Peroral cricopharyngeal myotomy for the management of Zenker's diverticulum in the hands of a general surgeon.

BACKGROUND: The treatment of Zenker's diverticulum has been shifted from open cricopharyngeal myotomy and rigid endoscopy to the use of flexible endoscopy. Few studies evaluate general surgeon's performance of flexible endoscopic management of Zenker's diverticulum as the majority are performed by gastroenterologists. The objective of our case series is to show that general surgeons trained in surgical endoscopy can perform this procedure with favorable outcomes. METHODS: A retrospective review of peroral cricopharyngeal myotomies performed at Spectrum Health hospital in Grand Rapids, Michigan by a single surgical endoscopist between the 2018 and 2021 was conducted. The primary outcome was the improvement of dysphagia. Intra-procedural complications, post-procedural complications, hospital length of stay, time to oral intake, and recurrence were also evaluated. Age, sex, body mass index, diverticulum size, and procedure time were abstracted. Median (ranges) and frequencies (percentages) are used to describe the patient population and outcomes. RESULTS: Forty patients were included in the study. Median age was 74 years old (60-95) with a male predominance (n = 27, 67.5%). Median BMI was 28 kg/m2 (18-43), average procedure length of 64 min (41-119), diverticulum size of 28 mm (19-90), and average length of stay of 0.9 days (0-8). There were no intra-procedural complications. All patients had a post-procedural esophagram prior to initiation of diet. Esophageal leak was the only complication that occurred, which was found on post-procedural esophagram (n = 5). Only two patients had clinical sequelae. All leaks closed without additional surgical intervention. The majority of patients had their diet resumed and discharged the same day of the procedure. Frequency of recurrence was 17.5% (n = 7). CONCLUSION: Our study demonstrates that general surgeons trained in endoscopy can perform endoscopic myotomies for Zenker's diverticula on a wide range of sizes, with favorable patient outcomes, and few complications.

The robot can break bars with the best of them: a novel approach to treating cricopharyngeal bars with myotomy.

INTRODUCTION: Failure of the cricopharyngeus to relax results in oropharyngeal dysphagia, which over time results in hypertrophy and increased risk for aspiration. Open myotomy is one definitive treatment option, however there are several drawbacks attributable to the long neck incision, ± drain placement, and invasiveness of the procedure. We aim to share our experience using the DaVinci robotic platform to perform a minimally invasive cricopharyngeal myotomy, which has never been described before in the literature. METHODS: All robotic cricopharyngeal myotomies performed in adult patients by a single surgeon from 2021 to 2022 were retrospectively reviewed. No patients were excluded. Outcomes of interest included length of procedure, time to diet resumption, hospital length of stay, complications, symptom improvement at follow-up, and symptom recurrence. RESULTS: Eight robotic cricopharyngeal myotomies were performed. The median age was 65 years old (62-91) and mostly female (n = 5, 56%) with a median BMI of 28.9 kg/m2 (21.7-39.5). The median procedure length was 113 min (94-141) and there were no intraoperative complications. All patients underwent a post-procedural esophagram with no leaks were identified. All patients were started on clear liquids in recovery and transitioned to full liquids prior to discharge. All but one patient was subsequently discharged home on the same day as procedure. All patients had routine 2-week post-operative follow-up in addition to phone follow-up at a later date (6-11 months post-operative). All patients reported resolution of symptoms. There were no complications or readmissions. No instances of recurrence were reported. On cost analysis, the minimally invasive robotic approach allows for an outpatient procedure with similar cost to an open approach with a one-night stay. CONCLUSION: Our experience with the novel technique of minimally invasive robotic cricopharyngeal myotomy for cricopharyngeal bars with cervical dysphagia is safe, efficacious, less invasive, and cost saving, with excellent patient outcomes.

Direct to Operating Room for Decompressive Craniotomy/Craniectomy in Patients With Traumatic Brain Injury.

BACKGROUND: Emergent decompressive craniotomy/craniectomy can be a lifesaving surgical intervention for select patients with traumatic brain injury. Prompt management is critical as early decompression can impact traumatic brain injury outcomes. OBJECTIVE: This study aims to describe the feasibility and clinical impact of a new pathway for transporting patients with severe traumatic brain injury directly to the operating room from the trauma bay for decompressive craniotomy/craniectomy. METHODS: This is a retrospective cohort preintervention and postintervention study of severe traumatic brain injury patients undergoing decompressive craniectomy/craniotomy at a Midwestern U.S. Level I trauma center between 2016 and 2022. In the new pathway, the in-house trauma surgeon takes the patient directly to the operating room with the neurosurgery advanced practice provider to drape and prepare the patient for surgery while the neurosurgeon is en route to the hospital. RESULTS: A total of 44 patients were studied, five (5/44, 11.4%) of which were in the preintervention group and 39 (39/44, 88.6%) in the postintervention group. The median arrival-to-operating room time was shorter in the postintervention cohort (1.4 hr) than in the preintervention cohort (1.5 hr). In examining night shifts only, the preintervention cohort had shorter arrival-to-operating room times (1.2 hr) than the postintervention cohort (1.5 hr). CONCLUSION: The study demonstrated that the new pathway is feasible and expedites patient transport to the operating room while awaiting the arrival of the on-call neurosurgeon.

