Karen A. Chojnacki

Impact of obesity on perioperative morbidity and mortality after pancreaticoduodenectomy.

BACKGROUND Obesity has been implicated as a risk factor for perioperative and postoperative complications. The aim of this study was to determine the impact of obesity on morbidity and mortality in patients undergoing pancreaticoduodenectomy (PD). STUDY DESIGN Between January 2000 and July 2007, 262 patients underwent PD at Thomas Jefferson University Hospital, of whom 240 had complete data, including body mass index (BMI; calculated as kg/m(2)) for analysis. Data on BMI, preoperative parameters, operative details, and postoperative course were collected. Patients were categorized as obese (BMI >or= 30), overweight (BMI >or= 25 and < 30), or normal weight (BMI < 25). Complications were graded according to previously published scales. Other end points included length of postoperative hospital stay, blood loss, and operative duration. Analyses were performed using univariate and multivariable models. RESULTS There were 103 (42.9%) normal-weight, 71 (29.6%) overweight, and 66 (27.5%) obese patients. There were 5 perioperative deaths (2.1%), with no differences across BMI categories. A significant difference in median operative duration and blood loss between obese and normal-weight patients was identified (439 versus 362.5 minutes, p = 0.0004; 650 versus 500 mL, p = 0.0139). In addition, median length of stay was significantly longer for BMI (9.5 versus 8 days, p = 0.095). Although there were no significant differences in superficial wound infections, obese patients did have an increased rate of serious complications compared with normal-weight patients (24.2% versus 13.6%, respectively; p = 0.10). CONCLUSIONS Obese patients undergoing PD have a substantially increased blood loss and longer operative time but do not have a substantially increased length of postoperative hospital stay or rate of serious complications. These findings should be considered when assessing patients for operation and when counseling patients about operative risk, but they do not preclude obese individuals from undergoing definitive pancreatic operations.

Robot-assisted minimally invasive esophagectomy is equivalent to thoracoscopic minimally invasive esophagectomy

The use of the surgical robot has been increasing in thoracic surgery. Its three-dimensional view and instruments with surgical wrists may provide advantages over traditional thoracoscopic techniques. Our initial experience with thoracoscopic robot-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer was compared with our traditional thoracoscopic minimally invasive esophagectomy (MIE) approach for esophageal cancer. A retrospective review of a prospective database was performed. From July 2008 to October 2009, 43 patients underwent MIE resection. Patients who had benign disease and intrathoracic anastomosis were excluded. Results are presented as mean ± SD. Significance was set as P < 0.05. Eleven patients who underwent RAMIE and 26 who underwent MIE were included in the cohort. No differences in age, sex, race, body mass index, or preoperative radiotherapy or chemotherapy between the groups were observed. No significant differences in operative time, blood loss, number of resected lymph nodes, postoperative complications, days of mechanical ventilation, length of intensive care unit stay, or length of hospital stay were also observed. In this short-term study, RAMIE was found to be equivalent to thoracoscopic MIE and did not offer clear advantages.

Oncologic Efficacy Is Not Compromised, and May Be Improved with Minimally Invasive Esophagectomy

BACKGROUND Major morbidity and mortality rates continue to be high in large series of transthoracic esophagectomies. Minimally invasive approaches are being increasingly used. We compare our growing series of minimally invasive (combined thoracoscopic and laparoscopic) esophagectomies (MIEs) with a series of open transthoracic esophagectomies. STUDY DESIGN We identified 65 patients who underwent an MIE with thoracoscopy/laparotomy (n = 11), Ivor Lewis (n = 2), or 3-hole approach (n = 52). These patients were compared with 53 patients who underwent open Ivor-Lewis esophagectomy (n = 15) or 3-hole esophagectomy (n = 38) over the past 10 years. RESULTS The MIE and open groups were similar regarding gender and average age. The majority of patients in the open group underwent neoadjuvant chemoradiation therapy (81%); a significantly smaller (43%) number of patients in the MIE group underwent neoadjuvant therapy (p < 0.0001). Regarding oncologic efficacy, 97% and 94% of patients in both groups underwent R0 resections. Patients undergoing MIE had a significant increase in the number of harvested lymph nodes (median 20 vs 9; p < 0.0001). Length of stay was significantly decreased in patients who underwent MIE (8.5 days vs 16 days; p = 0.002). Finally, there were significantly fewer serious complications (grades 3-5) in the MIE group (19% vs 48%; p = 0.0008). CONCLUSIONS In this initial report of a single-institution series of MIE, we demonstrate that oncologic efficacy is not compromised and may actually be improved with a significantly increased number of harvested LNs. We also demonstrate that this approach is associated with fewer serious complications and a significant decrease in the length of postoperative hospital stay.

