Acute cholecystitis, obesity, and steatohepatitis constitute the lethal triad for bile duct injury (BDI) during laparoscopic cholecystectomy.

OBJECTIVE: The most feared complication during laparoscopic cholecystectomy remains a bile duct injury (BDI). Accurately risk-stratifying patients for a BDI remains difficult and imprecise. This study evaluated if the lethal triad of acute cholecystitis, obesity, and steatohepatitis is a prognostic measure for BDI. METHODS: A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) registry was performed. All laparoscopic cholecystectomy cases within the main NSQIP database for 2012-2019 were queried. Two study cohorts were constructed. One with the lethal triad of acute cholecystitis, BMI ≥ 30, and steatohepatitis. The other cohort did not have the full triad present. Multivariate analysis was performed via logistic regression modeling with calculation of odds ratios (OR) to identify independent factors for BDI. An uncontrolled and controlled propensity score match analysis was performed. RESULTS: A total of 387,501 cases were analyzed. 36,887 cases contained the lethal triad, the remaining 350,614 cases did not have the full triad. 860 BDIs were identified resulting in an overall incidence rate 0.22%. There were 541 BDIs within the lethal triad group with 319 BDIs in the other cohort and an incidence rate of 1.49% vs 0.09% (P < 0.001). Multivariate analysis identified the lethal triad as an independent risk factor for a BDI by over 15-fold (OR 16.35, 95%CI 14.28-18.78, P < 0.0001) on the uncontrolled analysis. For the controlled propensity score match there were 29,803 equivalent pairs identified between the cohorts. The BDI incidence rate remained significantly higher with lethal triad cases at 1.65% vs 0.04% (P < 0.001). The lethal triad was an even more significant independent risk factor for BDI on the controlled analysis (OR 40.13, 95%CI 7.05-356.59, P < 0.0001). CONCLUSIONS: The lethal triad of acute cholecystitis, obesity, and steatohepatitis significantly increases the risk of a BDI. This prognostic measure can help better counsel patients and potentially alter management.

Minimally invasive versus open distal pancreatectomy: a matched analysis using ACS-NSQIP.

BACKGROUND: Minimally invasive distal pancreatectomy (MIDP) is gaining popularity due to improved perioperative outcomes over open distal pancreatectomy (ODP). The purpose of this study is to compare outcomes of MIDP and ODP using patients within a nationwide cohort. METHODS: The American College of Surgeons' National Quality Improvement Program (2014-2018) was used to evaluate incidence of post-operative pancreatic fistula (POPF) as well as 30-day composite major morbidity for patients undergoing MIDP vs. ODP. Matching was performed with a Mahalanobis-distance model for demographic characteristics, preoperative risk factors, and benign versus malignant pathology. Outcomes were assessed via weighted multiple logistic regression. RESULTS: A total of 3940 patients underwent distal pancreatectomy (1978 MIDP, 1962 ODP). After matching, 2985 patients were included (1978 MIDP, 1007 ODP). The rates of major morbidity (8.65% MIDP vs. 9.76% ODP, p = 0.37) were similar between groups. The MIDP group was found to have significantly decreased length of stay (5.6 vs. 7 days, p ≤ 0.001), but greater rates (12.54% MIDP vs. 9.35% ODP, p = 0.02) of post-operative fistula. CONCLUSIONS: When matched for baseline patient characteristics, MIDP was associated with shorter length of hospitalization with similar rates of morbidity compared to ODP. However, MIDP was associated with significantly increased rates of POPF. Further studies are needed to investigate this difference in POPF rate, and determine how to optimize MIDP surgical technique to reduce this risk.

Same day discharge does not lead to worse outcomes in patients undergoing uncomplicated laparoscopic foregut surgery.

