Enhanced gastric decompression for palliation of malignant bowel obstruction.

BACKGROUND: Malignant bowel obstruction (MBO) is a sequela of advanced intraabdominal cancer and has a profound impact on quality of life. Common therapy is endoscopic decompressive gastrostomy tube placement. Standard gastrostomy tubes are poorly designed to completely evacuate the dependent portions of the stomach due to their location on the anterior gastric wall. In our institution we have begun placing the ASPIRE Assist gastrostomy tube (ASPIRE Bariatrics, Exton, PA) which includes a 15 cm long, 30Fr fenestrated gastric tube extension for enhanced gastric decompression. This tube is FDA indicated for gastric decompression and marketed for endoscopic weight loss. The purpose of this study is to review our experience managing MBO utilizing the ASPIRE Assist tube. METHODS: This is a retrospective analysis of outcomes at a single institution. All decompressive endoscopic gastrostomy tubes placed by two surgeons between November 2019 and July 2021 were reviewed. Endoscopic placement was performed utilizing standard safe tract and Ponsky pull techniques. RESULTS: Fourteen patients were identified (10F:4 M), mean age 70 (range 35-89). Primary cancer diagnoses included gynecologic (8), colorectal (3), bladder (1), small bowel (1), peritoneal serous (1). During the 12 months before decompressive gastrostomy tube placement, mean number of hospital admissions for MBO was 1.6 (range 1-3). Following tube placement, twelve patients had no further hospital admissions for MBO over their lifespan of mean 270 days (range 8-679 days). One patient had 1 admission for MBO in the 12 months before tube placement and 3 admissions in the 4 months after placement. A second patient had 2 admissions in the 12 months before tube placement and 1 admission in their 54-day lifespan after placement. There were no major complications. CONCLUSIONS: Endoscopic placement of the ASPIRE Assist gastrostomy tube is safe for palliation of MBO and may improve gastric decompression compared with standard endoscopic gastrostomy tubes. Enhanced gastric decompression can better manage symptoms, reduce hospital encounters, and improve quality of life. Further study is needed, however, our initial data appears promising.

Concomitant laparoscopic cholecystectomy and antegrade wire, rendezvous cannulation of the biliary tree may reduce post-ERCP pancreatitis events.

INTRODUCTION: For patients with a gallbladder in situ, choledocholithiasis is a common presenting symptom. Both two-session endoscopic retrograde cholangiopancreatography (ERCP) and subsequent cholecystectomy (CCY) and single-stage (simultaneous CCY/ERCP) have been described. We utilize an antegrade wire, rendezvous cannulation (AWRC) technique to facilitate ERCP during CCY. We hypothesized that AWRC would eliminate episodes of post-ERCP pancreatitis (PEP). METHODS: An IRB approved, retrospective review of patients who underwent ERCP via AWRC for choledocholithiasis during CCY was performed. Patient characteristics, pre/postoperative laboratory values, complications, and readmissions were reviewed. AWRC was conducted during laparoscopic or open CCY for evidence of choledocholithiasis with or without preoperative biliary pancreatitis or cholangitis. Following confirmatory intraoperative cholangiogram, a flexible tip guidewire was inserted antegrade into the cystic ductotomy, through the bile duct across the ampulla and retrieved in the duodenum with a duodenoscope. Standard ERCP maneuvers to clear the bile duct are then performed over the wire. RESULTS: Thirty-seven patients (27 female, age 19-77, BMI 21-50 kg/m2) underwent intraoperative ERCP via AWRC technique during CCY. Seventeen underwent CCY for acute cholecystitis. Fifteen patients underwent transgastric ERCP in the setting of previous Roux-en-Y gastric bypass. Mean total operative time was 214 min. Mean ERCP time was 31 min. Thirty-three patients had biliary stents placed. There were no cannulations or injections of the pancreatic duct. There were no intraoperative complications associated with the ERCP and no patients developed PEP. Three patients developed a postoperative subhepatic abscess requiring drainage. CONCLUSION: AWRC is a useful technique for safe and efficient bile duct cannulation for therapeutic ERCP in the setting of choledocholithiasis at the time of CCY. Despite supine (rather than the traditional prone) positioning, total ERCP times were short and we eliminated any manipulation of the pancreatic duct. No patients in our series developed PEP or post-sphincterotomy bleeding.

Over-the-scope clip management of non-acute, full-thickness gastrointestinal defects.

