Multisociety research collaboration: timing of cholecystectomy following cholecystostomy drainage for acute cholecystitis.

BACKGROUND: Patients with acute cholecystitis (AC) presenting with unfavorable systemic or local conditions are often managed with percutaneous cholecystostomy (PC) as a temporary measure. The clinical outcomes of interval cholecystectomy following PC remain unclear. The aim of the study was to identify the association between the timing of cholecystectomy following PC for AC and perioperative complication rates at interval cholecystectomy. We hypothesized that there would be a specific time interval to cholecystectomy associated with lower risk for adverse events. METHODS: This was a retrospective (2018-2020) multicenter study at 8 participating hospital systems of adult patients with AC, managed with PC and interval cholecystectomy. Demographics, comorbidities, treatment details, and outcomes were examined. Patients were grouped based on quartiles for timing of surgery after PC (< 7, 7-9, 10-13, > 13 weeks). The primary outcome was a composite endpoint of bile duct injury, reoperation, readmission, image-guided intervention, endoscopic intervention, conversion to open surgery, or death. RESULTS: There were 188 patients with a median age of 66 years with AC classified as mild (41%), moderate (47%), and severe (12%). Median days from PC to surgery were 65 (Q1 = 48, Q3 = 91). Laparoscopic cholecystectomy (89.9%) was the most commonly planned approach (robotic 6.4%, 3.7% open) and 28 (14.9%) were converted to open. The composite endpoint was reported in 51 patients (27.1%). A biliary injury occurred in 7 (3.7%) patients. Time to surgery and intraoperative drain placement were independently associated with the composite outcome. Cholecystectomy within 7 weeks of PC was associated with decreased risk (OR = 0.36, 95% CI 0.13-0.97) of the composite endpoint, compared to patients undergoing surgery > 13 weeks after PC. CONCLUSION: Timing of surgery following PC was associated with procedural outcomes. Patients undergoing surgery before 7 weeks experienced significantly less morbidity than patients having delayed cholecystectomy. These results should be considered in patient selection and management after PC.

Impact of COVID-19 on common non-elective general surgery diagnoses.

BACKGROUND: During the COVID-19 pandemic, public health and hospital policies were enacted to decrease virus transmission and increase hospital capacity. Our aim was to understand the association between COVID-19 positivity rates and patient presentation with EGS diagnoses during the COVID pandemic compared to historical controls. METHODS: In this cohort study, we identified patients ≥ 18 years who presented to an urgent care, freestanding ED, or acute care hospital in a regional health system with selected EGS diagnoses during the pandemic (March 17, 2020 to February 17, 2021) and compared them to a pre-pandemic cohort (March 17, 2019 to February 17, 2020). Outcomes of interest were number of EGS-related visits per month, length of stay (LOS), 30-day mortality and 30-day readmission. RESULTS: There were 7908 patients in the pre-pandemic and 6771 in the pandemic cohort. The most common diagnoses in both were diverticulitis (29.6%), small bowel obstruction (28.8%), and appendicitis (20.8%). The lowest relative volume of EGS patients was seen in the first two months of the pandemic period (29% and 40% decrease). A higher percentage of patients were managed at a freestanding ED (9.6% vs. 8.1%) and patients who were admitted were more likely to be managed at a smaller hospital during the pandemic. Rates of surgical intervention were not different. There was no difference in use of ICU, ventilator requirement, or LOS. Higher 30-day readmission and lower 30-day mortality were seen in the pandemic cohort. CONCLUSIONS: In the setting of the COVID pandemic, there was a decrease in visits with EGS diagnoses. The increase in visits managed at freestanding ED may reflect resources dedicated to supporting outpatient non-operative management and lack of bed availability during COVID surges. There was no evidence of a rebound in EGS case volume or substantial increase in severity of disease after a surge declined.

Robotic median arcuate ligament release: management algorithm and clinical outcomes from a large minimally invasive series.

