A cost-conscious establishment of a robotic abdominal wall reconstruction program in a publicly funded healthcare system

PURPOSE

Despite reports of better short-term outcomes, the main criticism for the adoption of the robotic surgery platform for abdominal wall reconstruction (AWR) has been the associated cost, especially in countries with a publicly funded healthcare system such as Canada. We describe our experience in implementation of robotic AWR while ensuring cost-effectiveness.

METHODS

This is a retrospective cohort analysis of all patients with ventral hernias ranging between 5 to 15 cm who underwent either open or robotic AWR between January 2020 to August 2022. We reviewed patient characteristics, operative time, post-operative length of stay (LOS), and average cost of surgery.

RESULTS

45 patients underwent open repair and 28 underwent robotic repair in the study period. There was no difference in major patient characteristics between the two groups. Operative time was shorter for open repairs (233.2 ± 96.6 min vs. 299.3 ± 71.8 min, p < 0.001). LOS was significantly longer for open repairs (5 days (interquartile range = 4-6) vs. 2 days (IQR = 1.75-3), p < 0.001) and there were significantly more patients who underwent robotic repair who left hospital in less than 3 days (13.3 vs. 64.3%, p < 0.001). The average overall hospital-based cost for each open repair was $26,952.18 when the cost for equipment, operative time, inpatient hospital stay, and epidural use are accounted for, compared to $17,447.40 for robotic repair ($9,504.78 saving per case).

CONCLUSION

With proper selection of patients based on size of hernia, we demonstrate cost conscious adaptation of the robotic technology to AWR. Our future studies will continue to explore the benefits and limits of this approach in complex hernia repair.

Rigid vs articulating instrumentation for task completion in single-port surgery

BACKGROUND

Single-port access surgery (SPA) may provide benefits but there is a steep learning curve. We compare traditional in-line instruments with articulating instruments.

METHODS

Fundamentals of laparoscopic surgery peg transfer task was performed using a 3-port approach or SPA device. Standard rigid instrumentation was compared with articulating instrumentation.

RESULTS

Twenty surgeons completed all tasks. Average time using a conventional approach was shorter than SPA (144 ± 54 vs 198 ± 74 seconds, P < .001). Articulating instruments required longer procedural time than rigid instrumentation (201 ± 66 vs 141 ± 58 seconds, P < .001). In the conventional model, task time was lower with rigid instruments than with articulating instruments (108 vs 179 seconds, P < .001). Task time in the SPA model was lower with rigid instruments (173 vs 223 seconds, P =.013).

CONCLUSIONS

All tasks required longer time to complete in SPA when compared with a conventional approach. Articulating instruments have an increased benefit in SPA surgery.

Fluorescent cholangiography in laparoscopic cholecystectomy: the initial Canadian experience

BACKGROUND

Bile duct injury remains a worrisome complication of laparoscopic cholecystectomy. Indocyanine Green (ICG) fluorescent cholangiography (FC) is a new approach that facilitates real-time intraoperative identification of biliary anatomy. This technology is hoped to improve the safety of dissection within Calot's triangle.

METHOD

Demographics, intraoperative details, and subjective surgeon data were recorded for elective cholecystectomy cases involving ICG. Goals were to identify rates of bile duct identification, and assess the perceived benefit of the device.

RESULTS

ICG was used in 12 biliary cases in Canada. Visualization rates of the cystic and common bile ducts were 100% and 83%, respectively. Also, 83% of surgeons felt that FC incorporated smoothly into the operation. No complications have been related to the technology.

CONCLUSIONS

FC allows noninvasive real-time visualization of the extrahepatic biliary tree. This novel technique has received positive feedback in its initial Canadian use and will likely be a durable adjunct for minimally invasive surgery.

Outcomes of the adjustable gastric band in a publicly funded obesity program

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) is considered a safe and effective treatment for severe obesity and obesity-related comorbidities. We sought to examine the outcome of LAGB delivered through a Canadian publicly funded obesity program.

METHODS

We retrospectively analysed the cases of patients who underwent LAGB within a comprehensive, multidisciplinary, publically funded obesity program.

