Outcomes following laparoscopic transhiatal esophagectomy for esophageal cancer.

BACKGROUND: Most published minimally invasive esophagectomy techniques involve a multiple field approach, including laparoscopic and thoracoscopic esophageal mobilization. Laparoscopic transhiatal esophagectomy (LTE) should potentially reduce the complications associated with thoracotomy. This study aims to compare outcomes of LTE with open transhiatal esophagectomy (OTE) and en-bloc esophagectomy (EBE). METHODS: Retrospective chart review was performed on all patients who had an LTE for cancer between July 2008 and July 2012 at our institution. Data was compared with an historic cohort of patients who underwent OTE and EBE at the same institution from July 2002 to July 2008. RESULTS: There were 33 patients with LTE, compared with 60 patients with OTE and 139 with EBE. The presence of minor operative complications was similar (p = 0.36), but major complications were significantly less common in the LTE group (12, 23 and 33 %, respectively; p = 0.04). The median number of blood transfusions during hospitalization was significantly lower in the LTE group (0, 2.5 and 3, respectively; p = 0.005). Median tumor size was significantly smaller (1.5, 2.2, and 3 cm, respectively; p = 0.03), but the LTE group had a significantly higher percentage of patients with neoadjuvant treatment (39, 14 and 29 %, respectively; p = 0.008). Median lymph node yield for LTE was lower (24, 36 and 48, respectively; p < 0.0001), but the percentage of patients with positive nodes was similar (33, 33 and 39 %, respectively; p = 0.69). Mortality was equivalent among the groups (0, 2 and 4 %, respectively; p = 0.38). The median LOS for the LTE group was significantly lower (10, 13 and 15 days, respectively; p < 0.0001). Overall survival was not different between the three groups (p = 0.65), with median survival at 24 months of 70, 65 and 65 %, respectively. CONCLUSION: LTE can be performed safely with less major complications and shorter hospital stay than open esophagectomy. The reduced lymph-node harvest did not impact overall survival.

Biologic versus nonbiologic mesh in ventral hernia repair: a systematic review and meta-analysis.

BACKGROUND: The current standard of treatment for most ventral hernias is a mesh-based repair. Little is known about the safety and efficacy of biologic versus nonbiologic grafts. A meta-analysis was performed to examine two primary outcomes: recurrence and wound complication rates. METHODS: Electronic databases and reference lists of relevant articles were systematically searched for all clinical trials and cohort studies published between January 1990 and January 2012. A total of eight retrospective studies, with 1,229 patients, were included in the final analysis. RESULTS: Biologic grafts had significantly fewer infectious wound complications (p < 0.00001). However, the recurrence rates of biologic and nonbiologic mesh were not different. In subgroup analysis, there was no difference in recurrence rates and wound complications between human-derived and porcine-derived biologic grafts. CONCLUSIONS: Use of biologic mesh for ventral hernia repair results in less infectious wound complications but similar recurrence rates compared to nonbiologic mesh. This supports the application of biologic mesh for ventral hernia repair in high-risk patients or patients with a previous history of wound infection only when the significant additional cost of these materials can be justified and synthetic mesh is considered inappropriate.

The cost of obesity for nonbariatric inpatient operative procedures in the United States: national cost estimates obese versus nonobese patients.

