Teaching peroral endoscopic myotomy (POEM) to surgeons in practice: an "into the fire" pre/post-test curriculum.

INTRODUCTION: With the increasing adoption of peroral endoscopic myotomy (POEM) as a first-line therapy for achalasia as well as a growing list of other indications, it is apparent that there is a need for effective training methods for both endoscopists in training and those already in practice. We present a hands-on-focused with pre- and post-testing methodology to teach these skills. METHODS: Six POEM courses were taught by 11 experienced POEM endoscopists at two independent simulation laboratories. The training curriculum included a pre-training test, lectures and discussion, mentored hands-on instruction using live porcine and ex-plant models, and a post-training test. The scoring sheet for the pre- and post-tests assessed the POEM performance with a Likert-like scale measuring equipment setup, mucosotomy creation, endoscope navigation, visualization, myotomy, and closure. Participants were stratified by their experience with upper-GI endoscopy (Novices <100 cases vs. Experts ≥100 cases), and their data were analyzed and compared. RESULTS: Sixty-five participants with varying degrees of experience in upper-GI endoscopy and laparoscopic achalasia cases completed the training curriculum. Participants improved knowledge scores from 69.7 ± 17.1 (pre-test) to 87.7 ± 10.8 (post-test) (p < 0.01). POEM performance increased from 15.1 ± 5.1 to 25.0 ± 5.5 (out of 30) (p < 0.01) with the greatest gains in mucosotomy [1.7-4.4 (out of 5), p < 0.01] and equipment (3.4-4.7, p < 0.01). Novices had significantly lower pre-test scores compared with Experts in upper-GI endoscopy (overall pre-score: 11.9 ± 5.6 vs. 16.3 ± 4.6, p < 0.01). Both groups improved significantly after the course, and there were no differences in post-test scores (overall post-score: 23.9 ± 6.6 vs. 25.4 ± 5.1, p = 0.34) between Novices and Experts. CONCLUSIONS: A multimodal curriculum with procedural practice was an effective curricular design for teaching POEM to practitioners. The curriculum was specifically helpful for training surgeons with less upper-GI endoscopy experience.

Quality of life after laparoscopic totally extraperitoneal repair of an asymptomatic inguinal hernia.

BACKGROUND: When considering an asymptomatic inguinal hernia, surgeons must weigh the risks of watchful waiting against the risk of operative complications. Laparoscopy offers the benefit of reduced postoperative pain, which, for appropriate surgical candidates, may strengthen the case for repair. This study compares general and disease-specific quality of life following totally extraperitoneal (TEP) laparoscopic inguinal hernia repair (LIHR) of asymptomatic and symptomatic hernias. METHODS: We summarize prospective data from 387 patients who underwent TEP LIHR between 2009 and 2015 by four surgeons at a single institution. Asymptomatic individuals were identified by pain scores of zero at preoperative clinic visits. Validated quality of life (QOL) measurements were administered preoperatively and at 3 weeks, 6 months, and 1-year postop. Comparisons were made using Chi-square test, t test, or Mann-Whitney U test. Changes over time were assessed using longitudinal mixed effects models. RESULTS: A cohort of 79 asymptomatic cases were compared to 308 symptomatic individuals. The asymptomatic cohort had larger median hernia defects (2.5 vs 2 cm, p < 0.01), was older (mean 63.0 vs 58.9 years, p = 0.03), included fewer indirect hernias (57.7 vs 74.9%, p < 0.01), took pain medication for fewer days (mean 1.2 ± 1.5 vs 2.2 ± 3.0 days, p = 0.02), returned to baseline activities of daily living earlier (median 3 vs 5 days, p < 0.01), and reported decreased postoperative pain (p = 0.02). There was no significant difference in general QOL. There was one recurrence in the asymptomatic group and were two in the symptomatic cohort. CONCLUSIONS: Asymptomatic individuals undergoing TEP LIHR reported less postoperative pain, returned to baseline activities, and discontinued pain medication sooner than symptomatic patients. These results are encouraging and may inform patient-centered discussions about asymptomatic hernia repair.

Does Treatment of the Tibia Matter in Bipolar Chondral Defects of the Knee? Clinical Outcomes with Greater Than 2 Years Follow-up.

