1
|
Joliat GR, de Man R, Rijckborst V, Cimino M, Torzilli G, Choi GH, Lee HS, Goh BKP, Kokudo T, Shirata C, Hasegawa K, Nishioka Y, Vauthey JN, Baimas-George M, Vrochides D, Demartines N, Halkic N, Labgaa I. Long-term outcomes of ruptured hepatocellular carcinoma: international multicentre study. Br J Surg 2024; 111:znae093. [PMID: 38630792 PMCID: PMC11023170 DOI: 10.1093/bjs/znae093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 02/19/2024] [Accepted: 03/12/2024] [Indexed: 04/19/2024]
Affiliation(s)
- Gaëtan-Romain Joliat
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Robert de Man
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Vincent Rijckborst
- Department of Gastroenterology and Hepatology, Ikazia Hospital, Rotterdam, the Netherlands
| | - Matteo Cimino
- Department of Hepatobiliary and General Surgery, Humanitas University, Humanitas Clinical and Research Centre, IRCCS, Rozzano, Milan, Italy
| | - Guido Torzilli
- Department of Hepatobiliary and General Surgery, Humanitas University, Humanitas Clinical and Research Centre, IRCCS, Rozzano, Milan, Italy
| | - Gi Hong Choi
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyung Soon Lee
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, National Cancer Centre Singapore and Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Takashi Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Chikara Shirata
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yujiro Nishioka
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria Baimas-George
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Carolinas Medical Centre, Charlotte, North Carolina, USA
| | - Dionisios Vrochides
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Carolinas Medical Centre, Charlotte, North Carolina, USA
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Nermin Halkic
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Ismail Labgaa
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| |
Collapse
|
2
|
Rouhi AD, Castle RE, Hoeltzel GD, Williams NN, Dumon KR, Baimas-George M, Wachs M, Nydam TL, Choudhury RA. Sleeve Gastrectomy Reduces the Need for Liver Transplantation in Patients with Obesity and Non-Alcoholic Steatohepatitis: a Predictive Model. Obes Surg 2024; 34:1224-1231. [PMID: 38379059 DOI: 10.1007/s11695-024-07102-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 02/09/2024] [Accepted: 02/15/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Non-alcoholic steatohepatitis (NASH) is one of the leading indications for liver transplantation (LT) in the United States. As with the current obesity epidemic, the incidence of NASH continues to rise. However, the impact of broad utilization of bariatric surgery (BS) for patients with NASH is unknown, particularly in regard to mitigating the need for LT. METHODS Markov decision analysis was performed to simulate the lives of 20,000 patients with obesity and concomitant NASH who were deemed ineligible to be waitlisted for LT unless they achieved a body mass index (BMI) < 35 kg/m2. Life expectancy following medical weight management (MWM) and sleeve gastrectomy (SG) were estimated. Base case patients were defined as having NASH without fibrosis and a pre-intervention BMI of 45 kg/m2. Sensitivity analysis of initial BMI was performed. RESULTS Simulated base case analysis patients who underwent SG gained 14.3 years of life compared to patients who underwent MWM. One year after weight loss intervention, 9% of simulated MWM patients required LT compared to only 5% of SG patients. Survival benefit for SG was observed above a BMI of 32.2 kg/m2. CONCLUSION In this predictive model of 20,000 patients with obesity and concomitant NASH, surgical weight loss is associated with a reduction in the progression of NASH, thereby reducing the need for LT. A reduced BMI threshold of 32 kg/m2 for BS may offer survival benefit for patients with obesity and NASH.
Collapse
Affiliation(s)
- Armaun D Rouhi
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Rose E Castle
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Gerard D Hoeltzel
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Noel N Williams
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kristoffel R Dumon
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Maria Baimas-George
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Michael Wachs
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Trevor L Nydam
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Rashikh A Choudhury
- Division of Transplantation, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| |
Collapse
|
3
|
Jensen S, Baimas-George M, Yang H, Paton L, Barbat S, Matthews B, Reinke C, Schiffern L. Remote triage practices in general surgery patients from freestanding emergency departments: A 6-year analysis. Surgery 2024; 175:387-392. [PMID: 38016899 DOI: 10.1016/j.surg.2023.10.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 09/07/2023] [Accepted: 10/24/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Freestanding emergency departments have risen in popularity as a means to expand access to care. Although some evaluation of freestanding emergency department utility in specific patient populations exists, management of surgical patients via remote triage and disposition has not been previously described. We report our experience with remote triage to discharge home, level I trauma center, or community hospital admission for general surgery patients who present to an affiliated freestanding emergency department. METHODS A retrospective cohort study of patients presenting to freestanding emergency departments requiring surgical consultation between 2016 and 2021 was conducted. Outcomes included disposition, length of stay, surgical intervention, 30-day mortality, and readmission. Undertriage and overtriage rates were calculated and defined as the following: (1) discharge undertriage-discharge home with 30-day emergency department visit/readmission; 2) transfer undertriage-transfers to community hospital requiring transfer to trauma center; and (3) overtriage-admissions <24 hours without surgery. RESULTS Of 1,105 patients, 15% were discharged home, 27% were transferred to trauma centers, and 58% were transferred to community hospitals. Patients admitted to trauma centers were older and had higher acuity pathology, whereas patients admitted to community hospitals had higher operative rates with shorter lengths of stay, operating room time, 30-day readmission, and mortality. Transfer undertriage was 0.9% (n = 6), with only 1 patient requiring transfer from a community hospital to a trauma center for disease acuity. Discharge undertriage was 12% (n = 20) due to worsening or persistent pathology. Overtriage was 5.5% (n = 52), with most having a partial small bowel obstruction or ambiguous diagnostic imaging requiring observation. CONCLUSION Remote surgery triage at freestanding emergency departments, without an in-person examination, demonstrated both low undertriage and overtriage rates, reflecting appropriate triage practices.
Collapse
Affiliation(s)
| | | | - Hongmei Yang
- Atrium Health, Information and Analytics Services, Charlotte, NC
| | - Lauren Paton
- Carolinas Medical Center, Department of Surgery, Charlotte, NC
| | - Selwan Barbat
- Carolinas Medical Center, Department of Surgery, Charlotte, NC
| | - Brent Matthews
- Carolinas Medical Center, Department of Surgery, Charlotte, NC
| | - Caroline Reinke
- Carolinas Medical Center, Department of Surgery, Charlotte, NC
| | | |
Collapse
|
4
|
Lorenz W, Yang H, Paton L, Barbat S, Matthews B, Reinke CE, Schiffern L, Baimas-George M. Virtual triage from freestanding emergency departments: a propensity score-weighted analysis of short-term outcomes in emergency general surgery. Surg Endosc 2023; 37:7901-7907. [PMID: 37418149 DOI: 10.1007/s00464-023-10241-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/23/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Freestanding emergency departments (FSEDs) have generated improved hospital metrics, including decreased ED wait times and increased patient selection. Patient outcomes and process safety have not been evaluated. This study investigates the safety of FSED virtual triage in the emergency general surgery (EGS) patient population. METHODS AND PROCEDURES A retrospective review evaluated all adult EGS patients admitted to a community hospital between January 2016 and December 2021 who either presented at a FSED and received virtual evaluation from a surgical team (fEGS) or presented at the community hospital emergency department and received in-person evaluation from the same surgical group (cEGS). Patients' demographics, acute care utilization history, and clinical characteristics at the onset of the index visit were used to build a propensity score model and stabilized Inverse Probability of Treatment Weights (IPTW) were used to create a weighted sample. Multivariable regression models were then employed to the weighted sample to evaluate the treatment effect of virtual triage compared to in-person evaluation on short-term outcomes, including length of stay (LOS) and 30-day readmission and mortality. Variables which occurred during the index visit (such as surgery duration and type of surgery) were adjusted for in the multivariable analyses. RESULTS Of 1962 patients, 631 (32.2%) were initially evaluated virtually (fEGS) and 1331 (67.8%) underwent an in-person evaluation (cEGS). Baseline characteristics demonstrated significant differences between the cohorts in gender, race, payer status, BMI, and CCI score. Baseline risks were well balanced in the IPTW-weighted sample (SD range 0.002-0.18). Multivariable analysis found no significant differences between the balanced cohorts in 30-day readmission, 30-day mortality, and LOS (p > 0.05 for all). CONCLUSION Patients who undergo virtual triage have similar outcomes to those who undergo in-person triage for EGS diagnoses. Virtual triage at FSED for these EGS patients may be an efficient and safe means for initial evaluation.
Collapse
Affiliation(s)
- William Lorenz
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Hongmei Yang
- Atrium Health, Information and Analytics Services, 720 East Morehead St, Charlotte, NC, 28203, USA
| | - Lauren Paton
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Selwan Barbat
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Brent Matthews
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Caroline E Reinke
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Lynnette Schiffern
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Maria Baimas-George
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA.
- Carolinas Medical Center, 1025 Morehead Medical Plaza, Suite #300, Charlotte, NC, 28204, USA.
| |
Collapse
|
5
|
Baimas-George M, Strand MS, Davis JM, Eskind LB, Lessne M, Levi DM, Vrochides D. Future liver remnant augmentation preceding ex vivo hepatectomy with IVC replacement: a strategy to achieve R0 margins. Langenbecks Arch Surg 2023; 408:156. [PMID: 37086277 DOI: 10.1007/s00423-023-02902-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 04/17/2023] [Indexed: 04/23/2023]
Abstract
PURPOSE Ex vivo hepatectomy with autotransplantation (EHAT) provides opportunity for R0 resection. As EHAT outcomes after future liver remnant (FLR) augmentation techniques are not well documented, we examine results of EHAT after augmentation for malignant tumors. METHODS Retrospective analysis of six cases of EHAT was performed. Of these, four occurred after preoperative FLR augmentation between 2018 and 2022. RESULTS Six patients were offered EHAT of 26 potential candidates. Indications for resection were involvement of hepatic vein outflow and inferior vena cava (IVC) with metastatic colorectal carcinoma (n = 3), cholangiocarcinoma (n = 2), or leiomyosarcoma (n = 1). Five patients were treated with neoadjuvant chemotherapy and four had preoperative liver augmentation. One hundred percent of cases achieved R0 resection. Of the augmented cases, three patients are alive after median follow-up of 28 months. Postoperative mortality due to liver failure was 25% (n = 1). CONCLUSIONS For select patients with locally advanced tumors involving all hepatic veins and the IVC for whom conventional resection is not an option, EHAT provides opportunity for R0 resection. In addition, in patients with inadequate FLR volume, further operative candidacy with acceptable results can be achieved by combined liver augmentation techniques. To better characterize outcomes in this small subset, a registry is needed.
