Jennifer Kaplan

A prospective, randomized controlled trial of single-incision laparoscopic vs conventional 3-port laparoscopic appendectomy for treatment of acute appendicitis.

BACKGROUND Proponents of single-incision laparoscopic surgery (SILS) claim patients have less pain, faster recovery, and better long-term cosmetic results than patients who undergo multiport laparoscopy. However, randomized comparisons are lacking. This study presents the results of a prospective randomized trial of SILS or 3-port laparoscopic appendectomy. STUDY DESIGN Adults with uncomplicated acute appendicitis were randomized 1:1 to either SILS or 3-port laparoscopic appendectomy. The primary end point was early postoperative pain (measured by opiate usage and pain score in the first 12 hours). Secondary end points were operative time, complication rate (including conversions), and recovery time (days of oral opiate usage and return to work). After 6 months, body image and cosmetic appearance were assessed using a validated survey. RESULTS The trial was planned for 150 patients, but was halted after 75 patients when planned interim analysis showed that SILS patients had more postoperative pain (pain score: 4.4 ± 1.6 vs 3.5 ± 1.5; p = 0.01) and higher inpatient opiate usage (hydromorphone use: 3.9 ± 1.9 mg vs 2.8 ± 1.7 mg; p = 0.01) than 3-port laparoscopy. Operative time for SILS averaged 40% longer (54 ± 17 minutes vs 38 ± 11 minutes; p < 0.01). Only 1 SILS case was converted to 3-port. There were no significant differences in length of stay, complications, oral pain medication usage after discharge, or return to work. After 6 months, body image and cosmetic appearance were excellent for both groups and indistinguishable by most measures. However, 3-port patients reported better physical attractiveness (4.0 ± 0.4 vs 3.8 ± 0.4; p = 0.04) and SILS patients reported better scars (score 18.4 ± 2.7 vs 16.4 ± 3.0; p < 0.01). Results are reported as mean ± SD. CONCLUSIONS Single-incision laparoscopic surgery appendectomy resulted in more pain and longer operative times without improving short-term recovery or complications. Long-term body image and cosmetic appearance were excellent in both groups.

NORADRENERGIC INNERVATION OF THE RAT SPINAL CORD CAUDAL TO A COMPLETE SPINAL CORD TRANSECTION: EFFECTS OF OLFACTORY ENSHEATHING GLIA

Transplantation of olfactory bulb-derived olfactory ensheathing glia (OEG) combined with step training improves hindlimb locomotion in adult rats with a complete spinal cord transection. Spinal cord injury studies use the presence of noradrenergic (NA) axons caudal to the injury site as evidence of axonal regeneration and we previously found more NA axons just caudal to the transection in OEG- than media-injected spinal rats. We therefore hypothesized that OEG transplantation promotes descending coeruleospinal regeneration that contributes to the recovery of hindlimb locomotion. Now we report that NA axons are present throughout the caudal stump of both media- and OEG-injected spinal rats and they enter the spinal cord from the periphery via dorsal and ventral roots and along large penetrating blood vessels. These results indicate that the presence of NA fibers in the caudal spinal cord is not a reliable indicator of coeruleospinal regeneration. We then asked if NA axons appose cholinergic neurons associated with motor functions, i.e., central canal cluster and partition cells (active during fictive locomotion) and somatic motor neurons (SMNs). We found more NA varicosities adjacent to central canal cluster cells, partition cells, and SMNs in the lumbar enlargement of OEG- than media-injected rats. As non-synaptic release of NA is common in the spinal cord, more associations between NA varicosities and motor-associated cholinergic neurons in the lumbar spinal cord may contribute to the improved treadmill stepping observed in OEG-injected spinal rats. This effect could be mediated through direct association with SMNs and/or indirectly via cholinergic interneurons.

