Shanu N. Kothari

Training in Laparoscopic Suturing Skills Using a New Computer-Based Virtual Reality Simulator (MIST-VR) Provides Results Comparable to Those with an Established Pelvic Trainer System

BACKGROUND We hypothesized that the Minimally Invasive Surgery Trainer (MIST-VR; VP Medical R, London, U.K.) would be as effective as the Yale Laparoscopic Skills Course in improving laparoscopic intracorporeal suturing skills. MATERIALS AND METHODS Each student made six attempts to tie a knot laparoscopically. Students were then randomized to train on the MIST-VR for five sessions (six skills/session) or the Yale Skills for five sessions (three skills/session) over 5 days. On completion of training, all students were evaluated by a test consisting of six attempts to tie a laparoscopic knot. RESULTS The percentage improvement in knot tying time did not differ significantly in the pelvic trainer group (30 +/- 21%) (from 443 +/- 135 to 311 +/- 137 seconds) and the MIST-VR group (39 +/- 21%) (from 409 +/- 109 to 256 +/- 140 seconds) (P = 0.308). CONCLUSIONS The MIST-VR is equivalent to the Yale Skills Course for training in the advanced laparoscopic skill of intracorporeal suturing.

Effect of preoperative weight loss on laparoscopic gastric bypass outcomes

BACKGROUND Requiring patients to lose weight before weight reduction surgery is controversial. The goal of this study was to determine whether preoperative weight loss affects laparoscopic Roux-en-Y gastric bypass surgery outcomes. METHODS The medical records of all laparoscopic Roux-en-Y gastric bypass patients from September 1, 2001 to March 31, 2005 were retrospectively reviewed in our prospective database. Depending on their habitus, patients were selectively required to lose >4.54 kg (10 lb) preoperatively (WL group). Their outcomes were compared with those of the patients not required to lose weight preoperatively (no-WL group). Statistical analysis was performed with the chi-square test and Students t test for demographic data. Students t test was used to assess the outcome data. P <.05 was considered significant. RESULTS Of the 353 patients, 74 (21%) were in the WL group. The operative times in the WL group averaged 10 minutes longer than in the no-WL group (P = .022). The mean length of stay was not significantly different between the 2 groups. Of the 353 patients, 262 (74%) completed 1 year of follow-up. The mean net postoperative weight loss was not significantly different between the 2 groups. The no-WL patients had a greater percentage of excess postoperative weight loss than the WL group (74% versus 66%; P = .01). Net complications occurred less frequently in the WL group (P = .035). CONCLUSION Preoperative weight loss did not decrease the operative times or the length of stay. Preoperative weight loss increased neither the mean net postoperative weight loss nor the percentage of excess postoperative weight loss at 1-year follow-up. However, the WL group had fewer net complications.

Ascorbic acid deficiency in bariatric surgical population.

BACKGROUND To determine the prevalence of ascorbic acid deficiency in the surgical population, whether the body mass index (BMI) has an effect on ascorbic acid concentrations; and whether an association exists between ascorbic acid deficiency and adverse surgical outcomes. METHODS Preoperative plasma ascorbic acid concentrations were prospectively assessed in 20-60-year-old patients undergoing elective abdominal surgery. Ascorbic acid deficiency was defined as any concentration < or =0.3 mg/dL and depletion as any concentration >0.3-0.59 mg/dL. RESULTS Of the 266 patients evaluated, 167 had a BMI > or =35 kg/m(2). A greater BMI was associated with lower mean ascorbic acid concentrations (P = .021). Of the 266 patients, 96 (36%) had abnormally low ascorbic acid concentrations, with 57 (21%) depleted and 39 (15%) deficient. The factors associated with decreased mean ascorbic acid concentrations included younger age (P = .004) and limited vegetable and fruit intake (P = .026). Ascorbic acid supplementation was associated with lower depletion and deficiency rates (P = .001). CONCLUSION Ascorbic acid depletion and deficiency occur within the surgical population. The contributing factors included younger age, limited intake of fruits and vegetables, lack of vitamin supplementation, and greater BMI. Low concentrations of ascorbic acid did not affect the surgical outcome.

