Image-Guided Navigation in Lymph Node Biopsy

Background and Objectives:

Image-guided navigation is an effective intra-operative technology in select surgical sub-specialties. Laparoscopic and open lymph node biopsy are frequently undertaken to obtain adequate tissue of difficult lesions. Image-guided navigation may positively augment the precision and success of surgical lymph node biopsies.

Methods:

In this prospective pilot study, pre-operative imaging was uploaded into the navigation platform software, which superimposed the imaging and the subject's real-time anatomy. This required anatomical landmarks on the subject's body to be spatially registered with the platform using an infrared camera. This was then used to guide dissection and biopsy in laparoscopic and subcutaneous biopsies.

Results:

Image-guided lymph node biopsy was undertaken in 15 cases. Successful biopsy locations included: retroperitoneum, porta hepatis, mesentery, iliac region, para-aortic, axilla, and inguinal region. There was an 87% total absolute success rate in biopsies (89% in laparoscopic image-guided navigation [LIGN] and 83% in subcutaneous image-guided navigation [SIGN]). There was a 92% absolute success rate in lesions with fixed locations. There was a 67% absolute success rate in lesions with mobile locations.

Conclusion:

The investigators successfully incorporated image-guidance into surgical biopsy of lymph nodes in a diverse variety of locations. This image-guided technique for surgical biopsy can accurately and safely localize target lesions minimizing unnecessary dissection, conversion to open procedure, and re-operation for further tissue characterization. This technique was useful in the morbidly obese, instances of limited foci of disease, PET-active lesions, identifying areas of highest PET-avidity, and lesions with critical surrounding anatomy.

Acute cholecystitis: comparing clinical outcomes with TG13 severity and intended laparoscopic versus open cholecystectomy in difficult operative cases

INTRODUCTION

The revised Tokyo Guidelines include criteria for determining the severity of acute cholecystitis with treatment algorithms based on severity. The aim of this study was to investigate the relationship of the revised Tokyo Guidelines severity grade to clinical outcomes of cholecystectomy for acute cholecystitis.

METHODS

We identified 66 patients with acute cholecystitis from a prior study of difficult cholecystectomy cases. We examined the relationship between severity grade and multiple variables related to perioperative and postoperative outcomes.

RESULTS

A more severe revised Tokyo Guidelines grade was associated with a higher number of complications (p = 0.03) and a higher severity of complications (p = 0.01). Severity grade did not predict operative time, estimated blood loss, intensive care unit admission or length of stay. Compared to planned open cholecystectomy, intended laparoscopic cholecystectomy was associated with significantly fewer total and Clavien-Dindo grade 3 complications, fewer intensive care unit admissions, and shorter length of stay (p values range from 0.03 to < 0.0001).

CONCLUSION

In technically difficult operations for acute cholecystitis, the revised Tokyo guidelines severity grade correlates with the number and severity of complications. However, intended performance of laparoscopic cholecystectomy rather than open cholecystectomy in difficult operations predicts broader beneficial outcomes than severity grade.

Outcomes and Use of Laparoscopic Versus Open Gastric Resection

BACKGROUND AND OBJECTIVES

The advantages of laparoscopy over open surgery are well established. Laparoscopic resection for gastric cancer is safe and results in equivalent oncologic outcomes when compared with open resection. The purpose of this study was to assess the use of laparoscopy to treat gastric cancer and the associated outcomes.

METHODS

The American College of Surgeons National Surgical Quality Improvement Project (NSQIP) dataset was queried for patients with gastric cancer (ICD-9 Code 151.0-151.9) from January 2005 through December 2012. Logistic regression was used to evaluate the 30-day morbidity and mortality of open gastrectomy (CPT code 43620-2, 43631-4) versus that of the laparoscopic procedure on the stomach (CPT code 43650), while adjusting for preoperative risk factors.

RESULTS

A total of 4116 patients with gastric cancer were identified and divided by surgical approach into 2 groups: open gastrectomy (n = 3725; 90.5%) and laparoscopic procedure on the stomach (n = 391; 9.5%). After adjustment for preoperative risk factors, complications were significantly fewer in laparoscopic versus open gastric resection (odds ratio [OR] 0.61, 95% confidence interval [CI] = 0.45-0.82; P = .001). After adjusting for preoperative risk factors, there was no statistically significant difference in mortality with laparoscopic compared to open gastric resection (OR 0.74; 95% CI = 0.32-1.72; P = .481).

