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BACKGROUND: The surgical management of midline ventral hernias complicated by concomitant diastasis recti presents a significant clinical challenge. The Endoscopic Onlay Repair (ENDOR) offers a minimally invasive solution, effectively addressing both conditions. This study focuses on describing the adaptation of ENDOR to a robotic platform, termed R-ENDOR, aiming to report initial outcomes along with other established robotic surgical approaches. METHODS: This retrospective case series study included consecutive adult patients who underwent R-ENDOR approach from October 2018 to April 2023, performed by a single surgeon. A comprehensive description of the surgical technique is included. Patient demographics, operative, and hernia-specific characteristics, as well as clinical outcomes are described. RESULTS: A total of 15 patients undergoing R-ENDOR for ventral hernia repair with diastasis recti plication were included. The median age was 59 years (IQR 42-63), with 60% (n = 9) female patients. The majority (86%, n = 13) had an ASA score of ≤ 2, and the median BMI was 24 kg/m2, with 20% (n = 3) classified as obese. Median hernia size was 2 cm (IQR 2-2.25), with a median diastasis length of 19 cm (IQR 15-21.5) and width of 4 cm (IQR 3-6). The median operative time was 129 min (IQR 113-166). Most repairs (93%, n = 14) were reinforced with mesh, predominantly self-fixating (73.3%, n = 11). Eighty percent of patients (n = 12) were discharged on the same day, with a median follow-up of 153 days (IQR 55-309). Notable complications included clinically significant seromas in 20% of patients (n = 3), long-term hypoesthesia in 40% (n = 6), and readmission in one patient (6.6%) for surgical site infection (SSI) requiring IV antibiotic therapy. CONCLUSION: Midline ventral hernias associated to diastasis recti can be managed robotically by ENDOR with safe and consistent 90-day outcomes in a carefully selected group of patients.
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INTRODUCTION: Suboptimal weight loss or weight regain may occur after Roux-en-Y gastric bypass (RYGB). For this reason, revisional surgery has gained increasing interest. We aimed to compare the percentage of total body weight loss (%TBWL) at one-year follow-up among three different techniques: Jejuno-jejunostomy distalization (JJD), Sleeve resection of the gastrojejunostomy and gastric pouch (SRGJP), and the combination of both (JJD + SRGJP). METHODS: This retrospective cohort study included all patients who underwent revisional surgery after RYGB (2020-2021). The cohort was stratified by the type of revisional technique performed. Postoperative bariatric outcomes and nutritional deficiencies were compared among groups. RESULTS: A total of 78 patients underwent revisional surgery after RYGB: JJD was performed in 8 (10.3%), SRGJP in 34 (43.6%), and JJD + SRGJP in 36 (46.1%) patients. The most common indication for surgery was weight regain, in 72 (92.3%) patients. The median lengths of the BP limbs before and after distalization, were 50 cm (IQR 40-75 cm) and 175 cm (IQR 150-200 cm), respectively. The median length of the new common limb (NCL) and total alimentary limb length (TALL) were 277 cm (IQR 250-313 cm) and 400 cm (IQR 375-475 cm), respectively. Median percentage of total body weight loss (%TBWL) at one year was 15% (IQR 15-19%) for JJD, 20% (IQR 13-26%) for SRGJP, and 21% (IQR 15- 28%) for JJD + SRGJP (p = 0.40). CONCLUSIONS: In this study, the combined procedure (JJD + SRGJP) exhibited higher %TBWL at one year, however no statistically significant difference was identified among the three techniques.
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Derivação Gástrica , Obesidade Mórbida , Reoperação , Redução de Peso , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos de Coortes , Derivação Gástrica/métodos , Obesidade Mórbida/cirurgia , Estudos RetrospectivosRESUMO
BACKGROUND: Surgical pain management is a critical component in the success of bariatric procedures. With the opioid epidemic, there have been increased efforts to decrease opioid use. In 2019, the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program developed the BSTOP protocol, a multimodal perioperative pain management regimen to minimize opioid use. The objective of this study is to evaluate the effectiveness of the BSTOP protocol on patients' need for opioid medications during their perioperative care. METHODS: This is a single-institution prospective cohort study on patients who underwent bariatric surgery from 10/2019 to 5/2021. Data was collected on morphine equivalent dose of opioids during different stages of inpatient and outpatient care. BSTOP was implemented on 7/2020. Primary outcomes were total inpatient and outpatient opioid use as well as hospital length of hospital stay (LOS). Gabapentin was removed from the protocol between 10/20/2020 and 12/31/2020 due to side effects; it was re-implemented on 1/1/2021 due to observed spikes in opioid use during its absence. RESULTS: 1264 patients who had bariatric surgery between 10/2019 and 5/2021 were included in the study, with 409 patients before (pre-BSTOP) and 855 patients after BSTOP implementation. There was a 36% reduction in total inpatient opiate use and a 57% reduction in total outpatient opiate use. LOS also significantly decreased, from 1.53 to 1.28 days. 179 patients received BSTOP without gabapentin. These patients used more opioids in the post-anesthesia care unit and on the inpatient floors compared to pre-BSTOP and BSTOP with gabapentin patients. With total inpatient and outpatient opioid use, patients on BSTOP without gabapentin used fewer opioids than those pre-BSTOP. However, those on BSTOP without gabapentin used more opioids than those with gabapentin. CONCLUSION: The BSTOP protocol significantly reduced inpatient and outpatient opioid use as well as LOS. Gabapentin is a crucial component of the BSTOP protocol.
