Postoperative Recovery in Frail, Pre-frail, and Non-frail Elderly Patients Following Abdominal Surgery.

BACKGROUND: The objective of this study is to explore the association between frailty and surgical recovery over a 6-month period, in elderly patients undergoing elective abdominal surgery. METHODS: A total of 144 patients were categorized as frail, pre-frail, and non-frail based on five criteria: weight loss, exhaustion, weakness, slowness, and low activity. Recovery to preoperative functional status (activities of daily living (ADL) and instrumental activities of daily living (IADL)), cognition, quality of life, and mental health was assessed at 1, 3, and 6 months postoperatively. A repeated measure logistic regression was used to analyze the effect of frailty on recovery over time. The effect of frailty on hospitalization outcomes was also evaluated. RESULTS: Mean age was 78 ± 5 years with 17.4% of patients categorized as frail, 60.4% pre-frail, and 22.2% non-frail. At 6 months, the percent of patients who had recovered to preoperative values were: ADL 90%; IADL 76%; cognition 75.5%; mental health 66%; and quality of life 70%. While more frail patients experienced adverse hospitalization outcomes and fewer had recovered to preoperative functional status, these differences were not found to be statistically significant. Overall, frailty status was not significantly associated with the trajectory of recovery or hospitalization outcomes. CONCLUSION: Strong, institutional commitment to quality surgical care, as well as appropriate strategies for older patients, may have mitigated the impact of frailty on recovery. Further research is needed to examine the role of frailty in the surgical recovery process.

The impact of postoperative complications on the recovery of elderly surgical patients.

BACKGROUND: While the negative impact of postoperative complications on hospital costs, survival, and cancer recurrence is well known, few studies have quantified the impact of postoperative complications on patient-centered outcomes such as functional status. The objective of this study was to estimate the impact of postoperative complications on recovery of functional status after elective abdominal surgery in elderly patients. METHODS: Elderly patients (70 years and older) undergoing elective abdominal surgery, with a planned length of stay >1 day, were prospectively enrolled between July 2012 and December 2014. The primary outcome was time to recovery to the preoperative functional status measured by the short physical performance battery (SPPB) preoperatively and at 1 week, 1, 3, and 6 months after surgery. The comprehensive complication index was calculated to grade the severity and number of postoperative complications. A Weibull survival model with interval censoring was performed, controlling for age, sex, body mass index (BMI), comorbidities (Charlson comorbidity index-CCI), frailty, presence of cancer, nutritional status, wound class, preoperative functional status, and surgical approach. RESULTS: Hundred and forty-nine patients (79 men and 70 women) were included in the analysis. Mean age was 77.7 ± 4.9 years, mean BMI was 27.2 ± 5.5 kg/m(2), and the median CCI was 3 (IQR 2-6). The mean preoperative SPPB score was 9.62 ± 2.33. A total of 52 patients (34.9 %) experienced one or more postoperative complications, including four mortalities, and a total of 72 complications. The mean comprehensive complication index score for these patients was 25.7 ± 23.8. In the presence of all other variables included in the model, a higher comprehensive complication index score was found to significantly decrease the hazard of recovery (HR 0.96, CI 0.94-0.98, p value = 0.0004) and hence increase the time to recovery. CONCLUSION: Following elective abdominal surgery, elderly patients who experience a greater number and more severe postoperative complications take longer to return to their preoperative functional status.

Ongoing evolution of practice gaps in gastrointestinal and endoscopic surgery: 2014 report from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Continuing Education Committee.

BACKGROUND: In an effort to fulfill the charge to develop and maintain a comprehensive educational program to serve the members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), the SAGES Continuing Education Committee reports a summary of findings related to the evaluation of the 2014 SAGES annual meeting. METHODS: All attendees to the 2014 annual meeting had the opportunity to complete an immediate post-meeting questionnaire as part of their continuing medical education (CME) certification, and identify up to two learning themes, answer questions related to potential practice change items based on these learning themes, and complete a needs assessment for relevant learning topics for future meetings. In addition, participants in the postgraduate and hands-on courses were asked to complete questions about case volume and comfort level related to procedures/topics in those courses. All respondents to this initial survey were sent a 3-month follow-up questionnaire in which they were asked how successful they had been in the implementation of the targeted practice changes and what, if any, barriers were encountered. Descriptive statistical analysis of de-identified data was undertaken. SAGES University attendees respond to a post-test and post-activity evaluation. RESULTS: Response rates were 43 and 31 % for CME-eligible attendees/respondents for the immediate post-meeting and 3-month follow-up questionnaires, respectively. Top learning themes for respondents were foregut, hernia, bariatric, and colorectal. Improving minimally invasive surgical (MIS) technique and managing complications related to MIS procedures were top intended practice changes. Partial implementation was common with top barriers including lack of resources and lack of time. Desired topics for future meetings included management of complications, enhanced recovery after surgery, introduction of new procedures into clinical practice, and re-operative surgery. CONCLUSIONS: The SAGES 2014 annual meeting analysis provides insight into the educational needs among respondents, which is meaningful information for planning future meeting educational content.