Collapse
Affiliation(s)
- Maria Baimas-George
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Atrium Health, Charlotte, NC, 28203, USA
- Division of Abdominal Transplant Surgery, Atrium Health, Charlotte, NC, 28203, USA
| | - Matthew S Strand
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Atrium Health, Charlotte, NC, 28203, USA
| | - Joshua M Davis
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Atrium Health, Charlotte, NC, 28203, USA
| | - Lon B Eskind
- Division of Abdominal Transplant Surgery, Atrium Health, Charlotte, NC, 28203, USA
| | - Mark Lessne
- Division of Interventional Radiology, Atrium Health, Charlotte, NC, 28203, USA
| | - David M Levi
- Division of Abdominal Transplant Surgery, Atrium Health, Charlotte, NC, 28203, USA
| | - Dionisios Vrochides
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Atrium Health, Charlotte, NC, 28203, USA.
- Division of Abdominal Transplant Surgery, Atrium Health, Charlotte, NC, 28203, USA.
| |
Collapse
|
6
|
Baimas-George M, Behrns K, Wexner SD. Arts and Scalpels: Exploring the Role of Art in Surgery. Surgery 2022; 172:1595-1597. [PMID: 36410941 DOI: 10.1016/j.surg.2022.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
| | | | - Steven D Wexner
- Cleveland Clinic Florida, Department of Colorectal Surgery, Weston, FL
| |
Collapse
|
7
|
Baimas-George M, Schiffern L, Yang H, Reinke CE, Wexner SD, Matthews BD, Paton BL. Deconstructing the roadmap to surgical residency: a national survey of residents illuminates factors associated with recruitment success as well as applicants' needs and beliefs. Global Surg Educ 2022; 1:66. [PMID: 38013708 PMCID: PMC9640817 DOI: 10.1007/s44186-022-00070-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 09/05/2022] [Accepted: 10/23/2022] [Indexed: 11/09/2022]
Abstract
Purpose As applications increase and residency becomes more competitive, applicants and programs will be challenged by increased demands on recruitment, metric assessment, and rank determination. Studies have investigated program opinions; however, this survey sought to illuminate the process from an applicant's perspective. Methods An anonymous survey was distributed to past or current surgery residents nationwide using social media and program director emails. Regression analyses were performed to assess factors correlating with percentage of programs which offered the applicant an interview. Results There were 223 respondents who applied to an average of 61 programs (± 40) with 16 (± 11) interviews offered. Applicants believed that programs were most interested in (1) personality, (2) letter of recommendation (LOR) writers, and (3) medical school reputation. Top factors considered by applicants in ranking were resident culture, location, program reputation, and autonomy. Bivariate analysis found factors that decreased percent of interview invites to be Asian race, whereas factors that increased interview invites included age, year of match, surgery clerkship grade, medicine clerkship grade, AOA status, honor surgery rotation, gold humanism (GHHS) status, phone call for interview made, and step scores (all p < 0.05). AOA status, step scores, honor surgery rotation, year of match, and Asian race remained significant after multivariate analysis. Conclusions National surveys illuminate how applicants approach the application process and what programs and applicants appear to value. This information provides insight and guidance to candidates and programs as the process of matching becomes more challenging with surging application numbers, changes in testing parameters and virtual interviews. Supplementary Information The online version contains supplementary material available at 10.1007/s44186-022-00070-9.
Collapse
Affiliation(s)
- Maria Baimas-George
- Department of Surgery, Carolinas Medical Center, Medical Education Building; 6th Floor, 1000 Blythe Blvd, Charlotte, NC 28203 USA
| | - Lynnette Schiffern
- Department of Surgery, Carolinas Medical Center, Medical Education Building; 6th Floor, 1000 Blythe Blvd, Charlotte, NC 28203 USA
| | - Hongmei Yang
- Atrium Health, Information and Analytics Services, 720 East Morehead St, Charlotte, NC 28203 USA
| | - Caroline E. Reinke
- Department of Surgery, Carolinas Medical Center, Medical Education Building; 6th Floor, 1000 Blythe Blvd, Charlotte, NC 28203 USA
| | - Steven D. Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331 USA
| | - Brent D. Matthews
- Department of Surgery, Carolinas Medical Center, Medical Education Building; 6th Floor, 1000 Blythe Blvd, Charlotte, NC 28203 USA
| | - B. Lauren Paton
- Department of Surgery, Carolinas Medical Center, Medical Education Building; 6th Floor, 1000 Blythe Blvd, Charlotte, NC 28203 USA
| |
Collapse
|
8
|
Joliat GR, de Man R, Rijckborst V, Cimino M, Torzilli G, Choi GH, Lee HS, Goh B, Kokudo T, Shirata C, Hasegawa K, Nishioka Y, Vauthey JN, Baimas-George M, Vrochides D, Demartines N, Halkic N, Labgaa I. Long-term outcomes of ruptured hepatocellular carcinoma: An international multicentric propensity score-matched study. Br J Surg 2022. [DOI: 10.1093/bjs/znac178.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Objective
Long-term outcomes of patients with ruptured hepatocellular carcinoma (rHCC) remain scant. This study aimed to assess disease-free survival (DFS) and overall survival (OS) after surgical resection of rHCC compared to non-ruptured HCC (nrHCC).
Methods
Patients with rHCC and nrHCC were collected from 8 centers in Europe, Asia, and North America. Resected rHCC patients were matched 1:1 to patients undergoing surgery for nrHCC using propensity score and nearest-neighbor method (matching criteria: age, tumor size, cirrhosis, Child-Pugh score, Barcelona Clinic Liver Cancer stage, resection status, grade, and microvascular invasion). Survival rates were calculated using Kaplan-Meier method.
Results
A total of 2033 patients were included: 226 rHCC patients (172 operated: 68 with upfront surgery and 104 after embolization) and 1807 nrHCC patients. Median DFS and OS of rHCC patients (all treatments confounded) were 10 months (95% CI 7–13) and 22 months (95% CI 13–31). Prognostic factors for worse OS among rHCC patients were absence of preoperative arterial embolization (HR 2.3, 95% CI 1.2–4.6, p=0.016), cirrhosis Child B/C (HR 2.4, 95% CI 1.1–5.4, p=0.040), and R1/R2 margins (HR 2, 95% CI 1–5, p=0.049). Survivals were similar between Western and Eastern rHCC patients.
After propensity score matching, 106 rHCC patients and 106 nrHCC patients displayed similar characteristics. Patients with rHCC had shorter median DFS (12 months, 95% CI 7–17 vs. 22 months, 95% CI 12–32, p=0.011), but similar median OS compared to nrHCC patients (43 months, 95% CI 21–65 vs. 63 months, 95% CI 21–105, p=0.060).
Conclusion
In this large dataset including Eastern and Western patients, rHCC was associated with shorter DFS compared to nrHCC, while OS was similar.
Collapse
Affiliation(s)
- G-R Joliat
- Department of Visceral Surgery, Lausanne University Hospital , Lausanne, Switzerland
| | - R de Man
- Department of Gastroenterology and Hepatology, Erasmus Medical Center , Rotterdam, The Netherlands
| | - V Rijckborst
- Department of Gastroenterology and Hepatology, Erasmus Medical Center , Rotterdam, The Netherlands
| | - M Cimino
- Department of General and Minimally Invasive Surgery, Humanitas Clinical and Research Hospital , Milan, Italy
| | - G Torzilli
- Department of General and Minimally Invasive Surgery, Humanitas Clinical and Research Hospital , Milan, Italy
| | - G H Choi
- Department of Surgery, Yonsei University College of Medicine , Seoul, South Korea
| | - H S Lee
- Department of Surgery, Yonsei University College of Medicine , Seoul, South Korea
| | - B Goh
- Department of Surgery, Singapore General Hospital , Singapore, Singapore
| | - T Kokudo
- Department of Surgery, The University of Tokyo Hospital , Tokyo, Japan
| | - C Shirata
- Department of Surgery, The University of Tokyo Hospital , Tokyo, Japan
- Department of Visceral Surgery, Lausanne University Hospital , Lausanne, Switzerland
| | - K Hasegawa
- Department of Surgery, The University of Tokyo Hospital , Tokyo, Japan
| | - Y Nishioka
- Department of Surgical Oncology, MD Anderson Cancer Center , Houston, USA
| | - J-N Vauthey
- Department of Surgical Oncology, MD Anderson Cancer Center , Houston, USA
| | - M Baimas-George
- Department of Surgery, Atrium Health, Carolinas Medical Center , Charlotte, USA
| | - D Vrochides
- Department of Surgery, Atrium Health, Carolinas Medical Center , Charlotte, USA
| | - N Demartines
- Department of Visceral Surgery, Lausanne University Hospital , Lausanne, Switzerland
| | - N Halkic
- Department of Visceral Surgery, Lausanne University Hospital , Lausanne, Switzerland
| | - I Labgaa
- Department of Visceral Surgery, Lausanne University Hospital , Lausanne, Switzerland
| |
Collapse
|
9
|
Baimas-George M, Schiffern L, Yang H, Paton L, Barbat S, Matthews B, Reinke CE. Emergency general surgery transfer to lower acuity facility: The role of right-sizing care in emergency general surgery regionalization. J Trauma Acute Care Surg 2022; 92:38-43. [PMID: 34670959 DOI: 10.1097/ta.0000000000003435] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Regionalization of emergency general surgery (EGS) has primarily focused on expediting care of high acuity patients through interfacility transfers. In contrast, triaging low-risk patients to a nondesignated trauma facility has not been evaluated. This study evaluates a 16-month experience of a five-surgeon team triaging EGS patients at a tertiary care, Level I trauma center (TC) to an affiliated community hospital 1.3 miles away. METHODS All EGS patients who presented to the Level I TC emergency department from January 2020 to April 2021 were analyzed. Patients were screened by EGS surgeons covering both facilities for transfer appropriateness including hemodynamics, resource need, and comorbidities. Patients were retrospectively evaluated for disposition, diagnosis, comorbidities, length of stay, surgical intervention, and 30-day mortality and readmission. RESULTS Of 987 patients reviewed, 31.5% were transferred to the affiliated community hospital, 16.1% were discharged home from the emergency department, and 52.4% were admitted to the Level I TC. Common diagnoses were biliary disease (16.8%), bowel obstruction (15.7%), and appendicitis (14.3%). Compared with Level I TC admissions, Charlson Comorbidity Index was lower (1.89 vs. 4.45, p < 0.001) and length of stay was shorter (2.23 days vs. 5.49 days, p < 0.001) for transfers. Transfers had a higher rate of surgery (67.5% vs. 50.1%, p < 0.001) and lower readmission and mortality (8.4% vs. 15.3%, p = 0.004; 0.6% vs. 5.0%, p < 0.001). Reasons not to transfer were emergency evaluation, comorbidity burden, operating room availability, and established care. No transfers required transfer back to higher care (under-triage). Bed days saved at the Level I TC were 693 (591 inpatients). Total operating room minutes saved were 24,008 (16,919, between 7:00 am and 5:00 pm). CONCLUSION Transfer of appropriate patients maintains high quality care and outcomes, while improving operating room and bed capacity and resource utilization at a tertiary care, Level I TC. Emergency general surgery regionalization should consider triage of both high-risk and low-risk patients. LEVEL OF EVIDENCE Prospective comparative cohort study, Level II.