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Cirurgia Bariátrica , Transtornos Relacionados ao Uso de Opioides , Humanos , Analgésicos Opioides/uso terapêutico , Gabapentina/uso terapêutico , Estudos Prospectivos , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/prevenção & controle , Dor Pós-Operatória/epidemiologia , Cirurgia Bariátrica/efeitos adversos , Morfina/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/etiologia , Prescrições , Estudos RetrospectivosRESUMO
INTRODUCTION: Reinforcement of crural closure with synthetic resorbable mesh has been proposed to decrease recurrence rates after hiatal hernia repair, but continues to be controversial. This systematic review aims to evaluate the safety, efficacy, and intermediate-term results of using biosynthetic mesh to augment the hiatus. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed throughout this systematic review. The Risk of Bias in Non-Randomized Studies of Interventions and Risk of Bias in Randomized Trials tools were used to perform qualitative assessment of all studies included in this review. Recommendations were then summarized for the following pre-defined key items: protocol, research question, search strategy, study eligibility, data extraction, study design, risk of bias, publication bias, and statistical analysis. RESULTS: The systematic literature search found 520 articles, 101 of which were duplicates and 355 articles were determined to be unrelated to our study and excluded. The full text of the remaining 64 articles was thoroughly assessed. A total of 18 articles (1846 patients) were ultimately included for this review, describing hiatal hernia repair using three different biosynthetic meshes-BIO-A, Phasix ST, and polyglactin mesh. Mean operative time varied from 127 to 223 min. Mean follow up varied from 12 to 54 months. There were no mesh erosions or explants. One mesh-related complication of stenosis requiring reoperation was reported with BIO-A. Studies showed significant improvement in symptom and quality-of-life scores, as well as satisfaction with surgery. Recurrence was reported as radiologic or clinical recurrence. Overall, recurrence rate varied from 0.9 to 25%. CONCLUSION: The use of biosynthetic mesh is safe and effective for hiatal hernia repair with low complications rates and high symptom resolution. The reported recurrence rates are highly variable due to significant heterogeneity in defining and evaluating recurrences. Further randomized controlled trials with larger samples and long-term follow-up should be performed to better analyze outcomes and recurrence rates.
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Hérnia Hiatal , Laparoscopia , Humanos , Hérnia Hiatal/cirurgia , Telas Cirúrgicas , Herniorrafia/métodos , Laparoscopia/métodos , Recidiva , Resultado do Tratamento , Estudos RetrospectivosRESUMO
BACKGROUND: Small bowel obstruction is typically managed nonoperatively; however, refractory small bowel obstructions or closed loop obstructions necessitate operative intervention. Traditionally, laparotomy has long been the standard operative intervention for lysis of adhesions of small bowel obstructions. But as surgeons become more comfortable with minimally invasive techniques, laparoscopy has become a widely accepted intervention for small bowel obstructions. The objective of this study was to compare the outcomes of laparoscopy to open surgery in the operative management of small bowel obstruction. METHODS: This is a retrospective analysis of operative small bowel obstruction cases at a single academic medical center from June 2016 to December 2019. Data were obtained from billing data and electronic medical record for patients with primary diagnosis of small bowel obstruction. Postoperative outcomes between the laparoscopic and open intervention groups were compared. The primary outcome was time to return of bowel function. Secondary outcomes included length of stay, 30-day mortality, 30-day readmission, VTE, and reoperation rate. RESULTS: The cohort consisted of a total of 279 patients with 170 (61%) and 109 (39%) patients in the open and laparoscopic groups, respectively. Patients undergoing laparoscopic intervention had overall shorter median return of bowel function (4 vs 6 days, p = 0.001) and median length of stay (8 vs 13 days, p = 0.001). When stratifying for bowel resection, patients in the laparoscopic group had shorter return of bowel function (5.5 vs 7 days, p = 0.06) and shorter overall length of stay (10 vs 16 days, p < 0.002). Patients in the laparoscopic group who did not undergo bowel resection had an overall shorter median return of bowel function (3 vs 5 days, p < 0.0009) and length of stay (7 vs 10 days, p < 0.006). When comparing surgeons who performed greater than 40% cases laparoscopically to those with fewer than 40%, there was no difference in patient characteristics. There was no significant difference in return of bowel function, length of stay, post-operative mortality, or re-admission laparoscopic preferred or open preferred surgeons. CONCLUSION: Laparoscopic intervention for the operative management of small bowel obstruction may provide superior clinical outcomes, shorter return of bowel function and length of stay compared to open operation, but patient selection for laparoscopic intervention is based on surgeon preference rather than patient characteristics.
