Mark Joseph

Single incision laparoscopic cholecystectomy is associated with a higher bile duct injury rate: a review and a word of caution.

Objective: To compare the incidence of bile duct injuries during single incision laparoscopic cholecystectomy (SILC) in relation to the accepted historic rate of 0.4% to 0.5% for standard laparoscopic cholecystectomy (SLC). Background: Technically, SILC is more challenging than SLC. The role and benefit of SILC in patient care has yet to be defined. Bile duct injuries have been reported in several series of SILC. Method: A comprehensive database search of MEDLINE, EMBASE, CINAHL, and PubMed Central was performed to generate all reported cases of SILC to present. The search was limited to reports of 20 or more patients based on current literature of existing SILC learning curves. Data were analyzed using the Student t test and &khgr;2 analyses where appropriate. Results: A total of 76 candidate studies were identified; 45 studies met inclusion criteria for an aggregate total of 2626 patients. Most SILCs were performed in the absence of acute cholecystitis (90.6%). The aggregate complication rate was 4.2%, and complications were graded according to the Dindo-Clavien Classification System. Nineteen bile duct injuries were identified for a SILC-associated bile duct injury rate of 0.72%. Conclusions: There seems to be an increase in the rate of bile duct injuries during SILC when compared with historic rates during SLC. Because most SILCs are performed in optimal conditions, such as lack of acute inflammation, we urge caution in applying this technique to inflamed gallbladder pathology. Controlled trials are needed before conclusions are made regarding safety of SILC.

Rapid On-Site Pathologic Evaluation Does Not Increase the Efficacy of Endobronchial Ultrasonographic Biopsy for Mediastinal Staging

BACKGROUND Endobronchial ultrasonography with transbronchial needle aspiration (EBUS-TBNA) has been shown to be equivalent to mediastinoscopy in lung cancer staging for mediastinal node involvement. Rapid on-site evaluation (ROSE) to determine the adequacy of nodal sampling has been claimed to be beneficial. METHODS A retrospective evaluation was performed in 170 patients who underwent EBUS-TBNA from July 2008 to May 2011. The patients were classified as having either high or low pretest probability for mediastinal disease based on history and radiographic imaging. ROSE was compared with the final pathology reports based on slides and cell blocks. RESULTS One hundred thirty-one (77%) patients were classified as being in the high pretest cohort based on clinical staging. Of these, 101 (77%) patients had adequate tissue sampling based on ROSE, with 70 (69%) patients having positive mediastinal disease. In the 30 (23%) patients who had inadequate tissue by ROSE, the final analysis of all the prepared slides and cell blocks allowed for a diagnosis in all but 8 patients. The sensitivity and specificity of ROSE in the high pretest probability cohort were 89.5% and 96.4%, respectively, whereas the overall sensitivity and specificity of EBUS-TBNA was 92.1% and 100%, respectively. Despite having inadequate tissue on ROSE in 30 of 131 patients, sufficient tissue was available on final analysis for diagnosis in 22 of 30 patients. CONCLUSIONS ROSE does not impact clinical decision making if a thorough mediastinal staging using EBUS is performed. Despite inadequate tissue sampling assessment by ROSE, a final diagnosis was made in most patients, potentially avoiding an additional surgical procedure to prove mediastinal disease.

Can residents safely and efficiently be taught single incision laparoscopic cholecystectomy

OBJECTIVE Single incision laparoscopic cholecystectomy (SILC) has recently emerged as an option for selected patients undergoing gallbladder removal. While SILC appears safe when performed by experienced surgeons under controlled conditions, there are no studies evaluating the SILC learning curve for incorporation into resident education and the effect on OR efficiency. DESIGN, SETTING, AND PARTICIPANTS Chief residents were taught and evaluated by a single attending surgeon facile with SILC techniques. Residents were transitioned from assistants to primary surgeon during their clinical rotation. Outcomes data were prospectively tabulated compared with data from standard laparoscopic SLC and attending surgeon SILC outcomes. The setting was an academic, tertiary care teaching hospital. Participants were chief residents rotating on hepatobiliary surgery service. Residents previously had demonstrated mastery of basic laparoscopic surgical techniques. RESULTS Seven chief residents were evaluated with a total of 49 SILCs with a mean of 7 (range 5-12) SILCS/resident. Five conversions to SLC occurred, all within the first 3 SILCs performed by the resident as operative surgeon. Mean blood loss was 30 mL. Median length of stay was <1 day. Average length of operation increased after the first 2 cases, reflecting the transition of the attending surgeon from primary surgeon to assistant role. By the fifth case, operative times returned to the attending surgeon SILC baseline and historical operative times for SLC at our institution. Factors associated with longer-length of surgery were increasing BMI and presence of acute or chronic cholecystitis, choledocholithiasis, and use of intraoperative cholangiogram. Five postoperative complications occurred and were not associated with position along the residents learning curve. One death occurred due to metastatic laryngeal cancer within 30 days of SILC. CONCLUSIONS Residents can safely be taught the techniques of SILC with minimal disruption to operating room efficiency. Residents already proficient in the use of standard laparoscopic techniques transition to SILC quickly with a short learning curve and proper instruction.

Early extracorporeal life support as rescue for Wegener granulomatosis with diffuse alveolar hemorrhage and acute respiratory distress syndrome: a case report and literature review.

