Bile duct injuries (BDI) in the advanced laparoscopic cholecystectomy era.

BACKGROUND: Laparoscopic cholecystectomy is the most commonly performed laparoscopic procedure. It is superior in nearly every regard compared to open cholecystectomies. The one significant aspect where the laparoscopic approach is inferior regards the association with bile duct injuries (BDI). The BDI rate with laparoscopic cholecystectomy is approximately 0.5%; nearly triple the rate compared to the open approach. We propose that 0.5% BDI rate with the laparoscopic approach is no longer accurate. METHODS: The National Surgical Quality Improvement Program (NSQIP) registry was retrospectively reviewed. All laparoscopic cholecystectomies performed between 2012 and 2016 were extracted. A total of 217,774 cases meeting inclusion criteria were analyzed. The primary data points were the overall BDI incidence rate and time of diagnosis. BDI were identified by ICD-9 and ICD-10 codes. Secondary data points were variables associated with BDI. RESULTS: The BDI rate was 0.19%. 77% of cases were diagnosed after the index surgical admission. Intra-operative cholangiography (IOC) use was associated with a higher BDI rate and higher identification rate of a BDI intraoperatively (P value < 0.0001). Resident teaching cases were protective with a RR score of 0.56 (P value < 0.0001). The presence of cholecystitis increased the risk of a BDI with a RR score of 1.20 (P value < 0.0001). There was a low conversion rate of 0.04% however converted cases had a nearly hundredfold increase in BDI at 15% (P value < 0.0001). CONCLUSIONS: The performance of laparoscopic cholecystectomies in North America is no longer associated with higher BDI rates compared to open. IOC use still is not protective against BDI, and cholecystitis continues to be a risk factor for BDI. When a cholecystectomy requires conversion from a laparoscopic to an open approach the BDI increases a hundredfold; which may raise the concern if this approach is still a safe bailout method for a difficult laparoscopic dissection.

Improved hemostasis with major hepatic resection in the current surgical era.

BACKGROUND: Major hepatic resection, predominantly performed for oncologic intent, is a complex procedure with the potential for severe intraoperative hemorrhage. The current surgical era has the ability to improve hemostasis throughout the performance of major hepatic resections which decreases blood transfusions and the detrimental effects associated with transfusion. We evaluated hemostasis and outcomes in the current surgical era of performing hepatic resections. METHODS: Utilizing the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database all major hepatic resections performed between 2012 and 2016 were analyzed in regards to hemostasis. Hemostasis was evaluated by the need for and magnitude of blood transfusions. Additional perioperative variables (including operative time, length of hospital stay, and mortality rates) were analyzed to assess for outcomes with hemostasis. The NSQIP results were compared to previous publications involving major hepatic resections to detect improvement in hemostasis and outcomes in the current surgical era. RESULTS: A total of 22777 major hepatic resections met the inclusion criteria for analysis in the NSQIP database. An additional 21198 cases were compiled within the selected publications for comparative analysis. The transfusion rate in the current surgical era was 13.3% versus 38.7% in the previous era (P = 0.0001). When a transfusion was required in the current surgical era there was a two-fold reduction in the number of units transfused (1.5 U vs. 3.8 U, P = 0.0001). Statistically significant improvements in operative time and length of hospital stay were presented within the current surgical era (P = 0.0001). When a transfusion was required there was an increased relative risk score of 7 for mortality (4.9% vs. 0.7%, P = 0.0001), however, improvement in mortality rates did not reach statistical significance across surgical eras (1.3% vs. 4.0%, P = 0.0001). CONCLUSIONS: The conduction of major hepatic resection in the current surgical era is more hemostatic. Correlated with improved hemostasis are better outcomes for both clinical and financial endpoints. These findings should encourage continued and increased performance of major hepatic resections.

Effect of three-dimensional intraoperative imaging on surgical outcomes with breast conservation therapy.

