Jeffrey Mino

Trends and disparities in education between specialties in thyroid and parathyroid surgery: An analysis of 55,402 NSQIP patients

PURPOSE To determine practice patterns/outcomes and educational opportunities in endocrine surgery by resident involvement in general surgery (GS) and otolaryngology (ENT). METHODS We queried the American College of Surgeon National Surgical Quality Improvement Program for thyroid/parathyroid operations. Resident involvement was categorized by postgraduate year (PGY) and specialty. RESULTS Of 38,257 thyroid patients, attendings alone performed 28% in GS versus 65% in ENT, and of 17,145 parathyroid patients, 22.1% vs 66.5%. Of GS cases done with housestaff, the percentages with junior residents (PGY1-3), senior residents (PGY4,5), and fellows were 42%, 50%, and 7%, respectively, whereas for ENT operations, the percentages were 35%, 46%, and 16%. For parathyroidectomies, the percentages were 41.1%/46.8%/12.1% vs 38.7%/45.9%/15.5%. Operative time was less for GS (115 minutes) versus ENT (123 minutes). Time in the operating room increased with increasing PGY in ENT, but not in GS. Case complexity and outcomes were similar. Duration of hospital stay was greater in ENT. CONCLUSION No differences exist in case complexity between specialties. More thyroid/parathyroid operations are performed with residents in GS; junior residents in GS perform a large percentage of these cases (∼40%), indicating early exposure to endocrine surgery and balanced experience between resident levels with minimal effect of fellows. Although junior residents receive exposure in ENT, a greater proportion is performed by fellows. Outcomes were similar by resident level, except operative time, which was greater for ENT at all levels. Ultimately, equal outcomes but lesser operating times and durations of hospital stay are seen with GS residents than their ENT counterparts.

Line-associated thrombosis as the major cause of hospital-acquired deep vein thromboses: an analysis from National Surgical Quality Improvement Program data and a call to reassess prophylaxis strategies

BACKGROUND Quality improvement has mitigated the occurrence of postoperative deep vein thromboses (DVTs); however, despite adherence to protocols, they continue to occur. This study aimed to characterize their rate and distribution at our institution, and appropriate use of thromboprophylaxis. METHODS Local American College of Surgeons National Surgical Quality Improvement Program data were queried for general surgery cases complicated by DVT from 2009 to 2011. Medical records were evaluated to ascertain the following: classify DVTs by site, ascertain if appropriate prophylactic measures were instituted, evaluate treatment instituted, evaluate the occurrence of a PE if the DVT was line-associated, and if so, the indication for the central line. RESULTS Of 1,857 patients, 39 had postoperative DVTs (2.1%). Fourteen lower-extremity (35.9%) DVTs, 4 central (10%) DVTs, and 21 upper-extremity (53.8%) DVTs (UEDVTs) were captured. All but 2 had appropriate thromboprophylaxis. All but one UEDVT was line-associated. Diagnoses were prompted by symptoms in 72% of the patients. Pulmonary emboli developed in 3 of 39 patients. CONCLUSIONS An unexpected finding was that line-associated UEDVTs comprised over half of all DVTs, mostly in patients without cancer. This analysis highlights the need for more selective central-line use; choosing peripheral access may reduce DVT rates further. Improved pharmacoprophylaxis protocols would likely benefit this population.

Diffuse malignant epithelioid mesothelioma in a background of benign multicystic peritoneal mesothelioma: a case report and review of the literature

Peritoneal mesotheliomas are unusual entities with diverse origins and outcomes. Both benign and malignant variants exist. Benign multicystic peritoneal mesotheliomas (BMPMs), also known as multiple or multilocular peritoneal inclusion cysts, are extremely rare tumours arising from the peritoneal mesothelium covering the abdominal serous cavity. Even though these entities are considered benign tumours, BMPMs tend to recur after surgical resection, and in two cases have been reported to undergo malignant transformation. In contrast, diffuse malignant peritoneal mesotheliomas, while also quite rare, are the second most common form of malignant mesothelioma after the pleural variety with extremely high mortality and poor response to many treatments to date. We present a rare case of diffuse malignant peritoneal mesothelioma within a large component of a BMPM in a young man admitted to our service.