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Obstrução Intestinal , Laparoscopia , Humanos , Estudos Retrospectivos , Resultado do Tratamento , Complicações Pós-Operatórias/cirurgia , Tempo de Internação , Obstrução Intestinal/cirurgia , Laparoscopia/métodosRESUMO
BACKGROUND: While many cases of the coronavirus disease 2019 (COVID-19) are mild, patients with underlying medical conditions such as hypertension (HTN), diabetes mellitus (DM), older age, and morbid obesity are at higher risk of hospitalization and death. These conditions are characteristic of patients eligible for bariatric surgery, many of whom underwent weight loss procedures in the months prior to cessation of elective surgery in March 2020. The effects of the virus on these high-risk patients who had increased healthcare exposure in the early days of the pandemic are currently unknown. OBJECTIVES: To describe the experience of patients who underwent bariatric surgery during the early evolution of the COVID-19 pandemic. METHODS: This is a cross-sectional study including patients from a single center who underwent bariatric surgery from January 1st, 2020 to March 18th, 2020. A database was created to analyze patients' demographics, operative variables, and postoperative outcomes. All patients were contacted and a telephone survey was completed to inquire about COVID-19 exposure, symptoms, and testing 30 days before and after surgery. RESULTS: A total of 190 patients underwent bariatric surgery during the study period. Laparoscopic sleeve gastrectomy was the most common procedure (71.6%). One hundred seventy-eight patients (93.7%) completed the telephone survey. Postoperatively, 19 patients (10.7%) reported COVID-19 compatible symptoms, and six patients (3.4%) went on to test positive for COVID-19. There were no COVID-19-related hospital admissions or mortalities in this population. CONCLUSIONS: Morbidly obese patients are at high risk of severe disease secondary to COVID-19, and those undergoing bariatric surgery during the evolution of the pandemic reported symptoms at a rate of 10.7% 30 days after the surgery. While none of these patients suffered severe COVID-19 disease, the temporal relationship of their symptomatology and increased exposure to the healthcare system as a result of their surgery suggest an increased risk of disease with elective surgery.
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Cirurgia Bariátrica , COVID-19 , Derivação Gástrica , Laparoscopia , Obesidade Mórbida , Idoso , Cirurgia Bariátrica/efeitos adversos , Estudos Transversais , Gastrectomia , Humanos , Obesidade Mórbida/complicações , Obesidade Mórbida/cirurgia , Pandemias , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , SARS-CoV-2 , Resultado do TratamentoRESUMO
BACKGROUND: Hepatobiliary Scintigraphy (HIDA) aids the diagnosis of acute cholecystitis (AC) but has limitations. We sought to design a model based on the Tokyo Guidelines 2018 (TG18) to predict HIDA results. METHODS: A retrospective review of patients who underwent a HIDA scan during the evaluation of AC was performed. Using logistic regression techniques incorporating the TG18 criterion and additional readily available patient characteristics, a prediction model was created to identify patients likely to test negative for acute cholecystitis by HIDA scan. RESULTS: In 235 patients with suspected AC, a HIDA scan was performed. Variables associated with positive HIDA results were male gender (RR 2.0 (CI 1.33-2.99), age (OR 1.02 (CI 1.01-1.04), right upper quadrant tenderness (RR 1.7 (CI 1.1-2.8)), clinical Murphy's sign (RR 2.2 (CI 1.5-3.4)), ultrasound findings suggestive of AC by any of its components (RR 3.2 (CI 1.6-6.5)), gallbladder wall thickening (RR 2.0 (CI 1.3-3.1)), and gallbladder distention (RR 1.9 (CI 1.3-2.9)). These variables allowed for creation of a model to predict HIDA results. The model predicted HIDA results in 36.9% of patients with an area under the curve of 0.81. CONCLUSIONS: In the era of TG18, HIDA is probably over utilized. We developed an accurate, simple model based on TG18 that identifies a group of patients for whom a HIDA scan is unnecessary to establish the diagnosis of AC.
