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Blaustein M, Sillcox R, Wright AS, Tatum R, Yates R, Bryant MK, Oelschlager BK. Laparoscopic Heller myotomy with Toupet fundoplication: revisiting GERD in treated achalasia. Surg Endosc 2024; 38:1283-1288. [PMID: 38102398 DOI: 10.1007/s00464-023-10643-4] [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: 10/05/2023] [Accepted: 12/03/2023] [Indexed: 12/17/2023]
Abstract
INTRODUCTION With the advent of the laparoscopic era in the 1990s, laparoscopic Heller myotomy replaced pneumatic dilation as the first-line treatment for achalasia. An advantage of this approach was the addition of a fundoplication to reduce gastroesophageal reflux disease (GERD). More recently, Peroral Endoscopic Myotomy has competed for first-line therapy, but the postoperative GERD may be a weakness. This study leverages our experience to characterize GERD following LHM with Toupet fundoplication (LHM+T ) so that other treatments can be appropriately compared. METHODS A single-institution retrospective review of adult patients with achalasia who underwent LHM+T from January 2012 to April 2022 was performed. We obtained routine 6-month postoperative pH studies and patient symptom questionnaires. Differences in questionnaires and reflux symptoms in relation to pH study were explored via Kruskal-Wallis test or chi-square tests. RESULTS Of 170 patients who underwent LHM+T , 51 (30%) had postoperative pH testing and clinical symptoms evaluation. Eleven (22%) had an abnormal pH study; however, upon manual review, 5 of these (45.5%) demonstrated low-frequency, long-duration reflux events, suggesting poor esophageal clearance of gastric refluxate and 6/11 (54.5%) had typical reflux episodes. Of the cohort, 7 (15.6%) patients reported GERD symptoms. The median [IQR] severity was 1/10 [0, 3] and median [IQR] frequency was 0.5/4 [0, 1]. Patients with abnormal pH reported more GERD symptoms than patients with a normal pH study (3/6, 50% vs 5/39, 12.8%, p = 0.033). Those with a poor esophageal clearance pattern (n = 5) reported no concurrent GERD symptoms. CONCLUSION The incidence of GERD burden after LHM+T is relatively low; however, the nuances relevant to accurate diagnosis in treated achalasia patients must be considered. Symptom correlation to abnormal pH study is unreliable making objective postoperative testing important. Furthermore, manual review of abnormal pH studies is necessary to distinguish GERD from poor esophageal clearance.
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Affiliation(s)
- Megan Blaustein
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Rachel Sillcox
- Department of Surgery, University of Washington, Seattle, WA, USA.
- , Washington, USA.
| | - Andrew S Wright
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Roger Tatum
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Robert Yates
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Mary Kate Bryant
- Department of Surgery, University of Washington, Seattle, WA, USA
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2
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Hantouli MN, Droullard DJ, Nash MG, Benson LS, Wright AS, Flum DR, Davidson GH. Operative vs Nonoperative Management of Acute Cholecystitis During the Different Trimesters of Pregnancy. JAMA Surg 2024; 159:28-34. [PMID: 37966823 PMCID: PMC10652218 DOI: 10.1001/jamasurg.2023.5803] [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] [Accepted: 08/27/2023] [Indexed: 11/16/2023]
Abstract
Importance Acute cholecystitis (AC) management during pregnancy requires balancing the risk of pregnancy loss or preterm delivery (adverse pregnancy outcomes [APOs]) with or without surgery. Guidelines recommend cholecystectomy across trimesters; however, trimester-specific evidence on the risks of AC and its management is lacking. Objective To assess cholecystectomy frequency in pregnant people with AC, compare the rates of APOs in pregnant people with or without AC, and compare the rates of APOs in people with AC who did or did not undergo cholecystectomy. Design, Setting, and Participants This retrospective, population-based cohort study used data for pregnant people with AC from the IBM MarketScan Commercial Claims and Encounters Database from January 1, 2007, to December 31, 2019, and a propensity score-matched cohort of pregnant people without AC. Trimester status (first [T1], second [T2], and third [T3]), APOs, and cholecystectomy were defined by administrative claims. Data were analyzed from October 2021 to July 2022. Exposures Pregnant patients with or without AC. Pregnant patients with AC who did or did not receive cholecystectomy. Main Outcomes and Measures