Predictive Factors for Developing GERD After Sleeve Gastrectomy: Is Preoperative Endoscopy Necessary?

INTRODUCTION: Sleeve gastrectomy (SG) is the most common bariatric procedure performed in the USA. There is a concern for new gastroesophageal reflux disease (GERD) and Barrett's esophagus after SG. Endoscopic screening before bariatric surgery is controversial. We sought to identify preoperative endoscopic factors that may predict the development of GERD after SG. METHODS: We prospectively evaluated 217 patients undergoing primary robotic-assisted SG. All patients underwent endoscopy before SG and for-cause postoperatively. Patients were followed for the development of GERD, diagnosed by either biopsy-proven reflux esophagitis or a positive esophageal pH test. Patients were separated into 2 groups: Those who developed GERD after surgery (GERD group) and those who did not (No GERD group). Patients with a positive preoperative pH test, LA Grade B or greater esophagitis, or hiatal hernia > 5 cm on preoperative endoscopy were counseled to undergo gastric bypass and excluded. RESULTS: There were more males in the No GERD group (25.6% vs. 8.1%; p = 0.02). More patients had preoperative heartburn symptoms in the GERD group (40.5% vs. 23.9%; p = 0.04). Endoscopically identified esophagitis was more common in the GERD group (29.7% vs. 13.3%; p = 0.01), as was biopsy-proven esophagitis (24.3% vs. 11.1%; p = 0.03). There was no significant difference in the incidence or size of hiatal hernia or in the rate of H. pylori infection between the groups. On multivariate analysis, the strongest predictors of GERD after SG were endoscopically identified esophagitis (odds ratio [OR] 2.79; 95% confidence interval [CI]1.17-6.69; p = 0.02) and biopsy-proven esophagitis (OR 2.80; 95% CI 1.06-7.37; p = 0.04). Male patients were less likely to develop GERD after SG (OR 0.23; 95% CI 0.06-0.85; p = 0.03). CONCLUSION: Our findings strengthen the rationale for routine preoperative endoscopy and highlight critical clinical and endoscopic criteria that should prompt consideration of alternatives to SG for weight loss.

A cost analysis of two- versus three-instrument robotic-assisted inguinal hernia repair with mesh: time is money.

Equipment expenses and operating times can lead to higher costs with robotic surgery. We compared the cost-effectiveness of 2- vs. 3-instrument (2i vs. 3i) approach to robotic transabdominal preperitoneal inguinal hernia repair. We conducted a retrospective study of 172 patients, with 86 patients in each group. Procedure cost, operative time, morbidity, length of stay, readmission rate, and hernia recurrence at 90 days were compared. Statistical significance was assigned to p < 0.05. No significant differences in preoperative variables nor in postoperative outcomes were identified. Mean operative time was 6 min longer in the 2i group and this approach cost $300 less. The 2i approach was cost-effective for operating room (OR) costs of less than $50 per minute. Surgeon efficiency and OR dollar-per-minute value influence the potential for cost savings with fewer instruments in robotic herniorrhaphy. There is no difference in outcomes when fewer instruments are used.

Bupivacaine liposome use reduces length of post-anesthesia care unit stay and postoperative narcotic use following robotic inguinal herniorrhaphy.

In the current opioid crisis, multimodal analgesic protocols should be considered to reduce or eliminate narcotic usage in the postoperative period. We assess the impact of bupivacaine liposome used along with a standard analgesia protocol following robotic inguinal hernia repair. A retrospective review of a prospectively maintained data including robotic inguinal hernia repairs (IHR) by two surgeons in the United States was performed. Within a multimodal analgesic protocol, local anesthetic was administered intraoperatively. One group received a mix of bupivacaine and bupivacaine liposome (BL), and one received standard bupivacaine (SB). Recovery room and home opiate doses were recorded. Primary outcomes included length of stay (LOS) and postoperative medication requirements. Statistical analysis was performed using Chi-square or Fisher's exact test and Mann-Whitney U test as appropriate. 122 robotic IHRs were included; 55 received BL and 67 received SB. Hospital LOS (hours) was reduced in the BL group (2.8 ± 1.1 vs 3.5 ± 1.2; p = 0.0003). There was no significant difference in recovery room parenteral MME requirements between the groups; however, BL group had less oral MME requirements (5.0 ± 6.5 MME vs. 8.1 ± 6.9 MME, p = 0.02). The BL group had a higher rate of zero opiate doses at home (44% vs 5%, p = 0.0005). Of those that did require opiates at home, there was a significant reduction in number of narcotic pills used by the BL compared to the SB group (median 1 vs 5, respectively; p < 0.0001). Intraoperative administration of BL as part of a pain management protocol may decrease length of hospital stay, and reduce or eliminate the need for narcotic analgesic use at home.