Surgical Trainee Performance and Alignment With Surgical Program Director Expectations.

OBJECTIVE: To examine the alignment between graduating surgical trainee operative performance and a prior survey of surgical program director expectations. BACKGROUND: Surgical trainee operative training is expected to prepare residents to independently perform clinically important surgical procedures. METHODS: We conducted a cross-sectional observational study of US general surgery residents' rated operative performance for Core general surgery procedures. Residents' expected performance on those procedures at the time of graduation was compared to the current list of Core general surgery procedures ranked by their importance for clinical practice, as assessed via a previous national survey of general surgery program directors. We also examined the frequency of individual procedures logged by residents over the course of their training. RESULTS: Operative performance ratings for 29,885 procedures performed by 1861 surgical residents in 54 general surgery programs were analyzed. For each Core general surgery procedure, adjusted mean probability of a graduating resident being deemed practice-ready ranged from 0.59 to 0.99 (mean 0.90, standard deviation 0.08). There was weak correlation between the readiness of trainees to independently perform a procedure at the time of graduation and that procedure's historical importance to clinical practice ( p = 0.22, 95% confidence interval 0.01-0.41, P = 0.06). Residents also continue to have limited opportunities to learn many procedures that are important for clinical practice. CONCLUSION: The operative performance of graduating general surgery residents may not be well aligned with surgical program director expectations.

Timing of mastectomy and the effect on the likelihood of outpatient surgery and cost savings in breast cancer patients.

BACKGROUND: Same-day discharge after mastectomy has potential patient- and hospital-level benefits; however, few data are available regarding factors affecting the likelihood of same-day discharge in order to address barriers. We sought to evaluate factors contributing to same-day discharge, focusing on the timing of mastectomy during the operative day. METHODS: We conducted a single-institution retrospective review of patients who underwent mastectomies for malignancy over a 3-y time frame. Clinicopathologic variables were collected along with a binary variable for mastectomy start time (morning versus afternoon). Our primary endpoint was rate of same-day discharge. A multivariable logistic regression model was constructed from significant univariate variables to determine independent predictors of same-day discharge. A secondary endpoint was a cost-utility analysis for morning versus afternoon start time, using hospital cost data. RESULTS: There were 451 patients included in the analysis. Factors associated with same-day discharge rate included the American Society of Anesthesiologists score, use of a preoperative regional anesthesia block, type of mastectomy performed, individual surgeon variation, and a morning start for the mastectomy. On multivariable analysis, morning start was a strong independent predictor of same-day discharge (odd ratio = 2.83; 95% CI, 1.75-4.60). The cost-utility analysis favored a morning start, with average cost savings of $550 per patient. CONCLUSION: Despite patient- and surgeon-specific variations, simple scheduling policies can improve same-day discharge rates after mastectomy, leading to improved hospital bed use and cost reduction.

Neoadjuvant Chemotherapy and Radiation Improves Recurrence-free and Overall Survival in Resectable and Borderline Resectable Pancreatic Ductal Adenocarcinoma.

OBJECTIVE: The objective of this study is to analyze the outcomes of patients with resectable/borderline resectable PDAC who receive total neoadjuvant therapy vs upfront surgery. METHODS AND ANALYSIS: Patients who were treated at a single institution from 2006 to 2021 were included. The primary outcome was overall survival (OS). Secondary outcomes included disease free survival (DFS), rates of lymph node positivity, and R0 resection. All survival analyses were performed with intention-to-treat. RESULTS: 26 patients received neoadjuvant chemotherapy and radiation (TNT), 28 received neoadjuvant chemotherapy only (NAC), and 168 received upfront surgery. Demographics were comparable across all three groups. Patients who received TNT or NAC had longer OS and DFS compared to the surgery first patients (P < .01). Patients who received TNT had a lymph node positivity rate of 0% at time of surgery compared to 5.3% and 13.3% in the NAC and surgery-first groups, respectively (P < .01). The rate of R0 resection did not differ between groups (P = .17). CONCLUSION: Patients with resectable/borderline resectable PDAC who receive neoadjuvant therapy have longer OS and RFS relative to those who receive upfront surgery.