PURPOSE: To compare the osteochondral allograft (OCA) outcomes of bipolar defects with isolated femoral defects and to investigate the optimal treatment of bipolar defects by comparing femoral OCA with tibial debridement to femoral OCA and tibial microfracture. METHODS: A series of patients with 2-year follow-up from March 2004 to September 2015 after femoral OCA for bipolar chondral defects was identified. Group 1 contained patients with tibial defects treated with debridement and group 2 contained patients with microfractured tibial defects. A third group (group 3) with isolated femoral defects treated with OCA was identified and matched by gender, body mass index (BMI), laterality, and OCA size to groups 1 and 2. Patient-specific, defect-specific, intraoperative, and postoperative data including patient-reported outcomes were collected on all patients. The study groups were compared using analyses of variance, paired sample t tests, and χ-square analyses. RESULTS: Thirty-six patients who had femoral OCA for bipolar lesions were identified with 20 patients in group 1 and 16 patients in group 2. Group 3 had 20 patients. There were no differences between the 3 groups in terms of gender (P = .616), BMI (P = .271), number of previous surgeries (P = .451), femoral or tibial defect size (P = .296), and OCA size (P = .981). Preoperative to postoperative patient-reported clinical outcomes (PROs) revealed statistical and clinically meaningful improvement in all 3 groups, but did not differ between groups. Patient-specific and defect-specific factors did not correlate with PROs. The graft survivorship for group 1 was 85% at 4.5 years, 100% for group 2 at 2.5 years, and 95% for group 3 at 3.8 years. CONCLUSIONS: Regardless of tibial treatment, patients with bipolar defects treated with femoral OCA have clinically meaningful improvements in PROs and excellent graft survivorship comparable to isolated femoral OCAs at more than 2 years. LEVEL OF EVIDENCE: Level III, case-control study.

Outcomes following 50 consecutive endoscopic gastrojejunal revisions for weight gain following Roux-en-Y gastric bypass: a comparison of endoscopic suturing techniques for stoma reduction.

BACKGROUND: Approximately 20-30 % of morbidly obese patients undergoing Roux-en-Y gastric bypass (RYGB) will experience significant weight regain in the years following surgery. Endoscopic gastrojejunal revision (EGJR) has been shown to be a safe, effective and less invasive alternative to revisional surgery, with promising weight loss outcomes. However, minimal data exist regarding how to perform the procedure most effectively and what factors may predict good outcomes. We compared weight loss outcomes between patients undergoing endoscopic stoma revision by one of two full-thickness suturing techniques. METHODS: A retrospective review of patients undergoing EGJR between 06/2012 and 09/2015 was performed. Included patients were adults 18-74 years of age who had experienced weight regain ≥2 years after initial RYGB with stoma dilation ≥15 mm in diameter. Revision was done with either an interrupted (IRT) or purse-string (PST) suture technique. A linear mixed effects model was constructed to predict postoperative weight loss. RESULTS: Fifty revisions (IRT = 36, PST = 14) were performed in 47 patients (92 % female, mean age of 50.9 ± 10.9 years and body mass index of 41.4 ± 7.1 kg/m2). Technical success (stoma diameter ≤10 mm) was achieved in all cases. Final diameter was significantly smaller in the PST group, 6.6 ± 2.2 mm versus 4.8 ± 1.8 mm (p < 0.01), resulting in a significantly greater % stoma reduction (76.8 ± 8.5 % vs. 84.2 ± 5.1 %, p < 0.01) versus the IRT group. PST resulted in greater % excess weight loss over time compared to IRT. Sixteen comorbid conditions resolved among 12 patients. No major complications occurred. CONCLUSION: Endoscopic revision of the gastric outlet results in meaningful weight loss and comorbidity resolution in select patients experiencing weight regain following RYGB. A PST revision likely results in higher and more sustainable weight loss when compared to IRT.

Long-term patterns and predictors of pain following laparoscopic inguinal hernia repair: a patient-centered analysis.