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Colecistite Aguda , Colecistite Aguda/diagnóstico por imagem , Humanos , Masculino , Cintilografia , Estudos Retrospectivos , TóquioRESUMO
BACKGROUND: Outcomes after adrenalectomy in patients with primary aldosteronism (PA) are variable. The aldosteronoma resolution score (ARS) uses preoperative variables to calculate a score that identifies those patients that are more likely to have resolution of hypertension after adrenalectomy. We aim to determine the efficacy of adrenalectomy and whether the ARS accurately predicts clinical success in a Black and Hispanic population. METHODS: We reviewed patients who underwent adrenalectomy for PA from 2004 to 2018 at two academic centers treating primarily Hispanic and Black patients. Postoperative outcomes were evaluated based on the primary aldosteronism surgical outcome consensus criterion. Retrospectively, the accuracy of ARS was determined by a receiver operating characteristic curve and the area under the curve (AUC). RESULTS: Forty-three Hispanic and 10 Black patients underwent adrenalectomy for PA. Twenty-two patients (41.5%) had complete clinical success. Variables associated with complete clinical success in the univariate analysis were female gender (p = 0.026), younger age (p = 0.001), lower preoperative aldosterone (p = 0.035), lower preoperative systolic blood pressure (p = 0.001), fewer number of preoperative antihypertensive medications (p = 0.007) and a higher ARS (p = 0.003). On multivariate analysis, only fewer number of preoperative antihypertensive medications was independently associated with complete clinical success (p = 0.026). The AUC of the ARS was 0.746. CONCLUSION: The rate of clinical success from adrenalectomy is good for Hispanic and Black patients with PA. Our analysis shows that the ARS is an accurate test of clinical success in Hispanic and Black patients. The ARS may be utilized preoperatively to frame expectations after adrenalectomy in these populations.
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Adenoma Adrenocortical , Hiperaldosteronismo , Hipertensão , Adrenalectomia , Adenoma Adrenocortical/cirurgia , Negro ou Afro-Americano , Aldosterona , Feminino , Hispânico ou Latino , Humanos , Hiperaldosteronismo/cirurgia , Hipertensão/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Conventional petrochemical plastics have become a serious environmental problem. Its unbridled use, especially in non-durable goods, has generated an accumulation of waste that is difficult to measure, threatening aquatic and terrestrial ecosystems. The replacement of these plastics with cleaner alternatives, such as polyhydroxyalkanoates (PHA), can only be achieved by cost reductions in the production of microbial bioplastics, in order to compete with the very low costs of fossil fuel plastics. The biggest costs are carbon sources and nutrients, which can be appeased with the use of photosynthetic organisms, such as cyanobacteria, that have a minimum requirement for nutrients, and also using agro-industrial waste, such as the livestock industry, which in turn benefits from the by-products of PHA biotechnological production, for example pigments and nutrients. Circular economy can help solve the current problems in the search for a sustainable production of bioplastic: reducing production costs, reusing waste, mitigating CO2, promoting bioremediation and making better use of cyanobacteria metabolites in different industries.
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Cianobactérias/metabolismo , Química Verde/métodos , Plásticos , Poli-Hidroxialcanoatos , Biotecnologia , Plásticos/química , Plásticos/metabolismo , Poli-Hidroxialcanoatos/biossíntese , Poli-Hidroxialcanoatos/químicaRESUMO
OBJECTIVE: to verify the association between seminal quality and seminal transferrin (ST) level and fertility index in patients undergoing chronic hemodialysis (CH). MATERIAL AND METHODS: This is a cross-sectional study in a group of 60 men (case) undergoing CH for more than 6 months, and a group of 30 healthy men (control), aged 18-60 years, without clinical or laboratory signs of infection/inflammation. Spermiogram was performed, fertility index (FI) was calculated and ST and sex hormones (SH) levels were measured, including follicle-stimulating hormone, luteinizing hormone, total testosterone, and prolactin. RESULTS: All individuals were eugonadal. No differences for age (49.47 ± 5.56, 47.90 ± 6.2, p = 0.22) were observed between cases and controls, whereas there were significant differences between the individuals in the case and control groups with respect to the mean FI (p = 0.000), seminal parameters (SP) (p = 0.000), and ST levels (40.12 ± 08.25 vs 73.32 ± 06.8, p = 0.000). ST levels were correlated with FI (r = 0.787, p = 0.00) and SP (motility: r = 0.857, p = 0.000; vitality: r = 0.551, p = 0.000; density: r = 0.850, p = 0.000; normal morphology: r = 0.386, p = 0.000). Linear regression model showed relationship of ST levels with total sperm motility (R2 = 0.701; p = 0.000) and and FI (R2 = 0.569; p = 0.000). CONCLUSIONS: Our results suggest that seminal quality is associated with ST levels and FI and that it can be used the initial investigation of subfertility/infertility of patients undergoing chronic hemodialysis..
