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Castelan JDB, Zapelini AP, Cacciatori FA, Zilberstein B. CHOLECYSTECTOMY WITH INTRAOPERATIVE ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY: DOES THE ORDER MATTER? ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2024; 37:e1816. [PMID: 39166653 PMCID: PMC11338519 DOI: 10.1590/0102-6720202400023e1816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 05/18/2024] [Indexed: 08/23/2024]
Abstract
BACKGROUND The recommended treatment for cholecystocholedocholithiasis is cholecystectomy (CCT) associated with endoscopic retrograde cholangiopancreatography (ERCP). CCT with intraoperative ERCP is associated with higher success rates and lower hospital stays and hospital costs. However, some case series do not describe the exact methodology used: whether ERCP or CCT was performed first. AIMS Verify if there is a difference, in terms of outcomes and complications, when intraoperative ERCP is performed immediately before or after CCT. METHODS This is a retrospective case-control study analyzing all patients who underwent CCT with intraoperative ERCP between January 2021 and June 2022, in a tertiary hospital in southern Brazil, for the treatment of cholecystocholedocholithiasis. RESULTS Out of 37 patients analyzed, 16 (43.2%) underwent ERCP first, immediately followed by CCT. The overall success rate for the cannulation of the bile duct was 91.9%, and bile duct clearance was achieved in 75.7% of cases. The post-ERCP pancreatitis rate was 10.8%. When comparing the "ERCP First" and "CCT First" groups, there was no difference in technical difficulty for performing CCT. The "CCT First" group had a higher rate of success in bile duct cannulation (p=0.020, p<0.05). Younger ages, presence of stones in the distal common bile duct and shorter duration of the procedure were factors statistically associated with the success of the bile duct clearance. Lymphopenia and cholecystitis as an initial presentation, in turn, were associated with failure to clear the bile duct. CONCLUSIONS There was no significant difference in terms of complications and success in clearing the bile ducts among patients undergoing CCT and ERCP in the same surgical/anesthetic procedure, regardless of which procedure was performed first. Lymphopenia and cholecystitis have been associated with failure to clear the bile duct.
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Affiliation(s)
| | | | - Felipe Antônio Cacciatori
- Hospital São José, General Surgery Service – Criciúma (SC), Brazil
- Santa Casa de Misericórdia, Hepatobiliopancreatic and Liver Transplant Service – Porto Alegre (RS), Brazil
- Universidade Federal do Rio Grande do Sul, Master in Surgical Sciences – Porto Alegre (RS), Brazil
| | - Bruno Zilberstein
- Universidade de São Paulo, Faculty of Medicine, Cancer Institute – São Paulo (SP), Brazil
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Sabat N, McSweeney W, Konno T, Gilberd MA, Molloy C, Pretorius C. Advanced skills for general surgeons and carving out a niche: Endoscopic retrograde cholangiopancreatography in regional Australia. ANZ J Surg 2023; 93:1768-1772. [PMID: 37150893 DOI: 10.1111/ans.18506] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 04/27/2023] [Accepted: 04/28/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND The provision of high-quality healthcare in rural Australian hospitals has necessitated general surgeons to take up the challenge and expand their expertise to advanced endoscopy techniques including endoscopic retrograde cholangiopancreatography (ERCP). This study examines the utility of ERCP in a regional setting especially in decreasing patient transfers and associated costs while achieving exceptional safety by measuring key indicators of safety and efficacy. METHODS A single-centre retrospective cross-sectional cohort review in a rural Queensland hospital of patients who underwent ERCP (emergent and elective) from January 2019 until July 2022. Standardized international ERCP performance indicators were collected and compared to benchmark literature values including the rate of cannulation, stone extraction, successful stent placement, and post-ERCP pancreatitis. RESULTS The majority of the ERCP performance indicator benchmarks were met. 100% of patients had an appropriate indication for the procedure and consent. 98.95% successful CBD cannulation with only 14.14% requiring multiple attempts. 92.22% successful stone retrieval with 100% stent placement, well above guideline targets. The post-procedural complication rate was 6.81% (2.09% pancreatitis; 1.05% pancreatitis; 1.05% duodenal perforation). Antibiotic prophylaxis adherence was identified to require improvement (12.57%). CONCLUSION High-quality ERCP procedures can be performed in a regional hospital by general surgeons in a safe and cost-effective manner, significantly decreasing the costs associated with patient transfer. This study reflects strong evidence for consistently achieving international ERCP performance benchmarks and the provision of high-quality healthcare by a regional hospital and provides a strong argument for increasing access to ERCP in rural and remote hospitals.
