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Sanmoto Y, Hasegawa M, Kinuta S. Factors contributing to prolonged operative time for laparoscopic cholecystectomy performed by trainee surgeons: a retrospective single-center study. Surg Today 2024:10.1007/s00595-024-02857-3. [PMID: 38691221 DOI: 10.1007/s00595-024-02857-3] [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: 03/03/2024] [Accepted: 04/04/2024] [Indexed: 05/03/2024]
Abstract
PURPOSE Laparoscopic cholecystectomy for a benign disease is often the initial endoscopic surgery performed by trainee surgeons. However, a lack of surgical experience is associated with prolonged operative times, which may increase the risk of postoperative complications and poor outcomes. This study aimed to identify the factors associated with prolonged operative times for laparoscopic cholecystectomy performed by inexperienced surgeons. METHODS This retrospective single-center study was conducted between January 2018 and December 2023. We performed a multivariate analysis to identify the factors associated with prolonged operative time by analyzing elective cases of laparoscopic cholecystectomy performed by surgeons with limited experience. RESULTS The study included 323 patients, subjected to a median operative time of 89 min. Multivariate analysis identified that patient characteristics such as male sex, increased body mass index, and a history of conservative treatment for cholecystitis, as well as operating surgeon's post-graduation years (< 4 years), and an attending surgeon without endoscopic surgical skill certification from the Japan Society of Endoscopic Surgery, were independent risk factors for a prolonged operative time. CONCLUSION Our findings suggest that endoscopic surgical skill-certified attending surgeons have excellent coaching skills and mitigate the operative time for elective cholecystectomy.
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Affiliation(s)
- Yohei Sanmoto
- Department of Surgery, Takeda General Hospital, 3-27 Yamagachou Aizuwakamatsu-Shi, Fukushima, 965-8585, Japan.
| | - Makoto Hasegawa
- Department of Surgery, Takeda General Hospital, 3-27 Yamagachou Aizuwakamatsu-Shi, Fukushima, 965-8585, Japan
| | - Shunji Kinuta
- Department of Surgery, Takeda General Hospital, 3-27 Yamagachou Aizuwakamatsu-Shi, Fukushima, 965-8585, Japan
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2
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Tian WM, Chang D, Pressley M, Muhammed M, Fong P, Webster W, Herbert G, Gallagher S, Watters CR, Yoo JS, Zani S, Agarwal S, Allen PJ, Seymour KA. Development of a prospective biliary dashboard to compare performance and surgical cost. Surg Endosc 2023; 37:8829-8840. [PMID: 37626234 DOI: 10.1007/s00464-023-10376-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 07/30/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Transparency around surgeon level data may align healthcare delivery with quality care for patients. Biliary surgery includes numerous procedures performed by both general surgeons and subspecialists alike. Cholecystectomy is a common surgical procedure and an optimal cohort to measure quality outcomes within a healthcare system. METHODS Data were collected for 5084 biliary operations performed by 68 surgeons in 11 surgical divisions in a health system including a tertiary academic hospital, two regional community hospitals, and two ambulatory surgery centers. A privacy protected dashboard was developed to compare surgeon performance and cost between July 2018 and June 2022. A sample cohort of patients ≥ 18 years who underwent cholecystectomy were compared by operative time, cost, and 30-day outcomes. RESULTS Over 4 years, 4568 cholecystectomy procedures were performed by 57 surgeons. Operations were done by 57 surgeons in four divisions and included 3846 (84.2%) laparoscopic cholecystectomies, 601 (13.2%) laparoscopic cholecystectomies with cholangiogram, and 121 (2.6%) open cholecystectomies. Patients were admitted from the emergency room in 2179 (47.7%) cases while 2389 (52.3%) cases were performed in the ambulatory setting. Individual surgeons were compared to peers for volume, intraoperative data, cost, and outcomes. Cost was lowest at ambulatory surgery centers, yet only 4.2% of elective procedures were performed at these facilities. Prepackaged kits with indocyanine green were more expensive than cholangiograms that used iodinated contrast. The rate of emergency department visits was lowest when cases were performed at ambulatory surgery centers. CONCLUSION Data generated from clinical dashboards can inform surgeons as to how they compare to peers regarding quality metrics such as cost, time, and complications. In turn, this may guide strategies to standardize care, optimize efficiency, provide cost savings, and improve outcomes for cholecystectomy procedures. Future application of clinical dashboards can assist surgeons and administrators to define value-based care.
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Affiliation(s)
| | - Doreen Chang
- Department of Surgery, Duke University, Durham, NC, USA
| | - Melissa Pressley
- Performance Services, Duke University Health System, Durham, NC, USA
| | - Makala Muhammed
- Performance Services, Duke University Health System, Durham, NC, USA
| | - Philip Fong
- Department of Surgery, Duke University, Durham, NC, USA
| | - Wendy Webster
- Department of Surgery, Duke University, Durham, NC, USA
| | - Garth Herbert
- Department of Surgery, Duke University, Durham, NC, USA
| | | | | | - Jin S Yoo
- Department of Surgery, Duke University, Durham, NC, USA
| | - Sabino Zani
- Department of Surgery, Duke University, Durham, NC, USA
| | | | - Peter J Allen
- Department of Surgery, Duke University, Durham, NC, USA
| | - Keri A Seymour
- Department of Surgery, Duke University, Durham, NC, USA.
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Lombardi PM, Mazzola M, Veronesi V, Granieri S, Cioffi SPB, Baia M, Del Prete L, Bernasconi DP, Danelli P, Ferrari G. Learning curve of laparoscopic cholecystectomy: a risk-adjusted cumulative summation (RA-CUSUM) analysis of six general surgery residents. Surg Endosc 2023; 37:8133-8143. [PMID: 37684403 DOI: 10.1007/s00464-023-10345-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 07/30/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LapC) is one of the most frequently performed surgical procedures worldwide. Reaching technical competency in performing LapC is considered one essential task for young surgeons. Investigating the learning curve for LapC (LC-LapC) may provide important information regarding the learning process and guide the training pathway of residents, improving educational outcomes. The present study aimed to investigate LC-LapC among general surgery residents (GSRs). METHODS Operative surgical reports of consecutive patients undergoing LapC performed by GSRs attending the General Surgery Residency Program at the University of Milan were analysed. Data on patient- and surgery-related variables were obtained from the ICD-9-CM diagnosis codes and gathered. A multidimensional assessment of the LC was performed through Cumulative Sum (CUSUM) and Risk-Adjusted (RA)-CUSUM analysis. RESULTS 340 patients operated by 6 GSRs were collected. The CUSUM and RA-CUSUM graphs based on surgical failures allowed to distinguish two defined phases for all GSRs: an initial phase ending at the peak, so-called learning phase, followed by a phase in which there was a significant decrease in failure incidence, so-called proficiency phase. The learning phase was completed for all GSRs at most within 25 procedures, but the trend of the curves and the number of procedures needed to achieve technical competency varied among operators ranging between 7 and 25. CONCLUSIONS The present study suggested that at most 25 procedures might be sufficient to acquire technical competency in LapC. The variability in the number of procedures needed to complete the LC, ranging between 7 and 25, could be due to the heterogeneous scenarios in which LapC was performed, and deserves to be investigated through a prospective study involving a larger number of GSRs and institutions.
