B. Todd Heniford

Long-term Outcomes of Laparoscopic Resection of Gastric Gastrointestinal Stromal Tumors

Objective:Gastric gastrointestinal stromal tumors (GISTs) are rare neoplasms that require excision for cure. Although the feasibility of minimally invasive resection of gastric GIST has been established, the long-term safety and efficacy of these techniques are unclear. We hypothesized that complete resection of gastric GISTs using a combination of laparoscopic or laparoendoscopic techniques results in low perioperative morbidity and an effective long-term control of the disease. Methods:Between August 1996 and June 2005, 50 consecutive patients undergoing laparoscopic or laparoendoscopic resection of gastric GISTs were identified in a prospectively collected database. Outcome measures included patient demographics and outcomes, operative findings, morbidity, and histopathologic characteristics of the tumor. Patient and tumor characteristics were analyzed to identify risk factors for tumor recurrence. Results:Fifty patients, mean age 60 years (range, 34–84 years), underwent 47 local and 3 segmental laparoscopic gastric resections. GI bleeding and dyspepsia were the most common symptoms. Mean tumor size was 4.4 cm (range, 1.0–8.5 cm) with the majority of the lesions located in the proximal stomach. Mean operative time was 135 minutes (range, 49–295 minutes), the mean blood loss was 85 mL (range, 10–450 mL), and the mean length of hospitalization was 3.8 days (range 1–10 days). There were no major perioperative complications or mortalities. All lesions had negative resection margins (range, 2–45 mm). Nine patients had 10 or more mitotic figures per 50 high power fields, while 11 had ulceration and/or necrosis of the lesion. At a mean follow-up of 36 months, 46 (92%) patients were disease free, 1 patient was alive with disease, 1 patient with metastases died of a cardiac event, and 2 (4%) patients died of metastatic disease. No local or port site recurrences have been identified. Patient age, tumor size, mitotic index, tumor ulceration, and necrosis were statistically associated with tumor recurrence. The presence of 10 or more mitotic figures per 50 high power fields was an independent predictor of disease progression (P = 0.006). Conclusion:A laparoscopic approach to surgical resection of gastric GIST is associated with low morbidity and short hospitalization. As found in historical series of open operative resection, the tumor mitotic index predicts local recurrence. The long-term disease-free survival of 92% in our study establishes laparoscopic resection as safe and effective in treating gastric GISTs. Given these findings as well as the advantages afforded by minimally invasive surgery, a laparoscopic approach may be the preferred resection technique in most patients with small- and medium-sized gastric GISTs.

The burden of Clostridium difficile in surgical patients in the United States.

BACKGROUNDnClostridium difficile colitis is the predominant hospital-acquired gastrointestinal infection in the United States and has emerged as an important nosocomial cause of morbidity and death. Although several institutional studies have examined the effects of C. difficile on hospitalized patients, its nationwide impact on surgical patients has yet to be defined.nnnMETHODSnTo provide a national estimate of the burden of C. difficile, we performed a five-year retrospective analysis of the Agency for Healthcare Research and Qualitys National Inpatient Sample Database, which represents a stratified 20% sample of hospitals in the United States, from 1999 to 2003. All surgical inpatient discharge data from 997 hospitals in 37 states were analyzed to determine the association of C. difficile infections with patient demographics, hospital characteristics, surgical procedure, length of stay (LOS), total charges, and in-hospital mortality rate. Univariate analysis was performed to identify any association between the presence of C. difficile infection and the outcome variables using chi-square contingency table analysis or the Student t-test following the exclusion of patients with other medical complications. Multivariate regression analysis was used to determine whether the presence of C. difficile infection was an independent predictor of increased LOS, total charges, and in-hospital mortality rate when controlling for surgery type, age, sex, payor, and hospital characteristics.nnnRESULTSnClostridium difficile infection was reported as a discharge diagnosis for 8,113 (0.52%) of all 1,553,597 inpatients who had undergone a general surgical procedure. The incidence increased significantly in 2002 (34% higher than in 2001; p < 0.0001). The following patient and hospital characteristics were associated with the highest incidence of C. difficile infection (all p < 0.0001): Age > 64 years (0.95%); Medicare beneficiary status (0.94%); north-eastern hospital location (0.73%); and large (0.55%), urban (0.56%), or teaching hospital (0.61%). Patients undergoing an emergency operation were at higher risk than those having operations performed electively (0.8% vs. 0.3%; p < 0.0001). Colectomy, small-bowel resection, and gastric resection were associated with the highest risk of C. difficile infection (incidence after colectomy 1.11%; odds ratio [OR] 2.77, 95% confidence interval [CI] 2.65, 2.89, p < 0.0001; small-bowel resection 1.17%, OR 2.40, 95% CI 2.26, 2.54, p < 0.0001; gastric resection 1.02%, OR 2.26, 95% CI 2.03, 2.52, p < 0.0001). Patients undergoing cholecystectomy and appendectomy had the lowest risk of C. difficile infection (cholecystectomy 0.41%, OR 0.37, 95% CI 0.35, 0.39, p < 0.0001; appendectomy 0.20%, OR 0.45, 95% CI 0.42, 0.49, p < 0.0001). Multivariable analysis demonstrated that C. difficile was an independent predictor of LOS, which increased by 16.0 days (95% CI 15.6, 16.4 days; p < 0.0001) in the presence of infection. Total charges increased by

