Long-term Follow-up of Patients With Hernia Using the Hernia-Specific Quality-of-Life Mobile App: Feasibility Questionnaire Study

BACKGROUND

Hernia repair is one of the most common surgical procedures; however, the long-term outcomes are seldom reported due to incomplete follow-up.

OBJECTIVE

The aim of this study was to examine the use of a mobile app for the long-term follow-up of hernia recurrence, complication, and quality-of-life perception.

METHODS

A cloud-based corroborative system drove a mobile app with the HERQL (Hernia-Specific Quality-of-Life) questionnaire built in. Patients who underwent hernia repair were identified from medical records, and an invitation to participate in this study was sent through the post.

RESULTS

The response rate was 11.89% (311/2615) during the 1-year study period, whereas the recurrence rate was 1.0% (3/311). Causal relationships between symptomatic and functional domains of the HERQL questionnaire were indicated by satisfactory model fit indices and significant regression coefficients derived from structural equational modeling. Regarding patients' last hernia surgeries, 88.7% (276/311) of the patients reported them to be satisfactory or very satisfactory, 68.5% (213/311) of patients reported no discomfort, and 61.1% (190/311) of patients never experienced mesh foreign body sensation. Subgroup analysis for the most commonly used mesh repairs found that mesh plug repair inevitably resulted in worse symptoms and quality-of-life perception from the group with groin hernias.

CONCLUSIONS

The mobile app has the potential to enhance the quality of care for patients with hernia and facilitate outcomes research with more complete follow-up.

Deciphering Genetic Alterations of Taiwanese Patients with Pancreatic Adenocarcinoma through Targeted Sequencing

Pancreatic adenocarcinoma (PAC) is the 8th leading cause of cancer-related deaths in Taiwan, and its incidence is increasing. The development of PAC involves successive accumulation of multiple genetic alterations. Understanding the molecular pathogenesis and heterogeneity of PAC may facilitate personalized treatment for PAC and identify therapeutic agents. We performed tumor-only next-generation sequencing (NGS) with targeted panels to explore the molecular changes underlying PAC patients in Taiwan. The Ion Torrent Oncomine Comprehensive Panel (OCP) was used for PAC metastatic lesions, and more PAC samples were sequenced with the Ion AmpliSeq Cancer Hot Spot (CHP) v2 panel. Five formalin-fixed paraffin-embedded (FFPE) metastatic PAC specimens were successfully assayed with OCP, and KRAS was the most prevalent alteration, which might contraindicate the use of anti-EGFR therapy. One PAC patient harbored a FGFR2 p. C382R mutation, which might benefit from FGFR tyrosine kinase inhibitors. An additional 38 samples assayed with CHP v2 showed 100 hotspot variants, collapsing to 54 COSMID IDs. The most frequently mutated genes were TP53, KRAS, and PDGFRA (29, 23, 10 hotspot variants), impacting 11, 23, and 10 PAC patients. Highly pathogenic variants, including COSM22413 (PDGFRA, FATHMM predicted score: 0.88), COSM520, COSM521, and COSM518 (KRAS, FATHMM predicted score: 0.98), were reported. By using NGS with targeted panels, somatic mutations with therapeutic potential were identified. The combination of clinical and genetic information is useful for decision making and precise selection of targeted medicine.

An examination of surgical and survival outcomes in the elderly (65-79 years of age) and the very elderly (≥80 years of age) who received surgery for gastric cancer

Objective: The purpose of this study was to examine surgical and survival outcomes in the elderly (65-79 years of age) and the very elderly (≥80 years of age) who received surgery for gastric cancer.Methods: This study retrospectively reviewed the records of patients ≥65 years old who received a gastrectomy for gastric adenocarcinoma. Demographic, clinical, and pathological data were extracted from the medical records. Patients were divided into two groups: those 65-79 years of age and those ≥80 years of age. Data and survival outcomes were compared between the groups.Results: Sixty-four patients were included, 32 males and 32 females. The mean age in the 65-79 years old group was 73.4 ± 4.5 years, and in the ≥80 years group was 85.2 ± 3.4 years (p < .001). Three patients in the older group had chronic kidney disease, as compared to none in the 65-79 years group (p = .04); all other demographic, clinical, tumor, and surgical characteristics were similar between the groups, except for surgical time (all, p > .05). Patients ≥80 years had a higher incidence of pulmonary complications (24% vs 4.7%, p = .03), but there was no significant difference in in-hospital mortality. The ≥80 years group had a higher overall survival, but the difference between the groups was not statistically significant (42.9% and 34.9%, p = .224).Conclusions: Curative intent resection, gastrectomy with D1+/D2 lymph node dissection is a viable option for elders ≥80 years old with gastric carcinoma.