Collapse
Affiliation(s)
- Maria Baimas-George
- From the Department of Surgery (M.B.-G., L.S., L.P., S.B., B.M., C.E.R.), Carolinas Medical Center, Charlotte, North Carolina; and Clinical Analytics, Department of Information and Analytics Services (H.Y.), Atrium Health, Charlotte, North Carolina
| | | | | | | | | | | | | |
Collapse
|
10
|
Baimas-George M, Watson M, Martinie J, Vrochides D. Curriculum matrix development for a hepato-pancreato-biliary robotic surgery fellowship. Can J Surg 2021; 64:E657-E662. [PMID: 34880057 PMCID: PMC8677573 DOI: 10.1503/cjs.002620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2021] [Indexed: 11/17/2022] Open
Abstract
Robotic surgery is being increasingly used for complex benign and malignant hepato-pancreato-biliary (HPB) cases. As use of robotics increases, fellowships to excel in complex robotic procedures will be sought after. With this dedicated training, attending surgeon positions can be obtained that can incorporate and teach this skill set. Unfortunately, there are no evidence-based approaches for constructing a curriculum for an HPB robotic surgery fellowship. This paper describes a technique to develop a structured curriculum to ensure competence and fulfil the learning and practice needs for robotic HPB fellows.
Collapse
Affiliation(s)
- Maria Baimas-George
- From the Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina, USA
| | - Michael Watson
- From the Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina, USA
| | - John Martinie
- From the Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina, USA
| | - Dionisios Vrochides
- From the Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina, USA
| |
Collapse
|
11
|
Tschuor C, Lyman WB, Passeri M, Salibi PN, Baimas-George M, Iannitti DA, Baker EH, Vrochides D, Martinie JB. Robotic-assisted completion cholecystectomy: A safe and effective approach to a challenging surgical scenario - A single center retrospective cohort study. Int J Med Robot 2021; 17:e2312. [PMID: 34261193 DOI: 10.1002/rcs.2312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/30/2021] [Accepted: 07/09/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Reoperation following a previous subtotal or aborted cholecystectomy presents a challenging surgical scenario that has traditionally required an open completion cholecystectomy. The aim of this study was to describe an institutional experience with a robotic-assisted approach to completion cholecystectomy. METHODS A database was retrospectively audited to identify all patients who underwent robotic-assisted cholecystectomy performed by two hepatopancreatobiliary surgeons at a single centre from 2010 to 2019. RESULTS Twenty six patients who underwent a robotic-assisted completion cholecystectomy were identified. Median operative time was 142 min (48-247 min) with a blood loss of 50 cc (0-500 cc). Minor complications (Clavien-Dindo ≤ II 90 days) occurred in three patients (11.5%) with no major complication or mortality reported. Median hospital length of stay was 1 day (0-6 days) with one patient readmitted. CONCLUSION This study represents to our knowledge the largest series of robotic-assisted completion cholecystectomies to date. The robotic approach appears to be a safe and effective procedure associated with a low morbidity and high success rate.
Collapse
Affiliation(s)
- Christoph Tschuor
- Division of HPB Surgery, Department of General Surgery, Atrium Health - Carolinas Medical Center, Charlotte, North Carolina, USA.,Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - William B Lyman
- Division of HPB Surgery, Department of General Surgery, Atrium Health - Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Michael Passeri
- Division of HPB Surgery, Department of General Surgery, Atrium Health - Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Patrick N Salibi
- Division of HPB Surgery, Department of General Surgery, Atrium Health - Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Maria Baimas-George
- Division of HPB Surgery, Department of General Surgery, Atrium Health - Carolinas Medical Center, Charlotte, North Carolina, USA
| | - David A Iannitti
- Division of HPB Surgery, Department of General Surgery, Atrium Health - Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Erin H Baker
- Division of HPB Surgery, Department of General Surgery, Atrium Health - Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of General Surgery, Atrium Health - Carolinas Medical Center, Charlotte, North Carolina, USA
| | - John B Martinie
- Division of HPB Surgery, Department of General Surgery, Atrium Health - Carolinas Medical Center, Charlotte, North Carolina, USA
| |
Collapse
|
12
|
Robinson J, Watson M, Baimas-George M, Iannitti D, Martinie J, Vrochides D. Objective evaluation of technical dexterity in robotic hepaticojejunostomy: Assessment of hepatopancreatobiliary fellows using cumulative sum analytics. Int J Med Robot 2021; 17:e2294. [PMID: 34077625 DOI: 10.1002/rcs.2294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/27/2021] [Accepted: 05/31/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND The development of technical dexterity is a critical for surgeons in training. This study describes and assesses the feasibility of an objective method for the evaluation of procedure-specific technical dexterity in hepatopancreatobiliary (HPB) surgery using cumulative sum (CUSUM) analysis. METHODS Dry-lab HPB procedures were divided into procedural steps with binary outcomes (success or failure). Two HPB fellows completed 20 dry lab hepaticojejunostomy (HJ) procedures. Participant progress was tracked over time with CUSUM analytics to establish a learning curve for procedural proficiency. RESULTS The CUSUM charts for 20 consecutive dry-lab HJ procedures were analysed. A learning curve was created and used to identify areas of weakness to facilitate improvement in technical proficiency. CONCLUSIONS CUSUM is effective tool for objective evaluation of technical dexterity offering both simplicity and adaptability. We demonstrate its use and feasibility for surgical education and plan to expand its' application to assess residents performing general surgery procedures.
Collapse
Affiliation(s)
- Jordan Robinson
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Michael Watson
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Maria Baimas-George
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - David Iannitti
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - John Martinie
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| |
Collapse
|
13
|
Baimas-George M, Watson M, Murphy KJ, Sarantou J, Vrochides D, Martinie JB, Baker EH, Mckillop IH, Iannitti DA. Treatment of spontaneously ruptured hepatocellular carcinoma: use of laparoscopic microwave ablation and washout. HPB (Oxford) 2021; 23:444-450. [PMID: 32994101 DOI: 10.1016/j.hpb.2020.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/28/2020] [Accepted: 08/03/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ruptured, or bleeding, hepatocellular carcinoma (rHCC) is a relatively rare disease presentation associated with high acute mortality rates. This study sought to evaluate outcomes following laparoscopic microwave ablation (MWA) and washout in rHCC. METHODS A retrospective single-center review was performed to identify patients with rHCC (2008-2018). The treatment algorithm consisted of transarterial embolization (TAE) or trans-arterial chemoembolization (TACE) followed by laparoscopic MWA and washout. RESULTS Fifteen patients with rHCC were identified (n = 5 single lesion, n = 5 multifocal disease, n = 5 extrahepatic metastatic disease). Median tumor size was 83 mm (range 5-228 mm), and 10 of 15 underwent TAE or TACE followed by laparoscopic MWA/washout. One patient required additional treatment for bleeding after MWA with repeat TAE. Thirty-day mortality was 6/15. For those patients discharged (n = 9), additional treatments included chemotherapy (n = 5), TACE (n = 3), and/or partial lobectomy (n = 2). Median follow-up was 18.2 months and median survival was 431 days (range 103-832) (one-year survival n = 7; two-year survival n = 4; three-year survival n = 3). Six patients had post-operative imaging from which one patient demonstrated recurrence. CONCLUSION Using laparoscopic MWA with washout may offer advantage in the treatment of ruptured HCC. It not only achieves hemostasis but also could have oncologic benefit by targeting local tumor and decreasing peritoneal carcinomatosis risk.
Collapse
Affiliation(s)
- Maria Baimas-George
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Michael Watson
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Keith J Murphy
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - John Sarantou
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - John B Martinie
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Erin H Baker
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Iain H Mckillop
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - David A Iannitti
- Division of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
| |
Collapse
|
14
|
Baimas-George M, Yelverton S, Ross SW, Rozario N, Matthews BD, Reinke CE. Palliative Care in Emergency General Surgery Patients: Reduced Inpatient Mortality And Increased Discharge to Hospice. Am Surg 2020; 87:1087-1092. [PMID: 33316173 DOI: 10.1177/0003134820956942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Admissions due to emergency general surgery (EGS) are on the rise, and patients who undergo emergency surgery are at increased risk of mortality. We hypothesized that utilization of palliative care and discharge to hospice in the EGS population have increased over time and that this is associated with a decrease in inpatient mortality. METHODS Using the 2002-2011 nationwide inpatient sample and American Association for the Surgery of Trauma-defined EGS diagnosis codes, we identified patients ≥18 years old with an EGS admission. Demographics, hospitalization characteristics, mortality, use of palliative care services, and discharge to hospice were queried. All Patient Refined-Diagnosis Related Group risk of mortality was used to categorize those with an extreme likelihood of dying (ELD). Multivariable logistic regression was used to investigate the association between palliative care consult and discharge to hospice. RESULTS Of the included patients, 0.3% received palliative care and 0.2% were discharged to hospice. Over time, rates of palliative care and hospice discharge increased while inpatient mortality decreased. In the 4% of patients with ELD, 3% received palliative care, 5% were transitioned to hospice care, and 22% suffered inpatient mortality. Controlling for patient characteristics, utilization of palliative care services was associated with increased odds of discharge to hospice compared to inpatient mortality (OR = 1.78 all patients and OR = 2.04 for ELD). CONCLUSIONS Despite the known increased risks associated with emergency surgical diagnoses, palliative care services remain infrequently utilized in the EGS population. This may be an opportunity for lessening suffering, improving patient-concordant care and outcomes, and reducing nonbeneficial and unwanted care.