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Affiliation(s)
- Pietro Maria Lombardi
- Division of Minimally-Invasive Surgical Oncology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.
| | - Michele Mazzola
- Division of Minimally-Invasive Surgical Oncology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Valentina Veronesi
- Bicocca Bioinformatics Biostatistics and Bioimaging Center - B4, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Stefano Granieri
- General Surgery Unit, ASST-Brianza, Vimercate Hospital, Via Santi Cosma e Damiano 10, 20871, Vimercate, Italy
| | - Stefano Piero Bernardo Cioffi
- General Surgery and Trauma Team, ASST Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - Marco Baia
- Sarcoma Service, Department of Surgery, IRCCS Fondazione Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Luca Del Prete
- IRCCS Fondazione Cà Granda Ospedale Maggiore Policlinico di Milan - General Surgery and Transplant Unit, Milan, Italy
- University of Milan - Translational Medicine PhD Program, Milan, Italy
| | - Davide Paolo Bernasconi
- Bicocca Bioinformatics Biostatistics and Bioimaging Center - B4, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Functional Department for Higher Education, Research, and Development, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Piergiorgio Danelli
- Department of Biomedical and Clinical Sciences, "Luigi Sacco" Hospital, University of Milan, Via Giovanni Battista Grassi 74, 20157, Milan, Italy
| | - Giovanni Ferrari
- Division of Minimally-Invasive Surgical Oncology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
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Mollah T, Gillespie C, Cocco A, Taylor L, Chong L, Hii MW. Defining Physiological Ketosis Following Very-Low-Calorie Diets. J Surg Res 2023; 290:197-202. [PMID: 37271067 DOI: 10.1016/j.jss.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 04/30/2023] [Accepted: 05/01/2023] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Very low-calorie diets (VLCDs) are used preoperatively in bariatric-metabolic surgery; however, this can lead to physiological ketosis. Euglycemic ketoacidosis is an increasingly recognized complication in diabetic patients on sodium-glucose-cotransporter-2 inhibitors (SGLT2i) undergoing surgery and requires assessment of ketones for diagnosis and monitoring. VLCD induced ketosis may confound monitoring in this group. We aimed to evaluate the influence of VLCD, compared to standard fasting, on perioperative ketone levels and acid-base balance. MATERIALS AND METHODS Twenty-seven patients were prospectively recruited to the intervention group and 26 to the control group from two tertiary referral centres in Melbourne, Australia. Intervention group patients were severely obese (body mass index) (BMI) (≥35), undergoing bariatric-metabolic surgery, and prescribed 2 wk of VLCD preoperatively. Control group patients underwent general surgical procedures and prescribed standard procedural fasting only. Patients were excluded if diabetic or prescribed SGLT2i. Ketone and acid-base measurements were taken at regular intervals. Univariate and multivariate regression was utilised with significance defined as P < 0.005. CLINICALTRIALS gov ID: NCT05442918. RESULTS Patients on VLCD, compared to standard fasting, had an increased median preoperative (0.60 versus 0.21 mmol/L), immediate postoperative (0.99 versus 0.34 mmol/L) and day 1 postoperative (0.69 versus 0.21 mmol/L) ketone level (P < 0.001). Preoperative acid-base balance was normal in both groups, however VLCD patients were found to have a metabolic acidosis immediately postoperatively (pH 7.29 versus pH 7.35) (P = 0.019). Acid-base balance had normalized in VLCD patients on postoperative day 1. CONCLUSIONS Preoperative VLCD resulted in increased pre- and postoperative ketone levels with immediate postoperative values consistent with metabolic ketoacidosis. This should be considered particularly when monitoring diabetic patients prescribed SGLT2i.
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Affiliation(s)
- Taha Mollah
- Department of Upper GI and Hepatobiliary Surgery, St. Vincent's Hospital, Melbourne, Australia.
| | - Carla Gillespie
- Department of Upper GI and Hepatobiliary Surgery, St. Vincent's Hospital, Melbourne, Australia
| | - Anthony Cocco
- Department of Upper GI and Hepatobiliary Surgery, St. Vincent's Hospital, Melbourne, Australia
| | - Lillian Taylor
- Department of Upper GI and Hepatobiliary Surgery, St. Vincent's Hospital, Melbourne, Australia
| | - Lynn Chong
- Department of Upper GI and Hepatobiliary Surgery, St. Vincent's Hospital, Melbourne, Australia; The Department of Surgery, St Vincent's Hospital, The University of Melbourne, Melbourne, Australia
| | - Michael W Hii
- Department of Upper GI and Hepatobiliary Surgery, St. Vincent's Hospital, Melbourne, Australia; The Department of Surgery, St Vincent's Hospital, The University of Melbourne, Melbourne, Australia
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Benissan-Messan DZ, Tamer R, Pieper H, Meara M, Chen X(P. What factors impact surgical operative time when teaching a resident in the operating room. Heliyon 2023; 9:e16554. [PMID: 37251464 PMCID: PMC10220402 DOI: 10.1016/j.heliyon.2023.e16554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/27/2023] [Accepted: 05/19/2023] [Indexed: 05/31/2023] Open
Abstract
Purpose Resident involvement would likely lead to prolonged operative time of a surgical case performed at academic medical centers. However, little is known about factors beneath this phenomenon. The purpose of this study was to investigate whether factors from case (procedure type, surgical case complexity, and surgical approach), teacher (attending surgeon experience and gender), and learner (resident postgraduate training year and gender) would influence operative time of surgical cases involved teaching a resident (SCT). Methods A single-institution retrospective analysis of 3 common general surgery procedures, including cholecystectomies, colectomies, and inguinal hernia, with involvement of general surgery residents between 2016 and 2020 was conducted. Surgical operative time was defined as the "cut-to-close" time from incision to completion of wound closure. Analysis of variance for continuous variables and multivariable linear regression were applied. Results A total of 4,417 eligible SCT were included. The average operative time was 114.8 ± 78.7 min. SCT with male resident involvement showed a significantly longer operative time than those with female residents (117 vs. 112, p = 0.01). Comparable operative time was observed between male and female attending surgeon cases (115.5 vs. 110.8, p = 0.15). SCT operating time decreased with increased resident training level, except for SCT with involvement of Year2 residents. SCT with Year5 residents demonstrated the lowest time to case completion (110.5 min); SCT with major complications took least time to complete (105.7 min). Univariate and multivariate analysis revealed resident training year level, resident gender, and case complexity as factors associated with significant differences in operative time. Attending surgeon experience, surgeon gender, surgical approach, and procedure type did not impact SCT operative time. Conclusion Our study findings suggest resident training level, resident gender, and case complexity are factors significantly associated with SCT operative time of cholecystectomies, colectomies, and inguinal hernia. Attending surgeons are recommended to factor them into pre-operative planning.
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Affiliation(s)
- Dathe Z. Benissan-Messan
- Division of General and Gastrointestinal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center Ohio, USA
| | - Robert Tamer
- Division of General and Gastrointestinal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center Ohio, USA
| | - Heidi Pieper
- Center for Advanced Robotic Surgery and Center for Minimally Invasive Surgery, The Ohio State University Wexner Medical Center Ohio, USA
| | - Michael Meara
- Division of General and Gastrointestinal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center Ohio, USA
| | - Xiaodong (Phoenix) Chen
- Division of General and Gastrointestinal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center Ohio, USA
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Martínez-Mier G, Mendez-Rico D, Reyes-Ruiz JM, Moreno-Ley PI, Bernal-Dolores V, Avila-Mercado O. External Validation of Two Scoring Tools to Predict the Operative Duration and Open Conversion of Elective Laparoscopic Cholecystectomy in a Mexican Population. Dig Surg 2023; 40:108-113. [PMID: 37231840 DOI: 10.1159/000531087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/14/2023] [Indexed: 05/27/2023]
Abstract
INTRODUCTION This study aimed to evaluate the use of laparoscopic cholecystectomy (LC) operative time (CholeS score) and conversion to an open procedure (CLOC score) outside their validation dataset in Mexican population. METHODS Patients >18 years who underwent elective LC were analyzed in a single-center retrospective chart review study. Association between scores (CholeS and CLOC) with operative time and conversion to open procedures was assessed with Spearman correlation. The predictive accuracy of the CholeS score and CLOC score was evaluated by receiver operator characteristic. RESULTS 200 patients were included in the study (33 excluded for emergency case or missing data). Spearman coefficient correlations between CholeS or CLOC score and operative time were 0.456 (p < 0.0001) and 0.356 (p < 0.0001), respectively. Area under the curve (AUC) for operative prediction time (>90 min) by CholeS score was 0.786 with a 3.5-point cutoff (80% sensitivity and 63.2% specificity). AUC for open conversion (CLOC score) was 0.78 with a 5-point cutoff (60% sensitivity and 91% specificity). The CLOC score had a 0.740 AUC (64% sensitivity and 72.8% specificity) for operative time >90 min. CONCLUSIONS The CholeS and the CLOC scores predicted LC long operative time and risk for conversion to an open procedure, respectively, outside their original validation set.