OBJECTIVE: To evaluate the economic impact of obesity on hospital costs associated with the commonest nonbariatric, nonobstetrical surgical procedures. BACKGROUND: Health care costs and obesity are both rising. Nonsurgical costs associated with obesity are well documented but surgical costs are not. METHODS: National cost estimates were calculated from the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) database, 2005-2009, for the highest volume nonbariatric nonobstetric procedures. Obesity was identified from the HCUP-NIS severity data file comorbidity index. Costs for obese patients were compared with those for nonobese patients. To control for medical complexity, each obese patient was matched one-to-one with a nonobese patient using age, sex, race, and 28 comorbid defined elements. RESULTS: Of 2,309,699 procedures, 439,8129 (19%) were successfully matched into 2 medically equal groups (obese vs nonobese). Adjusted total hospital costs incurred by obese patients were 3.7% higher with a significantly (P < 0.0001) higher per capita cost of $648 (95% confidence interval [CI]: $556-$736) compared with nonobese patients. Of the 2 major components of hospital costs, length of stay was significantly increased in obese patients (mean difference = 0.0253 days, 95% CI: 0.0225-0.0282) and resource utilization determined by costs per day were greater in obese patients due to an increased number of diagnostic and therapeutic procedures needed postoperatively (odds ratio [OR] = 0.94, 95% CI: 0.93-0.96). Postoperative complications were equivalent in both groups (OR = 0.97, 95% CI: 0.93-1.02). CONCLUSIONS: Annual national hospital expenditures for the largest volume surgical procedures is an estimated $160 million higher in obese than in a comparative group of nonobese patients.

Single-access laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Single-incision laparoscopic surgery has been proposed as a minimally invasive technique with the advantages of fewer scars and reduced pain. The aim of this study was to perform a systematic review and meta-analysis of prospective randomized clinical trials of single-access laparoscopic cholecystectomy (SALC) versus classic laparoscopic cholecystectomy (CLC). METHODS: All randomized controlled trials were identified through electronic searches (MEDLINE, PubMed, SAGES, and Cochrane Central Register of Controlled Trials) up to October 2011. Methodologically appropriate clinical trials identified in the search process were included in a meta-analysis to provide a pooled estimate of effect. RESULTS: Nine true randomized controlled trials were included in the analysis and reported a total of 695 patients, divided into the SALC group of 362 patients and the CLC group of 333 patients. Median operating time was longer with 57 minutes in SALC versus 45 minutes in CLC (P=0.00001). There was no significant difference in length of stay (SALC 1.36 d vs. CLC 1.15 d, P=0.18). Conversion to laparotomy in either group was similar; however, in 18 of 66 SALC patients an additional instrument was used, compared with 1 of 67 CLC patients (P=0.0003). Complications were not significant different [16% in SALC vs. 12% in the CLC group (P=0.74)]. Median postoperative pain with the visual analog scale score was 3.8 points in SALC versus 3.15 points in the CLC group (P=0.48). Cosmetic satisfaction was significantly more satisfying with 9 points favoring SALC versus 0 points favoring CLC (P=0.0005) in contrast to the quality-of-life questionnaire where there was no significant difference in patient overall satisfaction between SALC and CLC groups (P=0.0515). CONCLUSIONS: SALC required longer operative times than CLC without significant benefits in patient overall satisfaction, postoperative pain, and hospital stay. Only satisfaction with the cosmetic result showed a significantly higher preference towards SALC.

Argon beam coagulation versus fibrin sealant for hemostasis following liver resection: a randomized study in a porcine model.

BACKGROUND/AIMS: Bleeding from the raw liver surface represents a significant surgical complication after elective liver resection or hepatic trauma. The application of argon beam coagulation (ABC) has been proposed to improve hemostasis, but is associated with significant necrosis of the liver parenchyma. Topical hemostatic agents, i.e. fibrin sealant (FS), have also been recommended, yet the optimal management is under debate. This study compares the efficacy and safety of both methods following liver resection in an animal model. METHODOLOGY: Twenty pigs underwent liver resection, and were then randomized into ABC or FS group for treatment of raw liver surfaces. Intraoperative and postoperative parameters were studied. Animals were sacrificed at day 12, and extent of necrosis was assessed using a scoring system and morphometry. RESULTS: Intraoperative parameters did not show any significant difference between two groups except for shorter time of application in the FS group. Postoperatively, animals in the FS group showed significantly higher hemoglobin levels (p=0.0001). Histologically, FS showed a smaller depth of necrosis than ABC (p=0.022). CONCLUSIONS: The use of FS is superior to ABC for management of the raw liver surface after liver resection, in terms of application time, postoperative bleeding and the extent of liver tissue necrosis.

