Ashkan Moazzez

Laparoscopic versus open anterior abdominal wall hernia repair: 30-day morbidity and mortality using the ACS-NSQIP database.

Objective:To compare short-term outcomes after laparoscopic and open abdominal wall hernia repair. Methods:Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2005–2009), 71,054 patients who underwent an abdominal wall hernia repair were identified (17% laparoscopic, 83% open). Laparoscopic and open techniques were compared. Regression models and nonparametric 1:1 matching algorithms were used to minimize the influence of treatment selection bias. The association between surgical approach and risk-adjusted adverse event rates after abdominal wall hernia repair was determined. Subgroup analysis was performed between inpatient/outpatient surgery, strangulated/reducible, and initial/recurrent hernias as well as between umbilical, incisional and other ventral hernias. Results:Patients undergoing laparoscopic repair were less likely to experience an overall morbidity (6.0% vs. 3.8%; odds ratio [OR], 0.62; 95% confidence interval [CI], 0.56–0.68) or a serious morbidity (2.5% vs. 1.6%; OR, 0.61; 95% CI, 0.52–0.71) compared to open repair. Analysis using multivariate adjustment and patient matching showed similar findings. Mortality rates were the same. Laparoscopically repaired strangulated and recurrent hernias, had a significantly lower overall morbidity (4.7% vs. 8.1%, P < 0.0001 and 4.1% vs. 12.2%, P < 0.0001, respectively). Significantly lower overall morbidity was also noted for the laparoscopic approach when the hernias were categorized into umbilical (1.9% vs. 3.0%, P = 0.009), ventral (3.9% vs. 6.3%, P < 0.0001), and incisional (4.3% vs. 9.1%, P < 0.0001). No differences were noted between laparoscopic and open repairs in patients undergoing outpatient surgery, when the hernias were reducible. Conclusion:Laparoscopic hernia repair is infrequently used and associated with lower 30-day morbidity, particularly when hernias are complicated.

Laparoscopic vs Open Appendectomy in Obese Patients: Outcomes Using the American College of Surgeons National Surgical Quality Improvement Program Database

BACKGROUND Although open and laparoscopic appendectomies are comparable operations in terms of outcomes, it is unknown whether this is true in the obese patient. Our objective was to compare short-term outcomes in obese patients after laparoscopic vs open appendectomy. STUDY DESIGN Using the American College of Surgeons National Surgical Quality Improvement Program database (2005-2009), 13,330 obese patients (body mass index ≥ 30) who underwent an appendectomy were identified (78% laparoscopic, 22% open). The association between surgical approach (laparoscopic vs open) and outcomes was first evaluated using multivariable logistic regression. Next, to minimize the influence of treatment selection bias, we created a 1:1 matched cohort using all 41 of the preoperative covariates in the National Surgical Quality Improvement Program database. Reanalysis was then performed with the unmatched patients excluded. Main outcomes measures included patient morbidity and mortality, operating room return, operative times, and hospital length of stay. RESULTS Laparoscopic appendectomy was associated with a 57% reduction in overall morbidity in all the obese patients after the multivariable risk-adjusted analysis (odds ratio = 0.43; 95% CI, 0.36-0.52; p < 0.0001), and a 53% reduction in risk in the matched cohort analysis (odds ratio = 0.47; 95% CI, 0.32-0.65; p < 0.0001). Mortality rates were the same. In the matched cohort, length of stay was 1.2 days shorter for obese patients undergoing laparoscopic appendectomy compared with open appendectomy (mean difference 1.2 days; 95% CI, 0.98-1.42). CONCLUSIONS In obese patients, laparoscopic appendectomy had superior clinical outcomes compared with open appendectomy after accounting for preoperative risk factors.

Laparoscopic appendectomy: new concepts.

Over the last three decades more surgeons have used laparoscopic appendectomy as their surgical approach of choice in the management of patients with appendicitis. This includes special groups of patients, namely, pediatric, pregnant, and obese patients. Laparoscopy has the benefit of lower morbidity, decreased rate of wound complications, faster recovery, shorter length of hospital stay, and faster return to work over open appendectomy.

Percutaneous cholecystostomy versus laparoscopic cholecystectomy in patients with acute cholecystitis and failed conservative management: a matched-pair analysis.

Introduction: The role of percutaneous cholecystostomy (PC) or laparoscopic cholecystectomy (LC) in the management of patients with acute cholecystitis presenting beyond 72 hours from the onset of symptoms is unclear and undefined. The aim of this study was to examine and compare the outcomes of PC or LC in the management of these patients, who failed 24 hours of initial nonoperative management. Patients and Methods: A retrospective chart review between January 1999 and October 2010 revealed 261 patients with acute calculus cholecystitis beyond 72 hours from onset of symptoms who failed initial nonoperative management. Twenty-three of 261 (8.8%) underwent PC and were compared with a similar 1:1 matched cohort of LC, matched using sex, age, race, BMI, diabetes, and sepsis to minimize the influence of treatment selection bias. Results: There was no significant difference between PC versus LC regarding morbidity [4/23 (17%) vs. 2/23 (9%), P=0.665] and mortality [3/23 (13%) vs. 0/23 (0%), P=0.233]. The length of hospital stay was significantly longer in the PC group (15.9±12.6 vs. 7.6±4.9 d, P=0.005). Conclusion: In this matched cohort analysis, PC failed to show a significant reduction in morbidity compared with LC and was associated with a significantly longer hospital stay.

