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Phillips MR, Joseph M, Dellon ES, Grimm I, Farrell TM, Rupp CC. Surgical and endoscopic management of remnant cystic duct lithiasis after cholecystectomy--a case series. J Gastrointest Surg 2014; 18:1278-83. [PMID: 24810238 DOI: 10.1007/s11605-014-2530-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 04/21/2014] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Postcholecystectomy syndrome (PCS) as a result of remnant cystic duct lithiasis (RCDL), or gallstones within the cystic duct after cholecystectomy, can cause persistent or recurrent symptoms after cholecystectomy. STUDY DESIGN A retrospective descriptive analysis was performed for all patients with RDCL at a single institution between 2001 and 2012. Details of presentation, diagnosis, and surgical and endoscopic treatments, and outcomes were collected and analyzed. RESULTS Twelve patients with RCDL were identified. The interval between cholecystectomy to RCDL discovery was 34.2 months (range 0.5-168 months). On a standard liver enzyme panel, 75% of patients had derangements in ≥1 indices, with the most common single laboratory test abnormality occurring in gamma-glutamyl transferase (GGT) (80%). Eight operative reports noted that the cystic duct was noticeably dilated at the time of cholecystectomy. Two patients developed a cystic duct leak (Strasberg type A bile duct injury) postoperatively, which was managed nonoperatively. Six cases of RCDL required surgery, and six were managed endoscopically. CONCLUSION RCDL is a potential cause of postcholecystectomy syndrome, but the true incidence is unknown. Laboratory analysis and imaging are helpful in establishing the diagnosis of RCDL. Endoscopic therapy has a role in the treatment of RCDL, but surgical excision of the remnant cystic duct lithiasis may be required.
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Dehmer JJ, Amos KD, Farrell TM, Meyer AA, Newton WP, Meyers MO. Competence and confidence with basic procedural skills: the experience and opinions of fourth-year medical students at a single institution. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2013; 88:682-7. [PMID: 23524922 DOI: 10.1097/acm.0b013e31828b0007] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
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.
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Carr J, Deal AM, Dehmer J, Amos KD, Farrell TM, Meyer AA, Meyers MO. Who teaches basic procedural skills: Student experience versus faculty opinion. J Surg Res 2012; 177:196-200. [DOI: 10.1016/j.jss.2012.05.084] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Revised: 05/09/2012] [Accepted: 05/30/2012] [Indexed: 10/28/2022]
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Farrell TM, Bergman S, Selim N, Paige JT, Harzman AE, Schwarz E, Hori Y, Levine J, Scott DJ. Practice gaps in gastrointestinal and endoscopic surgery (2011): a report from the Society of Gastrointestinal and Endoscopic Surgeons (SAGES) Continuing Education Committee. Surg Endosc 2012; 26:3367-81. [PMID: 22936435 DOI: 10.1007/s00464-012-2491-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Accepted: 06/29/2012] [Indexed: 11/29/2022]
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Overby DW, Kohn GP, Colton KJ, Stavas JM, Dixon RG, Passannante A, Farrell TM. Central Venous Line Placement prior to Gastric Bypass Improves Operating Room Efficiency. ISRN SURGERY 2012; 2012:816871. [PMID: 22830049 PMCID: PMC3399345 DOI: 10.5402/2012/816871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 04/19/2012] [Indexed: 11/23/2022]
Abstract
Background. Bariatric surgery has increased across America. Venous access is difficult in these patients. Anesthesiologists often utilize valuable operating room (OR) time acquiring reliable intravenous lines. Our objective was to determine if outpatient central venous line (CVL) placement improves OR efficiency and professional reimbursement for CVL insertion. Methods. In our bariatric practice, selected surgery patients have outpatient CVLs placed during prophylactic vena cava filter placement. In a cohort of 268 gastric bypass patients operated between 1/01 and 11/06, we compared time-to-incision between 106 with pre-established CVLs and 162 without. In addition, we determined professional compensation rates for CVLs placed outpatient versus CVLs inserted in the OR. Results. Patients with preoperative (outpatient) CVLs required 35.6 ± 12.5 minutes to skin incision compared with 42.5 ± 13.9 minutes for controls (P < 0.0001), and 34.9% had skin incision in <30 minutes compared with 16.4% of controls. Radiologists collected 28.2% of outpatient billings for CPT code 36556, compared with anesthesiologists who collected <1% when placing CVLs in the OR. Conclusions. Outpatient CVLs prior to gastric bypass improve efficiency in the OR with earlier skin incision. Professional reimbursement is better for outpatient CVLs than intraoperative inpatient CVLs.
