Jason Bingham

Routine intraoperative leak testing for sleeve gastrectomy: is the leak test full of hot air?

BACKGROUND Staple line leak after sleeve gastrectomy (SG) is a rare but dreaded complication with a reported incidence of 0% to 8%. Many surgeons routinely test the staple line with an intraoperative leak test (IOLT), but there is little evidence to validate this practice. In fact, there is a theoretical concern that the leak test may weaken the staple line and increase the risk of a postop leak. METHODS Retrospective review of all SGs performed over a 7-year period was conducted. Cases were grouped by whether an IOLT was performed, and compared for the incidence of postop staple line leaks. The ability of the IOLT for identifying a staple line defect and for predicting a postoperative leak was analyzed. RESULTS Five hundred forty-two SGs were performed between 2007 and 2014. Thirteen patients (2.4%) developed a postop staple line leak. The majority of patients (n = 494, 91%) received an IOLT, including all 13 patients (100%) who developed a subsequent clinical leak. There were no (0%) positive IOLTs and no additional interventions were performed based on the IOLT. The IOLT sensitivity and positive predictive value were both 0%. There was a trend, although not significant, to increase leak rates when a routine IOLT was performed vs no routine IOLT (2.6% vs 0%, P = .6). CONCLUSIONS The performance of routine IOLT after SG provided no actionable information, and was negative in all patients who developed a postoperative leak. The routine use of an IOLT did not reduce the incidence of postop leak, and in fact was associated with a higher leak rate after SG.

Predictors of appendiceal perforation in an equal access system

BACKGROUND Discrepancies in socioeconomic factors have been associated with higher rates of perforated appendicitis. As an equal-access health care system theoretically removes these barriers, we aimed to determine if remaining differences in demographics, education, and pay result in disparate outcomes in the rate of perforated appendicitis. MATERIALS AND METHODS All patients undergoing appendectomy for acute appendicitis (November 2004-October 2009) at a tertiary care equal access institution were categorized by demographics and perioperative data. Rank of the sponsor was used as a surrogate for economic status. A multivariate logistic regression model was performed to determine patient and clinical characteristics associated with perforated appendicitis. RESULTS A total of 680 patients (mean age 30±16 y; 37% female) were included. The majority were Caucasian (56.4% [n=384]; African Americans 5.6% [n=38]; Asians 1.9% [n=13]; and other 48.9% [n=245]) and enlisted (87.2%). Overall, 6.4% presented with perforation, with rates of 6.6%, 5.8%, and 6.7% (P=0.96) for officers, enlisted soldiers, and contractors, respectively. There was no difference in perforation when stratified by junior or senior status for either officers or enlisted (9.3% junior versus 4.40% senior officers, P=0.273; 6.60% junior versus 5.50% senior enlisted, P=0.369). On multivariate analysis, parameters such as leukocytosis and temperature, as well as race and rank were not associated with perforation (P=0.7). Only age had a correlation, with individuals aged 66-75 y having higher perforation rates (odds ratio, 1.04; 95% confidence interval, 1.02-1.05; P<0.001). CONCLUSIONS In an equal-access health care system, older age, not socioeconomic factors, correlated with increased appendiceal perforation rates.

Biliary Leak Rates After Cholecystectomy and Intraoperative Cholangiogram in Surgical Residency

