John Kuckelman

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.

Smartphone-based mobile thermal imaging technology to assess limb perfusion and tourniquet effectiveness under normal and blackout conditions

BACKGROUND Over the past decade, there has been a resurgence of tourniquet use in civilian and military settings. Several key challenges include assessment of limb perfusion and adequacy of tourniquet placement, particularly in the austere or prehospital environments. We investigated the utility of thermal imaging to assess adequacy of tourniquet placement. METHODS The FLIR ONE smartphone-based thermal imager was utilized. Ten swine underwent tourniquet placement with no associated hemorrhage (n = 5) or with 40% hemorrhage (n = 5). Experiment 1 simulated proper tourniquet application, experiment 2 had one of two tourniquets inadequately tightened, and experiment 3 had one of two tourniquets inadequately tightened while simulating blackout-combat conditions. Static images were taken at multiple time points up to 30 minutes. Thermal images were then presented to blinded evaluators who assessed adequacy of tourniquet placement. RESULTS The mean core temperature was 38.3 °C in non-hemorrhaged animals versus 38.2 °C in hemorrhaged animals. Hemorrhaged animals were more hypotensive (p = 0.001), anemic (p < 0.001), vasodilated (p = 0.008), and had a lower cardiac output (p = 0.007) compared to non-hemorrhaged animals. The thermal imaging temperature reading decreased significantly after proper tourniquet placement in all animals, with no difference between hemorrhaged and non-hemorrhaged groups at 30 minutes (p = 0.23). Qualitative thermal image analysis showed clearly visible perfusion differences in all animals between baseline, adequate tourniquet, and inadequate tourniquet in both hemorrhaged and non-hemorrhaged groups. Ninety-eight percent of blinded evaluators (n = 62) correctly identified adequate and inadequate tourniquet placement at 5 minutes. Images in blackout conditions showed no adverse impact on thermal measurements or in the ability to accurately characterize perfusion and tourniquet adequacy. CONCLUSIONS A simple handheld smartphone-based forward looking infrared radiometry device demonstrated a high degree of accuracy, reliability, and ease of use for assessing limb perfusion. Forward looking infrared radiometry also allowed for rapid and reliable identification of adequate tourniquet placement that was not affected by major hemorrhage or blackout conditions.

Standard vs Expanded Indications for Esophageal Magnetic Sphincter Augmentation for Reflux Disease

PACIFIC COAST SURGICAL ASSOCIATION Standard vs Expanded Indications for Esophageal Magnetic Sphincter Augmentation for Reflux Disease Magnetic sphincter augmentation (MSA) has proven to be safe and effective for appropriate candidates with gastroesophageal refluxdisease(GERD).1 Standardindicationsincludepatientswith GERD, normal motility, body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) <35, no prior foregut surgery, and no or small (<3 cm) hiatal defect. Although many surgeons are now offering MSA to candidates with expanded criteria, there are scant data on outcomes in these patients. Our aim was to evaluate the postoperative outcomes associated with MSA for expanded indications.

Panniculectomy after bariatric surgical weight loss: Analysis of complications and modifiable risk factors

INTRODUCTION Bariatric surgery results in massive weight loss, leaving many patients with redundant skin that can cause significant physical and psychosocial limitations. We sought to identify variables associated with postoperative complications and adjuncts associated with the mitigation of postoperative complications. METHODS A retrospective review was performed of all post-bariatric surgery patients who underwent panniculectomy over a 10-year period. RESULTS Total 706 patients included. Overall complication rate was 56%: dehiscence (24%), surgical site infection (22%), seroma (18%), and post-operative bleeding (5%). Return to operating room rate was 12%. Significant factors were: BMI >26 (p < 0.01), fleur-de-lis panniculectomy (p < 0.01), concomitant hernia repair (p < 0.01). Multivariate regression analysis demonstrated ASA class >2 (OR 1.97, p < 0.05) and incision type (OR 1.64, p < 0.05) to be independent predictors of morbidity. CONCLUSION High morbidity for post-bariatric panniculectomy is primarily local wound complications. Potentially modifiable factors that increase the complication risk profile include higher BMI, higher ASA class, and the use of fleur-de-lis incision.

Esophageal Magnetic Sphincter Augmentation as a Novel Approach to Post-bariatric Surgery Gastroesophageal Reflux Disease

BackgroundWe sought to evaluate the safety and effectiveness of magnetic sphincter augmentation (MSA) in patients with GERD after bariatric surgery.MethodsPre- and post-operative GERD quality of life (G-QOL) surveys were conducted. Standard indications (SI) group or the post-bariatric group (PB) created. Outcomes were compared between groups.ResultsTwenty-eight patients analyzed with no losses to follow-up. All patients had preoperative testing confirming normal motility and presence of GERD. No patients were lost to follow-up. The PB group (N = 10) were mostly prior sleeve gastrectomies (N = 8) with two previous gastric bypasses. PB patients required larger MSA device size (16 beads) compared to the SI group (14 beads, p < 0.001). Outcomes were no different with percent improvement between pre- and post-operative G-QOL survey scores with 70% improvement for PB and 84% for SI (p = 0.13). Medication cessation was possible in 90% for PB versus 94% for SI (p = 0.99). Rates of post-operative dysphagia were similar between the two groups.ConclusionsAlthough larger prospective randomized studies are needed, there is an exciting potential for the role of MSA, providing surgeons a new and much needed tool in their armamentarium against refractory or de novo GERD after bariatric procedures.