Recurrence of biliary disease following non-operative management in elderly patients.

INTRODUCTION: The purpose of this study was to determine the proportion of symptomatic recurrence following initial non-operative management of gallstone disease in the elderly and to test possible predictors. METHODS: This is a single institution retrospective chart review of patients 65 years and older with an initial hospital visit (V1) for symptomatic gallstone disease, over a 4-year period. Patients with initial "non-operative" management were defined as those without surgery at V1 and without elective surgery at visit 2 (V2). Baseline characteristics included age, sex, Charlson comorbidity index (CCI), diagnosis, and interventions (ERCP or cholecystostomy) at V1. Outcomes assessed over 1 year were as follows: recurrence (any ER/admission visit following V1), surgery, complications, and mortality. A survival analysis using a Cox proportional hazards model was performed to assess predictors of recurrence. RESULTS: There were 195 patients initially treated non-operatively at V1. Mean age was 78.3 ± 7.8 years, 45.6% were male, and the mean CCI was 2.1 ± 1.9. At V1, 54.4% had a diagnosis of biliary colic or cholecystitis, while 45.6% had a diagnosis of cholangitis, pancreatitis, or choledocholithiasis. 39.5% underwent ERCP or cholecystostomy. Excluding 10 patients who died at V1, 31.3% of patients had a recurrence over the study period. Among these, 43.5% had emergency surgery, 34.8% had complications, and 4.3% died. Median time to first recurrence was 2 months (range 6 days-4.8 months). Intervention at V1 was associated with a lower probability of recurrence (HR 0.3, CI [0.14-0.65]). CONCLUSION: One-third of elderly patients will develop a recurrence following non-operative management of symptomatic biliary disease. These recurrences are associated with significant rates of emergency surgery and morbidity. Percutaneous or endoscopic therapies may decrease the risk of recurrence.

Early experience with robotic pancreatic surgery in a Canadian institution.

BACKGROUND: Pancreatic resections have traditionally been associated with substantial morbidity and mortality. The robotic platform is believed to improve technical aspects of the procedure while offering minimally invasive benefits. We sought to determine the safety and feasibility of the first robotic pancreaticoduodenectomies performed at our institution. METHODS: We retrospectively reviewed data on all patients who underwent robotic-assisted pancreaticoduodenectomy (RAPD) between July 2010 and June 2014 and compared them to outcomes of patients undergoing hybrid laparoscopic pancreaticoduodenectomies (HLAPD) during the same time period. RESULTS: Fifteen patients were scheduled for RAPD; 2 were converted to an open approach and 1 to a mini-laparotomy during the laparoscopic portion of the procedure. Patients who had RAPD (n = 12) had a median duration of surgery of 596.6 (range 509-799) minutes, estimated blood loss of 275 (range 50-1000) mL and median length of stay of 7.5 (range 5-57) days. Mean total opioid use up to postoperative day 7 was 142.599 ± 68.2 versus 176.9 ± 112.7 mg equivalents of intravenous morphine for RAPD and HLAPD, respectively. There was no significant difference between RAPD and HLAPD in any parameters, highlighting the safety and feasibility of a step-wise minimally invasive learning platform. Most patients in the RAPD group had malignant pathology (88.2%). Oncologic outcomes were maintained with no significant difference in ability to resect lymph nodes or achieve negative margins. There were 4 (28.5%) Clavien I-II complications and 3 (29.4%) Clavien III- IV complications, 2 of which required readmission. There were no reported deaths at 90 days. Complication, pancreatic leak and mortality rates did not differ significantly from our laparoscopic experience. CONCLUSION: Outcomes of RAPD and HLAPD were comparable at our centre, even during the early stages of our learning curve. These results also highlight the safety, feasibility and patient benefits of a step-wise transition from open to hybrid to fully robotic pancreaticoduodenectomies in a high-volume academic centre.

