Francisco Schlottmann

Comparative Analysis of Perioperative Outcomes and Costs Between Laparoscopic and Open Antireflux Surgery

BACKGROUND Laparoscopic antireflux surgery (LARS) has proven to be as effective as open antireflux surgery (OARS), but it is associated with a shorter hospital stay and a faster recover. The aims of this study were to assess the national use of LARS in the US and to compare the perioperative outcomes between laparoscopic and open antireflux procedures in a national cohort. STUDY DESIGN A retrospective population-based analysis was performed using the National Inpatient Sample for the period 2000 to 2013. The study included adult patients (18 years and older) diagnosed with gastroesophageal reflux disease (GERD), who underwent either laparoscopic or open fundoplication. Multivariable linear and logistic regression, adjusted for patient demographics, comorbidities, and hospital characteristics were used to assess the effect of the laparoscopic approach on patient outcomes. RESULTS A total of 75,544 patients were included, with 44,089 having LARS (58.4%) and 31,455 having OARS (41.6%). The rate of laparoscopic procedures increased from 24.8 LARS per 100 procedures in 2000, to 84.3 LARS per 100 procedures in 2013 (p < 0.0001). Patients undergoing laparoscopic surgery were less likely to experience postoperative venous thromboembolism, wound complications, infection, esophageal perforation, bleeding, cardiac failure, renal failure, respiratory failure, shock, and inpatient mortality. On average, the laparoscopic approach reduced length of stay by 2.1 days, and decreased hospital charges by

Gastroesophageal reflux disease and morbid obesity: To sleeve or not to sleeve?

9,530. CONCLUSIONS The use of the laparoscopic approach for the surgical treatment of GERD has increased significantly in the last decade in the US. This approach is associated with lower morbidity and mortality, shorter hospital stay, and lower costs for the health care system.

International medical graduates and unfilled positions in abdominal transplant surgery fellowships in the United States

Laparoscopic sleeve gastrectomy (LSG) has reached wide popularity during the last 15 years, due to the limited morbidity and mortality rates, and the very good weight loss results and effects on comorbid conditions. However, there are concerns regarding the effects of LSG on gastroesophageal reflux disease (GERD). The interpretation of the current evidence is challenged by the fact that the LSG technique is not standardized, and most studies investigate the presence of GERD by assessing symptoms and the use of acid reducing medications only. A few studies objectively investigated gastroesophageal function and the reflux profile by esophageal manometry and 24-h pH monitoring, reporting postoperative normalization of esophageal acid exposure in up to 85% of patients with preoperative GERD, and occurrence of de novo GERD in about 5% of cases. There is increasing evidence showing the key role of the surgical technique on the incidence of postoperative GERD. Main technical issues are a relative narrowing of the mid portion of the gastric sleeve, a redundant upper part of the sleeve (both depending on the angle under which the sleeve is stapled), and the presence of a hiatal hernia. Concomitant hiatal hernia repair is recommended. To date, either medical therapy with proton pump inhibitors or conversion of LSG to laparoscopic Roux-en-Y gastric bypass are the available options for the management of GERD after LSG. Recently, new minimally invasive approaches have been proposed in patients with GERD and hypotensive LES: the LINX® Reflux Management System procedure and the Stretta® procedure. Large studies are needed to assess the safety and long-term efficacy of these new approaches. In conclusion, the recent publication of pH monitoring data and the new insights in the association between sleeve morphology and GERD control have led to a wider acceptance of LSG as bariatric procedure also in obese patients with GERD, as recently stated in the 5th International Consensus Conference on sleeve gastrectomy.