Diagnostic Laparoscopy Prior to Neoadjuvant Therapy in Pancreatic Cancer Is High Yield: an Analysis of Outcomes and Costs

BackgroundThere is currently no standardized regimen for management of borderline resectable pancreatic cancer (BRPC), and treatment includes varying sequences of surgery, chemotherapy, and/or radiation. This study examines the diagnostic yield and cost of performing staging diagnostic laparoscopy (SDL) prior to neoadjuvant therapy (NAT) in BRPC.MethodsSequential patients treated for BRPC between January 2010 and October 2013 were included. SDL was adopted in a staged fashion due to surgeon preference, and included biopsy of visible lesions and washings for cytology. Cost ratios (CRs) were calculated to compare the direct cost of the SDL versus no-SDL groups and to compare patients with positive versus negative SDL.ResultsOf 116 patients evaluated for BRPC, 75 patients underwent SDL and 19 (25%) revealed occult metastatic disease. Sixteen patients had a positive biopsy and three had positive cytology alone. There was no difference in overall treatment cost (CR 0.95, 95% CI 0.62–1.37), oncologic treatment (CR 0.66, 95% CI 0.32–1.23), or remaining surgical treatment (CR 1.14, 95% CI 0.77–1.71) for patients who underwent SDL compared to those who did not. Patients with a positive SDL incurred lower overall cost compared to those with a negative SDL (CR 0.23, 95% CI 0.16–0.32) due to lack of further surgery or radiation, and less intensive chemotherapy regimens.ConclusionsSDL prior to NAT is a useful adjunct to CT to diagnose occult metastatic disease in BRPC.

The use of negative pressure dressings over closed incisions for prevention of surgical site infection in colorectal patients undergoing revisional surgery – a video vignette

open approach. Surgical dissection criteria included the ‘grade’ of TME, uninvolved circumferential resection margin and distal resection margin. Our results and your recent editorial [4] prompted this short communication. During these 12 months 54 patients (mean age 64, range 35 86 years) underwent TME for rectal cancer. They included 27 laparoscopic (five conversions) and 27 open operations of which 24% received preoperative neoadjuvant chemoradiotherapy (seven and six respectively). Anterior resection with sphincter preservation was performed in 75% with the remainder undergoing abdominoperineal excision (n = 13). With respect to the grade of TME dissection (‘mesorectal fascia’, ‘intra-mesorectal’ and ‘muscularis propria’) one (4%) patient in the laparoscopic group and two (7%) in the open group had histopathological evidence of dissection exposing the muscularis propria. With regard to the distal resection margin this was uninvolved in all the laparoscopic cases but in only 25 (93%) of 27 open resections. Thus overall complete TME was achieved in 94% (51/54) of this small cohort and in essence there was no difference with regard to the surgical approach. In contrast to these data, the circumferential resection margin positivity (< 1 mm) was one (4%) in the laparoscopic cases but five (19%) in the open cases. This difference was probably due to our MDT policy of offering screendetected cancers minimally invasive surgery whenever possible. Indeed screened cancers accounted for 11 (41%) of the laparoscopic cases compared with six (22%) in the open cases where Stage T3/4 disease (70%) was more common. Although these are small numbers, these non-randomized comparative data in 1 year from a single MDT suggest that well trained laparoscopic surgeons [5] do achieve good quality rectal dissection. Appropriate case selection certainly plays a key part in the success of a laparoscopic approach, which is part of competent surgical decision taking. Maybe ‘surgeon outcomes’ considered by the ACP, with regard to completeness of TME, should also be recorded as we have nothing to hide and can all ‘hold our head high’ in this and probably many other MDTs [3].

