Affan Umer

Surgical Value of Elective Minimally Invasive Gallbladder Removal: A Cost Analysis of Traditional 4-Port vs Single-Incision and Robotically Assisted Cholecystectomy

BACKGROUND As the cost of health care is subjected to increasingly greater scrutiny, the assessment of new technologies must include the surgical value (SV) of the procedure. Surgical value is defined as outcome divided by cost. STUDY DESIGN The cost and outcome of 50 consecutive traditional (4-port) laparoscopic cholecystectomies (TLC) were compared with 50 consecutive, nontraditional laparoscopic cholecystectomies (NTLC), between October 2012 and February 2014. The NTLC included SILS (n = 11), and robotically assisted single-incision cholecystectomies (ROBOSILS; n = 39). Our primary outcomes included minimally invasive gallbladder removal and same-day discharge. Thirty-day emergency department visits or readmissions were evaluated as a secondary outcome. The direct variable surgeon costs (DVSC) were distilled from our hospital cost accounting system and calculated on a per-case, per item basis. RESULTS The average DVSC for TLC was

Role of Microcirculatory Disturbances and Diabetic Autonomic Neuropathy in Takotsubo Cardiomyopathy.

929 and was significantly lower than NTLC at

Commentary: Robotic vs. standard laparoscopic technique - what is better?

2,344 (p < 0.05), SILS at

Role of Pericardiectomy in Postcardiac Transplant Constrictive Pericarditis

1,407 (p < 0.05), and ROBOSILS at

Autoimmune Polyglandular Syndrome Type 2 Complicated by Acute Adrenal Crisis and Pericardial Tamponade in the Setting of Normal Thyroid Function

2,608 (p < 0.05). All patients achieved the same primary outcomes: minimally invasive gallbladder removal and same day discharge. There were no differences observed in secondary outcomes in 30-day emergency department visits (TLC [2%] vs NTLC [6%], p = 0.61) or readmissions (TLC [4%] vs NTLC [2%], p > 0.05), respectively. The relative SV was significantly higher for TLC (1) compared with NTLC (0.34) (p < 0.05), and SILS (0.66) and ROBOSILS (0.36) (p < 0.05). CONCLUSIONS Nontraditional, minimally invasive gallbladder removal (SILS and ROBOSILS) offers significantly less surgical value for elective, outpatient gallbladder removal.

Constrictive pericarditis complicating cardiac transplantation

To the Editor: We read with great interest the article by Boland et al (1) in the recent issue of Critical Care Medicine, which gives a comprehensive review on the pathophysiology of Takotsubo cardiomyopathy (TC). However, we wanted to highlight a few important points relevant to the article. There is compelling evidence to suggest that abnormalities of coronary blood flow exist during the acute phase and followup period of TC when measured using noninvasive techniques, such as Doppler guidewire, Thrombolysis In Myocardial Infarction (TIMI) frame count (TFC), and TIMI myocardial perfusion grade calculation (2–5). These strategies provide angiographic evidence that impaired myocardial perfusion due to abnormal microvascular blood flow may play a pivotal role in the evolution of TC (2–5). TFC is a novel method described by Gibson et al (6) to analyze the coronary flow reserve and is calculated by counting the number of frames required for contrast material to travel from the coronary ostium to the standardized distal landmark. Corrected TIMI frame counts (CTFC) are used for the left anterior descending artery (LAD) to adjust for its longer length compared with the other vessels viz. the right coronary artery (RCA) and the left circumflex artery (LCX) (6). We recently performed a retrospective comparison of TFCs in three coronary arteries in 16 patients with TC and 15 patients without coronary artery disease (controls). Our results showed no difference in TFC in RCA and LCX branches in the two subgroups; however, patients with TC had higher CTFC in the LAD by a mean value of 3 frames (p = 0.04) when compared with controls (2, 3). This is in contrast to the previous similar studies, which demonstrate abnormal TFC in all three coronary vessels (not LAD alone) depicting diffuse or multivessel coronary spasm in the acute phase alone or both the acute and recovery phase (2, 3). Three important conclusions from our studies are as follows: 1) CTFC may be abnormal in patients with TC in the LAD territory, suggesting disturbances in endothelial or microvascular function. 2) The preferential distribution of CTFC abnormality in the LAD region may possibly explain why apex is mostly affected in the apical ballooning syndrome; however, the exact reason for this regional ventricular involvement is unclear. 3) Only 1 of 16 of the patients with TC (6.25%) had diabetes mellitus, which is consistent with the reported low prevalence of diabetes reported in patients with TC (2, 3, 7). This may suggest that the blunted autonomic responses or catecholamine secretions in patients with diabetic neuropathy may be protective against the development of TC in the background of stressful triggers (2, 3, 7). Furthermore, as authors’ rightly pointed out, sympathetic blockade as an effective treatment strategy and absence of cardiac dysfunction in animal models after sympathectomy further support this hypothesis (1). In conclusion, disturbances in microcirculation or endothelial function may play an important role in the evolution of Takotsubo syndrome. Alteration of autonomic nervous system in conditions like diabetic neuropathy may result in decreased sympathetic tone or gain of the hypothalamic-pituitary-axis, which could have potential protective effects in patients with TC. The authors have disclosed that they do not have any potential conflicts of interest.

Commentary: How Long Do We Need to Follow-Up Our Hernia Patients to Find the Real Recurrence Rate?