CONCLUSIONS

Laparoscopy is underused in the treatment of gastric cancer. Given that laparoscopic gastric resection has a lower morbidity in comparison to open resection, steps should be made toward advancing the use of laparoscopy for gastric cancer.

The effect of tobacco use on outcomes of laparoscopic and open ventral hernia repairs: a review of the NSQIP dataset

INTRODUCTION

Tobacco smoking is a known risk factor for complications after major surgical procedures. The full effect of tobacco use on these complications has not been studied over large populations for ventral hernia repairs. This effect is more important as the preoperative conditioning, and optimization of patients is adopted. We sought to use the prospectively collected ACS-NSQIP dataset to evaluate respiratory and infectious complications for patients undergoing both laparoscopic and open ventral hernia repairs.

METHODS

The ACS-NSQIP dataset was queried for patients who underwent open or laparoscopic ventral hernia repairs, by primary procedure CPT codes, between years 2009-2012. Smoking use was registered as defined by the ACS-NSQIP, as both a current smoker (within the prior 12 months) or as a history of smoking (having ever smoked). Univariate and multivariate analyses were used to investigate postoperative complications for 30-day morbidity and mortality by smoking status while adjusting for preoperative risk factors.

RESULTS

The majority of cases were open, 82 %, compared to laparoscopic 18 %. Sex was evenly distributed with 58 % female and 42 % male; however, there was a difference in the distribution of current smokers (p = 0.03). On analysis there were significantly more respiratory complications (p = 0.0003) and infectious complications (p < 0.0001). When controlling for sex, age, and type of surgery, using logistic regression, there were associations between smoking in the prior 12 months and respiratory complications, including pneumonia (p < 0.0001), and re-intubation (p < 0.0001). Similar associations were seen on logistic regression if a patient ever smoked; including pneumonia (p < 0.0001), re-intubation (p < 0.0001), and failure to wean (p < 0.0001).

CONCLUSION

Smoking tobacco, both current and historical use, leads to an increase in both respiratory and infectious complications. As more centers try to preoperatively condition patients for elective hernia repairs, it is important to note that patients may never return to the baseline outcomes of patients who never smoked.

Primary Anastomosis versus Ostomy after Colon Resection during Debulking of Ovarian Carcinomatosis: A NSQIP Analysis

Ovarian carcinomatosis poses a dilemma for the surgeon. When resecting colon for tumor invasion, one must decide between diversion and primary anastomosis (PA). We examined the National Surgical Quality Improvement Program to determine whether PA associated with more complications than ostomy. The National Surgical Quality Improvement Program dataset was queried for patients with ovarian carcinomatosis between 2007 and 2012. Current Procedural Terminology codes were used to further identify patients undergoing colectomy with PA or ostomy. Logistic regression was used to evaluate 30-day morbidity and mortality. The 1013 ovarian carcinomatosis patients who underwent elective colon surgery were divided into primary repair (n = 453, 43.5%) or ostomy (n = 586, 56.5%) groups. Preoperative demographics were similar; however, ostomy patients had more severe preoperative laboratory derangements. The 30-day mortality and postoperative transfusion requirements were higher in the ostomy group. On multivariate analysis controlling for confounders, the differences were no longer significant. In conclusion, 30-day mortality and postoperative complications were increased in the ostomy group. Given the laboratory derangements in this group, this may reflect tendency to allocate ostomies to more ill patients. Primary repair in a selected population does not worsen outcomes. Prospective evaluation would help determine the impact of PA in the ovarian carcinomatosis population.

