Reoperations for Long-Term Complications Following Laparoscopic Adjustable Gastric Banding: Analysis of Incidence and Causality.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) gained popularity in the early 2000s as a purely restrictive procedure with modest weight loss. The potential for complications requiring reoperation has since become evident. A retrospective review was performed to determine the incidence of long-term complications and predictive factors requiring surgical reintervention after LAGB. METHODS: Institutional review board approval was obtained, and a retrospective review of 200 consecutive patients undergoing LAGB over a period of six years was conducted at a single institution with American Society of Metabolic and Bariatric Surgery Center of Excellence designation. Data were collected on patient characteristics, comorbid conditions and complications requiring reintervention. Statistical analysis was performed using SPSS Statistics software (IBM Corp., Armonk, NY). RESULTS: Of the 200 patients, 176 (90.7%) were female with an average age of 53.6 years and preoperative body mass index (BMI) of 44.2 kg/m2. The average follow-up was 46 months. Complications occurred in 55 (28.4%) patients with band slippage/prolapse as the most common need for reoperation. Younger age, lack of comorbidities and diet/exercise compliance were associated with reintervention. CONCLUSIONS: LAGB has a high rate of reoperation secondary to complications associated with younger age. Alternative bariatric procedures may be more appropriate in these patients who have fewer comorbid conditions and are motivated to improve his or her health.

Laparoscopic Inguinal Hernia Repair Using ProGrip Self-Fixating Mesh: Technical Learning Curve and Mid-Term Outcomes.

PURPOSE: Self-fixating mesh has been introduced to further improve the quality results already seen with laparoscopic inguinal hernia repair. An observational study was undertaken to evaluate the technical learning curve and mid-term outcomes associated with the use of ProGrip (Medtronic, Minneapolis, MN, USA) laparoscopic self-fixating mesh in transabdominal preperitoneal (TAPP) inguinal herniorrhaphy. METHODS: Patients who underwent elective laparoscopic TAPP inguinal herniorrhaphy by a single surgeon using ProGrip laparoscopic self-fixating mesh within a one-year period were studied. The primary outcome measures included the time from mesh introduction to the final position (MI-FP), surgical complications, and pain scores. Demographic and other perioperative outcome data were collected and analyzed. RESULTS: Forty hernias were repaired in 29 patients with a laparoscopic TAPP approach. The average MI-FP was 249.4 seconds for the first 20 repairs, and 118.6 seconds (p < 0.001) for the final 20. Minor post-operative surgical complications were reported by 13.8% of patients; there were no major surgical complications. The average pain score on a scale of 0 to 5 was 0.9 (SD = 0.67, range 0-3). CONCLUSIONS: Surgeons with reasonable laparoscopic experience can expect to become fully proficient in the manipulation of self-fixating mesh after 15 to 20 repairs. Use of this product yielded low intraoperative and mid-term postoperative complication rates as well as low postoperative pain.

Outcomes of intraoperative extracorporeal membrane oxygenation versus cardiopulmonary bypass for lung transplantation.

OBJECTIVE: The study objective was to compare the outcomes of intraoperative extracorporeal membrane oxygenation versus cardiopulmonary bypass support in lung transplantation. METHODS: We performed a retrospective cohort study from a prospective database of adult lung transplantations performed at the University of Toronto from 2007 to 2013. Among 673 lung transplantations performed in the study period, 267 (39.7%) required cardiopulmonary support. There were 39 cases of extracorporeal membrane oxygenation (2012-2013) and 228 cases of cardiopulmonary bypass (2007-2013). Patients who were bridged with extracorporeal life support, underwent a concomitant cardiac procedure, received a combined liver or heart transplant, were colonized with Burkholderia cenocepacia, or required emergency cannulation for cardiopulmonary support were excluded. Finally, 33 extracorporeal membrane oxygenation cases were matched with 66 cases of cardiopulmonary bypass according to age (±10 years), lung transplantation indication, and procedure type (bilateral vs single lung transplantation). RESULTS: Recipient factors such as body mass index and gender were not different between extracorporeal membrane oxygenation and cardiopulmonary bypass groups. Furthermore, donor variables were similar, including age, body mass index, last PaO2/FiO2 ratio, smoking history, positive airway cultures, and donor type (brain death and donation after cardiac death). Early outcomes, such as mechanical ventilation requirement, length of intensive care unit stay, and length of hospital stay, significantly favored extracorporeal membrane oxygenation (median 3 vs 7.5 days, P = .005; 5 vs 9.5 days, P = .026; 19 vs 27 days, P = .029, respectively). Perioperative blood product transfusion requirement was lower in the extracorporeal membrane oxygenation group. The 90-day mortality for the extracorporeal membrane oxygenation group was 6% versus 15% for cardiopulmonary bypass (P = .32). CONCLUSIONS: Extracorporeal membrane oxygenation may be considered as the first choice of intraoperative cardiorespiratory support for lung transplantation.

The relationship between confidence and competence in the development of surgical skills.

BACKGROUND: Confidence is a crucial trait of any physician, but its development and relationship to proficiency are still unknown. This study aimed to evaluate the relationship between confidence and competency of medical students undergoing basic surgical skills training. METHODS: Medical students completed confidence surveys before and after participating in an introductory workshop across 2 samples. Performance was assessed via video recordings and compared with pretraining and posttraining confidence levels. RESULTS: Overall, 150 students completed the workshop over 2 years and were evaluated for competency. Most students (88%) reported improved confidence after training. Younger medical students exhibited lower pretraining confidence scores but were just as likely to achieve competence after training. There was no association between pretraining confidence and competence, but confidence was associated with demonstrated competence after training (p < 0.001). CONCLUSIONS: Most students reported improved confidence after a surgical skills workshop. Confidence was associated with competency only after training. Future training should investigate this relationship on nonnovice samples and identify training methods that can capitalize on these findings.

A method for the consistent creation and quantitative testing of postoperative pelvic adhesions in a porcine model.

INTRODUCTION: The assessment of methods for the prevention of postoperative pelvic adhesions is hampered by the lack of a quantifiable adhesion measurement technique. Currently available methods for adhesion model assessment rely on qualitative grading scales; a quantitative method would have many attendant benefits, including standardized reporting. METHODS: A technique was developed to generate consistent and significant adhesions in a swine model that are suitable for quantitative assessment using a Material Testing System (MTS) machine platform. In this method, the uterine horns are cannulated and then attached to the pelvic sidewall using loose silk sutures. The underlying sidewall and adjacent uterine serosa are injured with electrocautery. Following a two-week survival the entire complex of uterine horn and sidewall are excised en bloc and prepared for MTS testing. RESULTS: Extrication of the adhesion, as measured by the MTS platform, generates a quantitative assessment of adhesion strength that can be scaled and analyzed to produce several continuous variable descriptions. DISCUSSION: This technique represents a novel quantitative method for adhesion assessment in an animal model. This quantitative technique may then be applied to accurately assess a range of adhesion prevention techniques, producing results which can be standardized for comparison.