In-Person Clinic Visits After Laparoscopic Cholecystectomy: Lessons Learned From COVID-19 Pandemic.

INTRODUCTION: The utility of routine in-person clinic appointments after laparoscopic cholecystectomy (LC) is uncertain, especially after the increase of telehealth visits during the COVID-19 pandemic. The purpose of this study was to evaluate the utility of routine in-person follow-up for patients undergoing LC prior to changes implemented during the pandemic and to determine whether a return to routine in-person follow-up is warranted. METHODS: We retrospectively reviewed follow-up encounters for all patients undergoing LC from April 2018 to February 2020. All patients were routinely scheduled for in-person postoperative clinic follow-up 2-4 wk after discharge. Follow-up was considered nonroutine if new studies or medications were ordered, the patient was referred to the emergency department or readmitted, or malignancy was identified on pathology review. RESULTS: Of 661 patients undergoing LC, 449 (68%) attended their scheduled in-person postoperative appointment and 212 (32%) did not. The postoperative appointment was nonroutine for 39 patients (9% of clinic attenders). Readmission occurred in 42 patients, with no differences between clinic attenders and nonattenders (P = 0.12). Furthermore, attending a postoperative clinic visit did not affect odds of readmission (odds ratio: 0.705, 95% confidence interval: 0.368, 1.351; P = 0.29). Readmission occurred on median day 9 after discharge in both groups. CONCLUSIONS: The incidence of nonroutine follow-up after LC is low, and attendance at follow-up clinic was not associated with reduced readmissions. A return to routinely scheduling in-person follow-up 2-4 wk after discharge may not be warranted. Telehealth visits within 1 wk of discharge after LC should be considered.

Fast-Track Nonelective Laparoscopic Cholecystectomy is Safe and Feasible.

INTRODUCTION: Ample evidence exists to support the safety of fast-track discharge after elective laparoscopic cholecystectomy (LC), but there is currently no data available to support the safety of fast-tracking patients undergoing nonelective LC. We sought to determine whether fast-tracking patients undergoing nonelective LC is safe and feasible. METHODS: We performed a retrospective cohort review of 661 consecutive patients undergoing LC at a single teaching institution from April 2018 to January 2020. Subjects were divided into two groups: elective LC (ELC) and fast-track nonelective LC (FTLC). FTLC was defined as nonelective LC with total length of stay <36 h. Patients undergoing nonelective LC with length of stay exceeding 36 h were excluded. The primary outcome of interest was readmission within 30 d. The secondary outcomes included incidences of return to emergency department within 30 d, retained stone, bile leak, and wound infection. RESULTS: Of 661 LC, 185 (27%) were ELC and 476 (72%) were nonelective. FTLC included 121 (25%) of the nonelective LC. Preoperative characteristics were similar among the groups. On final pathology, chronic cholecystitis was predominant in both groups, but FTLC exhibited higher rates of acute cholecystitis (P < 0.0001). There was no significant difference in the primary outcome among groups: readmission within 30 d occurred in 6 (3%) ELC patients and 4 (3%) FTLC patients (P = 1.0). There were no significant differences in rates of return to emergency department within 30 d, retained stone, bile leak, or wound infection. CONCLUSIONS: With comparable postoperative complication rates to ELC, FTLC can be safely used in select patients. Additional studies are needed to determine preoperative predictors of FTLC suitability to prospectively identify appropriate patients.

Development and Validation of Task-Specific Metrics for the Assessment of Linear Stapler-Based Small Bowel Anastomosis.

INTRODUCTION: Task-specific metrics facilitate the assessment of surgeon performance. This 3-phased study was designed to (1) develop task-specific metrics for stapled small bowel anastomosis, (2) obtain expert consensus on the appropriateness of the developed metrics, and (3) establish its discriminant validity. METHODS: In Phase I, a hierarchical task analysis was used to develop the metrics. In Phase II, a survey of expert colorectal surgeons established the importance of the developed metrics. In Phase III, to establish discriminant validity, surgical trainees and surgeons, divided into novice and experienced groups, constructed a side-to-side anastomosis on porcine small bowel using a linear cutting stapler. The participants' performances were videotaped and rated by 2 independent observers. Partial least squares regression was used to compute the weights for the task-specific metrics to obtain weighted total score. RESULTS: In Phase II, a total of 45 colorectal surgeons were surveyed: 28 with more than 15 years, 13 with 5 to 15 years, and 4 with less than 5 years of experience. The consensus was obtained on all the task-specific metrics in the more experienced groups. In Phase III, 20 subjects participated equally in both groups. The experienced group performed better than the novice group regardless of the rating scale used: global rating scale (p = 0.009) and the task-specific metrics (p = 0.012). After partial least squares regression, the weighted task-specific metric score continued to show that the experienced group performed better (p < 0.001). CONCLUSION: Task-specific metric items were developed based on expert consensus and showed good discriminant validity compared with a global rating scale between experienced and novice operators. These items can be used for evaluating technical skills in a stapled small bowel anastomosis model.

Postnatal Hyperplasic Effects of ActRIIB Blockade in a Severely Dystrophic Muscle.

The efficacy of two ActRIIB ligand-trapping agents (RAP-031 and RAP-435) in treating muscular dystrophy was examined by determining their morphological effects on the severely dystrophic triangularis sterni (TS) muscle of the mdx mouse, a model for Duchenne muscular dystrophy. These agents trap all endogenous ligands to the ActRIIB receptor and thereby block myostatin signaling in a highly selective manner. Short-term (1 month) and long-term (3 months) in vivo treatment of 1-month-old mdx mice increased myonuclei and fiber cross section (FCS) density but did not alter individual fiber size. Vehicle-treated mdx mice exhibited age-dependent increases in myonuclei and FCS density, and age-dependent reductions in centronucleation that were each enhanced by treatment with RAP-435. Distributions of FCS area (FCSA) in the mdx TS were 90% identical to those from untreated age-matched nondystrophic mice and were unaltered by the substantial fiber hyperplasia observed with age and RAP-435 treatment. These results were inconsistent with injury-induced fiber regeneration which produces altered FCSA distributions characterized by a distinct class of smaller regenerated fibers. Nondystrophic mice exhibited a constant postnatal density of fiber cross sections and myonuclei, and RAP-435 treatment of nondystrophic mice increased TS mean FCSA but had no effects on myonuclei or FCS density. These results demonstrating a continual postnatal proliferation and fusion of satellite cells and a response to myostatin blockade characteristic of developing prenatal muscle suggest that the lack of dystrophin directly results in unrestrained postnatal satellite cell activation that is not necessarily dependent upon prior fiber degeneration. J. Cell. Physiol. 232: 1774-1793, 2017. © 2016 Wiley Periodicals, Inc.