INTRODUCTION: With the advancement of minimally invasive surgical techniques surgeons have moved away from elective open foregut surgeries. Despite studies demonstrating the safety of same day discharge in appropriate patient populations, ambulatory surgery has yet to be established as the practice norm for patients undergoing uncomplicated laparoscopic foregut surgery. METHODS: The ACS-NSQIP database was queried from 2005 to 2018 for patients who had undergone elective and non-emergent laparoscopic Heller myotomy, fundoplication, and paraesophageal hernia repairs with and without mesh. The primary endpoints in this study included number and severity of complications as classified by the Clavien-Dindo Classification, readmission, and return to the operating room. RESULTS: 6893 patients who met inclusion criteria were identified, 696 (10.1%) of which were discharged on the day of surgery. Patients who were discharged on post-operative day one were matched at a 3:1 ratio producing 2088 comparisons. There was no difference in overall morbidity (p = 0.264), readmission (OR 0.849, 95% CI 0.522-1.419), or return to the operating room (OR 1.15, 95% CI 0.531-2.761) between the two groups. CONCLUSION: Same day discharge for patients without life threatening comorbidities undergoing elective minimally invasive Heller myotomy, Nissen and Toupet fundoplication, and paraesophageal hernia repairs is safe and feasible.

The Hirsch Index and Self-Citation in Academic Physiatry Among Graduate Medical Education Program Directors.

ABSTRACT: The Hirsch Index is a measure of academic productivity which captures both the quantity and quality of an author's output. A well-accepted bibliometric, the Hirsch Index still may be influenced by self-citation, which has been assessed in other medical and surgical specialties. This study aims to evaluate research output and self-citation in physiatry, establishing a benchmark for the field, in addition to identifying differences between physical medicine and rehabilitation subspecialties. This study identified physical medicine and rehabilitation residency and fellowship program directors and analyzed the number of publications, citations, self-citations, and h-indices. A total of 169 program directors were identified, and the mean number ± SD of publications, citations, and Hirsch Index for the cohort were 16.7 ± 29.5, 348 ± 753, and 5.7 ± 6.7, respectively. When self-citation was excluded, less than 2% of program directors (3 of 169) had changes in Hirsch Index greater than one integer, and none greater than two integers. The Hirsch Index remained unchanged for 90% (152 of 169). Spinal cord injury fellowship directors had significantly higher mean number of publications (28, P = 0.04), mean number of citations (672, P = 0.03), and Hirsch Index (9.2, P < 0.01; 95% confidence interval). Overall, self-citation is infrequent in physical medicine and rehabilitation, and spinal cord injury directors had more robust academic profiles.

Post-operative outcomes for patients with liver-related ascites undergoing non-emergent laparoscopic cholecystectomy.

INTRODUCTION: Surgical procedures in patients with cirrhosis and associated ascites carry significant morbidity and mortality. However, these patients often undergo non-emergent but necessary procedures such as laparoscopic cholecystectomy. The purpose of this study is to determine the impact of cirrhosis with ascites on non-emergent laparoscopic cholecystectomy. METHODS: The ACS-NSQIP database was queried from 2005 to 2017 for patients undergoing non-emergent laparoscopic cholecystectomy with or without intra-operative cholangiogram. Groups were propensity score matched for age, sex, BMI, smoking, inpatient status, ASA Class, presence of pre-operative SIRS/sepsis, and the individual components of the 5-item modified frailty index. RESULTS: 346,105 patients were identified, 591 of which who had liver-related ascites. Patients without ascites were matched at a 5:1 ratio, producing 2955 controls. Patients with ascites had significantly higher rates of overall morbidity (15.6% vs. 11.3%, p = 0.0039), mortality (3.6% vs. 1.5%, p = 0.0020), and longer hospitalizations (7.4 vs. 4.4 days, p < 0.0001). Patients with ascites and a MELD score less than or equal to 9 had no difference in morbidity (p = 0.1124) or mortality (p = 0.6021) when compared to patients without ascites. Patients with ascites and a MELD score greater than 9 had significantly higher rates of both morbidity (25.8%, p = 0.0056) and mortality (7.1%, p = 0.0333). CONCLUSION: Patients with cirrhosis and ascites have many comorbidities in addition to their liver disease. These patients are at significant risk for both morbidity and mortality related to non-emergent laparoscopic cholecystectomy. Surgeons should proceed with caution for patients with ascites and MELD scores greater than 9. These cases should only be performed by surgeons comfortable with difficult gallbladders at facilities equipped to take care of cirrhotic patients.

Does the h-index and self-citation affect external funding of orthopedic surgery research? An analysis of fellowship directors and their subspecialties.