BACKGROUND: Endoscopic management of full-thickness gastrointestinal tract defects (FTGID) has become an attractive management strategy, as it avoids the morbidity of surgery. We have previously described the short-term outcomes of over-the-scope clip management of 22 patients with non-acute FTGID. This study updates our prior findings with a larger sample size and longer follow-up period. METHODS: A retrospective analysis of prospectively collected data was conducted. All patients undergoing over-the-scope clip management of FTGID between 2013 and 2019 were identified. Acute perforations immediately managed and FTGID requiring endoscopic suturing were excluded. Patient demographics, endoscopic adjunct therapies, number of endoscopic interventions, and need for operative management were evaluated. Success was strictly defined as complete FTGID closure. RESULTS: We identified 92 patients with 117 FTGID (65 fistulae and 52 leaks); 27.2% had more than one FTGID managed simultaneously. The OTSC device (Ovesco Endoscopy, Tubingen, Germany) was utilized in all cases. Additional closure attempts were required in 22.2% of defects. With a median follow-up period of 5.5 months, overall defect closure success rate was 66.1% (55.0% fistulae vs. 79.6% leaks, p = 0.007). There were four mortalities from causes unrelated to the FTGID. Only 14.9% of patients with FTGID underwent operative management. There were no complications related to endoscopic intervention and no patients required urgent surgical intervention. CONCLUSIONS: Over-the-scope clip management of FTGID represents a safe alternative to potentially morbid operative intervention. When strictly defining success as complete closure of all FTGID, endoscopy was successful in 64.4% of patients with only a small minority of patients ultimately requiring surgery.

Endoscopic Management of Acute Biliopancreatic Disorders.

PURPOSE: Endoscopy is playing an ever-increasing role in the management of acute biliopancreatic disorders. With the management paradigm shifting away from more invasive surgical approaches, surgeons need to be aware of the treatment options available to improve patient care. Our manuscript serves to improve surgeons' knowledge and understanding of these emerging treatment modalities to expand their algorithmic approach to biliopancreatic disorders. METHODS: Specific acute biliopancreatic disorders were identified from the literature and personal practice to create a structured review of common problems experienced by a surgeon of the gastrointestinal tract. An exhaustive literature review was performed to identify and analyze endoscopic treatment modalities for these disorders. RESULTS: Endoscopic therapies continue to expand rapidly with a robust supportive literature. Data on endoscopic treatment strategies for acute biliopancreatic disorders demonstrate valuable improvements in outcomes in a number of these disorders. DISCUSSION: Acute biliopancreatic disorders represent one of the most challenging pathophysiologies that a surgeon of the gastrointestinal tract may face. This manuscript represents a review of available endoscopic instrumentation as well as the author's interpretation of the current literature regarding indications and outcomes of endoscopic management for acute biliopancreatic disorders. Although this article does not supplant formal training in therapeutic endoscopy, surgeons reading this article should understand the role endoscopy plays in the management of acute biliopancreatic disorders.

Optimizing Hospital Resource Utilization in Bariatric Readmission.

BACKGROUND AND OBJECTIVES: The prevalence of patients with a history of bariatric surgery is climbing. Medical and surgical questions arising in this patient population may prompt them to present to the nearest emergency department (ED), irrespective of that facility's experience with bariatric surgery. The emergency physician is the first to evaluate patients with a history of bariatric surgery who present with abdominal symptoms. As a quality improvement project aimed at reducing resource utilization, we sought to determine which patients presenting to the ED could be treated in an outpatient setting in lieu of hospital admission. METHODS: We conducted a retrospective review of bariatric patients admitted from our ED with abdominal symptoms, including abdominal pain, nausea, vomiting, dysphagia, obstruction, and hematemesis. We collected the following variables: type of bariatric operation, admission and discharge diagnoses, and all interventions performed during admission. RESULTS: One hundred sixty-nine patients (76.1%) had a history of laparoscopic Roux-en-Y gastric bypass. The time from bariatric operation to presentation averaged 42 ± 4.63 (SD) months. The most common symptom was abdominal pain (80.2%). Ninety-four percent of patients underwent invasive management via upper endoscopy, laparoscopy, or laparotomy. The most common postprocedural diagnoses were stricture, bowel obstruction, inflammatory findings, and cholecystitis. CONCLUSION: Most patient encounters resulted in invasive management (204/282; 72.3%). The subset of these patients requiring endoscopic evaluation or therapy (37.7%) may be suitable for outpatient management if appropriate measures are available for rapid follow-up and procedural scheduling.

Best Practices for Robotic Surgery Programs.