Care of the Postoperative Pulmonary Resection Patient

Patients undergoing pulmonary resection all exhibit, to some degree, a level of pulmonary dysfunction. This is due to the physiologic stress of the procedure performed, the patient’s comorbidities, and preexisting cardiopulmonary reserve. Although prognostic factors for intensive care requirement exist, to date, there is no consensus for postoperative admission. Institutional practices vary across the country, with patients often admitted to intensive care for surveillance. Guidelines published from the American Thoracic Society in 1999 emphasize that admission to the ICU be reserved for those patients requiring care and monitoring for severe physiologic instability. Admissions following pulmonary resection are typically due to respiratory complications and are an independent predictor of mortality. The following chapter will review the indications for admission to the ICU and common issues encountered following pulmonary resection and conclude with a discussion of the management of patients undergoing pulmonary transplantation.

MASCAL Management from Baghdad to Boston: Top Ten Lessons Learned from Modern Military and Civilian MASCAL Events

Purpose of ReviewThis article reviews the key steps required for preparation and execution of patient care during mass casualty (MASCAL) events.Recent FindingsThe experience provided by the recent conflicts in the Middle East as well as multiple civilian attacks or incidents resulting in mass number of casualties have afforded the health care providers with a wealth of data and experience to aid in the preparation and execution when forced to deal with this type of situation.SummaryThe following compiles the lessons learned by presenting the reader with ten critical concepts that are crucial to proper preparation and deployment of resources to effectively manage and successfully approach a mass casualty event.

Thoracic Trauma: a Combat and Military Perspective

Purpose of ReviewThis article reviews the finer points of thoracic trauma seen during combat and provides parallels to the civilian sector for potential implementation.Recent FindingsLessons learned during recent conflicts in Iraq (Operation Iraqi Freedom), Afghanistan (Operation Enduring Freedom) as well as the ongoing military actions targeting the Islamic State (ISIS) have equipped combat surgeons with a breadth of knowledge concerning the management of complex thoracic trauma. The unique environment provided by war inherently fosters the development of innovation. Management of combat injuries has become more crucial to all trauma surgeons, as high-velocity weaponry and global terrorism can produce similar injury patterns in the civilian trauma setting.SummaryThis review focuses on unique injuries seen in austere war-time environments with focus on thoracic trauma. Applications to civilian trauma are highlighted throughout the article with the hope that the experience gained by combat surgeons may aide in the advancement of trauma care.

Evaluation of a novel thoracic entry device versus needle decompression in a tension pneumothorax swine model

INTRODUCTION Tension pneumothorax (tPTX) remains a major cause of preventable death in trauma. Needle decompression (ND) has up to a 60% failure rate. METHODS Post-mortem swine used. Interventions were randomized to 14G-needle decompression (ND, n = 25), bladed trocar with 36Fr cannula (BTW, n = 16), bladed trocar alone (BTWO, n = 16) and surgical thoracostomy (ST = 11). Simulated tPTX was created to a pressure(p) of 20 mmHg. RESULTS Success (p < 5 mmHg by 120 s) was seen in 41 of 68 (60%) interventions. BTW and BTWO were consistently more successful than ND with success rates of 88% versus 48% in ND (p < .001). In successful deployments, ND was slower to reach p < 5 mmHg, average of 82s versus 26s and 28s for BTW and BTWO respectively (p < .001). Time to implement procedure was faster for ND with an average of 3.6s versus 16.9s and 15.3s in the BTW and BTWO (p < .001). Final pressure was significantly less in BTW and BTWO at 1.7 mmHg versus 7 mmHg in ND animals (p < .001). CONCLUSION Bladed trocars can safely and effectively tPTX with a significantly higher success rates than needle decompression.

Traumatic thoracic rib cage hernias: Operative management and proposal for a new anatomic-based grading system

BACKGROUND Traumatic Rib Cage Hernias (TRCH) requiring operative repair are rare and there is currently no literature to guiding surgical management. METHODS Perioperative review of TRCH over 32 years. Five operative grades were developed based on extent of tissue/bone damage, size, and location. RESULTS Twenty-four patients (20 blunt, 4 penetrating) underwent operative repair. Lung was the herniated organ in 88% with a median of 4 rib fractures and average size of 60.25 cm. Types of operation were well clustered by assigned TRCH grade. The majority required mesh (75%) and/or rib plating (79%). Complex tissue flap reconstruction was required in 10%. Full range-of-motion was maintained in 88% with79% returning to pre-injury activity levels. Five patients had continued pain at final follow up (mean = 7months). CONCLUSION The size and degree of injury has important implications in the optimal surgical management of TRCHs. These operative grades effectively direct surgical care for these rare and complex injuries.