Safety and effectiveness of 1-stage conversion of adjustable gastric band-to-sleeve gastrectomy: a single-institution case-control study.

BACKGROUND: Patients are increasingly referred for conversion of laparoscopic adjustable gastric band (LAGB) to laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (SG). The safety of a 1- versus 2-stage approach to this revision is debated. OBJECTIVES: We examined the safety and efficacy of 1-stage conversion of LAGB to SG at our institution. SETTING: University hospital. METHODS: An institutional database was used to retrospectively identify patients who underwent single-stage LAGB-to-SG conversion between 2010 and 2018. Patients were matched 1:1 for age, sex, and body mass index with primary SG patients during this same period. Primary endpoints were operative time, complication rate, length of hospital say, and weight loss 12 months from surgery. RESULTS: Two-hundred and twenty-nine patients undergoing conversion of LAGB to SG were identified. Median postoperative length of hospital stay was 2 days. Two patients (.8%) developed surgical site infection. One patient (.4%) developed a postoperative myocardial infarction. There were 4 total readmissions (1.7%) and 1 reoperation within 30 days (.4%). There were no statistically significant differences in 30-day complication rates between groups. Weight loss at 12 months was significantly different: Median body mass index loss for conversion patients was 5.1 kg/m2 compared with 8.85 kg/m2 for patients in the primary SG group (P < .0001). CONCLUSION: Single-stage conversion of LAGB to SG is safe and effective. Patients may not experience the same extent of weight loss as those with primary SG. Our findings represent the largest single-institutional experience to date and support a 1-stage approach whenever feasible.

Surgeon Burnout: Defining, Identifying, and Addressing the New Reality.

Surgeon wellness is a multidimensional commitment that encompasses occupational, mental, physical, emotional, and social domains. Loss of professional control, autonomy, and flexibility; inefficient processes; disjointed workplace relationships and goals; excessive administrative burdens; poor work-life balance; and frustrations with medical record and order entry systems have all been associated with burnout. Described as a syndrome of emotional exhaustion, depersonalization, and loss of a sense of personal accomplishment, burnout can have myriad untoward consequences. The strong link between surgeons' personal and professional identities can lead to a perfect storm of burnout, depression, compromised patient safety and quality of care, physician job loss and career dissatisfaction, substance abuse, damage to personal relationships, and suicide. The alarming scope of this problem cannot be confined to a single specialty or practice setting and is expected to increase without much needed changes to surgeon work practices and work environments. A heightened focus on wellness in the workplace with attention to improving workflow, scheduling, collaboration, and resource allocation is a welcome step taken by several institutions and championed by professional societies. Much more research is needed to reliably gauge the overall effectiveness of these approaches, further address the nuances of burnout as it applies specifically to surgeons, and ensure that members of the surgical workforce remain at their peak throughout the duration of their careers.

Early versus late salvage abdominoperineal resection for anal squamous cell carcinoma: Is there a difference in survival?

BACKGROUND/OBJECTIVES: The first-line treatment for anal squamous cell carcinoma is Nigro protocol chemoradiotherapy. Some patients will fail curative intent chemoradiotherapy and have persistent disease while others may have an initial response followed by disease recurrence. The goal of this study is to investigate survival in anal squamous cell carcinoma patients who fail first-line treatment. METHODS: The National Cancer Database (2004-2013) was used to identify patients with anal squamous cell carcinoma. The primary outcome was overall survival. RESULTS: There were 256 patients in the early salvage group who underwent abdominoperineal resection (APR) within 6 months of completing chemoradiotherapy and 181 patients in the late salvage group who had APR 6 months or more after completion of chemoradiotherapy. Both groups of patients had similar tumor size (45 vs 50 mm; P = 0.07) and rate of positive margins (21.5% vs 15.6%;P = 0.13). There was no significant difference in overall survival between early and late salvage APR (hazard ratio [HR]: 0.81; 95% confidence interval [CI]: 0.50-1.32; P = 0.40). CONCLUSIONS: The overall survival of anal squamous cell carcinoma patients undergoing early vs late salvage APR after failure of chemoradiotherapy is similar. As a result, patients with persistent disease should be offered surgery just as readily as those with recurrent disease.