Thirty-day outcomes of laparoscopic versus open appendectomy in elderly using ACS/NSQIP database.

BACKGROUND: Although laparoscopic appendectomy is becoming the procedure of choice over open appendectomy in the treatment of appendicitis, its role in the elderly has not been widely studied. The objective of this study was to compare the 30-day outcomes after laparoscopic versus open for appendicitis in the elderly patients. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS/NSQIP) databases for years 2005-2009, 3,674 patients (age >65 years) who underwent an appendectomy for appendicitis were identified. Seventy-two percent of the procedures were performed laparoscopically. In addition to aggregate cohort analysis, propensity score 1:1 matching was used to minimize the treatment selection bias. The association between surgical approach and morbidity, mortality, and length of stay (LOS) were analyzed. RESULTS: In the aggregate cohort analysis, patients who underwent an open appendectomy had a higher rate of minor morbidity (9.3% vs. 4.5%; p < 0.001), overall morbidity (13.4% vs. 8.2%, p < 0.001), and mortality (2% vs. 0.9%, p = 0.003). However, in the matched cohort analysis, open appendectomy was only associated with a higher rate of minor morbidity (9.3% vs. 5.7%; p = 0.002) and overall morbidity (13.4% vs. 10.1%; p = 0.02) but similar mortality rates (2% vs. 1.5%; p = 0.313). In matched cohort analysis, open appendectomy also was associated with a higher rate of superficial surgical site infection (SSI) (3.8% vs. 1.4%; p < 0.001) and a lower rate of organ/space SSI (1.3% vs. 2.9%; p = 0.009). Laparoscopic appendectomy was associated with a shorter LOS in both aggregate and matched cohorts compared with open appendectomy (p < 0.001). CONCLUSIONS: Within ACS NSQIP hospitals, elderly patients benefited from a laparoscopic approach to appendicitis with regards to a shorter LOS and a lower minor and overall morbidity. Laparoscopic appendectomy was associated with lower superficial SSI and higher organ/space SSI rates.

Minimally invasive surgical approach for the treatment of gastroparesis.

BACKGROUND: Gastroparesis is a chronic disorder resulting in decreased quality of life. The gastric electrical stimulator (GES) is an alternative to gastrectomy in patients with medically refractory gastroparesis. The aim of this study was to analyze the outcomes of patients treated with the gastric stimulator versus patients treated with laparoscopic subtotal or total gastrectomy. METHODS: A retrospective chart review was performed of all patients who had surgical treatment of gastroparesis from January 2003 to January 2012. Postoperative outcomes were analyzed and symptoms were assessed with the Gastroparesis Cardinal Symptom Index (GCSI). RESULTS: There were 103 patients: 72 patients (26 male/46 female) with a GES, implanted either with laparoscopy (n = 20) or mini-incision (n = 52), and 31 patients (9 male/22 female) who underwent laparoscopic subtotal (n = 27), total (n = 1), or completion gastrectomy (n = 3). Thirty-day morbidity rate (8.3% vs. 23%, p = 0.06) and in-hospital mortality rate (2.7% vs. 3%, p = 1.00) were similar for GES and gastrectomy. There were 19 failures (26%) in the group of GES patients; of these, 13 patients were switched to a subtotal gastrectomy for persistent symptoms (morbidity rate 7.7%, mortality 0). In total, 57% of patients were treated with GES while only 43% had final treatment with gastrectomy. Of the GES group, 63% rated their symptoms as improved versus 87% in the primary gastrectomy group (p = 0.02). The patients who were switched from GES to secondary laparoscopic gastrectomy had 100% symptom improvement. The median total GCSI score did not show a difference between the procedures (p = 0.12). CONCLUSION: The gastric electrical stimulator is an effective treatment for medically refractory gastroparesis. Laparoscopic subtotal gastrectomy should also be considered as one of the primary surgical treatments for gastroparesis given the significantly higher rate of symptomatic improvement with acceptable morbidity and comparable mortality. Furthermore, the gastric stimulator patients who have no improvement of symptoms can be successfully treated by laparoscopic subtotal gastrectomy.