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Affiliation(s)
- Gustavo Martínez-Mier
- Department Organ Transplantation and General Surgery, Unidad Médica de Alta Especialidad, Hospital de Especialidades No. 14, Centro Médico Nacional "Adolfo Ruiz Cortines", Instituto Mexicano del Seguro Social (IMSS), Veracruz, Mexico
- Department Organ Transplantation and General Surgery, SESVER Hospital de Alta Especialidad "Virgilio Uribe" 20 de Noviembre 1074 Centro, Veracruz, Veracruz, Mexico
- Department of Research, Unidad Médica de Alta Especialidad, Hospital de Especialidades No. 14, Centro Médico Nacional "Adolfo Ruiz Cortines," Instituto Mexicano del Seguro Social (IMSS), Veracruz, Mexico
| | - Daniel Mendez-Rico
- Department Organ Transplantation and General Surgery, Unidad Médica de Alta Especialidad, Hospital de Especialidades No. 14, Centro Médico Nacional "Adolfo Ruiz Cortines", Instituto Mexicano del Seguro Social (IMSS), Veracruz, Mexico
| | - José Manuel Reyes-Ruiz
- Department of Research, Unidad Médica de Alta Especialidad, Hospital de Especialidades No. 14, Centro Médico Nacional "Adolfo Ruiz Cortines," Instituto Mexicano del Seguro Social (IMSS), Veracruz, Mexico
- Facultad de Medicina, Región Veracruz, Universidad Veracruzana, Veracruz, Mexico
| | - Pedro Ivan Moreno-Ley
- Department Organ Transplantation and General Surgery, Unidad Médica de Alta Especialidad, Hospital de Especialidades No. 14, Centro Médico Nacional "Adolfo Ruiz Cortines", Instituto Mexicano del Seguro Social (IMSS), Veracruz, Mexico
- Department Organ Transplantation and General Surgery, SESVER Hospital de Alta Especialidad "Virgilio Uribe" 20 de Noviembre 1074 Centro, Veracruz, Veracruz, Mexico
| | - Victor Bernal-Dolores
- Department of Research, Unidad Médica de Alta Especialidad, Hospital de Especialidades No. 14, Centro Médico Nacional "Adolfo Ruiz Cortines," Instituto Mexicano del Seguro Social (IMSS), Veracruz, Mexico
| | - Octavio Avila-Mercado
- Department of General Surgery, Unidad Médica de Alta Especialidad, Hospital de Especialidades No. 14, Centro Médico Nacional "Adolfo Ruiz Cortines," Instituto Mexicano del Seguro Social (IMSS), Veracruz, Mexico
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Influence of Operative Time in the Results of Elective Endovascular Repair of Abdominal Aortic Aneurysms. Ann Vasc Surg 2022; 92:195-200. [PMID: 36566912 DOI: 10.1016/j.avsg.2022.12.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 11/21/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND A prolonged operative time (OT) is a well-recognized risk factor of postoperative complications after many open surgical procedures, although little is known about its impact in less-invasive endovascular procedures. We aimed to define the characteristics related to a prolonged OT in the endovascular treatment of aorto-iliac aneurysms (EVAR) and to evaluate the influence of OT on postoperative outcomes. METHODS Retrospective analysis of 284 consecutive patients (mean age 75 years, 95% male) who underwent an elective EVAR between 2000 and 2019. Operative characteristics related to OT and the impact of OT in postoperative results was studied using multiple lineal and logistic regression analyses, respectively. RESULTS The mean surgical time was 200 min. OT was associated (regression model) with the implantation of straight endografts (-38 min, P = 0.007), femoral artery surgery (+80 min, P < 0.001), hypogastric preservation procedures (+70 min, P < 0.001), associated peripheral arterial disease (+22 min, P = 0.013), general anesthesia (+34 min, P < 0.001), and aneurysm diameter (+9 min/cm, P = 0.002). During the postoperative period (<30 days or at discharge), 21% presented a complication and 2.8% died. OT was independently associated with a higher incidence of postoperative complications (odds ratio [OR] for each additional 30' of surgery = 1.34, P < 0.001), such as immediate (OR = 1.48, P = 0.003) and 6-month mortality (OR = 1.28, P = 0.025). CONCLUSIONS A prolonged OT is an independent risk factor for complications and mortality after EVAR. Surgeons must take this factor into consideration when defining the best therapeutic strategy for abdominal aortic aneurysms.
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Muacevic A, Adler JR, Al Hawaj K, Alhashim IW, Al Rebh FN. Laparoscopic Cholecystectomy in a Morbidly Obese Patient With Situs Inversus Totalis: A Case Report. Cureus 2022; 14:e32304. [PMID: 36628025 PMCID: PMC9823198 DOI: 10.7759/cureus.32304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 12/12/2022] Open
Abstract
Situs inversus totalis (SIT) is a rare congenital condition characterized by a mirror-image transposition of both the abdominal and the thoracic organs. Due to the reversal of organs, laparoscopic cholecystectomy (LC) poses a significant challenge in patients with SIT. After the first reported case of LC in a patient with SIT in 1991, 120 more such reports have been published in the literature, but very few of them were carried out on morbidly obese patients. We report a morbidly obese patient, a known case of SIT, who presented with persistent biliary colic and underwent successful laparoscopic cholecystectomy in our institution. At surgery we used reverse Trendelenburg position with left tilt up and mirror-image of usual laparoscopic cholecystectomy port sites for the procedure. The procedure proved to be challenging, both due to the morbid obesity of the patient and the reversal of organs, which affected orientation and dexterity. A successful outcome has been reported in all the cases before us as well as our case, but it is noteworthy to mention that such cases must be performed by well-trained laparoscopic surgeons with impeccable manual dexterity who must take extreme care to avoid iatrogenic injuries.
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Maassen H, Leuvenink HGD, van Goor H, Sanders JSF, Pol RA, Moers C, Hofker HS. Prolonged Organ Extraction Time Negatively Impacts Kidney Transplantation Outcome. Transpl Int 2022; 35:10186. [PMID: 35221788 PMCID: PMC8863594 DOI: 10.3389/ti.2021.10186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 12/27/2021] [Indexed: 11/13/2022]
Abstract
Main Problem: Following cold aortic flush in a deceased organ donation procedure, kidneys never reach the intended 0–4°C and stay ischemic at around 20°C in the donor’s body until actual surgical retrieval. Therefore, organ extraction time could have a detrimental influence on kidney transplant outcome. Materials and Methods: We analyzed the association between extraction time and kidney transplant outcome in multicenter data of 5,426 transplant procedures from the Dutch Organ Transplantation Registry (NOTR) and 15,849 transplant procedures from the United Network for Organ Sharing (UNOS). Results: Extraction time was grouped per 10-min increment. In the NOTR database, extraction time was independently associated with graft loss [HR 1.027 (1.004–1.050); p = 0.022] and with DGF [OR 1.043 (1.021–1.066); p < 0.005]. An extraction time >80 min was associated with a 27.4% higher hazard rate of graft failure [HR 1.274 (1.080–1.502); p = 0.004] and such kidneys had 43.8% higher odds of developing DGF [OR 1.438, (1.236–1.673); p < 0.005]. In the UNOS database, increasing extraction times in DCD donors were associated with DGF [OR 1.036 (1.016–1.055); p < 0.005]. An extraction time >30 min was associated with 14.5% higher odds of developing DGF [OR 1.145 (1.063–1.233); p < 0.005]. Discussion: Prolonged kidney extraction time negatively influenced graft survival in Dutch donors and increased DGF risk in all deceased donor recipients.
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Affiliation(s)
- Hanno Maassen
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- *Correspondence: Hanno Maassen,
| | - Henri G. D. Leuvenink
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Harry van Goor
- Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Jan-Stephan F. Sanders
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Robert A. Pol
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Cyril Moers
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - H. Sijbrand Hofker
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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10
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Nogoy DM, Padmanaban V, Balazero LL, Rosado J, Sifri ZC. Predictors of Difficult Laparoscopic Cholecystectomy on Humanitarian Missions to Peru Difficult LC in Surgical Missions. J Surg Res 2021; 267:102-108. [PMID: 34157489 DOI: 10.1016/j.jss.2021.04.020] [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: 08/24/2020] [Revised: 04/07/2021] [Accepted: 04/10/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) is the gold standard treatment of gallstone disease. On short-term surgical missions (STSMs), it is unclear what factors can predict safety of LC. This study evaluates patient risk factors of difficult LC in Northern Peru, towards optimizing outcomes. MATERIALS AND METHODS A retrospective review was performed of patients who underwent LC during short-term surgical missions to Peru from 2016-2019 under the International Surgical Health Initiative (ISHI). Difficult and routine LC groups were compared for: age, weight, gender, symptom duration, pain on presentation, history of abdominal or pelvic surgery, diabetes and hypertension. RESULTS 68 of 194 patients underwent LC; 42 patients (62%) were classified as difficult with OR (operating room) time > 70 min (90%), 2 cases converted to open (5%) and 2 aborted cases (5%). Higher weight class was found to correlate with difficult LC. CONCLUSION Increased patient weight was correlated to longer operative time during STSMs. Patients undergoing LC must be selected carefully to mitigate risks of difficult operations on STSMs.