The main outcomes were cholecystectomy during pregnancy and APOs (ie, preterm delivery and pregnancy loss). Pregnant patients with and without AC were compared to assess the association of AC with risk of APOs. Propensity score inverse-probability weighting was used to calculate treatment-associated APO risk among patients with 1-year follow-up. Results The study included 5759 pregnant patients with AC (mean [SD] age, 30.1 [6.6] years) and 23 036 controls (mean [SD] age, 29.9 [6.7] years) after propensity score matching. Among 3426 pregnant patients with AC and 1-year follow-up, 1182 (34.5%) underwent cholecystectomy during the pregnancy (684 [41.7%] presenting with AC in T1, 404 [40.4%] in T2, and 94 [12.0%] in T3). Acute cholecystitis during pregnancy, irrespective of treatment, was associated with higher odds of APO compared with no AC during pregnancy across all trimesters (odds ratio [OR], 1.69 [95% CI, 1.54-1.85]). Compared with nonoperative management, receipt of surgery was associated with lower odds of APOs across all trimesters (OR, 0.75 [95% CI, 0.63-0.87]), in T1 (OR, 0.81 [95% CI, 0.66-1.00]), in T2 (OR, 0.71 [95% CI, 0.50-1.00]), and in T3 (OR, 0.45 [95% CI, 0.28-0.70]). Conclusions and Relevance In this study, cholecystectomy was associated with lower risk of APO in patients with AC across all trimesters, with the greatest benefit in T3. However, only 34.5% overall and 12.0% of patients in T3 had a cholecystectomy. These findings support guidelines recommending cholecystectomy during pregnancy and should inform decision-making discussions. Greater guideline adherence and surgery use, especially in T3, may represent an opportunity to improve outcomes for pregnant people with AC.
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Affiliation(s)
| | | | - Michael G. Nash
- Department of Biostatistics, School of Public Health, University of Washington, Seattle
| | - Lyndsey S. Benson
- Department of Obstetrics and Gynecology, University of Washington, Seattle
| | | | - David R. Flum
- Department of Surgery, University of Washington, Seattle
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Bryant MK, Sillcox R, Dort J, Schwarz E, Wright AS. Application of the acquisition of data for outcomes and procedure transfer (ADOPT) method to a hands-on course for teaching extended-view totally extraperitoneal (eTEP) hernia repair to practicing surgeons. Surg Endosc 2023; 37:8057-8063. [PMID: 37488443 DOI: 10.1007/s00464-023-10290-9] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/05/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND After completion of training, practicing surgeons rely on hands-on courses to expand their procedure armamentarium and improve their surgical technique. However, such courses vary in standardized teaching methods. SAGES developed the Acquisition of Data for Outcomes and Procedure Transfer (ADOPT) program as a method of longitudinal instruction utilizing standardized teaching techniques, mentorship, and webinars to cover additional techniques. This study examines the adoption of learned techniques and participant confidence before and after an ADOPT course focused on extended-view totally extraperitoneal (eTEP) hernia repair. METHODS A hands-on course focused on eTEP hernia repair was conducted with enrollment capped at 10 participants. Pre-course and post-course surveys at 3, 6, and 12 months determined implementation of the learned procedure, case volume, and confidence with eTEP skills. A 5-point Likert scale (1 = not confident at all to 5 = completely confident) assessed confidence levels. Survey responses were summarized using descriptive statistics. RESULTS Of the 10 participants, 10 (100%) completed the pre-course survey, and 7 (70%) completed at least one post-course survey. Median age was 48.5 years (36,56) with a median of 16 years (2,23) in practice, mostly in the community setting (70%). After the course, 50% had performed an eTEP procedure, and 100% reported considering this technique during surgical planning. Participants reported higher confidence in eTEP-specific skills at three months post-course from pre-course levels. The highest change in confidence was seen for the following skills: accessing the retromuscular/extraperitoneal space for ventral hernia and recognizing when the linea alba has been violated, p < 0.05. CONCLUSION This study shows that rapid incorporation of learned techniques can be achieved through the ADOPT format. Furthermore, through longitudinal mentorship and a structured hands-on course, the ADOPT course supports practicing surgeons to attain autonomy and confidence even when teaching a relatively technically challenging procedure, such as eTEP.