CONTEXTE: L'ablation du pancréas a de tout temps été associée à une morbidité et une mortalité importantes. Le recours à une plateforme assistée par robot devrait vraisemblablement améliorer les aspects techniques de l'intervention et offrir en même temps les avantages d'une intervention minimalement effractive. Nous avons voulu déterminer l'innocuité et la faisabilité des premières pancréatoduodénectomies assistées par robot effectuées dans notre établissement. MÉTHODES: Nous avons passé en revue de manière rétrospective les données concernant tous les patients ayant subi une pancréatoduodénectomie assistée par robot (PDAR) entre juillet 2010 et juin 2014 et nous les avons comparées aux résultats enregistrés chez les patients ayant subi une pancréatoduodénectomie laparoscopique hybride (PDLH) au cours de la même période. RÉSULTATS: Quinze patients ont été pressentis pour une PDAR; 2 ont plutôt subi une intervention ouverte et 1 a subi une mini-laparotomie durant la portion laparoscopique de l'intervention. Chez les patients soumis à la PDAR (n = 12), la durée médiane de la chirurgie a été de 596,6 (plage de 509 à 799) minutes, les pertes sanguines estimées ont été de 275 (plage de 50 à 1000) mL et la durée médiane du séjour hospitalier a été de 7,5 (plage de 5 à 57) jours. L'utilisation totale moyenne d'opioïdes jusqu'au septième jour postopératoire a été de 142,599 ± 68,2 mg équivalents de morphine intraveineuse contre 176,9 ± 112,7 pour la PDAR et la PDLH, respectivement. On n'a noté aucune différence significative entre la PDAR et la PDLH au plan des paramètres, ce qui souligne l'innocuité et la faisabilité d'une plateforme d'apprentissage séquentielle minimalement effractive. La plupart des patients du groupe soumis à la PDAR étaient atteints d'un cancer (88,2 %). Les paramètres oncologiques se sont maintenus, sans différence significative quant à la capacité de réséquer les ganglions lymphatiques ou d'obtenir des marges négatives. On a dénombré 4 (28,5 %) complications de stade I­II et 3 (29,4 %) de stade III­IV selon la classification de Clavien; 2 de ces dernières ont nécessité une réadmission. On n'a déploré aucun décès à 90 jours. Les taux de complications, de fuite pancréatique et de mortalité n'ont pas différé significativement par rapport à nos interventions laparoscopiques. CONCLUSION: Les résultats de la PDAR et de la PDLH ont été comparables dans notre établissement, même aux premières étapes de notre courbe d'apprentissage. De tels résultats soulignent l'innocuité, la faisabilité et les bienfaits pour les patients d'une transition graduelle des pancréatoduodénectomies ouvertes, hybrides puis entièrement assistées par robot dans un centre universitaire traitant de forts volumes de patients.

Perioperative systemic chemotherapy for appendiceal mucinous carcinoma peritonei treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

BACKGROUND: The role of systemic chemotherapy (SC) in conjunction with cytoreductive surgery (CS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in appendiceal mucinous carcinoma peritonei (MCP) is unknown. METHODS: A retrospective review (1999-2011) of MCP patients who had undergone CS/HIPEC with or without perioperative SC. RESULTS: Twenty-two low-grade MCP patients treated with CS/HIPEC and SC were matched to patients who received CS/HIPEC alone. Median overall survival (OS) was 107 months for patients treated with perioperative SC compared to 72 without (P = 0.46). CS/HIPEC was performed on 109 patients with high-grade MCP: 70 were treated with perioperative SC, while 39 were not. Median OS (22.1 vs. 19.6 months, P = 0.74) and progression-free survival (PFS) (10.9 vs. 7.0 months, P = 0.47) were similar in patients treated with SC compared to CS/HIPEC alone. Progression while on pre-operative SC was seen in eight patients (17%), while four (8%) had a partial response. Treatment with post-operative SC was associated with longer PFS (13.6 months) compared to pre-operative SC (6.8 months, P < 0.01) and CS/HIPEC alone (7.0 months, P = 0.03). CONCLUSIONS: Post-operative SC appears to improve PFS in patients with high-grade appendiceal MCP treated with CS/HIPEC. In contrast, there is no evidence to support the routine use of perioperative SC in low-grade disease.

Simulation-based training improves the operative performance of totally extraperitoneal (TEP) laparoscopic inguinal hernia repair: a prospective randomized controlled trial.