PURPOSE: Determine the impact of self-citation on external funding for orthopedic fellowship directors. METHODS: The San Francisco Match's website identified directors encompassing 8 subspecialties. The Scopus database identified the number of publications, citations, and h-index for each director. H-index was assessed with/without self-citation. RESULTS: Mean publications, citations, self-citation rate, and h-index for the 446 directors were 71.2, 1816, 3.86%, and 18.3, respectively. Excluding self-citations reduces mean h-index to 18.0; and h-index changed by ≤ 1 integer in 95% of directors. CONCLUSIONS: Self-citation has minimal impact among fellowship directors and should not be adjusted for when considering external funding.

Normalized Competitive Index: Analyzing Trends in Surgical Fellowship Training Over the Past Decade (2009-2018).

OBJECTIVE: There is a lack of literature describing how competitive surgical fellowships are, especially across specialties. Such information would be valuable to prospective candidates, especially as immediate postresidency subspecialty training becomes the norm for general surgery. Match-rates alone may be misleading indicators as programs may not fill positions with unqualified applicants. We propose a simple metric to analyze the competitiveness of various surgical subspecialties to each other and themselves over time. DESIGN: Retrospective cohort study. The Competitive Index is defined as the percentage of filled programs within each specialty divided by the match-rate for that specialty. For ease of comparison, a Normalized Competitive Index (NCI) was developed, normalizing the metric for all specialties in that year to a value of 1. SETTING: The National Resident Matching Program, The Fellowship Council, and the San Francisco Match publicly available match data from 2009 to 2018. PARTICIPANTS: General Surgery Associated Fellowship Applicants (Abdominal Transplant, Colorectal, Surgical Oncology, Minimally Invasive Surgery, Pediatric, Plastic, Critical Care, Thoracic, and Vascular). RESULTS: The overall match rate for all specialties was 74.6% and 84.0% of all programs were filled. Over the past decade, pediatric surgery was significantly more competitive than other specialties (NCI 1.67, p < 0.0001), while surgical critical care (NCI 0.58, p < 0.0001) and vascular (NCI 0.90, p < 0.0492) were significantly less competitive. When comparing the NCI within each specialty from the first 5 years (2009-2013) to the last 5 years, (2014-2018), surgical critical care (NCI 0.54 vs. 0.62, p = 0.0462) and thoracic (NCI 0.74 vs. 1.08, p=0.0025) became significantly more competitive, while transplant (NCI 1.10 vs. 0.92, p = 0.0343) and colorectal (NCI 1.32 vs. 1.09, p = 0.0021) became significantly less competitive. CONCLUSION: The NCI is a metric which might be useful to prospective applicants and which could be provided annually by organizations sponsoring fellowship matching processes. Further research must be performed to establish what defines a qualified applicant in each specialty.

Who gets a PEG? An analysis of simultaneous PEG placement during elective laparoscopic paraesophageal hernia repair.

INTRODUCTION: Percutaneous Endoscopic Gastrostomy (PEG) is an infrequent adjunct in elective paraesophageal hernia repair (PEHR). Guidelines denote that PEG "may facilitate postoperative care in selected patients." Though there is sparse literature defining which patients may benefit. The purpose of this study is to determine factors associated with simultaneous PEG placement during PEHR and their subsequent outcomes. METHODS: The NSQIP database was queried from 2011 to 2016 for patients undergoing elective laparoscopic PEHR. Cases were excluded if PEHR or fundoplasty was not the primary procedure, a concomitant bariatric procedure was performed, or if the primary surgeon was not a general or cardiothoracic surgeon. Groups were Propensity Score Matched for age, BMI, and ASA Class. RESULTS: 15700 patients were identified, 371 who underwent simultaneous PEG placement (2.4%). Non-PEG patients were matched at a 5:1 ratio, producing 1855 controls. PEG patients had higher rates of pre-operative dyspnea (OR 1.45, p = 0.0110), pre-operative weight loss (OR 2.87, p = 0.0001), and lower pre-operative albumin (3.92 vs. 4.01, p = 0.0129). PEG patients had more intra-operative contamination (mean Wound Classification 1.54 vs. 1.38, p < 0.0001) and longer case durations (170 vs. 148 min, p < 0.0001). PEG patients had longer lengths of stay (3.4 vs. 2.5 days, p = 0.0001), rates of superficial SSI (OR 5.82, p = 0.0012), peri-operative transfusions (OR 2.68, p = 0.0197), and pulmonary emboli (OR 3.61, p = 0.0359). CONCLUSION: Patients undergoing simultaneous PEG during PEHR are more likely to have respiratory symptoms, markers of malnutrition, and intra-operative factors indicative of more technically challenging cases. These patients have longer hospitalizations, higher rates of superficial SSI, and more pulmonary emboli.