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Affiliation(s)
- Danielle M Nogoy
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey.
| | - Vennila Padmanaban
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | | | - Jesus Rosado
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Ziad C Sifri
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
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11
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Bludevich BM, Danielson PD, Snyder CW, Nguyen ATH, Chandler NM. Does speed matter? A look at NSQIP-P outcomes based on operative time. J Pediatr Surg 2021; 56:1107-1113. [PMID: 33762117 DOI: 10.1016/j.jpedsurg.2021.02.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 02/05/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND Appendicitis is a common pediatric surgical condition, comprising a large burden of healthcare costs. We aimed to determine if prolonged operative times were associated with increased 30-day complication rates when adjusting for pre-operative risk factors. METHODS Patients <18 years old, diagnosed intraoperatively with acute uncomplicated appendicitis and undergoing laparoscopic appendectomy were identified from the NSQIP-P 2012-2018 databases. The primary outcome, "infectious post-operative complications", is a composite of sepsis, deep incisional surgical site infections, wound disruptions, superficial, and organ space infections within 30-days of the operation. Secondary outcomes included return to the operating room and unplanned readmissions within 30 days. Logistic regression models were used to assess associations between operative time and each outcome. A Receiver Operating Characteristic (ROC) curve was generated from the predicted probabilities of the multivariate model for infectious post-operative complications to examine operative times. RESULTS Between 2012 and 2018, 27,763 pediatric patients with acute uncomplicated appendicitis underwent a laparoscopic appendectomy. Over half the population was male (61%) with a median operative time of 39 min (IQR 29-52 min). Infectious post-operative complication rate was 2.8% overall and was highest (8%) among patients with operative time ≥ 90 min (Fig. 1). Unplanned readmission occurred in 2.9% of patients, with 0.7% returning to the operating room. Each 30-min increase in operating time was associated with a 24% increase in odds of an infectious post-operative complication (OR=1.24, 95% CI=1.17-1.31) in adjusted models. Operative time thresholds predicted with ROC analysis were most meaningful in younger patients with higher ASA class and pre-operative SIRS/Sepsis/Septic shock. Longer operative times were also associated with higher odds of unplanned readmission (OR=1.11, 95% CI=1.05-1.18) and return to the operating room (OR=1.13, 95% CI=1.02-1.24) in adjusted models. CONCLUSION There is a risk-adjusted association between prolonged operative time and the occurrence of infectious post-operative complications. Infectious postoperative complications increase healthcare spending and are currently an area of focus in healthcare value models. Future studies should focus on addressing laparoscopic appendectomy operative times longer than 60 min, with steps such as continuation of antibiotics, shifting roles between attending and resident surgeons, and simulation training. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Bryce M Bludevich
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, Saint Petersburg, FL, United States; Department of General Surgery, UMass Medical School, Worcester, MA, United States
| | - Paul D Danielson
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, Saint Petersburg, FL, United States
| | - Christopher W Snyder
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, Saint Petersburg, FL, United States
| | - Anh Thy H Nguyen
- Epidemiology and Biostatistics Unit, Johns Hopkins All Children's Institute for Clinical and Translational Research, Saint Petersburg, FL, United States
| | - Nicole M Chandler
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, Saint Petersburg, FL, United States.
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12
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Evaluating the Effect of Surgical Skill on Outcomes for Laparoscopic Sleeve Gastrectomy: A Video-based Study. Ann Surg 2021; 273:766-771. [PMID: 31188214 DOI: 10.1097/sla.0000000000003385] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prior studies have demonstrated a correlation between surgical skill and complication rates after laparoscopic Roux-en-Y gastric bypass. However, the impact of surgical skill on a similar but less technically challenging procedure such as sleeve gastrectomy (SG) is unknown. METHODS Practicing bariatric surgeons (n = 25) participating in a statewide quality improvement collaborative submitted an unedited deidentified video of a representative laparoscopic SG. Videos were obtained between 2015 and 2016 and were rated by bariatric surgeons in a blinded fashion using a validated instrument that assesses surgical skill. Overall scores were based on a 5-point Likert scale with 5 representing a "master surgeon" and 1 representing a "surgeon-in-training." Risk-adjusted 30-day complication rates, 1-year weight loss among cases performed during the study period, and operative technique were compared between surgeons rated in the top and bottom quartiles according to skill. RESULTS Surgeon ratings for skill varied between 2.73 and 4.60. Ratings for skill did not correlate with overall 30-day risk-adjusted complication rates (Pearson correlation coefficient, 0.213, P = 0.303). However, surgeons with higher skill ratings had lower rates of specific surgical complications, including postoperative obstruction (0.13% vs 0.3%, P = 0.017), hemorrhage (0.85% vs 1.27%, P = 0.005), and reoperation (0.24% vs 0.92%, P < 0.0001). Surgeons ranked in the top quartile for skill had faster operating times for SG (59.0 vs 82.1 min, P < 0.0001) and higher annual case volumes for both SG and any bariatric procedure (224.3 cases/yr vs 73.4 cases/yr, P = 0.009 and 244.9 cases/yr and 93.9 cases/yr, P = 0.009) when compared with surgeons in the bottom quartile. When comparing operative technique, top rated surgeons were noted to have a higher likelihood of using buttressing (83.3% vs 0%, P = 0.0041) and intraoperative endoscopy (83.3% vs 0%, P = 0.0041). CONCLUSIONS Peer ratings for surgical skill varied for laparoscopic sleeve gastrectomy but did not have a significant impact on overall complication rates. Top rated surgeons had lower rates of obstruction, hemorrhage, and reoperation; however, severe morbidity remained extremely low among all surgeons.
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13
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Roof MA, Feng JE, Anoushiravani AA, Schoof LH, Friedlander S, Lajam CM, Vigdorchik J, Slover JD, Schwarzkopf R. The effect of patient point of entry and Medicaid status on quality outcomes following total hip arthroplasty. Bone Joint J 2020; 102-B:78-84. [DOI: 10.1302/0301-620x.102b7.bjj-2019-1424.r2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims Previous studies have reported an increased risk for postoperative complications in the Medicaid population undergoing total hip arthroplasty (THA). These studies have not controlled for the surgeon’s practice or patient care setting. This study aims to evaluate whether patient point of entry and Medicaid status plays a role in quality outcomes and discharge disposition following THA. Methods The electronic medical record at our institution was retrospectively reviewed for all primary, unilateral THA between January 2016 and January 2018. THA recipients were categorized as either Medicaid or non-Medicaid patients based on a visit to our institution’s Hospital Ambulatory Care Center (HACC) within the six months prior to surgery. Only patients who had been operated on by surgeons (CML, JV, JDS, RS) with at least ten Medicaid and ten non-Medicaid patients were included in the study. The patients included in this study were 56.33% female, had a mean age of 60.85 years, and had a mean BMI of 29.14. The average length of follow-up was 343.73 days. Results A total of 426 hips in 403 patients were included in this study, with 114 Medicaid patients and 312 non-Medicaid patients. Medicaid patients had a significantly lower mean age (54.68 years (SD 12.33) vs 63.10 years (SD 12.38); p < 0.001), more likely to be black or ‘other’ race (27.19% vs 13.46% black; 26.32% vs 12.82% other; p < 0.001), and more likely to be a current smoker (19.30% vs 9.29%; p = 0.001). After adjusting for patient risk factors, there was a significant Medicaid effect on length of stay (LOS) (rate ratio 1.129, 95% confidence interval (CI) 1.048 to 1.216; p = 0.001) and facility discharge (odds ratio 2.010, 95% CI 1.398 to 2.890; p < 0.001). There was no Medicaid effect on surgical time (exponentiated β coefficient 1.015, 95% CI 0.995 to 1.036; p = 0.136). There was no difference in 30-day readmission, 90-day readmission, 30-day infections, 90-day infections, and 90-day mortality between the two groups. Conclusion After controlling for patient variables, there was a statistically significant Medicaid effect on LOS and facility discharge. These results indicate that clinically similar outcomes can be achieved for Medicaid patients; however, further work is needed on maximizing social support and preoperative patient education with a focus on successful home discharge. Cite this article: Bone Joint J 2020;102-B(7 Supple B):78–84.