Objective The study’s objective was to report a case and review the literature on the use of extracorporeal life support in the face of severe pulmonary hemorrhage for acute respiratory distress syndrome. Study Selection This study is a single case report of a pediatric patient who was successfully managed on venovenous extracorporeal life support for severe acute respiratory distress syndrome with acute pulmonary hemorrhage secondary to Wegener disease. Conclusions Extracorporeal life support can be used successfully in selected patients with respiratory failure with pulmonary hemorrhage. The cautious use of anticoagulation should be balanced with the risk of bleeding, mindful of the need for other measures to mitigate severe bleeding if this should occur.

Laparoscopic-assisted percutaneous gastrostomy tube placement in the initial management of resectable esophageal and gastroesophageal junction carcinoma.

T U l m s a i m a f c w alnutrition and weight loss secondary to dysphagia are ommon presenting symptoms in patients with resectable sophageal and gastroesophageal (GE) junction cancers. pwards of 80% of patients with esophageal cancer may be alnourished. Many of these patients will subsequently ndergo neoadjuvant chemotherapy or chemoradiotherpy, both of which may intensify the malnutrition caused y the inability to eat and may lead to treatment delays. espite nutritional supplementation, some of these paients will require additional means of nutritional alimenation. Although esophageal stenting will alleviate sympoms in some patients, a feeding tube will be needed in any. Evidence clearly indicates the use of enteral nutriion to be effective in patients with dysphagia or those eceiving radiation to the head and neck, along with critially ill patients with impaired gastric emptying. The quesion remains as to what type of enteral access to use if atients cannot have adequate oral intake. In patients with esophageal or GE junction cancer, this as traditionally been accomplished in one of two ways: ejunostomy or gastrostomy. Jejunostomy tube placement as the advantage of avoiding use of the stomach, which ill commonly be used to restore gastrointestinal continuty at the time of definitive resection. However, it has most ommonly been performed as an open procedure because ercutaneous and laparoscopic approaches to jejunostomy, lthough described, have not gained widespread accepance and may require more advanced technical skills. As uch, this often requires an inpatient hospitalization after ube placement. In addition, jejunostomy tubes have a igher rate of complication than gastrostomy tubes, and atients may find them more difficult to manage. Gastrosomy has most commonly been accomplished via percutaeous endoscopic (PEG) means and has the advantage of

Single Incision Laparoscopic Cholecystectomy: A Combined Analysis of Resident and Attending Learning Curves at a Single Institution

Single-incision laparoscopic cholecystectomy (SILC) is a recent technical modification on standard laparoscopic cholecystectomy that has been shown to be safe and feasible. Recent studies suggest that experienced laparoscopic surgeons have a short learning curve to become proficient in SILC. However, little is known about the interaction of the learning curves of residents and attending surgeons at academic programs. We prospectively evaluated various metrics of both attending and resident surgeons as they progressed in their experience with SILC. Patients were placed into cohorts of 25 based on teaching surgeon experience. Data recorded included patient-specific and operative variables along with complications, conversion to standard laparoscopic cholecystectomy, and outcomes. One hundred one patients underwent SILC. Twelve per cent of patients required conversion to standard laparoscopic cholecystectomy. No significant difference was found in operative times compared within the experience-based cohorts (P = 0.21). A reduction in operative time was shown in residents who were proficient in standard laparoscopic cholecystectomy (SLC) along their learning curve. Operative times remained the same for the teaching surgeon regardless of experience of resident surgeon. SILC has a short learning curve for resident surgeons who are proficient in standard laparoscopic surgery. SILC can be effectively taught with few complications and outcomes similar to SLC with preservation of operative efficiency and safety. Further studies are warranted, however, at a national/international level to define the place and use for SILC as well as the incorporation of single-incision techniques into resident curriculum.

Use of a new novel humidification system with high frequency percussive ventilation in a patient with inhalation injury

Historically, it has been difficult to provide adequate humidification delivery with the high frequency percussive ventilator (HFPV) used in many burn centers. It is possible burn centers have avoided using HFPV because of the risk of mucus plugging, dried secretions, and cast formation. Experiences with HFPV provided doubt that the HFPV ventilator circuit could supply adequate humidification to patients receiving this mode of ventilation. Independent gas-flow delivery through the ventilator circuit inherent in HFPV provided a challenge in maintaining adequate humidification delivery to the patient. This report describes a dramatic reduction in dried, inspissated secretions by using a novel new humidification device with HFPV. The new device called the Hydrate Omni (Hydrate, Inc., Midlothian, VA) uses a small ceramic disk to provide fine water particles delivered by a pump to the HFPV circuit. This new device may alleviate previous concerns related to the delivery of adequate humidification with the HFPV. This case report was approved by the University of North Carolina School of Medicine Institutional Review Board.

Hybrid atrial fibrillation ablation via direct right atrial approach: first-ever case.

A 60-year-old female with persistent atrial fibrillation (AF) and flutter was referred for hybrid AF ablation. She had an occluded inferior vena cava filter from a history of deep vein thrombosis and pulmonary embolism. Via a right mini-thoracotomy, the pericardium was accessed …

Congenital tracheobiliary fistula combined with hypoplastic common hepatic duct: Management by percutaneous transhepatic drainage

Congenital tracheobiliary or bronchobiliary fistula is a rare developmental anomaly with a persistent communication between the biliary system and the trachea or bronchus. We report a case of a congenital tracheobiliary fistula and hypoplastic common hepatic duct associated with hypoplastic left heart syndrome in a 5-day old boy presenting with bilious endotracheal-tube secretions. The tracheobiliary fistula was treated by surgical resection. Subsequent cholangiography demonstrated dilated intrahepatic bile ducts and a residual fistulous tract with cystic proximal stump that were successfully decompressed by transhepatic drainage catheters before corrective biliary surgery.