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Affiliation(s)
- Mary K Bryant
- Department of Surgery, University of Washington, 1959 NE Pacific St., Box 3564101, Seattle, WA, 98195, USA
| | - Rachel Sillcox
- Department of Surgery, University of Washington, 1959 NE Pacific St., Box 3564101, Seattle, WA, 98195, USA
| | - Jonathan Dort
- Department of Surgery, Inova Fairfax Medical Campus, Falls Church, VA, USA
| | | | - Andrew S Wright
- Department of Surgery, University of Washington, 1959 NE Pacific St., Box 3564101, Seattle, WA, 98195, USA.
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Sillcox R, Carrera R, Wright AS, Oelschlager BK, Yates RB, Tatum RP. Esophageal Motility Patterns in Paraesophageal Hernia Patients Compared to Sliding Hiatal Hernia: Bigger Is Not Better. J Gastrointest Surg 2023; 27:2039-2044. [PMID: 37340102 DOI: 10.1007/s11605-023-05754-1] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/11/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND In patients with paraesophageal hernias (PEH), the course of the esophagus is often altered, which may affect esophageal motility. High-resolution manometry (HRM) is frequently used to evaluate esophageal motor function prior to PEH repair. This study was performed to characterize esophageal motility disorders in patients with PEH as compared to sliding hiatal hernia and to determine how these findings affect operative decision-making. METHODS Patients referred for HRM to a single institution from 2015 to 2019 were included in a prospectively maintained database. HRM studies were analyzed for the appearance of any esophageal motility disorder using the Chicago classification. PEH patients had confirmation of their diagnosis at the time of surgery, and the type of fundoplication performed was recorded. They were case-matched based on sex, age, and BMI to patients with sliding hiatal hernia who were referred for HRM in the same period. RESULTS There were 306 patients diagnosed with a PEH who underwent repair. When compared to case-matched sliding hiatal hernia patients, PEH patients had higher rates of ineffective esophageal motility (IEM) (p<.001) and lower rates of absent peristalsis (p=.048). Of those with ineffective motility (n=70), 41 (59%) had a partial or no fundoplication performed during PEH repair. CONCLUSION PEH patients had higher rates of IEM compared to controls, possibly due to a chronically distorted esophageal lumen. Offering the appropriate operation hinges on understanding the involved anatomy and esophageal function of each individual. HRM is important to obtain preoperatively for optimizing patient and procedure selection in PEH repair.
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Affiliation(s)
- Rachel Sillcox
- Department of Surgery, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA.
| | - Rocio Carrera
- Department of Surgery, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Andrew S Wright
- Department of Surgery, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Brant K Oelschlager
- Department of Surgery, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Robert B Yates
- Department of Surgery, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Roger P Tatum
- Department of Surgery, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
- Department of Surgery, VA Puget Sound HCS, University of Washington, Seattle, WA, USA
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Sillcox R, Gitonga B, Meiklejohn DA, Wright AS, Oelschlager BK, Bryant MK, Tarefder R, Khan Z, Zhu J. The environmental impact of surgical telemedicine: life cycle assessment of virtual vs. in-person preoperative evaluations for benign foregut disease. Surg Endosc 2023:10.1007/s00464-023-10131-9. [PMID: 37237107 DOI: 10.1007/s00464-023-10131-9] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND Health care accounts for almost 10% of the United States' greenhouse gas emissions, accounting for a loss of 470,000 disability-adjusted life years based on the health effects of climate change. Telemedicine has the potential to decrease health care's carbon footprint by reducing patient travel and clinic-related emissions. At our institution, telemedicine visits for evaluation of benign foregut disease were implemented for patient care during the COVID-19 pandemic. We aimed to estimate the environmental impact of telemedicine usage for these clinic encounters. METHODS We used life cycle assessment (LCA) to compare greenhouse gas (GHG) emissions for an in-person and a telemedicine visit. For in-person visits, travel distances to clinic were retrospectively assessed from 2020 visits as a representative sample, and prospective data were gathered on materials and processes related to in-person clinic visits. Prospective data on the length of telemedicine encounters were collected and environmental impact was calculated for equipment and internet usage. Upper and lower bounds scenarios for emissions were generated for each type of visit. RESULTS For in-person visits, 145 patient travel distances were recorded with a median [IQR] distance travel distance of 29.5 [13.7, 85.1] miles resulting in 38.22-39.61 carbon dioxide equivalents (kgCO2-eq) emitted. For telemedicine visits, the mean (SD) visit time was 40.6 (17.1) min. Telemedicine GHG emissions ranged from 2.26 to 2.99 kgCO2-eq depending on the device used. An in-person visit resulted in 25 times more GHG emissions compared to a telemedicine visit (p < 0.001). CONCLUSION Telemedicine has the potential to decrease health care's carbon footprint. Policy changes to facilitate telemedicine use are needed, as well as increased awareness of potential disparities of and barriers to telemedicine use. Moving toward telemedicine preoperative evaluations in appropriate surgical populations is a purposeful step toward actively addressing our role in health care's large carbon footprint.