BACKGROUND: Laparoscopic inguinal hernia repair has been shown to offer patients the benefit of less postoperative pain as compared to traditional open techniques. However, the risk of experiencing significant postoperative pain may affect patient's decision making. We aimed to elucidate potential patterns of pain and the predictors of such, up to 2 years postoperatively, using both generic and specific quality of life tools. METHODS: Patients undergoing laparoscopic totally extra-peritoneal inguinal hernia repair were identified from a prospectively maintained database. Short form-36, Surgical Outcomes Measurement System (SOMS) and Carolinas Comfort Scale (CCS) surveys were administered pre- and postoperatively at 3 weeks, 6 months, 1 and 2 years. Patients with concomitant procedures were excluded. Significant pain was considered mild but bothersome or worse on either specific tool (SOMS scores ≥3/4, CCS scores ≥2). Predictors of significant pain were determined by logistic regression. RESULTS: From 2009 to 2015, 482 patients enrolled in our database underwent elective TEP repair of 626 hernias and completed an assessment tool. Mean age was 57 (±15) years, with 93 % male. Reported pain on all three tools improved significantly from baseline over time (p < 0.01). Significant pain on either specific tool, related or unrelated to surgery, was reported by 52 % of respondents (158/301) preoperatively, and postoperatively by 50 % at 3 weeks (111/220), 21 % at 6 months (15/70), 13 % at 1 year (14/108), and 25 % at 2 years (30/121). Significant pain at 6 months-2 years correlated more significantly with general health status than surgical factors. CONCLUSIONS: Significant pain can be as high as 50 % at 3 weeks on surgery-specific quality of life measures, but with significant improvement by 6 months which is maintained through 2 years. Poor quality of life and general health were the main predictors of pain after 6 months.

International multicenter experience with peroral endoscopic myotomy for the treatment of spastic esophageal disorders refractory to medical therapy (with video).

BACKGROUND: Limited data exist on the use of peroral endoscopic myotomy (POEM) for therapy of spastic esophageal disorders (SEDs). OBJECTIVE: To study the efficacy and safety of POEM for the treatment of patients with diffuse esophageal spasm, jackhammer esophagus, or type III (spastic) achalasia. DESIGN: Retrospective study. SETTING: International, multicenter, academic institutions. PATIENTS: All patients who underwent POEM for treatment of SEDs refractory to medical therapy at 11 centers were included. INTERVENTIONS: POEM. MAIN OUTCOME MEASUREMENTS: Eckardt score and adverse events. RESULTS: A total of 73 patients underwent POEM for treatment of SEDs (diffuse esophageal spasm 9, jackhammer esophagus 10, spastic achalasia 54). POEM was successfully completed in all patients, with a mean procedural time of 118 minutes. The mean length of the submucosal tunnel was 19 cm, and the mean myotomy length was 16 cm. A total of 8 adverse events (11%) occurred, with 5 rated as mild, 3 moderate, and 0 severe. The mean length of hospital stay was 3.4 days. There was a significant decrease in Eckardt scores after POEM (6.71 vs 1.13; P = .0001). Overall, clinical response was observed in 93% of patients during a mean follow-up of 234 days. Chest pain significantly improved in 87% of patients who reported chest pain before POEM. Repeat manometry after POEM was available in 44 patients and showed resolution of initial manometric abnormalities in all cases. LIMITATIONS: Retrospective design and selection bias. CONCLUSION: POEM offers a logical therapeutic modality for patients with SEDs refractory to medical therapy. Results from this international study suggest POEM as an effective and safe platform for these patients.

A Model of Cost Reduction and Standardization: Improved Cost Savings While Maintaining the Quality of Care.

BACKGROUND: Surgeon instrument choices are influenced by training, previous experience, and established preferences. This causes variability in the cost of common operations, such as laparoscopic appendectomy. Many surgeons are unaware of the impact that this has on healthcare spending. OBJECTIVE: We sought to educate surgeons on their instrument use and develop standardized strategies for operating room cost reduction. DESIGN: We collected the individual surgeon instrument cost for performing a laparoscopic appendectomy. Sixteen surgeons were educated about these costs and provided with cost-effective instruments and techniques. SETTINGS: This study was conducted in a university-affiliated hospital system. PATIENTS: Patients included those undergoing a laparoscopic appendectomy within the hospital system. MAIN OUTCOME MEASURES: Patient demographics, operating room costs, and short-term outcomes for the fiscal year before and after the education program were then compared. RESULTS: During fiscal year 2013, a total of 336 laparoscopic appendectomies were performed compared with 357 in 2014. Twelve surgeons had a ≥5% reduction in average cost per case. Overall, the average cost per case was reduced by 17% (p < 0.001). Switching from an energy device to a stapler load or reusable plastic clip applier resulted in the largest savings per case at $321 or $442 per case. There were no differences in length of stay, 30-day readmissions, postoperative infections, operating time, or reoperations. LIMITATIONS: This retrospective study is subject to the accuracy of the medical chart system. In addition, specific instrument costs are based on our institution contracts and vary compared with other institutions. CONCLUSIONS: In this study we demonstrate that operative instrument costs for laparoscopic appendectomy can be significantly reduced by informing the surgeons of their operating room costs compared with their peers and providing a low-cost standardized instrument tray. Importantly, this can be realized without any incentive or punitive measures and does not negatively impact outcomes. Additional work is needed to expand these results to more operations, hospital systems, and training programs.