BACKGROUND: Laparoscopic surgery has an important role to play in the care of patients with inguinal hernias, but the procedure is difficult to learn. This study aimed to assess whether training to proficiency using a novel laparoscopic inguinal hernia repair (LIHR) simulation curriculum improved operating room (OR) performance. METHODS: For this study, 17 surgical residents [postgraduate years (PGYs) 2-5] participated in a didactic LIHR course and then were randomized to a training (T) or a control (C, standard residency) group. Performance of totally extraperitoneal (TEP) LIHR in the OR at baseline and after the study was measured using the Global Operative Assessment of Laparoscopic Skills-Groin Hernia (GOALS-GH). RESULTS: Of the 17 residents, 14 (5 T and 9 C) completed their final evaluations. The two groups showed no differences in terms of LIHR experience. The baseline GOALS-GH scores in the OR were similar (T 14.8; range 12.8-16.8 vs. C 13.6; range 12.3-14.8; P = 0.20). The mean number of training sessions needed to achieve proficiency was 4.8 (range 4.4-5.2), and the mean total training time was 109 min (range 61.9-149.1 min). After training, OR performance improved in the T group by 3.4 points (range 2.0-4.8 points; P = 0.002), whereas no significant change was seen in the C group [1.2; (range -1.1 to 3.6; P = 0.27)]. The final total GOALS-GH scores showed a trend toward better performance in the T group than in the C group [18.2; (range 14.9-21.5) vs. 14.8; (range 12.4-17.1); P = 0.06). CONCLUSIONS: This study demonstrated the skills required for transfer of LIHR to the OR using a low-cost procedure-specific simulator. Residents who trained to proficiency on the McGill Laparoscopic Inguinal Hernia Simulator (MLIHS) showed greater skill improvement than their colleagues who did not. These results provide evidence supporting the use of simulation to teach and assess LIHR.

Bridging the gap between open and minimally invasive pancreaticoduodenectomy: the hybrid approach.

BACKGROUND: Minimally invasive pancreatic surgery has evolved rapidly, but total laparoscopic pancreaticoduodenectomy has not been widely adopted owing to its technical complexity. Hybrid laparoscopy-assisted pancreaticoduodenectomy (HLAPD) combines the relative ease of open surgery with the benefits of a minimally invasive approach. This study evaluates the safety and effectiveness of the hybrid approach compared with open surgery. METHODS: We retrospectively analyzed data of consecutive patients undergoing either hybrid or open pancreaticoduodenectomy (OPD) at our institution between September 2009 and December 2013. Demographic, operative and oncologic data were collected to compare outcomes between HLAPD and OPD. RESULTS: Our analysis included 33 patients (HLAPD: n = 13; OPD: n = 20). There were no differences in patient demographics, comorbidities or surgical indications. The HLAPD group had significantly lower intraoperative blood loss (450 mL v. 1000 mL, p = 0.023) and shorter length of hospital stay (8 v. 12 d, p = 0.025) than the OPD group. Duration of surgery did not differ significantly between the groups. There were no differences in postoperative analgesic requirements, Clavien grade I/II or grade III/IV complications or 90-day mortality. Oncologic outcomes showed no significant differences in tumour size, R1 resection rate or number of lymph nodes harvested. CONCLUSION: In select patients, HLAPD is a safe and effective procedure with comparable outcomes to conventional open surgery. Wider adoption of the hybrid approach will allow a greater number of patients to benefit from a less invasive procedure while facilitating the transition toward purely minimally invasive pancreaticoduodenectomy.

CONTEXTE: La chirurgie pancréatique minimalement effractive a rapidement évolué, mais la pancréatoduodénectomie laparoscopique totale n'a pas été largement adoptée en raison de sa complexité technique. La pancréatoduodénectomie hybride sous laparoscopie (PDHL) allie la relative facilité de la chirurgie ouverte aux avantages d'une approche minimalement effractive. Cette étude compare l'innocuité et l'efficacité de l'approche hybride à celles de la chirurgie ouverte. MÉTHODES: Nous avons analysé de manière rétrospective les données concernant des patients consécutifs soumis à une pancréatoduodénectomie hybride ou ouverte (PDO) dans notre établissement entre septembre 2009 et décembre 2013. Les données démographiques, opératoires et oncologiques ont été recueillies pour comparer les résultats entre la PDHL et la PDO. RÉSULTATS: Notre analyse a inclus 33 patients (PDHL : n = 13; PDO : n = 20). Il n'y avait aucune différence quant aux caractéristiques démographiques, comorbidités ou indications chirurgicales chez les patients. Le groupe soumis à la PDHL a connu des pertes sanguines peropératoires significativement moindres (450 mL c. 1000 mL, p = 0,023) et un séjour hospitalier significativement plus bref (8 j c. 12 j, p = 0,025) comparativement au groupe soumis à la PDO. La durée de la chirurgie n'a pas significativement différé entre les groupes. On n'a noté aucune différence sur le plan des besoins en analgésiques postopératoires, des complications de grade I/II ou III/IV sur l'échelle de Clavien ou de la mortalité à 90 jours. Quant aux paramètres oncologiques, aucune différence significative n'a été notée pour ce qui est de la taille de la tumeur, du taux de résection R1 ou du nombre de ganglions recueillis. CONCLUSION: Pour certains patients, la PDHL est une intervention sécuritaire et efficace qui donne des résultats comparables à la chirurgie ouverte classique. L'adoption à plus grande échelle de l'approche hybride permettra à plus de patients de bénéficier d'une intervention moins effractive et facilitera la transition complète vers la pancréatoduodénectomie minimalement effractive.

