Erica D. Kane

Quantifying and exploring the recent national increase in surgical stabilization of rib fractures

BACKGROUND Surgical stabilization of rib fractures (SSRF) has become pivotal in the management of severe chest injuries. Recent literature supports improved outcomes and mortality in severe fracture and flail chest patients who undergo SSRF compared with nonoperative management (NOM). A 2014 National Trauma Data Bank review provided a point prevalence of 0.7% SSRF in flail patients. We hypothesize that this prevalence is increasing and that temporal, regional, and American College of Surgeons (ACS) trauma designation vary in SSRF utilization. METHODS Retrospective National Trauma Data Bank data were extracted for years 2007 to 2014 for patients with rib fractures. Cases were divided into SSRF versus NOM. SSRF frequencies were analyzed across year, region, and ACS level. Patient demographics, injury severity score, number of fractured ribs, and hospital characteristics were identified for multivariable analysis. RESULTS Between 2007 and 2014, 687,137 rib fracture patients were identified; 29,981 (4.36%) underwent SSRF. SSRF increased by 76% nationally during the review period (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.50–1.67; p < 0.001). Compared with the north, SSRF was used more in the west (OR, 1.6; 95% CI, 1.57–1.71), south (OR, 1.48; 95% CI, 1.43–1.54), then midwest (OR, 1.4; 95% CI, 1.34–1.46; p < 0.001). Although likelihood of SSRF is higher at ACS Level I (LI) centers compared with Level II (LII) centers (OR, 0.67; 95% CI, 0.65–0.69) or Level III (LIII) (OR, 0.24; 95% CI, 0.22–0.26); p < 0.001), frequency of SSRF increased dramatically at lower-level centers from 2007 to 2014 (LI, 41.4%; LII, 53.6%; LIII, 60.0%). Overall SSRF mortality was 1.58% (NOM, 5.3%; p < 0.001), decreasing significantly between 2007 and 2014 (p < 0.0001). ACS LII had higher mortality than LI (OR, 1.82; 95% CI, 1.39–2.39; p < 0.0001), controlled by Injury Severity Score. CONCLUSION Utilization of SSRF has risen considerably nationwide. Prevalence varies by region and ACS level. Although greatest growth is occurring at LII hospitals, mortality is also the highest at these centers. Further research is needed to determine the need for regionalization of care and center of excellence designation. LEVEL OF EVIDENCE Epidemiological study, level III.

Multicenter proficiency benchmarks for advanced laparoscopic suturing tasks

BACKGROUND Advanced laparoscopic suturing (LS) tasks were developed based on a needs assessment. Initial validity evidence has been shown. The purpose of this multicenter study was to determine expert proficiency benchmarks for these tasks. METHODS 6 tasks were included: needle handling (NH), offset-camera forehand suturing (OF), offset-camera backhand suturing (OB), confined space suturing (CF), suturing under tension (UT), and continuous suturing (CS). Minimally invasive surgeons experienced in LS completed the tasks twice. Mean time and median accuracy scores were used to establish the benchmarks. RESULTS Seventeen MIS surgeons enrolled, from 7 academic centers. Mean (95% CI) time in seconds to complete each task was: NH 169 (149-189), OF 158 (134-181), OB 189 (154-224), CF 181 (156-205), UT 379 (334-423), and CS 416 (354-477). Very few errors in accuracy were made by experts in each of the tasks. CONCLUSIONS Time- and accuracy-based proficiency benchmarks for 6 advanced LS tasks were established. These benchmarks will be included in an advanced laparoscopic surgery curriculum currently under development.

Myotomy length informed by high-resolution esophageal manometry (HREM) results in improved per-oral endoscopic myotomy (POEM) outcomes for type III achalasia

IntroductionHigh-resolution esophageal manometry (HREM) is essential in characterizing achalasia subtype and the extent of affected segment to plan the myotomy starting point during per-oral endoscopic myotomy (POEM). However, evidence is lacking that efficacy is improved by tailoring myotomy to the length of the spastic segment on HREM. We sought to investigate whether utilizing HREM to dictate myotomy length in POEM impacts postoperative outcomes.MethodsComparative analysis of HREM-tailored to non-tailored patients from a prospectively collected database of all POEMs at our institution January 2011 through July 2017. A tailored myotomy is defined as extending at least the length of the diseased segment, as initially measured on HREM.ResultsForty patients were included (11 tailored versus 29 non-tailored). There were no differences in patient age (p = 0.6491) or BMI (p = 0.0677). Myotomy lengths were significantly longer for tailored compared to non-tailored overall (16.6 ± 2.2 versus 13.5 ± 1.8; p < 0.0001), and for only type III achalasia (15.9 ± 2.4 versus 12.7 ± 1.2; p = 0.0453), likely due to more proximal starting position in tailored cases (26.0 ± 2.2 versus 30.0 ± 2.7; p < 0.0001). Procedure success (Eckardt < 3) was equivalent across groups overall (p = 0.5558), as was postoperative Eckardt score (0.2 ± 0.4 versus 0.8 ± 2.3; p = 0.4004). Postoperative Eckardt score was significantly improved in the tailored group versus non-tailored for type III only (0.2 ± 0.4 versus 1.3 ± 1.5; p = 0.0435). A linear correlation was seen between increased length and greater improvement in Eckardt score in the non-tailored group (p = 0.0170).ConclusionsUsing HREM to inform surgeons of the proximal location of the diseased segment resulted in longer myotomies, spanning the entire affected segment in type III achalasia, and in lower postoperative Eckardt scores. Longer myotomy length is often more easily achieved with POEM than with Heller myotomy, which raises the question of whether POEM results in better outcomes for type III achalasia, as types I and II do not generally have measurable spastic segments.