Laparoscopic vs open appendectomy in obese patients: outcomes using the American College of Surgeons National Surgical Quality Improvement Program database.

BACKGROUND: Although open and laparoscopic appendectomies are comparable operations in terms of outcomes, it is unknown whether this is true in the obese patient. Our objective was to compare short-term outcomes in obese patients after laparoscopic vs open appendectomy. STUDY DESIGN: Using the American College of Surgeons National Surgical Quality Improvement Program database (2005-2009), 13,330 obese patients (body mass index ≥ 30) who underwent an appendectomy were identified (78% laparoscopic, 22% open). The association between surgical approach (laparoscopic vs open) and outcomes was first evaluated using multivariable logistic regression. Next, to minimize the influence of treatment selection bias, we created a 1:1 matched cohort using all 41 of the preoperative covariates in the National Surgical Quality Improvement Program database. Reanalysis was then performed with the unmatched patients excluded. Main outcomes measures included patient morbidity and mortality, operating room return, operative times, and hospital length of stay. RESULTS: Laparoscopic appendectomy was associated with a 57% reduction in overall morbidity in all the obese patients after the multivariable risk-adjusted analysis (odds ratio = 0.43; 95% CI, 0.36-0.52; p < 0.0001), and a 53% reduction in risk in the matched cohort analysis (odds ratio = 0.47; 95% CI, 0.32-0.65; p < 0.0001). Mortality rates were the same. In the matched cohort, length of stay was 1.2 days shorter for obese patients undergoing laparoscopic appendectomy compared with open appendectomy (mean difference 1.2 days; 95% CI, 0.98-1.42). CONCLUSIONS: In obese patients, laparoscopic appendectomy had superior clinical outcomes compared with open appendectomy after accounting for preoperative risk factors.

Evaluation and treatment of patients with cardiac disease undergoing bariatric surgery.

BACKGROUND: Bariatric surgery is a proven tool in reducing the co-morbidities associated with morbid obesity. The aim of the present review was to assess the current data and discuss the strategies for preoperative evaluation, preoperative treatment, and intraoperative management of the obese patient with cardiac disease seeking bariatric surgery, including those who have undergone previous angiographic intervention with coronary stenting and/or antiplatelet therapy. The setting was a university hospital in the United States. METHODS: A search of the English-language reports using the keywords morbid obesity, bariatric surgery, perioperative risk assessment, coronary artery disease, coronary stents, and antiplatelet therapy was conducted. RESULTS: The methods of preoperative cardiac risk assessment found in the published studies included the use of certain criteria, stress echocardiography, and single-photon emission computed tomography. Preoperative medical treatment optimization with ß-blockers and statins is recommended. Perioperative antiplatelet therapy in the form of aspirin 81 mg can be safely continued, but clopidogrel should be stopped and reinitiated with caution. CONCLUSION: Preoperative assessment of morbidly obese patients with coexisting cardiac issues presents unique challenges. Safe patient care and good clinical outcomes can be achieved with adherence to evidence-based practice.

Meta-analysis of randomized trials comparing antibiotic therapy with appendectomy for acute uncomplicated (no abscess or phlegmon) appendicitis.