A new and standardized approach for trocar placement in laparoscopic Roux-en-Y gastric bypass

IntroductionSuper-morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) present unique technical challenges. In our experience the ease of the operation and the operative time seem to be more dependent on body habitus than body mass index (BMI). We hypothesized that the distance between the xyphoid process and the umbilicus (the XU distance) correlated with surgical difficulty and described an original modification of trocar placement based on this measurement to improve the ease of the operation.MethodsSeven hundred and seventy-four patients underwent LRYGB, and the XU distance was measured in a subset of 38 patients midway through the experience. The need for additional trocars was assessed intraoperatively and the relationship between the XU distance and the need for extra trocars was subsequently analyzed. A standardized approach for trocar placement was implemented in the second half of our series. The operative time was compared between the standardized and nonstandardized groups.ResultsFifty percent of the patients required a five-trocar technique. Median XU distance in this group was 21.4 cm (range 17–25 cm). In the remaining 19 patients additional trocars were added; median XU distance was 27.3 cm (range 24–33 cm). From the 774 patients included in the study period, the operative time for the first 322 patients who were completed with a nonstandardized trocar approach was significantly longer than the subsequent 452 cases in which the standardized trocar approach was used (210 versus 173 min, p < 0.001).ConclusionsWe define XU distance as the key element in determining the choice of trocar placement. When XU distance is less then 25 cm, the basic approach should be used and if it is greater than 25 cm, the advanced trocar approach is recommended. This standardized technique leads to decreased operative time and improved ease of operation.

Establishing an acute care surgery service: lessons learned from the epidemiology of emergent non-trauma patients and increasing utilization of laparoscopy.

BACKGROUND Acute care surgery is a fellowship training model created to address the growing crisis in emergency healthcare due to decreased availability of on-call surgeons and reduction in operative procedures for trauma. Our objective was to identify the demographics and spectrum of diseases in patients presenting with non-trauma surgical emergencies and the use of laparoscopy in emergent surgery in light of implementing an acute care surgery model. METHODS All non-trauma emergency surgical consultations at a large urban academic medical center from January 2005 to December 2008 were retrospectively reviewed. A clinician-completed registry was used to obtain patient information. Diagnoses were categorized into five broad groups for statistical analysis. RESULTS Median age was 41 years (range, 6 weeks to 97 years), 50% were men, and the majority (67%) was Hispanic. The most common disease category was infectious followed by hepatobiliary. Prevalence of disease categories differed significantly among various racial groups. Majority (86%) of consult patients required admission. Thirty-eight percent of the consults resulted in an operative procedure, 40% of which were laparoscopic. The percentage of laparoscopic procedures increased during the 4-year study period. CONCLUSION Patients with non-trauma surgical emergencies are young with a significantly wide range of diseases based on race. Less than half require emergent surgery. Laparoscopy is prevalent in emergency surgery and growing. Resources should be allocated to maximize the ability to treat infectious and hepatobiliary diseases, and to increase utilization of laparoscopy. The acute care surgeon needs to be proficient in laparoscopy.

Argon beam coagulation versus fibrin sealant for hemostasis following liver resection: a randomized study in a porcine model.

BACKGROUND/AIMS Bleeding from the raw liver surface represents a significant surgical complication after elective liver resection or hepatic trauma. The application of argon beam coagulation (ABC) has been proposed to improve hemostasis, but is associated with significant necrosis of the liver parenchyma. Topical hemostatic agents, i.e. fibrin sealant (FS), have also been recommended, yet the optimal management is under debate. This study compares the efficacy and safety of both methods following liver resection in an animal model. METHODOLOGY Twenty pigs underwent liver resection, and were then randomized into ABC or FS group for treatment of raw liver surfaces. Intraoperative and postoperative parameters were studied. Animals were sacrificed at day 12, and extent of necrosis was assessed using a scoring system and morphometry. RESULTS Intraoperative parameters did not show any significant difference between two groups except for shorter time of application in the FS group. Postoperatively, animals in the FS group showed significantly higher hemoglobin levels (p=0.0001). Histologically, FS showed a smaller depth of necrosis than ABC (p=0.022). CONCLUSIONS The use of FS is superior to ABC for management of the raw liver surface after liver resection, in terms of application time, postoperative bleeding and the extent of liver tissue necrosis.