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Diálise Renal , Análise do Sêmen , Sêmen/química , Transferrina/análise , Adolescente , Adulto , Fatores Etários , Estudos de Casos e Controles , Estudos Transversais , Fertilidade , Hormônios Esteroides Gonadais/análise , Humanos , Infertilidade Masculina/etiologia , Masculino , Pessoa de Meia-Idade , Obesidade/complicações , Adulto JovemRESUMO
Background: Bariatric surgery is a frequently performed procedure in the United States, accounting for â¼40,000 procedures annually. Patients undergoing bariatric surgery are at high risk for postoperative thrombosis, with a venous thromboembolism (VTE) rate of up to 6.4%. Despite this risk, there is a lack of guidelines recommending postoperative VTE prophylaxis and it is not routine practice at most hospitals. The postoperative bleeding rate after bariatric surgery is only 1.5%; however, the risk of bleeding may lead to hesitancy for more liberal VTE prophylaxis. Methods: This is a retrospective analysis of bariatric surgeries at a single institution in 2019 and 2021. Data were obtained from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) and electronic medical record review for all patients undergoing sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), or conversion to RYGB. The primary outcomes were composite bleeding events, which included postoperative transfusion, postoperative endoscopy or return to operating room (OR) (for bleeding), intra-abdominal hematoma, gastrointestinal (GI) bleeding, or incisional hematoma. Results: There were a total of 2067 patients in the cohort, with 1043 surgeries in 2019 and 1024 surgeries in 2021. There was no difference between bleeding events after instituting a deep venous thrombosis (DVT) prophylaxis protocol in 2021 (27 versus 28 events, P = .76). There was no difference in individual bleeding events between 2019 and 2021. Additionally, there was no significant difference in the rate of VTE between 2019 and 2021 (2 versus 5 events, P = .28). Conclusions: After instituting a standard protocol of prophylactic heparin postdischarge, we did not find an increased rate of bleeding events in patients undergoing bariatric surgery. Thus, surgeons can consider prescribing postdischarge chemical VTE prophylaxis without concern for bleeding.
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Anticoagulantes , Cirurgia Bariátrica , Heparina , Hemorragia Pós-Operatória , Tromboembolia Venosa , Humanos , Cirurgia Bariátrica/efeitos adversos , Estudos Retrospectivos , Hemorragia Pós-Operatória/epidemiologia , Hemorragia Pós-Operatória/prevenção & controle , Feminino , Masculino , Tromboembolia Venosa/prevenção & controle , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/epidemiologia , Pessoa de Meia-Idade , Heparina/administração & dosagem , Heparina/efeitos adversos , Adulto , Anticoagulantes/administração & dosagem , Anticoagulantes/uso terapêutico , Incidência , Protocolos ClínicosRESUMO
Despite the paucity of evidence on robotic ventral hernia repair (RVHR) in patients with obesity, the robotic platform is being used more frequently in hernia surgery. The impact of obesity on RVHR outcomes has not been thoroughly studied. Obesity is considered a major risk factor for the development of recurrent ventral hernias and postoperative complications; however, we hypothesize that patients undergoing robotic repairs will have similar complication profiles despite their body mass index (BMI). We performed a retrospective analysis of patients aged 18-90 years who underwent RVHR between 2013 and 2023 using data from the Abdominal Core Health Quality Collaborative registry. Preoperative, intraoperative, and postoperative characteristics were compared in non-obese and obese groups, determined using a univariate and logistic regression analysis to compare short-term outcomes. The registry identified 9742 patients; 3666 were non-obese; 6076 were classified as obese (BMI > 30 kg/m2). There was an increased odds of surgical site occurrence in patients with obesity, mostly seroma formation; however, obesity was not a significant factor for a complication requiring a procedural intervention after RVHR. In contrast, the hernia-specific quality-of-life scores significantly improved following surgery for all patients, with those with obesity having more substantial improvement from baseline. Obesity does increase the risk of certain complications following RVHR in a BMI-dependent fashion; however, the odds of requiring a procedural intervention are not significantly increased by BMI. Patients with obesity have a significant improvement in their quality of life, and RVHR should be carefully considered in this population.
