Timothy M. Farrell

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.

SAGES guidelines for the surgical treatment of esophageal achalasia

The guidelines for the surgical treatment of esophageal achalasia are a series of systematically developed statements to assist surgeon (and patient) decisions about the appropriate use of minimally invasive techniques for the treatment of achalasia in specific clinical circumstances. It addresses the indications, risks, benefits, outcomes, alternatives, and controversies of the procedures used to treat this condition. The statements included in this guideline are the product of a systematic review of published work on the topic, and the recommendations are explicitly linked to the supporting evidence. The strengths and weaknesses of the available evidence are highlighted, and expert opinion is sought where published evidence lacks depth. Disclaimer

Clinical application of laparoscopic bariatric surgery: an evidence-based review

BackgroundApproximately one-third of U.S. adults are obese. Current evidence suggests that surgical therapies offer the morbidly obese the best hope for substantial and sustainable weight loss, with a resultant reduction in morbidity and mortality. Minimally invasive methods have altered the demand for bariatric procedures. However, no evidence-based clinical reviews yet exist to guide patients and surgeons in selecting the bariatric operation most applicable to a given situation.MethodsThis evidenced-based review is presented in conjunction with a clinical practice guideline developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). References were reviewed by the authors and graded as to the level of evidence. Recommendations were developed and qualified by the level of supporting evidence available at the time of the associated SAGES guideline publication. The guideline also was reviewed and co-endorsed by the American Society for Metabolic and Bariatric Surgery.ResultsBariatric surgery is the most effective treatment for severe obesity, producing durable weight loss, improvement of comorbid conditions, and longer life. Patient selection algorithms should favor individual risk–benefit considerations over traditional anthropometric and demographic limits. Bariatric care should be delivered within credentialed multidisciplinary systems. Roux-en-Y gastric bypass (RGB), adjustable gastric banding (AGB), and biliopancreatic diversion with duodenal switch (BPD + DS) are validated procedures that may be performed laparoscopically. Laparoscopic sleeve gastrectomy (LSG) also is a promising procedure. Comparative data find that procedures with more dramatic clinical benefits carry greater risks, and those offering greater safety and flexibility are associated with less reliable efficacy.ConclusionsLaparoscopic RGB, AGB, BPD + DS, and primary LSG have been proved effective. Currently, the choice of operation should be driven by patient and surgeon preferences, as well as by considerations regarding the relative importance placed on discrete outcomes.

Recent trends in bariatric surgery case volume in the United States.

BACKGROUND Reports of increasing bariatric surgery volumes have driven resource allocation by health care systems and device manufacturers. Professional organizations and third-party payers have embraced credentialing systems to limit frivolous expansion. The underlying data upon which these reports are based are disparate and derived from imperfect methodologies. We queried the Nationwide Inpatient Sample (NIS) using several established search strategies to validate the current understanding of bariatric trends. METHODS NIS search algorithms capture bariatric admissions by the presence of International Classification of Disease, Ninth-Revision, Clinical Modification (ICD-9-CM) codes for obesity and bariatric procedures, with varying levels of inclusiveness for related foregut procedure codes. We applied 1 novel and 4 established algorithms to NIS data sets from 1998 to 2006 to generate contemporary case-volume curves, and we supplemented our data with industry estimates of ambulatory surgery volumes. RESULTS From 1998 to 2003, the number of bariatric operations increased markedly by all search strategies. Since then, a greater variation was observed in case volume estimates but no evidence of continuing growth was identified, irrespective of the search protocol employed. CONCLUSION Bariatric procedures peaked in 2003 and have since plateaued. The estimation of case volumes is limited by deficiencies in data and nonuniform search criteria. These factors should be considered by surgeons, professional organizations, hospitals, and third-party payers when planning for the future.

National Trends in Esophageal Surgery—Are Outcomes as Good as We Believe?

IntroductionPositive volume–outcome relationships in esophagectomy have prompted support for regionalization of care; however, outcomes have not recently been analyzed. This study examines national trends in provision of esophagectomy and reassesses the volume–outcome relationship in light of changing practice patterns and training paradigms.MethodsThe Nationwide Inpatient Sample was queried from 1998 to 2006. Quantification of patients’ comorbidities was made using the Charlson Index. Using logistic regression modeling, institutions’ annual case volumes were correlated with risk-adjusted outcomes over time, as well as presence or absence of fellowship and residency training programs.ResultsA nationwide total of 57,676 esophagectomies were recorded. In-hospital unadjusted mortality fell from 12% to 7%. Adjusting for comorbidities, greater esophagectomy volume was associated with improvements in the incidence of most measured complications, though mortality increased once greater than 100 cases were performed. Hospitals supporting fellowship training or a surgical residency program did not have higher rates of mortality or total complications.ConclusionsThe current national mortality rate of 7% following esophagectomy is higher than is reported in most contemporary case series. A greater annual esophagectomy volume improves outcomes, but only up to a point. Current training paradigms are safe.