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Affiliation(s)
- Mackenzie A. Roof
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - James E. Feng
- Department of Orthopaedic Surgery, Beaumont Health, Royal Oak, Michigan, USA
| | | | - Lauren H. Schoof
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Scott Friedlander
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Claudette M. Lajam
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Jonathan Vigdorchik
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - James D. Slover
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
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14
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Tracy BM, Paterson CW, Torres DM, Young K, Hochman BR, Zielinski MD, Burruss SK, Mulder MB, Yeh DD, Gelbard RB. Risk factors for complications after cholecystectomy for common bile duct stones: An EAST multicenter study. Surgery 2020; 168:62-66. [PMID: 32466829 DOI: 10.1016/j.surg.2020.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/13/2020] [Accepted: 04/07/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND We sought to prospectively identify risk factors for biliary complications and 30-day readmission after cholecystectomy for choledocholithiasis and gallstone pancreatitis across multiple US hospitals. METHODS We performed a prospective, observational study of patients who underwent same admission cholecystectomy for choledocholithiasis and gallstone pancreatitis between 2016 and 2019 at 12 US centers. Patients with prior history of endoscopic retrograde cholangiopancreatography or diagnosis of cholangitis were excluded. We used logistic regression to determine associations between preoperative demographics, labs, and imaging on primary outcomes: postoperative biliary complications and 30-day readmission. RESULTS There were 989 patients in the cohort. There were 16 (1.6%) patients with postoperative biliary complications, including intra-abdominal abscesses, endoscopic retrograde cholangiopancreatography-induced pancreatitis, and biliary leaks. Increasing operative time (odds ratio 1.01, 95% confidence interval 1.00-1.01, P = .02), worsening leukocytosis (odds ratio 1.16, 95% confidence interval 1.07-1.25, P = .0002), and jaundice (odds ratio 3.25, 95% confidence interval 1.01-10.42, P = .04) were associated with postoperative biliary complications. There were 36 (3.6%) patients readmitted within 30 days owing to a surgical complication. A prior postoperative biliary complication (odds ratio 7.8, 95% confidence interval 1.63-37.27, P = .01), male sex (odds ratio 2.42, 95% confidence interval 1.2-4.87, P = .01), and index operative duration (odds ratio 1.01, 95% confidence interval 1.00-1.01, P = .03) were associated with 30-day readmission. CONCLUSION Among patients undergoing cholecystectomy for common bile duct stones, jaundice, worsening leukocytosis, and longer operations are associated with postoperative biliary complications. A prior biliary complication is also predictive of a 30-day readmission. Surgeons should recognize these factors and avoid prematurely discharging at-risk patients given their propensity to develop complications and require readmission.
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Affiliation(s)
- Brett M Tracy
- Department of Surgery, Emory University School of Medicine, Atlanta, GA; Emory Department of Surgery, Grady Memorial Hospital, Atlanta, GA.
| | - Cameron W Paterson
- Department of Surgery, Emory University School of Medicine, Atlanta, GA; Emory Department of Surgery, Grady Memorial Hospital, Atlanta, GA
| | - Denise M Torres
- Department of Surgery, Geisinger Medical Center, Danville, PA
| | - Katelyn Young
- Department of Surgery, Geisinger Medical Center, Danville, PA
| | - Beth R Hochman
- Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Martin D Zielinski
- Department of Trauma, Critical Care, and General Surgery, Mayo Clinic, Rochester, MN
| | - Sigrid K Burruss
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | | | | | - Rondi B Gelbard
- Department of Surgery, Emory University School of Medicine, Atlanta, GA; Emory Department of Surgery, Grady Memorial Hospital, Atlanta, GA
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15
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Quick JA, Bukoski AD, Doty J, Bennett BJ, Crane M, Randolph J, Ahmad S, Barnes SL. Case Difficulty, Postgraduate Year, and Resident Surgeon Stress: Effects on Operative Times. JOURNAL OF SURGICAL EDUCATION 2019; 76:354-361. [PMID: 30146460 DOI: 10.1016/j.jsurg.2018.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 07/30/2018] [Accepted: 08/01/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE We aimed to evaluate resident operative times in relation to postgraduate year (PGY), case difficulty and resident stress while performing a single surgical procedure. DESIGN We prospectively examined operative times for 268 laparoscopic cholecystectomies, and analyzed relationships between PGY, case difficulty, and resident surgeon stress utilizing electrodermal activity. Each case operative times were divided into 3 separate time periods. Case Start and End times were recorded, as well as the time between the start of the operation and the time until the cystic structures were divided (Division). Case difficulty was determined by multiple trained observers with a high inter-rater concordance. SETTING University of Missouri, a tertiary academic medical institution. PARTICIPANTS All categorical general surgery residents at our institution. RESULTS For each operative time period examined during laparoscopic cholecystectomy, operative time increased, with each incremental increase in difficulty resulting in approximately 130% longer times. Minimal differences in operative times were seen between PGY levels, except during the easiest cases (Start-End times: 38.5 ± 10.4 minutes vs 34.2 ± 10.8 minutes vs 28.9 ± 10.9 minutes, p 0.002). Resident stress poorly correlated with operative times regardless of case difficulty (Pearson coefficient range 0.0-0.22). CONCLUSIONS Operative times are longer with increasing case difficulty. PGY level and resident surgeon stress appear to have minimal to no correlation with operative times, regardless of case difficulty.
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Affiliation(s)
- Jacob A Quick
- University of Missouri, School of Medicine, Department of Surgery, Columbia, Missouri.
| | - Alex D Bukoski
- University of Missouri, College of Veterinary Medicine, Columbia, Missouri
| | - Jennifer Doty
- University of Missouri, School of Medicine, Department of Surgery, Columbia, Missouri
| | - Bethany J Bennett
- University of Missouri, School of Medicine, Department of Surgery, Columbia, Missouri
| | - Megan Crane
- University of Missouri, School of Medicine, Department of Surgery, Columbia, Missouri
| | - Jennifer Randolph
- University of Missouri, School of Medicine, Department of Surgery, Columbia, Missouri
| | - Salman Ahmad
- University of Missouri, School of Medicine, Department of Surgery, Columbia, Missouri
| | - Stephen L Barnes
- University of Missouri, School of Medicine, Department of Surgery, Columbia, Missouri
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16
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Fruscione M, Kirks RC, Cochran A, Murphy K, Baker EH, Martinie JB, Iannitti DA, Vrochides D. Routine versus difficult cholecystectomy: using predictive analytics to assess patient outcomes. HPB (Oxford) 2019; 21:77-86. [PMID: 30049644 DOI: 10.1016/j.hpb.2018.06.1805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 06/18/2018] [Accepted: 06/21/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The American College of Surgeons National Surgical Quality Improvement Program® (NSQIP) Surgical Risk. Calculator (SRC) estimates postoperative outcomes. The aim of this study was to develop and validate a specific predictive outcomes model for cholecystectomy procedures. METHODS Patients who underwent cholecystectomy between 2008 and 2016 and were deemed too high risk for acute care general surgery (GS) and had surgery performed by the Division of Hepatopancreatobiliary Surgery (HPB) were identified. Outcomes of the HPB cholecystectomies were matched against cholecystectomies performed by GS. New predictive models for postoperative outcomes were constructed. Area under the curve was used to assess predictive accuracy for both models and internal validation was performed using bootstrap logistic regression. RESULTS A total of 169/934 (18%) cholecystectomies were identified as too high risk for GS. These 169 patients were matched with 126 patients who had cholecystectomy performed by GS. For GS and HPB cholecystectomies, the proposed model demonstrated better discriminative ability compared to the SRC based on ROC curves (proposed model: 0.589-0.982; SRC: 0.570-0.836) for each of the predicted outcomes. CONCLUSION For patients undergoing cholecystectomy, customized models are superior for predicting individual perioperative risk and allow more accurate, patient-specific delivery of care.
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Affiliation(s)
- Mike Fruscione
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Russell C Kirks
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Allyson Cochran
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Keith Murphy
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Erin H Baker
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - John B Martinie
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - David A Iannitti
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA.