BACKGROUND: Median arcuate ligament syndrome (MALS) is a rare and debilitating condition that remains difficult to diagnose. Proper patient selection remains key to achieving favorable outcomes for those undergoing MALR. The robotic technique facilitates a minimally invasive MALR approach given the fine precision of the instrumentation and stability of visualization. Here we describe our management algorithm and clinical outcomes for a large series of robotic MALR patients. METHODS: This retrospective cohort study analyzed adult patients who underwent robotic MALR performed by a single surgeon at a tertiary academic hospital from 2014 to 2021. The diagnosis of MALS was made using objective criteria from celiac artery duplex ultrasound with a peak systolic velocity of > 350 cm/s combined with a right upper quadrant abdominal ultrasound, esophagogastroduodenoscopy, and computer tomography or magnetic resonance angiography to exclude other diagnoses. Information on patient demographics, perioperative factors, and patient reported symptoms up to 1-year post-operatively were collected. RESULTS: A total of 74 patients underwent robotic MALR during the study period. The mean age was 27.3 ± 7.9 years and the majority of patients were female (n = 60/74, 81.1%). The most common presenting symptom was post-prandial abdominal pain (n = 65/74, 87.7%). The mean operative time was 52.6 ± 18.1 min. There were no conversions to open surgery and minimal blood loss (mean = 13.9 ± 8.4 mL). At 3-months, 12% (n = 9/74) of patients had persistent abdominal pain and underwent additional imaging. 5 of these 9 patients had persistently elevated DUS expiratory PSV and were referred for angioplasty. 3 of these 5 referred patients had resolution of abdominal pain after angioplasty. At 1-year follow up, 90.3% (n = 56/62) continued to have no abdominal pain. CONCLUSIONS: Through this series, the largest set of minimally invasive (laparoscopic or robotic) MALR procedures published to date, we show that with strict adherence to a management algorithm, the robotic approach to MALR is safe and feasible, with good patient outcomes.

The use of advanced robotic simulation labs to advance and assess senior resident robotic skills and operating room leadership competency: a pilot study.

BACKGROUND: General surgery has the fastest growing robotic operative volume in the United States, but most robotic curricula are focused on basic psychomotor skills. There are limited curricula focused on advanced robotic technical and related non-technical skills. We describe a novel pilot curriculum for robotic hiatal hernia repair developed for senior surgical residents to provide training and standardized assessment of higher-order robotic technical and leadership skills. METHODS: Twelve senior residents, post-graduate year (PGY) 4 & 5, participated in a robotic hiatal hernia repair skills curriculum. Residents completed a pre- and post-survey on confidence and ability ratings on a 5-point Likert-type Scale, and a knowledge assessment. An informal faculty-led didactic was provided prior to the simulation. Residents were scored on two validated assessment tools: Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) and Global Ratings Scale of Operative Performance (GRS) by faculty proctors. RESULTS: Confidence in ability to independently complete a robotic hiatal hernia case increased from mean of 2.6 ± 0.8 to 3.3 ± 0.6 (p = 0.0007). Following the simulation, residents reported increased overall confidence and ability to operate independently with mean scores of 3.3 ± 0.8 and 3.8 ± 0.9, respectively. Mean O-SCORE and GRS scores were 3.6 (range 2 - 4) and 25.4 (range 12 - 31), respectively. Number of prior live robotic cases was strongly positively correlated to O-SCORE (R = 0.84, p = 0.0006) and GRS (R = 0.88, p = 0.0002). CONCLUSION: Our pilot study suggests live-operative robotic training is not sufficient alone for advanced robotic skill training. Simulations such as this can be used to (1) practice advanced robotic technical and relevant non-technical skills such as communication and operating room leadership in a low stake setting and (2) assess residents in a standardized environment to eventually evaluate robotic competency.

Technique and Outcomes in Laparoscopic Repair of Morgagni Hernia in Adults.

Background: Morgagni hernias (MHs) are rare anteromedial congenital diaphragmatic hernias. This study describes the effectiveness of a laparoscopic approach for these defects. Methods: A prospectively collected institutional database at a tertiary referral center was queried for patients (≥18 years) with MHs. Results: Fifteen adults underwent laparoscopic MH repair. Abdominal pain was the most common presentation (71.5%), and 2 patients (13.3%) presented with acute obstruction. Laparoscopic bridged mesh repair was the most common approach (66.7%) and was achieved by suturing a bridged synthetic mesh to the diaphragmatic portion of the defect and fixing it with transfascial sutures and/or tacks to the anterior abdominal wall. Primary suture repair was utilized for smaller defects. No mortalities or recurrences occurred after 20.2 months median follow-up. Conclusions: Laparoscopic synthetic mesh repair of adult MHs offers an effective hernia repair with minimal complications and no detected recurrences in long-term follow-up of this patient sample.

Non-elective paraesophageal hernia repair: surgical approaches and short-term outcomes.