Collapse
Affiliation(s)
| | - Sam Yelverton
- Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Samuel W Ross
- Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Nigel Rozario
- Center for Outcomes Research and Evaluation, Charlotte, NC, USA
| | - Brent D Matthews
- Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| | - Caroline E Reinke
- Department of Surgery, 22442Carolinas Medical Center, Charlotte, NC, USA
| |
Collapse
|
15
|
Baimas-George M, Watson M, Thompson K, Shastry V, Iannitti D, Martinie JB, Baker E, Parala-Metz A, Vrochides D. Prehabilitation for Hepatopancreatobiliary Surgical Patients: Interim Analysis Demonstrates a Protective Effect From Neoadjuvant Chemotherapy and Improvement in the Frailty Phenotype. Am Surg 2020; 87:714-724. [PMID: 33170023 DOI: 10.1177/0003134820952378] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Prehabilitation encompasses multidisciplinary interventions to improve health and lessen incidence of surgical deterioration by reducing physiologic stress and functional decline. This study presents an interim analysis to demonstrate prehabilitation for hepatopancreatobiliary (HPB) surgical patients. METHODS In 2018, a structured prehabilitation pilot program was implemented. Eligibility required HPB malignancy, neoadjuvant chemotherapy, and residence within hour drive. Patients were enrolled into the 4-month program. The fitness component was composed of timed up and go test and grip strength with exercise recommendations. Nutrition involved evaluation of sarcopenic obesity, glucose management, and smoking and alcohol counseling. Psychological services included psychosocial assessments and advanced care planning, with social work referrals. Component were evaluated monthly by a physician using laboratory results, nutritional data and questionnaires, psychological assessments, and validated fitness tests. Nurse navigators spoke with patients weekly to monitor compliance. RESULTS At 12 months, nineteen patients were enrolled. Ten completed prehabilitation, neoadjuvant chemotherapy and underwent their surgical procedure. There were no differences found after prehabilitation in functional status, physical performance, psychosocial assessments, or nutrition. Frailty, as assessed by Fried frailty criteria, improved significantly after prehabilitation (P < .0001). Symptom severity and laboratory values did not change. Length of stay was 6.5 days and all patients were discharged to home. There was 1 readmission for transient ischemic attack and 90-day mortality rate was 0%. DISCUSSION Prehabilitation to improve recovery is a promising concept encompassing a wide array of multidisciplinary assessments and interventions. It may demonstrate a protective effect on physiologic decline from chemotherapy and may reverse frailty phenotypes.
Collapse
Affiliation(s)
- Maria Baimas-George
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Michael Watson
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Kyle Thompson
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Vivek Shastry
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - David Iannitti
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - John B Martinie
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Erin Baker
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Armida Parala-Metz
- Department of Supportive Oncology, Levine Cancer Institute, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| |
Collapse
|
16
|
Watson M, Baimas-George M, Hanna Baker E, Bennett Martinie J, Vrochides DV, Anthony Iannitti D, Mayer Ocuin L. Failure to Operate on Early Stage Pancreatic Cancer in the Era of Modern Chemotherapy: An Analysis of the National Cancer Database. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.08.419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
17
|
Baimas-George M, Tschuor C, Watson M, Sulzer J, Salibi P, Iannitti D, Martinie JB, Baker E, Clavien PA, Vrochides D. Current trends in vena cava reconstructive techniques with major liver resection: a systematic review. Langenbecks Arch Surg 2020; 406:25-38. [PMID: 32979105 DOI: 10.1007/s00423-020-01989-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/07/2020] [Indexed: 11/11/2022]
Abstract
PURPOSE Historically, invasion of the inferior vena cava (IVC) represented advanced and often unresectable hepatic disease. With surgical and anesthetic innovations, IVC resection and reconstruction have become feasible in selected patients. This review assesses technical variations in reconstructive techniques and post-operative management. METHODS A comprehensive literature search was performed according to PRISMA. Inclusion criteria were (i) peer-reviewed articles in English; (ii) at least three cases; (iii) hepatic IVC resection and reconstruction (January 2015-March 2020). Primary outcomes were reconstructive technique, anti-thrombotic regimen, post-operative IVC patency, and infection. Secondary outcomes included post-operative complications and malignant disease survival. RESULTS Fourteen articles were included allowing for investigation of 351 individual patients. Analysis demonstrated significant heterogeneity in surgical reconstructive technique, anti-thrombotic management, and post-operative monitoring of patency. There was increased utilization of ex vivo approaches and decreased use of venovenous bypass compared with previously published reviews. CONCLUSION This review of literature published between 2015 and 2020 reveals persistent heterogeneity of hepatic IVC reconstructive techniques and peri-operative management. Increased utilization of ex vivo approaches and decreased use of venovenous bypass point towards improved operative techniques, peri-operative management, and anesthesia. In order to gain evidence for consensus on management, a registry would be beneficial.
Collapse
Affiliation(s)
- Maria Baimas-George
- Division of Hepatopancreatobiliary Surgery, Department of General Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive; Suite 600, Charlotte, NC, 28204, USA
| | - Christoph Tschuor
- Division of Hepatopancreatobiliary Surgery, Department of General Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive; Suite 600, Charlotte, NC, 28204, USA.,Department of Surgery & Transplantation, University Hospital of Zurich, Zurich, Switzerland
| | - Michael Watson
- Division of Hepatopancreatobiliary Surgery, Department of General Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive; Suite 600, Charlotte, NC, 28204, USA
| | - Jesse Sulzer
- Division of Hepatopancreatobiliary Surgery, Department of General Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive; Suite 600, Charlotte, NC, 28204, USA
| | - Patrick Salibi
- Division of Hepatopancreatobiliary Surgery, Department of General Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive; Suite 600, Charlotte, NC, 28204, USA
| | - David Iannitti
- Division of Hepatopancreatobiliary Surgery, Department of General Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive; Suite 600, Charlotte, NC, 28204, USA
| | - John B Martinie
- Division of Hepatopancreatobiliary Surgery, Department of General Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive; Suite 600, Charlotte, NC, 28204, USA
| | - Erin Baker
- Division of Hepatopancreatobiliary Surgery, Department of General Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive; Suite 600, Charlotte, NC, 28204, USA
| | - Pierre-Alain Clavien
- Department of Surgery & Transplantation, University Hospital of Zurich, Zurich, Switzerland
| | - Dionisios Vrochides
- Division of Hepatopancreatobiliary Surgery, Department of General Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive; Suite 600, Charlotte, NC, 28204, USA.
| |
Collapse
|
18
|
Baimas-George M, Watson M, Pickens RC, Sulzer J, Murphy KJ, Ocuin L, Baker E, Martinie J, Iannitti D, Vrochides D. Faster Return to Intended Oncologic Treatment (RIOT) After Trisectionectomy Does Not Translate to Better Outcomes. Am Surg 2020; 87:309-315. [PMID: 32936007 DOI: 10.1177/0003134820950687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Resection with trisectionectomy may necessitate liver molding for adequate future liver remnant (FLR), and subsequent complications can impact return to intended oncologic therapy (RIOT). This study evaluated whether a difference in RIOT exists with the use of molding and between liver molding techniques (associating liver partition and portal vein ligation for staged hepatectomy [ALPPS] and portal vein embolization [PVE]) with trisectionectomy. METHODS A retrospective review evaluated trisectionectomies for malignancy. Outcomes were compared with and without molding, and RIOT was determined. RESULTS Fifty-one patients underwent trisectionectomy: 11 ALPPS, 14 PVE, 26 without molding. 73% of ALPPS, 64% of PVE, and 58% without molding achieved RIOT (P = .971). There were no differences found in baseline characteristics, R0 rate, length of stay, readmission, complications, or mortality. Time to RIOT was significantly different (ALPPS: 3.3 months; PVE: 5.2 months; none: 2.4 months, P = .0203). There were no differences in recurrence or survival. CONCLUSIONS Liver molding should not cause apprehension as there are no differences in achieving RIOT. Although technique alters time to RIOT, this does not translate into improved outcomes, implicating disease biology, and regeneration stimulus.
Collapse
Affiliation(s)
- Maria Baimas-George
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Michael Watson
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Ryan C Pickens
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Jesse Sulzer
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Keith J Murphy
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Lee Ocuin
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Erin Baker
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - John Martinie
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - David Iannitti
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| |
Collapse
|
19
|
Baimas-George M, Watson M, Salibi P, Tschuor C, Murphy KJ, Iannitti D, Baker E, Ocuin L, Vrochides D, Martinie JB. Oncologic Outcomes of Robotic Left Pancreatectomy for Pancreatic Adenocarcinoma: A Single-Center Comparison to Laparoscopic Resection. Am Surg 2020; 87:45-49. [PMID: 32915060 DOI: 10.1177/0003134820949524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Feasibility and safety of robotic surgery for pancreatic disease has been well demonstrated; however, there is scarce literature on long-term oncologic outcomes. We compared perioperative and oncologic outcomes between robotic left pancreatectomy (RLP) and laparoscopic left pancreatectomy (LLP) for pancreatic adenocarcinoma. METHODS A retrospective review evaluated left pancreatectomies performed for pancreatic adenocarcinoma from 2009 to 2019 in a tertiary institution. Baseline characteristics, operative and oncologic outcomes were compared between RLP and LLP. RESULTS There were 75 minimally invasive left pancreatectomy cases for pancreatic adenocarcinoma identified of which 33 cases were done robotically and 42 laparoscopically. Baseline characteristics demonstrated no difference in gender, age, BMI, T stage, N stage, neoadjuvant, or adjuvant chemotherapy. An analysis of operative variables demonstrated no difference in blood loss, increased duration, and higher lymph node yield with RLP (20 vs 12; P = .0029). Postoperatively, both cohorts had 30% pancreatic fistulas and no difference in complications. There were no differences in length of stay (LOS), 30- or 90-day readmission rates, or 90-day mortality. The analysis of oncologic outcomes demonstrated similar R0 resections (RLP: 72% vs OLP: 67%), recurrence rates (RLP: 36% vs OLP: 41%), and time to recurrence (RLP: 324 vs OLP 218 days). There was increased survival in the RLP cohort that was not significant (32 vs 19 months). CONCLUSION This analysis demonstrates RLP is at least equivalent to LLP in perioperative and oncologic outcomes. The significantly higher lymph node yield and trend toward an improved survival suggests oncologic advantage. Randomized controlled studies are needed to clarify benefit.