The Impact of MELD/PELD Revisions on the Mortality of Liver-Intestine Transplantation Candidates

Patients listed for liver–intestine transplantation suffer higher waiting list mortality than those listed for liver‐only, thus leading to policy revisions seeking to close the gap. We sought to determine the impact of key model for end‐stage liver disease (MELD)/pediatric end‐stage liver disease (PELD) policy modifications on the waiting list mortality of adult and pediatric liver–intestine candidates as compared to liver‐only candidates. Analysis of UNOS data separated into adult and pediatric categories and based on time periods of policy implementation revealed higher mortality in liver–intestine candidates over all time periods studied (p < 0.001 pediatric and adult). After implementation of a revision to augment their MELD scores based on a sliding scale, adult liver–intestine candidates with calculated MELD > 15 no longer suffered higher mortality although this change did not completely eliminate the mortality disparity for candidates with MELD < 15 (p < 0.01). The waiting list mortality of pediatric liver–intestine candidates dropped significantly after a revision that gave them 23 additional MELD/PELD points (p < 0.01) although the mortality disparity with pediatric liver‐only candidates was not eliminated. Following this revision, mortality in pediatric liver‐only and liver–intestine Status 1 candidates was similar, however more liver–intestine candidates were listed as Status 1B. This data demonstrates that a mortality disparity remains for liver–intestine candidates compared with candidates listed for liver‐only.

Morbidity and Mortality Associated With Elective or Emergency Paraesophageal Hernia Repair

PACIFIC COAST SURGICAL ASSOCIATION Morbidity and Mortality Associated With Elective or Emergency Paraesophageal Hernia Repair For decades, the standard of care for a paraesophageal hiatal hernia (PEH) was surgical repair after diagnosis, irrespective of symptoms. This standard of care was based on the reported high risk of acute gastric volvulus, strangulation, bleeding, or obstruction associated with untreated PEH and on the high mortality associated with emergency repair.1,2 A paradigm shift occurred in 2002, when Stylopoulos et al,3 using Markov analysis, found that watchful waiting was superior to elective repair for patients older than 65 years of age with a minimally symptomatic PEH. As a result, many patients with a PEH deferred surgery and opted for watchful waiting. A predictable consequence of watchful waiting has been an increase in the number of patients presenting with an acute PEH, sometimes with catastrophic outcomes.4 We characterized outcomes of emergency PEH repair in the modern era compared with elective repair using data from the American College of Surgeons National Surgical Quality Improvement Program. Methods | We reviewed all PEH repairs reported to the American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2012. Inclusion criteria were an age of 18 years or older at the time of surgery, an International Classification of Diseases, Ninth Revision (ICD-9) primary diagnosis code of diaphragmatic hernia (ie, ICD-9 code 551.3, 552.3, or 553.3), and a primary Current Procedural Terminology code indicating repair, as described by Mungo et al.5 Demographic data, comorbidities, and preoperative laboratory values were reviewed. The primary outcome was 30-day mortality. Secondary outcomes were hospital length of stay and serious morbidity (defined as return to the operating room, cardiac complication, sepsis, shock, ventilation >48 hours, unplanned reintubation, or cerebrovascular accident or stroke). Because this research involves only deidentified patient information, it did not require institutional review board approval from the University of California, San Francisco. Predictors of serious morbidity and 30-day mortality were identified in univariate logistic regression. Multivariate predictors were identified using backward-stepwise logistic regression. Statistical significance was defined as P < .05.

Expanded indications for bariatric surgery: should patients on chronic steroids be offered bariatric procedures?