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Affiliation(s)
- Nestor Sabat
- Department of General Surgery, Mackay Base Hospital, West Mackay, Queensland, Australia
| | - William McSweeney
- Department of General Surgery, Mackay Base Hospital, West Mackay, Queensland, Australia
| | - Takuma Konno
- James Cook University, Townsville, Queensland, Australia
| | | | - Charles Molloy
- Department of General Surgery, Mackay Base Hospital, West Mackay, Queensland, Australia
| | - Casper Pretorius
- Department of General Surgery, Mackay Base Hospital, West Mackay, Queensland, Australia
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Wikiel KJ, Powlan FJ, Jones TS, Robinson TN, Jones EL. Robotic stray energy with constant-voltage versus constant-power regulating electrosurgical generators. Surg Endosc 2023; 37:580-586. [PMID: 35612638 DOI: 10.1007/s00464-022-09316-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 04/27/2022] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Stray energy from surgical energy instruments can cause unintended thermal injuries. There are no published data regarding electrosurgical generators and their influence on stray energy transfer during robotic surgery. There are two approved generators for the DaVinci Xi robotic platform: a constant-voltage regulating generator (cVRG) and a constant-power regulating generator (cPRG). The purpose of this study was to quantify and compare stray energy transfer in the robotic Xi platform using a cVRG versus a cPRG. METHODS An ex vivo bovine model was used to simulate a standard multiport robotic surgery. The DaVinci Xi (Intuitive Surgical, Sunnyvale, CA) robotic platform was attached to a trainer box using robotic ports. A 5 s, open-air activation of the monopolar scissors was done with commonly used electrosurgical settings using a cPRG (ForceTriad, Covidien-Medtronic, Boulder, CO) or cVRG (ERBE VIO 300 dV 2.0, ERBE USA, Marietta, GA). Stray energy transfer was quantified as the change in tissue temperature (°C) nearest the tip of the assistance grasper (which was not in direct contact with the active monopolar scissors). RESULTS Stray energy transfer occurred with both generators. Utilizing common, comparable settings for standard coagulation, significantly less stray energy was transferred with the cVRG versus cPRG (4.4 ± 1.6 °C vs. 41.1 ± 13.0 °C, p < 0.001). Similarly, less stray energy was transferred using cut modes with the cVRG compared to the cPRG (5.61 ± 1.79 °C vs. 33.9 ± 18.4 °C, p < 0.001). CONCLUSION Stray energy transfer increases tissue temperatures more than 45C in the DaVinci Xi robotic platform. Low voltage modalities, such as cut or blend; as well as a cVRG generator, significantly reduces stray energy. Robotic surgeons can minimize the risk of stray energy injuries by using these low risk modes and/or generator.
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Affiliation(s)
- Krzysztof J Wikiel
- Department of Surgery, The University of Colorado School of Medicine, Aurora, CO, USA. .,Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA.