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Hérnia Ventral , Herniorrafia , Obesidade , Complicações Pós-Operatórias , Procedimentos Cirúrgicos Robóticos , Humanos , Hérnia Ventral/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Herniorrafia/métodos , Herniorrafia/efeitos adversos , Obesidade/complicações , Pessoa de Meia-Idade , Feminino , Idoso , Masculino , Adulto , Estudos Retrospectivos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Resultado do Tratamento , Idoso de 80 Anos ou mais , Índice de Massa Corporal , Adolescente , Adulto Jovem , Qualidade de Vida , Bases de Dados FactuaisRESUMO
OBJECTIVE: To evaluate the skin characteristics and quality of life of patients with breast cancer undergoing radiotherapy. METHOD: Cross-sectional study conducted with 60 women. The classification scales of skin changes resulting from exposure to ionizing radiation (RTOG) and the validated versions in Portuguese of those that classified skin types (Fitzpatrick), symptoms (RISRAS) and quality of life (DLQI) were applied. in the period between December 2021 and October 2022. For data analysis, Fisher's Exact Test, Chi-Square and Asymptotic General Independence Test were used. RESULTS: 100% of patients had skin irritation. As the treatment progressed and the radiodermatitis appeared or worsened, there was a tendency for the intensity of signs and symptoms to increase, such as: sensitivity, discomfort or pain, itching, burning and heat, dry and wet desquamation, which may have impacted the quality of life and reflected in other aspects, such as: shopping activities or outings (p=0.0020), social activities or leisure activities (p=0.0420). CONCLUSION: Radiodermatitis is a common condition that affects women with breast cancer undergoing radiotherapy, skin characteristics and quality of life of patients affected during this treatment.
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Neoplasias da Mama , Radiodermite , Feminino , Humanos , Radiodermite/etiologia , Radiodermite/diagnóstico , Qualidade de Vida , Estudos Transversais , Neoplasias da Mama/radioterapia , PruridoRESUMO
Interpersonal psychotherapy (IPT) is a highly regarded evidence-based psychotherapy that aims to alleviate the suffering of clients and improve their interpersonal functioning. Research has demonstrated the effectiveness of IPT in depressive, bipolar and eating disorders. IPT also focuses on grief and loss as a problem area to help clients address and process their grief symptoms, leading them to reach a phase of finding meaning. However, traumatic grief which is characterized by someone who has both symptoms of trauma and grief can further complicate treatment. As for Posttraumatic Stress Disorder (PTSD), IPT can be a choice of treatment by addressing perceived isolation and emotional dysregulation through mobilizing adequate social support. This case study highlights the efficacy of IPT in treating complicated grief with traumatic experiences caused by the loss of a loved one during the COVID-19 pandemic, without undergoing exposure-based therapy. The treatment course consisted of 12 sessions scheduled twice weekly, and the client received antidepressant medication augmented with antipsychotic medication. After undergoing IPT, the client experienced an improvement in symptoms, gradual recovery of functional disability, and more meaningful interpersonal relationships. The case study presented provides evidence to suggest that IPT is a promising treatment approach for individuals struggling with trauma related to grief.
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Introduction: Resident participation in advanced minimally invasive and bariatric surgeries is controversial. The aim of this study is to evaluate the safety of resident participation in robotic and laparoscopic sleeve gastrectomy (SG). Methods: Prospectively maintained institutional Metabolic and Bariatric Surgery Accreditation Quality Improvement Program database was used to identify patients who underwent SG, which was performed at our institution between January, 2018, and December, 2021. Operative notes were reviewed to determine the training level of the assistant. These were then classified into 7 groups: postgraduate years 1-5 residents, bariatric fellow (6), and attending surgeons (7). Each group was stratified and their outcomes, which included duration of surgery, length of stay (LOS), postoperative complications, readmissions, and reoperations, were compared. Results: Out of 2571 cases, the assistants for the procedures were minimally invasive surgery (MIS) fellows (n = 863, 58.8%), fifth- and fourth-year residents (n = 228, 15.5%), third- and second-year residents (n = 164, 11.2%), no assistants (n = 212, 14.5%), and 134 robotic SG. Mean body mass index was higher in cases wherein the attending surgeon performed by himself (47.1, standard deviation 7.7) when compared with other groups. There were no conversions to open. Mean LOS was 1.3 days, and there was no difference between groups (P = .242). Postoperative complications were low, with 11 reoperations in 30 days (3.3%) and no difference between groups. There was no mortality in 30 or 90 days. Conclusion: Postoperative outcomes were similar for patients who underwent SG regardless of the assistant's level of training. Including residents in bariatric procedures is safe and does not affect patient safety. Encouraging residents to participate in complex MIS procedures is recommended as part of their training.