Quality of life assessment after peroral endoscopic myotomy.

BACKGROUND: Peroral Endoscopic Myotomy (POEM) is a promising treatment option for motor disorders of the esophagus. The purpose of this study was to assess quality of life (QOL) postoperatively. METHODS: All patients who presented to our institution for surgical treatment of achalasia after 2011 were asked to complete QOL (SF-36), dysphagia, reflux severity index, and GERD questionnaires in clinic preoperatively and postoperatively at approximately 3 weeks, 6 months, and 1 year. RESULTS: Those patients who underwent a POEM procedure (n = 37) demonstrated a significant improvement in dysphagia scores, reflux severity scores, and GERD scores (p < 0.05) at each time point. SF-36 questionnaires specifically demonstrated a significant improvement in several concepts. At 3 weeks, emotional well-being scores were significantly higher (p = 0.006). At 6 months, the following concepts were significantly higher: emotional well-being (p = 0.039), social functioning (p = 0.038), and general health (p = 0.029). At 1 year, the following concepts were significantly higher: role limitations due to physical health (p = 0.001) and social functioning (p = 0.002). CONCLUSION: There is a significant improvement in several measures of QOL after POEM, which is comparable to that seen after laparoscopic Heller myotomy.

Patient-centered outcomes following laparoscopic inguinal hernia repair.

BACKGROUND: Inguinal hernia repair is the most common surgery in the world. Health-related quality of life (HRQOL) outcomes are arguably the most important elements of successful repair. This study is aimed to describe short- and long-term quality of life outcomes in patients undergoing laparoscopic inguinal hernia repair. METHODS: We prospectively followed patients who underwent totally extraperitoneal laparoscopic inguinal hernia repair (TEP) as part of an Institutional Review Board-approved study. HRQOL was measured preoperatively, or 3 weeks, 6 months, and 1 year postoperatively using Short Form 36 Health Survey Version 2 (SF-36v2) and Carolinas Comfort Scale. Postoperative HRQOL scores were compared to baseline using paired t tests. RESULTS: Between June 2009 and February 2014, 1,175 patients underwent TEP by four surgeons. Of those, 301 patients with 388 hernias were registered in the database and followed by a research coordinator. Mean age was 56.4 ± 15.2 years and 93% were male. Mean body mass index was 26.1 ± 3.7 kg/m(2). Seventy-eight percent presented with pain, the majority of which were described as mild. Hernias were unilateral right-sided in 43%, left-sided in 28%, and bilateral in 29 %. Eighty-five percent were primary hernias. Average operative time was 43.5 ± 17.9 min and there were no intraoperative complications. Urinary retention occurred in 6%. Visual analog scale at discharge was 1.9 ± 1.7. Analgesics were used an average of 2.5 ± 3.4 days and return to activities of daily living and work occurred on postoperative 5.5 ± 4.4 and 5.6 ± 3.9 days. Recurrence occurred in 2.1%. Significant improvements between baseline and 1 year were found in role limitations due to physical health (81.5 ± 25.6 vs. 91.8 ± 19.4, p = 0.02), social functioning (87.4 ± 21.3 vs. 92.9 ± 15.3, p = 0.02), and pain (78.2 ± 19.7 vs. 86.6 ± 15.9, p = 0.007). CONCLUSIONS: TEP results in significant improvement in HRQOL including physical health, social functioning, and pain at 1 year. On average, patients are able to return to activities of daily living and work within a week.

Evaluation of Vessel Sealing Performance Among Ultrasonic Devices in a Porcine Model.

BACKGROUND: As new technologies emerge, it is imperative to define which new devices are most likely to provide a reproducible, effective result for the patient and surgeon. The purpose of our study was to analyze 3 commercially available ultrasonic energy devices; the Sonicision (SC), the Harmonic ACE (HA), and the THUNDERBEAT (TB). MATERIAL AND METHODS: Eight female Yorkshire pigs were used for data collection and vessel harvest. Three devices were evaluated and compared with each other with respect to seal failure and cutting speed in vivo. After vessel harvest, one end of the fragment was sent for histological evaluation, and the other was used for burst pressure measurement testing in a blinded fashion. The coagulation and cut levels of all the generators were set up at a similar and constant level. RESULTS: Eighty-four vessels (47 arteries and 37 veins) were tested. Mean vessel diameter was equal among the groups. Cutting speed was significantly faster with TB (3.4 ± 0.7 seconds) than SC or HA (5.8 ± 2.4 and 6.1 ± 3.1 seconds; P < .0001). Burst pressure trended higher after ligation with TB (505.4 ± 349.4 mm Hg) than SC and HA (435.8 ± 403.0 and 437.6 ± 291.3 mm Hg). There were 2 seal failures in the SC group and HA group and none in the TB group. Histologically, the perpendicular width of tissue seal with TB (1.250 ± 0.55 mm) was significantly longer than that of the SC and the HA (0.772 ± 0.23 and 0.686 ± 0.23 mm; P < .0001). CONCLUSIONS: TB has proven to provide the most rapid and reliable seal. Therefore, TB may be safer and may decrease time during surgical procedures.