Evolution of practice gaps in gastrointestinal and endoscopic surgery: 2012 report from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Continuing Education Committee.

BACKGROUND: In an effort to fulfill its charge to develop and maintain a comprehensive educational program to serve the members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), the SAGES Continuing Education Committee (CEC) reports a summary of findings related to its evaluation of the 2012 SAGES annual meeting. METHODS: All attendees to the 2012 annual meeting had the opportunity to complete an immediate postmeeting questionnaire as part of their continuing medical education (CME) certification in which they identified up to two learning themes, answered questions related to potential practice change items that are based on those learning themes, and complete a needs assessment related to important learning topics for future meetings. In addition, participants in the postgraduate and hands-on courses were asked to complete questions about case volume and comfort levels related to procedures/topics in those courses. All respondents to this initial survey were sent a 3-month follow-up questionnaire in which they were asked how successfully they had implemented the intended practice changes and what, if any, barriers they encountered. Postgraduate and hands-on course participants completed case volume and comfort level questions. Descriptive statistical analysis of this deidentified data was undertaken. RESULTS: Response rates were 42% and 56% for CME-eligible attendees/respondents for the immediate postmeeting and 3-month follow-up questionnaires, respectively. Top learning themes for respondents were Bariatric, Hernia, Foregut, and Colorectal. Improving minimally invasive surgical (MIS) technique and managing complications related to MIS procedures were top intended practice changes. Partial implementation was common with top barriers including cost restrictions, lack of institutional support, and lack of time. CONCLUSIONS: The 2012 annual meeting analysis provides insight into educational needs among respondents and will help with planning content for future meetings.

Bilateral parotitis as the initial presentation of childhood sarcoidosis.

The differential diagnosis of bilateral parotid gland enlargement in children includes infectious, inflammatory, and neoplastic disorders. We present the case of a 13-year-old male who presented with a 5-week history of bilateral parotid swelling. On exam, both parotid glands were nontender, smooth, and diffusely enlarged. He had slightly elevated inflammatory markers, but other lab results were normal. A neck CT revealed symmetric enlargement of the parotid, submandibular, and sublingual glands. A chest CT revealed scattered peripheral pulmonary nodules and bilateral hilar adenopathy. A parotid gland biopsy showed multiple noncaseating granulomas with multinucleated giant cells surrounded by lymphocytes, consistent with the diagnosis of sarcoidosis. Special stains for acid-fast and fungal organisms were negative. Using this illustrative case, we discuss the differential diagnosis of bilateral salivary gland enlargement in children and review the etiology, diagnosis, clinical manifestations, and treatment of pediatric sarcoidosis.

Implementing geriatric assessment and management for older Canadians with cancer: Adherence to and satisfaction with the intervention, results of the 5C study.

INTRODUCTION: Geriatric assessment and management (GAM) is recommended by professional organizations and recently several randomized controlled trials (RCTs) demonstrated benefits in multiple health outcomes. GAM typically leads to one or more recommendations for the older adult on how to optimize their health. However, little is known about how well recommendations are adhered to. Understanding these issues is vital to designing GAM trials and clinical programs. Therefore, the aim of this study was to examine the number of GAM recommendations made and adherence to and satisfaction with the intervention in a multicentre RCT of GAM for older adults with cancer. MATERIALS AND METHODS: The 5C study was a two-group parallel RCT conducted in eight hospitals across Canada. Each centre kept a detailed recruitment and retention log. The intervention teams documented adherence to their recommendations. Medical records were also reviewed to assess which recommendations were adhered to. Twenty-three semi-structured interviews were conducted with 12 members of the intervention teams and 11 oncology team members to assess implementation of the study and the intervention. RESULTS: Of the 350 participants who were enrolled, 173 were randomized to the intervention arm. Median number of recommendations was seven. Mean adherence to recommendations based on the GAM was 69%, but it varied by type of recommendation, ranging from 98% for laboratory tests to 28% for psychosocial/psychiatry oncology referrals. There was no difference in the number of recommendations or non-adherence to recommendations by sex, level of frailty, or functional status. Oncologists and intervention team members were satisfied with the study implementation and intervention delivery. DISCUSSION: Adherence to recommendations was variable. Adherence to laboratory investigations and further imaging were generally high but much lower for recommendations regarding psychosocial support. Further collaborative work with older adults with cancer is needed to understand how to optimize the intervention to be consistent with patient goals, priorities, and values to ensure maximal impact on health outcomes.

Impact of Geriatric Assessment and Management on Quality of Life, Unplanned Hospitalizations, Toxicity, and Survival for Older Adults With Cancer: The Randomized 5C Trial.