Contemporary Surgical Management and Outcomes for Anal Melanoma: A National Cancer Database Analysis.

BACKGROUND: Anal melanoma is a rare disease with a poor prognosis. Limited data are available regarding oncologic outcomes during the last decade and surgical practice patterns. This study aimed to investigate survival and operative oncologic outcomes for patients with anal melanoma. METHODS: The National Cancer Database (2004-2013) was used to identify patients with nonmetastatic anal melanoma who underwent surgical treatment. The primary outcome was overall survival. RESULTS: The study enrolled 439 patients in the local excision group and 214 patients in the abdominoperineal resection (APR) group. The patients in the APR group were older (70 vs 65 years; p < 0.001) and had larger tumors (40 vs 25 mm; p < 0.001). After resection, the APR patients were more likely to have positive lymph nodes (65.7% vs 12.5%; p < 0.001) and less likely to have positive margins (10% vs 29.8%; p < 0.001). Overall survival did not differ significantly between the APR and local excision patients (hazard ratio [HR], 0.82; 95% confidence interval [CI], 0.67-1.01; p = 0.06). The patients undergoing local excision showed was a significant survival advantage for those with negative margins (HR, 0.70, 95% CI, 0.53-0.93; p = 0.009). Among the patients undergoing APR, a significant survival advantage was observed for those with negative nodes (HR, 0.50; 95% CI, 0.35-0.69; p = 0.002) and negative margins (HR, 0.34; 95% CI, 0.15-0.77; p < 0.001). CONCLUSIONS: The overall survival of anal melanoma patients is similar after local excision and APR. Patients with positive margins, positive lymph nodes, or both have a significantly decreased overall survival.

A Rare Case of Interdigitating Dendritic Cell Sarcoma of the Rectum: Review of Histopathology and Management Strategy.

Interdigitating dendritic cell sarcoma (IDCS) is a rare neoplasm arising from a subclass of dendritic cells, known for their role in mediating various immunological functions, including T-cell mediated immunity. Although existing literature on IDCS is limited to scattered reports, extranodal manifestation in the gastrointestinal tract, and in particular, the rectum is extremely rare. To our knowledge, we report only the second case of IDCS arising in the rectum in a young 20-year-old man, successfully managed surgically and with a good oncological outcome. Existing literature on the incidence, pathophysiology and treatment strategies is also examined.

The Development of Enhanced Recovery After Surgery Across Surgical Specialties.

BACKGROUND: Enhanced recovery after surgery (ERAS®) principles have gained traction in variety of surgical disciplines. The promise of a reduced length of stay without compromising patient safety or increasing readmission rates has produced a body of literature examining the implementation of ERAS in the care of general, thoracic, urologic, and gynecologic surgery patients. METHODS: We performed a review of the literature pertaining to studies of ERAS implementation across colorectal surgery, general surgery, thoracic surgery, urology, and gynecology. The extent of ERAS implementation and reported outcomes across key studies as well as systematic reviews and meta-analyses in each field were summarized. RESULTS: The implementation of ERAS protocols has not been uniform across surgical specialties. Despite this, ERAS has produced improvements in patient outcomes. The most commonly described benefit of ERAS application has been reduced length of stay; complication and readmission rates are most consistently decreased in the colorectal literature. Studies have started to measure more nuanced measures of postoperative patient well-being. Efforts are growing to standardize ERAS protocols across diverse fields and call attention to the need for quality control. CONCLUSIONS: Challenges remain in the study and execution of ERAS. Controlling for adherence to ERAS components and implementing uniform ERAS protocols across studies are burgeoning topics that have significant implications for study design. The practice of ERAS and its benefits to patients are expected to evolve. Assessing improvements in postdischarge quality of life, timing of return to work and independent living, and adherence to scheduled delivery of adjuvant treatments will strengthen future ERAS investigations.