Primary Anastomosis versus Ostomy after Colon Resection during Debulking of Ovarian Carcinomatosis: A NSQIP Analysis

Ovarian carcinomatosis poses a dilemma for the surgeon. When resecting colon for tumor invasion, one must decide between diversion and primary anastomosis (PA). We examined the National Surgical Quality Improvement Program to determine whether PA associated with more complications than ostomy. The National Surgical Quality Improvement Program dataset was queried for patients with ovarian carcinomatosis between 2007 and 2012. Current Procedural Terminology codes were used to further identify patients undergoing colectomy with PA or ostomy. Logistic regression was used to evaluate 30-day morbidity and mortality. The 1013 ovarian carcinomatosis patients who underwent elective colon surgery were divided into primary repair (n = 453, 43.5%) or ostomy (n = 586, 56.5%) groups. Preoperative demographics were similar; however, ostomy patients had more severe preoperative laboratory derangements. The 30-day mortality and postoperative transfusion requirements were higher in the ostomy group. On multivariate analysis controlling for confounders, the differences were no longer significant. In conclusion, 30-day mortality and postoperative complications were increased in the ostomy group. Given the laboratory derangements in this group, this may reflect tendency to allocate ostomies to more ill patients. Primary repair in a selected population does not worsen outcomes. Prospective evaluation would help determine the impact of PA in the ovarian carcinomatosis population.

Laparoscopic transgastric esophageal mucosal resection: a treatment option for patients with high-grade dysplasia in Barrett's esophagus

BACKGROUND

We present long-term follow-up data on patients with esophageal high-grade dysplasia and/or carcinoma in situ who were treated with laparoscopic transgastric esophageal mucosal resection (LTEMR).

METHODS

Patient demographics, operative outcomes, and follow-up results were tabulated.

RESULTS

LTEMR was performed in 11 patients (9 male, 2 female). The median age was 54 (44 to 75) years. The 30-day morbidity or mortality was zero. The median follow-up was 5.2 (2 to 12) years. Upper endoscopy was performed at 3, 6, and 12 month, and yearly thereafter. All patients regenerated squamous epithelium at 6 months. One patient developed a recurrence of Barrett's epithelium 2 years after resection. No recurrences of high-grade dysplasia or carcinoma were observed in any of the patients. Two patients developed an esophageal stricture; both were treated successfully with endoscopic balloon dilation and have suffered no further sequelae.

CONCLUSIONS

LTEMR is safe and effective alternative method to treat patients with Barrett's esophagus with high-grade dysplasia.

Cutaneous angiosarcoma metastatic to small bowel with nodal involvement

A 77-year-old male with a history of metastatic scalp angiosarcoma presented with intractable gastrointestinal bleeding from a jejunal mass detected on capsule endoscopy. He underwent laparoscopic-assisted resection of the mass. Intraoperatively, an isolated small bowel mass with bulky lymphadenopathy was seen and resected en bloc. Pathology showed a 6.8cm high-grade metastatic angiosarcoma with nodal involvement and negative margins. Angiosarcoma is a sarcoma with a grim prognosis. The incidence is 2% of all soft tissue sarcomas; cutaneous lesions comprise 27% of manifestations and usually appear on head and neck. Risk factors include lymphedema, neurofibromatosis, vinyl chloride, arsenic, and anabolic steroids. Overall 5-year survival is 30-35% and is higher in patients younger than 60, those without metastasis, tumors less than 5 cm, and favorable histology. Angiosarcoma metastasis to small bowel is rare but nodal involvement is even more unusual, reported only three times in the literature. This case is the first with nodal involvement to present at a resectable stage. To diagnose disease when still at a resectable stage, a high index of suspicion must be maintained with any gastrointestinal symptoms in a patient with a history of angiosarcoma. Laparoscopic-assisted resection is safe for the resection of small bowel angiosarcoma.

Current practices in biliary surgery: Do we practice what we teach?

INTRODUCTION

Since the widespread adoption of laparoscopic techniques in biliary surgery, the incidence of bile duct injures (BDI) has not significantly declined despite increased operative experience and recognition of the critical view of safety (CVS) method for anatomic identification. We hypothesized that operative approaches in clinical practice may vary from well-described technical recommendations. The objective of this study was to access how practicing surgeons commonly identify anatomy during laparoscopic cholecystectomy (LC).

METHODS

We performed a cohort study assessing practices in biliary surgery among current practicing surgeons. Surgeons belonging to the Midwest Surgical Association and the Society of American Gastrointestinal and Endoscopic Surgeons were surveyed. Items surveyed include preferred methods for cystic duct identification, recognition of the CVS, and use of intraoperative imaging.