Telemedicine: Does it have a place in surgical oncology practice?

BACKGROUND: Telemedicine has gained traction in surgical subspecialties, particularly since the COVID-19 pandemic. This study aims to identify whether telemedicine can be appropriately integrated within surgical oncology practice. METHODS: This retrospective study evaluated patients who received either telemedicine or office follow-up after undergoing surgical oncology operations between 2016 and 2021. The telemedicine group (TG) and office group (OG) received a 15-question survey regarding their satisfaction with their care. Patient outcomes and responses were analyzed utilizing propensity-score matching in 1:1 fashion. RESULTS: Telemedicine group and OG each had 21 patients. Length of stay, complication frequency, follow-up frequency, and readmissions frequency within 90-days were comparable between groups. Telemedicine group expressed comparable satisfaction with postoperative care relative to OG (95.2% vs. 85.7%, p = 0.61). All telemedicine patients said they would utilize telemedicine again in the future and would recommend its use to others. CONCLUSION: Patient satisfaction with postoperative telemedicine follow-up is comparable to those with in-person follow-up.

The international variability of surgery for rectal prolapse.

Objective: There is a lack of consensus regarding the optimal approach for patients with full-thickness rectal prolapse. The aim of this international survey was to assess the patterns in treatment of rectal prolapse. Design: A 23-question survey was distributed to the Pelvic Floor Consortium of the American Society of Colorectal Surgeons, the Colorectal Surgical Society of Australia and New Zealand, and the Pelvic Floor Society. Questions pertained to surgeon and practice demographics, preoperative evaluation, procedural preferences, and educational needs. Setting: Electronic survey distributed to colorectal surgeons of diverse practice settings. Participants: 249 colorectal surgeons responded to the survey, 65% of which were male. There was wide variability in age, years in practice, and practice setting. Main outcome measures: Responses to questions regarding preoperative workup preferences and clinical scenarios. Results: In preoperative evaluation, 19% would perform anorectal physiology testing and 70% would evaluate for concomitant pelvic organ prolapse. In a healthy patient, 90% would perform a minimally invasive abdominal approach, including ventral rectopexy (56%), suture rectopexy (31%), mesh rectopexy (6%) and resection rectopexy (5%). In terms of ventral rectopexy, surgeons in the Americas preferred a synthetic mesh (61.9% vs 38.1%, p=0.59) whereas surgeons from Australasia preferred biologic grafts (75% vs 25%, p<0.01). In an older patient with comorbidities 81% would perform a perineal approach. Procedure preference (Delormes vs Altmeier) varied according to location (Australasia, 85.9% vs 14.1%; Europe, 75.3% vs 24.7%; Americas, 14.1% vs 85.9%). Most participants were interested in education regarding surgical approaches, however there is wide variability in preferred methods. Conclusion: There is significant variability in the preoperative evaluation and surgery performed for rectal prolapse. Given the lack of consensus, it is not surprising that most surgeons desire further education on the topic.

Does Hispanic ethnicity play a role in outcomes for diverticular surgery in the USA?

OBJECTIVE: The aim of this study is to investigate whether origins of ethnicity affect the outcomes of surgery for diverticulitis in the USA. DESIGN: The American College of Surgeons National Surgical Quality Improvement Programme database from 2008 to 2017 was used to identify patients undergoing colectomy for diverticulitis. Patient demographics, comorbidities, procedural details and outcomes were captured and compared by ethnicity status. RESULTS: A total of 375 311 surgeries for diverticulitis were included in the final analysis. The average age of patients undergoing surgery for diverticulitis remained consistent over the time frame of the study (62 years), although the percentage of younger patients (age 18-39 years) rose slightly from 7.8% in 2008 to 8.6% in 2017. The percentage of surgical patients with Hispanic ethnicity increased from 3.7% in 2008 to 6.6% of patients in 2017. Hispanic patients were younger than their non-Hispanic counterparts (57 years vs 62 years, p<0.01) at time of surgery. There were statistically significant differences in the proportion of laparoscopic cases (51% vs 49%, p<0.01), elective cases (62% vs 66%, p<0.01) and the unadjusted rate of postoperative mortality (2.8% vs 3.4%, p<0.01) between Hispanic patients compared with non-Hispanic patients, respectively. Multivariable logistic regression models did not identify Hispanic ethnicity as a significant predictor for increased morbidity (p=0.13) or mortality (p=0.80). CONCLUSION: Despite a significant younger population undergoing surgery for diverticulitis, Hispanic ethnicity was not associated with increased rates of emergent surgery, open surgery or postoperative complications compared with a similar non-Hispanic population.

