Dan Winger

A clinical prediction rule for perioperative mortality and major morbidity after laparoscopic giant paraesophageal hernia repair

OBJECTIVEnIn the current era, giant paraesophageal hernia repair by experienced minimally invasive surgeons has excellent perioperative outcomes when performed electively. However, nonelective repair is associated with significantly greater morbidity and mortality, even when performed laparoscopically. We hypothesized that clinical prediction tools using pretreatment variables could be developed that would predict patient-specific risk of postoperative morbidity and mortality.nnnMETHODSnWe assessed 980 patients who underwent giant paraesophageal hernia repair (1997-2010; 80% elective and 97% laparoscopic). We assessed the association between clinical predictor covariates, including demographics, comorbidity, and urgency of operation, and risk for in-hospital or 30-day mortality and major morbidity. By using forward stepwise logistic regression, clinical prediction models for mortality and major morbidity were developed.nnnRESULTSnUrgency of operation was a significant predictor of mortality (elective 1.1% [9/778] vs nonelective 8% [16/199]; P < .001) and major morbidity (elective 18% [143/781] vs nonelective 41% [81/199]; P < .001). The most common adverse outcomes were pulmonary complications (n = 199; 20%). A 4-covariate prediction model consisting of age 80 years or more, urgency of operation, and 2 Charlson comorbidity index variables (congestive heart failure and pulmonary disease) provided discriminatory accuracy for postoperative mortality of 88%. A 5-covariate model (sex, age by decade, urgency of operation, congestive heart failure, and pulmonary disease) for major postoperative morbidity was 68% predictive.nnnCONCLUSIONSnPredictive models using pretreatment patient characteristics can accurately predict mortality and major morbidity after giant paraesophageal hernia repair. After prospective validation, these models could provide patient-specific risk prediction, tailored for individual patient characteristics, and contribute to decision-making regarding surgical intervention.

Introduction of laparoscopic sacral colpopexy to a fellowship training program.

Introduction and hypothesisMinimally invasive sacral colpopexy has increased over the past decade, with many senior physicians adopting this new skill set. However, skill acquisition at an academic institution in the presence of postgraduate learners is not well described. This manuscript outlines the introduction of laparoscopic sacral colpopexy to an academic urogynecology service that was not performing minimally invasive sacral colpopexies, and it also defines a surgical learning curve.MethodsThe first 180 laparoscopic sacral colpopexies done by four attending urogynecologists from January 2009 to December 2011 were retrospectively analyzed. The primary outcome was operative time. Secondary outcomes included conversion to laparotomy, estimated blood loss, and intra- and postoperative complications. Linear regression was used to analyze trends in operative times. Fisher’s exact test compared surgical complications and counts of categorical variables.ResultsMean total operative time was 250u2009±u200952xa0min (range 146–452) with hysterectomy and 222u2009±u200945 (range 146–353) for sacral colpopexy alone. When compared with the first ten cases performed by each surgeon, operative times in subsequent groups decreased significantly, with a 6–16.3xa0% reduction in overall times. There was no significant difference in the rate of overall complications regardless of the number of prior procedures performed (pu2009=u20090.262).ConclusionsIntroduction of laparoscopic sacral colpopexy in a training program is safe and efficient. Reduction in operative time is similar to published learning curves in teaching and nonteaching settings. Introducing this technique does not add additional surgical risk as these skills are acquired.

Adoption of robotic sacrocolpopexy at an academic institution.

Objectives: To describe the introduction of robotic sacrocolpopexy (RSC) in a urogynecology fellowship program, including operative times and patient outcomes. Methods: Data were retrospectively extracted from all women who underwent RSC between May 1, 2009 and December 31, 2011 by a single urogynecologist with fellow and resident assistance. Patient demographics, operative times, intraoperative complications, length of hospital stay, and postoperative course were analyzed. Cases were grouped chronologically in blocks of 10 for analysis. Trend analysis of operative time was done with linear and negative binomial regression. Fishers exact test was used to compare complications among blocks. Results: Fifty-two patients (mean age 58.5 ± 8.4 years) underwent RSC. The majority (75%) had stage III prolapse. Forty-one patients (79%) had concomitant procedures, including supracervical hysterectomy (44%), bilateral salpingo-oophorectomy (9.6%), midurethral sling (9.6%), and lysis of adhesions (40.4%). There was no trend toward decreased operative time with increased surgical experience (linear regression P = .453, negative binomial regression P = .998). Mean operative time was 301.1 ± 53.1 minutes (range 205–440). Overall complication rate was not associated with number of robotic cases performed (P = .771). Nine cases (17.3%) were converted to laparotomy. Five of these occurred in the first 15 cases. There were 2 bladder injuries (3.8%) and no bowel injuries. Conclusions: Although a learning curve was not demonstrated, the adoption of RSC into a urogynecology fellowship program yields similar rates of bladder/bowel injuries, postoperative complications, and operative times when compared with other published studies.

806 Propensity Matched Analysis of Surgeon-Driven Treatment Allocation for Locoregionally Advanced Esophageal and Gastroesophageal Junction Adenocarcinoma

Introduction: There are few options available for treatment of fistulas, leaks, and perforations endoscopically. Here we describe our experience with a new endoscopic clipping system. Methods: A retrospective review of all cases using the Over-The-Scope-Clip system (Ovesco Endoscopy AG, Tuebingen, Germany) between August 2011 and November 2011. Resolution of leak was determined by a swallow study or CT scan. Results: The system was utilized in ten patients with clinically significant gastrointestinal surgical complications. Three patients were referred for treatment of gastric leaks following a sleeve gastrectomy, two had postoperative colonic leaks, two had gastro-gastric fistulas following roux-en-y gastric bypass, and three had esophageal perforations. All three gastric leaks occurred just distal to the GE junction and each had undergone previous attempts at treatment with other endoscopic methods. The average number of over the scope clips placed in these three patients was 2. In two patients there was complete resolution of the leak, one requiring a second clip placement. The third patient had a contained leak following clip placement that was followed clinically, follow up swallow study at six days showed improvement, and she was discharged home. Two patients had gastro-gastric fistulas following roux-en-y gastric bypass surgery. One of these patients had complete resolution of the fistula. The other had initial success but the clip displaced and fistula recurred. Two patients presented with anastomotic leak following colon resection. In one case the patient had extensive adhesions resulting in a rigid colon and the Ovesco system on a pediatric scope was too large to reach the fistula, so the procedure was aborted. In the second case, the leak was successfully treated with a single clip. Three patients were successfully treated for esophageal perforation. One had a 9 mm mid-esophageal perforation that required staged placement of two clips. One had two separate distal esophageal perforation sites, each requiring one clip. The final esophageal perforation was treated with a single clip. The average operative time for clip placement was 61 minutes. There were no complications. Conclusions: This over the scope endoscopic clip system is simple to use, safe, and successful in approximating tissue to treat traditionally difficult surgical complications. There is a potential for broad applications of this new technology. Further experience and longer follow up are needed to assess its indications as related to defect size and location.