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Affiliation(s)
- Rachel Sillcox
- Department of Surgery, University of Washington, 1318 22nd St NW, Seattle, WA, 20037, USA.
| | - Baraka Gitonga
- Department of Surgery, University of Washington, 1318 22nd St NW, Seattle, WA, 20037, USA
| | - Duncan A Meiklejohn
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Andrew S Wright
- Department of Surgery, University of Washington, 1318 22nd St NW, Seattle, WA, 20037, USA
| | - Brant K Oelschlager
- Department of Surgery, University of Washington, 1318 22nd St NW, Seattle, WA, 20037, USA
| | - Mary Kate Bryant
- Department of Surgery, University of Washington, 1318 22nd St NW, Seattle, WA, 20037, USA
| | - Rafiqul Tarefder
- Department of Civil, Construction and Environmental Engineering, University of New Mexico, Albuquerque, NM, USA
| | - Zafrul Khan
- Department of Civil, Construction and Environmental Engineering, University of New Mexico, Albuquerque, NM, USA
| | - Jay Zhu
- Department of Surgery, University of New Mexico Hospital, Albuquerque, NM, USA
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Ceron REC, Yates RB, Wright AS, Rodriguez HA, Lopez RG, Pellegrini CA, Oelschlager BK. Type II hiatal hernias: do they exist or are they actually parahiatal hernias? Surg Endosc 2023; 37:1956-1961. [PMID: 36261642 DOI: 10.1007/s00464-022-09641-9] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 09/13/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Type II hiatal hernias (HH) are characterized by a portion of the gastric fundus located above the esophageal hiatus adjacent to the esophagus while the gastroesophageal junction (GEJ) remains fixed below the esophageal hiatus. This type of HH has been called the "true" paraesophageal hernia (PEH) because the fundus appears to the side of the esophagus. In our experience, Type II HHs are occasionally identified on radiographic testing, however they are rarely, if ever, confirmed intraoperatively. This led to our question: Does Type II HH exist? METHODS We searched for evidence of type II HH in three locations: 1. Retrospective review of all first-time PEH repairs (excluding Type I HHs and re-operative cases) performed at the University of Washington Medical Center from 1994 to 2021; 2. Operative videos available on YouTube and WebSurg websites; and 3. Abstracts from the SAGES annual meetings from 2005 to 2021. RESULTS We found no evidence of Type II HH in any of our three searches. We performed 846 PEH repairs: 760 Type III, 75 Type IV, and 11 parahiatal. Upon website video review, we found only one possible type II hernia, though it too was likely a para-hiatal hernia. No video or case presentations of a type II HH were identified within SAGES annual meeting abstracts. CONCLUSION Type II HHs do not exist as they are currently defined. Although uncommon, parahiatal hernia can easily be misinterpreted as Type II HH. We should consider changing the hiatal hernia classification system to prevent ongoing clinical confusion.