Postoperative bile leak (BL) after cholecystectomy is a rare but dreaded complication, and is felt to be increased during surgical training. We sought to determine the incidence of BL after selective intraoperative cholangiogram (IOC) at a teaching hospital and identify risk factors for predicting BLs. A retrospective review was performed analyzing all cholecystectomy with IOCs between September 2004 and September 2011. Residents performed under staff supervision. Of 1,799 cholecystectomies performed during the study period, only 96 (5.3%) were with IOCs (mean age 43, 65% female) and 4 BLs occurred (4.2%, 1 major duct injury, 3 cystic duct stump leaks). Univariate analysis demonstrated that male gender, significant medical comorbidities, case duration, preoperative endoscopic retrograde cholangiopancreatography, and surgery type (laparoscopic versus open) increased the patients risk of BL; however, age, performance of secondary procedures, common bile duct exploration, resident level (PGY), and diagnosis did not increase BL risk. Multivariate regression revealed that only surgery type lead to an increased risk of BL (p = 0.001) (OR 31.61, 95% CI 3.96-252.18). Patient factors and PGY level did not significantly affect BL rates, although open and converted procedures were associated with higher rates, suggesting an increased risk of a BL with more complex cases.

Assessing serum hemoglobin levels without venipuncture: accuracy and reliability of Pronto-7 noninvasive spot-check device

BACKGROUND Hemoglobin is a frequently obtained test in hospital settings. We analyzed accuracy of a noninvasive device compared to standard laboratory analyzers in a variety of settings. METHODS A noninvasive hemoglobin monitoring device was analyzed for reliability, correlation, precision, and bias. Hemoglobin levels were obtained from standard laboratory and point-of-care hemoglobin analyzers and compared to noninvasive hemoglobin in inpatient and military field environments. RESULTS Ninety-seven patients were enrolled. Overall, the noninvasive hemoglobin device had high correlation compared to invasive laboratory values. Stratified by location, the device had high correlation in hospital and low correlation in austere environment. The highest variation in accuracy was seen in the austere environment. CONCLUSIONS Overall, the noninvasive spot-check hemoglobin device is reliable and highly correlates to standard hemoglobin analysis. Use in an austere setting requires further study.

Mesenteric irritation as a means to prevent internal hernia formation after laparoscopic gastric bypass surgery

INTRODUCTION Internal hernias (IHs) occur more frequently in laparoscopic gastric bypass (LGB) surgery than in the classic open procedure. The incidence of small bowel obstruction after LGB ranges from 1.8% and 9.7%. Some have theorized that this occurs because of decreased adhesion formation. METHODS The mesenteric irritation technique is performed after closure of the jejunojejunal mesenteric defect with a running 2-0 silk suture. A sponge is then rubbed against the closed visceral peritoneal mesentery until petechiae are visualized on the surface of the mesentery. RESULTS In all, 338 LGBs were performed using the standard closure technique with an IH incidence of 5.3% (range 1.7% to 7.8%). When using the mesenteric irritation technique, 72 LGBs were performed with an IH rate of 1.4% (P = .13). CONCLUSIONS Mesenteric irritation is a novel technique performed with minimal additional time and no additional equipment. This technique may prove beneficial in reducing the incidence of IHs.

The true impact of breast magnetic resonance imaging on the management of in situ disease: more is not better.

BACKGROUND The optimal role of breast magnetic resonance imaging (MRI) in the management of ductal carcinoma in situ (DCIS) remains controversial. We sought to better define the impact of breast MRIs when utilized during the workup of DCIS. METHODS Patients with biopsy-proven DCIS without any additional invasive disease were prospectively enrolled in the multidisciplinary breast cancer pathway and comprised the study group. Patients who met any additional criteria for MRI screening were excluded. RESULTS From 2008 to 2014, 93 women met the inclusion criteria. 81 patients underwent MRI as part of their workup. One patient benefited from MRI via identification of occult malignancy not previously identified. 35 MRIs identified no additional information whereas 46 had additional findings. These findings led to 23 procedures and 16 negative biopsies; recommendations for 16 radiographic studies that were normal; and influenced nodal sampling in 7 women with 1 positive metastatic focus. CONCLUSIONS The routine use of breast MRI for women diagnosed with DCIS has limited benefit. Often, it leads to multiple procedures and studies that are clinically insignificant and delays surgical treatment.