Travel Distance Does Not Affect Outcomes in Hip Preservation Surgery: A Case for Centers of Excellence.

BACKGROUND: Previous studies have evaluated the effect of distance to high-volume centers on outcomes after joint replacement. However, there is limited evidence on whether this distance has an effect on outcomes after undergoing hip arthroscopic surgery for femoroacetabular impingement syndrome (FAIS). PURPOSE: To determine whether increased distance from a patient's home to his or her primary orthopaedic clinic has an influence on the ability to achieve the minimal clinically important difference (MCID) on outcome measures after surgery for FAIS. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective cohort analysis was performed on patients undergoing surgery for FAIS by a single surgeon from January 2012 through January 2017. A total of 692 patients were identified and split into 2 groups: driving distance of <50 miles from our institution (referral group) and driving distance of <50 miles from our institution (local group). Preoperative and 2-year postoperative scores on patient-reported outcome measures (PROMs), including the Hip Outcome Score Activities of Daily Living and Sport-Specific subscales, International Hip Outcome Tool-12, and modified Harris Hip Score, were assessed. Patients achieving the MCID on any included PROM were analyzed using a chi-square analysis. Logistic regression was performed to determine whether driving distance and other demographic variables of interest had an effect on achieving the MCID. Study data were analyzed using PatientIQ, a cloud-based research and analytics platform for health care. RESULTS: There were 647 patients who completed 2-year follow-up and were included in the analysis. Of these patients, 116 (17.9%) were identified as being ≥50 miles from their orthopaedic provider, and 531 (82.1%) were identified as having a driving distance of <50 miles. A total of 100 patients (86.2%) in the referral group reached the MCID, and 476 patients (89.6%) in the local group reached the MCID. There was no statistically significant difference in reaching the MCID on any of the included PROMs between the 2 groups (P = .364). The same result held when controlling for a number of factors including age, body mass index, and adjusted gross income with logistic regression. CONCLUSION: When controlling for a number of factors including age, body mass index, and adjusted gross income, distance to a high-volume hip arthroscopic surgery center did not have an effect on postoperative outcome scores or achieving the MCID 2 years after undergoing surgery for FAIS.

5 Points on Meniscal Allograft Transplantation.

Meniscus allograft transplantation (MAT) has yielded excellent long-term functional outcomes when performed in properly indicated patients. When evaluating a patient for potential MAT, it is imperative to evaluate past medical history and past surgical procedures. The ideal MAT candidate is a chronologically and physiologically young patient (<50 years) with symptomatic meniscal deficiency. Existing pathology in the knee needs to be carefully considered and issues such as malalignment, cartilage defects, and/or ligamentous instability may require a staged or concomitant procedure. Once an ideal candidate is identified, graft selection and preparation are critical steps to ensure a proper fit and long-term viability of the meniscus. When selecting the graft, accurate measurements must be taken, and this is most commonly performed using plain radiographs for this. Graft fixation can be accomplished by placing vertical mattress sutures and tying those down with the knee in full extension.

Increasing compliance with the World Health Organization Surgical Safety Checklist-A regional health system's experience.