Warfarin Overdose Associated Inferior Mesentery Artery Aneurysm Rupture Mimicking Spontaneous Bowel Hematoma

Inferior mesentery artery (IMA) aneurysm rupture is easily overlooked in patients with abdominal pain due to its uncommon occurrence. It may result in catastrophic consequence once misdiagnosed as spontaneous bowel hematoma in patients with anticoagulant overdose and intra-abdominal hematoma, as treatment strategy for both diseases varies differently. We present a case of a 70-year-old male who came to our emergency department with the chief complaint of abdominal pain over periumbilical area, eventually diagnosed as anticoagulant overdose associated IMA aneurysm rupture without occlusion of superior mesentery artery (SMA) and celiac artery (CA). This case report alerts us to consider the rare other source of bleeding, for instance ruptured inferior mesentery aneurysm, while encountering such an extraordinary large intra-abdominal hematoma in patients on anticoagulant.

Quality of life of inguinal hernia patients in Taiwan: The application of the hernia-specific quality of life assessment instrument

BACKGROUND

With the development of prosthetic mesh and tension free techniques, the recurrence rate following inguinal hernia repair has been reduced, and hernia outcomes research should focus on post-operative quality of life and potential complications.

STUDY DESIGN

A novel hernia quality of life assessment instrument, HERQL, was developed. The HERQL questionnaire comprises a 4-item summative pain score measuring pain and discomfort resulting from various strenuous activities. Symptomatic and functional domains, as well as post-operative satisfaction are evaluated as well.

RESULTS

A total of 386 HERQL surveys were completed by 183 patients with inguinal hernias. Internal consistency reliability of the summative pain score was satisfactory, with a Cronbach's alpha of 0.85. Criterion validity was examined by concomitant assessment of the pain/discomfort and health impact subscales of the EQ-5D questionnaire, with substantial to moderate correlations. Pre-operative patients reported more severe hernia protrusion, more pain during mild to heavy exercise, and worse activity restriction and health impairment than the follow-up patients, indicating clinical validity. The conceptual structure of the HERQL demostrated the causal relationship between the formative symptomatic subscales and the reflective functional status indicators. Repeated measurement of the summative pain scores revealed an estimated time effect of -1.63, which was the rate of change in the summative pain score across the pre-operative, immediately post-operative, and follow-up 3-month periods suggesting the clinical responsiveness of the HERQL.

CONCLUSIONS

This study will facilitate inguinal hernia outcomes research and enhance the quality of care for this common disease by providing a validated HERQL instrument with enhanced sensitivity.

Surgical site infection and timing of prophylactic antibiotics for appendectomy

BACKGROUND

Pre-operative prophylactic antibiotics may decrease the frequency of surgical site infection after appendectomy. However, the optimal timing for administration of pre-operative prophylactic antibiotics is unknown. The purpose of this study was to evaluate the effect of timing of prophylactic antibiotics on the frequency of surgical site infection after appendectomy.

METHODS

Medical records were reviewed retrospectively for 577 consecutive patients who had appendectomy for acute appendicitis from 2006 to 2009. Quality assurance guidelines for timing of prophylactic antibiotics before the skin incision were changed from 0 to 30 min before the skin incision (before June 2008) to 30 to 60 min before the skin incision (after June 2008).

RESULTS

Surgical site infection occurred in 28 patients (4.9%). There was no difference in frequency of surgical site infection with different timing of pre-operative prophylactic antibiotic (pre-operative time 0 to 30 min: 9 infections [3.6%]; 31 to 60 min: 13 infections [5.4%]; 61 to 120 min: 5 infections [7.0%]; >120 min: 1 infection [6.6%]). Multivariable analysis showed that surgical site infection was associated significantly with medical comorbidity but not perforated appendicitis.

CONCLUSIONS

The frequency of surgical site infection was independent of timing of preoperative prophylactic antibiotics but was associated with the presence of medical comorbidity.

System Approach to Prevent Common Bile Duct Injury and Enhance Performance of Laparoscopic Cholecystectomy

