Revisional surgery after failed esophagogastric myotomy for achalasia: successful esophageal preservation.

BACKGROUND: Treatment failure with recurrent dysphagia after Heller myotomy occurs in fewer than 10 % of patients, most of whom will seek repeat surgical intervention. These reoperations are technically challenging, and as such, there exist only limited reports of reoperation with esophageal preservation. METHODS: We retrospectively reviewed the records of patients who sought operative intervention from March 1998 to December 2014 for obstructed swallowing after esophagogastric myotomy. All patients underwent a systematic approach, including complete hiatal dissection, takedown of prior fundoplication, and endoscopic assessment of myotomy. Patterns of failure were categorized as: fundoplication failure, inadequate myotomy, fibrosis, and mucosal stricture. RESULTS: A total of 58 patients underwent 65 elective reoperations. Four patients underwent esophagectomy as their initial reoperation, while three patients ultimately required esophagectomy. The remainder underwent reoperations with the goal of esophageal preservation. Of these 58, 46 were first-time reoperations; ten were second time; and two were third-time reoperations. Forty-one had prior operations via a trans-abdominal approach, 11 via thoracic approach, and 6 via combined approaches. All reoperations at our institution were performed laparoscopically (with two conversions to open). Inadequate myotomy was identified in 53 % of patients, fundoplication failure in 26 %, extensive fibrosis in 19 %, and mucosal stricture in 2 %. Intraoperative esophagogastric perforation occurred in 19 % of patients and was repaired. Our postoperative leak rate was 5 %. Esophageal preservation was possible in 55 of the 58 operations in which it was attempted. At median follow-up of 34 months, recurrent dysphagia after reoperation was seen in 63 % of those with a significant fibrosis versus 28 % with inadequate myotomy, 25 % with failed wrap, and 100 % with mucosal stricture (p = 0.10). CONCLUSIONS: Laparoscopic reoperation with esophageal preservation is successful in the majority of patients with recurrent dysphagia after Heller myotomy. The pattern of failure has implications for relief of dysphagia with reoperative intervention.

Current trends in surgical society membership: What does the future hold?

BACKGROUND: Motivations for joining and maintaining surgical society memberships include networking, educational, and social opportunities. We hypothesized surgeons have membership lapses despite these benefits. We aimed to assess society members motivations for joining, satisfaction with membership, any lapses and if so, reasons for these lapses. METHODS: A survey was sent via email to members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), American Society for Metabolic and Bariatric Surgery (ASMBS), and the Society for Surgery of the Alimentary Tract (SSAT), using society directories. RESULTS: The majority (60%) of respondents felt satisfied with membership. However, 68% reported a lapse in membership. The most common reason for lapse was cost, followed closely by time constraints. CONCLUSION: Despite a high rate of member satisfaction, a majority of respondents had allowed a membership to lapse, with cost and time constraints being the most common reasons. Surgical societies should take these trends into account as they expand and recruit new membership.

Do One, Do One, Teach One: Altering the Dogma Using Simulation-Based Training to Maximize Efficiency of Surgical Resident Education.

BACKGROUND: Graduating surgery residents often feel unprepared to practice autonomously in the current era of surgical training. We implemented an integrated simulation curriculum to improve residents' autonomy and increase their confidence to practice independently. In this study, we chose a laparoscopic ventral hernia repair (LVHR) as our pilot operation to test proof of concept and on which we would construct our integrated curriculum. STUDY DESIGN: The curriculum included a web-based cognitive component, inanimate model simulation session with follow-up at 2 weeks and 6 months, and self-confidence questionnaires. Faculty rated each resident's procedure-specific skill by using a modified Global Operative Assessment of Laparoscopic Skills (GOALS) criteria and a task-specific checklist. RESULTS: Thirteen junior residents, 7 senior residents, and 7 faculty surgeons completed the curriculum. Four junior residents (31%) achieved proficiency at their first session, 10 (77%) after the second session (p = 0.031), and 6 (67%) at 6 months (p ≥ 0.99). Three residents regressed and did not maintain proficiency after the second assessment. Performance (GOALS) scores improved (p = 0.0313) at week 2 and were maintained at 6 months (p = 0.5625). Required faculty direction decreased (p = 0.004), and resident confidence in completing the procedure independently improved (p < 0.004) over the 6-month curriculum. CONCLUSIONS: Assessing procedure-specific and global laparoscopic skills through a simulation-based curriculum is feasible and can be used to augment resident training. Our curriculum demonstrated improvement in proficiency and self-confidence while performing an LVHR. Additional study is needed to examine the optimal way to integrate procedure-specific simulation models into training programs.

The emergency surgical airway: Bridging the gap from quality outcome to performance improvement through a novel simulation based curriculum.

BACKGROUND: Emergency surgical airway is a low frequency, high risk clinical scenario. Implementing a simulation-based curriculum may bridge the gap in surgical training and address quality assurance/performance improvement (QAPI) needs. METHODS: We designed and implemented an Advanced Surgical Airway Curriculum (ASAC) modeled after proficiency-based training. General Surgery residents and student nurse anesthetists were enrolled. Evaluation consisted of cognitive tests, procedure checklists and questionnaire. RESULTS: In total, 78 participants successfully completed the ASAC. Trainees agreed that the curriculum provided the cognitive and psychomotor skills necessary to perform both an open and needle cricothyroidotomy. CONCLUSIONS: In the age of increased patient safety concerns, QAPI initiatives can serve as a driver for simulation-based training curricula, with particular focus on individualized, active learning. This may be particularly useful in high risk, low frequency scenarios in which the traditional method of "See one, Do one, Teach one," is not feasible.

Single-incision cholecystectomy for left-sided gallbladder.

True left-sided gallbladder (sinistroposition) is a rare anatomic anomaly in which the gallbladder is found to the left of the falciform ligament, under the left lobe of the liver. Though uncommon, it is important for the surgeon to recognize this finding because the ductal anatomy is unique and the mechanics of the operation provide a technical challenge. Multiple case reports have documented safe management of sinistroposition encountered during conventional laparoscopic cholecystectomy. We present a case of sinistroposition encountered during a single-incision laparoscopic cholecystectomy. We believe that the single-site laparoscopic technique is not only a safe option but may actually provide certain benefits in approaching this difficult anatomy in the properly selected patient and the experienced single-site surgeon's hands.

Long-term efficacy of laparoscopic cholecystectomy for the treatment of biliary dyskinesia.

BACKGROUND: Laparoscopic cholecystectomy is the treatment of choice for biliary dyskinesia; however, long-term outcomes remain unclear. METHODS: A retrospective review of patients diagnosed with biliary dyskinesia and treated with laparoscopic cholecystectomy at a single institution between 2001 and 2012 was conducted. Long-term outcome data were obtained by telephonic interview using a modified Likert scale. RESULTS: Sixty-seven patients met inclusion criteria, of which 34 patients (51%) had long-term follow-up data. Mean time of follow-up was 65 (range: 6 to 134) months. Long-term follow-up demonstrated symptom response in 88% (n = 30) of patients (responders), compared to no response in 12% (n = 4) of patients (nonresponders). Responders underwent a mean of 1.56 preoperative diagnostic procedures, compared to 2.5 for nonresponders (P = .01). CONCLUSION: This represents the longest mean time of follow-up study demonstrating the success of laparoscopic cholecystectomy to improve symptoms in patients with biliary dyskinesia.