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17
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Migliore M, Arezzo A, Arolfo S, Passera R, Morino M. Safety of single-incision robotic cholecystectomy for benign gallbladder disease: a systematic review. Surg Endosc 2018; 32:4716-4727. [PMID: 29943057 DOI: 10.1007/s00464-018-6300-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 06/18/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Multiport laparoscopic cholecystectomy (MLC) is the gold standard technique for cholecystectomy. In order to reduce postoperative pain and improve cosmetic results, the application of the single-incision laparoscopic cholecystectomy (SILC) technique was introduced, leading surgeons to face important challenges. Robotic technology has been proposed to overcome some of these limitations. The purpose of this review is to assess the safety of single-incision robotic cholecystectomy (SIRC) for benign disease. METHODS An Embase and Pubmed literature search was performed in February 2017. Randomized controlled trial and prospective observational studies were selected and assessed using PRISMA recommendations. Primary outcome was overall postoperative complication rate. Secondary outcomes were postoperative bile leak rate, total conversion rate, operative time, wound complication rate, postoperative hospital stay, and port site hernia rate. The outcomes were analyzed in Forest plots based on fixed and random effects model. Heterogeneity was assessed using the I2 statistic. RESULTS A total of 13 studies provided data about 1010 patients who underwent to SIRC for benign disease of gallbladder. Overall postoperative complications rate was 11.6% but only 4/1010 (0.4%) patients required further surgery. A postoperative bile leak was reported in 3/950 patients (0.3%). Conversion occurred in 4.2% of patients. Mean operative time was 86.7 min including an average of 42 min should be added as for robotic console time. Wound complications occurred in 3.7% of patients. Median postoperative hospital stay was 1 day. Port site hernia at the latest follow-up available was reported in 5.2% of patients. CONCLUSIONS The use of the Da Vinci robot in single-port cholecystectomy seems to have similar results in terms of incidence and grade of complications compared to standard laparoscopy. In addition, it seems affected by the same limitations of single-port surgery, consisting of an increased operative time and incidence of port site hernia.
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Affiliation(s)
- Marco Migliore
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Torino, Italy
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Torino, Italy.
| | - Simone Arolfo
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Torino, Italy
| | - Roberto Passera
- Division of Nuclear Medicine, University of Torino, Torino, Italy
| | - Mario Morino
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Torino, Italy
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18
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Cheng H, Clymer JW, Po-Han Chen B, Sadeghirad B, Ferko NC, Cameron CG, Hinoul P. Prolonged operative duration is associated with complications: a systematic review and meta-analysis. J Surg Res 2018; 229:134-144. [PMID: 29936980 DOI: 10.1016/j.jss.2018.03.022] [Citation(s) in RCA: 383] [Impact Index Per Article: 63.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 02/27/2018] [Accepted: 03/14/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND The aim of this study was to systematically synthesize the large volume of literature reporting on the association between operative duration and complications across various surgical specialties and procedure types. METHODS An electronic search of PubMed, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews from January 2005 to January 2015 was conducted. Sixty-six observational studies met the inclusion criteria. RESULTS Pooled analyses showed that the likelihood of complications increased significantly with prolonged operative duration, approximately doubling with operative time thresholds exceeding 2 or more hours. Meta-analyses also demonstrated a 14% increase in the likelihood of complications for every 30 min of additional operating time. CONCLUSIONS Prolonged operative time is associated with an increase in the risk of complications. Given the adverse consequences of complications, decreased operative times should be a universal goal for surgeons, hospitals, and policy-makers. Future study is recommended on the evaluation of interventions targeted to reducing operating time.
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19
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Li N, Kong H, Li SL, Zhu SN, Wang DX. Combined epidural-general anesthesia was associated with lower risk of postoperative complications in patients undergoing open abdominal surgery for pheochromocytoma: A retrospective cohort study. PLoS One 2018; 13:e0192924. [PMID: 29466473 PMCID: PMC5821342 DOI: 10.1371/journal.pone.0192924] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 01/16/2018] [Indexed: 01/09/2023] Open
Abstract
Background Current evidences show that regional anesthesia is associated with decreased risk of complications after major surgery. However, the effects of combined regional-general anesthesia remain controversial. The purpose of our study was to analyze the impact of anesthesia (combined epidural-general anesthesia vs. general anesthesia) on the risk of postoperative complications in patients undergoing open surgery for pheochromocytoma. Methods This was a retrospective cohort study. 146 patients who underwent open surgery for pheochromocytoma (100 received combined epidural-general anesthesia and 46 received general anesthesia) in Peking University First Hospital from January 1, 2002 to December 31, 2015 were enrolled. The primary outcome was the occurrence of postoperative complications during hospital stay after surgery. Multivariate Logistic regression models were used to analyze the association between the choice of anesthetic method and the risk of postoperative complications. Results 17 (11.6%) patients developed complications during postoperative hospital stay. The incidence of postoperative complications was lower in patients with combined epidural-general anesthesia than in those with general anesthesia (6% [6/100] vs. 23.9% [11/46], P = 0.006). Multivariate Logistic regression analysis showed that use of combined epidural-general anesthesia (OR 0.219, 95% CI 0.065–0.741; P = 0.015) was associated with lower risk, whereas male gender (OR 5.213, 95% CI 1.283–21.177; P = 0.021) and perioperative blood transfusion (OR 25.879; 95% CI 3.130–213.961; P = 0.003) were associated with higher risk of postoperative complications. Conclusions For patients undergoing open surgery for pheochromocytoma, use of combined epidural-general anesthesia may decrease the occurrence of postoperative complications.
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Affiliation(s)
- Nan Li
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Hao Kong
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Shuang-Ling Li
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Sai-Nan Zhu
- Department of Biostatistics, Peking University First Hospital, Beijing, China
| | - Dong-Xin Wang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
- * E-mail:
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20
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The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy. Surg Endosc 2018; 32:3149-3157. [PMID: 29340820 PMCID: PMC5988776 DOI: 10.1007/s00464-018-6030-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 01/03/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND The ability to accurately predict operative duration has the potential to optimise theatre efficiency and utilisation, thus reducing costs and increasing staff and patient satisfaction. With laparoscopic cholecystectomy being one of the most commonly performed procedures worldwide, a tool to predict operative duration could be extremely beneficial to healthcare organisations. METHODS Data collected from the CholeS study on patients undergoing cholecystectomy in UK and Irish hospitals between 04/2014 and 05/2014 were used to study operative duration. A multivariable binary logistic regression model was produced in order to identify significant independent predictors of long (> 90 min) operations. The resulting model was converted to a risk score, which was subsequently validated on second cohort of patients using ROC curves. RESULTS After exclusions, data were available for 7227 patients in the derivation (CholeS) cohort. The median operative duration was 60 min (interquartile range 45-85), with 17.7% of operations lasting longer than 90 min. Ten factors were found to be significant independent predictors of operative durations > 90 min, including ASA, age, previous surgical admissions, BMI, gallbladder wall thickness and CBD diameter. A risk score was then produced from these factors, and applied to a cohort of 2405 patients from a tertiary centre for external validation. This returned an area under the ROC curve of 0.708 (SE = 0.013, p < 0.001), with the proportions of operations lasting > 90 min increasing more than eightfold from 5.1 to 41.8% in the extremes of the score. CONCLUSION The scoring tool produced in this study was found to be significantly predictive of long operative durations on validation in an external cohort. As such, the tool may have the potential to enable organisations to better organise theatre lists and deliver greater efficiencies in care.
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Varban OA, Niemann A, Stricklen A, Ross R, Ghaferi AA, Finks JF, Dimick JB. Far from Standardized: Using Surgical Videos to Identify Variation in Technique for Laparoscopic Sleeve Gastrectomy. J Laparoendosc Adv Surg Tech A 2017; 27:761-767. [PMID: 28686537 DOI: 10.1089/lap.2017.0184] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Video assessment is an emerging tool for understanding variation in surgical technique. METHODS Representative videos of laparoscopic sleeve gastrectomy (LSG) were voluntarily submitted by 20 surgeons who participated in a statewide quality improvement collaborative. The amount of time required to complete the salient steps of the operation was measured and variations in the tasks performed during each step were captured. RESULTS Twenty-two videos of LSG were submitted and 11 videos included concurrent hiatal hernia repair. Data obtained from video analysis identified variation in time to complete each step of the procedure: prestapling dissection of stomach (5-25 minutes), gastric stapling (8-20 minutes), and management of the staple line (1-25 minutes). Time required to perform a hiatal hernia repair also varied (1-26 minutes), as did the type of repair: 55% were performed with a posterior cruropexy, 27% were performed with an anterior cruropexy, and 18% were performed with both. Ten different permutations of staple heights and buttressing material were used during division of the stomach with a gastric stapler. Management of the staple line included use of buttressing (64%), fibrin sealant (36%), oversewing (9%), surgical clips (18%), imbrication of the staple line (36%), and omentoplasty (55%). CONCLUSIONS LSG technique is not uniform. Video analysis identified variation in (1) time to complete each step of the procedure, (2) hiatal hernia repair technique, (3) stapling technique, and (4) post-transection staple line management. Future efforts linking video analysis with clinical outcomes can provide objective evidence to support best practices.