Number of weight loss attempts and maximum weight loss before Roux-en-Y laparoscopic gastric bypass surgery are not predictive of postoperative weight loss

BACKGROUND Many insurance companies have mandated that bariatric surgery candidates already satisfying the National Institutes of Health criteria make an additional attempt at medically supervised weight loss. The objective of this study was to determine whether a correlation exists between the number of weight loss attempts (WLAs) or maximal preoperative weight loss (MWL) and the percentage of excess weight loss (%EWL) after laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery. METHODS The WLAs and MWL data were collected by bariatric medical record review. The postoperative %EWL was obtained by retrospective review of a prospectively enrolled bariatric database. Patients whose records contained 1 year of follow-up data and either the WLAs or MWL were included in the study. The data were analyzed using Pearson correlations and odds ratios. RESULTS From September 2001 to 2006, 530 patients underwent LRYGB. Of these, 384 met the study criteria (82.6% were women). The mean WLAs was 4.3+/-1.8. The mean MWL was 46.6+/-31.2 lb (21.2+/-14.2 kg). At surgery, the mean patient age was 43.3+/-9.3 years, and the mean body mass index was 48.0+/-5.9 kg/m2. At 1 year after LRYGB, the mean body mass index was 30.2+/-5.0 kg/m2, and the mean %EWL was 72.3%+/-15.3%. Statistical analysis revealed no correlations between the %EWL at 1 year after LRYGB and the WLAs (R2=.011) or MWL (R2=.005). CONCLUSION Neither the WLAs nor the MWL correlated with the %EWL at 1 year after LRYGB. Our results showed no evidence that the WLAs or MWL before surgery correlates with the %EWL in patients undergoing LRYGB.

Intensive care unit stay not required for patients with obstructive sleep apnea after laparoscopic Roux-en-Y gastric bypass

BACKGROUND Many programs admit morbidly obese patients with obstructive sleep apnea (OSA) to the intensive care unit after laparoscopic gastric bypass (LGB), fearing pulmonary complications. Our practice has been to admit these patients to the surgical floor. Our objective was to compare the perioperative course and outcomes in morbidly obese patients with OSA to those of patients without OSA undergoing LGB in a physician-led health system with a 325-bed community teaching hospital serving 19 counties. METHODS We retrospectively reviewed the medical records of 650 patients who had undergone LGB from 2001 to 2008 and divided them into 2 groups: patients with OSA as confirmed by polysomnography (OSA group) and those without OSA (non-OSA group). The patients who reported a diagnosis of OSA without documentation confirming the diagnosis were excluded. The statistical analysis included t tests and chi-square tests. RESULTS A total of 217 patients met the inclusion criteria for the OSA cohort and 368 for the non-OSA cohort. Of the 650 patients, 65 reported a history of OSA without confirmation and were excluded from the present study, leaving 585 patients. The demographic data were similar between the 2 groups, and no difference was found between the OSA and non-OSA groups for the length of postanesthesia care unit stay (105.4 versus 106.3 minutes), length of hospital stay (2.2 days for both groups), and 30-day major complication rate (3.7% versus 5.2%). No deaths and no intensive care unit admissions for pulmonary complications occurred in either group. CONCLUSION The results of our study have shown that morbidly obese patients with OSA undergoing LGB have a perioperative course and postoperative pulmonary complication rate similar to that of patients without OSA. Thus, routine admission to the intensive care unit after LGB in patients with OSA is not indicated.

Laparoscopic Telescope with Alpha Port and Aesop to View Open Surgical Procedures

Laparoscopy has advanced surgery by allowing the surgeon to operate within a patients abdominal and pelvic cavity with minimal trauma and scarring. The coupling of a video camera to the laparoscopic telescope has had the secondary effect of allowing others to view the surgical field either on color video monitors or by watching the video feed over the Internet at a remote location. These advancements have allowed better teaching and mentoring of operations. Open procedures can benefit from this technology as well but have suffered in the past from inadequate methods to depict the open surgical field. We used the Alpha Port and Aesop robot to position a sterile laparoscopic telescope near the surgical field to view open cholecystectomies performed on five pigs and to send the video feed over the Internet to remote physicians. Viewing the video on the monitor, the surgeons performed the operation in a comfortable ergonomic upright position. Both the surgeons and the remote physicians found the quality of the video to be excellent, and the remote physicians felt comfortable learning and mentoring surgical procedures using this technique.