Scholarly output and the impact of self-citation among surgical fellowship program directors.

OBJECTIVE: The purpose of this study is to define the publication patterns and the impact of self-citation among program directors of surgical fellowships. METHODS: Program directors were identified through the respective fellowship accrediting council and association websites for eleven surgical subspecialties. Using the Scopus database, the number of publications, citations, self-citations, and h-indices were calculated. RESULTS: 781 program directors were identified. The mean number ±â€¯SD of publications, citations, and h-index for the cohort were 74.6 ±â€¯88.2, 2141 ±â€¯3486, and 18.8 ±â€¯14.5, respectively. The self-citation rate for the entire cohort was 3.17%. After excluding self-citations, the h-index remained unchanged for 72% of surgeons. After propensity score matching for h-index, colorectal surgeons (1.48%, p = 0.04) had significantly lower self-citation rates. CONCLUSION: Overall, self-citation is infrequent among program directors of surgical fellowships. There is a lower rate of self-citation among colorectal surgeons when compared to program directors in other specialties with similar baseline metrics.

Arthroscopic Repair of 270- and 360-Degree Glenoid Labrum Tears: A Systematic Review.

PURPOSE: To review the current literature available and evaluate the efficacy of arthroscopic repair of 270° and 360° labral tears, as well as the complication rates associated with such. In addition, we intend to investigate whether consistent clinical findings can be observed in these patients. METHODS: This review is registered in the PROSPERO database. The MEDLINE, Cochrane Library, Scopus, and EMBASE databases were queried, and additional searches were performed manually. Studies that reported outcomes after arthroscopic repair of a minimum of 270° of glenoid labrum were included. Technique articles, repairs of less than 270°, studies on atraumatic multidirectional instability, and studies that lacked observable outcomes were excluded. RESULTS: In total, 3031 studies/documents were identified from database and manual searching. Screening, removal of duplicates, and assessment for inclusion/exclusion criteria resulted in 6 level IV studies for review. History and physical examination, as well as advanced imaging findings, were variable across studies. All studies reported satisfactory outcomes at short- to mid-term follow-up, although there was heterogeneity in type of outcomes used. Return to sport ranged from 75% to 100%. Complication rates ranged from 10% to 30%. Notably, recurrence of instability and need for secondary surgery occurred in up to 15% of patients. CONCLUSIONS: The current literature suggests that although clinical and radiographic variability exist in the diagnosis of 270° and 360° glenoid labrum tears, successful outcomes and return to work/sport can be achieved with arthroscopic management at an average minimum follow-up of 1 year. These figures, however, are limited by heterogenous studies containing small numbers of patients. Complications occur in up to 30% of cases, including an instability recurrence rate of up to 15%. LEVEL OF EVIDENCE: Systematic review of Level IV evidence.

Laparoscopic Paraesophageal Hernia Repair and Pulmonary Embolism.

OBJECTIVE: Pulmonary embolism (PE) following laparoscopic paraesophageal hernia repair (PEHR) is rare but occurs at a higher frequency than other laparoscopic procedures. We describe a series of patients who developed PEs after PEHR in hopes of capturing potential risk factors for further study. MATERIALS AND METHODS: Five cases of PE after PEHR were observed between 2017 and 2018. Individual and perioperative risk factors, and postoperative courses were reviewed. RESULTS: Patients had a mean age of 73 years (range, 59 to 86). All were female. Two patients presented acutely. Three patients underwent revisional surgery. The average procedure duration was 248 minutes (range, 162 to 324). All patients had gastrostomy tubes placed. The diagnosis of PE occurred within 3 to 19 days postoperatively. Four were treated with 3 months of oral anticoagulation; 1 was managed expectantly. CONCLUSIONS: Highly complex cases, marked by revisional status, need for mesh, large hernia size, and percutaneous endoscopic gastrostomy placement are likely at increased risk for PEs. Preoperative venous thromboembolism chemoprophylaxis should be considered in the majority of laparoscopic PEHR patients.