Endoscopic Treatment of High-Grade Dysplasia and Early Esophageal Cancer

Dear Editors, The United States (US) is facing a serious shortage in its healthcare workforce [1]. Specifically, the United States could anticipate an increasing demand for transplant surgeons due to growth in the donor population and attrition of older surgeons. International medical graduates (IMGs) are a potential solution to the impending shortage. Therefore, we aimed to compare the composition of abdominal transplant surgical fellowships with other surgical fellowships programs, with special focus on trends in the proportion of IMGs and unfilled positions. We obtained fellowship match data from 2008 to 2016 from the National Resident Matching Program (NRMP). NRMP comprises data obtained from applications and successful matches for fellowship positions each year. Reports are available at the NRMP website [2]. US graduates are those who graduated from a school of medicine in the United States, and IMGs are those who graduated from a medical school abroad. We compared the proportion of IMGs and unfilled positions in abdominal transplant surgery positions with other three fellowships: colorectal surgery, thoracic surgery and vascular surgery. During the study period, the percentage of IMGs was significantly different among the programmes: 53.9% in abdominal transplant, 22.4% in vascular, 20.5% in thoracic and 18.3% in colorectal. In addition, while the trend of IMGs remained stable for vascular, thoracic and colorectal surgery, the percentage of IMGs raised from 47.6% in 2008 to 60.3% in 2016 for abdominal transplant surgery fellowships (Fig. 1). The percentage of unfilled positions decreased in all the analysed fellowship programmes. However, in 2016, still 24.7% of the positions were vacant in abdominal transplant surgery, as compared to 5.0% in vascular, 3.2% in colorectal and 0% in thoracic surgery (Fig. 2). We aimed to compare the composition of abdominal transplant surgical fellowships with other surgical fellowships programmes, and we found a significant increase of IMGs and a high percentage of unfilled positions in abdominal transplant surgical fellowships, as compared to colorectal, thoracic and vascular fellowship programmes. A survey conducted among transplant programme directors showed that 96% of the US medical school graduates located transplant positions after completing their training [3]. However, American physicians may be reluctant to undertake transplant surgery careers because of the demanding lifestyle related to the specialty. A previous study compared transplant surgeons to 13 other surgical specialties and found that transplant surgeons reported a high workload, with a mean workweek of 68.8 h/week and an average of 4.3 nights on call per week (rank 1st) [4]. In addition, transplant surgery is associated with considerable levels of burnout, high levels of emotional exhaustion and low levels of personal accomplishment [5]. IMGs, on the other hand, find in transplant surgery an attractive door to enter into the American healthcare workforce. Interestingly, whether an IMG stays in the US as a transplant surgeon upon completion of the fellowship relies largely in where they did their surgical training. As previously reported, while 73% of the IMG with US/Canadian surgical training obtained a job in transplantation in the US immediately after their fellowship training, this percentage drops to 28% for those with surgical training abroad. In this latter group, 50% found a transplant surgery position abroad [3]. Overall, the proportion of IMGs is higher among transplant surgery (32%) than among all physicians (27%) or general surgeons (17%) [6].

Surgical Treatment of Gastroesophageal Reflux Disease

BackgroundThe emergence of novel endoscopic modalities has challenged the role of surgery for patients with Barrett’s esophagus (BE) and high-grade dysplasia (HGD) or early esophageal adenocarcinoma.AimThe aim of this study was to review the available evidence of the endoscopic treatment of HGD and early esopahgeal adenocarcinoma.ResultsFor most patients with BE and HGD, endoscopic ablative therapy is the preferred treatment strategy. Patients with intramucosal adenocarcinoma (T1a) should be treated with endoscopic mucosal resection (EMR) followed by ablative therapy, in order to eradicate the remaining intestinal metaplasia. The best approach to treatment of adenocarcinoma with submucosal invasion (T1b) remains elusive. Endoscopic resection may be suitable for low-risk T1b tumors (well differentiated, without lymphovascular invasion and with superficial submucosal invasion); however, further data are necessary to better risk stratify this group. Careful endoscopic surveillance is recommended following complete eradication of intestinal metaplasia to detect recurrent disease.ConclusionPatients with BE and HGD should undergo endoscopic ablative therapy. Patients with T1a adenocarcinoma should be treated with EMR and subsequent ablation of the entire BE segment. Low-risk T1b tumors may be suitable for endoscopic resection.