Collapse
Affiliation(s)
- Maria Baimas-George
- 22442Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Michael Watson
- 22442Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Patrick Salibi
- 22442Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Christoph Tschuor
- 22442Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Keith J Murphy
- 22442Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - David Iannitti
- 22442Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Erin Baker
- 22442Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Lee Ocuin
- 22442Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Dionisios Vrochides
- 22442Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - John B Martinie
- 22442Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| |
Collapse
|
20
|
Baimas-George M, Kirks RC, Cochran A, Baker EH, Lauren Paton B, Schiffern LM, Matthews BD, Martinie JB, Vrochides D, Iannitti DA. Patient Factors Lead to Extensive Variation in Outcomes and Cost From Cholecystectomy. Am Surg 2020; 86:643-651. [PMID: 32683960 DOI: 10.1177/0003134820923311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cholecystectomy is a common procedure with significantly varied outcomes. We analyzed differences in comorbidities, outcomes, and cost of cholecystectomy by acute care surgery (ACS) versus hepatopancreaticobiliary (HPB) surgery. STUDY DESIGN Patients were retrospectively identified between 2008 and 2015. Exclusion criteria included the following: (1) part of another procedure; (2) abdominal trauma; (3) ICU admission; vasopressors. RESULTS One hundred and twenty-six ACS and 122 HPB patients were analyzed. The HPB subset had higher burden of comorbid disease and significantly lower projected 10-year survival (87.4% ACS vs 68.5% HPB, P < .0001). Median lengths of stay were longer in HPB patients (2 vs 5 days, P < .0001) as were readmission rates (30-day 5.6% vs 13.1%, P = .040; 90-day 7.9% vs 20.5%, P = .005). Median cost was higher including operative supply cost ($969.42 vs $1920.66, P < .0001) and total cost of care ($7340.66 vs $19 338.05, P < .0001). A predictive scoring system for difficult gallbladders was constructed and a phone application was created. CONCLUSION Cholecystectomy in a complicated patient can be difficult with longer hospital stays and higher costs. The utilization of procedure codes to explain disparities is not sufficient. Incorporation of comorbidities needs to be addressed for planning and reimbursement.
Collapse
Affiliation(s)
- Maria Baimas-George
- 22442 Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Russell C Kirks
- 22442 Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Allyson Cochran
- 22442 Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Erin H Baker
- 22442 Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - B Lauren Paton
- 22442 Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Lynnette M Schiffern
- 22442 Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Brent D Matthews
- 22442 Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - John B Martinie
- 22442 Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Dionisios Vrochides
- 22442 Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - David A Iannitti
- 22442 Division of Hepatopancreatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| |
Collapse
|
21
|
Baimas-George M, Vrochides D. The Sorting Hat of Medicine: Why Hufflepuffs Wear Stethoscopes and Slytherins Carry Scalpels. J Surg Educ 2020; 77:772-778. [PMID: 32033915 DOI: 10.1016/j.jsurg.2020.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 01/14/2020] [Accepted: 01/17/2020] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Choosing a medical specialty is a complex decision comprised of a combination of intrinsic and extrinsic factors that can include economic status, personal interest, input from mentors, and personality traits. The fictional world of Harry Potter, a generational literary phenomenon, describes 4 distinct houses in the wizarding Hogwarts school; each valuing particular traits of mortality that correspond with personality types. As such, we hypothesized that with each medical specialty often attracting particular personalities, the percentage of residents who self-sorted into the different Hogwarts' houses would vary depending on their chosen specialty. METHODS A web survey was sent out nationwide to surgical coordinators and residents, collecting demographic information and responses regarding specialty type and Hogwarts' house self-sorting. RESULTS The survey was completed by 251 residents (49.4% from surgical specialties) with a 12.6% response rate of surgical coordinator dissemination and a 43.1% resident response rate at Carolinas Medical Center. Surgical specialties were found to have significantly fewer self-sorted Hufflepuffs (p = 0.002) and more Slytherins (p = 0.0061) than nonsurgical specialties. General surgery had significantly more Gryffindors (p = 0.04) and fewer Hufflepuffs (p = 0.0017) whereas orthopedic surgery had significantly more Slytherins (p = 0.0282). Pediatrics had significantly fewer Gryffindors (p = 0.0096) and more Hufflepuffs (p = 0.0006). Obstetrics and gynecology had significantly fewer Gryffindors (p = 0.0082) and the highest percentage of Ravenclaws when compared to all other specialties (35.3% vs 19.9%; p = 0.1344). Family medicine had no self-proclaimed Slytherins. CONCLUSIONS The discrepancies between specialties in the ratios of residents per Hogwarts house highlights that certain attributes may be more essential, advantageous, or complementary to a specific specialty. This information may guide medical students in choosing a satisfying and successful career path.
Collapse
Affiliation(s)
- Maria Baimas-George
- Division of Hepatobiliary and Pancreatic Surgery, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina.
| | - Dionisios Vrochides
- Division of Hepatobiliary and Pancreatic Surgery, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina
| |
Collapse
|
22
|
Baimas-George M, Watson M, Sulzer J, Salibi P, Murphy KJ, Levi D, Martinie JB, Vrochides D, Baker EH, Ocuin L, Iannitti DA. Pathologic response translates to improved patient survival after locoregional treatment for hepatocellular carcinoma: the importance of minimally invasive microwave ablation. Surg Endosc 2020; 35:3122-3130. [PMID: 32588344 DOI: 10.1007/s00464-020-07747-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/16/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hepatectomy or transplantation can serve as curative treatment for early-stage hepatocellular carcinoma (HCC). Unfortunately, as progression remains a reality, locoregional therapies (LRT) for curative or bridging intent have become common. Efficacy on viability, outcomes, and accuracy of imaging should be defined to guide treatment. METHODS Patients with HCC who underwent minimally invasive (MIS) microwave ablation (MWA), transarterial chemoembolization (TACE), or both (MIS-MWA-TACE) prior to hepatectomy or transplantation were identified. Tumor response and preoperative computed tomography (CT) accuracy were assessed and compared to pathology. Clinical and oncologic outcomes were compared between MIS-MWA, TACE, and MIS-MWA-TACE. RESULTS Ninety-one patients, with tumors from all stages of the Barcelona Clinic Liver Cancer (BCLC) staging, were identified who underwent LRT prior to resection or transplant. Fourteen patients underwent MIS-MWA, 46 underwent TACE, and 31 underwent both neoadjuvantly. TACE population was older; otherwise, there were no differences in demographics. Fifty-seven percent of MIS-MWA patients had no viable tumor on pathology whereas only 13% of TACE patients and 29% of MIS-MWA-TACE patients had complete destruction (p = 0.004). The amount of remaining viable tumor in the explant was also significantly different between groups (MIS-MWA: 17.2%, TACE: 48.7%, MIS-MWA-TACE: 18.6%; p ≤ 0.0001). Compared with TACE, the MIS-MWA and MIS-MWA-TACE groups had significantly improved overall survival (MIS-MWA: 99.94 months, TACE: 75.35 months, MIS-MWA-TACE: 140 months; p = 0.017). This survival remained significant with stratification by tumor size. CT accuracy was found to be 50% sensitive and 86% specific for MIS-MWA. For TACE, CT had an 82% sensitivity and 33% specificity and for MIS-MWA-TACE, there was a 42% sensitivity and 78% specificity. CONCLUSION The impact of locoregional treatments on tumor viability is distinct and superior with MIS-MWA alone and MIS-MWA-TACE offering significant advantage over TACE alone. The extent of this effect may be implicated in the improved overall survival.
Collapse
Affiliation(s)
- Maria Baimas-George
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Michael Watson
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Jesse Sulzer
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Patrick Salibi
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Keith J Murphy
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - David Levi
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - John B Martinie
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Erin H Baker
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Lee Ocuin
- Division of Hepatobiliary Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - David A Iannitti
- Division of Hepatopancreaticobiliary Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 600, Charlotte, NC, 28204, USA.
| |
Collapse
|
23
|
Baimas-George M, Watson M, Murphy KJ, Iannitti D, Baker E, Ocuin L, Vrochides D, Martinie JB. Robotic pancreaticoduodenectomy may offer improved oncologic outcomes over open surgery: a propensity-matched single-institution study. Surg Endosc 2020; 34:3644-3649. [PMID: 32328825 DOI: 10.1007/s00464-020-07564-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 04/10/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND The robotic platform in pancreatic disease has gained popularity in the hepatobiliary community due to significant advantages it technically offers over conventional open and laparoscopic techniques. Despite promising initial studies, there remains scant literature on operative and oncologic outcomes of robotic pancreaticoduodenectomy (RPD) for pancreatic adenocarcinoma. METHODS A retrospective review evaluated all RPD performed for pancreatic adenocarcinoma from 2008 to 2019 in a single tertiary institution. RPD cases were matched to open cases (OPD) by demographic and oncologic characteristics and outcomes compared using Mann-Whitney U test, log rank tests, and Kaplan-Meier methods. RESULTS Thirty-eight RPD cases were matched to 38 OPD. RPD had significantly higher lymph node (LN) yield (21.5 vs 13.5; p = 0.0036) and no difference in operative time or estimated blood loss (EBL). RPD had significantly lower rate of delayed gastric emptying (DGE) (3% vs 32%; p = 0.0009) but no difference in leaks, infections, hemorrhage, urinary retention ,or ileus. RPD had significantly shorter length of stay (LOS) (7.5 vs. 9; p = 0.0209). There were no differences in 30- or 90-day readmissions or 90-day mortality. There was an equivalent R0 resection rate and LN positivity ratio. There was a trend towards improved median overall survival in RPD (30.4 vs. 23.0 months; p = 0.1105) and longer time to recurrence (402 vs. 284 days; p = 0.7471). OPD had two times the local recurrent rate (16% vs. 8%) but no difference in distant recurrence. CONCLUSIONS While the feasibility and safety of RPD has been demonstrated, the impact on oncologic outcomes had yet to be investigated. We demonstrate that RPD not only offers similar if not superior immediate post-operative benefit by decreasing DGE but more importantly may offer improved oncologic outcomes. The significantly higher LN yield and decreased inflammatory response demonstrated in robotic surgery may improve overall survival.
Collapse
Affiliation(s)
- Maria Baimas-George
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Michael Watson
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Keith J Murphy
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - David Iannitti
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Erin Baker
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Lee Ocuin
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - John B Martinie
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA.