Grit: A marker of residents at risk for attrition?

BACKGROUND Attrition from general surgery residency remains constant at approximately 20% despite nearly a decade of work-hour reform and studies aiming to identify common risk factors. High rates of attrition from training have a wide impact, from the overall quality of trainees produced to implications on public health and the broader surgical work force. We set out to evaluate a novel character trait, grit, defined as passion and perseverance for long-term goals, as a marker and potential risk factor for resident attrition. METHODS Twelve Accreditation Council for Graduate Medical Education-approved general surgery residency programs participated in a prospective, multi-institutional, survey-based analysis of grit and attrition during the 2012-2013 academic year. Participating individuals were blinded with regards to the primary outcome of the study. Participating institutions were blinded to the responses of their trainees. Participating residency programs were located in a variety of settings, from university-based health systems to community hospitals. RESULTS Sixty-eight percent (68%) of residents (180 of 265) at participating institutions completed the study. The primary end point for this study was attrition from residency as a function of grit. Secondary end points included an evaluation of the utility of the grit score in surgical residents, variability of grit according to postgraduate year, sex, measurements of resident satisfaction with current program, lifestyle, and career goals. Finally, the study included an analysis of key resident support strategies. The attrition rate across 12 institutions surveyed was approximately 2% (5 residents). Of those five, three participated in our study. All three had below-median levels of grit. Those residents with below-median grit were more likely to contemplate leaving surgical residency. Given the low attrition rate, no variable surveyed reached statistical significance in our analysis. Key support strategies for residents responding included family, friends outside of residency, co-residents, and formal mentorship through their particular residency. CONCLUSION In this preliminary underpowered study, grit appears to be a promising marker and risk factor for attrition from surgical residency. In an effort to retain residents, programs should consider screening for grit in current residents and directing support to those residents with below-median values, with a focus on building family, friend, and formal mentor relationships.

Minimally Invasive Esophagectomy Provides Significant Survival Advantage Compared with Open or Hybrid Esophagectomy for Patients with Cancers of the Esophagus and Gastroesophageal Junction

BACKGROUND Minimally invasive esophagectomy (MIE) is increasingly being used to treat patients with cancer of the esophagus and gastroesophageal junction. We previously reported that oncologic efficacy may be improved with MIE compared with open or hybrid esophagectomy (OHE). We compared survival of patients undergoing MIE and OHE. STUDY DESIGN Our contemporary series of patients who underwent MIE (2008 to 2013) was compared with a cohort undergoing OHE (3-hole [n = 39], Ivor Lewis [n = 16], hybrid [n = 13], 2000 to 2013). Summary statistics were calculated by operation type; Kaplan-Meier methods were used to compare survival. Cox regression was used to assess the impact of operation type (MIE vs OHE) on mortality, adjusting for age, sex, total lymph nodes, lymph node ratio (LNR), neoadjuvant chemoradiotherapy (CRT), and stage. RESULTS The MIE (n = 104) and OHE (n = 68) groups were similar with respect to age and sex. The MIE group tended to have higher BMI, earlier stage disease, and was less likely to receive CRT. The MIE group experienced lower operative mortality (3.9% vs 8.8%, p = 0.35) and significantly fewer major complications. Five-year survival between groups was significantly different (MIE, 64%, OHE, 35%, p < 0.001). Multivariate analysis demonstrated that patients undergoing OHE had a significantly worse survival compared with MIE independent of age, LNR, CRT, and pathologic stage (hazard ratio 2.00, p = 0.019). CONCLUSIONS This study supports MIE for EC as a superior procedure with respect to overall survival, perioperative mortality, and severity of postoperative complications. Several biases may have affected these results: earlier stage in the MIE group and disparity in timing of the procedures. These results will need to be confirmed in future prospective studies with longer follow-up.