| | - Franklin J Powlan
- Department of Surgery, The University of Colorado School of Medicine, Aurora, CO, USA
| | - Teresa S Jones
- Department of Surgery, The University of Colorado School of Medicine, Aurora, CO, USA.,Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
| | - Thomas N Robinson
- Department of Surgery, The University of Colorado School of Medicine, Aurora, CO, USA.,Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
| | - Edward L Jones
- Department of Surgery, The University of Colorado School of Medicine, Aurora, CO, USA.,Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
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Liao Y, Cai Q, Zhang X, Li F. Single-stage intraoperative ERCP combined with laparoscopic cholecystectomy versus preoperative ERCP Followed by laparoscopic cholecystectomy in the management of cholecystocholedocholithiasis: A meta-analysis of randomized trials. Medicine (Baltimore) 2022; 101:e29002. [PMID: 35451394 PMCID: PMC8913127 DOI: 10.1097/md.0000000000029002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 01/04/2022] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES The optimal treatment strategy for cholecystocholedocholithiasis is still controversial. We conducted an up-to-date meta-analysis to compare the efficacy and safety of the intra- endoscopic retrograde cholangiopancreatography (ERCP) + LC procedure with the traditional pre-ERCP + laparoscopic cholecystectomy (LC) procedure in the management of cholecystocholedocholithiasis. METHODS We searched the PubMed, Embase, Cochrane Library, and Web of Science databases up to September 2020. Published randomized controlled trials comparing intra-ERCP + LC and pre-ERCP + LC were considered. This meta-analysis was performed by Review Manager Version 5.3, and outcomes were documented by pooled risk ratio (RR) and mean difference (MD) with 95% confidence intervals. RESULTS Eight studies with a total of 977 patients were included in this meta-analysis. There was no significant difference between the two groups regarding CBD stone clearance (RR = 1.03, P = .27), postoperative papilla bleeding (RR = 0.41, P = .13), postoperative cholangitis (RR = 0.87, P = .79), and operation conversion rate (RR = 0.71, P = .26). The length of hospital stay was shorter in the intra-ERCP + LC group (MD = -2.75, P < .05), and intra-ERCP + LC was associated with lower overall morbidity (RR = 0.54, P < .05), postoperative pancreatitis (RR = 0.29, P < .05) and cannulation failure rate (RR = 0.22, P < .05). CONCLUSIONS Intra-ERCP + LC was a safer approach for patients with cholecystocholedocholithiasis. It could facilitate intubation, shorten hospital stay, and lower postoperative complications, especially postoperative pancreatitis, and reduce stone residue and reduce the possibility of reoperation for stone removal.
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Affiliation(s)
- Yang Liao
- Department of Hepatobiliary Surgery, Zigong First People's Hospital, Zigong, Sichuan, China
| | - Qichen Cai
- Department of Hepatobiliary Surgery, Chengdu Second People's Hospital, Sichuan, China
| | - Xiaozhou Zhang
- Department of Hepatobiliary Surgery, Zigong First People's Hospital, Zigong, Sichuan, China
| | - Fugui Li
- Department of Hepatobiliary Surgery, Zigong First People's Hospital, Zigong, Sichuan, China
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Should Surgeons Do Endoscopy? A Survey. Indian J Surg 2022. [DOI: 10.1007/s12262-021-03252-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Impact of preoperative biliary drainage on postoperative outcomes in hilar cholangiocarcinoma. Asian J Surg 2021; 45:993-1000. [PMID: 34588138 DOI: 10.1016/j.asjsur.2021.07.075] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 03/19/2021] [Accepted: 07/21/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND/OBJECTIVE Complete resection is the most effective treatment of hilar cholangiocarcinoma (HC) but may result in high morbidity and mortality. Most HC patients have jaundice, and preoperative biliary drainage may reduce their risk of obstructive jaundice. ERCP and PTBD have been advocated for this purpose. This retrospective study investigated the influence of ERCP versus PTBD versus their combination on the short-term outcomes of curative HC resection. METHODS Patients having curative HC resection with preoperative biliary drainage in a span of 26 years were reviewed and divided into groups according to drainage modality. Drainage-related and surgical complications and hospital mortality were compared between groups. Intention-to-treat analysis using a separate set of initial drainage data was performed. RESULTS Eighty-six patients were divided into: Group A, ERCP only, n = 32 (32/86 = 37.2%); Group B, PTBD only, n = 10 (10/86 = 11.6%); Group C, ERCP + PTBD, n = 44 (44/86 = 51.2%). International normalized ratio was significantly higher in Group B (p = 0.008). The three groups were comparable in operative details, hospital stay, and mortality. Fifty-two patients had postoperative complications. Significantly more patients in Groups A and C had subphrenic abscess (A: 25%, B: 0%, C: 9.1%; p = 0.035) and subsequent radiological drainage. Group A had insignificantly more patients with wound infection (31.3% vs 10% vs 22.7%, p = 0.334), chest infection (28.1% vs 20% vs 11.4%, p = 0.178), and urinary tract infection (6.3% vs 0% vs 0%, p = 0.133). The three groups had similar rates of major complications (p = 0.501). They also had comparable survival outcomes (overall, p = 0.370; disease-free, p = 0.569). Fifteen and 71 patients received PTBD and ERCP respectively as first drainage mode. These two groups were comparable in liver function, preoperative comorbidity, intraoperative details, and postoperative outcomes. CONCLUSION In the preoperative management of HC, the use of ERCP, PTBD or their combination is acceptable and can optimize patients' condition for curative HC resection.