RESULTS

A total of 178 patients underwent LAGB. Mean percentage total body weight loss at 1, 2 and 3 years was 15.8%, 20.7% and 20.3%, respectively. The most common short-term complication was postoperative nausea (19%). The medium-term complications included band migration (5.6%) and port site complications, band leakage and incisional hernia at 1% each. The reoperation rate was 4.5%. The mean surgery duration was 56 minutes and the mean length of stay was 1.4 days. The average numbers of clinic visits and band adjustments were highest in the first year. The most common investigation for postoperative symptoms was fluoroscopy (86%). An outcome comparison between the 2 generations of the REALIZE gastric band was inconclusive, requiring further data collection.

CONCLUSION

Publicly funded LAGB results in effective weight loss and acceptable safety over the short term. Our patients may represent a distinct population that differs from that in the private system. Long-term data are necessary to determine the cost-effectiveness of this important surgical option for severe obesity.

The process of treating pediatric appendicitis

BACKGROUND

A large service and distant geographical area can make the process of diagnosing and treating appendicitis a challenge.

METHODS

Hospital records of children treated for appendicitis between 2007 and 2009 were retrospectively analyzed, including time from emergency (ER) to operating room (OR), diagnostic imaging (DI) utilization, preoperative antibiotic usage, operating time, length of stay (LOS), and perforation rate.

RESULTS

The perforation rate was 34%, with longer LOS. Transfer time to the children's hospital between ER inside and outside the city was not different. ER to OR time was significantly shorter for patients assessed at the children's hospital directly. Ultrasound remained the most used DI modality (55%). Preoperative antibiotics were only fully administered in 42% of the cases.

CONCLUSION

A clinical pathway for pediatric appendicitis may address the challenges of the process of pre-ER, ER to OR, and OR care to maintain an acceptable perforation rate.

Perceived challenges and priorities in co-morbidity management of older patients with Type 2 diabetes

AIMS

To explore older patients' perceived impact of chronic co-morbid conditions on Type 2 diabetes self-management.

METHODS

We used purposive sampling to select 32 mentally alert community-dwelling adults, aged 60 years or older, diagnosed with Type 2 diabetes and at least one other chronic health condition to participate in focus groups. We summarized the discussions following each focus group and identified codes to describe the overarching themes.

RESULTS

We conducted eight 90-min focus groups, each consisting of two to six patients. Three themes emerged. (i) Diabetes complications as a motivator: managing co-morbid conditions made health an important focal point in the lives of older patients. Most patients acknowledged the positive effect complications had on their diabetes self-management by motivating them to pay greater attention to their diabetes to diminish the progression of these complications. (ii) Prioritizing health conditions: patients reported prioritizing health conditions and selectively attending to the management of those conditions based on perceived severity or importance. Further, many patients perceived some conditions as more serious than others and admitted to prioritizing another health condition over their diabetes. (iii) Emotional impact of co-morbidity management: patients described feeling frustrated, confused, and overwhelmed in response to conflicting treatment recommendations, particularly for diet, physical activity and medication regimens.

CONCLUSIONS

Complications and co-morbidities may have differential impacts on the diabetes self-management of older patients. Addressing the perceived impact of co-morbidity on diabetes self-management may improve patients' outcomes; however, the most effective method of utilizing this information in clinical practice needs to be examined.

Association between genetic polymorphism of tumor necrosis factor-alpha and risk of oral submucous fibrosis, a pre-cancerous condition of oral cancer

Many cytokines have been thought to play important roles in the pathogenesis of oral submucous fibrosis (OSF), an areca nut chewing-specific pre-cancerous condition characterized by the deposition of collagen in oral submucosa. Tumor necrosis factor-alpha (TNF-alpha), situated in the class III region of human leukocyte antigen (HLA), is a mediator with multiple functions, including the regulation of inflammatory reaction and transcriptions of collagen and collagenase. In total, 809 male subjects were recruited for assessment of the association of OSF with a bi-allelic promoter-region (-308) polymorphism on the TNFA gene. The high production allele, TNF2, was significantly lower among OSF subjects (n = 166) than in areca-chewing controls (n = 284). This association was independent of oral cancer status. The multivariate-adjusted odds ratio for the TNFA 11 genotype was 2.6 (95% confidence interval = 1.4-4.9; p = 0.004). The finding may imply a multifunctional etiological factor of TNF-alpha in OSF pathogenesis.