Experience collected from 5200 cases of laparoscopic cholecystectomy (LC) and 29 patients (6 ours, 23 referred) with major common bile duct (CBD) injury during LC in our institute between December 1990 and July 2004 was reported to demonstrate that the system approach we applied in performing LC prevents CBD injury and enhances surgical performance. Each case of CBD injury was meticulously analyzed to identify causative factors. We developed preventive strategies focusing on 4 dimensions: patient, environment, procedure, and operator. Surgical performance was then evaluated to demonstrate improvements. Incidence of CBD injury was calculated for early and latter halves of the series to compare 5 parameters of surgical performance: patient selection, operation time, indwelling drainage tube, surgeon, and conversion rate. Results of accident analysis demonstrated that CBD injury followed definite mechanisms; several warning signs appearing before and during injury were identified and classified. According to these results, we designed strategies to prevent injury, including: setting up patient-selection program, controlling surgical environment, developing error-proof procedures, and constructing training programs. Incidence of CBD injury in the whole series was 0.12% (6/5200), 0.27% in early half (6/2224), and zero (0/2967) in latter half. Attending doctors had significantly shorter operation times in latter period for both elective and emergent LC. Rate of using drainage tubes for elective surgery by attending doctors was significantly decreased in latter period. Operation time for elective surgery by residents was similar in both early and latter periods. However, residents in latter period had longer operation times (around 23 min long, P<0.001) for emergent LC. Steps of our system approach include: (1) detailed accident analysis focusing on patient, environment, procedure, and surgeon; (2) developing 4 strategies directly responding to accident analysis results, including proper patient selection, control of environment, error-proof procedures, and a well-designed training program; and (3) demonstrating improved patient safety and surgical performance. Consistent use of systems approach promises continuing quality improvement. We believe our working model will help perform safer LC and also benefit other medical disciplines.

Laparoscopic common bile duct exploration with T-tube choledochotomy for the management of choledocholithiasis

Although laparoscopic cholecystectomy (LC) has become the gold standard for the management of gallstone disease, the application of laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis has been slower. The aim of this study is to determine the feasibility and effectiveness of LCBDE. A retrospective cohort study was conducted to compare LCBDE (n = 82) with conventional common bile duct exploration (CCBDE) (n = 75) and endoscopic sphincterotomy (EST) (n = 80) in the management of choledocholithiasis. All our LCBDEs were performed through choledochotomy with T-tube placement. The mean operative time of the LCBDE group (124 +/- 48 minutes) was not significantly longer then the CCBDE group (118 +/- 35 minutes), while the postoperative hospitalization was shorter in both the LCBDE (8 +/- 5 days) and EST (9 +/- 4 days) groups than in the CCBDE (13 +/- 6 days) group. In the LCBDE group, 14 patients (17.1%) required postoperative choledochoscopy to clear residual stones through the T-tube tract. The only mortality occurred in the CCBDE group. The morbidity rate was 3.7% (3/82) in the LCBDE group, including bile leakage in 1 case and bile peritonitis in 2 cases; 6.7% (5/75) in the CCBDE group, including atlectasis in 2 cases, sepsis in 1, and wound infection in 2. There were 2 cases of postoperative pancreatitis (2.5%; 2/80) in the EST group. The difference in the average number of sessions needed for complete clearance of choledocholithiasis in each group was statistically significant (EST, 1.46 +/- 0.67; LCBDE, 1.23 +/- 0.42; and CCBDE, 1.09 +/- 0.28; P < 0.0001). Our results suggested that EST and LCBDE tended to require more therapeutic sessions then CCBDE, although these sessions were less invasive. The benefits of LCBDE include minimal invasiveness, concurrent treatment of gallbladder stone and CBD stones in a single session, and a shorter postoperative hospital stay. However a longer learning curve is needed. Selection of the most suitable therapeutic option for individual patients by an experienced surgeon gives the most benefits to patients.

Management of bile leakage after laparoscopic cholecystectomy based on etiological classification

PURPOSE

To analyze and classify bile leakage after laparoscopic cholecystectomy (LC) according to its etiology. This classification will help to determine the most appropriate management strategy, whereby unnecessary intervention can be avoided.

METHODS

We examined the medical records of 16 patients in whom bile leakage occurred as a complication of LC.

RESULTS

Bile leakage was classified according to its cause into the following groups: insecure closure of the cystic duct stump (n = 3); retention of a common bile duct (CBD) stone (n = 1); CBD injury (n = 10); unsuspected accessory bile ducts (n = 1); and unknown origin (n = 1). The management strategies included observation (n = 3), laparoscopic intervention with drainage (n = 4), laparotomy with drainage (n = 3), and laparotomy with Roux-en-Y choledochojejunostomy for CBD transection (n = 6). All 16 patients recovered uneventfully with similar hospitalization.

CONCLUSIONS

Bile leakage is not always caused by bile duct injury, and it would be inappropriate to attribute leakage to bile duct injury if there is a retained CBD stone, an unsuspected accessory duct, or an unsecured cystic duct stump. Thus, the management of each condition should vary accordingly. Reviewing a videotape of the surgery and early cholangiogram can help to establish the etiological diagnosis and select the most appropriate course of action.