BACKGROUND: The majority of laparoscopic paraesophageal hernia (PEH) repairs are performed electively. We aimed to investigate the frequency of non-elective laparoscopic (MIS) PEH repair and compare 30-day outcomes to elective MIS repairs and non-elective open repairs. We hypothesized that an increasing percentage of non-elective PEH repairs would be performed laparoscopically and that this population would have improved outcomes compared to non-elective open PEH counterparts. METHODS: The 2011-2016 NSQIP PUFs were used to identify patients who underwent PEH repair. Case status was classified as open vs. MIS and elective versus non-elective. Preoperative patient characteristics, operative details, discharge destination, and 30-day postoperative complication rates were compared. Logistic regression was used to examine the impact of case status on 30-day mortality. RESULTS: We identified 20,010 patients who underwent PEH. There were an increasing number of MIS PEH repairs in NSQIP between 2011 and 2016. Non-elective repairs were performed in 2,173 patients and 73.4% of these were completed laparoscopically. Elective MIS patients were younger, had a higher BMI, and were more likely to be functionally independent (p < 0.01) than their non-elective counterparts. Non-elective MIS patients had a higher wound class and ASA class compared to their elective counterparts. Compared to elective MIS cases, non-elective MIS PEH repair was associated with increased odds of mortality, even after controlling for patient characteristics (OR = 1.76, p = 0.02). There was no statistically significant difference in mortality for non-elective MIS vs. non-elective open PEH repair. There is an increase in non-elective PEH repairs recorded in NSQIP over time studied. CONCLUSIONS: The population undergoing non-elective MIS PEH repairs is different from their elective MIS counterparts and experience a higher postoperative mortality rate. While the observed increased utilization of MIS techniques in non-elective PEH repairs likely provides benefits for the patient, there remain differences in outcomes for these patients compared to elective PEH repairs.

Surgery Resident Time Consumed by the Electronic Health Record.

OBJECTIVE: Time spent on the Electronic Health Record (EHR) influences surgical residents' clinical availability. Objective data assessing EHR usage among surgical residents are lacking and necessary. DESIGN/PARTICIPANTS: Active EHR usage data for 70 surgical residents were collected from April 2015 through April 2016. Active EHR usage was defined as more than 15 keystrokes, or 3 mouse clicks, or 1700 "mouse miles" per minute. Usage data of different specialties, interns (PGY 1), juniors (PGY 2, 3), and seniors (PGY 4, 5) were compared. SETTING: Carolinas Medical Center, Charlotte, NC. RESULTS: Interns spent more time than juniors on total EHR activities per day (134.5 vs 105.5 minutes, p < 0.001) and juniors spent more time per day than seniors (105.5 vs 78.7 minutes, p < 0.001). Among different EHR activities per patient, interns spent greater time than juniors on chart review (8.1 vs 6.2 minutes, p < 0.001), documentation (9.0 vs 6.5 minutes, p < 0.001), and orders (3.6 vs 3.0 minutes, p < 0.001). Juniors spent the same time as seniors on chart review (6.2 vs 6.5 minutes, p = 0.2). Juniors spent more time than seniors on documentation (6.5 vs 5.2 minutes, p < 0.001) and orders (3.0 vs 2.7 minutes, p < 0.05). Comparing EHR activities per patient among different specialties, General Surgery residents spent more time than Orthopedic residents on total EHR time (19.9 vs 15.9 minutes, p < 0.001), chart review (6.8 vs 5.7 minutes, p < 0.001), documentation (6.3 vs 5.6 minutes, p < 0.001), and orders (3.6 vs 2.6 minutes, p < 0.001). General Surgery residents spent less time than OB/GYN residents on total EHR time (19.9 vs 22 minutes, p < 0.01), chart review (6.8 vs. 7.5 minutes, p < 0.05), and documentation (6.3 vs 7.6 minutes, p < 0.001), but more time on orders (3.6 vs 2.9 minutes, p < 0.001). CONCLUSIONS: These are the first reported objective findings on surgical resident use of the EHR and may provide an opportunity for improvement in EHR training and usage.

Trends and Outcomes in the Operative Management of Traumatic Vascular Injuries: A Comparison of Open versus Endovascular Approaches.

