of patients with osteomyelitis, pathologic fractures, and spinal cord compression syndromes. These procedures are associated with a significant risk of morbidity and mortality, but they are effective in achieving spinal stabilization and alleviating neurologic symptoms.