The Formula for a Successful Laparoscopic Skills Curriculum

77,483 (95% CI

The Role of Thoracoscopy in the Management of Retained Thoracic Collections After Trauma

75,174,

Prospective, Long-Term Comparison of Quality of Life in Laparoscopic Versus Open Ventral Hernia Repair

79,793; p < 0.0001), and there was a 3.4-fold increase in the mortality rate (95% CI 3.02, 3.77; p < 0.0001) compared with patients who did not acquire C. difficile.nnnCONCLUSIONSnEpidemiologic data suggest that the incidence of C. difficile infection is increasing in U.S. surgical patients and that the infection is most prevalent after emergency operations and among patients having intestinal tract resections. Infection with C. difficile is an independent predictor of increased LOS, total charges, and mortality rate after surgery and represents a considerable burden to both patients and hospitals. Preventing C. difficile infection offers a potentially significant improvement in patient outcomes, as well as a reduction in hospital costs and resource expenditures.

Comparing quality-of-life outcomes in symptomatic patients undergoing laparoscopic or open ventral hernia repair.

Although multiple simulators have been validated as effective training tools, curriculum development is lagging, and considerable work is needed to determine the best methods for training. This article identifies the factors that influence the successful incorporation of simulator training into the resident curriculum, reviews the evidence regarding laparoscopic curriculum development in the surgical literature, and provides a formula for effective curriculum design. A successful laparoscopic skills curriculum depends on many factors including participant motivation, available resources and personnel, and trainee and faculty commitment. It should encompass goal-oriented training, sensitive and objective performance metrics, appropriate methods of instruction and feedback, deliberate, distributed, and variable practice, an amount of overtraining, maintenance training, and a cognitive component. A curriculum that follows these principles is likely to spark trainee interest, ensure their satisfaction and participation in training sessions, and lead to an effective and efficient way of acquiring new skills using simulators. A skills curriculum is a dynamic process that should be tailored to individual needs and be continuously optimized based on accumulated evidence and experience.

Traumatic retropharyngeal hematoma—A cause of acute airway obstruction

BACKGROUNDnRetained hemothorax and infected thoracic collections after trauma can be seen in up to 20% of patients initially treated with tube thoracostomy and have traditionally been treated nonoperatively, often with prolonged hospital stays.nnnMETHODSnTwenty-five patients with retained thoracic collections were reviewed. They underwent 26 thoracoscopies to evacuate undrained blood with or without infection.nnnRESULTSnIn 19 patients (76%), the collections were evacuated thoracoscopically. In 4 patients the procedure was converted to an open thoracotomy, and 2 patients required additional procedures to drain these collections. Failure of thoracoscopy correlated with the time between injury and operation and the type of collection, but not with the mechanism of injury. When thoracoscopy was performed in less than 7 days after admission, no cases of empyema were noted at operation.nnnCONCLUSIONSnVideothoracoscopy is an accurate, safe, and reliable operative therapy to evacuate retained thoracic collections. In 90% of the patients in whom the procedure was completed, good results were obtained, reducing hospital stay and possible complications. Videothoracoscopy should be the initial treatment in trauma patients with retained thoracic collections and should be used earlier and more frequently in these patients.