Comparison of Robotic, Laparoscopic, and Open Unilateral Repair of Non-recurrent Inguinal Hernia.

BACKGROUND: There is a paucity of data comparing open, robotic, and laparoscopic approaches on unilateral, non-recurrent inguinal hernias. Our study presents a large, retrospective triple-arm outcome analysis between robotic, laparoscopic, and open unilateral, non-recurrent inguinal hernia repairs at a single institution. METHODS: 706 patients who underwent elective, non-recurrent inguinal hernia repair performed by 8 general surgeons at a single institution from 2016 to 2019 were reviewed retrospectively. Patient baseline characteristics, operative times, resident involvement, and postoperative outcomes were analyzed for all repair types. A cost analysis of the different procedures was performed. RESULTS: There were 305 laparoscopic repairs, 207 robotic repairs, and 194 open repairs. Open and laparoscopic repairs were performed on patients who were older (p =< .001) and with a higher Charlson Comorbidity Index (p =< .001). Patient BMI was higher in minimally invasive repair than open repair (P = .021). There were no significant differences in complication rates on pairwise analysis. Robotic and open repairs had significantly longer operative times than laparoscopic repairs (P < .001). There was less resident involvement in robotic repair than with the other approaches (P < .001). Resident involvement was associated with shorter OR times (P = .001) and no significant difference in postoperative complications. There was a trend over the study period toward faster operative times and more robotic repair. Robotic repair is the most expensive repair, followed by laparoscopic and open repairs. CONCLUSION: All 3 repair techniques can be performed without significant differences in outcomes. The technique utilized should be based on surgeon preference and patient characteristics.

Representativeness of Workplace-Based Operative Performance Assessments for Resident Operative Experience.

OBJECTIVE: Workplace-based assessment is increasingly prevalent in surgical education, especially for assessing operative skill. With current implementations, not all observed clinical performances are assessed, in part because trainees often have discretion about when they seek assessment. As a result, these samples of observed operative performances may not be representative of the full breadth of experience of surgical trainees. Therefore, analyses of these samples may be biased. We aimed to benchmark patterns of procedures logged in the SIMPL operative performance assessment system against records of trainee experience in Accreditation Council for Graduate Medical Education (ACGME) case logs. DESIGN: We analyzed SIMPL longitudinal intraoperative performance assessments from categorical trainees in US general surgery residency programs. We compared overall patterns of how procedures are logged in SIMPL and in ACGME case logs using a Pearson correlation, and we examined differences in how individual procedures are logged in each system using Fisher's exact test. RESULTS: Total procedure frequency from the SIMPL dataset was strongly correlated with total procedure frequency from ACGME case logs (r = 0.86, 95% CI 0.80-0.90). A subset of these procedures (10 of 116 procedures) was logged more frequently in the SIMPL dataset. These 10 procedures accounted for 56% of SIMPL observations and 30% of ACGME logged cases. Case complexity was comparable for assessments initiated by residents and faculty. CONCLUSIONS: Samples of intraoperative performance ratings gathered using the SIMPL application largely resemble ACGME case logs. There is no evidence to indicate that residents preferentially select fewer complex cases for assessment.

Shortened pre-clerkship medical school curriculum associated with reduced student performance on surgery clerkship shelf exam.

BACKGROUND: Many U.S. medical schools are modifying their curricula with limited understanding of the impact on students' clinical knowledge. METHODS: The surgical rotations and Surgery Shelf Exam score reports of 1514 students at a single medical school over nine academic years (2010-2018), which included a four-year transition period to a condensed pre-clerkship curriculum. Subject-specific results were compared by rotation type using Mann-Whitney tests. Regression analysis was used to assess the relationship between scores and time. RESULTS: Data from 1514 students were included. Shelf scores decreased each year of the transition curriculum compared to the reference year (2014-2015). However, clinical exposure to specific rotations resulted in better scores in related shelf subjects. For example, students who rotated on Vascular Surgery achieved statistically better scores on the related subject than their colleagues (3.62 vs. 3.44; p = 0.0014). CONCLUSIONS: The transition curriculum was associated with a lower performance on the surgical shelf exam when compared to the traditional curriculum, regardless of when surgery was taken during their clerkship year.

Post-traumatic intercostal and diaphragm hernias following a sneezing episode.

Trauma and sneeze-induced or cough-induced intercostal and diaphragm hernias are both rare phenomena, especially in combination. Management of these hernias is not well described, and there is no good evidence to guide operative management. Here we describe a rare presentation of coexisting intercostal and diaphragm hernias and surgical management with primary repair via a thoracotomy.