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Joseph M, Phillips M, Farrell TM, Rupp CC. Can residents safely and efficiently be taught single incision laparoscopic cholecystectomy? JOURNAL OF SURGICAL EDUCATION 2012; 69:468-472. [PMID: 22677583 DOI: 10.1016/j.jsurg.2012.03.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Revised: 02/24/2012] [Accepted: 03/21/2012] [Indexed: 06/01/2023]
Abstract
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 resident's 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.
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Darido E, Overby DW, Brownley KA, Farrell TM. Evaluation of gastric fundus invagination for weight loss in a porcine model. Obes Surg 2012; 22:1293-7. [PMID: 22576563 DOI: 10.1007/s11695-012-0666-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Gastric fundus compliance allows stomach volume increase in response to food intake. Absence of this postprandial relaxation alters hormonal signals and induces early satiety and weight loss. This study demonstrates the effect of gastric fundus invagination on the growth rate of juvenile pigs. After institutional animal care and use committee approval, 15 juvenile pigs were divided into two groups. In the first group, six pigs were anesthetized, weighed, and submitted to laparotomy, stomach manipulation, and short gastric vessel ligation. This is the control group and is referred to as "Sham". In the second group, gastric fundus invagination was added by using a circular stapler. This is the procedure group and is designated as "GFI". Postoperatively, body weight and food intake were measured for 5 weeks. Pigs were euthanized and the stomachs examined. Growth patterns were compared. Three animals were excluded from the analysis. At the end of the 5-week study period, six GFI pigs had intact anastomosis with an invaginated fundus. The mean percent growth rate for the GFI group (54.2 ± 2.8 %) was significantly less than the Sham group (77.7 ± 4.9 %). Gastric fundus invagination significantly decreases the growth rate in juvenile pigs.
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Farrell TM, Pettengill OS, Longnecker DS, Cate CC, Cohn KH. Growing colorectal tumors: minimizing microbial and stromal competition and assessing in vitro selection pressures. Cytotechnology 2011; 34:205-11. [PMID: 19003396 DOI: 10.1023/a:1008131428992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Development of primary colorectal cancer cell lines ishampered by contamination from regional microbes, overgrowthof stromal cells, and purported genetic drift from selectionpressures in vitro. We initiated 32 primaryadenocarcinomas, 3 recurrences and 6 distant metastases incell culture. Twelve cell lines from eleven tumors weregenerated (26.8%) overall. Nine of 32 primary tumorsyielded 10 cell lines, 5 were lost to contamination, 13 wereoverwhelmed by stromal cells, and 5 demonstrated no growth.Addition of isobutyl methyl xanthine (IBMX) to culturelimited fibroblastoid growth. There was no associationbetween tumor location (p = 0.535, mid-P), degree ofdifferentiation (p = 0.850, mid-P) or clinicopathologic stage(p = 0.400, mid-P), and the ability of cells to becomeestablished in culture. The majority of cell lines hadsimilar nuclear DNA content and expression of cell-surfaceantigens compared with their parent tumors. Microbialcontamination and stromal cell overgrowth present thegreatest obstacle to capturing a representative bank ofcolon tumors in vitro.
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Rupp CC, Farrell TM, Meyer AA. Single Incision Laparoscopic Cholecystectomy Using a “Two-Port” Technique Is Safe and Feasible: Experience in 101 Consecutive Patients. Am Surg 2011. [DOI: 10.1177/000313481107700731] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Single incision laparoscopic cholecystectomy (SILC) is a new minimally-invasive technique that has recently been developed to address several disease processes of the gallbladder. However, the safety and feasibility of this technique are still being evaluated. Utilizing a “two-port” technique with transabdominal suture retraction and a rigorous adherence to the critical view of safety, we evaluated our experience in a prospectively maintained database and compared this with standard laparoscopic cholecystectomy (SLC) over the same period. SILC was completed successfully in 87 per cent of patients. Operative times were found to be similar between SLC and SILC (75 and 76 minutes, respectively; P = 0.12). Operative blood loss, hospital stay, and short-term complications were not statistically different between SILC and SLC. Cholangiograms, obtained on a selective basis, were performed in 19 per cent of SILCs. No bile duct injuries occurred during SILC or SLC. Although our aggregate number is not enough to accurately assess the rate or safety of bile duct injuries, SILC seems to be safe and feasible when evaluating other metrics and does not seem to interfere with operative efficiency compared with SLC.