RESULTS

In total, 374 of 849 surgeons responded. The CVS was not correctly identified by 75 % of surgeons descriptively and by 21 % of surgeons visually. 56 % of surgeons practiced the infundibular method for identification of the cystic duct; 27 % practiced the CVS method. Intraoperative cholangiography was used by 16 % and laparoscopic ultrasound by <1 %.

CONCLUSION

A majority of surgeons preferably do not use the CVS method of identification during LC. A large percentage of practicing surgeons are unable to describe or visually identify the CVS. These results suggest an urgent need to reexamine the tenets of how LC is being taught and disseminated and present a clear target for improvement to reduce BDI.

A NSQIP Analysis of MELD and Perioperative Outcomes in General Surgery

It is well known that liver disease has an adverse effect on postoperative outcomes. However, what is still unknown is how to appropriately risk stratify this patient population based on the degree of liver failure. Because data are limited, specifically in general surgery practice, we analyzed the model of end-stage liver disease (MELD) in terms of predicting postoperative complications after one of three general surgery operations: inguinal hernia repair (IHR), umbilical hernia repair (UHR), and colon resection (CRXN). National Surgical Quality Improvement Program data on 17,812 total patients undergoing one of three general surgery operations from 2008 to 2012 were analyzed retrospectively. There were 7402 patients undergoing IHR; 5014 patients undergoing UHR; 5396 patients undergoing CRXN. MELD score was calculated using international normalized ratio, total bilirubin, and creatinine. The primary end point was any postoperative complication. The statistical method used was logistic regression. For IHR, UHR, and CRXN, the overall complication rates were 3.4, 6.4, and 45.9 per cent, respectively. The mean MELD scores were 8.6, 8.5, and 8.5, respectively. For every 1-point increase greater than the mean MELD score, there was a 7.8, 13.8, and 11.6 per cent increase in any postoperative complication. The overall 30-day mortality rate was 0.9 per cent. In conclusion, the MELD score continuum adequately predicts patients’ increased risk of postoperative complications after IHR, UHR, and CRXN. Therefore, MELD could be used for preoperative risk stratification and guide clinical decision making for general surgery in the cirrhotic patient.

The impact of visiting student electives on surgical Match outcomes

BACKGROUND

Residency applicants commonly complete visiting student electives (VSEs) hoping to increase their odds of matching at host institutions. Existing evidence on Match outcomes for applicants who complete VSEs is limited. As VSEs involve monetary and opportunity costs to students and administrators, data on their utility are vital for student well-being, preparedness for residency, and, ultimately, success in the Match. We investigated the utilization and impact of VSEs for all applicants. We hypothesized that completion of VSEs would increase the likelihood of matching at a host institution.

MATERIALS AND METHODS

A retrospective review was conducted of academic records and National Resident Matching Program outcomes for the graduates of one institution and visiting students to that institution over the course of 7 y.

RESULTS

Utilization of VSEs varied significantly among specialties. Across all specialties and in general surgery, applicants were more likely to match into host programs than others. The size of the effect of VSEs on outcomes varied by specialty. Host programs were applicants' top choice for residency in 48% of cases.

CONCLUSIONS

Completion of VSEs may give surgical applicants increased control over Match outcomes. Our findings may assist future students in strategic decision making when determining whether and where to use VSEs.

The impact of operative timing on outcomes of appendicitis: a National Surgical Quality Improvement Project analysis

BACKGROUND

Surgery is indicated for acute uncomplicated appendicitis but the optimal timing is controversial. Recent literature is conflicting on the effect of time to intervention.

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Project dataset for patients undergoing laparoscopic and open appendectomy between 2007 and 2012. Logistic regression was used to evaluate 30-day morbidity and mortality of intervention at different time periods, adjusting for preoperative risk factors.

RESULTS

A total of 69,926 patients undergoing appendectomy were identified. Groups were divided by time to intervention: group 1, less than 24 hours (n = 55,839; 79.9%); group 2, 24 to 48 hours (n = 13,409; 18.6%); and group 3, greater than 48 hours (n = 1,038; 1.5%). After adjustment, the risk of complication remained increased for group 3 versus group 1 or 2 (odds ratio 1.66, 95% confidence interval 1.34 to 2.07).