PURPOSE: American Society of Clinical Oncology recommends that older adults with cancer being considered for chemotherapy receive geriatric assessment (GA) and management (GAM), but few randomized controlled trials have examined its impact on quality of life (QOL). PATIENTS AND METHODS: The 5C study was a two-group parallel 1:1 single-blind multicenter randomized controlled trial of GAM for 6 months versus usual oncologic care. Eligible patients were age 70+ years, diagnosed with a solid tumor, lymphoma, or myeloma, referred for first-/second-line chemotherapy or immunotherapy or targeted therapy, and had an Eastern Cooperative Oncology Group performance status of 0-2. The primary outcome QOL was measured with the global health scale of the European Organisation for the Research and Treatment of Cancer QOL questionnaire and analyzed with a pattern mixture model using an intent-to-treat approach (at 6 and 12 months). Secondary outcomes included functional status, grade 3-5 treatment toxicity; health care use; satisfaction; cancer treatment plan modification; and overall survival. RESULTS: From March 2018 to March 2020, 350 participants were enrolled. Mean age was 76 years and 40.3% were female. Fifty-four percent started treatment with palliative intent. Eighty-one (23.1%) patients died. GAM did not improve QOL (global QOL of 4.4 points [95% CI, 0.9 to 8.0] favoring the control arm). There was also no difference in survival, change in treatment plan, unplanned hospitalization/emergency department visits, and treatment toxicity between groups. CONCLUSION: GAM did not improve QOL. Most intervention group participants received GA on or after treatment initiation per patient request. Considering recent completed trials, GA may have benefit if completed before treatment selection. The COVID-19 pandemic may have affected our QOL outcome and intervention delivery for some participants.

Knowing the operative game plan: a novel tool for the assessment of surgical procedural knowledge.

BACKGROUND: What is the source of inadequate performance in the operating room? Is it a lack of technical skills, poor judgment or a lack of procedural knowledge? We created a surgical procedural knowledge (SPK) assessment tool and evaluated its use. METHODS: We interviewed medical students, residents and training program staff on SPK assessment tools developed for 3 different common general surgery procedures: inguinal hernia repair with mesh in men, laparoscopic cholecystectomy and right hemicolectomy. The tools were developed as a step-wise assessment of specific surgical procedures based on techniques described in a current surgical text. We compared novice (medical student to postgraduate year [PGY]-2) and expert group (PGY-3 to program staff) scores using the Mann-Whitney U test. We calculated the total SPK score and defined a cut-off score using receiver operating characteristic analysis. RESULTS: In all, 5 participants in 7 different training groups (n = 35) underwent an interview. Median scores for each procedure and overall SPK scores increased with experience. The median SPK for novices was 54.9 (95% confidence interval [CI] 21.6-58.8) compared with 98.05 (95% CP 94.1-100.0) for experts (p = 0.012). The SPK cut-off score of 93.1 discriminates between novice and expert surgeons. CONCLUSION: Surgical procedural knowledge can reliably be assessed using our SPK assessment tool. It can discriminate between novice and expert surgeons for common general surgical procedures. Future studies are planned to evaluate its use for more complex procedures.

Laparoscopic splenectomy: learning curve comparison between benign and malignant disease.

BACKGROUND: New surgical techniques should be formally evaluated for feasibility and safety. As a model for this evaluation, this study examines the authors' institution's experience with splenectomy for benign and malignant hematologic disease since the introduction of laparoscopic splenectomy (LS) in 1996. The authors present the evaluation of the recognized surgeon/institutional learning curve using CUSUM (cumulative sum) analysis. METHODS: This is a single institution retrospective chart review of consecutive splenectomies for hematologic disease performed between 1996 and 2008. The primary outcome was conversion to open splenectomy. The learning curve for LS was evaluated using CUSUM analysis. RESULTS: A total of 123 splenectomies were performed for benign (51.2%) or malignant (48.7%) hematologic disease. 58% of patients underwent planned LS, with a 21% conversion rate. The surgeon's overall learning curves for LS, as well as that for malignant disease, were maintained within acceptable conversion thresholds. However, the learning curve for benign disease did cross the unacceptable conversion threshold at case 29. With additional experience, the curve again approached the acceptable conversion threshold. Patients with malignant disease were significantly older (P = .0004), had larger spleens (P = .0004), were more likely to undergo open splenectomy (P = .001), and had longer lengths of stay (P = .01). However, there was no significant difference in operative time, transfusion requirements, morbidity rates, or mortality rates between patients with benign and malignant disease. CONCLUSION: LS, for benign or for malignant hematologic disease, is associated with a significant learning curve. This evaluation model illustrates that careful patient selection and ongoing quality assessment is essential when introducing a new technique.