Natural history and metabolic consequences of morbid obesity for patients denied coverage for bariatric surgery

BACKGROUND Patients satisfying the National Institutes of Health criteria and deemed appropriate candidates often do not undergo bariatric surgery for insurance-related reasons. Our objective was to explore the natural history of these patients compared with that of those who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS The medical records of the patients evaluated for LRYGB from 2001 to 2007 were retrospectively reviewed. The presence of co-morbidities was assessed at the initial evaluation and within a 3-year follow-up period for patients who had undergone LRYGB and those denied surgery. The statistical analysis included chi-square tests. RESULTS A total of 189 patients were in the denied cohort and 587 in the LRYGB cohort. The age, gender, and body mass index were similar between the 2 cohorts at the initial evaluation. The percentage of patients with a diagnosis of a co-morbidity in the denied and LRYGB cohorts at the initial evaluation was 20% and 25% with diabetes mellitus, 51% and 43% with hypertension, 20% and 22% with obstructive sleep apnea, 34% and 24% with lipid disorders, and 62% and 49% with gastroesophageal reflux disease, respectively. The body mass index at the initial evaluation and during follow-up was 47.3 and 46.8 kg/m(2) in the denied cohort (n = 165, P = .236) and 48.5 and 30.5 kg/m(2) in the LRYGB cohort (n = 544, P <.001), respectively. During the follow-up period, a greater incidence of new-onset diabetes (P <.001), hypertension (P <.001), obstructive sleep apnea (P <.001), gastroesophageal reflux disease (P <.001), and lipid disorders (P <.001) was observed in the denied cohort. CONCLUSION Patients denied LRYGB had a greater incidence of new co-morbidities diagnosed within a short follow-up period, without a significant change in their body mass index.

Advanced laparoscopic fellowship and general surgery residency can coexist without detracting from surgical resident operative experience.

OBJECTIVE Concern has been voiced that general surgery residents who train at institutions that also offer advanced laparoscopic fellowships may receive inadequate advanced laparoscopic operative experience. The purpose of our study was to compare the operative experience of general surgery residents who graduated from our institution before initiation of an advanced laparoscopic fellowship with the experience of those who graduated after the fellowship began. METHODS Operative case logs of surgery residents who graduated from 2000 through 2007 and of advanced laparoscopic fellows from 2004 through 2007 were reviewed. Surgery resident experience with basic and nonbariatric advanced laparoscopic cases during the 4 years before the fellowship was compared with the experience during the 4 years after the fellowship began. RESULTS Residents who graduated before 2004 performed a mean of 140.5 +/- 19.4 basic and 77.0 +/- 17.8 advanced laparoscopic cases during their 5-year residency, compared with 193.3 +/- 34.5 basic (p = 0.003) and 113.3 +/- 23.5 advanced cases (p = 0.005) performed by those who graduated in 2004 or later. The number of nonbariatric advanced laparoscopic cases performed by each graduating surgical resident during the chief year ranged from 26 to 47 cases from 2000 to 2003 and from 36 to 69 cases from 2004 to 2007. Fellows reported from 40 to 85 nonbariatric advanced laparoscopic cases annually. CONCLUSIONS General surgery residents did not experience a reduction in the total number of basic and nonbariatric advanced laparoscopic cases with the addition of an advanced laparoscopic fellowship, nor did they perform fewer cases during the chief year. As the result of a cooperative venture between the surgery residency and fellowship directors as well as an expansion of the total number of laparoscopic cases performed at our institution because of changes in clinical practice, surgery residents reported an increase in the number of laparoscopic cases while a successful fellowship was established.

Dexamethasone-induced congestive heart failure in a patient with dilated cardiomyopathy caused by occult pheochromocytoma

DILATED CARDIOMYOPATHY CAUSED BY occult pheochromocytoma has been described infrequently. We report a 34-year-old woman who had acute congestive heart failure 12 hours after steroid administration for an atypical migraine. Four months later a pheochromocytoma was diagnosed and removed without incident. This patient clearly had cardiomyopathy as the result of catecholamine secretion from the pheochromocytoma. We postulate that the acute episode was induced by steroid administration that increased the production of epinephrine causing β2-stimulation, peripheral vasodilation, and congestive heart failure.

Benefits of laparoscopic fellowship training: a survey of former fellows.

Objective: The objective of this study was to assess the impact of minimally invasive surgery (MIS) fellowship training on the fellows’ clinical practice as well as former fellows’ perception of their fellowship experience. Methods: A survey composed of 50 multiple-choice questions was e-mailed to 268 former MIS fellows who began a fellowship in the United States between 2000 and 2005. E-mail addresses were obtained from Covidien, an industry sponsor of MIS fellowships. Results: The response rate was 30%. The most frequent reason for choosing an MIS fellowship was to enhance laparoscopic skills (34%). A total of 85% believed that an MIS fellowship provided an edge on referral of advanced laparoscopic procedures. In all, 75% indicated that their fellowship was extremely beneficial, and 86% would recommend their former fellowship to future applicants. Conclusion: The majority of respondents felt that their MIS fellowship experience was beneficial and had a positive impact on their laparoscopic knowledge base, skills, referrals, and career.