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Cirurgia Bariátrica , Derivação Gástrica , Internato e Residência , Laparoscopia , Obesidade Mórbida , Humanos , Obesidade Mórbida/cirurgia , Estudos Retrospectivos , Cirurgia Bariátrica/métodos , Laparoscopia/métodos , Gastrectomia/métodos , Complicações Pós-Operatórias/etiologia , Resultado do Tratamento , Derivação Gástrica/métodosRESUMO
OBJECTIVE: To characterize the sociodemographic, clinical and survival profile of adult metastatic patients. METHOD: Retrospective cross-sectional study, with secondary data from an oncology care unit, analyzed using logistic regression, Chi-Square test and Fisher's exact test, Kaplan-Meier and Log-Rank tests. RESULTS: From the 678 patients, male gender, mean age 59.54 years old and low education level prevailed. The mean time between diagnosis and initiation of treatment was 89.50 days (± 58.87). Increased risk of primary cancer in the digestive tract (OR 1.42). Prevalence of adenocarcinoma (OR 1.53) and metastasis to bone (OR 2.59), lymph nodes (OR 1.75), liver and peritoneum (OR 1.42). The mean overall survival was 4.16 months and a median of 3.0 months. CONCLUSION: The main primary site was the digestive system, and the identification of metastases was predominantly unifocal liver in both genders. Overall patient survival was reduced by cancer progression.
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Neoplasias , Adulto , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estudos Transversais , Prognóstico , Taxa de SobrevidaRESUMO
Background: Enhanced laparoscopic instruments are filling the gap between straight-stick laparoscopic equipment and robotic platforms. We sought to evaluate the performance and cost of the HandX™ device during mesh fixation and peritoneal flap closure of transabdominal preperitoneal (TAPP) inguinal hernia repairs. Methods: The video recordings of a consecutive series of TAPP surgeries using the articulated needle driver device were compared with a series of surgeries on the DaVinci robotic platform by a single surgeon. Two critical steps of the procedure were analyzed: mesh fixation and peritoneal closure. A cost analysis between the two platforms was completed. Results: We analyzed 27 cases using the new needle driver and 27 cases using the DaVinci Surgical Robotic system. To evaluate the learning curve (LC) with the HandX device, we created three groups (G1, G2, and G3). The two latter groups were combined and called after LC. Mean fixation time using the DaVinci system was 258.1 seconds (±100.4) compared with 391.5 (±95.9) using the articulating handheld laparoscopic needle driver after LC (P < .001). The average time for peritoneal closure was 418.6 (±192.1) seconds for DaVinci and 634.5 (±159.5) seconds for HandX (P < .001). When comparing the after-LC HandX cases and the DaVinci system stratified by side, there was no significant difference in peritoneal closure in the right side (520.1 seconds (84.3) with the HandX versus 444.2 seconds (229.7) using the DaVinci system (P = .353). When evaluating direct cost of the instruments, HandX cases had a lower cost (310 USD) when compared with the cost of using DaVinci (973 USD). Conclusions: The new smart articulating needle driver may be a cost-effective means of bringing some of the benefits of the robotic platform to laparoscopy.
Assuntos
Hérnia Inguinal , Laparoscopia , Procedimentos Cirúrgicos Robóticos , Humanos , Hérnia Inguinal/cirurgia , Herniorrafia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Telas Cirúrgicas , Laparoscopia/métodosRESUMO
BACKGROUND: Primary closure of a fascial defect during ventral hernia repair is associated with lower rates of recurrence and better patient satisfaction compared with bridging repairs. Robotic surgery offers enhanced ability to close these defects and this has likely been aided by the use of barbed suture. The goal of this study was to evaluate the perioperative safety and the long-term outcomes for the use of barbed suture for the primary closure of hernia defects during robotic ventral hernia repair (rVHR) with mesh. METHODS: This is a retrospective study of adult patients who underwent rVHR with the use of a barbed suture for fascial defect closure from August 2018 to August 2020 in an academic center. All the patients included were queried by phone to complete a quality of life assessment to assess patient-reported outcomes (PROs). Subjective sense of a bulge and pain at the previous hernia site has been shown to correlate with hernia recurrence. These questions were used in conjunction with a Hernia-related Quality of Life Survey (HerQles) score to assess a patient's quality of life. RESULTS: A total of 81 patients with 102 hernias were analyzed. Sixty patients (74%) were successfully reached and completed the PRO form at median postoperative day 356 (range: 43 to 818). Eight patients (13% of patients with PRO data) claimed to have both a bulge and pain at their previous hernia site, concerning for possible recurrence. Median overall HerQLes score was 82 [Interquartile Range (IQR): 54 to 99]. Patients with a single hernia defect, when compared with those with multiple defects, had a lower rate of both a bulge (15% vs. 30%) and symptoms (33% vs. 48%), as well as a higher median HerQLes score (85 vs. 62) at the time of PRO follow-up. Patients with previous hernia repair had a lower median HerQLes score of 65 (IQR: 43 to 90) versus 88 (IQR: 62-100). These patients also had a higher rate of sensing a bulge (29% vs. 18%), whereas a sense of symptoms at the site was less (33% vs. 44%). CONCLUSIONS: Barbed suture for fascial defect closure in rVHR was found to be safe with an acceptable rate of possible recurrence by the use of PRO data. Patients with multiple hernias and previous repairs had a higher likelihood of recurrence and a lower quality of life after rVHR.