Laparoscopic Sleeve Gastrectomy Outcomes in Patients with Polycystic Ovary Syndrome.

Polycystic ovary syndrome (PCOS) is a common disease among the bariatric population. However, there are limited data regarding the impact of laparoscopic sleeve gastrectomy (SG) on these patients. The study was conducted at University Hospital, United States. The purpose of this study was to examine per cent excess body weight loss (%EWL) and diabetes control in patients who have PCOS compared with those without PCOS. A total of 550 female patients underwent SG between December 2011 and October 2016. Retrospective analysis was completed to include follow-up data at 1, 3, 6, and 12 months and yearly after that. Outcomes measured were %EWL and hemoglobin A1c (HgbA1c). The mean and median follow-up for the entire cohort was 21 and 15 months, respectively. Seventy-eight per cent of patients completed at least 12 months of follow-up for %EWL, although only 21 per cent had similar follow-up for HgbA1c. PCOS patients had similar age (36.3 vs 36.2 years, P = 0.90), preoperative BMI (47.2 vs 47.2, P = 0.99), preoperative HgbA1c (6% vs 5.8%, P = 0.31), conversion rate to gastric bypass, and other associated comorbidities compared with non-PCOS comparisons. There was no difference in %EWL at 12-month (49.7% vs 53.1%, P = 0.53) or 24-month (43% vs 49.8%, P = 0.46) postoperative intervals. There was no difference in absolute change of HgbA1c at 12 months (-0.47% vs -0.67%, P = 0.39). SG has equivalent short-term results in %EWL and reduction in HgbA1c for patients who have PCOS and those who do not.

Academic inertia: Examining changes of scholarly output over time among academic minimally invasive surgeons.

INTRODUCTION: The purpose of this study is to assess how the Hirsch Index (h-index) and other academic metrics change over time for academic minimally invasive surgeons (MIS). METHODS: Through the Fellowship Council's website, MIS program-directors and associate program-directors were identified in 2017 and again in 2018. Using the Scopus database, the number of publications, citations, self-citations, and h-indices were calculated. RESULTS: A total of 222 surgeons were included. The median increase of publications, citations, and h-index were 4, 134, and 1, respectively. 75% of surgeons (166/222) saw their h-index increase. In 2017, 26% of surgeons (57/222) had an increase of their h-index due to self-citation. One-year later, 35% of those surgeons (20/57) no longer demonstrated that change. CONCLUSION: Self-citation remains infrequent within MIS. The h-index of most surgeons will increase over one-year. Many surgeons demonstrating an increase in h-index due to self-citation will see that change eliminated over time.

Publication patterns and the impact of self-citation among minimally invasive surgery fellowships.

INTRODUCTION: The h-index is a widely utilized academic metric that measures both productivity and citation impact. The purpose of this study is to define the impact of self-citation among minimally invasive surgery (MIS) fellowship program directors. METHODS: Through the Fellowship Council's website, all program directors and associate program directors from the 148 MIS fellowship programs were identified. Using the Scopus database, we calculated the number of publications, citations, self-citations, and h-index for each surgeon. RESULTS: A total of 274 surgeons were identified. The mean number±SD of publications, citations, and h-index for the cohort were 60.5 ±â€¯77.2, 1765 ±â€¯4024, and 16.0 ±â€¯15.0, respectively. The self-citation rate for the entire cohort was 3.23%. Excluding self-citations reduces the mean number of citations to 1708 ±â€¯3887 and h-index to 15.8 ±â€¯14.6. The h-index remained unchanged for 77% (210/274) of surgeons. Only 5% (15/274) of surgeons had a change in h-index of greater than one integer and no surgeon had a change greater than three integers. CONCLUSION: Self-citation is infrequent and has a minimal impact on the academic profile of program directors of MIS fellowships.