CONCLUSIONS

These data demonstrate equivalent outcomes between time to appendectomy of less than 24 and 24 to 48 hours. There was a 2-fold increase in complication rate for patients delayed longer than 48 hours.

Laparoscopy has a superior diagnostic yield than percutaneous image-guided biopsy for suspected intra-abdominal lymphoma

INTRODUCTION

To date, no study has compared laparoscopy (LB) to percutaneous (PB) biopsy for the diagnosis of abdominal lymphoma. The objective of this study is to compare the success rate and safety profile of laparoscopic lymph node biopsy to the percutaneous approach in patients with intra-abdominal lymphadenopathy concerning for lymphoma.

MATERIALS AND METHODS

We performed a multi-institution, retrospective review of patients undergoing lymph node biopsy for suspected intra-abdominal lymphoma between 2005 and 2013. Our primary outcome was adequate tissue yield between the two techniques, both for histologic diagnosis and for ancillary studies such as flow cytometry. Secondary outcomes included 30-day morbidity, 30-day readmission rates, the need for additional lymph node biopsy procedures, and length of stay.

RESULTS

All 34 of the LB patients had adequate specimen for histologic diagnosis compared to 92.3% of patients with a PB (p = 0.18). Significantly more patients in the LB group had sufficient tissue for ancillary studies when needed than in the PB group, 95.5 and 68.2%, respectively (p = 0.04). A second biopsy was pursued in 23.1% of failed PB patients, 0% with success on second attempt.

DISCUSSION

When index of suspicion is high or when biopsy is performed for patient previously diagnosed with lymphoma and recurrence/transformation is suspected, LB safely and consistently provides adequate tissue for initial diagnosis and for ancillary studies. In contrast, image-guided PB may be more appropriate for patients for whom ancillary studies are unlikely to add to planned treatments or when there is a high risk of complications from either general anesthesia or patient comorbidities.

Improved Patient Outcomes in Paraesophageal Hernia Repair Using a Laparoscopic Approach: A Study of the National Surgical Quality Improvement Program Data

A consensus on the optimal surgical approach for repair of a paraesophageal hernia has not been reached. The aim of this study was to examine the outcomes of open and laparoscopic paraesophageal hernia repairs (PHR), both with and without mesh. A review of the National Surgical Quality Improvement Program (NSQIP) database from 2007 to 2011 was conducted. Patients who underwent an open or laparoscopic PHR were included. The primary outcome was 30-day mortality. Secondary outcomes included infections, respiratory and cardiac complications, intraoperative or perioperative transfusions, sepsis, and septic shock. Statistical analyses using odds ratios were performed comparing the open and laparoscopic approaches. A total of 4470 patients were identified using NSQIP; 2834 patients had a laparoscopic repair and the remaining 1636 patients underwent an open PHR. Compared with the laparoscopic approach, the open repair group had significantly higher 30-day mortality (odds ratio, 4.75; 95% confidence interval, 2.67 to 8.47; P < 0.0001). The laparoscopic approach had a statistically significant decrease in infections, respiratory and cardiac events/complications, transfusion requirements, episodes of sepsis, and septic shock ( P < 0.05). Our data suggest increased perioperative morbidity associated with an open PHR compared with laparoscopic. There was no statistically significant difference in any of the primary or secondary outcomes in patients repaired with mesh compared with those without. The overall use of mesh in paraesophageal hernia repairs has increased. The NSQIP data show significantly increased 30-day mortality in open repair compared with laparoscopic as well as a significantly higher perioperative complication rate.

Improved patient outcomes in paraesophageal hernia repair using a laparoscopic approach: a study of the national surgical quality improvement program data