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Rupp CC, Farrell TM, Meyer AA. Single incision laparoscopic cholecystectomy using a "two-port" technique is safe and feasible: experience in 101 consecutive patients. Am Surg 2011; 77:916-921. [PMID: 21944359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Single incision laparoscopic cholecystectomy (SILC) is a new minimally-invasive technique that has recently been developed to address several disease processes of the gallbladder. However, the safety and feasibility of this technique are still being evaluated. Utilizing a "two-port" technique with transabdominal suture retraction and a rigorous adherence to the critical view of safety, we evaluated our experience in a prospectively maintained database and compared this with standard laparoscopic cholecystectomy (SLC) over the same period. SILC was completed successfully in 87 per cent of patients. Operative times were found to be similar between SLC and SILC (75 and 76 minutes, respectively; P = 0.12). Operative blood loss, hospital stay, and short-term complications were not statistically different between SILC and SLC. Cholangiograms, obtained on a selective basis, were performed in 19 per cent of SILCs. No bile duct injuries occurred during SILC or SLC. Although our aggregate number is not enough to accurately assess the rate or safety of bile duct injuries, SILC seems to be safe and feasible when evaluating other metrics and does not seem to interfere with operative efficiency compared with SLC.
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Kohn GP, Bitar RS, Farber MA, Marston WA, Overby DW, Farrell TM. Treatment Options and Outcomes for Celiac Artery Compression Syndrome. Surg Innov 2011; 18:338-43. [DOI: 10.1177/1553350610397383] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. Abdominal pain attributed to compression of the celiac artery at the level of the median arcuate ligament (MAL) of the diaphragm is an uncommon disorder. Although ultrasound investigation and arteriography can be suggestive of the diagnosis, no definitive criteria exist with only cases reports in the literature. This study presents the only known reported case series in which a combination of open and laparoscopic access techniques of MAL decompression are reported. Methods. A retrospective review of prospectively collected electronic databases of the University of North Carolina at Chapel Hill was performed for the period February 1999 until February 2009. Patients having undergone operation for celiac artery compression syndrome were identified and participated in a telephone interview. Questions were asked about the success of the operation, the recovery period, and patient satisfaction. Results. Six patients were identified, 3 were male; mean age was 37.7 years. Four underwent open MAL division and celiac ganglion neurolysis, and 2 underwent a laparoscopic approach. Mean follow-up was 48.6 months. All patients experienced symptomatic improvement and were satisfied with their outcome. No patient had symptoms recurrence. Conclusion. In this limited experience, MAL division with celiac ganglion neurolysis appears to be an effective treatment for celiac artery compression syndrome in appropriately selected patients. Both the open and laparoscopic approaches are safe with durable midterm follow-up results.
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Kohn GP, Galanko JA, Farrell TM. Reply. J Am Coll Surg 2010. [DOI: 10.1016/j.jamcollsurg.2010.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Kohn GP, Galanko JA, Overby DW, Farrell TM. 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. J Am Coll Surg 2010; 210:909-18. [PMID: 20510799 DOI: 10.1016/j.jamcollsurg.2010.03.005] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Revised: 02/26/2010] [Accepted: 03/03/2010] [Indexed: 12/18/2022]
Abstract
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 institution's 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.