Fundoplication improves disordered esophageal motility

Patients with gastroesophageal reflux disease (GERD) and disordered esophageal motility are at risk for postoperative dysphagia, and are often treated with partial (270-degree) fundoplication as a strategy to minimize postoperative swallowing difficulties. Complete (360-degree) fundoplication, however, may provide more effective and durable reflux protection over time. Recently we reported that postfundoplication dysphagia is uncommon, regardless of preoperative manometric status and type of fundoplication. To determine whether esophageal function improves after fundoplication, we measured postoperative motility in patients in whom disordered esophageal motility had been documented before fundoplication. Forty-eight of 262 patients who underwent laparoscopic fundoplication between 1995 and 2000 satisfied preoperative manometric criteria for disordered esophageal motility (distal esophageal peristaltic amplitude ≤30 mm Hg and/or peristaltic frequency ≤80%). Of these, 19 had preoperative manometric assessment at our facility and consented to repeat study. Fifteen (79%) of these patients had a complete fun-doplication and four (21%) had a partial fundoplication. Each patient underwent repeat four-channel esophageal manometry 29.5 ± 18.4 months (mean ± SD) after fundoplication. Distal esophageal peristaltic amplitude and peristaltic frequency were compared to preoperative data by paired t test. After fun-doplication, mean peristaltic amplitude in the distal esophagus increased by 47% (56.8 ± 30.9 mm Hg to 83.5 ± 36.5 mm Hg; P < 0.001) and peristaltic frequency improved by 33% (66.4 ± 28.7% to 87.6 ± 16.3%; P< 0.01). Normal esophageal motor function was present in 14 patients (74%) after fundoplication, whereas in five patients the esophageal motor function remained abnormal (2 improved, 1 worsened, and 2 remained unchanged). Three patients with preoperative peristaltic frequencies of 0%, 10%, and 20% improved to 84%, 88%, and 50%, respectively, after fundoplication. In most GERD patients with esophageal dysmotility, fundoplication improves the amplitude and frequency of esophageal peristalsis, suggesting refluxate has an etiologic role in motor dysfunction. These data, along with prior data showing that postoperative dysphagia is not common, imply that surgeons should apply complete fun-doplication liberally in patients with disordered preoperative esophageal motility.

Competence and confidence with basic procedural skills: the experience and opinions of fourth-year medical students at a single institution.

Purpose Data indicate that students are unprepared to perform basic medical procedures on graduation. The authors’ aim was to characterize graduating students’ experience with and opinions about these skills. Method In 2011, an online survey queried 156 fourth-year medical students about their experience with, and actual and desired levels of competence for, nine procedural skills (Foley catheter insertion, nasogastric tube insertion, venipuncture, intravenous catheter insertion, arterial puncture, basic suturing, endotracheal intubation, lumbar puncture, and thoracentesis). Students self-reported competence on a four-point Likert scale (4 = independently performs skill; 1 = unable to perform skill). Data were analyzed by analysis of variance and Student t test. A five-point Likert scale was used to assess student confidence. Results One hundred thirty-four (86%) students responded. Two skills were performed more than two times by over 50% of students: Foley catheter insertion and suturing. Mean level of competence ranged from 3.13 ± 0.75 (Foley catheter insertion) to 1.7 ± 0.7 (thoracentesis). A gap in desired versus actual level of competence existed for all procedures (P < .0001). There was a correlation between the number of times a procedure had been performed and self-reported competence for all skills except arterial puncture and suturing. Conclusions Participants had performed most skills infrequently and rated themselves as being unable to perform them without assistance. Strategies to improve student experience and competence of procedural skills must evolve to improve the technical competency of graduating students because their current competency varies widely.