A consensus on the optimal surgical approach for repair of a paraesophageal hernia has not been reached. The aim of this study was to examine the outcomes of open and laparoscopic paraesophageal hernia repairs (PHR), both with and without mesh. A review of the National Surgical Quality Improvement Program (NSQIP) database from 2007 to 2011 was conducted. Patients who underwent an open or laparoscopic PHR were included. The primary outcome was 30-day mortality. Secondary outcomes included infections, respiratory and cardiac complications, intraoperative or perioperative transfusions, sepsis, and septic shock. Statistical analyses using odds ratios were performed comparing the open and laparoscopic approaches. A total of 4470 patients were identified using NSQIP; 2834 patients had a laparoscopic repair and the remaining 1636 patients underwent an open PHR. Compared with the laparoscopic approach, the open repair group had significantly higher 30-day mortality (odds ratio, 4.75; 95% confidence interval, 2.67 to 8.47; P < 0.0001). The laparoscopic approach had a statistically significant decrease in infections, respiratory and cardiac events/complications, transfusion requirements, episodes of sepsis, and septic shock (P < 0.05). Our data suggest increased perioperative morbidity associated with an open PHR compared with laparoscopic. There was no statistically significant difference in any of the primary or secondary outcomes in patients repaired with mesh compared with those without. The overall use of mesh in paraesophageal hernia repairs has increased. The NSQIP data show significantly increased 30-day mortality in open repair compared with laparoscopic as well as a significantly higher perioperative complication rate.

Radiographic predictability of hiatal hernia prior to gastric band surgery

Background:

Hiatal hernia (HH) is closely associated with morbid obesity. There is controversy over the need for preoperative imaging before laparoscopic adjustable gastric band placement. The aim of this study is to determine the predictive value of preoperatively diagnosing HH with upper gastrointestinal (UGI) series imaging.

Methods:

A retrospective review of a single surgeon's experience with laparoscopic adjustable gastric band placements was performed. All patients received a preoperative UGI series. The decision to perform an HH repair at the time of gastric banding was based on intraoperative findings. Each patient's UGI study was compared with the operative report. Patients' outpatient records were also reviewed for subjective reflux symptoms or use of antireflux medications.

Results:

Of 146 patients, 63 (43%) had intraoperative findings consistent with an HH and underwent repair. Of these, only 32 (50%) had a preoperative UGI study that showed an HH (positive predictive value, 50%). Of the 83 patients who did not have an intraoperative HH, only 51 (61%) had a congruent UGI (negative predictive value, 62%). No correlation was found between patient-reported symptoms and either radiologic or intraoperative findings.

Conclusions:

UGI series have poor positive and negative predictive values in preoperatively diagnosing HH. In addition, subjective patient symptoms and the need for antireflux medication did not correlate with either radiologic or intraoperative findings of HH. Our results suggest that direct operative diagnosis is a more accurate method of detecting HH.

Minimally invasive technique leads to decreased morbidity and mortality in small bowel resections compared to an open technique: an ACS-NSQIP identified target for improvement

BACKGROUND

We hypothesize that currently minimally invasive techniques are underutilized, leading to unnecessary morbidity and mortality. The objective of the study was to compare morbidity and mortality rates in patients receiving a minimally invasive (MIS) small bowel resection to patients receiving an open (OP) small bowel resection.

METHODS

Patients in the National Surgical Quality Improvement Program (NSQIP) database who underwent a small bowel resection between 2007 and 2011 were enrolled in the study and grouped whether they received a MIS procedure (n = 1,780) or an OP procedure (n = 17,701). The primary endpoint of the study was to evaluate the difference in morbidity (excluding mortality) and mortality in patients undergoing a minimally invasive procedure compared to an open procedure.

RESULTS

The MIS technique is utilized in 9.0 % of patients undergoing a small bowel resection. Significantly lower mortality rate (2.9 vs. 8.2 %; p < 0.001) and mean morbidity rate (1.7 vs. 4.3 %; p < 0.001) were demonstrated in the MIS group. Significantly lower mean major morbidity rate (1.4 vs. 3.9 %; p < 0.001) and mean minor morbidity rate (2.6 vs. 5.5 %; p < 0.001) were demonstrated in the MIS group.

CONCLUSION

The MIS technique in small bowel resections appears to be underutilized, with only 9.0 % of patients in need of a small bowel resection undergo the minimally invasive approach. Wider utilization of the MIS technique could lead to significantly decreased morbidity and mortality.

Single-incision versus conventional laparoscopic adjustable gastric banding

BACKGROUND AND OBJECTIVES

Laparoscopic adjustable gastric banding is an effective and popular bariatric surgery for weight loss in obese patients that traditionally involves up to 5 incisions. Recently, a more minimally invasive single-incision technique has been developed. In this retrospective study, we compare conventional and single-incision laparoscopic adjustable gastric banding with regard to weight loss and complication rates in a cohort of demographically similar patients.

