A community hospital's experience with robotic thoracic surgery.

INTRODUCTION: The emergence of minimally invasive thoracic surgery has positively impacted postoperative recovery. Robotic-assisted thoracoscopic surgery (RATS) has been shown to have equivalent short- and long-term outcomes as compared with video-assisted thoracoscopic surgery (VATS). The introduction of RATS offers a three-dimensional high-definition image, improved ergonomics, and wristed movement. The purpose of this paper was to define the learning curve of RATS. METHODS: This study is a retrospective review of a single surgeon's RATS experience in a community hospital. All patients who underwent RATS between December 2011 and April 2014 were included. The cohort was divided into 2 groups: "early" and "late." These groups were created based on the date before or after February 2013, respectively. Data is presented as means and percentages. Significance was defined as a P value < 0.05. All categorical variables were evaluated with Fisher's exact t test and all continuous variables were compared via a paired t test. RESULTS: Seventy-nine patients were identified with a mean age of 59. There were 39 patients in the early group and 40 in the late. Rates of conversion to open thoracotomy (13% vs 10%, P = 0.74) and operative time (180 vs 204 min, P = 0.34) did not demonstrate any statistical significance between the two cohorts. Postoperative morbidity (21% vs 28%, P = 0.60) and mortality (3% vs 0%, P = 1.00) were equivalent between both groups. There was a higher percentage of lobectomies performed during the late group (38% vs 65%, P = 0.02). Furthermore, these lobectomies were performed at a faster rate in the late group. CONCLUSION: Based on our experience, the complexity of the operations that can be performed robotically increased with the number of operations performed without an impact on postoperative morbidity and mortality.

Study of the gastrointestinal bioavailability of a pancreatic extract product (Zenpep) in chronic pancreatitis patients with exocrine pancreatic insufficiency.

INTRODUCTION: The Food and Drug Administration in 2006 required that all pancreatic enzyme products demonstrate bioavailability of lipase, amylase, and protease in the proximal small intestine. METHODS: In this phase I open-label, randomized, crossover trial, 17 adult chronic pancreatitis (CP) patients with severe exocrine pancreatic insufficiency (EPI) underwent two separate gastroduodenal perfusion procedures (Dreiling tube suctioning and [14C]-PEG instillation by an attached Dobhoff tube in the duodenal bulb). Patients received Ensure Plus® alone and Ensure Plus with Zenpep (75,000 USP lipase units) in random order. The bioavailability of Zenpep was estimated by comparing the recovery of lipase, amylase, chymotrypsin activity in two treatment conditions. 14C-PEG was used to correct duodenal aspirates volume. The primary efficacy endpoint was lipase delivery in the duodenum after Zenpep administration under fed conditions. Secondary efficacy endpoints included chymotrypsin and amylase delivery, serum CCK levels, and measuring duodenal and gastric pH. RESULTS: Zenpep administration with a test meal was associated with significant increase in duodenal aspiration of lipase (p = 0.046), chymotrypsin (p = 0.008), and amylase (p = 0.001), compared to the test meal alone, indicating release of enzymes to the duodenum. Lipase delivery was higher in the pH subpopulation (the efficacy population with acid hypersecretors excluded) (p = 0.01). Recovery of [14C]-PEG was 61%. Zenpep was generally well tolerated. All adverse events were mild and transient. CONCLUSIONS: In CP patients with severe EPI, lipase, chymotrypsin and amylase were released rapidly into the duodenum after ingestion of Zenpep plus meal compared to meals alone. Results also reflected the known pH threshold for enzyme release from enteric coated products.

Iatrogenic Bilothorax: A Rare Complication of Orthotopic Liver Transplant.

Bilothorax is a rare condition involving drainage of bile from the biliary system into the lung's pleural space. Several cases have been reported in the literature, where the most commonly reported cause is iatrogenic injury. To date, no cases of bilothorax as a complication of liver transplantation have been reported. Given its rarity and concurrent morbidity, early recognition is paramount as this condition can quickly deteriorate into adult respiratory distress syndrome.

Use of Computerized Tomography in Abdominal Pain.

Annually, approximately 70 million computed tomography (CT) scans are performed in emergency department (ED) settings in the United States of America. From 1995 to 2007, there has been a 5.9-fold increase in the use of CT scans nationally. The radiation risks and high costs associated with CT scans underscore the fact that the imaging modality, although necessary, carries a myriad of long-term risks to both patients and providers. For the workup of abdominal pain, most algorithms include the use of CT scan as an early step. To understand better the use of CT scans in our ED, we performed a retrospective review of patients presenting to the ED with abdominal pain. Two main questions were addressed: 1) what were the reasons for scans and how often did the scans reveal pathology related to the presenting symptoms, 2) how often were incidental findings identified. Our results showed that among patients presenting with abdominal pain to the ED, 50 per cent of the scans were normal, about 20 per cent of the patients had findings correlating with acute abdominal pain, whereas the rest (30%) had incidental findings that may have led to further outpatient studies or long standing abdominal pain. Most patients who presented to the ED had nonspecific abdominal pain i.e. 64.4 per cent. There was a low agreement between the presenting quadrant of pain and final pathological diagnosis (9.5-33.3% concordance), with left flank pain presentation having the highest level of agreement with the final pathologic diagnosis.