Ailín C. Rogers

Meta-Analysis of Enhanced Recovery Protocols in Bariatric Surgery

BackgroundEnhanced recovery after surgery (ERAS) guidelines, fast-track protocols, and alternative clinical pathways have been widely promoted in a variety of disciplines leading to improved outcomes in post-operative morbidity and length of stay (LOS). This meta-analysis assesses the implications of standardized management protocols in bariatric surgery.MethodsThe PRISMA guidelines were adhered to. Databases were searched with the application of pre-defined inclusion and exclusion criteria. Results were reported as mean differences or pooled odds ratios (OR) with 95% confidence intervals (95% CI). Individual protocols and surgical approaches were assessed through subgroup analysis, and sensitivity analysis of methodological quality was performed.ResultsA total of 1536 studies were screened; 13 studies were eventually included for meta-analysis involving a total of 6172 patients. Standardized perioperative techniques were associated with a savings of 19.5xa0min in operative time (pxa0<u20090.01), as well as a LOS which was shortened by 1.5xa0days (pxa0<u20090.01). Pooled post-operative morbidity rates also favored enhanced recovery care protocols (OR 0.7%, 95% CI 0.6–0.9%, pxa0<u20090.01).ConclusionBariatric surgery involves a complex cohort of patients who require high-quality evidence-based care to improve outcomes. Consensus guidelines on the feasibility of ERAS and alternative clinical pathways are required in the setting of bariatric surgery.

Technical description of laparoscopic Morgagni hernia repair with primary closure and onlay composite mesh placement

IntroductionMorgagni hernias rarely present in adult life and, thus, little data exist on the optimal method of surgical repair. The laparoscopic approach has grown in popularity since the first reported case in 1992. This article showcases a method for laparoscopic repair of Morgagni hernias using both primary closure and mesh reinforcement.Operative approachThere were three obese women who presented in adulthood with cardiopulmonary symptoms; in all cases, the symptoms were attributable to local compressive effects of large Morgagni hernias. All three hernias were repaired laparoscopically, first by approximating the diaphragm to the fascia of the anterior abdominal wall, followed by insertion of a composite mesh, tacked to the diaphragm, to buttress the closure. All patients had excellent outcomes with symptom resolution.DiscussionThis case series describes a method of laparoscopic Morgagni hernia repair using primary closure reinforced with a mesh, with excellent postoperative outcomes. Others have described thoracic or open approaches. The authors feel that the method described herein is likely to reduce recurrence in a patient population who are often overweight or obese and, thus, have a high risk of this complication. Furthermore, we discuss all reported laparoscopic repair cases in the literature and highlight the paucity of evidence on the optimal approach.

Meta-analysis of the clinicopathological characteristics and peri-operative outcomes of colorectal cancer in obese patients

BACKGROUNDnThe effect of obesity on the clinicopathological characteristics of colorectal cancer (CRC) has not been clearly characterized. This meta-analysis assesses the pathological and perioperative outcomes of obese patients undergoing surgical resection for CRC.nnnMETHODSnMeta-analysis was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Databases were searched for studies reporting outcomes for obese and non-obese patients undergoing primary CRC resection, based on body-mass index measurement. Results were reported as mean differences or pooled odds ratios (OR) with 95% confidence intervals (95% CI).nnnRESULTSnA total of 2183 citations were reviewed; 29 studies comprising 56,293 patients were ultimately included in the analysis, with an obesity rate of 19.3%. Obese patients with colorectal cancer were more often female (OR 1.2, 95% CI 1.1-1.2, p<0.001) but there was no difference in the proportion of rectal cancers, T4 tumours, tumour differentiation or margin positivity. Obese patients were significantly more likely to have lymph node metastases (OR 1.2, 95% CI 1.1-1.2, p<0.001), have a lower nodal yield, were associated with a longer duration of surgery, more blood loss and conversions to open surgery (OR 2.6, 95% CI 1.6-4.0, p<0.001) but with no difference in length of stay or post-operative mortality.nnnCONCLUSIONnThis meta-analysis demonstrates that obese patients undergoing resection for CRC are more likely to have node positive disease, longer surgery and higher failure rates of minimally invasive approaches. The challenges of colorectal cancer resection in obese patients are emphasized.