- Division of Hepatopancreatobiliary Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28203, USA.
| |
Collapse
|
24
|
Baimas-George M, Passeri MJ, Lyman WB, Dries A, Narang T, Deal S, Lewis J, Chauhan S, Martinie J, Vrochides D, Baker E, Iannitti D. A Single-Center Experience with Minimally Invasive Transgastric ERCP in Patients with Previous Gastric Bypass: Lessons Learned and Technical Considerations. Am Surg 2020. [DOI: 10.1177/000313482008600425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
As bariatric surgery increases, there is a growing population of patients with biliary obstruction and anatomy which precludes transoral access through endoscopic retrograde cholangiopancreatography (ERCP). Minimally invasive transgastric ERCP (TG-ERCP) offers a feasible alternative for the treatment. A retrospective review was performed of all patients who underwent laparoscopic or robotic-assisted TG-ERCP between 2010 and 2017. Chart abstraction collected demographics, procedural details, success rate, and postoperative outcomes. Forty patients were identified, of which 38 cases were performed laparoscopically and two robotically. Median operative time was 163 minutes, with an estimated blood loss of 50 cc. TG-ERCP was performed successfully in 36 cases (90%); sphincterotomy was completed in 35 patients (97%). Sixty per cent already had a cholecystectomy; in the remaining patients, it was performed concurrently. Major complications included stomach perforation (n = 1), pancreatitis (n = 3), and anemia requiring transfusion (n = 2). In patients with biliary obstruction and anatomy not suitable for ERCP, TG-ERCP can be performed in a minimally invasive fashion, with a high rate of technical success and low morbidity. We describe a stepwise, reproducible technique because it is an essential tool for the shared armamentarium of endoscopists and surgeons.
Collapse
Affiliation(s)
- Maria Baimas-George
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Michael J. Passeri
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - William B. Lyman
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Andrew Dries
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Tarun Narang
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Stephen Deal
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Jason Lewis
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Shailendra Chauhan
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - John Martinie
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Dionisios Vrochides
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Erin Baker
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - David Iannitti
- From the Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| |
Collapse
|
25
|
Baimas-George M, Passeri MJ, Lyman WB, Dries A, Narang T, Deal S, Lewis J, Chauhan S, Martinie J, Vrochides D, Baker E, Iannitti D. A Single-Center Experience with Minimally Invasive Transgastric ERCP in Patients with Previous Gastric Bypass: Lessons Learned and Technical Considerations. Am Surg 2020; 86:300-307. [PMID: 32391753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
As bariatric surgery increases, there is a growing population of patients with biliary obstruction and anatomy which precludes transoral access through endoscopic retrograde cholangiopancreatography (ERCP). Minimally invasive transgastric ERCP (TG-ERCP) offers a feasible alternative for the treatment. A retrospective review was performed of all patients who underwent laparoscopic or robotic-assisted TG-ERCP between 2010 and 2017. Chart abstraction collected demographics, procedural details, success rate, and postoperative outcomes. Forty patients were identified, of which 38 cases were performed laparoscopically and two robotically. Median operative time was 163 minutes, with an estimated blood loss of 50 cc. TG-ERCP was performed successfully in 36 cases (90%); sphincterotomy was completed in 35 patients (97%). Sixty per cent already had a cholecystectomy; in the remaining patients, it was performed concurrently. Major complications included stomach perforation (n = 1), pancreatitis (n = 3), and anemia requiring transfusion (n = 2). In patients with biliary obstruction and anatomy not suitable for ERCP, TG-ERCP can be performed in a minimally invasive fashion, with a high rate of technical success and low morbidity. We describe a stepwise, reproducible technique because it is an essential tool for the shared armamentarium of endoscopists and surgeons.
Collapse
|
26
|
Baimas-George M, Cunningham KW, Ross SW, Savell A, Monteruil K, Christmas AB, Sing RF. Filled to the brim: The characteristics of over-triage at a level I trauma center. Am J Surg 2019; 218:1074-1078. [PMID: 31540682 DOI: 10.1016/j.amjsurg.2019.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 08/29/2019] [Accepted: 08/30/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Interfacility transfers are necessary and valuable for the trauma system, but despite regional guidelines, many patients are inappropriately transferred. We evaluated over-triage at our Level I center and identified risk factors for over-triage. METHODS Retrospective analysis at our Level I urban trauma center assessed patients transferred from regional facilities during 2017. Over-triage was defined as patients discharged <48 h without procedures. Exclusion criteria were leaving against medical advice or no outside records. RESULTS Overall, 2352 patients met criteria. Nine hundred thirty (39.5%) with complete hospital records were discharged in <48 h; 498 (53.5%) received no procedural intervention and 909 (97.7%) were ultimately discharged home. CONCLUSION Many patients are inappropriately transferred to tertiary care centers without a definitive need for advanced services. Studies are needed to improve triage criteria without increasing under-triage.
Collapse
Affiliation(s)
- Maria Baimas-George
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
| | - Kyle W Cunningham
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
| | - Samuel W Ross
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
| | - Anita Savell
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
| | - Kelly Monteruil
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
| | - A Britton Christmas
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
| | - Ronald F Sing
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
| |
Collapse
|
27
|
Pickens RC, Jensen S, Sulzer JK, Baimas-George M, Baker EH, Vrochides D, Martinie JB, Ocuin LM, Iannitti DA. Minimally Invasive Surgical Management as Effective First-Line Treatment of Large Pyogenic Hepatic Abscesses. Am Surg 2019. [DOI: 10.1177/000313481908500830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Management of pyogenic hepatic abscesses (PHA) varies among surgeons and institutions. Recent studies have advocated for first-line percutaneous drainage (PD) of all accessible hepatic abscesses, with surgery reserved as rescue only. Our study aimed to internally validate an established multimodal algorithm for PHA at a high-volume hepatopancreatobiliary center. Patients treated by the hepatopancreatobiliary service for PHA were retrospectively reviewed from 2008 through 2018. The algorithm defined intended first-line treatment as antibiotics for type I abscesses (<3 cm), PD for type II (≥3, unilocular), and surgical intervention (minimally invasive drainage or resection, when possible) for type III (≥3 cm, multilocular). Outcomes were compared between patients who received first-line treatment following the algorithm versus alternate therapy. Of 330 patients with PHA, 201 met inclusion criteria. Type III abscesses had significantly lower failure following algorithmic approach with surgery compared with PD (4% vs 28%, P = 0.018). Type II abscesses failed first-line PD in 27 per cent (13/48) with 11 patients requiring surgical rescue, whereas first-line surgery failed in only 13 per cent (2/15). No deaths occurred after any surgical intervention, and there was no statistical difference in major complications between first-line surgical intervention and PD for type II or III abscesses. These results support the algorithmic approach and demonstrate that minimally invasive surgical intervention is a safe and effective modality for large PHA. We recommend that select patients with large, complex abscesses should be considered for a first-line minimally invasive surgical approach depending on surgical experience and available resources.
Collapse
Affiliation(s)
- Ryan C. Pickens
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Stephanie Jensen
- School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Jesse K. Sulzer
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Maria Baimas-George
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Erin H. Baker
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - John B. Martinie
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Lee M. Ocuin
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - David A. Iannitti
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| |
Collapse
|
28
|
Pickens RC, Jensen S, Sulzer JK, Baimas-George M, Baker EH, Vrochides D, Martinie JB, Ocuin LM, Iannitti DA. Minimally Invasive Surgical Management as Effective First-Line Treatment of Large Pyogenic Hepatic Abscesses. Am Surg 2019; 85:813-820. [PMID: 31560300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Management of pyogenic hepatic abscesses (PHA) varies among surgeons and institutions. Recent studies have advocated for first-line percutaneous drainage (PD) of all accessible hepatic abscesses, with surgery reserved as rescue only. Our study aimed to internally validate an established multimodal algorithm for PHA at a high-volume hepatopancreatobiliary center. Patients treated by the hepatopancreatobiliary service for PHA were retrospectively reviewed from 2008 through 2018. The algorithm defined intended first-line treatment as antibiotics for type I abscesses (<3 cm), PD for type II (≥3, unilocular), and surgical intervention (minimally invasive drainage or resection, when possible) for type III (≥3 cm, multilocular). Outcomes were compared between patients who received first-line treatment following the algorithm versus alternate therapy. Of 330 patients with PHA, 201 met inclusion criteria. Type III abscesses had significantly lower failure following algorithmic approach with surgery compared with PD (4% vs 28%, P = 0.018). Type II abscesses failed first-line PD in 27 per cent (13/48) with 11 patients requiring surgical rescue, whereas first-line surgery failed in only 13 per cent (2/15). No deaths occurred after any surgical intervention, and there was no statistical difference in major complications between first-line surgical intervention and PD for type II or III abscesses. These results support the algorithmic approach and demonstrate that minimally invasive surgical intervention is a safe and effective modality for large PHA. We recommend that select patients with large, complex abscesses should be considered for a first-line minimally invasive surgical approach depending on surgical experience and available resources.
Collapse
|
29
|
Motz BM, Baimas-George M, Barnes TE, Ragunanthan BV, Symanski JD, Christmas AB, Sing RF, Ross SW. Mitigating clinical waste in the trauma intensive care unit: Limited clinical utility of cardiac troponin testing for trauma patients with atrial fibrillation. Am J Surg 2019; 219:1050-1056. [PMID: 31371023 DOI: 10.1016/j.amjsurg.2019.07.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 07/03/2019] [Accepted: 07/22/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND The clinical significance of obtaining cardiac troponin (cTn) levels among trauma patients with new onset arrhythmias is unknown. We aimed to assess whether cTn levels actually influence clinical decision making or represent an inappropriate use of resources. METHODS Trauma patients admitted from 2013 to 2014 diagnosed with atrial fibrillation (AF) were retrospectively reviewed using the institutional trauma database. Demographics, cTn levels, and myocardial infarction (MI) diagnosis data were recorded. Standard univariate tests were used to compare data between patients with and without cTn. RESULTS There were 258 patients included of which 126 patients had cTn levels obtained (48.8%, TEST group). The remaining 132 patients (51.2%) were untested (noTEST group). Among TEST patients, use of echocardiography nearly doubled and cardiology consultations increased (all p < 0.05). No TEST patients suffered MI or PE. CONCLUSIONS Obtaining cTn values in trauma patients with new-onset AF resulted in increased resource utilization without clinical utility.