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Robotic-assisted onlay technique: new approach using anterior mesh positioning in ventral hernia repair-an easy way to spread robotic surgery. J Robot Surg 2021; 15:971-974. [PMID: 33683532 DOI: 10.1007/s11701-021-01218-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 02/20/2021] [Indexed: 10/22/2022]
Abstract
There is still a lot of debate about what is the best technique for ventral hernia (VH) repair surgery. Robotic-assisted procedures are an excellent alternative to overcome the technical difficulties of regular laparoscopic surgery. The onlay technique is one of the most performed surgeries worldwide in open ventral hernia surgery, and the anatomy is easily recognized by all surgeons. Introducing the robotic onlay approach, using robotic-assisted surgery to perform ventral hernia repair with a technique is usual for most surgeons. This "new" approach may change the initial concept that minimally invasive abdominal wall surgery requires specific and tedious training and can help standardize ventral hernia repair by robotic surgery and facilitate training, allowing more surgeons to perform minimally invasive abdominal wall surgery. Finally, clinical studies are needed to measure the impact of Robotot implementation in MIS ventral hernia repair and long-term results.
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Addo A, Lu R, Broda A, George P, Zahiri HR, Belyansky I. Hybrid versus open retromuscular abdominal wall repair: early outcomes. Surg Endosc 2020; 35:5593-5598. [PMID: 33034775 DOI: 10.1007/s00464-020-08060-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 09/29/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The hybrid approach to abdominal wall reconstruction (AWR) for abdominal wall hernias combines minimally invasive posterior component separation and retromuscular dissection with open fascial closure and mesh implantation. This combination may enhance patient outcomes and recovery compared to the open approach alone. The purpose of this study is to evaluate the operative outcomes of hybrid vs. open abdominal wall reconstruction. METHODS A retrospective review was conducted to compare patients who underwent open versus hybrid AWR between September 2015 and August of 2018 at Anne Arundel Medical Center. Patient demographics and perioperative data were collected and analyzed using univariate analysis. RESULTS Sixty-five patients were included in the final analysis: 10 in the hybrid and 55 in the open groups. Mean age was higher in the hybrid vs. open group (65.1 vs. 56.2 years, p < 0.05). The hybrid and open groups were statistically similar (p > 0.05) in gender distribution, mean BMI, and ASA score. Intraoperative comparison found hybrid patients parallel to open patients (p > 0.05) in mean operative time (294.5 vs. 267.5 min), defect size (14.4 vs. 13.6 cm), mesh area, and drain placement. The mean total hospital cost was lower in the hybrid group compared to the open group ($16,426 vs. $19,054, p = 0.43). The hybrid group had a shorter length of stay (5.3 vs. 3.6 days, p = 0.03) after surgery and was followed for a similar length of time (12.3 vs. 12.6 months, p = 0.91). The hybrid group showed a lower trend of seroma, hematoma, wound infection, ileus, and readmission rates after surgery. CONCLUSION A review of patient outcomes after hybrid AWR highlights a trend towards shorter length of stay, lower hospital cost, and fewer complications without significant addition to operative time. Long-term studies on a larger number of patients are definitively needed to characterize the comprehensive benefits of this approach.
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Affiliation(s)
- Alex Addo
- Department of Surgery, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 100, Annapolis, MD, 21401, USA
| | - Richard Lu
- Department of Surgery, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 100, Annapolis, MD, 21401, USA
| | - Andrew Broda
- Department of Surgery, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 100, Annapolis, MD, 21401, USA
| | - Philip George
- Department of Surgery, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 100, Annapolis, MD, 21401, USA
| | - H Reza Zahiri
- Department of Surgery, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 100, Annapolis, MD, 21401, USA
| | - Igor Belyansky
- Department of Surgery, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 100, Annapolis, MD, 21401, USA.