Effect of a lacto-ovo vegetarian diet on fasting small intestinal motility

BACKGROUND

Changes in diet can alter gastric and small intestinal (SI) motility. The effects of a vegetarian diet on fasting SI motility are unknown.

METHODS

Manometric studies were performed in 9 lacto-ovo vegetarians (7 women) and 9 omnivores (7 women) of similar age and body mass index. On each study day, manometry was used to assess SI motility for 5 h, or 3 complete cycles of the interdigestive motor complex (IDMC). Lacto-ovo vegetarians were studied once: omnivores were studied twice, on their usual diet, and after consuming a 14-day lacto-ovo vegetarian diet. Diet diaries were kept for 5 days prior to each manometric study. Data were analysed for dietary composition and for cycle length and duration of each phase (I, II and III) of the IDMC.

RESULTS

Dietary intake did not differ between chronic vegetarians and chronic omnivores apart from a trend to higher fibre intake (29 +/- 3 versus 20 +/- 3 g/day; P = 0.058). Omnivores eating a vegetarian diet showed a trend to decreased alcohol consumption (P = 0.068), but did not increase their fibre intake (20 +/- 3 versus 21 +/- 3 g/day). Neither cycle length nor duration of each IDMC phase differed between chronic vegetarians and chronic omnivores. After 14 days of a vegetarian diet, omnivores had a reduction in cycle length (128 +/- 19 versus 86 +/- 12 min; P = 0.02), with a non-significant reduction of Phase II (99 +/- 20 versus 50 +/- 8 min: P = 0.066).

CONCLUSIONS

A chronic vegetarian diet has no major effect on fasting SI motility; but acute dietary change may alter the cycle length and component phases of the IDMC.

Myopia and contrast sensitivity function

PURPOSE

to measure the contrast sensitivity function of varying degrees of myopia with two types of optical correction (spectacle lens and contact lens).

METHODS

One hundred and five myopic eyes and twenty-eight emmetropic eyes were collected. The myopic group included 105 eyes corrected with spectacle lenses and 71 eyes of them corrected with contact lenses, too; all had corrected vision acuity of 20/20 or better. The myopic eyes were divided into four groups: group 1 (-1D to -3D), low myopia; group 2 (-3.25D to -6D), medium myopia; group 3 (-6.25D to -12D), high myopia; and group 4 (> -12D), severe myopia. Spatial contrast sensitivity was measured using the OPTEC 2000 Contrast Sensitivity System.

RESULTS

In groups 1 and 2, no statistically significant difference was found between myopes and emmetropes. In group 3, statistically significant loss of contrast sensitivity at higher spatial frequencies was found for myopic subjects corrected with spectacle lens, but not for myopes corrected with contact lens. In group 4, myopic subjects corrected with spectacle lenses showed significantly reduced contrast sensitivity function at all spatial frequencies; subjects corrected with contact lenses showed statistical sensitivity losses at 6, 12, 18 cycle/degree spatial frequencies.

CONCLUSIONS

1. We may suppose that low and medium myopes (groups 1 and 2), who showed normal contrast sensitivity functions, had no retinal dysfunction. 2. For high myopes, contact lens correction could reduce optical defocus and improve contrast sensitivity function in high spatial frequencies. 3. As retinal function disturbances occurred in severe myopes, the diminished contrast sensitivity was not fully compensated by contact lens correction. 4. Loss of contrast sensitivity might be interpreted as evidence for early retinal function disruption before retinal pathological events occur in severe myopes.