BACKGROUND: In 2009, NorthShore University HealthSystem adapted the World Health Organization Surgical Safety Checklist (SSC) at each of its 4 hospitals. Despite evidence that SSC reduces intraoperative mistakes and increase patient safety, compliance was found to be low with the paper form. In November 2013, NorthShore integrated the SSC into the electronic health record (EHR). The aim was to increase communication between operating room (OR) personnel and to encourage best practices during the natural workflow of surgeons, anesthesiologists, and nurses. The purpose of this study was to examine the impact of an electronic SSC on compliance and patient safety. METHODS: An anonymous OR observer selected cases at random and evaluated the compliance rate before the rollout of the electronic SSC. In June 2014, an electronic audit was performed to assess the compliance rate. Random OR observations were also performed throughout the summer in 2014. Perioperative risk events, such as consent issues, incorrect counts, wrong site, and wrong procedure were compared before and after the electronic SSC rollout. A perception survey was also administered to NorthShore OR personnel. RESULTS: Compliance increased from 48% (n = 167) to 92% (n = 1,037; P < .001) after the SSC was integrated into the electronic health record. Surgeons (91% vs 97%; P < .001), anesthesiologists (89% vs 100%; P < .001), and nurses (55% vs 93%; P < .001) demonstrated an increase in compliance. A comparison between risk events in the pre- and post-rollout period showed a 32% decrease (P < .01). Hospital-wide indicators including length of stay and 30-day readmissions were lower. In a survey to assess the OR personnel's perceptions of the new checklist, 76% of surgeons, 86% of anesthesiologists, and 88% of nurses believed the electronic SSC will have a positive impact on patient safety. CONCLUSIONS: The World Health Organization SSC is a validated tool to increase patient safety and reduce intraoperative complications. The electronic SSC has demonstrated an increased compliance rate, a reduced number of risk events, and most OR personnel believe it will have a positive impact on patient safety.

Effectiveness of Lavage Techniques in Removing Immunogenic Elements from Osteochondral Allografts.

Objective This study aimed to compare standard saline lavage to combination saline and high-pressure carbon dioxide (CO2) lavage in removing marrow elements from osteochondral allografts. Design Six fresh hemicondyles were obtained. Three osteochondral allograft plugs (15-mm diameter, 6-mm depth) were harvested from each hemicondyle and randomized to 1 of 3 treatment arms: A, no lavage; B, 1 L standard saline lavage; C, simultaneous saline (1 L) and 1-minute high-pressure CO2 lavage. After hematoxylin and eosin staining, a "percentage fill" of remaining marrow elements was calculated for each overall sample and then repeated in 3 distinct compartments for each sample based on depth from surface: 1, deepest third; 2, middle third; and 3, most superficial third. Trial arms B and C were compared with 1-tailed Student t tests. Results Group A had an overall percentage fill of 51.2% ± 8.8%. While both lavage techniques decreased overall remaining marrow elements, group B yielded significantly higher percentages of remaining marrow elements than group C (28.6% ± 16.5%, 14.6% ± 8.7%, P = 0.045). On depth analysis, group A exhibited homogenous filling of trabecular space (63.0% ± 15.5%, 67.6% ± 13.7%, and 55.2% ± 10.1% in zones 1, 2, and 3, respectively). Both lavage arms equally removed marrow elements from superficial zone 3 (B, 17.4% ± 9.2%; C, 15.6% ± 12.4%, P = 0.41) and middle zone 2 (B, 30.2% ± 17.7%; C, 21.4% ± 15.5%, P = 0.18). However, group C lavage removed significantly more marrow elements in deep zone 1 than group B (29.7% ± 10.9%, 58.5% ± 25.2%, P = 0.01). Conclusion Combination saline and high-pressure CO2 lavage more effectively clears marrow elements from osteochondral allografts than saline alone.

Malalignment: A Requirement for Cartilage and Organ Restoration.

The treatment of combined knee pathology is a challenging problem that requires careful attention to all aspects of the underlying disease. This is true of the interplay among malalignment and meniscal or articular cartilage restoration in the knee. Optimal outcomes are contingent on a comprehensive preoperative evaluation of patient-specific factors (patient expectations, patient age, and activity level), as well as disease-specific factors of the knee. Surgical intervention for meniscal or chondral deficiencies without attention to malalignment will lead to inferior outcomes. The focus of this review is to highlight the importance of malalignment correction when treating meniscal and articular cartilage pathology. This objective will be accomplished by outlining the approach to the preoperative evaluation, discussing the indications for surgical intervention, reviewing the preferred surgical techniques for correcting coronal malalignment of the knee, and providing a discussion of clinical outcomes.

Deciding How Best to Treat Cartilage Defects.