METHODS

From February 2009 to February 2010, 59 patients underwent laparoscopic adjustable gastric banding by one surgeon at an outpatient surgery center. All patients were compared by age, sex, preoperative body mass index, 30-day complication rates, and excess weight loss. Thirty-seven operations were performed by a conventional, 5-incision technique, whereas 22 patients underwent the single-incision technique. The success of these techniques was determined by comparing complication rates and average percentage excess weight loss at 6-month follow-up intervals.

RESULTS

Patients who underwent conventional laparoscopic adjustable gastric banding had a mean age of 41.2 years and preoperative body mass index of 48.2 kg/m(2) compared with 43.9 years and 40.3 kg/m(2), respectively, for the single-incision patients. The mean operative time in the single-incision group was longer than that in the conventional group: 47.1 minutes versus 37.4 minutes (P = .0027). The overall percentage excess weight loss was not statistically different between the 2 groups for each follow-up period. There were no complications or deaths in either group.

CONCLUSION

Although patients undergoing bariatric surgery may choose the single-incision technique for cosmetic purposes, this retrospective review comparing single-incision and conventional laparoscopic adjustable gastric banding shows longer operative times with equivalent weight loss and morbidity.

Unusual complications of gallstones

Extrinsic compression of the bile duct from gallstone disease is associated with bilio-biliary fistulization, requiring biliary-enteric reconstruction. Biliary-enteric fistulas are associated with intestinal obstruction at various levels. The primary goal of therapy is relief of intestinal obstruction; definitive repair is performed for selected patients. Hemobilia from gallstone-related pseudoaneurysms is preferentially controlled by selective arterial embolization. Rapidly increasing jaundice with relatively normal liver enzymes is a diagnostic hallmark of bilhemia. Acquired thoraco-biliary fistulas are primarily treated by percutaneous and endoscopic interventions.

A subjective assessment of medical student perceptions on animal models in medical education

BACKGROUND

There remains increasing societal pressure to limit the use of animals in medical education. The purpose of this study was to explore the subjective perceptions that medical students exposed to an animal model curriculum feel about the laboratory and its continued use.

METHODS

A 6-month prospective study was performed during the medical college core surgical clerkship. Medical students participated in both a trainer-based simulation workshop (dry laboratory) and a live-tissue animal laboratory (wet laboratory) in addition to their operative experience. Students completed a 23-question Likert survey at the end of the surgical clerkship. Data were compared using the chi-square test.

RESULTS

More students reported increased subjective stress levels in the wet laboratory (32.4%) compared with the dry laboratory (5.4%, p < 0.001). In addition, more students felt the wet laboratory (vs dry laboratory) prepared them for the anxiety (55.4% vs 24.3%, p < 0.001) and technical demands (67.6% vs 44.6%, p = 0.005) of the operating room. The majority of medical students (>90%) felt the wet laboratory was an important experience and should be continued.

CONCLUSIONS

The results of this study show a subjective benefit perceived by medical students when it comes to participation in an animal laboratory during their surgical clerkship. As such, over 90% of participating medical students feel the animal laboratory is important in medical education and should be continued in their surgical curriculum.

Phase-diverse Fresnel coherent diffractive imaging of malaria parasite-infected red blood cells in the water window

Phase-diverse Fresnel coherent diffractive imaging has been shown to reveal the structure and composition of biological specimens with high sensitivity at nanoscale resolution. However, the method has yet to be applied using X-ray illumination with energy in the so-called 'water-window' that lies between the carbon and oxygen K edges. In this range, differences in the strength of the X-ray interaction for protein based biological materials and water is increased. Here we demonstrate a proof-of-principle application of FCDI at an X-ray energy within the water-window to a dehydrated cellular sample composed of red blood cells infected with the trophozoite stage of the malaria parasite, Plasmodium falciparum. Comparison of the results to both optical and electron microscopy shows that the correlative imaging methods that include water-window FCDI will find utility in studying cellular architecture.

Permanent mesh results in long-term symptom improvement and patient satisfaction without increasing adverse outcomes in hiatal hernia repair

BACKGROUND

The purpose of this study is to evaluate symptom relief, patient satisfaction, and safety of permanent mesh following Nissen fundoplication and hiatal hernia repair.