Cloning and nucleotide sequencing of the S4 genome segment of avian reovirus S1133

The sequence of RNA genome segment S4 of the avian reovirus (ARV) strain S1133 was determined. S4 RNA is 1185 base pairs long and contains one open reading frame encoding a protein of 367 amino acid residues (40.6 kDa), the similar size as the known S4 gene product (sigma NS), with a net charge of -1 at neutral pH. The S4 RNA sequence possesses a pentanucleotide sequence UCAUC at the 3'-terminus of its plus strand like in ARV S1 and S3 segments and ten segments of mammalian reovirus (MRV). The predicted amino acid sequence comparison revealed that the homology is 44.02%, 45.71%, and 42.33% for ARV sigma NS and three serotypes of MRV sigma NS, respectively. The relatively high content of alpha-helix structure in the C-terminal portion of ARV sigma NS suggests that this protein may functionally relate to MRV sigma NS. Northern blot hybridization showed that a 32P-labeled cDNA insert S4-49 from ARV S4 RNA cross-hybridized with the corresponding RNA segments of all seven strains of ARV tested.

The roles of ventilation and perfusion in lung metabolism

The lung, like other viable organs, requires the adequate supply of oxygen and metabolic substrates for its functional and structural integrity. Therefore, we studied the metabolic and ultrastructural consequences in the canine lung following bronchial and/or pulmonary arterial occlusions. The results indicate that the lung can maintain its bioenergetic levels for 5 hours with either the ventilation or perfusion alone. Ultrastructural changes appear to precede metabolic alterations measured. When both the ventilation and perfusion were interrupted, rapid biochemical and structural deteriorations occurred, whereas the combinations of alveolar obliteration and hypoxemia, induced with low F102, produced intermediate damage. The implications of these findings on the pathogenesis and evolution of acute respiratory distress syndrome, on the lung preservation for transplantation, and on the rationale for membrane oxygenator support are discussed.

Epithelial lesions in low flow states: a unifying concept

Several epithelium-lined organs are highly vulnerable in low flow states, and may lead to lesions such as hemorrhagic enteritis, stress ulcer, renal tubular necrosis, acalculous cholecystitis and "shock lung". A hypothesis is presented which postulated that the redistribution of the subepithelial microcirculatory blood flow and the subsequent damage to the epithelial barrier are the crucial processes in their pathogenesis. Presently available evidence in support of this thesis is summarized.

Spontaneous aortocaval fistula secondary to ruptured abdominal aortic aneurysm

Two patients with the rare condition of spontaneous aortocaval fistula secondary to ruptured abdominal aortic aneurysm were treated successfully by surgical closure of the fistula. In view of the existing controversies on certain aspects of the pathophysiology involved, canine experiments were performed to elucidate the pathogenesis of regional venous hypertension and hematuria observed in these patients. The experiments demonstrated that regional venous hypertension is a purely rheologic phenomenon and that hematuria originates from a congested lower urinary tract.

Why do radial artery grafts for aortocoronary bypass fail? A reappraisal

The reasons for the high failure rate of radial artery grafts for aortocoronary bypass (ACB) are appraised. Each of 11 dogs received four types of grafts: femoral arteries were grafted to carotid arteries, and jugular veins were grafted to femoral arteries bilaterally. One of each pair of grafts was wrapped in a plastic sheet in order to interfere with the regeneration of vasa vasorum. The grafts were examined 2 months later. The results suggest that although operative trauma and intraluminal pressure change play important roles, the thick-walled artery appears to depend more on vasa vasorum for its integrity than does the thin-walled vein. A free radical artery graft, with vasa vasorum disrupted at both ends, cannot regenerate readily from the adjacent tissue, as is the case at the ACB position, and is therefore more vulnerable to subintimal hyperplasia and occlusion than either the vein graft or the internal mammary artery graft; both of these grafts are thinner, and the internal mammary artery graft remains undisrupted at one end.