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Affiliation(s)
- Oliver A Varban
- 1 Department of Surgery, University of Michigan Health Systems , Ann Arbor, Michigan
| | - Adam Niemann
- 2 Department of Surgery, University of Michigan Medical School , Ann Arbor, Michigan
| | - Amanda Stricklen
- 3 Department of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan , Ann Arbor, Michigan
| | - Rachel Ross
- 3 Department of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan , Ann Arbor, Michigan
| | - Amir A Ghaferi
- 3 Department of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan , Ann Arbor, Michigan
| | - Jonathan F Finks
- 1 Department of Surgery, University of Michigan Health Systems , Ann Arbor, Michigan
| | - Justin B Dimick
- 1 Department of Surgery, University of Michigan Health Systems , Ann Arbor, Michigan.,3 Department of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan , Ann Arbor, Michigan
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22
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Prolonged operative time in laparoscopic appendectomy: Predictive factors and outcomes. Int J Surg 2016; 36:225-232. [PMID: 27794471 DOI: 10.1016/j.ijsu.2016.10.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 10/22/2016] [Accepted: 10/24/2016] [Indexed: 11/22/2022]
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23
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Tandon A, Sunderland G, Nunes QM, Misra N, Shrotri M. Day case laparoscopic cholecystectomy in patients with high BMI: Experience from a UK centre. Ann R Coll Surg Engl 2016; 98:329-33. [PMID: 27087326 DOI: 10.1308/rcsann.2016.0125] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Symptomatic gall stones may require laparoscopic cholecystectomy (LC), which is one of the most commonly performed general surgical operations in the western world. Patients with a high body mass index (BMI) are at increased risk of having gall stones, and are often considered at high risk of surgical complications due to their increased BMI. We believe that day case surgery could nevertheless have significant benefits in terms of potential cost savings and patient satisfaction in this population. We therefore compared the outcomes of day case patients undergoing LC stratified by BMI, with a specific focus on the safety and success of the procedure in obese and morbidly obese groups. METHODS We reviewed a database of day case procedures performed between January 2004 and December 2012, including all patients with symptomatic gall stone disease who underwent LC. The patients were divided in four BMI groups: less than 25 kg/m(2), 25-29 kg/m(2), 30-39 kg/m(2) and 40 kg/m(2) or above. RESULTS The overall success rate for day case surgery was 78%. There were no significant differences in rates of intra-abdominal collection or readmission with increasing BMI. However, increasing BMI was associated with a significant increase in the rate of wound infection. CONCLUSIONS LC in patients with a high BMI is safe and can be performed effectively as a day case procedure.
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Affiliation(s)
- A Tandon
- Aintree University Hospital , Liverpool , UK
| | | | - Q M Nunes
- Aintree University Hospital , Liverpool , UK.,Royal Liverpool & Broadgreen University Hospitals NHS Trust , UK
| | - N Misra
- Aintree University Hospital , Liverpool , UK
| | - M Shrotri
- Aintree University Hospital , Liverpool , UK
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24
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Scott J, Singh A, Mayhew PD, Brad Case J, Runge JJ, Gatineau M, Kilkenny J. Perioperative Complications and Outcome of Laparoscopic Cholecystectomy in 20 Dogs. Vet Surg 2016; 45:O49-O59. [DOI: 10.1111/vsu.12534] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 05/26/2016] [Indexed: 12/13/2022]
Affiliation(s)
- Jacqueline Scott
- Department of Clinical Studies; Ontario Veterinary College, University of Guelph; Guelph Ontario Canada
| | - Ameet Singh
- Department of Clinical Studies; Ontario Veterinary College, University of Guelph; Guelph Ontario Canada
| | - Philipp D. Mayhew
- Department of Surgical and Radiological Sciences; University of California-Davis; Davis California
| | - J. Brad Case
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine; University of Florida; Gainesville Florida
| | - Jeffrey J. Runge
- Department of Clinical Studies; Matthew J. Ryan Veterinary Hospital at the University of Pennsylvania; Philadelphia Pennsylvania
| | | | - Jessica Kilkenny
- Department of Clinical Studies; Ontario Veterinary College, University of Guelph; Guelph Ontario Canada
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25
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Aziz H, Pandit V, Joseph B, Jie T, Ong E. Age and Obesity are Independent Predictors of Bile Duct Injuries in Patients Undergoing Laparoscopic Cholecystectomy. World J Surg 2016; 39:1804-8. [PMID: 25663013 DOI: 10.1007/s00268-015-3010-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Iatrogenic bile duct injury is a serious complication of cholecystectomy. The aim of this study was to assess predictors of bile duct injury using a national database. METHODS The Nationwide Inpatient Sample (2010-2012) was queried for laparoscopic cholecystectomy. We used a) diagnoses for bile duct injury and b) bile duct injury repair procedure codes as a surrogate marker for bile duct injuries. RESULTS A total of 1,015 patients had bile duct injury. The mean age was 58.2 ± 19.7 years, 53.5 % were males, and median Charlson co-morbidity score was 2 [2, 3]. Multivariate analysis revealed morbid obesity [2.8 (2.1-4.3); p = 0.03] and age >65 [1.5 (1.05-2.1); p = 0.01] as the independent predictors for bile duct injury in patients undergoing cholecystectomy. CONCLUSION Our study finds a new association between obesity, aging, and bile duct injuries which has never been reported in literature before.
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Affiliation(s)
- Hassan Aziz
- Division of HepatoPancreaticoBiliary Surgery, University of Arizona, Tucson, AZ, USA,
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26
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Admission after the gold interval in acute calculous cholecystitis: Should we really cool it off? Eur J Trauma Emerg Surg 2016; 43:73-77. [PMID: 26742919 DOI: 10.1007/s00068-015-0617-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 11/30/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE The aim of this study was to compare early and delayed cholecystectomy for the treatment of acute calculous cholecystitis (ACC). MATERIALS AND METHODS The medical records of patients who were diagnosed to have ACC by combined clinical and radiological examination were evaluated retrospectively. The patients were divided into two non-randomized groups according to the duration between the onset of symptoms and cholecystectomy. Group 1 included the patients who underwent cholecystectomy within the first 72 h after the onset of symptoms and Group 2 those who underwent beyond the 72nd hour after the onset of symptoms. RESULTS We reviewed records for 203 patients. There were 109 patients in Group 1 and 74 patients in Group 2. Access-related complications occurred in four patients. One patient in Group 1 and two patients in Group 2 had trocar site bleeding. In one patient in Group 1, liver trauma occurred. Two patients had bile duct injury in Group 1 as Type D injury according to the Strasberg classification in one patient and E2 injury in other. CONCLUSION Early cholecystectomy in acute cholecystitis with biliary stones could be performed regardless of time with similar complication, mortality and conversion rates.
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27
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Lavy R, Halevy A, Hershkovitz Y. The Effect of Afternoon Operative Sessions of Laparoscopic Cholecystectomy Performed by Senior Surgeons on the General Surgery Residency Program: A Comparative Study. JOURNAL OF SURGICAL EDUCATION 2015; 72:1014-1017. [PMID: 25980825 DOI: 10.1016/j.jsurg.2015.03.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 02/23/2015] [Accepted: 03/25/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE Laparoscopic cholecystectomy (LC) has been the gold standard for surgical treatment of gallbladder disease since 1980. This laparoscopic surgical procedure is one of the first to be performed by general surgery residents. There is a learning curve required to excel at performing LC. During this period, the operation needs to be performed under the supervision of a senior surgeon. The purpose of this study was to compare LC performed by residents with that performed by senior surgeons using the following parameters: operative time, conversion rate, complication rate, and mean length of hospital stay. METHODS This retrospective study included 1219 patients who underwent elective LC in our institute-788 operated on by a senior surgeon and 431 by a resident. RESULTS The mean operative time was 39 ± 19 minutes. There was a significant difference between the groups, as the mean operative time for the resident group was 49.9 ± 13 compared with 33.7 ± 6 for the senior surgeon group. The overall conversion rate was 2.1%, the complication rate was 2.2%, and the mean length of hospital stay was 1.5 days. There were no statistically significant differences between the groups for these parameters. CONCLUSIONS The only significant difference between the groups was a longer operative time, as the conversion rate, complication rate, and mean length of stay were the same. Therefore, it is safe for LC to be performed by residents supervised by a senior surgeon.