Collapse
Affiliation(s)
- Benjamin M Motz
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd., MEB Suite 601, Charlotte, NC, 28203, USA
| | - Maria Baimas-George
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd., MEB Suite 601, Charlotte, NC, 28203, USA
| | - T Ellis Barnes
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd., MEB Suite 601, Charlotte, NC, 28203, USA
| | - Branavan V Ragunanthan
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd., MEB Suite 601, Charlotte, NC, 28203, USA
| | - John D Symanski
- Sanger Heart & Vascular Institute, Department of Cardiology, Carolinas Medical Center, 1001 Blythe Blvd., Suite 300, Charlotte, NC, USA
| | - A Britton Christmas
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd., MEB Suite 601, Charlotte, NC, 28203, USA
| | - Ronald F Sing
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd., MEB Suite 601, Charlotte, NC, 28203, USA
| | - Samuel W Ross
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd., MEB Suite 601, Charlotte, NC, 28203, USA.
| |
Collapse
|
30
|
Baimas-George M, Fleischer B, Korndorffer JR, Slakey D, DuCoin C. The Economics of Private Practice versus Academia in Surgery. J Surg Educ 2018; 75:1276-1280. [PMID: 29674107 DOI: 10.1016/j.jsurg.2018.03.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 03/18/2018] [Accepted: 03/19/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Residents often make career decisions regarding future practice without adequate knowledge to the realities of professional life. Currently there is a paucity of data regarding economic differences between practice models. This study seeks to illuminate the financial differences of surgical subspecialties between academic and private practice. DESIGN Data were collected from the Association of American Medical College (AAMC) and the Medical Group Management Association's (MGMA) 2015 reports of average annual salaries. Salaries were analyzed for general surgery and 7 subspecialties. Fixed time of practice was set at 30 years. Assumptions included 5 years as assistant professor, 10 years as associate professor, and 15 years as full professor. Formula used: (average yearly salary) × [years of practice (30 yrs - fellowship/research yrs)] + ($50,000 × yrs of fellowship/research) = total adjusted lifetime revenue. RESULTS As a full professor, academic surgeons in all subspecialties make significantly less than their private practice counterparts. The largest discrepancy is in vascular and cardiothoracic surgery, with full professors earning 16% and 14% less than private practitioners. Plastic surgery and general surgery are the only 2 disciplines that have similar lifetime revenues to private practitioners, earning 2% and 6% less than their counterparts' lifetime revenue. CONCLUSIONS Academic surgeons in all surgical subspecialties examined earn less lifetime revenue compared to those in private practice. This difference in earnings decreases but remains substantial as an academic surgeon advances. With limited exposure to the diversity of professional arenas, residents must be aware of this discrepancy.
Collapse
Affiliation(s)
- Maria Baimas-George
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Brian Fleischer
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - James R Korndorffer
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Douglas Slakey
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Christopher DuCoin
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana.
| |
Collapse
|
31
|
DuCoin C, Hahn A, Baimas-George M, Slakey DP, Korndorffer JR. The Change in Surgical Case Diversity over the past 15 Years and the Influence on the Pursuit of Surgical Fellowship. Am Surg 2018. [DOI: 10.1177/000313481808400953] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The surgical community has expressed concern that residents do not receive the same caliber training as their predecessors and the increase in fellowships have been described as secondary to perceived lack of preparation. Yet, data show no change in total cases even after implementation of the 80-hour workweek. It is hypothesized that the increasing subspecialization of general surgery may decrease in certain resident case numbers. Data were collected from the Accreditation Council for Graduate Medical Education (ACGME) General Surgery Case Logs National Data Report (1999–2014) of mean number of procedures per resident for 19 surgical categories. Statistical analysis was performed with analysis of variance over three time periods between 1999 and 2014. The number of total cases performed by residents has not changed significantly. There was a statistically significant difference observed in the variety of cases: vascular, esophageal, breast, and trauma cases decreased (P < 0.01), whereas major intestinal, hernia, liver, pancreatic, and biliary cases increased (P < 0.01). There are many reasons to pursue additional training after residency. The demonstrated change in case variability, presumably secondary to increasing fellowships, may play a significant role on training and preparation. Close monitoring of curriculums is essential to ensure a comprehensive general surgical education.
Collapse
Affiliation(s)
- Christopher DuCoin
- From the Department of Surgery, Division of General Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Alexandra Hahn
- From the Department of Surgery, Division of General Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Maria Baimas-George
- From the Department of Surgery, Division of General Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Douglas P. Slakey
- From the Department of Surgery, Division of General Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - James R. Korndorffer
- From the Department of Surgery, Division of General Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| |
Collapse
|
32
|
DuCoin C, Hahn A, Baimas-George M, Slakey DP, Korndorffer JR. The Change in Surgical Case Diversity Over the Past 15 Years and the Influence on the Pursuit of Surgical Fellowship. Am Surg 2018; 84:1476-1479. [PMID: 30268179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The surgical community has expressed concern that residents do not receive the same caliber training as their predecessors and the increase in fellowships have been described as secondary to perceived lack of preparation. Yet, data show no change in total cases even after implementation of the 80-hour workweek. It is hypothesized that the increasing subspecialization of general surgery may decrease in certain resident case numbers. Data were collected from the Accreditation Council for Graduate Medical Education (ACGME) General Surgery Case Logs National Data Report (1999-2014) of mean number of procedures per resident for 19 surgical categories. Statistical analysis was performed with analysis of variance over three time periods between 1999 and 2014. The number of total cases performed by residents has not changed significantly. There was a statistically significant difference observed in the variety of cases: vascular, esophageal, breast, and trauma cases decreased (P < 0.01), whereas major intestinal, hernia, liver, pancreatic, and biliary cases increased (P < 0.01). There are many reasons to pursue additional training after residency. The demonstrated change in case variability, presumably secondary to increasing fellowships, may play a significant role on training and preparation. Close monitoring of curriculums is essential to ensure a comprehensive general surgical education.
Collapse
|
33
|
Baimas-George M, Cetrulo L, Kao A, Kasten KR. Perforated diverticulitis in the setting of ulcerative colitis: An unusual case report. Int J Surg Case Rep 2018; 49:126-130. [PMID: 30005364 PMCID: PMC6037666 DOI: 10.1016/j.ijscr.2018.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 06/12/2018] [Accepted: 06/20/2018] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION The association of diverticulitis with ulcerative colitis (UC) is rare and not well described. The sequelae of inflammatory bowel disease (IBD) such as perforation and fistula formation can mimic diverticular complications. Therefore, in an IBD patient, it can be difficult to distinguish the etiology of such complications and render definitive care. PRESENTATION OF CASE A 43-year-old man with a long history of UC presented with spontaneous sigmoid perforation and subsequent complications of colovesicular and colocutaneous fistulae requiring multiple procedural interventions. Ultimately, the etiology was confirmed as perforated diverticulitis superimposed on severe ulcerative colitis. DISCUSSION As perforated diverticulitis superimposed on UC is a rare entity in the current literature and there are many diagnostic difficulties that complicate this scenario. It is important to rule out other entities such as misdiagnosis of IBD or segmental colitis associated with diverticula (SCAD) that may have overlapping features. CONCLUSION Although diverticulitis in the setting of UC is an uncommon presentation, it remains important for medical practitioners to consider this scenario when encountering patients who may present in a similar fashion. As such, we put forth a process to aid in a diagnosis and management such that definitive care may not be delayed.
Collapse
Affiliation(s)
- M Baimas-George
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, United States
| | - L Cetrulo
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, United States
| | - A Kao
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, United States
| | - K R Kasten
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, United States.
| |
Collapse
|
34
|
Baimas-George M, Baker E, Kamionek M, Salmon JS, Sastry A, Levi D, Vrochides D. A Complete Pathological Response to Pembrolizumab following ex vivo Liver Resection in a Patient with Colorectal Liver Metastases. Chemotherapy 2018; 63:90-94. [PMID: 29621772 DOI: 10.1159/000487814] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 02/16/2018] [Indexed: 02/28/2024]
Abstract
Advances in the systemic treatment of stage IV colorectal cancer with liver metastases has offered improved survival rates for patients who otherwise face a dismal prognosis. However, a pathologically complete response (PCR) to chemotherapy for colorectal liver metastases is still rare, and its significance is not fully understood. In this case report, we describe a patient who achieved PCR after neoadjuvant immunotherapy with pembrolizumab and a left hepatectomy using an ex vivo resection technique.
Collapse
Affiliation(s)
- Maria Baimas-George
- Department of General Surgery, Carolinas Medical Center, Carolinas Healthcare Systems, Charlotte, North Carolina, USA
| | - Erin Baker
- Department of Hepatopancreatobiliary Surgery, Carolinas Medical Center, Carolinas Healthcare Systems, Charlotte, North Carolina, USA
| | - Michal Kamionek
- Department of Pathology, Carolinas Medical Center, Carolinas Healthcare Systems, Charlotte, North Carolina, USA
| | - J Stuart Salmon
- Department of Medical Oncology, Carolinas Medical Center, Carolinas Healthcare Systems, Charlotte, North Carolina, USA
| | - Amit Sastry
- Department of Hepatopancreatobiliary Surgery, Carolinas Medical Center, Carolinas Healthcare Systems, Charlotte, North Carolina, USA
| | - David Levi
- Department of Transplant Surgery, Carolinas Medical Center, Carolinas Healthcare Systems, Charlotte, North Carolina, USA
| | - Dionisios Vrochides
- Department of Hepatopancreatobiliary Surgery, Carolinas Medical Center, Carolinas Healthcare Systems, Charlotte, North Carolina, USA
| |
Collapse
|
35
|
Baimas-George M, Fleischer B, Korndorffer JR, Slakey D, DuCoin C. The Economics of Academic Advancement Within Surgery. J Surg Educ 2018; 75:299-303. [PMID: 28870711 DOI: 10.1016/j.jsurg.2017.08.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 07/31/2017] [Accepted: 08/05/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND The success of an academic surgeon's career is often viewed as directly related to academic appointment; therefore, the sequence of promotion is a demanding, rigorous process. This paper seeks to define the financial implication of academic advancement across different surgical subspecialties. STUDY DESIGN Data was collected from the Association of American Medical College's 2015 report of average annual salaries. Assumptions included 30 years of practice, 5 years as assistant professor, and 10 years as associate professor before advancement. The base formula used was: (average annual salary) × (years of practice [30 years - fellowship/research years]) + ($50,000 × years of fellowship/research) = total adjusted lifetime salary income. RESULTS There was a significant increase in lifetime salary income with advancement from assistant to associate professor in all subspecialties when compared to an increase from associate to full professor. The greatest increase in income from assistant to associate professor was seen in transplant and cardiothoracic surgery (35% and 27%, respectively). Trauma surgery and surgical oncology had the smallest increases of 8% and 9%, respectively. With advancement to full professor, the increase in lifetime salary income was significantly less across all subspecialties, ranging from 1% in plastic surgery to 8% in pediatric surgery. CONCLUSION When analyzing the economics of career advancement in academic surgery, there is a substantial financial benefit in lifetime income to becoming an associate professor in all fields; whereas, advancement to full professor is associated with a drastically reduced economic benefit.