Comparative study of wound complications: Isolated panniculectomy versus panniculectomy combined with ventral hernia repair

Objectives:To compare laparoscopic ventral hernia repair (LVHR) versus open ventral hernia repair (OVHR) for quality of life (QOL), complications, and recurrence in a large, prospective, multinational study. Introduction:As recurrence rates have decreased for LVHR and OVHR, QOL has become an extremely important differentiating outcomes measure. Methods:A prospective, international database was queried from September 2007 to July 2011 for LVHR and OVHR. Carolinas Comfort Scale (CCS) was utilized to quantify QOL (pain, movement limitation, and mesh sensation) preoperatively and at 1, 6, and 12 months postoperatively. Results:A total of 710 repairs included 402 OVHR and 308 LVHR. Demographics were mean age 57.1 ± 13.3 years, 49.6% male, 21.7% recurrent hernias, mean body mass index of 30.3 ± 6.6, and mean defect size of 89.4 ± 130.8. Preoperatively, 56.9% had pain, and 53.2% experienced movement limitation. At 1-month follow-up, 587 (82.7%) patients were provided CCS scores; more LVHR patients experienced pain (P < 0.001) and movement limitations (P < 0.001). At 6 and 12 months, there were no differences in QOL with 466 (65.6%) and 478 (67.3%) patients responding, respectively. After controlling for confounding variables, LVHR was independently associated with more frequent discomfort [odds ratio (OR) = 1.9, confidence interval (CI): 1.2–3.1], movement limitation (OR = 1.6, CI: 1.0–2.7), and overall symptoms (OR = 1.6, CI: 1.0–2.6) at 1 month. LVHR resulted in a shorter length of stay (LOS) (P < 0.001) and fewer infections (P = 0.004), but overall complication rates were equal. Recurrence rates were also equal (P = 0.66). Conclusion:In the largest, prospective QOL study comparing LVHR and OVHR, LVHR is associated with a decrease in QOL in the short term. LOS and infection rates are decreased in LVHR, but overall complication and recurrence rates are equal.

Basic Instrumentation for Laparoscopic Surgery

BACKGROUNDnThe aim of this study was to compare quality-of-life outcomes in patients with symptomatic hernias who were undergoing laparoscopic and open repairs.nnnMATERIALS AND METHODSnClinical data for patients undergoing ventral hernia repair were reviewed with quality-of-life surveys administered before and at least 6 months following surgery.nnnRESULTSnThe study included 56 symptomatic patients. Forty-one patients (73%) underwent laparoscopic repair, and 15 patients (27%) underwent open repair. There was no difference in preoperative quality-of-life scores on the SF-36 Health Survey between patients having laparoscopic or open repairs. Postoperative quality-of-life scores on the SF-36 survey were significantly improved in the laparoscopic group, compared with the open group, in general health (46% vs. 37%; P=0.0217), vitality (53% vs. 45%; P=0.0491), role-emotional (45% vs. 35%; P=0.0480), and mental health (49% vs. 39%; P=0.0381). Postoperative quality-of-life scores on the Carolinas Comfort Scale (CCS) were significantly improved in the laparoscopic group, compared with the open group, in bending over (3.15 vs. 5.87, P=0.0158), sitting up (2.51 vs. 5.13; P=0.0211), activities of daily living (2.48 vs. 5.75; P=0.0139), coughing or deep breathing (2.95 vs. 5.75; P=0.0314), walking (2.36 vs. 4.62; P=0.0427), exercising (3.19 vs. 6.14; P=0.0222), and total comfort scale (17.62 vs. 40.23; P=0.0084).nnnCONCLUSIONSnLaparoscopic ventral hernia repair provides improved quality-of-life, compared with open repair, 6 months postoperatively. Nearly all physical variables measured by the CCS were significantly better when ventral hernias were repaired laparoscopically.

Impact of common crystalloid solutions on resuscitation markers following Class I hemorrhage: A randomized control trial.

Blunt trauma causing a retropharyngeal hematoma without an associated cervical fracture is a relatively rare occurrence. This article presents the case of a patient with airway compromise from a retropharyngeal hematoma, and discusses the diagnosis, airway management, and treatment of this condition.