METHODS

Patients who underwent Nissen fundoplication and hiatal hernia repair with permanent mesh (Crurasoft; Davol, Inc, Bard, Warwick, RI) between 2005 and 2011 were identified. A retrospective chart review was conducted. Long-term follow-up data were obtained via telephone interviews using a modified 5-point Likert scale.

RESULTS

Forty-one patients were identified. Twenty-six patients (63%) had complete follow-up data. Mean follow-up period was 65 months (14 to 96 months). Symptomatic improvement occurred in 23 patients (88%). Twenty-three patients (88%) reported overall satisfaction with the procedure as either excellent or good, and 23 of 26 patients (89%) would undergo surgery again. Three patients (12%) reported hernia recurrence. There were no mesh erosions.

CONCLUSION

The use of permanent (Crurasoft; Davol, Inc) mesh resulted in symptom improvement as well as patient satisfaction, and no mesh erosions were seen.

Combined synchrotron X-ray tomography and X-ray powder diffraction using a fluorescing metal foil

This study realizes the concept of simultaneous micro-X-ray computed tomography and X-ray powder diffraction using a synchrotron beamline. A thin zinc metal foil was placed in the primary, monochromatic synchrotron beam to generate a divergent wave to propagate through the samples of interest onto a CCD detector for tomographic imaging, thus removing the need for large beam illumination and high spatial resolution detection. Both low density materials (kapton tubing and a piece of plant) and higher density materials (Egyptian faience) were investigated, and elemental contrast was explored for the example of Cu and Ni meshes. The viability of parallel powder diffraction using the direct beam transmitted through the foil was demonstrated. The outcomes of this study enable further development of the technique towards in situ tomography∕diffraction studies combining micrometer and crystallographic length scales, and towards elemental contrast imaging and reconstruction methods using well defined fluorescence outputs from combinations of known fluorescence targets (elements).

Long-term symptom relief and patient satisfaction after Heller myotomy and Toupet fundoplication for achalasia

BACKGROUND

The goal of this study was to review the results, symptom relief, and patient satisfaction after laparoscopic Heller myotomy and Toupet fundoplication.

METHODS

A cohort of patients who underwent laparoscopic esophagomyotomy and a Toupet fundoplication was identified. A retrospective chart review was conducted and patients then were interviewed by telephone using a modified 5-point Likert scale.

RESULTS

Long-term follow-up data were obtained for 51 patients with a mean of 5.9 years. Thirty-two (63%) patients reported infrequent or no dysphagia. Chest pain, heartburn, or regurgitation were reported in 6 of 51 (12%) patients, 14 of 51 (27%) patients, and 11 of 51 (22%) patients, respectively. Two patients (3.9%) had pneumatic dilation and 1 patient underwent completion esophagectomy (1.9%). Thirty-three (33 of 51; 65%) patients were on acid-suppression therapy. Forty-one (80%) patients reported their overall satisfaction with the procedure was either excellent or good, and 46 of 51 (90%) patients stated they would undergo surgery again.

CONCLUSIONS

Our data show acceptable long-term results.

The erythromycin biosynthetic gene cluster of Aeromicrobium erythreum

The erythromycin-biosynthetic (ery) gene cluster of Aeromicrobium erythreum was cloned and characterized. The 55.4-kb cluster contains 25 ery genes. Homologues were found for each gene in the previously characterized ery gene cluster from Saccharopolyspora erythraea. In addition, four new predicted ery genes were identified. Two of the new predicted genes, coding for a phosphopantetheinyl transferase (eryP) and a type II thioesterase (eryTII), were internal to the ery cluster. The other two new genes, coding for a thymidine 5'-diphosphate-glucose synthase (eryDI) and a MarR-family transcriptional repressor (ery-ORF25), were found at the two ends of the ery cluster. A knockout in eryDI showed it to be essential for erythromycin biosynthesis. The gene order of the two ery clusters was conserved within a core region of 15 contiguous genes, with the exception of IS1136 which was not found in the A. erythreum cluster. Beyond the core region, gene shuffling had occurred between the two sides of the cluster. The flanking regions of the two ery clusters were not alike in the type of genes found.