Effects of exogenous cyclic adenosine monophosphate in hemorrhagic shock

Hemorrhageic shock produces potentially damaging alterations in the metabolism of cyclic adenosine 3',5'-monophosphate (cAMP), which is an intracellular second messenger for many hormones. The hypothesis that the administration of exogenous cAMP might have salutary effects on cardiovascular hemodynamics in shock was tested in canine experimetns. Intravenous bolus injection of dibutyryl cAMP (2 mg. per kilogram) produced hyperglycemia, but no changes occurred in heart rate, arerial pressure cardiac output, or in the first derivative of left ventricualr pressure (dp/dt). The findings were similar in conscious and anesthetized (Nembutal) normotensive dogs, in dogs after 3 hours of shock (at blood pressure of 40 mm. Hg) and after the reinfusion of shed blood. The only hemodynamic change noted was a transient hypotensionupon injection of massive doses of dibutyryl-(db-) cAMP or cAMP (greater than 10 mg. per kilogram). The implication of these findings in light of earlier reported hemodynamic effects of cAMP is discussed.

Selective arterialization of coronary veins for diffuse coronary occlusion. An experimental evaluation

The selective arterialization of coronary veins as a surgical therapy for diffuse coronary arteriosclerosis was studied in canine and sheep experiments. The arterialized blood can be delivered promptly to the selected region of the myocardium and an adequate runoff exists for this mode of revascularization, so that myocardial edema and hemorrhage do not occur. The retrograde blood flow through an anastomosis between the internal mammary artery (IMA) and great cardiac vein (GCV) is excellent, with a predominantly diastolic flow pattern. Follow-up studies indicate significant but partial protection of the myocardium against diffuse LAD occlusion. The size of infarcts is decreased. However, the focal or small transmural infarcts observed are usually located near the apex of the heart. The studies with radioactive microspheres (15 plus or minus 5 mu diameter) revealed that the degree of capillary trapping of microspheres is very much less when the microspheres are injected retrograde into the vein than when injected into the artery. This may indicate that significant "shunt" blood flow exists when the coronary vein is arterialized. Thus this study demonstrates both the potential and the limitation of the selective arterialization of coronary veins in revascularizing patients suffering from diffuse coronary arteriosclerosis.

Cyclic AMP response to epinephrine and shock

Hormonal regulation is fundamental to homeostasis, and the response in tissues is mediated by adenosine 3':5' equals cyclic phosphate (cyclic AMP). Since circulating levels of catecholamines are elevated during hemorrhagic shock, experiments were carried out to study the effects of epinephrine and of shock on cyclic AMP levels of plasma and of the intestine, a particularly vulnerable organ in canine hemorrhagic shock. Epinephrine was given to normotensive dogs as a constant infusion (group 1) or as a single pulse (group 2). Sequential blood samples showed a marked increase in circulating cyclic AMP, especially in portal and hepatic venous blood. Little change was noted in the tissues. Hemorrhagic shock (group 3) induced a marked increase in plasma cyclic AMP, with a depletion of mucosal cyclic AMP and adenosine triphosphate (ATP). Pretreatment before shock with alpha-blockade (group 4) abolished the decrease in mucosal cyclic AMP and ATP, and reduced the increase in plasma cyclic AMP.

The roles of intraluminal chyme and vasomotor response in the pathogenesis of non-occlusive intestinal infarcts

The purpose of this study is to clarify the role of intraluminal chyme and the splanchnic vasomotor reaction on the pathogenesis of non-occlusive intestinal infarcts. In 5 mongrel dogs, 3 types of intestinal loops were created. A cervical loop, which is a heterotopic autotransplant of a segment of intestine, contains no chyme and is disconnected from the splanchnic innervation. A Thiry-Vella loop simultaneously constructed in the abdomen is also devoid of intraluminal chyme, but is still innervated. The intestine-in-continuity possesses both splanchnic innervation and intraluminal chyme. Hemorrhagic shock was then induced and the morphological response of the three types of intestine examined. The results indicate that the cervical loop is least damaged, whereas both the Thiry-Vella loop and the intestine-incontinuity are both severely damaged. It is concluded that in the non-occlusive hemorrhagic infarction of the intestinal mucosa, the peculiar splanchnic vasomotor response plays the dominant role. The pathogenesis of non-occlusive intestinal infarcts and its clinical implications are discussed.

Volume deficit versus toxic absorption: a study of canine shock after mesenteric arterial occlusion

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