BACKGROUND AND OBJECTIVES: Robotic surgical programs are increasing in number. Efficient methods by which to monitor and evaluate robotic surgery teams are needed. METHODS: Best practices for an academic university medical center were created and instituted in 2009 and continue to the present. These practices have led to programmatic development that has resulted in a process that effectively monitors leadership team members; attending, resident, fellow, and staff training; credentialing; safety metrics; efficiency; and case volume recommendations. RESULTS: Guidelines for hospitals and robotic directors that can be applied to one's own robotic surgical services are included with examples of management of all aspects of a multispecialty robotic surgery program. CONCLUSION: The use of these best practices will ensure a robotic surgery program that is successful and well positioned for a safe and productive environment for current clinical practice.

Transversus Abdominis Release for Abdominal Wall Reconstruction: Early Experience with a Novel Technique.

BACKGROUND: Ventral hernias are common sequelae of abdominal surgery. Recently, transversus abdominis release has emerged as a viable option for large or recurrent ventral hernias. Our objective was to determine the outcomes of posterior component separation via transversus abdominis release for the treatment of abdominal wall hernias in the first series of patients at one institution. METHODS: We performed a retrospective review of a prospectively maintained database of open ventral hernia repair patients to identify patients who underwent posterior component separation via transversus abdominis release at one institution from 2012 to 2015. Patients who were at least 1 year out from surgery were included. Patient demographic characteristics, operative details, perioperative and postoperative complications, and recurrences were analyzed. Postoperative imaging was reviewed for evidence of morbidity or recurrence. RESULTS: Thirty-seven patients met inclusion criteria; 23 (62.2%) of these patients were female, with a mean age of 57.5 ± 11 years and median BMI of 32.1 kg/m(2) (range 23.6 to 44.0 kg/m(2)). All patients underwent repair with mesh (81.1% polypropylene, 5.4% porcine dermal matrix, and 13.5% biologic/permanent synthetic hybrid). Median defect size was 392 cm(2) (range 250 to 2,700 cm(2)) and median mesh area was 930 cm(2) (range 600 to 3,600 cm(2)). Approximately 24% (9 of 37) of patients experienced a postoperative complication; ileus was the most common (4 patients). Surgical site events requiring intervention (ie drainage and antibiotics) developed in 2 patients. Median follow-up period was 21 months (range 12 to 42 months), during which one recurrence was identified (2.7%). CONCLUSIONS: Posterior component separation via transversus abdominis release is a safe and effective method of ventral herniorrhaphy with favorable rates of wound morbidity and recurrence.

How I do it: novel parastomal herniorrhaphy utilizing transversus abdominis release.

INTRODUCTION: Parastomal hernias are a complex surgical problem affecting a large number of patients. Recurrences continue to occur despite various methods of repair. We present a novel method of open parastomal hernia repair with retromuscular mesh reinforcement in a modified Sugarbaker configuration. METHODS: A full mildline laparotomy is performed and all adhesions are taken down. We then perform an open parastomal hernia repair by utilizing retromuscular dissection, posterior component separation via transversus abdominis release, and lateralization of the bowel utilizing a modified Sugarbaker mesh configuration within the retromuscular space. We demonstrate this technique in a cadaveric model for illustrative purposes. DISCUSSION: This repair provides the benefits of an open posterior component separation with transversus abdominis release and maintains the biomechanics of a functional abdominal wall, all while simultaneously benefitting from the advantages of mesh reinforcement in a modified Sugarbaker configuration. Our clinical experience with this novel technique to this point has been positive.

Implementing a robotics curriculum at an academic general surgery training program: our initial experience.

The robotic surgical platform is being utilized by a growing number of hospitals across the country, including academic medical centers. Training programs are tasked with teaching their residents how to utilize this technology. To this end, we have developed and implemented a robotic surgical curriculum, and share our initial experience here. Our curriculum was implemented for all General Surgical residents for the academic year 2014-2015. The curriculum consisted of online training, readings, bedside training, console simulation, participating in ten cases as bedside first assistant, and operating at the console. 20 surgical residents were included. Residents were provided the curriculum and notified the department upon completion. Bedside assistance and operative console training were completed in the operating room through a mix of biliary, foregut, and colorectal cases. During the fiscal years of 2014 and 2015, there were 164 and 263 robot-assisted surgeries performed within the General Surgery Department, respectively. All 20 residents completed the online and bedside instruction portions of the curriculum. Of the 20 residents trained, 13/20 (65 %) sat at the Surgeon console during at least one case. Utilizing this curriculum, we have trained and incorporated residents into robot-assisted cases in an efficient manner. A successful curriculum must be based on didactic learning, reading, bedside training, simulation, and training in the operating room. Each program must examine their caseload and resident class to ensure proper exposure to this platform.