We read with great interest the recently published article by Ferdinand Kockerling in Frontiers in Surgery (1). The author has provided expert insight into the role of robotic surgery in common abdominal, bariatric, colorectal, and oncologic procedures. The robotic approach allows superiority over the traditional laparoscopic abdominal surgery in terms of a three-dimensional high definition view, seven degrees of freedom of motion, intuitive movements, tremor filtering, and other advantages due to its inherent design (2). Experienced surgeons claim comparable or better outcomes for patients undergoing robotic surgery. We had recently compared the surgical value, which is defined as the outcome of the procedure divided by the cost to achieve that outcome, of traditional laparoscopic cholecystectomy to the robotic approach. Our outcomes were comparable to national standards in terms of complications, length of stay and readmissions but we became granular with the procedure cost wherein we accounted for supplies, equipment, per use or annual contract costs, and for the operating room (OR) time. Our calculations clearly showed a lower surgical value for the robotic approach. Similarly, concerns for a higher cost have been described for pancreatic surgery (3), colorectal surgery (4), and bariatric surgery (5). Some studies claim a lesser cumulative cost due to a reduction in the hospital length of stay, but at the same time the question arises that how is this reduction in length of stay being achieved if both the laparoscopic and robotic procedures are near similar. Waters et al. (3) reported a shorter average length of stay in their robotic distal pancreatic cohort but that was because of outliers in the laparoscopic group which stayed in excess of 3 weeks. Similarly, the literature is abundant with studies vouching for comparable outcomes but they are plagued with a selection bias for patients with favorable anatomy or a lesser acuity of the disease. This just highlights the dire need to shift from observational data and move toward prospective randomized trials. Robotic surgery is going through a phase of exponential growth (6). Salisbury et al. (7) commented that structured cross pollination between surgeons and engineers will bridge current deficiencies in robotics. Critical access hospitals may continue to stall on investing due to technology costs, but if this evolution in robotics leads to improved outcomes that argument will be very hard to hold onto. Future improvements expected in robotics aim to miniaturize the console and reduce OR set-up times. These improvements will also include tactile and force sensors to address the lack of haptic feedback. Other advancements are likely to include motion and force scaling for greater precision, and the ability to establish virtual operative boundaries to avoid damaging vital structures. With an industry geared and motivated to redefining surgical norms, my biggest concern is that general surgeons will fall behind the curve and be forced to play catch up. It is critical that adequate education and training keep pace with technology, so the next generation is prepared to recognize and take advantage of the opportunities robotics may provide. The robotics era is currently catering to the demand for increased patient autonomy but the question remains whether there is sufficient value for critical access hospitals to invest resources in a technology still in its infancy. Training and credentialing remains a big concern and so is the steep learning curve which can potentially introduce a risk for serious injury to patients. This may be part of the reason why penetrance of the robotic approach in visceral surgery has been slow and there has been negligible integration in residency curriculums to introduce the skill early in the surgical career of trainees. Having done this meticulous review, we would like to know the authors view on the future of robotic surgery. We do not think there is evidence in these observational studies that robotic surgery provides enough surgical value. That, however, may change with new innovations in the field. Is it possible that traditional laparoscopic surgeons are resisting the tide of change the same way general surgeons were when laparoscopy was first introduced?

Are You Capable of Providing High Quality Care

Vistarini and colleagues’ [1] recent work published in The Annals of Thoracic Surgery is of great interest. Their retrospective analysis spanning 2 decades provides valuable insight into the role of pericardiectomy for constrictive pericarditis (CP). CP is debilitating and eventually fatal if left untreated. Pericardiectomy offers the best chance for hemodynamic recovery in CP. Wewonder if the authors encountered any patients in whomCP had developed after cardiac transplantation. Constrictive pericarditis after cardiac transplantation evolved as a controversial issue because patients who undergo cardiac transplantation are free of most of the pericardial tissue. In recent years, it has been recognized as a real phenomenon and has gained more attention, especially in institutions with heart transplantation programs [2]. The underlying cause is attributed to insult to the residual pericardial tissue from pericardial effusion, hematoma, or mediastinitis [3]. Unfortunately, the data on how to treat CP after transplantation are very meager. Isolated cases have been successfully treated with pericardiectomy [3]. A case series describing 5 patients with noninfectious CP after transplantation advocated for its effectiveness in improving survival, especially if used in a timely manner [2]. In our experience, resorting to pericardiectomy for CP is often feared immediately after transplantation, but it has rarely been performed with success. We would greatly appreciate if the authors could provide separate data on such patients and share their experience. Vistarini and colleagues [1] reported that surgical treatment within 6 months of onset of symptoms is associated with reduced hospital mortality. This is an interesting finding because it somewhat favors the approach of an early intervention. Did the authors in their study find additional benefit of performing an earlier pericardiectomy (<3 months from onset of symptoms)? Future prospective controlled investigations would be able to shed more light on these issues and strengthen our understanding on this subject.

Healthcare-Associated Infections in Surgical Practice

We describe herein a 48-year-old Caucasian woman with a history of autoimmune polyglandular syndrome type 2 who presented with pericarditis, pericardial effusion, and pericardial tamponade preceded by acute adrenal crisis in the setting of normal thyroid function. The case highlights the importance of a rare yet important complication of autoimmune polyglandular syndrome type 2 that mandates early recognition and intervention.

Important Treatment Modalities for Symptomatic Malignant Pericardial Effusions

Constrictive pericarditis is a disease characterized by progressive pericardial fibrosis. If left untreated it can lead to progressive heart failure and can be severely disabling. Medical management with non-steroidal anti-inflammatory drugs in combination with colchicine is promising in the acute phase of the disease but for more chronic cases pericardiectomy offers the best chance for hemodynamic recovery. Constrictive pericarditis after cardiac transplantation is a rare phenomenon. Current literature suggests that early pericardiectomy may be the most effective treatment in this subset of patients as well.