Could an abdominal drainage be avoided in complicated acute appendicitis? Lessons learned after 1300 laparoscopic appendectomies

BackgroundGastroesophageal reflux disease (GERD) affects an estimated 20% of the population in the USA, and its prevalence is increasing worldwide. Lifestyle modifications and proton pump inhibitors (PPI) therapy are effective in the majority of patients and remain the mainstay of treatment of GERD. However, some patients will need surgical intervention because they have partial control of symptoms, do not want to be on long-term medical treatment, or suffer complications related to PPI therapy.AimsThe aim of this study was to review the available evidence that supports laparoscopic antireflux surgery, and to study the effect of surgical therapy on the natural history of GERD.ResultsThe key elements for the success of antireflux surgery are proper patient selection, careful analysis of the indications for surgery, complete pre-operative work-up, and proper execution of the surgical technique.ConclusionsWhen the key elements are respected, antireflux surgery is very effective in controlling GERD, and it is associated to minimal morbidity and mortality.

The Problem of Burnout Among Surgeons

INTRODUCTION Complicated appendicitis (CA) may be a risk factor for postoperative intra-abdominal abscess formation (IAA). In addition, several publications have shown an increased risk of postoperative collection after laparoscopic appendectomy. Most surgeons prefer to place a drain to collect contaminated abdominal fluid to prevent consequent abscess formation. We aimed to evaluate the utility of placing an intra-abdominal drain in laparoscopic appendectomy for complicated acute appendicitis. MATERIAL AND METHODS From January 2005 to June 2015 all charts of consecutive patients who underwent laparoscopic appendectomy for CA were revised. CA was defined as a perforated appendix with associated peritonitis. The sample was divided into two groups, G1: intra-abdominal drain and G2: no drain. Demographics, operative factors and 30-day postoperative complications were analyzed. RESULTS In the study period 1300 laparoscopic appendectomies were performed. Laparoscopic findings showed that 17.3% of the surgeries were for complicated acute appendicitis (225 patients). Fifty-six patients (25%) were in G1 and 169 patients (75%) in G2. No significant differences in clinical presentation and demographics were found (p: NS). G1 had an increased conversion rate (G1: 19.6% vs. G2: 7.1%; p: 0.007). No differences were found in the overall morbidity (G1: 32.1% vs. G2: 21.3%, p: NS). The rate of postoperative IAA was 14.2% in G1 and 8.9% in G2 (p: NS). Length of stay was higher in G1 (G1: 5.2 days vs. G2 2.9 days, p: 0.001). There was no mortality in either group. CONCLUSION The placement of intra-abdominal drain in complicated acute appendicitis may not present benefits and may even lengthen hospital stay. These observations suggest that there is no need of using a drain in laparoscopic appendectomy for complicated acute appendicitis.