A virtual outpatient department provides a satisfactory patient experience following endoscopy

PurposeThe purpose of this study was to investigate telephone follow-up of post-endoscopy patients as an alternative to attendance at the outpatient department.MethodsAccess to outpatient appointments is often a target for improvement in healthcare systems. Increased outpatient clinic capacity is not feasible without investment and extra manpower in an already constrained service. Outpatient attendance was audited at a busy colorectal surgical service. A subset of patients appropriate for follow-up in a “virtual outpatient department” (VOPD) were identified. A pilot study was designed and involved telephone follow-up of low-risk endoscopic procedures. Patient satisfaction was assessed using the Medical Interview Satisfaction Scale (MISS), which is a standardised survey of patient satisfaction with healthcare experiences. This was conducted via anonymous questionnaire at the end of the study.ResultsOf a total of 166 patients undergoing endoscopy in the time period, 79 were prospectively recruited to VOPD follow-up based on eligibility criteria. Overall, 67 (84.8xa0%) were successfully followed up by telephone consultation; nine patients (11.4xa0%) were contacted by mail. The remaining three patients (3.8xa0%) were brought back to the OPD. Patients recruited were more likely to be younger (55.82u2009±u200914.96 versus 60.78u2009±u200913.97xa0years, Pu2009=u20090.029) and to have had normal examinations (49.4 versus 31.0xa0%, χ2u2009=u20095.070, Pu2009=u20090.025). Nearly three quarters of patients responded to the questionnaire. The mean scores for all four aspects of the MISS were satisfactory, and overall patients were satisfied with the VOPD experience.ConclusionVOPD is a target for improved healthcare provision, with improved efficiency and a high patient satisfaction rate.

Meta-analysis of outcomes of endoscopic ultrasound-guided gallbladder drainage versus percutaneous cholecystostomy for the management of acute cholecystitis

BackgroundEndoscopic ultrasound-guided gallbladder drainage is a novel method of treating acute cholecystitis in patients deemed too high risk for surgery. It involves endoscopic stent placement between the gallbladder and the alimentary tract to internally drain the infection and is an alternative to percutaneous cholecystostomy (PC). This meta-analysis assesses the clinical outcomes of high-risk patients undergoing endoscopic drainage with an acute cholecystoenterostomy (ACE) compared with PC in acute cholecystitis.MethodsA literature search was performed using the preferred reporting items for systematic reviews and meta-analyses guidelines. Databases were searched for studies reporting outcomes of patients undergoing ACE or PC. Results were reported as mean differences or pooled odds ratios (OR) with 95% confidence intervals (95% CI).ResultsA total of 1593 citations were reviewed; five studies comprising 495 patients were ultimately selected for analysis. There were no differences in technical or clinical success rates between the two groups on pooled meta-analysis. ACE had significantly lower post-procedural pain scores (mean difference −u20093.0, 95% CI −u20092.3 to −u20093.6, pu2009<u20090.001, on a 10-point pain scale). There were no statistically significant differences in procedure complications between groups. Re-intervention rates were significantly higher in the PC group (OR 4.3, 95% CI 2.0–9.3, pu2009<u20090.001).ConclusionACE is a promising alternative to PC in high-risk patients with acute cholecystitis, with equivalent success rates, improved pain scores and lower re-intervention rates, without the morbidities associated with external drainage.

A study evaluating cost awareness amongst surgeons in a health service under financial strain

BACKGROUNDnDespite having considerable influence over resource allocation clinicians possess poor knowledge of healthcare costs. This study evaluated surgeons cost-awareness with regard to surgical equipment and assessed attitudes towards health economics training using survey format.nnnMATERIALS AND METHODSnAn online survey was distributed to 326 surgeons across a range of specialties in Ireland. Respondents were asked about their surgical expertise, previous training in health economics, and its role in the surgical curriculum. They were also asked to estimate the recommended retail price (RRP) of 17 commonly used items of surgical equipment. Answers within ±25% of the RRP were considered correct.nnnRESULTSnOf 140 respondents, 62 (44.3%) were on a surgical training scheme and 16 (11.4%) were consultants. Overall, surgeons correctly estimated the RRP of only 14.0% of items. There was no difference in accuracy between surgeons in later years of training compared to their junior counterparts (13.1u202f±u202f8.8% versus 15.0u202f±u202f8.8%, pu202f=u202f0.115). The highest individual score was six out of 17 items correctly estimated. Participants overestimated the cost of low-cost items by 347.7% and underestimated the cost of high-cost items by 35.5%. Only 5.7% of participants had received undergraduate training in health economics but 75.0% felt it should be included in the curriculum. Over two-thirds said their practice would change if they had better knowledge of the cost of surgical equipment.nnnCONCLUSIONnThe majority of surgeons receive little training in health economics and have poor knowledge of the cost of surgical equipment. Most would welcome more training at both an undergraduate and postgraduate level. An opportunity exists to promote cost awareness in the operating room, which could lead to a reduction in waste and improved use of resources.