BACKGROUND: The objective was to conduct a meta-analysis of randomized controlled trials evaluating the efficacy and morbidity of the management of acute uncomplicated (no abscess or phlegmon) appendicitis by antibiotics versus appendectomy. METHODS: Appropriate trials were identified. The seven outcome variables were overall complication rate, treatment failure rate for index hospital admission, overall treatment failure rate, length of stay (LOS), utilization of pain medication, duration of pain, and sick leave. Both fixed and random effects meta-analyses were performed using odds ratios (ORs) and weighted or standardized mean differences (WMDs or SMDs, respectively). RESULTS: Five trials totaling 980 patients (antibiotics=510, appendectomy=470) were analyzed. In three of the seven outcome analyses, the summary point estimates favored antibiotics over appendectomy, with a 46% reduction in the relative odds of complications (OR 0.54; 95% confidence interval [CI] 0.37, 0.78; p=0.001); a reduction in sick leave/disability (SMD -0.19; CI -0.33, -0.06; p=0.005), and decreased pain medication utilization (SMD -1.55; CI -1.96, -1.14; p<0.0001). For overall treatment failure, the summary point estimate favored appendectomy, with a 40.2% failure rate for antibiotics versus 8.5% for appendectomy (OR 6.72; CI 0.08, 12.99; p<0.001). Initial treatment failure, LOS, and pain duration were similar in the two groups. CONCLUSIONS: Non-operative management of uncomplicated appendicitis with antibiotics was associated with significantly fewer complications, better pain control, and shorter sick leave, but overall had inferior efficacy because of the high rate of recurrence in comparison with appendectomy.

Laparoscopic versus open anterior abdominal wall hernia repair: 30-day morbidity and mortality using the ACS-NSQIP database.

OBJECTIVE: To compare short-term outcomes after laparoscopic and open abdominal wall hernia repair. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2009), 71,054 patients who underwent an abdominal wall hernia repair were identified (17% laparoscopic, 83% open). Laparoscopic and open techniques were compared. Regression models and nonparametric 1:1 matching algorithms were used to minimize the influence of treatment selection bias. The association between surgical approach and risk-adjusted adverse event rates after abdominal wall hernia repair was determined. Subgroup analysis was performed between inpatient/outpatient surgery, strangulated/reducible, and initial/recurrent hernias as well as between umbilical, incisional and other ventral hernias. RESULTS: Patients undergoing laparoscopic repair were less likely to experience an overall morbidity (6.0% vs. 3.8%; odds ratio [OR], 0.62; 95% confidence interval [CI], 0.56-0.68) or a serious morbidity (2.5% vs. 1.6%; OR, 0.61; 95% CI, 0.52-0.71) compared to open repair. Analysis using multivariate adjustment and patient matching showed similar findings. Mortality rates were the same. Laparoscopically repaired strangulated and recurrent hernias, had a significantly lower overall morbidity (4.7% vs. 8.1%, P < 0.0001 and 4.1% vs. 12.2%, P < 0.0001, respectively). Significantly lower overall morbidity was also noted for the laparoscopic approach when the hernias were categorized into umbilical (1.9% vs. 3.0%, P = 0.009), ventral (3.9% vs. 6.3%, P < 0.0001), and incisional (4.3% vs. 9.1%, P < 0.0001). No differences were noted between laparoscopic and open repairs in patients undergoing outpatient surgery, when the hernias were reducible. CONCLUSION: Laparoscopic hernia repair is infrequently used and associated with lower 30-day morbidity, particularly when hernias are complicated.

Significant reduction of wound infections with daily probing of contaminated wounds: a prospective randomized clinical trial.

HYPOTHESIS: Local wound management using a simple wound-probing protocol (WPP) reduces surgical site infection (SSI) in contaminated wounds, with less postoperative pain, shorter hospital stay, and improved patient satisfaction. DESIGN: Prospective randomized clinical trial. SETTING: Academic medical center. PATIENTS: Adult patients undergoing open appendectomy for perforated appendicitis were enrolled from January 1, 2007, through December 31, 2009. INTERVENTIONS: Study patients were randomized to the control arm (loose wound closure with staples every 2 cm) or the WPP arm (loosely stapled closure with daily probing between staples with a cotton-tipped applicator until the wound is impenetrable). Intravenous antibiotic therapy was initiated preoperatively and continued until resolution of fever and normalization of the white blood cell count. Follow-up was at 2 weeks and at 3 months. OUTCOME MEASURES: Wound pain, SSI, length of hospital stay, other complications, and patient satisfaction. RESULTS: Seventy-six patients were enrolled (38 in the WPP arm and 38 in the control arm), and 49 (64%) completed the 3-month follow-up. The patients in the WPP arm had a significantly lower SSI rate (3% vs 19%; P = .03) and shorter hospital stays (5 vs 7 days; P = .049) with no increase in pain (P = .63). Other complications were similar (P = .63). On regression analysis, only WPP significantly affected SSI rates (P = .02). Age, wound length, body mass index, abdominal circumference, and diabetes mellitus had no effect on SSI. Patient satisfaction at 3 months was similar (P = .69). CONCLUSIONS: Surgical site infection in contaminated wounds can be dramatically reduced by a simple daily WPP. This technique is not painful and can shorten the hospital stay. Its positive effect is independent of age, diabetes, body mass index, abdominal girth, and wound length. We recommend wound probing for management of contaminated abdominal wounds.