Novel simulator for robotic surgery

Today the world of medicine in general, and of surgery in particular, is faced with a problem that is severely affecting both trainees and practicing physicians: burnout. In 1974, the American psychologist Herbert Freudenberger coined the term burnout to describe “the consequences of severe or prolonged stress and anxiety experienced by people working in the healing professions.”1(p160) Several years later,MaslachandJacksondefinedburnoutas“asyndrome of emotional exhaustion and cynicism that occurs frequentlyamongindividualswhodopeopleworkofsome kind.”2(p99) Burnout is often complicated by disruptive behaviors, such as depression, substance abuse, interpersonal conflicts, and even suicidal ideation. In a survey of 7905 surgeons performed in 2010 and funded by the American College of Surgeons, Shanafelt and colleagues3 found that 6.3% reported some element of suicidal ideation during the prior 12 months; only 26% of these surgeons sought psychiatric care, while the remainder were afraid to seek help, because they thought that it could affecttheirmedical license.Unfortunately,therateofburnout among surgeons is much greater than among the general population (53% vs 28%), and represents a major increasecomparedwithseveralyearsago,whenitwascloser to 40%.4 Based on the analysis by Maslach and Jackson,2 the following 3 aspects of burnout have emerged: emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment. There is no question that the origin of the problem is multifactorial. A survey of members of the American College of Surgeons in 2008 showed that factors independently associated with burnout included younger age, having children, area of specialization (trauma surgeons were more commonly affected), number of nights on call per week, work-home conflicts, and compensation based entirely on billing.5 In addition, increasing amounts of new and important information relevant to each specialty, ever-newer technology, patients’ increasing expectations, and the electronic medical records system all play a role in burnout.6 Although the electronic medical records system has made it easier to obtain immediate and comprehensive information about patients to improve the quality of care, it has also added a tremendous burden. The computer interface separates the surgeon from the patient, both in the office and in the hospital; an inordinate amount of time is spent sitting in front of a computer rather than caring for the patient.6 Legal issues also play an important role. Even though two-thirds of claims are dropped or dismissed, and 90% of trial verdicts are in favor of physicians, malpractice litigation also imposes a major toll, both emotional and economic, on surgeons.7 Finally, the emphasis on productivity increasingly imposed on the surgeon by the administration of their institution allows less time for interpersonal relationships and mentoring. Consequently, the residents they teach are faced with less guidance, are given less autonomy, and feel that the long years of training do not prepare them adequately for practice in terms of technical skills, patient care, and confidence in making independent decisions. The more senior surgeons resent the declining reimbursement and the lack of respect, fear litigation in the absence of tort reform, and experience the stress of recertification. At the end of the day, many surgeons feel that their stressful job no longer holds the appeal, the charisma, or the deserved respect of the patient or the administrative leadership of their institution that it had in the past. As a consequence of this dissatisfaction and frustration, it is sad that many surgeons would not recommend a career in surgery to their own children.5 Probably as a reflection of these facts, the last 20 years have witnessed a decrease in the number of US medical students going into surgery, with the ranks filled necessarily more and more by international medical graduates. In our opinion, while acknowledging that there is no easy solution, the implementation of some changes could ameliorate the situation.

Understanding the Chicago Classification: From Tracings to Patients

Surgical simulation avoids practicing skills in patients, allowing trainees to learn in a safe, controlled, and standardized environment. Current robotic surgical simulators available include virtual reality simulators, human cadavers, and live animals. The use of cadavers has the highest possible fidelity available to practice entire operations. Nevertheless, their cost, availability, tissue compliance, and infection risk outweigh the advantages of cadaver models. Drawbacks of using live animals include anatomical differences with humans, high costs due to their housing and handling requirements, and ethical concerns. We designed a novel robotic surgical simulator based on porcine perfused tissue blocks that allows the simulation of entire surgical procedures. Our simulation allows trainees to increase familiarity with the robotic console and its controls, as well as with the docking process. It provides an opportunity to learn not only universal skills needed in robotic surgery, such as camera and instrument targeting, but also to perform complete surgical procedures such as an antireflux procedure. The adoption of robotic simulation curricula with realistic models will decrease overall operative time while increasing resident participation.

Association of Surgical Volume With Perioperative Outcomes for Esophagomyotomy for Esophageal Achalasia

Current parameters of the Chicago classification include assessment of the esophageal body (contraction vigour and peristalsis), lower esophageal sphincter relaxation pressure, and intra-bolus pressure pattern. Esophageal disorders include achalasia, esophagogastric junction outflow obstruction, major disorders of peristalsis, and minor disorders of peristalsis. Sub-classification of achalasia in types I, II, and III seems to be useful to predict outcomes and choose the optimal treatment approach. The real clinical significance of other new parameters and disorders is still under investigation.