BACKGROUND: Breast conservation therapy (BCT) is frequently performed for breast cancer and associated with a significant risk for positive margins. Intraoperative three-dimensional (3-D) tomosynthesis potentially could limit the risk of positive margins. METHODS: Retrospective review of an institutional breast cancer registry. Evaluated BCT cases for a two year time period prior to and after the introduction of intraoperative 3-D tomosynthesis. Primary outcome was the effect of 3-D tomosynthesis on margin positivity rates. Secondary measures were the impact of 3-D tomosynthesis on additional margin procurements at the index surgery and operative time. RESULTS: A total of 228 cases were evaluated with 106 cases utilizing 3-D tomosynthesis and 122 cases with standard imaging. No significant difference in margin positivity rates between the cohorts at 23.9% versus 15.8% for 3-D tomosynthesis and standard imaging respectively (OR 1.53, CI 0.772-3.032, P = 0.221). 3-D tomosynthesis was associated with increased margin procurement rates (OR 2.34, 95%CI 1.303-4.190, P = 0.004) and longer operative times (P < 0.001). CONCLUSION: Intraoperative 3-D tomosynthesis was not found to limit margin positivity rates or improve the performance of the procedure.

Role of growth factors in improved skin flap viability caused by phosphodiesterase-5 inhibitor.

Flap necrosis is one of the major complications of reconstructive surgery and sildenafil citrate has been shown to decrease flap necrosis in preclinical animal models. However, the mechanisms underlying sildenafil's therapeutic efficacy are not known. As with other phosphodiesterase 5 selective inhibitors, sildenafil causes vasodilation and enhanced blood flow. In addition, sildenafil can also alter gene expression. This study is designed to test the hypothesis that increased expression of angiogenic growth factors may be responsible for therapeutic efficacy of sildenafil. A modified McFarlane flap measuring 3 x 10 cm was created on the dorsal skin of male Sprague-Dawley rats. For growth factor expression experiment, rats were administered either vehicle or sildenafil 10 mg/Kg intraperitoneal (IP). Ribonucleic acid (RNA) extracted from skin flap was analyzed to assess the messenger ribonucleic acid (mRNA) levels of different angiogenic growth factors. For skin flap viability experiment, fibrin film impregnated with vehicle, fibroblast growth factor (FGF) (5.0 microg) or vascular endothelial growth factor (VEGF) (2.0 microg) was applied to the wound. The skin flap was then returned to its native position and stapled in place. Total affected area (area of necrosis and blood flow stasis) of each rat on postoperative day 14 was analyzed with orthogonal polarization spectral imaging. Daily systemic treatment with sildenafil significantly (P < 0.05) increased the expression of FGF1 and FGF Receptor 3 on postoperative day 3 by 5.08- and 4.78-fold, respectively. In addition, sildenafil increased the expression of VEGF-A, VEGF-B, and VEGF-C by 2.66-, 2.02-, and 2.00-fold, respectively. Subcutaneous treatment with FGF but not VEGF-A tended to decrease total affected area in rats. These data demonstrate that sildenafil altered the expression of FGF and VEGF. Altered expression of growth factors may be, at least partly, responsible for the beneficial effects of sildenafil citrate on skin viability.

Disparities in Risk Reduction Therapy Recommendations for Young Women With Lobular Carcinoma In-Situ.

BACKGROUND: Endocrine therapy (ET) significantly reduces the risk of breast cancer development in high-risk patients diagnosed with lobular carcinoma in situ (LCIS). However, the variables impacting recommendation and use of ET in young adults (YAs) is not well-studied. We examined the role of provider recommendation and patient acceptance for ET for YAs with LCIS. MATERIALS AND METHODS: The National Cancer Database was queried for women aged < 40 years with primary LCIS between 2000 and 2012. Socioeconomic, demographic, and treatment variables were examined to determine their impact on ET provider recommendation and initial patient acceptance of risk-reducing therapy. RESULTS: Among 1650 YA patients with LCIS, only 749 (45.4%) were recommended ET. On multivariable analysis, women > 30 years of age were more likely recommended ET than women < 30 years (odds ratio [OR], 1.64; 95% confidence interval [CI], 1.10-2.47), African Americans more than other ethnicities (OR, 1.48; 95% CI, 1.1-2.0), and YAs treated in New England were more likely than those in the rest of the country (OR, 3.26; 95% CI, 2.0-5.2). Among YA women recommended ET, only 20.2% had a documented refusal. Only geography appeared to independently impact the likelihood of refusal, with YAs in the Southeastern-Central United States being most likely to refuse ET (OR, 5.4; 95% CI, 1.2-24.0). CONCLUSION: ET is underutilized for risk-reduction in YAs with LCIS. This underuse appears dependent on disparities in provider recommendation practices rather than non-acceptance of therapy. This may reflect regional practice patterns, community standards of care, or provider bias regarding the significance of LCIS as a risk factor for development of invasive cancer.