Antimesenteric jejunal diverticulosis after a remote history of necrotising enterocolitis: a case report

Jejunal diverticulosis is a rare, acquired pathology of the small bowel. While most patients are asymptomatic, the condition is difficult to diagnose. It may present with chronic abdominal pain, diarrhoea, bloating and complications including malabsorption, diverticulitis, bleeding, intestinal obstruction or perforation. This is a case presentation of a 27-year-old woman with a history of necrotising enterocolitis (NEC) requiring surgical resection as a premature newborn who presented with recurrent abdominal pain and was found to have several small bowel diverticula intraoperatively. She underwent resection with complete resolution of symptoms over a 2-year follow-up. This is the first case report to suggest that small bowel diverticular disease as a long-term complication of NEC may result in chronic morbidity in long-term survivors.

Su1851 Long-Term Outcomes of Combined Endoscopic/Laparoscopic Intragastric Enucleation of Gastric Stromal Tumors

S A T A b st ra ct s endophytic or in anatomically difficult locations. This technique allowed patients to avoid an extensive resection. Endoscopic resection alone was associated with a positive deep margin, which the push-pull technique managed with a laparoscopic, full-thickness, R0 resection site resection. In highly selected populations, this hybrid push pull technique may represent an improvement over standard endoscopic or laparoscopic management for gastric GISTs.

Mo1587 Pre-Operative Radiographic Findings Predictive of Laparoscopic Conversion to Open Procedures in Crohn's Disease

Purpose: Enhanced recovery after surgery (ERAS) lowers complications and shortens lengths of stay (LOS) compared with standard recovery. A key management strategy of ERAS protocols, especially if goal-directed fluid management is not available, is restrictive fluid management. However, it is unknown whether this is a safe strategy. Thus we aimed to evaluate whether restrictive fluid management was associated with increased acute kidney injury. Methods: We performed a retrospective review of consecutive patients undergoing abdominal surgery by a single ERAS-trained colorectal surgeon at an academic medical center from 1/11/2012 8/15/2013. Demographics, operative data, and short-term (30-day) outcomes are presented. Univariate analysis assessed between group differences to test the hypothesis that ERAS patients managed with restrictive fluids did not have an increased rate of post-operative acute kidney injury. Results are reported as median (interquartile range) or frequency (proportion). Results: One hundred twenty-eight patients were included: 82 (64%) ERAS and 46 (36%) STD recovery. Patient in the two groups were of similar age (52.4 vs. 54.8 years old, p=0.74), and BMI (26.8 vs. 27.4 kg/m2, p=0.98). Similar proportions underwent protectomy (22% vs. 28%, p=0.52), but more ERAS patients underwent minimally invasive surgery (61% vs. 41%, p=0.04), primary anastomosis (61% vs. 43%, p=0.04), and fewer had an ostomy (40% vs. 63%, p=0.02). Perioperative fluids (in cc/kg/hour) and creatinine levels are shown in Table 1. There was a trend towards ERAS patients receiving significantly less intra-operative fluids (p=0.07), and ERAS patients made significantly less urine intra-operatively (p=0.04). Post-operatively ERAS patients received significantly less IV fluids on POD#1 and POD#2 (p<0.0001), but had similar urine output on POD#1 and a trend toward reduced UOP on POD#2 (p=0.06). A total of 11 patients (8.6%) had a peak post-op creatinine ≥1.5; of these 8 (73%) recovered to <1.5 except three patients (2 ERAS1 malignant ureteral obstruction, 1 chronic renal insufficiency; 1 STD contrast induced nephropathy). No patients in the series required dialysis. ERAS patients, compared with STD patients, had earlier bowel function (POD 1.7 vs. 2.3, p=0.02), and shorter LOS 4 (36) vs. 6 (4-7) days, p=0.0002, and a similar readmission rate (8.5% vs. 10.9%, p=0.75), and need for return to the operating room (9.8% vs. 6.5%, p=0.75) Conclusions: Restrictive perioperative management after colorectal surgery is safe and does not result in a clinically or statistically increased rate of post-operative acute kidney injury.