Abdominoperineal Resection for Rectal Cancer

Abstract Each year approximately 40,000 new cases of rectal cancer will be diagnosed in the United States alone, comprising nearly 30% of all colorectal malignancies. Locally advanced rectal cancer may often require an extensive pelvic operation in conjunction with (neo)adjuvant chemoradiation therapy. Despite the increase in sphincter-sparing operations, the abdominoperineal resection (APR) remains the operation of choice for many low-lying rectal cancers, for certain recurrent rectal cancers, and as salvage therapy for anal cancers, as well as advanced gynecologic and genitourinary malignancies. Understanding the various options for planes of dissection is imperative to ensure optimal outcomes.

Patient Selection and General Patient Considerations

Colon and rectal surgery has witnessed a vast increase in both the use of and subsequent publications about single-incision laparoscopic surgery (SILS). While single-incision surgery goes by several different names, it is important to keep in mind that when learning any new approach, the operative procedure (with regard to safety and outcomes) should remain the same. Although there is a learning curve that each surgeon must complete and overcome in order to become proficient, the patient should not suffer in the interim. With regard to colon and rectal surgery, special populations such as those with inflammatory bowel disease, diverticulitis, large tumors, and other inflammatory disorders may present technical challenges for open as well as other minimally invasive approaches. Therefore, it is especially important when selecting the operative approach to match it to the individual patient at hand, as well as being realistic about one’s technical expertise and experience with a particular procedure. In this chapter, we will highlight the unique challenges of single-incision surgery, discuss general patient selection and consideration issues, and examine how this approach relates to those particular cohorts such as those with inflammatory bowel disease and obesity.

Combat Soft Tissue Injuries

Purpose of ReviewThe soft tissue injuries encountered in combat are generally orders of magnitude more dramatic that those seen in civilian practice. The goal of this chapter is to help shorten the learning curve to care for the extensive soft tissue wounds of war by reviewing the limited research available on the subject and sharing lessons learned from the battlefield.Recent FindingsData from recent conflicts in Iraq, Afghanistan, and Syria demonstrate that the soft tissue injuries sustained in a warzone are unique compared to the types of injuries seen in civilian practice. These injuries have high infection rates, result in extensive tissue loss, and require special strategies to optimize outcomes.SummaryDevastating soft tissue injuries in combat are often accompanied by multiple life-threatening injuries and one must have a systematic approach to evaluation and treatment. War wounds are highly contaminated. Early antibiotics, thorough exploration, serial debridement, and irrigation are the mainstays of therapy. While plans for wound closure must start with the first operation, all combat wounds should initially be left open.

Gastric Glomus Tumor: An Uncommon Source for an Acute Upper GI Bleed

Background Glomus tumors are uncommon mesenchymal neoplasms originating from modified smooth muscle cells in the glomus body. They are generally small, solitary lesions found in the distal extremities. Rarely, involvement in the abdominal viscera can occur. In such cases, hematemesis/melena and epigastric discomfort are the most common initial symptoms. Although gastric glomus tumors can demonstrate malignant behavior, criteria for identifying malignant potential have yet to be established. Case Presentation We present a rare case of gastric glomus tumor in an otherwise healthy 41-year-old female. The patient initially presented with a significant upper GI bleed requiring a 4 U PRBC transfusion for stabilization. An upper endoscopy with endoscopic ultrasound identified an ulcerated, submucosal mass thought to be consistent with GI stromal tumor (GIST). Once clinically stable, she was scheduled for elective resection. However, prior to resection she experienced a second hemodynamically significant upper GI bleed and underwent emergent laparotomy with distal gastrectomy. Pathologic examination revealed a 3 cm glomus tumor. Conclusion Gastric glomus tumors are rare solitary submucosal tumors for which preoperative diagnosis is challenging and can be confused with a GIST. Local resection with negative margins is the preferred treatment and the exact diagnosis relies heavily on histopathological examinations. Currently, there are no clear guidelines regarding the staging and malignant potential of glomus tumors of the stomach.