Controversy exists in vascular trauma regarding the best method of treatment-open versus endovascular techniques. Little has been published on this complex topic. Patients from 2005 to 2013 at a Level I trauma center with vascular injuries were identified via a prospectively trauma registry. Patient data, injury type/severity, treatment, and 30-day outcomes were obtained from the trauma registry and the chart review. Adverse events (limb loss, major disability, and death) were outcomes of interest. Univariate analysis and multivariate logistic regression were used to identify predictors of adverse events. In all, 346 patients were included (median age 34, range 1-93 years). Median Injury Severity Score (ISS) was 10 (1-59). Endovascular repairs (n = 52) increased from 0 per cent (2005) to 32 per cent (2013), and demonstrated equivalent outcomes to open approaches (P = 0.24). On multivariate analysis, higher ISS (P = 0.001), increasing age (P = 0.01), and lower extremity injuries (P = 0.001) were associated with adverse outcomes across the entire series. Endovascular approaches were most commonly used in vascular injuries of the chest/abdomen (39 of 52, 75% of all endovascular procedures in the series, P < 0.001), older patients (P = 0.003), blunt injury mechanism (P < 0.001), and patients with a higher ISS at presentation (P < 0.001). In conclusion, this large series, the use of endovascular procedures increased over time, and was associated with equivalent outcomes to open approaches, despite their higher usage in older patients, those with chest/abdominal injuries, and those with a higher ISS at presentation. Although these retrospective results are encouraging, further prospective study into the role of endovascular therapies in the treatment of vascular injuries.

A novel variant of the cleidocervicalis muscle with clinical implications for nerve compression/entrapment.

PURPOSE: The cleidocervicalis muscle occurs in approximately 1-3 % of the population that may be confused with pathological neck masses. We describe a novel variant of the muscle and its clinical implications. METHODS: This is a case report of a cleidocervicalis muscle variant identified during routine cadaveric dissection. RESULTS: The muscle identified originated on the C5 vertebra and inserted on the clavicle medial to the trapezius muscle. Innervation was provided by a C6 spinal nerve branch. Notably, a branch of the supraclavicular nerve was closely associated with the muscle, raising the possibility of compression of this nerve. CONCLUSIONS: Presence of a cleidocervicalis muscle should be considered in cases of shoulder pain consistent with supraclavicular nerve entrapment or compression.

Rational design of cyclopropane-based chiral PHOX ligands for intermolecular asymmetric Heck reaction.

A novel class of chiral phosphanyl-oxazoline (PHOX) ligands with a conformationally rigid cyclopropyl backbone was synthesized and tested in the intermolecular asymmetric Heck reaction. Mechanistic modelling and crystallographic studies were used to predict the optimal ligand structure and helped to design a very efficient and highly selective catalytic system. Employment of the optimized ligands in the asymmetric arylation of cyclic olefins allowed for achieving high enantioselectivities and significantly suppressing product isomerization. Factors affecting the selectivity and the rate of the isomerization were identified. It was shown that the nature of this isomerization is different from that demonstrated previously using chiral diphosphine ligands.

Highly diastereoselective formal nucleophilic substitution of bromocyclopropanes.

A highly diastereoselective formal nucleophilic substitution of bromocyclopropanes with oxygen- and nitrogen-based nucleophiles was demonstrated. The reaction proceeds via a base-assisted dehydrohalogenation producing a cyclopropene intermediate, which subsequently undergoes addition of a pronucleophile across the strained double bond. Very high chemoselectivity toward addition of primary and secondary alkoxides, as well as N-nucleophiles, in the presence of tert-butoxide base was observed, whereas phenoxides did not undergo addition under these reaction conditions. Facial selectivity of the addition can be efficiently controlled either by sterics or through a directing effect of an amide, carboxylate, and an o-aminomethylphenol function. Employment of tethered optically active amino alcohols as pronucleophiles allowed for efficient assembly of homochiral bicyclic compounds.

Rhodium-catalyzed hydroformylation of cyclopropenes.

The first catalytic diastereo- and enantioselective hydroformylation of cyclopropenes was demonstrated. The reaction proceeds efficiently under very mild conditions and low catalyst loadings providing high yields of cyclopropylcarboxaldehydes. This novel methodology represents a convenient, atom-economic approach toward optically active cyclopropylcarboxaldehydes from readily available prochiral cyclopropenes.

Palladium-catalyzed hydrophosphorylation and hydrophosphinylation of cyclopropenes.

Novel transition-metal-catalyzed addition of P-H entities across the cyclopropene double bond has been developed. This transformation allows for mild and efficient preparation of phosphorus-containing cyclopropanes in good yields and high degrees of diastereoselectivity.