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Single-stage management of choledocholithiasis: intraoperative ERCP versus laparoscopic common bile duct exploration. Surg Endosc 2020; 34:4616-4625. [PMID: 31617103 DOI: 10.1007/s00464-019-07215-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 10/09/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) is the criterion standard for treating patients with symptomatic gallstone disease; however, the optimal technique for extracting common bile duct stones remains unclear. Recent studies have noted improved outcomes with single-stage techniques, such as intraoperative endoscopic retrograde cholangiopancreatography (iERCP) and laparoscopic common bile duct exploration (LCBDE); however only few studies have directly compared those two single-stage techniques. OBJECTIVES Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, we retrospectively analyzed the postoperative outcomes of all patients who underwent single-stage LC for choledocholithiasis from 2005 to 2017. Using Current Procedural Terminology (CPT) codes, as well as International Classification of Diseases, Ninth Revision (ICD-9) and 10th Revision (ICD-10) codes, we stratified patients into two cohorts: those who underwent iERCP and LCBDE. Applying univariate techniques, we evaluated baseline characteristics and postoperative outcomes for both cohorts. Our primary outcomes of interest were 30-day morbidity and 30-day mortality; our secondary outcomes included rates of reoperation, readmission, operative time, and hospital length of stay. RESULTS Of the 1814 single-stage LC patients during our 13-year study period, 1185 (65.3%) underwent LCBDE; 629 (34.6%) underwent iERCP. Our univariate analysis showed that the two cohorts were homogeneous in terms of baseline characteristics, including demographics, preoperative comorbidities, laboratory values, and American Society of Anesthesiologists (ASA) scores. 30-day postoperative morbidity (including infectious and noninfectious complications) and overall mortality between groups were low and comparable. The mean operative time was slightly longer with LCBDE (125.1 ± 62.0 min) than iERCP (113.5 ± 65.2 min; P < 0.001), however the mean hospital length of stay, readmission rate, and reoperation rate were similar. CONCLUSION We found that both iERCP and LCBDE resulted in low, comparable rates of morbidity and mortality. Centers with readily available endoscopic expertise might favor iERCP for its ease of access and shorter operative time. However, LCBDE remains an appropriate technique for patients with choledocholithiasis, especially when immediate endoscopic intervention is unavailable.
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Ross JT, Liang NE, Lebares CC, Carter JT, Harris HW, Cello JP, Rogers SJ, Lin MYC. Upper Gastrointestinal Endoscopy in an Academic General Surgical Program: Implications for Acute Care Surgeons. Surg Innov 2020; 27:669-674. [PMID: 32894031 DOI: 10.1177/1553350620957802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. Esophagogastroduodenoscopy (EGD) is an important tool in the evolving specialty of acute care surgery (ACS). Understanding the types of nonelective EGDs performed by ACS groups is important for the development of ACS programs and the training of future general surgeons. Methods. We conducted a retrospective review of all EGDs performed by ACS surgeons at a single urban academic center over a 5-year period (January 2013-December 2018). Results. A total of 495 EGDs were performed, of which 129 (26%) were urgent, nonelective procedures. Patients who underwent urgent EGD were younger than those who underwent elective procedures (median 55 vs 60 years, P = .03), had higher American Society of Anesthesiologists (ASA) classes (median ASA 3 vs 2, P = .0002), and longer hospital stays (median 5 days vs 0 days, P < .0001). The most common indications for urgent endoscopies were the management of leak, dysphagia, or stenosis in patients with a history of foregut surgery, followed by the management of esophageal perforation. The success rate of endoscopic therapy was high (median 88%, interquartile range (IQR) 78-89%). However, some patients required multiple interventions (median 1, IQR 1-3), and patients treated for leaks were less likely to be successfully treated with endoscopic therapy alone than patients treated for other indications (success rate 65% vs 88%, P = .003). Conclusions. Our experience suggests that EGD has an important role in current ACS practice and that endoscopic management is safe and effective in a range of urgent surgical scenarios. Future ACS surgeons should be facile with endoscopic techniques.