The decision-making regarding and treatment of cartilage abnormalities requires a systematic approach. This article reviews the concepts and principles that guide the management of this complex problem. The precise incidence, demographics, and progression of cartilage lesions have not been clearly delineated. Pursuing a patient-centered approach that considers the available nonsurgical and surgical options remains the cornerstone of patient care. The importance of determining concomitant knee pathologies, the proper interpretation and implications of imaging findings, and an accurate determination of the intra-articular and subchondral findings represent the primary elements of the decision analysis. Treatment options vary depending on patient goals, the disposition of the lesion, and a variety of other factors. The authors recommend proper patient education and consideration of how nonsurgical treatment or less invasive options such as arthroscopic debridement might be effective. If these strategies should fail, appropriate matching of a surgical procedure to the patient's pathology, goals, and expectations is warranted. Surgical options include debridement, marrow stimulation techniques, surface allograft treatments, autologous chondrocyte implantation, and osteochondral grafting (autograft and allograft) in addition to some emerging technologies. This article focuses on the decision-making process. [Orthopedics. 2016; 39(6):343-350.].

Laparoscopic Totally Extraperitoneal Groin Hernia Repair and Quality of Life at 2-Year Follow-Up.

BACKGROUND: The lack of long-term data on quality of life after groin hernia repair presents a challenge in setting patients' postoperative expectations. This study aimed to describe quality of life outcomes after laparoscopic totally extraperitoneal groin hernia repair with a minimum of 2 years follow-up. STUDY DESIGN: We prospectively evaluated 293 patients who had laparoscopic totally extraperitoneal groin hernia repair in an IRB-approved study. The Short-Form 36-item Health Survey (version 2), Surgical Outcomes Measurement System, and Carolinas Comfort Scale were administered pre- and postoperatively. Pairwise comparisons using nonparametric Wilcoxon signed rank test were made between time points. RESULTS: Mean patient age was 56 ± 15 years and 93% were male; 80% of patients presented with painful hernias and 15% of hernias were recurrent. Mean operative time was 43 ± 16 minutes. No operative complications occurred. Mean duration of narcotic pain medication use was 2.5 ± 3.4 days, and daily activities were resumed and return to work occurred 5.4 ± 4.4 days and 5.4 ± 3.9 days post operation, respectively. Recurrence rate was 2%. The Short-Form 36-item Health Survey outcomes improved from baseline for domains of Physical Functioning, Role Limitations due to Physical Health, and Pain at 2 years post operation; Surgical Outcomes Measurement System outcomes improved for domains of Pain Impact on Quality of Life, Body Image, and Patient Satisfaction (p ≤ 0.05). The percentage of patients reporting no or mild but not bothersome symptoms on the Carolinas Comfort Scale at 2 years post operation for sensation of mesh, pain, and movement limitations were 98%, 95%, and 97%, respectively. CONCLUSIONS: Measuring both general and procedure-specific quality of life, patients' perceptions of health status improved significantly 2 years after laparoscopic totally extraperitoneal groin hernia repair.

Efficacy of a Required Preoperative Weight Loss Program for Patients Undergoing Bariatric Surgery.

The efficacy of mandatory medically supervised preoperative weight loss (MPWL) prior to bariatric surgery continues to be a controversial topic. The purpose of this observational study was to assess the efficacy of a MPWL program in a single institution, which mandated at least 10% excess body weight loss before surgery, by comparing outcomes of patients undergoing primary bariatric surgery with and without a compulsory preoperative weight loss regimen. We analyzed our database of 757 patients who underwent primary bariatric surgery between March 2008 and January 2015. Patients were placed into two cohorts based on their participation in a MPWL program requiring at least 10% excess weight loss (EWL) prior to surgery. Patients were evaluated at 3, 6, 12, and 24 months after surgery for weight loss, comorbidity resolution, and the occurrences of hospital readmissions. A total of 717 patients met the inclusion criteria of whom 465 underwent surgery without a preoperative weight loss requirement and 252 participated in the MPWL program. One year after surgery, 67.1% of non-participants and 62.5% of MPWL participants showed a resolution of at least one of five associated comorbidities (p = 0.45). Non-participants showed an average of 58.6% EWL, while MPWL participants showed 59.1% EWL at 1 year postoperatively (p = 0.84). Readmission rates, excluding those which were ulcer-related, at 30 days (3.4 vs. 6.40%, p = 0.11) and 90 days (9.9 vs. 7.5%, p = 0.29) postoperatively were not significantly different between the non-participants and MPWL patients, respectively. A mandatory preoperative weight loss program prior to bariatric surgery did not result in significantly greater %EWL or comorbidity resolution 1 year after surgery compared to patients not required to lose weight preoperatively. Additionally, the program did not result in significantly lower 30- or 90-day readmission rates for these patients. The value of a MPWL program must be weighed against the potential loss of bariatric surgery candidates. Patients who fail to lose 10% excess weight preoperatively are thus ineligible for a procedure from which they would otherwise benefit. Our data suggest these patients will have similar positive outcomes.