Assuntos
Hérnia Ventral , Laparoscopia , Procedimentos Cirúrgicos Robóticos , Adulto , Hérnia Ventral/etiologia , Hérnia Ventral/cirurgia , Herniorrafia/efeitos adversos , Humanos , Dor/etiologia , Medidas de Resultados Relatados pelo Paciente , Qualidade de Vida , Recidiva , Estudos Retrospectivos , Telas Cirúrgicas , SuturasRESUMO
Background: Laparoscopic Roux-en-Y gastric bypass (LRYGB) has been established as a leading treatment of obesity. Surgical site infections (SSIs) remain the most common complication. Objective: To compare the incidence of SSIs before and after the implementation of our technique. Methods: Our intraoperative technique limits enteric contact with the abdominal wall through a wound protector at the end-to-end anastomosis stapler port site, with enteric retrieval with a specimen bag followed by betadine irrigation. We analyzed our SSIs outcomes before and after implementation of our technique in all RYGB and laparoscopic sleeve-to-bypass conversions at our institution performed by two providers between January 1, 2009 to December 31, 2011 and January 1, 2019 to December 31, 2021. We compared patient age, sex, body mass index, American Society of Anesthesiologists class; and comorbidities including hypertension, diabetes, and hyperlipidemia. The χ2, Fischer exact, Wilcoxon Rank Sum tests, and multivariate analysis were performed. Results: Four hundred twenty-nine patients underwent LRYGB and sleeve-to-bypass conversion during the two study periods. Group 1 (162 patients, 37.76%) all underwent RYGB. Group 2 (267 patients, 62.24%) of whom 199 underwent RYGB and 68 underwent a laparoscopic sleeve-to-bypass conversion. The SSI rate was 9.26% in Group 1 and 2.62% in Group 2 (p = 0.002514). Statistical significance was also noted for operating room time (137 min vs 123 min, p = 0.02) and hospital length of stay (2 - 3 interquartile range vs 1 - 2 interquartile range, p = 0.04). Conclusion: We propose a safe, reproducible technique that significantly reduces SSI rates during LRYGB.
Assuntos
Parede Abdominal , Derivação Gástrica , Humanos , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/prevenção & controle , Derivação Gástrica/efeitos adversos , Povidona-Iodo , Índice de Massa CorporalRESUMO
BACKGROUND: Poly-4-hydroxybutyrate (P4HB) is a naturally occurring polymer derived from transgenic E. coli bacteria with the longest degradation rate when compared to other available products. This polymer has been manufactured as a biosynthetic mesh to be used as reinforcement when repairing a variety of abdominal wall defects. OBJECTIVE: We aim to describe our center initial experience with this mesh and discuss the possible indications that may benefit from the use of P4HB mesh. METHODS: This is a descriptive retrospective study of patients who underwent abdominal wall repair with a P4HB mesh from October 2018 to December 2020 in a single, large volume, academic center. RESULTS: A total of 51 patients (mean age 54.4 years, range 12-89) underwent abdominal wall reconstruction with a P4HB mesh between October 2018 and December 2020. The mean BMI was 30.5 (range 17.2-50.6). Twenty-three (45%) patients had a prior hernia repair at the site. We grouped patients into six different indications for the use of P4HB mesh in our cohort: clean-contaminated, contaminated or infected field (57%), patient refusal for permanent meshes (14%), those with high risk for post-operative infection (12%), visceral protection of second mesh (10%), recurrence with related chronic pain from mesh (6%), and children (2%). Median follow-up was 105 days (range 8-648). Two patients had hernia recurrence (4%) and 8 (16%) patients developed seroma. CONCLUSION: P4HB mesh is a safe and a viable alternative for complex hernias and high-risk patients with a low complication rate in the short-term.