Laparoscopic appendectomy: new concepts.

Over the last three decades more surgeons have used laparoscopic appendectomy as their surgical approach of choice in the management of patients with appendicitis. This includes special groups of patients, namely, pediatric, pregnant, and obese patients. Laparoscopy has the benefit of lower morbidity, decreased rate of wound complications, faster recovery, shorter length of hospital stay, and faster return to work over open appendectomy.

Laparoscopic versus open appendectomy for the obese patient: a subset analysis from a prospective, randomized, double-blind study.

BACKGROUND: The clinical outcomes for patients randomized to either open or laparoscopic appendectomy are comparable. However, it is not known whether this is true in the subset of the adult population with higher body mass indexes (BMIs). This study aimed to compare the outcomes of open versus laparoscopic appendectomy in the obese population. METHODS: A subgroup analysis of a randomized, prospective, double-blind study was conducted at a county academic medical center. Of the 217 randomized patients, 37 had a BMI of 30 kg/m(2) or higher. Open surgery was performed for 14 and laparoscopic surgery for 23 of these patients. The primary outcome measures were the postoperative complication rates. The secondary outcomes were operative time, length of hospital stay, time to resumption of diet, narcotic requirements, and Medical Outcomes Survey Short Form 36 (SF-36) quality-of-life data. RESULTS: No differences in complications between the open and laparoscopic groups were found. Also, no significant differences were seen in any of the secondary outcomes except for a longer operative time among the obese patients. CONCLUSIONS: In this study, laparoscopic appendectomy did not show a benefit over the open approach for obese patients with appendicitis.

Fibrin glue for intraperitoneal laparoscopic mesh fixation: a comparative study in a swine model.

BACKGROUND: The classic method of mesh fixation in laparoscopic ventral hernia repair is transfascial sutures with tacks. This method has been associated with low recurrence rates, but yields significant morbidity from pain and bleeding. Fibrin glue has been used successfully in inguinal hernia repair with decreased incidence of chronic pain without an increase in recurrence rates, but its utility for laparoscopic ventral hernia repair is unknown. Our aim is to evaluate the efficacy of fibrin glue for laparoscopic mesh fixation to the anterior abdominal wall compared with other fixation methods. METHODS: Four different laparoscopic mesh fixation methods were randomly assigned to midline positions along the abdominal wall of 12 female pigs and compared: (1) fibrin glue only (GO), (2) transfascial sutures with tacks (ST), (3) fibrin glue with tacks (GT), and (4) tacks only (TO). At 4 weeks post implantation, tensile strength, adhesions, migration, contraction, and buckling/folding were assessed using Kruskal-Wallis one-way analysis by ranks test. RESULTS: There were no significant differences in tensile strength, adhesions or buckling/folding among the four fixation methods. A significant increase in mean migration (3.3 vs. 0.0 mm, p = 0.03) and percentage contraction (28% vs. 14%, p = 0.02) were identified in the GO group when compared with ST (see Table 3). CONCLUSIONS: Mesh fixation using fibrin glue has comparable tensile strength and adhesion rate to sutures with tacks in the swine model. Increased contraction and migration rates associated with fibrin glue alone may be an issue and warrants further study. On the other hand, the GT group showed similar biomechanical characteristics to the other groups and may represent a reasonable alternative to the use of transfascial sutures.