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Meyers MO, Meyer AA, Stewart RD, Dreesen EB, Barrick J, Lange PA, Farrell TM. Teaching technical skills to medical students during a surgery clerkship: results of a small group curriculum. J Surg Res 2010; 166:171-5. [PMID: 20828751 DOI: 10.1016/j.jss.2010.05.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2010] [Revised: 04/20/2010] [Accepted: 05/11/2010] [Indexed: 11/17/2022]
Abstract
BACKGROUND Opportunities for medical students to learn and perform technical skills during their clinical years have decreased. Alternative means to provide instruction are increasingly important. METHODS Third-year students were assigned to three weekly small group tutorial sessions during their surgery clerkship. One hour sessions covered the following: suturing/knot tying, tubes (Foley catheter/NG tube), and lines (i.v. placement/arterial puncture). Students used a self-reported checklist to report their experience performing these procedures in the hospital after being exposed to them in the skills sessions. These data were compared with results prior to the implementation of the skills curriculum. Results were compared by Fisher's exact test. RESULTS Seventy-seven students had evaluable checklists during the control period, and 69 were evaluable during the study period. Participations in four specific skills were compared: Foley catheter placement, nasogastric tube insertion/removal, i.v. placement, and arterial stick. In all four skills, students were more likely to have performed the task after having been introduced to it in the skills sessions. For both Foley catheter placement (96% versus 90%; P = 0.05) and NG tube insertion/removal (70% versus 53%; P = 0.06) there was a trend toward a higher incidence of participation, although statistical significance was not met. However, for both IV placement (64% versus 18%; P = 0.0001) and arterial puncture (48% versus 18%; P = 0.0002) there were significant increases in participation between the study periods. CONCLUSIONS These results suggest that a small group technical skills curriculum facilitates learning of specific technical skills and appears to increase participation in all of the skills taught and assessed. This may be one strategy to introduce students to technical skills during the surgery clerkship and improve participation of these skills in the hospital setting.
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Farrell TM, Kohn GP, Owen SM, Meyers MO, Stewart RA, Meyer AA. Low Correlation between Subjective and Objective Measures of Knowledge on Surgery Clerkships. J Am Coll Surg 2010; 210:680-3, 683-5. [DOI: 10.1016/j.jamcollsurg.2009.12.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Accepted: 12/15/2009] [Indexed: 11/16/2022]
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Dellon ES, Farrell TM, Bozymski EM, Shaheen NJ. Diagnosis of eosinophilic esophagitis after fundoplication for 'refractory reflux': implications for preoperative evaluation. Dis Esophagus 2010; 23:191-5. [PMID: 19863640 DOI: 10.1111/j.1442-2050.2009.01019.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
A small percentage of patients who carry the diagnosis of refractory gastroesophageal reflux disease (GERD) actually have eosinophilic esophagitis (EoE). The purpose of this study was to describe a series of patients who underwent fundoplication for presumed refractory GERD, but subsequently were found to have EoE. We performed a retrospective analysis of our EoE database. Patients diagnosed with EoE after Nissen were identified. Cases were defined according to recent consensus guidelines. Five patients underwent anti-reflux surgery for refractory GERD, but were subsequently diagnosed with EoE. None had esophageal biopsies prior to surgery, and in all subjects, symptoms persisted afterward, with no evidence of wrap failure. The diagnosis of EoE was typically delayed (range: 3-14 years), and when made, there were high levels of esophageal eosinophilia (range: 30-170 eos/hpf). A proportion of patients undergoing fundoplication for incomplete resolution of GERD symptoms will be undiagnosed cases of EoE. Given the rising prevalence of EoE, we recommend obtaining proximal and distal esophageal biopsies in such patients prior to performing anti-reflux surgery.
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Kohn GP, Galanko JA, Overby DW, Farrell TM. Recent trends in bariatric surgery case volume in the United States. Surgery 2009; 146:375-80. [DOI: 10.1016/j.surg.2009.06.005] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2009] [Accepted: 06/10/2009] [Indexed: 11/16/2022]
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Overby DW, Kohn GP, Cahan MA, Galanko JA, Colton K, Moll S, Farrell TM. Prevalence of thrombophilias in patients presenting for bariatric surgery. Obes Surg 2009; 19:1278-85. [PMID: 19579050 DOI: 10.1007/s11695-009-9906-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2009] [Accepted: 06/15/2009] [Indexed: 12/19/2022]
Abstract
BACKGROUND The rise in bariatric surgery has driven an increased number of complications from venous thromboembolism (VTE). Evidence supports obesity as an independent risk factor for VTE, but the specific derangements underlying the hypercoagulability of obesity are not well defined. To better characterize VTE risk for the purpose of tailoring prophylactic strategies, we developed a protocol for thrombophilia screening in patients presenting for bariatric surgery at our institution. METHODS Between April 2004 and April 2006, 180 bariatric surgery candidates underwent serologic screening for inherited thrombophilias (Factor V-Leiden mutation, low Protein C activity, low Protein S activity, Free Protein S deficiency) and acquired thrombophilias (D-Dimer elevation, Fibrinogen elevation, elevation of coagulation factors VIII, IX, and XI, elevation of Lupus anticoagulants and homocysteine level, and Antithrombin III deficiency). Prevalence rate of each thrombophilia in the subject group was compared to the actual prevalence rate of the general population. RESULTS Most plasma markers of both inherited and acquired thrombophilias were identified in higher than expected proportions, including D-Dimer elevation in 31%, Fibrinogen elevation in 40%, Factor VIII elevation in 50%, Factor IX elevation in 64%, Factor XI elevation in 50%, and Lupus anticoagulant in 13%. CONCLUSIONS Obesity is a well-described demographic risk factor for VTE. In bariatric surgery candidates routinely screened for serologic markers, both inherited and acquired thrombophilias occurred more frequently than in the general population, and may therefore prove to be useful for individualized VTE risk assessment and prophylaxis.