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Affiliation(s)
- Ron Lavy
- Division of Surgery, Assaf Harofeh Medical Center, Zerifin, Israel, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel
| | - Ariel Halevy
- Division of Surgery, Assaf Harofeh Medical Center, Zerifin, Israel, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel.
| | - Yehuda Hershkovitz
- Division of Surgery, Assaf Harofeh Medical Center, Zerifin, Israel, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel
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28
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Ri M, Miyata H, Aikou S, Seto Y, Akazawa K, Takeuchi M, Matsui Y, Konno H, Gotoh M, Mori M, Motomura N, Takamoto S, Sawa Y, Kuwano H, Kokudo N. Effects of body mass index (BMI) on surgical outcomes: a nationwide survey using a Japanese web-based database. Surg Today 2015; 45:1271-9. [DOI: 10.1007/s00595-015-1231-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 07/10/2015] [Indexed: 01/29/2023]
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29
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Delayed laparoscopic cholecystectomy is safe and effective for acute severe calculous cholecystitis in patients with advanced cirrhosis: a single center experience. Gastroenterol Res Pract 2014; 2014:178908. [PMID: 24772166 PMCID: PMC3977540 DOI: 10.1155/2014/178908] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2013] [Revised: 12/24/2013] [Accepted: 02/11/2014] [Indexed: 01/11/2023] Open
Abstract
Acute calculous cholecystitis is a common disease in cirrhotic patients. Laparoscopic cholecystectomy can resolve this problem but is performed based on the premise that the local inflammation must been controlled. An Initial ultrasound guided percutaneous transhepatic cholecystostomy may reduce the local inflammation and provide advantages in subsequent surgery. In this paper, we detailed our experience of treating acute severe calculous cholecystitis in patients with advanced cirrhosis by delayed laparoscopic cholecystectomy plus initiated ultrasound guided percutaneous transhepatic cholecystostomy and provided the analysis of the treatment effect. We hope this paper can provided a kind of standard procedure for this special disease; however, further prospective comparative randomized trials are needed to assess this treatment in cirrhotic patients with acute cholecystitis.
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Sato N, Yabuki K, Shibao K, Mori Y, Tamura T, Higure A, Yamaguchi K. Risk factors for a prolonged operative time in a single-incision laparoscopic cholecystectomy. HPB (Oxford) 2014; 16:177-82. [PMID: 23557447 PMCID: PMC3921014 DOI: 10.1111/hpb.12100] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 02/11/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND A prolonged operative time is associated with adverse post-operative outcomes in laparoscopic surgery. Although a single-incision laparoscopic cholecystectomy (SILC) requires a longer operative time as compared with a conventional laparoscopic cholecystectomy, risk factors for a prolonged operative time in SILC remain unknown. METHODS A total of 20 clinical variables were retrospectively reviewed to identify factors for a prolonged operative time (longer than 3 h) in a total of 220 consecutive patients undergoing SILC. RESULTS The median operative time was 145 min (range, 55-435) and a prolonged operative time was required in 62 patients (28%). Independent factors that predict a prolonged operative time as identified through multivariate analysis were body mass index (BMI) (P = 0.009), acute cholecystitis (P < 0.001) and operator (resident or staff surgeon) (P < 0.001). Furthermore, a prolonged operative time was significantly associated with an increased amount of intra-operative blood loss (P < 0.001) and a prolonged stay after surgery (P < 0.001). CONCLUSIONS These findings suggest that a higher BMI, acute cholecystitis and a resident as an operator significantly increase the duration of SILC procedures.
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Affiliation(s)
- Norihiro Sato
- Correspondence Norihiro Sato, Department of Surgery 1, School of Medicine, University of Occupational and Environmental Health, Kitakyushu 807-8555, Japan. Tel: +81 93 691 7441. Fax: +81 93 603 2361. E-mail:
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Shinozaki K, Ajiki T, Okazaki T, Ueno K, Matsumoto T, Ohtsubo I, Murakami S, Yoshida Y, Matsumoto I, Fukumoto T, Sugimoto T, Ohno M, Ku Y. Gallbladder bed pocket score as a preoperative measure for assessing the difficulty of laparoscopic cholecystectomy. Asian J Endosc Surg 2013; 6:285-91. [PMID: 23841893 DOI: 10.1111/ases.12051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 05/16/2013] [Accepted: 06/09/2013] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Laparoscopic cholecystectomy (Lap-C) is a standard surgery for symptomatic gallbladder stones and acute or chronic cholecystitis. Resident surgeons often perform this operation early in their training, but they sometimes encounter difficulties for various technical reasons. Although encountering a gallbladder buried deep within the gallbladder bed is a common operative difficulty, literature on the subject scarcely exists. METHODS Forty-two patients underwent Lap-C at our hospitals and were analyzed retrospectively. We defined the gallbladder bed pocket score (GBPS) as the maximum ratio between the height and width of the gallbladder bed measured based on multi-detector computed tomography (MDCT) images. GBPS and clinical factors were assessed in terms of their correlation with the time required for gallbladder dissection from the gallbladder bed. RESULTS Of the 42 patients, 20 had histories of acute or chronic cholecystitis. The mean gallbladder dissection time was 14.9 min, and the mean GBPS was 0.43 in the coronal MDCT section and 0.56 in the sagittal section. The correlation coefficient between the GBPS and gallbladder dissection time was 0.40 (P = 0.01) in the coronal section and 0.38 (P = 0.02) in the sagittal section of the MDCT images. There was no statistically significant correlation between gallbladder dissection time and the surgeon's experience, patient's history of cholecystitis, gallstone size, or blood loss. However, GBPS > 0.4 predicted more difficult and prolonged dissection. CONCLUSION GBPS is a useful tool for preoperatively predicting the time needed to dissect the gallbladder from the gallbladder bed during Lap-C. Cases with GBPS < 0.4 seem more suitable for resident surgeons who are performing gallbladder dissection early in their Lap-C training.
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Affiliation(s)
- Kenta Shinozaki
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Surgical management of gallbladder disease in the very elderly: are we operating them at the right time? Eur J Gastroenterol Hepatol 2013; 25:380-4. [PMID: 23169310 DOI: 10.1097/meg.0b013e32835b7124] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND As life expectancy rises worldwide and the prevalence of gallstones increases with age, the number of very elderly patients requiring treatment for gallstone diseases is increasing. The aim of this study was to compare the results of cholecystectomy in patients 80 years or older according to different clinical presentations. METHODS This is a retrospective study of 81 patients 80 years or older. Indications for surgery were stratified into three groups: outpatients (symptomatic chronic cholecystitis), inpatients (complicated gallstone diseases), and urgent patients (acute cholecystitis). Data analysis included age, sex, the American Society of Anesthesiologists score, indication for surgery, length of hospital stay, morbidity, and mortality. RESULTS The mean age of the patients was 83.9 (range 80-94 years); there were 34 (42%) men. Thirty patients were operated on for acute cholecystitis. Patients in the urgency group significantly required the ICU more often, required a longer hospital stay, and had more complications, with 32% mortality. No differences were found between inpatients and outpatients, with both groups presenting low morbidity, no mortality, and the same postoperative length of stay. CONCLUSION More than 80% of the patients were operated on because of complicated gallstone disease. Although the outcomes of patients undergoing semielective cholecystectomy were similar to those of patients treated as outpatients, patients operated with acute cholecystitis presented extremely high morbidity and mortality rates. Thus, we can only recommend that early elective cholecystectomy be performed in elderly patients as soon as they are found to have symptomatic gallstones. Also, further trials are required to elucidate the optimal management of acute cholecystitis in elderly patients.
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