Collapse
Affiliation(s)
- Maria Baimas-George
- Department of Surgery, Division of General Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Brian Fleischer
- Department of Surgery, Division of General Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - James R Korndorffer
- Department of Surgery, Division of General Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Douglas Slakey
- Department of Surgery, Division of General Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Christopher DuCoin
- Department of Surgery, Division of General Surgery, Tulane University School of Medicine, New Orleans, Louisiana.
| |
Collapse
|
36
|
Baimas-George M, Fleischer B, Slakey D, Kandil E, Korndorffer JR, DuCoin C. Is it All About the Money? Not All Surgical Subspecialization Leads to Higher Lifetime Revenue when Compared to General Surgery. J Surg Educ 2017; 74:e62-e66. [PMID: 28705484 DOI: 10.1016/j.jsurg.2017.06.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 06/21/2017] [Accepted: 06/24/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE It is believed that spending additional years gaining expertise in surgical subspecialization leads to higher lifetime revenue. Literature shows that more surgeons are pursuing fellowship training and dedicated research years; however, there are no data looking at the aggregate economic impact when training time is accounted for. It is hypothesized that there will be a discrepancy in lifetime income when delay to practice is considered. DESIGN Data were collected from the Medical Group Management Association's 2015 report of average annual salaries. Fixed time of practice was set at 30 years, and total adjusted revenue was calculated based on variable years spent in research and fellowship. All total revenue outcomes were compared to general surgery and calculated in US dollars. PARTICIPANTS The financial data on general surgeons and 9 surgical specialties (vascular, pediatric, plastic, breast, surgical oncology, cardiothoracic, thoracic primary, transplant, and trauma) were examined. RESULTS With fellowship and no research, breast and surgical oncology made significantly less than general surgery (-$1,561,441, -$1,704,958), with a difference in opportunity cost equivalent to approximately 4 years of work. Pediatric and cardiothoracic surgeons made significantly more than general surgeons, with an increase of opportunity cost equivalent to $5,301,985 and $3,718,632, respectively. With 1 research year, trauma surgeons ended up netting less than a general surgeon by $325,665. With 2 research years, plastic and transplant surgeons had total lifetime revenues approximately equivalent to that of a general surgeon. CONCLUSIONS Significant disparities exist in lifetime total revenue between surgical subspecialties and in comparison, to general surgery. Although most specialists do gross more than general surgeons, breast and surgical oncologists end up netting significantly less over their lifetime as well as trauma surgeons if they do 1 year of research. Thus, the economic advantage of completing additional training is dependent on surgical field and duration of research.
Collapse
Affiliation(s)
- Maria Baimas-George
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Brian Fleischer
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Douglas Slakey
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Emad Kandil
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - James R Korndorffer
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Christopher DuCoin
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana.
| |
Collapse
|
37
|
Hennings DL, O’Malley TJ, Baimas-George M, Al-Qurayshi Z, Kandil E, DuCoin C. Buckle of the bariatric surgery belt: an analysis of regional disparities in bariatric surgery. Surg Obes Relat Dis 2017; 13:1290-1295. [DOI: 10.1016/j.soard.2017.03.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 03/06/2017] [Accepted: 03/24/2017] [Indexed: 01/08/2023]
|
38
|
Baimas-George M, Hennings DL, Al-Qurayshi Z, Emad Kandil, DuCoin C. No more broken hearts: weight loss after bariatric surgery returns patients' postoperative risk to baseline following coronary surgery. Surg Obes Relat Dis 2017; 13:1010-1015. [PMID: 28216113 DOI: 10.1016/j.soard.2016.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 11/18/2016] [Accepted: 12/10/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND The obesity epidemic is associated with a rise in coronary surgeries because obesity is a risk factor for coronary artery disease. Bariatric surgery is linked to improvement in cardiovascular co-morbidities and left ventricular function. No studies have investigated survival advantage in postoperative bariatric patients after coronary surgery. OBJECTIVES To determine if there is a benefit after coronary surgery in patients who have previously undergone bariatric surgery. SETTING National Inpatient Sample. METHODS We performed a retrospective, cross-sectional analysis of the National Inpatient Sample database from 2003 to 2010. We selected bariatric surgical patients who later underwent coronary surgery (n = 257). A comparison of postoperative complications and mortality after coronary surgery were compared with controls (n = 1442) using χ2 tests, linear regression analysis, and multivariate logistical regression models. RESULTS A subset population was identified as having undergone coronary surgery (n = 1699); of this population, 257 patients had previously undergone bariatric surgery. They were compared with 1442 controls. The majority was male (67.2%), white (82.6%), and treated in an urban environment (96.8%). Patients with bariatric surgery assumed the risk of postoperative complications after coronary surgery that was associated with their new body mass index (BMI) (BMI<25 kg/m2: odds ratio (OR) 1.01, 95% CI .76-1.34, P = .94; BMI 25 to<35 kg/m2: OR .20, 95% CI .02-2.16, P = .19; BMI≥35 kg/m2: OR>999.9, 95% CI .18 to>999.9, P = .07). Length of stay was significantly longer in postbariatric patients (BMI<25, OR 1.62, 95% CI 1.14-2.30, P = .007). CONCLUSIONS Postoperative bariatric patients have a return to baseline risk of morbidity and mortality after coronary surgery.
Collapse
Affiliation(s)
- Maria Baimas-George
- Department of Surgery, Division of General Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Dietric L Hennings
- Department of Surgery, Division of General Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Zaid Al-Qurayshi
- Department of Surgery, Division of General Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Emad Kandil
- Department of Surgery, Division of General Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Christopher DuCoin
- Department of Surgery, Division of General Surgery, Tulane University School of Medicine, New Orleans, Louisiana.
| |
Collapse
|
39
|
Hennings D, Baimas-George M, DuCoin C, Al-Qurayshi Z. No More Broken Hearts: Weight Loss after Bariatric Surgery Returns Patients Post-Operative Risk to Baseline Following Coronary Surgery. Surg Obes Relat Dis 2016. [DOI: 10.1016/j.soard.2016.08.290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
40
|
Rao AD, Bonyhay I, Dankwa J, Baimas-George M, Kneen L, Ballatori S, Freeman R, Adler GK. Baroreflex Sensitivity Impairment During Hypoglycemia: Implications for Cardiovascular Control. Diabetes 2016; 65:209-15. [PMID: 26438610 PMCID: PMC4686952 DOI: 10.2337/db15-0871] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 09/28/2015] [Indexed: 11/13/2022]
Abstract
Studies have shown associations between exposure to hypoglycemia and increased mortality, raising the possibility that hypoglycemia has adverse cardiovascular effects. In this study, we determined the acute effects of hypoglycemia on cardiovascular autonomic control. Seventeen healthy volunteers were exposed to experimental hypoglycemia (2.8 mmol/L) for 120 min. Cardiac vagal baroreflex function was assessed using the modified Oxford method before the initiation of the hypoglycemic-hyperinsulinemic clamp protocol and during the last 30 min of hypoglycemia. During hypoglycemia, compared with baseline euglycemic conditions, 1) baroreflex sensitivity decreases significantly (19.2 ± 7.5 vs. 32.9 ± 16.6 ms/mmHg, P < 0.005), 2) the systolic blood pressure threshold for baroreflex activation increases significantly (the baroreflex function shifts to the right; 120 ± 14 vs. 112 ± 12 mmHg, P < 0.005), and 3) the maximum R-R interval response (1,088 ± 132 vs. 1,496 ± 194 ms, P < 0.001) and maximal range of the R-R interval response (414 ± 128 vs. 817 ± 183 ms, P < 0.001) decrease significantly. These findings indicate reduced vagal control and impaired cardiovascular homeostasis during hypoglycemia.
Collapse
Affiliation(s)
- Ajay D Rao
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, Temple University School of Medicine, Philadelphia, PA
| | - Istvan Bonyhay
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Joel Dankwa
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Maria Baimas-George
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Lindsay Kneen
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sarah Ballatori
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Roy Freeman
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Gail K Adler
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| |
Collapse
|
41
|
Garg R, Rao AD, Baimas-George M, Hurwitz S, Foster C, Shah RV, Jerosch-Herold M, Kwong RY, Di Carli MF, Adler GK. Mineralocorticoid receptor blockade improves coronary microvascular function in individuals with type 2 diabetes. Diabetes 2015; 64:236-42. [PMID: 25125488 PMCID: PMC4274801 DOI: 10.2337/db14-0670] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Reduced coronary flow reserve (CFR), an indicator of coronary microvascular dysfunction, is seen in type 2 diabetes mellitus (T2DM) and predicts cardiac mortality. Since aldosterone plays a key role in vascular injury, the aim of this study was to determine whether mineralocorticoid receptor (MR) blockade improves CFR in individuals with T2DM. Sixty-four men and women with well-controlled diabetes on chronic ACE inhibition (enalapril 20 mg/day) were randomized to add-on therapy of spironolactone 25 mg, hydrochlorothiazide (HCTZ) 12.5 mg, or placebo for 6 months. CFR was assessed by cardiac positron emission tomography at baseline and at the end of treatment. There were significant and similar decreases in systolic blood pressure with spironolactone and HCTZ but not with placebo. CFR improved with treatment in the spironolactone group as compared with the HCTZ group and with the combined HCTZ and placebo groups. The increase in CFR with spironolactone remained significant after controlling for baseline CFR, change in BMI, race, and statin use. Treatment with spironolactone improved coronary microvascular function, raising the possibility that MR blockade could have beneficial effects in preventing cardiovascular disease in patients with T2DM.
Collapse
Affiliation(s)
- Rajesh Garg
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ajay D Rao
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Maria Baimas-George
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Shelley Hurwitz
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Courtney Foster
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ravi V Shah
- Noninvasive Cardiovascular Imaging Program, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Michael Jerosch-Herold
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Raymond Y Kwong
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Marcelo F Di Carli
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA Noninvasive Cardiovascular Imaging Program, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Gail K Adler
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| |
Collapse
|