Gastric sleeve leak: a single institution's experience with early combined laparoendoscopic management.

BACKGROUND: Sleeve gastrectomy is an effective weight loss procedure that is technically less complex than Roux-en-Y gastric bypass. However, staple line leak (SLL) remains a significant complication of this procedure with reported incidence ranging from 1%-7%. Multiple treatment strategies for SLL are reported including surgical re-exploration, percutaneous drainage, and endoscopic stenting. Our objective was to review the results of our experience with combined laparoendoscopic procedures in managing SLL. METHODS: A retrospective review of patients with SLL after laparoscopic sleeve gastrectomy (LSG) between June 2008 and October 2013 was performed. Patient characteristics, operative details, and postoperative management strategies were reviewed. All patients were managed with a combination of early laparoscopic washout and endoscopic stenting. RESULTS: One hundred sixty-five patients underwent LSG with SLL identified in 4 patients (2.4%). One patient was transferred from an outside institution for SLL. Average time to SLL diagnosis was postoperative day 3 (range 1-7). After diagnosis patients underwent laparoscopic washout and initial endoscopic stenting. Three patients required additional endoscopic procedures to manage stent migration, and 2 required additional procedures for peri-stent leak. Complications were managed endoscopically with stent adjustment or replacement. Patients had indwelling stents for an average of 29 days (range 15-56). Mean hospital length of stay was 30 days (range 20-42). CONCLUSION: SLL after LSG can confer a high morbidity and mortality. Endoscopic management of SLL with stenting has been advocated because it successfully manages the leaks and avoids additional invasive procedures. Based on our experience, successful management of SLL can be achieved with an early combined laparoendoscopic approach.

Volumetric fat ratio and not body mass index is predictive of ileocolectomy outcomes in Crohn's disease patients.

BACKGROUND: Crohn's disease (CD) patients are typically underweight; however, a growing cohort of overweight CD patients is emerging. The current study investigates whether body mass index (BMI) or volumetric fat parameters can be used to predict morbidity after ileocolectomy for CD. METHODS: One hundred and forty-three CD patients who underwent elective ileocolectomy were identified from our Inflammatory Bowel Disease (IBD) Registry. Patient demographics and operative outcomes were recorded. Visceral (VA) and subcutaneous (SA) adiposity and abdominal circumference (AC) were analyzed on preoperative CT scans using Aquarius iNtuition software. A visceral/subcutaneous ratio (VSR) was calculated. RESULTS: BMI correlated with SA (p = 0.0001), VA (p = 0.0001) and AC (p = 0.0001) but not VSR (p > 0.05). BMI, VA and AC did not predict surgical morbidity (p > 0.05). In multivariate regression analysis, family history of IBD (p = 0.009), high American Society of Anesthesiologists score (p = 0.02) and increased VSR (p = 0.03) were independent predictors of postoperative morbidity. CONCLUSIONS: The visceral/subcutaneous fat ratio is a more reliable predictor of postoperative outcomes in CD patients undergoing ileocolectomy than conventional adiposity markers such as BMI. Preoperative calculation of the visceral/subcutaneous fat ratio offers the opportunity to optimize high-risk surgical patients, thus improving outcomes.

Clinical and surgical anatomy of the liver: a review for clinicians.

The liver is the largest gland in the body occupying 2.5% of total body weight and providing a host of functions necessary for maintaining normal physiological homeostasis. Despite the complexity of its functions, the liver has a homogenous appearance, making hepatic anatomy a challenging topic of discussion. To address this issue, scholars have devoted time to establishing a framework for describing hepatic anatomy to aid clinicians. Work by the anatomist Sir James Cantlie provided the first accurate division between the right and left liver in 1897. The French surgeon and anatomist Claude Couinaud provided additional insight by introducing the Couinaud segments on the basis of hepatic vasculature. These fundamental studies provided a framework for medical and surgical discussions of hepatic anatomy and were essential for the advancement of modern medicine. In this article, the authors review the normal anatomy and physiology of the liver with a view to enhancing the clinician's knowledge base. They also provide a convenient model to assist with understanding and discussion of liver anatomy.

Training current and future robotic surgeons simultaneously: initial experiences with safety and efficiency.