Gallstone disease in the elderly: are older patients managed differently?

BACKGROUND: This study aimed to describe the differences in the management of symptomatic gallstone disease within different elderly groups and to evaluate the association between older age and surgical treatment. METHODS: This single-institution retrospective chart review included all patients 65 years old and older with an initial hospital visit for symptomatic gallstone disease between 2004 and 2008. The patients were stratified into three age groups: group 1 (age, 65-74 years), group 2 (age, 75-84 years), and group 3 (age, ≥ 85 years). Patient characteristics and presentation at the initial hospital visit were described as well as the surgical and other nonoperative interventions occurring over a 1-year follow-up period. Logistic regression was performed to assess the effect of age on surgery. RESULTS: Data from 397 patient charts were assessed: 182 in group 1, 160 in group 2, and 55 in group 3. Cholecystitis was the most common diagnosis in groups 1 and 2, whereas cholangitis was the most common diagnosis in group 3. Elective admissions to a surgical ward were most common in group 1, whereas urgent admissions to a medical ward were most common in group 3. Elective surgery was performed at the first visit for 50.6% of group 1, for 25.6% of group 2, and for 12.7% of group 3, with a 1-year cumulative incidence of surgery of 87.4% in group 1, 63.5% in group 2, and 22.1% in group 3. Inversely, cholecystostomy and endoscopic retrograde cholangiopancreatography (ERCP) were used more often in the older groups. Increased age (odds ratio [OR], 0.87; 95% confidence interval [CI], 0.84-0.91) and the Charlson Comorbidity Index (OR, 0.80; 95% CI, 0.69-0.94) were significantly associated with a decreased probability of undergoing surgery within 1 year after the initial visit. CONCLUSION: Even in the elderly population, older patients presented more frequently with severe disease and underwent more conservative treatment strategies. Older age was independently associated with a lower likelihood of surgery.

Atypically located cardiac haemangioma of the mitral valve.

We report an adolescent with a benign cardiac haemangioma with attachments exclusively to the anterior leaflet of the mitral valve. On the basis of our review of the literature, this study has not been reported previously.

Do gastrotomies require repair after endoscopic transgastric peritoneoscopy? A controlled study.

BACKGROUND: The optimal method for closing gastrotomies after transgastric instrumentation has yet to be determined. OBJECTIVE: To compare gastrotomy closure with endoscopically delivered bioabsorbable plugs with no closure. DESIGN: Prospective, controlled study. SETTING: Animal laboratory. SUBJECTS: Twenty-three dogs undergoing endoscopic transgastric peritoneoscopy between July and August 2007. INTERVENTIONS: Endoscopic anterior wall gastrotomies were performed with balloon dilation to allow passage of the endoscope into the peritoneal cavity. The plug group (n = 12) underwent endoscopic placement of a 4 x 6-cm bioabsorbable mesh plug in the perforation, whereas the no-treatment group (n = 11) did not. Animals underwent necropsy 2 weeks after the procedure. MAIN OUTCOME MEASUREMENTS: Complications related to gastrotomy closure, gastric burst pressures, relationship of burst perforation to gastrotomy, and the degree of adhesions and inflammation at the gastrotomy site. RESULTS: After the gastrotomy, all dogs survived without any complications. At necropsy, burst pressures were 77 +/- 11 mm Hg and 76 +/- 15 mm Hg (P = .9) in the plug group and no-treatment group, respectively. Perforations occurred at the site of the gastrotomy in 2 of 12 animals in the plug group and in none of the 11 dogs in the no-treatment group (P = .5). Finally, there were minimal adhesions in all dogs (11/11) in the no-treatment group and minimal adhesions in 3 and moderate adhesions or inflammatory masses in 9 of the 12 animals in the plug group (P = .004). LIMITATIONS: Small number of subjects, animal model, no randomization. Gastrotomy trauma during short peritoneoscopy may not be applicable to longer procedures. CONCLUSIONS: After endoscopic gastrotomy, animals that were left untreated did not show any clinical ill effects and demonstrated adequate healing, with fewer adhesions and less inflammation compared with those treated with a bioabsorbable plug.

Transoral incisionless fundoplication for gastroesophageal reflux disease in an unselected patient population.