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Affiliation(s)
- James T Ross
- Department of Surgery, 8785University of California San Francisco, San Francisco, CA, USA
| | - Norah E Liang
- School of Medicine, 8785University of California San Francisco, San Francisco, CA, USA
| | - Carter C Lebares
- Department of Surgery, 8785University of California San Francisco, San Francisco, CA, USA
| | - Jonathan T Carter
- Department of Surgery, 8785University of California San Francisco, San Francisco, CA, USA
| | - Hobart W Harris
- Department of Surgery, 8785University of California San Francisco, San Francisco, CA, USA
| | - John P Cello
- Department of Medicine, Division of Gastroenterology, 8785University of California San Francisco, San Francisco, CA, USA
| | - Stanley J Rogers
- Department of Surgery, 8785University of California San Francisco, San Francisco, CA, USA
| | - Matthew Y C Lin
- Department of Surgery, 8785University of California San Francisco, San Francisco, CA, USA
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Are laparoscopic and open ventral hernia repairs truly comparable?: A propensity-matched study in large ventral hernias. Surg Endosc 2020; 35:4653-4660. [PMID: 32780243 DOI: 10.1007/s00464-020-07894-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 08/05/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The merits of laparoscopic (LVHR) and open preperitoneal ventral hernia repair (OPPVHR) have been debated for more than 2 decades. Our aim was to determine peri-operative and long-term outcomes in large hernias. METHODS A prospective, institutional database at a tertiary hernia center was queried for patients undergoing LVHR and OPPVHR. One-to-one propensity score matching was performed for hernia defect size and follow-up. RESULTS Three hundred and fifty-two LVHR and OPPVHR patients were identified with defect sizes closely matched between laparoscopic (182.0 ± 110.0 cm2) and open repairs (178.3 ± 99.8 cm2), p = 0.64. LVHR and OPPVHR patients were comparable: mean age 57.2 ± 12.1 vs 56.6 ± 12.0 years (p = 0.52), BMI: 32.9 ± 6.6 vs 32.0 ± 7.4 kg/m2 (p = 0.16), diabetes 19.0% vs 19.7% (p = 0.87), and smoking history 8.7% vs 23.0% (p < 0.001), respectively. OPPVHR had higher number of recurrent hernias (14.2% vs 44.9%, p < 0.001), longer operative time (168.1 ± 64.3 vs 186.7 ± 67.7 min, p = 0.006), and more components separation (0% vs 20.3%, p < 0.001). Mean mesh size was larger (p < 0.001) in the open group (634.4 ± 243.4 cm2 vs 841.8 ± 277.6 cm2). The hernia recurrence rates were similar (10.8% vs 9.2%, p = 0.62), with average follow-up of 39.3 ± 32.5 vs 40.0 ± 35.0 months (p = 0.89). Length of stay was higher in the OVHR cohort (5.4 ± 3.0 vs 6.3 ± 3.6 days, p < 0.001), but 30-day readmission rates (4.0% vs 6.4%, p = 0.31) were similar. Overall wound infection rate (2.9% vs 8.4%, p = 0.03) was higher in the OPPVHR group, but the mesh infection rate was similar between LVHR (1.7%) and OPPVHR (0.6%) (p = 0.33). Postoperative pain (41.1% vs 41.4%, p = 0.95) and overall QOL based on the Carolinas Comfort Scale at 6 months (p = 0.73) and 5-years (p = 0.36) were similar. CONCLUSION Laparoscopic and open preperitoneal repair for large ventral hernias have equivalent hernia recurrence rates, postoperative pain, and QOL on long-term follow-up. Patients undergoing OPPVHR were more likely to be recurrent, complex, require components separation, and more likely to develop postoperative wound complications.
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Endoscopic Management of Acute Biliopancreatic Disorders. J Gastrointest Surg 2019; 23:1055-1068. [PMID: 30820794 DOI: 10.1007/s11605-019-04143-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 01/28/2019] [Indexed: 01/31/2023]
Abstract
PURPOSE Endoscopy is playing an ever-increasing role in the management of acute biliopancreatic disorders. With the management paradigm shifting away from more invasive surgical approaches, surgeons need to be aware of the treatment options available to improve patient care. Our manuscript serves to improve surgeons' knowledge and understanding of these emerging treatment modalities to expand their algorithmic approach to biliopancreatic disorders. METHODS Specific acute biliopancreatic disorders were identified from the literature and personal practice to create a structured review of common problems experienced by a surgeon of the gastrointestinal tract. An exhaustive literature review was performed to identify and analyze endoscopic treatment modalities for these disorders. RESULTS Endoscopic therapies continue to expand rapidly with a robust supportive literature. Data on endoscopic treatment strategies for acute biliopancreatic disorders demonstrate valuable improvements in outcomes in a number of these disorders. DISCUSSION Acute biliopancreatic disorders represent one of the most challenging pathophysiologies that a surgeon of the gastrointestinal tract may face. This manuscript represents a review of available endoscopic instrumentation as well as the author's interpretation of the current literature regarding indications and outcomes of endoscopic management for acute biliopancreatic disorders. Although this article does not supplant formal training in therapeutic endoscopy, surgeons reading this article should understand the role endoscopy plays in the management of acute biliopancreatic disorders.
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