Evaluation of Operative Waste in a Military Medical Center: Analysis of Operating Room Cost and Waste during Surgical Cases.

Operating rooms (ORs) contribute to at least 40 per cent of hospital costs. There is an existing cost waste in ORs for surgical devices that are opened without being used. There is a paucity of data evaluating the hospital cost of opened but unused OR supplies. The goal of this observational study is to examine the cost of opened but unused OR supplies for general surgery cases. We performed a quality improvement project of OR cost waste by observing 30 cases. Surgical cases of a senior surgeon who had been at the institution for more than five years were evaluated for items opened appropriately and whether the items are used. The cases evaluated ranged from open hernia repairs to robotic-assisted hernia repairs. We found that the cost of instruments opened but not used was $4528.18. Of the cases evaluated, we found that a range of 0 per cent to 27 per cent of total items were wasted, an average of 8.3 per cent. We found that for the open inguinal hernia case, there was minimal waste. The highest waste was among complex cases such as the robotic-assisted inguinal hernia with an average waste and cost of 15.8 per cent and $379. We found that on average for less complex cases such as open inguinal hernia repairs, $1.44 was potentially wasted per case, whereas for more complex cases up to $379 was wasted per case. We identified the outdated preference cards, lack of instrument knowledge, circulating nurse, and surgical technician distractions as reasons for contributing to waste.

Pediatric-protocol of multimodal therapy is associated with improved survival in AYAs and adults with rhabdomyosarcoma.

BACKGROUND: Multimodal therapy is the standard treatment for pediatric rhabdomyosarcoma, but for adolescents and young adults (AYAs: ages 15-39) and older adults with rhabdomyosarcoma, the use of adjuvant therapy is variable, and survival is greatly decreased compared with younger patients. METHODS: All patients with rhabdomyosarcoma who had a curative operative were identified from the 1998-2012 National Cancer Database. Regression analyses identified independent factors relating to receipt of multimodal therapy (resection + chemotherapy + radiation) and the influence of multimodal therapy on 5-year overall survival. RESULTS: Of 2,312 patients, 44% were pediatric (age < 15 years), 22% AYA (ages 15-39), and 34% adult (age ≥ 40 years). Adults received multimodal therapy least often (pediatric: 62%, AYA: 46%, adults: 24%; P < .001), even after controlling for demographic characteristics, tumor features, and stage. In the entire cohort, multimodal therapy was associated with a decreased risk of death within 5 years (hazard ratio [HR] 0.72, 95% confidence interval [CI] 0.62-0.84), with similar findings after stratification by age (pediatric: HR 0.64, 95% CI 0.48-0.85; AYA: HR 0.72, 95% CI 0.55-0.95; adult: HR 0.74, 95% CI 0.58-0.93). In AYAs only, black and Hispanic patients had an increased risk of death within 5 years (black patients: HR 1.64, 95% CI 1.14-2.37; Hispanic patients: HR 1.62, 95% CI 1.11-2.36). CONCLUSION: This first large national study suggests that multimodal therapy is independently associated with improved survival for both AYAs and adults with rhabdomyosarcoma, similar to pediatric patients, but multimodal therapy is appreciably underused. Implementation of multimodal therapy for all patients could potentially improve overall outcomes of patients with rhabdomyosarcoma.