Current state of laparoscopic parastomal hernia repair: A meta-analysis.

AIM: To evaluate the efficacy and safety of the laparoscopic approaches for parastomal hernia repair reported in the literature. METHODS: A systematic review of PubMed and MEDLINE databases was conducted using various combination of the following keywords: stoma repair, laparoscopic, parastomal, and hernia. Case reports, studies with less than 5 patients, and articles not written in English were excluded. Eligible studies were further scrutinized with the 2011 levels of evidence from the Oxford Centre for Evidence-Based Medicine. Two authors reviewed and analyzed each study. If there was any discrepancy between scores, the study in question was referred to another author. A meta -analysis was performed using both random and fixed-effect models. Publication bias was evaluated using Begg's funnel plot and Egger's regression test. The primary outcome analyzed was recurrence of parastomal hernia. Secondary outcomes were mesh infection, surgical site infection, obstruction requiring reoperation, death, and other complications. Studies were grouped by operative technique where indicated. Except for recurrence, most postoperative morbidities were reported for the overall cohort and not by approach so they were analyzed across approach. RESULTS: Fifteen articles with a total of 469 patients were deemed eligible for review. Most postoperative morbidities were reported for the overall cohort, and not by approach. The overall postoperative morbidity rate was 1.8% (95%CI: 0.8-3.2), and there was no difference between techniques. The most common postoperative complication was surgical site infection, which was seen in 3.8% (95%CI: 2.3-5.7). Infected mesh was observed in 1.7% (95%CI: 0.7-3.1), and obstruction requiring reoperation also occurred in 1.7% (95%CI: 0.7-3.0). Other complications such as ileus, pneumonia, or urinary tract infection were noted in 16.6% (95%CI: 11.9-22.1). Eighty-one recurrences were reported overall for a recurrence rate of 17.4% (95%CI: 9.5-26.9). The recurrence rate was 10.2% (95%CI: 3.9-19.0) for the modified laparoscopic Sugarbaker approach, whereas the recurrence rate was 27.9% (95%CI: 12.3-46.9) for the keyhole approach. There were no intraoperative mortalities reported and six mortalities during the postoperative course. CONCLUSION: Laparoscopic intraperitoneal mesh repair is safe and effective for treating parastomal hernia. A modified Sugarbaker approach appears to provide the best outcomes.

Elderly and octogenarian cohort: Comparable outcomes with nonelderly cohort after open or laparoscopic inguinal hernia repairs.

PURPOSE: To understand whether the elderly (>65 years of age) or octogenarian cohort is at greater risk for poor clinical outcomes after open or laparoscopic inguinal hernia repairs. METHODS: Beginning in June 2009, all patients presenting to our institution for inguinal hernia repair were asked to participate in a prospective database. Demographics, presenting symptoms, preoperative findings on examination, intraoperative variables, postoperative outcomes, and readmission data were collected. Additionally, patient-centered outcomes were evaluated with the Short Form-36 and Carolina Comfort Score questionnaires at follow-up visits (3 weeks, 6 months, 1 year, and for the Short Form-36 preoperatively as well). RESULTS: A total of 471 patients were included in the study; 285 were nonelderly, 155 patients were aged 65-80 years, and 31 patients were older than 80 years of age. Of these patients, the percent who underwent laparoscopic repair was 86% for the nonelderly, 79% for the elderly, and 41.9% for the octogenarian cohorts (P < .001). After laparoscopic repairs, the older cohorts had greater rates of minor postoperative complications than the nonelderly cohort (38% and 58% vs 15%; P < .001) attributable to greater rates of seroma and urinary retention. Intraoperative complications and recurrence rates were not different among the cohorts; however, the octogenarian cohort was more likely to be readmitted compared with both the nonelderly and elderly cohorts (17% vs 2% and 2%, respectively, P < .001) and to have a greater duration of stay (P < .001). For laparoscopic repairs over all the cohorts, the Carolina Comfort Scale improved over time (P < .001). Laparoscopic repairs in the octogenarians (P = .07) but not in the elderly (P = .6) had better scores over time (8.1 and 1.0 and points less/better, respectively) than the nonelderly cohort. CONCLUSION: Laparoscopic inguinal hernia repair is safe and effective in elderly and octogenarian patients with no major morbidities or mortalities. Although these patients are at greater risk for postoperative seroma and urinary retention, and octogenarians are at greater risk for readmission, patient-centered outcomes may be better after laparoscopic repairs with the proper patient selection in the older population.