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Overby DW, Kohn GP, Cahan MA, Dixon RG, Stavas JM, Moll S, Burke CT, Colton KJ, Farrell TM. Risk-group targeted inferior vena cava filter placement in gastric bypass patients. Obes Surg 2009; 19:451-5. [PMID: 19127387 DOI: 10.1007/s11695-008-9794-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2008] [Accepted: 12/03/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite 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. METHODS A 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. RESULTS Of 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. CONCLUSIONS Risk-group targeted prophylactic inferior vena cava filter placement prior to RYGB is safe with a trend towards reduced occurrence of PE.
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Vasquez JC, Wayne Overby D, Farrell TM. Fewer gastrojejunostomy strictures and marginal ulcers with absorbable suture. Surg Endosc 2008; 23:2011-5. [DOI: 10.1007/s00464-008-0220-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2008] [Revised: 10/15/2008] [Accepted: 10/20/2008] [Indexed: 01/11/2023]
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Overby DW, Cahan MA, Galanko JA, Colton KJ, Moll S, Koruda MJ, Farrell TM. QS89. High Prevalence of Measurable Thrombophilias in Bariatric Surgery Patients. J Surg Res 2008. [DOI: 10.1016/j.jss.2007.12.329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bloomfield LL, Farrell TM, Sturdy CB. All “chick-a-dee” calls are not created equally. Behav Processes 2008; 77:87-99. [PMID: 17669600 DOI: 10.1016/j.beproc.2007.06.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2007] [Revised: 06/11/2007] [Accepted: 06/18/2007] [Indexed: 11/27/2022]
Abstract
The 'chick-a-dee' call, common to all members of the genus Poecile, is used by both sexes throughout the year to putatively co-ordinate flock movements and register alarm. In some regions, two or more chickadee species occupy overlapping territories, and therefore it is essential that these sympatric species learn to discriminate between the acoustically similar calls of the species. Previous work from our laboratory has shown that black-capped (P. atricapillus) and mountain chickadees (P. gambeli) discriminate between the species' calls and treat each species' calls as belonging to separate open-ended categories. In the current set of experiments we use an operant conditioning paradigm to gain an understanding of (1) how the birds perform this discrimination and (2) whether birds with different levels of experience with heterospecific calls perform this task differently. We use natural recordings of chick-a-dee calls and perform several manipulations to test the importance of the introductory 'chick-a' portion and the terminal 'dee' portion for discriminating among the calls of the two species. Evidence suggests that birds mainly use the terminal 'dee' portion, as all groups of birds responded similarly to these probe stimuli and control chick-a-dee calls. We propose that the terminal 'dee' portion, consisting of lower frequency notes, is more likely to be resistant to degradation, and therefore a more reliable species-specific marker.
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Balduf LM, Farrell TM. Attitudes, beliefs, and referral patterns of PCPs to bariatric surgeons. J Surg Res 2007; 144:49-58. [PMID: 17632126 DOI: 10.1016/j.jss.2007.01.038] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2006] [Revised: 01/25/2007] [Accepted: 01/30/2007] [Indexed: 11/24/2022]
Abstract
BACKGROUND As severe obesity (BMI >40kg/m(2)) and its surgical treatment rise, primary care physicians (PCPs) will more frequently evaluate, refer, and oversee the long-term medical management of bariatric patients. A cross-sectional mail survey was conducted to assess the attitudes, knowledge, and bariatric referral practices among family and internal medicine physicians in North Carolina. MATERIALS AND METHODS Forty-seven percent of 611 randomly chosen PCPs returned a self-completed questionnaire. The effect of demographics, PCP attitudes, and PCP knowledge on referral practices was evaluated. RESULTS Over 85% (221) of PCPs have treated operated bariatric patients within the last year and 76% (203) have referred patients for surgical evaluation. Thirty-five percent of practitioners felt unprepared to provide good quality long-term medical care to operated patients, and just 45% felt competent to address medical complications of bariatric surgery. Compared with nonreferring PCPs, referring physicians provided medical care to a greater number of severely obese (mean 9.9 versus 7.5, P < 0.001) and postoperative (mean 4.6 and 2.3, P < 0.001) bariatric patients. Referring providers were younger (46 versus 49, P = 0.02), had higher BMI (25.3 versus 23.5, P = 0.001), were more familiar with NIH guidelines (14.7% versus 3.0%, P = 0.02), and had completed more bariatric continuing medical education (49.8% versus 34.9%, P = 0.03). Also, they reported better resources (71.4% versus 35.4%, P < 0.001) and competency to provide good quality long-term care to postoperative bariatric patients (54.2% versus 15.4%, P < 0.001) than nonreferring peers. CONCLUSIONS Bariatric surgeons will optimize referrals and postoperative care for patients by working cooperatively with PCPs and by providing educational resources.