BACKGROUND: EsophyX is an endolumenal approach to the treatment of gastroesophageal reflux disease (GERD). This report describes one of the earliest and largest North American experiences with this device. METHODS: Prospective data were gathered on consecutive patients undergoing EsophyX fundoplication for a 1-year period between September 2007 and March 2009. During this time, the procedure evolved to the current technique. A P value less than 0.05 was considered significant. RESULTS: The study enrolled 26 patients with a mean age of 45 years. The patients included 16 women (62%) with a mean body mass index (BMI) of 28 and an American Society Anesthesiology (ASA) classification of 2. These patients included 11 with associated small hiatal hernias, 3 with Barrett's esophagus, and 5 with esophageal dysmotility. The procedure time was 65 min (range, 29-137 min), and the length of hospital stay was 1 day (range, 0-6 days). The postoperative valve circumference was 217 degrees, and the valve length was 2.7 cm. Two complications of postoperative bleed occurred, requiring transfusion. The mean follow-up period was 10 months. Comparison of pre- and postoperative Anvari scores (34-17; P = 0.002) and Velanovich scores (22-10; P = 0.0007) showed significant decreases. Although 68% of the patients were still taking antireflux medications, 21% had reduced their dose by half. Three patients had persistent symptoms requiring Nissen fundoplication, and there was one late death unrelated to the procedure. CONCLUSION: This study represents an initial single-institution experience with EsophyX. According to the findings, 53% of the patients had either discontinued their antireflux medication (32%) or had decreased their dose by half (21%). Both symptoms and health-related quality-of-life (HRQL) scores significantly improved after treatment. Further follow-up evaluation and objective testing are required.

Metastatic hepatocellular carcinoma mimicking acinic cell carcinoma of the parotid gland: a case report.

BACKGROUND: Fine needle aspiration (FNA) is becoming increasingly important in the diagnosis of salivary gland lesions. One of the diagnostic difficulties that arise from FNAs is the distinction between primary and metastatic tumors. We describe a case where a right cheek/parotid mass was originally diagnosed as acinic cell carcinoma (ACC) upon biopsy. Later, an FNA resampling of the mass was diagnosed as hepatocellular carcinoma (HCC), and indeed, a subsequently performed computed tomography scan showed that the patient had a previously unknown liver mass. CASE: A 75-year-old man presented with a pathologic mandibular fracture. An initial needle core biopsy of the lesion showed neoplastic cells with abundant granular cytoplasm and prominent nucleoli and was diagnosed as ACC. The patient shortly thereafter developed an abdominal lesion that upon FNA was found to be cytologically similar to the parotid mass. Immunohistochemical stains showed that the abdominal mass was Hep Par 1 positive, and HCC was diagnosed. An FNA resampling of the parotid lesion was then performed, and stains showed that it was also Hep Par 1 positive. The lesion was rediagnosed as metastatic HCC and not ACC. Radiologic scans of the patient then showed a liver mass as well as multiple bony lesions. CONCLUSION: A right cheek/parotid mass initially diagnosed as ACC was later found to be metastatic HCC. At times, the judicious use of immunohistochemical stains is necessary to distinguish primary salivary gland neoplasias from metastatic tumors.

Transgastric endoscopic peritoneoscopy does not require decontamination of the stomach in humans.

INTRODUCTION: Natural orifice translumenal endoscopic surgery (NOTES) is a rapidly evolving field that provides endoscopic access to the peritoneum via a natural orifice. One important requirement of this technique is the need to minimize the risk of clinically significant peritoneal contamination. We report the bacterial load and contamination of the peritoneal cavity in ten patients who underwent diagnostic transgastric endoscopic peritoneoscopy. METHODS: Patients participating in this trial were scheduled to undergo diagnostic laparoscopy for evaluation of presumed pancreatic cancer. Findings at diagnostic laparoscopy were compared with those of diagnostic transgastric endoscopic peritoneoscopy, using an orally placed gastroscope, blinding the endoscopist to the laparoscopic findings. We performed no gastric decontamination. Diagnostic findings, operative times, and clinical course were recorded. Gastroscope and peritoneal fluid aspirates were obtained prior to and after the gastrotomy. Each sample was sent for bacterial colony counts, culture, and identification of species. RESULTS: Ten patients, with an average age of 63.7 years, have completed the protocol. All patients underwent diagnostic laparoscopy followed by successful transgastric access and diagnostic peritoneoscopy. The average time for laparoscopy was 7.2 min, compared with 18 min for transgastric instrumentation. Bacterial sampling was obtained in all ten patients. The average number of colony-forming units (CFU) in the gastroscope aspirate was 132.1 CFU/ml, peritoneal aspirates prior to creation of a gastrotomy showed 160.4 CFU/ml, and peritoneal sampling after gastrotomy had an average of 642.1 CFU/ml. There was no contamination of the peritoneal cavity with species isolated from the gastroscope aspirate. No infectious complications or leaks were noted at 30-day follow-up. CONCLUSIONS: There was no clinically significant contamination of the peritoneal cavity from the gastroscope after transgastric endoscopic instrumentation in humans. Transgastric instrumentation does contaminate the abdominal cavity but, the pathogens do not mount a clinically significant response in terms of either the species or the bacterial load.