Trends in the treatment of rectal prolapse: a population analysis

PurposeRectal prolapse is a common condition, with conflicting opinions on optimal surgical management. Existing literature is predominantly composed of case series, with a dearth of evidence demonstrating current, real-world practice. This study investigated recent national trends in management of rectal prolapse in the Republic of Ireland (ROI).MethodsThis population analysis used a national database to identify patients admitted in the ROI primarily for the management of rectal prolapse, as defined by the International Classification of Diseases, 10th Revision (ICD-10). Demographics, procedures, comorbidities, and outcomes were obtained for patients admitted from 2005 to 2015 inclusive.ResultsThere were 2648 admissions with a primary diagnosis of rectal prolapse; 39.3% underwent surgical correction. The majority were treated with either a perineal resection (47.2%) or an abdominal rectopexy ± resection (45.1%). The population-adjusted rate of operative intervention increased over the study period, from 25 to 42 per million (pu2009<u20090.001), with no change in the mean age of patients over time (pu2009=u20090.229). The application of a laparoscopic approach increased over time (pu2009=u20090.001). Patients undergoing an abdominal rectopexy were younger than those undergoing a perineal procedure (64.1u2009±u200917.3 versus 75.2u2009±u200915.5xa0years, pu2009<u20090.001) despite having a similar Charlson Comorbidity Index (pu2009=u20090.097). The mortality rate for elective repair was 0.2%.ConclusionsDespite the popularization of ventral mesh rectopexy over the study period, perineal resection Delorme’s procedure remains the most common procedure employed for the correction of rectal prolapse in the ROI, with specific approach determined by age.

Media messaging in diagnosis of acute CXR pathology: an interobserver study among residents

The objectives of the study were to determine whether diagnostic accuracy and reliability by on-call teams is affected by communicating chest radiograph (CXR) images via instant messaging on smartphones in comparison to viewing on a workstation. 12 residents viewed 100 CXR images each with a 24% positive rate for significant or acute findings sent to their phones via a popular instant messaging application and reported their findings if any. After an interval of 42xa0days they viewed the original DICOM images on personal computers and again reported their findings. There were no statistically significant differences in accuracy, agreement, sensitivity, specificity, positive predictive value or negative predictive value between desktop workstation viewed images and images sent via the mobile application. Media messaging is a useful adjunct for quick second opinions on radiological images, without significant decay in diagnostic accuracy. If technical, ethical and legal issues are addressed, it could be incorporated into practice as a useful adjunct.

Reply to comment to: ‘Technical description of laparoscopic Morgagni hernia repair with primary closure and onlay composite mesh placement.’

Introduction Morgagni hernias rarely present in adult life and, thus, little data exist on the optimal method of surgical repair. The laparoscopic approach has grown in popularity since the first reported case in 1992. This article showcases a method for laparoscopic repair of Morgagni hernias using both primary closure and mesh reinforcement. Operative approach There were three obese women who presented in adulthood with cardiopulmonary symptoms; in all cases, the symptoms were attributable to local compressive effects of large Morgagni hernias. All three hernias were repaired laparoscopically, first by approximating the diaphragm to the fascia of the anterior abdominal wall, followed by insertion of a composite mesh, tacked to the diaphragm, to buttress the closure. All patients had excellent outcomes with symptom resolution. Discussion This case series describes a method of laparoscopic Morgagni hernia repair using primary closure reinforced with a mesh, with excellent postoperative outcomes. Others have described thoracic or open approaches. The authors feel that the method described herein is likely to reduce recurrence in a patient population who are often overweight or obese and, thus, have a high risk of this complication. Furthermore, we discuss all reported laparoscopic repair cases in the literature and highlight the paucity of evidence on the optimal approach.

Emergency surgery in octogenarians: Outcomes and factors affecting mortality in the general hospital setting: Emergency surgery in extremes of age

The Western world has an expanding older population, who are living longer with increasing numbers of comorbidities. In addition, expectations of patients and relatives are increasing. As a general hospital operating in a rural setting, our University Hospital Kerry, Tralee, Ireland, deals with a significant number of emergency presentations to the acute surgical service. The aim of the present study was to examine outcomes for patients in the extremes of age who present requiring emergency surgical procedures.