Impact of fellowship training on surgical outcomes after appendectomies: a retrospective cohort study.

BACKGROUND: Outcome studies have failed to show significant improvement related to formal fellowship training in different surgical specialties. We aimed to look whether laparoscopic fellowship-trained (FT) surgeons had better outcomes. METHODS: This is an IRB approved retrospective review from a single institution (inner city hospital) on adults undergoing appendectomy from 2008 to 2017. Demographics and 30-day complications were analyzed with univariate and multivariate logistic regression analyses. RESULTS: Total of 558 appendectomies were reviewed. 151 (27.36%) appendectomies were performed by FT surgeons (MIS/CRS), 401 (72.64%) performed by GS. No difference in age, ASA, BMI, race, gender, insurance status, smoking, diabetes mellitus (DM), or hypertension was found. Also, similar rates of non-iatrogenic perforated appendicitis were seen (16.37% GS vs 20% FT, p = 0.318). For major complications, no difference was found between GS and FT (p = 0.63). However, appendectomies performed by GS showed higher rates of post-op ileus (3.99% vs 0.66%, p = 0.04), higher conversion to open (7.55% vs 2.67%, p = 0.039), higher rates of choosing an open approach (17.46% vs 0.66%, p = < 0.001), and longer length of stay (LOS) (median 1.9 vs 1.8 days p = 0.048). Of the 16 patients with ileus from the GS group three were open, two converted to open, and eleven laparoscopic with mean OR time of 70 min and LOS of 13.3 days. The only laparoscopic case from the FT group with ileus had a mean operative time of 56 min and LOS of 15 days. On multivariate regression analysis, only DM was found as risk factor for major complications (OR 3.01, 95% CI 1.307-6.92, p = 0.01), while laparoscopic approach was seen as protective factor against major complications (OR 0.53, 95% CI 0.29-0.97, p = 0.04). CONCLUSION: Laparoscopic fellowship training had a positive outcome on post-op ileus and LOS after appendectomy. This seems to be related to the higher prevalence of choosing laparoscopic technique and lower rate of conversion to open.

Obesity and Ventral Hernia Repair: Is There Success in Staging?

Introduction: Obesity predisposes patients to the development of abdominal wall hernias. Ventral hernia incidence, size, and recurrence rate are all increased in this population. As such, the surgeon is likely to encounter patients presenting for metabolic and bariatric surgery with existing ventral hernias. Controversy persists regarding the algorithm for treatment in this situation. Do we wait to repair, or is the weight inconsequential? Materials and Methods: We critically reviewed the available literature accessed through PubMed on the repair of ventral hernias in the obese population. Specifically, we focused on the outcomes after staged repair versus concurrent repair at the time of bariatric surgery. We aim at providing an overview of the conclusions from past and present publications with commentary by the authors. Results: A review of the literature finds conflicting opinions regarding the safety and success of concurrent ventral hernia repair at the time of bariatric surgery. Obese patients frequently have complex hernias and are predisposed to poor wound healing and increased recurrence. Although some small studies find success with concurrent repair, large registry analyses as well as expert consensus statements advocate for staged repair. Conclusion: For the obese patient with large ventral hernia, the authors recommend a staged approach, beginning with bariatric surgery and deferring the hernia repair until significant weight loss is obtained. The exception exists, and each patient must be evaluated critically regarding hernia size, contents, and risk of obstruction if left untreated.

A Review of the Role of Robotics in Bariatric Surgery: Finding Our Future?

Introduction: Obesity rates continue to rise in America and around the World. Numerous studies show the benefit of bariatric surgery on all-cause mortality in obese patients. Given its substantial role in the future of patient care, we continue to search for the most beneficial ways to optimize patient outcomes and procedural costs in bariatric surgery. Much like laparoscopy was found to greatly improve the morbidity of weight loss surgery, we seek to evaluate the role of robotic surgery in bariatric procedures. Methods: We critically reviewed the available literature accessed through PubMed on the use of robotics in bariatric surgery. We aim to provide an overview of the conclusions from the most recent publications with commentary by the authors. Results: Although the outliers exist, it would appear that the majority of cases point to robotic surgery increasing operating room time and cost without providing significant generalizable improvements in patient outcomes. Promise exists in the use for special groups such as super obese patients or revisional bariatric procedures, however current studies in this subset are equally variable in their outcomes. Conclusion: Despite the current assumptions, we believe there is a future in bariatric surgery for robotics. This may inevitably be seen in the more demanding and difficult cases or in the advancement of the available technology. Likely, as robotics continues to mature, applied artificial intelligence will provide enhanced cues during surgery that augment the surgeon's judgment and skill and result in unanimously improved patient outcomes.

Synthesis of hydroxyapatite nanoparticles with tailorable morphologies and carbonate substitutions using a wet precipitation method.

Hydroxyapatite (HA) nanoparticles with different morphologies and variant levels of carbonate substitutions were synthesized using a wet precipitation method by adjusting the heating temperature and/or the initial ion concentration of the reaction system. Within the particles, crystalline domains with different lengths were aligned along each other and formed into nanoparticles with different sizes, shapes and topographies. Different from most reported studies, the nucleation, growth and morphology of the crystalline domains were found sensitive to heating temperature, but not significantly influenced by initial ion concentration within the studied range. The OH- and PO4(3-) ions within the HA particles were partially substituted by CO3(2-) ions. The substitution was dominated by the replacement of OH- instead of PO4(3-) in HA. The carbonate substitution was found to decrease with increasing heating temperature and/or initial ion concentration. Therefore, both the morphology and composition of the HA particles can be tailored by controlling the heating temperature and/or the initial ion concentration in the reaction system. Such synthesized HA nanoparticles can be used as biomaterials for bone tissue engineering.

ES cell cycle progression and differentiation require the action of the histone methyltransferase Dot1L.

Mouse embryonic stem cells (ESCs) proliferate with rapid cell cycle kinetics but without loss of pluripotency. The histone methyltransferase Dot1L is responsible for methylation of histone H3 at lysine 79 (H3K79me). We investigated whether ESCs require Dot1L for proper stem cell behavior. ESCs deficient in Dot1L tolerate a nearly complete loss of H3K79 methylation without a substantial impact on proliferation or morphology. However, shortly after differentiation is induced, Dot1L-deficient cells cease proliferating and arrest in G2/M-phase of the cell cycle, with increased levels of aneuploidy. In addition, many aberrant mitotic spindles occur in Dot1L-deficient cells. Surprisingly, these mitotic and cell cycle defects fail to trigger apoptosis, indicating that mouse ESCs lack stringent cell cycle checkpoint control during initial stages of differentiation. Transcriptome analysis indicates that Dot1L deficiency causes the misregulation of a select set of genes, including many with known roles in cell cycle control and cellular proliferation as well as markers of endoderm differentiation. The data indicate a requirement for Dot1L function for early stages of ESC differentiation where Dot1L is necessary for faithful execution of mitosis and proper transcription of many genes throughout the genome.