Long-term results of major bile duct injury associated with laparoscopic cholecystectomy

BACKGROUND

Major bile duct injury (MBDI) is the most serious complication associated with laparoscopic cholecystectomy (LC). This study reports on long-term outcomes and clinical factors which predicted the outcome of 25 patients with LC-associated MBDI.

METHODS

Twenty-five consecutive patients receiving either primary (n = 11) or redo (n = 14) biliary reconstructive surgery at Cathay General Hospital for LC-associated MBDI were prospectively followed for 2 to 10 (mean, 4.5) years to assess their long-term outcomes. Twelve clinical factors relevant to their outcomes were analyzed.

RESULTS

There was no mortality. Although the 1-year postoperative results were successful in 23 patients (92%), the mid- to long-term outcomes were successful in only 17 patients (68%). Eight patients (32%) developed biliary strictures at an average of 3.3 years postoperatively and required subsequent reoperation or biliary stenting. Statistical comparison of 12 risk factors between the successful and unsuccessful groups revealed that two were significant, namely, repair performed by a nonreferral surgeon (p = 0.02) and repair at a stage with recent active inflammation (p = 0.04). A serum alkaline phosphatase level greater than 400 IU in the sixth postoperative month was highly correlated with long-term nonsuccess (p = 0.01).

CONCLUSIONS

Only 68% of patients with LC-associated MBDI who underwent reconstructive surgery at our institution had long-term success. A serum alkaline phosphatase level above 400 IU in the sixth postoperative month was predictive of nonsuccess. For better long-term results, repair should be performed by the referral surgeon at a stage without coexisting active inflammation.

Complications of laparoscopic cholecystectomy: an analysis of 200 cases

Complications of the initial 200 cases of laparoscopic cholecystectomy (LC) at the Cathay General Hospital within a period of 11 months were reviewed from video documents of the operations and clinical records. The major complication rate was 3.5%, including one common bile duct (CBD) injury (0.5%), three retained CBD stones (1.5%), one subphrenic fluid accumulation (0.5%), one liver abscess (0.5%) and one cystic duct stump bile leakage (0.5%). All major complications were cholecystectomy-related, and only one of the seven occurred in cases of acute cholecystitis. Age and sex were not related to its occurrence. The rate of minor complications ranged from 0.5% to 10%; they were: shoulder and back pain (10%), gall bladder perforation (10%), retained stones in the abdominal cavity (5%), transient nausea and diarrhea (5%), extension of umbilical port to a mini-laparotomy (3.5%), prolonged operation time > three hours (2%), subcutaneous emphysema (1.5%), wound infection (1.5%) and prolonged ileus (0.5%). The minor complications occurred largely in patients with acute cholecystitis. The complications occurred mostly during the early period of our study, indicating a learning period phenomenon. These could have been avoided if we had had a thorough knowledge of the potential complications and had strictly followed the principles of laparoscopic surgery. We conclude that LC is safe and the complication rate is not higher than that for open cholecystectomy. Most of the complications are preventable if LC is performed by qualified biliary surgeons following strict precautions.

[Laparoscopic cholecystectomy: the first 50 patients]

Laparoscopic cholecystectomy (LC) has rapidly gained wide acceptance in the United States. The applicability, safety and efficacy of this new procedure for the treatment of cholelithiasis in Taiwan, however, needs evaluation. We performed LC in 50 out of 98 cases of cholelithiasis at Cathay General Hospital from 28 December 1990 to 28 April 1991. We found that the applicability rate was 51%. The reasons for not selecting LC in the 48 open cases were: acute and gangrenous cholecystitis (13), common bile duct stones (11), concomitant intra-abdominal malignancy (5), intrahepatic stones (5), multiple upper abdominal incisions (4), pancreatitis or pancreatic abscesses (3) and other causes (7). In the LC group, there were 44 patients with symptomatic chronic calculus cholecystitis, 3 patients with acute calculus cholecystitis and 3 patients with gall bladder polyps. The age of the patients ranged from 27 to 79. There were 14 males and 36 females. All of the patients had a detailed preoperative workup including complete liver function test and sonographic examination of the hepatobiliary system. Additional pre-operative endoscopic retrograde cholangiopancreatographies were done in 3 and operative cholangiograms were done in another 3 to confirm the absence of common bile duct stones or to delineate anatomy. Although we encountered a few problems during the operations, such as severe adhesion, bleeding, difficult dissection, CO2 leakage, difficult insufflation, or large stones, all of the 50 patients completed the LC successfully without conversion to open cholecystectomy. The average operation time was 60 minutes, ranging from 30 to 135 minutes. Drain tubes were used in 7 cases.(ABSTRACT TRUNCATED AT 250 WORDS)