BACKGROUND Patients who take chronic corticosteroids are increasingly referred for bariatric surgery. Little is known about their clinical outcomes. OBJECTIVE Determine whether chronic steroid use is associated with increased morbidity and mortality after stapled bariatric procedures. SETTING American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. METHODS All patients who underwent laparoscopic sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass and were reported to the ACS-NSQIP from 2011 to 2013 were reviewed. Patients were grouped based on type of surgery and history of chronic steroid use. Primary outcome measures were mortality and serious morbidity in the first 30 days. Regression analyses were used to determine predictors of outcome. RESULTS Of 23,798 patients who underwent laparoscopic sleeve gastrectomy and 38,184 who underwent Roux-en-Y gastric bypass, 385 (1.6%) and 430 (1.1%), respectively, were on chronic steroids. Patients on chronic steroids had a 3.4 times increased likelihood of dying within 30 days (95% confidence interval 1.4-8.1, P = .007), and 2-fold increased odds of serious complications (95% confidence interval 1.2-2.3, P = .008), regardless of surgery type. In multivariate regression, steroid usage remained an independent predictor of mortality and serious complications. CONCLUSION In a large, nationally representative patient database, steroid use independently predicted mortality and serious postoperative complications after stapled bariatric procedures. Surgeons should be cautious about offering stapled bariatric procedures to patients on chronic steroids.

Prenatal Screening for 22q11.2 Deletion Using a Targeted Microarray-Based Cell-Free DNA Test.

Objective: To determine the performance of a targeted microarray-based cell-free DNA (cfDNA) test (Harmony Prenatal Test®) for the identification of pregnancies at increased risk for 22q11.2 deletion. Methods: Test performance was determined in 2 steps including a total of 1,953 plasma samples. Analytical validation was performed in 1,736 plasma samples. Clinical verification of performance was performed in an additional 217 prospectively ascertained samples from pregnancies with fetal deletion status determined by diagnostic testing. Results: Analytical sensitivity was 75.4% (95% CI: 67.1–82.2%) based on 122 samples with deletions ranging from 1.96 to 3.25 Mb. In 1,614 presumed unaffected samples, specificity was determined to be at least 99.5% (95% CI: 99.0–99.7%). In the clinical cohort, 5 of 7 samples from pregnancies affected with 22q11.2 deletion were determined to have a high probability of deletion. There were no false positive results in the 210 unaffected samples in this cohort. These clinical data are consistent with the performance demonstrated in the analytical validation. Conclusions: cfDNA testing using a targeted microarray-based technology is able to identify pregnancies at increased risk for 22q11.2 deletions of 3.0 Mb and smaller while maintaining a low false positive rate.

Near-perfect compliance with SCIP Inf-9 had no effect on catheter utilization or urinary tract infections at an academic medical center

BACKGROUND The Joint Commissions SCIP Inf-9 mandated early removal of indwelling urinary catheters (IUCs), but the impact of compliance on catheter-associated urinary tract infection (CAUTI) and postoperative urinary retention (POUR) are unknown. METHODS Retrospective pre- and post-intervention study at a single tertiary academic medical center of all patients undergoing general surgery procedures with an IUC placed at the time of surgery who were admitted for at least two days before and after a Best Practice Advisory was put in place to improve compliance with SCIP Inf-9. RESULTS A total of 1036 patients were included (468 pre-intervention; 568 post-intervention). POUR occurred in 13% of patients and CAUTI in 0.8%. There was no change in POUR, CAUTI, or catheter utilization after the Best Practice Advisory was initiated. Both POUR and CAUTI predicted longer lengths of stay. CONCLUSIONS Near-perfect SCIP Inf-9 compliance had no effect on the CAUTI rate at our institution.

Peripheral Arterial Disease in the Elderly

The prevalence of peripheral arterial disease (PAD) increases with age and can impact quality of life and independence in this population. Understanding risk factors for the disease and its natural history is key to informed conversations with patients. Here we review approaches to diagnosis, medical management, exercise therapy, and revascularization for older patients across the spectrum of PAD. Patient education, lifestyle and risk factor modification, medical therapies, and exercise are cornerstones of treatment for PAD in all age groups. Clinical decision-making in elderly patients with advanced PAD requires a careful assessment of physiologic reserve, surgical risk, desired goals, and expected outcomes. An increasing array of options facilitates a tailored approach.