Laparoscopic Femoral Hernia Repair

The most prominent concern of a femoral hernia is the increased risk of bowel strangulation, as they are often missed or misdiagnosed on initial physical exam. For this reason, all patients with a femoral hernia diagnosed in the elective setting should be offered prompt intervention. The choice of technique utilized is based on the surgeon’s experience and comfort level, the patient’s physical exam, and their previous surgical history. Laparoscopic approaches are well suited for inguinal and femoral hernia repair and hold the benefit of being able to visualize and diagnose concurrent inguinal hernias which were not identified preoperatively. Minimally invasive techniques for repair of femoral hernias include total extraperitoneal (TEP), laparoscopic transabdominal preperitoneal (TAPP), intraperitoneal onlay mesh (IPOM), and robotic TAPP approaches. Key steps of the procedure include exposure of the entire myopectineal orifice, a wide peritoneal dissection to make room for mesh placement, sweeping back the peritoneal reflection to prevent a recurrence of a peritoneal hernia from under the lower edge of the mesh, exposure of the lacunar ligament, and blunt reduction of the hernia contents, avoiding the use of electrosurgery near the iliac vessels. If the contents remain incarcerated, a relaxing incision of the femoral ring may be made by incising the lacunar ring medially. The surgeon should inspect thoroughly for hemostasis after reduction of the hernia contents. While femoral hernia recurrence is a known complication, rates of recurrence requiring reoperation have been reported to be lower after laparoscopic repairs compared to open. Surgeon comfort with the anatomy and understanding of the surgical technique is critical to safe and appropriate repair.

Treatment of Achalasia with Per-Oral Endoscopic Myotomy: Analysis of 50 Consecutive Patients

BACKGROUND Peroral endoscopic myotomy (POEM) has become an acceptable incisionless treatment for achalasia based on encouraging outcomes in multiple series worldwide. This report reflects our early experience. METHODS Data were collected prospectively on all patients undergoing POEM between June 2011 and April 2016 under IRB approval. Diagnosis of achalasia was confirmed by standard preoperative work-up. Primary outcome was symptom relief, measured by Eckardt score. Secondary outcomes were operative time, length of stay (LOS), adverse events, failure, and recurrence. RESULTS Fifty patients were included; 30 were female. Mean age was 55.7 ± 17.7 years. Mean BMI was 29.5 ± 9.2. Median OR time was 133.5 minutes (range 70-462); average myotomy was 13.1 ± 2.3 cm. One early case was converted to a laparoscopic Heller myotomy due to extensive submucosal fibrosis from a recent Botox injection. Two cases were aborted; one due to extensive submucosal fibrosis and the other to intraoperative capnopericardium. Median LOS was 1 day (range 0.8-8). Two major complications occurred: intraoperative cardiac arrest due to capnopericardium and postoperative submucosal hemorrhage. There were no deaths. Mean postoperative Eckardt score was 1.0 ± 1.9 (range 0-8) at 2-6 weeks (vs. preoperative score 7.7 ± 2.8; P < .0001); mean dysphagia component 0.35 ± 0.28 (vs. preoperative score 2.6 ± 0.7; P < .0001). Two recurrences were identified, both at 6 months. CONCLUSIONS POEM is a safe and durable treatment for achalasia in the short term. We demonstrated marked improvement of symptoms in all completed cases. There was an acceptable serious adverse event rate of 4%, failure of 6% due to patient selection, and recurrences occurring in only 4% of cases.

NOTES Hernia Repair

Hernias are one of the most commonly treated general surgical problems, with over 20 million procedures per year. Despite the frequency of occurrence, modern techniques remain troubled by long-term recurrence and chronic pain syndromes postoperatively. Innovative techniques such as employing a natural orifice approach to the abdomen have the potential to reduce some of the concerns about current hernia operations. While there are scattered case reports about human NOTES hernia repairs, there has been an abundance of animal work demonstrating safety and feasibility. Work remains before widespread adoption of such a technique could take place.

A case report of unexpected pathology within an incarcerated ventral hernia

Highlights • Incarcerated appendicitis could be due to an unexpected inflammatory etiology.• Elucidating the etiology of inflammation is essential for directing management.• Ongoing inflammatory process after appendectomy may be due to Crohn’s disease.• Laparoscopic management of perforated hernial appendicitis provides excellent visualization.