Gastroduodenal intussusception of a gastrointestinal stromal tumor (GIST): case report and review of the literature.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors in adults. They frequently occur in the stomach. Gastric GISTs typically present as a gastrointestinal bleed but can sometimes cause obstructive symptoms such as nausea and vomiting. We present a patient with a gastric GIST and liver metastases who during treatment with iminitab therapy presented with an acute gastric outlet obstruction. A computed tomography scan revealed a gastroduodenal intussusception of the gastric GIST. The patient underwent a laparoscopic exploration and resection of the GIST. We reviewed the English language literature of GISTs that presented as a gastroduodenal intussusception and put our case in the context of the previously reported cases. We discuss the diagnostic and therapeutic challenges that arise when treating these patients.

Massive Portal Venous Air and Pneumatosis Intestinalis Associated with Cocaine-Induced Mesenteric Ischemia

BackgroundWe report a 53-year-old female who presented to the emergency department in distress with an acute abdomen after recreational use of cocaine.DiscussionThe patient’s computed tomography scan revealed extensive portal venous air with small-bowel pneumatosis intestinalis resulting from intestinal ischemia. Air could be seen throughout the superior mesenteric vein, portal vein, and hepatic portal venous distribution. The patient underwent extensive resuscitation and resection of small bowel requiring three operative interventions. A pertinent review of the literature of cocaine-induced small-bowel ischemia is provided covering the pathophysiology, clinical findings, and epidemiology.ConclusionCocaine-induced mesenteric ischemia is a serious disease causing significant morbidity and mortality. Operative therapy is often required.

Operative Management of Bile Duct Strictures

Abstract Bile duct strictures are common and result from both benign and malignant conditions. The most common causes include surgery of the gallbladder or biliary tree, other endoscopic or percutaneous interventions, or inflammatory or congenital conditions. The clinical presentation varies based upon the etiology of the bile duct stricture. Radiologic evaluation is essential to define the anatomy of the biliary tree and for planning of corrective intervention. Surgical management of bile duct strictures can involve either early repair or staged late repair. Control of sepsis is an important element that helps to determine the proper timing of repair. The most common operative approach to bile duct stricture repair involves Roux-en-Y hepaticojejunostomy. The use of transhepatic or transanastomotic biliary stenting at the time of stricture repair is controversial. The postoperative complication rates range between 20% and 40% in the literature, with mortality rates being in the 1% to 3% range. In all, bile duct injuries and strictures should be considered complex problems requiring a multidisciplinary approach involving surgeons, radiologists, and gastroenterologists. Excellent outcomes can be achieved in the majority of cases.

Fundamentals of Operating Room Setup and Surgical Instrumentation

The focus of this chapter will be to introduce the general principles of how operating rooms are designed in order to provide surgical interventions that improve patients’ lives. Although the basic operating room design was first heralded in the nineteenth century, today’s advances have introduced complex surgical equipment that necessitates integration in a fixed space. Moreover, in order to be able to effectively and efficiently carry out a surgical procedure, a highly reliable interdisciplinary and integrated team is necessary. This chapter will provide the reader with a basic overview of the operating room, the key players that work in this environment, and the commonly utilized equipment and instruments.

Mo1726 Laparoscopic Versus Open Esophagectomy: A Clinical and Cost Analysis

8-10) was reported by 13 (77 %) patients and good (grade 6-7) by 3 (18%) patients. The majority (88%) of patients stated that they would recommend the procedure to a friend if needed. Conclusion: RF can be safely performed laparoscopically in the majority of patients ≥ 65 years of age for recurrent GERD after initial fundoplication. The long-term postoperative outcomes in this subset of patients are satisfactory though associated with high peri-operative morbidity.