Robotic surgery is experiencing a rapidly-increasing presence in the field of general surgery. The adoption of any new technology carries the challenge of training current and future surgeons in a safe and effective manner. We report our experience with the initiation of a robotic general surgery program at an academic institution while simultaneously incorporating surgical trainees. The initial procedure performed was robotic-assisted cholecystectomy (RAC). Concurrent with the introduction of a robotic general surgical program, our institution implemented a progressive surgical trainee curriculum for all active residents and fellows. Immediately after being credentialed to perform RAC, attending surgeons began incorporating surgical trainees into robotic procedures. We retrospectively reviewed our first 50 RACs and compared them with our previous 50 standard laparoscopic cholecystectomies (SLC) to determine the impact of rapid integration of surgical trainees on developing technologies. Despite new technology and novice surgeons, there was no difference in mean operative time between the SLC and RAC groups (75.3 vs. 84.1 min, p = 0.077). Two patients in the robotic-assisted group required intraoperative conversion. Hospital length of stay was similar between groups, with the majority of patients leaving the same day. There were no postoperative complications in either group. A robotic general surgery program can be initiated while concurrently instructing surgical trainees on robotic surgery in a safe and efficient manner. We report our initial experience with the adoption of this rapidly advancing technology and describe our training model.

Laparoscopic-assisted transhiatal gastric transposition for long gap esophageal atresia in an infant.

Previous reports describing laparoscopic-assisted transhiatal gastric transposition for long gap esophageal atresia (LGEA) have focused on older infants (median age of 11 months). By performing this operation at an earlier age, patients may avoid esophagostomies or prolonged hospitalizations with nasoesophageal tubes. An additional benefit is the earlier introduction of oral feeds, which is likely to decrease the incidence of oral aversion and feeding difficulties. In this report, we describe our surgical technique for performing a laparoscopic-assisted gastric transposition in a 56-day-old former 36-week premature infant with LGEA.

Benefit of adding pioglitazone to statin therapy in non-diabetic patients with the metabolic syndrome.

Statins frequently do not control all of the lipid abnormalities found in patients with the metabolic sydrome. Pioglitizone (PIO), an insulin sensitizing agent, has been shown to have favorable lipid effects in diabetic patients. Little information is available regarding the effect of combined statin and PIO therapy in non-diabetic patients with the metabolic syndrome. We report our experience of adding PIO to statin therapy in non-diabetic patients with the metabolic syndrome. Pioglitazone was administered to 24 non-diabetic patients in our lipid clinic who were already on a statin yet continued to have significant lipid abnormalities. All patients had characteristic lipid abnormalities and clinical features of the metabolic syndrome. The treatment period was 59+/-29 (range 7-123) weeks. Lipid profiles, fasting glucose, and alanine aminotransferase were assessed before and at least 6 weeks after pioglitazone was added to statin. Triglyceride levels decreased from 307+/-295mg/dL to 173+/-129mg/dL (P=0.003), non-high-density lipoprotein cholesterol (non-HDL) decreased from 151+/-53mg/dL to 130+/-49mg/dL, (P=0.003), and high-density lipoprotein cholesterol (HDL) levels increased from 42+/-11mg/ dL to 45+/-12mg/dL, (P=0.039). The addition of PIO to statin in non-diabetic patients with metabolic sydrome produced significant additional benefits in the lipid profile over statin monotherapy. Favorable effects were seen in triglycerides, HDL, and non-HDL levels. Study limitations include: this is a small non-blinded observational study in which patients served as their own controls. The duration of combination therapy and type of statin employed were variable.

Effect of body mass index on insulin resistance and lipids in prepubertal and postpubertal children: SCHOOL observations.

As part of the School Children Have Early Onset of Leading Risk Factors for Cardiovascular Disease and Diabetes Mellitus (SCHOOL) project, this study examines the effect of elevated body mass index on metabolic parameters and its relationship to insulin resistance in prepubertal and postpubertal students from the Wausau School District in central Wisconsin. Two hundred forty-seven nondiabetic students were randomly selected (125 prepubertal [2nd graders] and 122 postpubertal [11th graders]). Waist/hip ratio and body mass index corrected for age and sex were calculated. Fasting insulin, glucose, and nuclear magnetic resonance lipid profiles were measured. Relative insulin resistance was defined as quantitative insulin sensitivity check index > 1 SD below the mean of normal-weight children. Twenty-eight percent of 2nd graders and 33% of 11th graders were overweight. Relative insulin resistance was present in 47% of overweight 2nd graders and 51 % of overweight 11th graders and was associated with higher triglycerides, lower high-density lipoprotein, smaller low-density lipoprotein particles and, in 11th graders, higher waist/hip ratio. Relative insulin resistance prevalence is high among overweight children and adolescents. Biomarkers of increased risk of adverse cardiovascular outcomes are already present in overweight school children.