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Johnson WH, Fernanadez AZ, Farrell TM, Macdonald KG, Grant JP, McMahon RL, Pryor AD, Wolfe LG, DeMaria EJ. Surgical revision of loop (“mini”) gastric bypass procedure: multicenter review of complications and conversions to Roux-en-Y gastric bypass. Surg Obes Relat Dis 2007; 3:37-41. [PMID: 17196443 DOI: 10.1016/j.soard.2006.09.012] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2006] [Revised: 09/21/2006] [Accepted: 09/28/2006] [Indexed: 11/24/2022]
Abstract
BACKGROUND The claim that the "mini"-gastric bypass (MGB) procedure with its loop gastrojejunostomy is safer and equally effective to the Roux-en-Y gastric bypass (RYGB) procedure has been promoted before validation. Rumors of unreported complications and the accuracy of follow-up are additional concerns. This study was undertaken to identify MGB patients who require or required revisional surgery at 5 hospitals within the region of the United States where the MGB procedure originated to assess the claim that revision to RYGB is rarely needed. METHODS The databases of 5 medical centers were retrospectively searched to identify patients undergoing surgical revision after a MGB procedure, all of which had been done elsewhere. RESULTS A total of 32 patients were identified who presented with complications after undergoing an MGB procedure and required or require revisional surgery. The complications included gastrojejunostomy leak in 3, bile reflux in 20, intractable marginal ulcer in 5, malabsorption/malnutrition in 8, and weight gain in 2. Of the 32 patients, 21 required conversion to RYGB and an additional 5 have planned revisions in the future. Also, 2 patients were treated with Braun enteroenterostomies and 4 required 1 or more abdominal explorations. CONCLUSIONS The results of this preliminary review have confirmed that MGB does require revision in some patients and that conversion to RYGB is a common form of revision. A national registry to record the complications and number of revisions is proposed to gain insight into the need for revision after MGB and other nontraditional bariatric procedures.
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Cahan MA, Balduf L, Colton K, Palacioz B, McCartney W, Farrell TM. Proton pump inhibitors reduce gallbladder function. Surg Endosc 2006; 20:1364-7. [PMID: 16858534 DOI: 10.1007/s00464-005-0247-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2005] [Accepted: 02/23/2006] [Indexed: 11/26/2022]
Abstract
BACKGROUND In the authors' previous study of gallbladder function before and after fundoplication, 58% of the patients demonstrated preoperative gallbladder motor dysfunction, and 86% of those retested after operation and cessation of proton pump inhibitors (PPIs) normalized. Because no study has directly assessed the impact of antisecretory agents on gallbladder function, this study measured gallbladder ejection fraction (GBEF) in healthy volunteers before and after initiation of PPIs. METHODS A total of 19 subjects completed the study, which included baseline determination of GBEF by cholecystokinin-stimulated hepatobiliary acid scan, 30 days of antisecretory therapy with omeprazole (40 mg daily), and repeat GBEF on day 30. Subjects were surveyed regarding compliance and symptoms. RESULTS For 15 of 19 subjects, PPI therapy was associated with reduced gallbladder motility. Evolution of symptoms consistent with a biliary etiology was reported by 26.7% of these subjects. CONCLUSIONS Short-term PPI therapy reduces gallbladder motility in healthy volunteers. Chronic PPI therapy may pose a risk for long-term gallbladder dysfunction and biliary complications.
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