High Case Volumes and Surgical Fellowships are Associated with Improved Outcomes for Bariatric Surgery Patients: A Justification of Current Credentialing Initiatives for Practice and Training

BACKGROUND Recent years have seen the establishment of bariatric surgery credentialing processes, center-of-excellence programs, and fellowship training positions. The effects of center-of-excellence status and of the presence of training programs have not previously been examined. The objective of this study was to examine the effects of case volume, center-of-excellence status, and training programs on early outcomes of bariatric surgery. STUDY DESIGN Data were obtained from the Nationwide Inpatient Sample from 1998 to 2006. Quantification of patient comorbidities was made using the Charlson Index. Using logistic regression modeling, annual case volumes were analyzed for an association with each institutions center-of-excellence status and training program status. Risk-adjusted outcomes measures were calculated for these hospital-level parameters. RESULTS Data from 102,069 bariatric operations were obtained. Adjusting for comorbidities, greater bariatric case volume was associated with improvements in the incidence of total complications (odds ratio [OR] 0.99937 for each single case increase, p = 0.01), in-hospital mortality (OR 0.99717, p < 0.01), and most other complications. Hospitals with a Fellowship Council-affiliated gastrointestinal surgery training program were associated with risk-adjusted improvements in rates of splenectomy (OR 0.2853, p < 0.001) and bacterial pneumonias (OR 0.65898, p = 0.02). Center-of-excellence status, irrespective of the accrediting entity, had minimal independent association with outcomes. A surgical residency program had a varying association with outcomes. CONCLUSIONS The hypothesized positive volume-outcomes relationship of bariatric surgery is shown without arbitrarily categorizing hospitals to case volume groups, by analysis of volume as a continuous variable. Institutions with a dedicated fellowship training program have also been shown, in part, to be associated with improved outcomes. The concept of volume-dependent center-of-excellence programs is supported, although no independent association with the credentialing process is noted.

Nissen fundoplication improves gastric motility in patients with delayed gastric emptying

BackgroundFundoplication hastens gastric emptying in pediatric patients with gastroesophageal reflux disease (GERD). However, among adult GERD patients with impaired gastric emptying, the degree of improvement offered by fundoplication and the value of pyloroplasty are less well defined. Therefore, we compared outcomes in GERD patients with delayed gastric emptying after fundoplication alone or fundoplication with pyloroplasty.MethodsOf 616 consecutive GERD patients who submitted to primary fundoplication (601 laparoscopic) between October 1991 and October 1997, 82 underwent preoperative solid-phase nuclear gastric emptying analysis. Of these, 25 had delayed gastric emptying (half-time >100 min). Of 12 patients with emptying half-times between 100 and 150 min, one underwent pyloroplasty at the time of Nissen fundoplication. Of 13 patients with emptying half-times >150 min, 11 had pyloroplasty at the time of Nissen fundoplication. Patients were asked to use a 0 (“none”) to 4 (“incapacitating”) scale to describe the severity of their symptoms of heartburn, regurgitation, dysphagia, bloating and diarrhea preoperatively and at 6 weeks and 1 year postoperatively. Eight patients consented to a postoperative analysis of gastric emptying.ResultsOne year after fundoplication, patients with delayed gastric emptying and controls reported a similar improvement in heartburn, regurgitation, and dysphagia, with no increase in undesirable side effects such as bloating and diarrhea. Among the patients with delayed gastric emptying who consented to undergo a repeat gastric emptying study after their operation, fundoplication alone provided a 38% improvement (p < 0.05) in gastric emptying, whereas fundoplication with pyloroplasty resulted in a 70% improvement in gastric emptying (p < 0.05).ConclusionFundoplication improves gastric emptying. The addition of pyloroplasty results in even greater improvement and may have particular value for patients with severe gastric hypomotility.

Risk-group targeted inferior vena cava filter placement in gastric bypass patients.

BackgroundDespite a growing body of evidence guiding appropriate perioperative thromboprophylaxis in the general population, few data direct strategies to reduce deep venous thrombosis (DVT) and pulmonary embolism (PE) in the morbidly obese. We have implemented a novel protocol for venous thromboembolism (VTE) risk stratification in Roux-en-Y gastric bypass (RYGB) candidates at our institution, which augments clinical assessment with screening for thrombophilias, to guide retrievable inferior vena cava (IVC) filter utilization.MethodsA retrospective review of prospectively collected data from patients who underwent primary RYGB between 2001 and 2008 at the University of North Carolina at Chapel Hill was completed. During that time, clinical assessment of VTE risk was amplified by focused plasma screening for common thrombophilias (factors VIII, IX, and XI, d-dimer, fibrinogen). Preoperative prophylactic IVC filters were offered to high-risk patients. The database was reviewed for perioperative DVTs, PEs, and filter-related complications.ResultsOf 330 patients, in 162 attempts, 160 had prophylactic IVC filters placed with four complications overall (2.47%). No patient had symptoms of PE during the planned 6-week filter period, though one had a PE occur immediately after filter removal (0.63%); in contrast, five of 170 patients (2.94%) without prophylactic IVC filters presented with symptomatic PE (p = 0.216). In total, 147 (91.88%) prophylactic filters were removed.ConclusionsRisk-group targeted prophylactic inferior vena cava filter placement prior to RYGB is safe with a trend towards reduced occurrence of PE.