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Affiliation(s)
- Rocio E Carrera Ceron
- Department of Surgery, University of Washington, 1959 NE Pacific St, Box 356410, Seattle, WA, 98195, USA
| | - Robert B Yates
- Department of Surgery, University of Washington, 1959 NE Pacific St, Box 356410, Seattle, WA, 98195, USA
| | - Andrew S Wright
- Department of Surgery, University of Washington, 1959 NE Pacific St, Box 356410, Seattle, WA, 98195, USA
| | | | - Rebecca G Lopez
- Department of Surgery, Piedmont Atlanta Hospital, Atlanta, GA, USA
| | - Carlos A Pellegrini
- Department of Surgery, University of Washington, 1959 NE Pacific St, Box 356410, Seattle, WA, 98195, USA
| | - Brant K Oelschlager
- Department of Surgery, University of Washington, 1959 NE Pacific St, Box 356410, Seattle, WA, 98195, USA.
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Zhu J, Lois AW, Gitonga B, Chen-Meekin JY, Williams EJ, Khandelwal S, Carrera Ceron R, Oelschlager BK, Wright AS. The impact of socioeconomic status on telemedicine utilization during the COVID-19 pandemic among surgical clinics at an academic tertiary care center. Surg Endosc 2022; 36:9304-9312. [PMID: 35332387 PMCID: PMC8945866 DOI: 10.1007/s00464-022-09186-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 03/07/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND The COVID-19 pandemic caused many surgical providers to conduct outpatient evaluations using remote audiovisual conferencing technology (i.e., telemedicine) for the first time in 2020. We describe our year-long institutional experience with telemedicine in several general surgery clinics at an academic tertiary care center and examine the relationship between area-based socioeconomic measures and the likelihood of telemedicine participation. METHODS We performed a retrospective review of our outpatient telemedicine utilization among four subspecialty clinics (including two acute care and two elective surgery clinics). Geocoding was used to link patient visit data to area-based socioeconomic measures and a multivariable analysis was performed to examine the relationship between socioeconomic indicators and patient participation in telemedicine. RESULTS While total outpatient visits per month reached a nadir in April 2020 (65% decrease in patient visits when compared to January 2020), there was a sharp increase in telemedicine utilization during the same month (38% of all visits compared to 0.8% of all visits in the month prior). Higher rates of telemedicine utilization were observed in the two elective surgery clinics (61% and 54%) compared to the two acute care surgery clinics (14% and 9%). A multivariable analysis demonstrated a borderline-significant linear trend (p = 0.07) between decreasing socioeconomic status and decreasing odds of telemedicine participation among elective surgery visits. A sensitivity analysis to examine the reliability of this trend showed similar results. CONCLUSION Telemedicine has many patient-centered benefits, and this study demonstrates that for certain elective subspecialty clinics, telemedicine may be utilized as the preferred method for surgical consultations. However, to ensure the equitable adoption and advancement of telemedicine services, healthcare providers will need to focus on mitigating the socioeconomic barriers to telemedicine participation.
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Affiliation(s)
- Jay Zhu
- Department of Surgery, University of New Mexico School of Medicine, MSC10 5610, 1 University of New Mexico, Albuquerque, NM, 87131, USA.
| | - Alex W Lois
- Department of Surgery, University of Washington School of Medicine, Seattle, USA
| | - Baraka Gitonga
- Department of Surgery, University of Washington School of Medicine, Seattle, USA
| | - Judy Y Chen-Meekin
- Department of Surgery, University of Washington School of Medicine, Seattle, USA
| | - Estell J Williams
- Department of Surgery, University of Washington School of Medicine, Seattle, USA
| | - Saurabh Khandelwal
- Department of Surgery, University of Washington School of Medicine, Seattle, USA
| | - Rocio Carrera Ceron
- Department of Surgery, University of Washington School of Medicine, Seattle, USA
| | - Brant K Oelschlager
- Department of Surgery, University of Washington School of Medicine, Seattle, USA
| | - Andrew S Wright
- Department of Surgery, University of Washington School of Medicine, Seattle, USA
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Abstract
Importance Several professional practice guidelines recommend per-oral endoscopic myotomy (POEM) as a potential first-line therapy for the management of achalasia, yet payers remain hesitant to reimburse for the procedure owing to unanswered questions regarding safety. Objective To evaluate the use, safety, health care utilization, and costs associated with the use of POEM for treatment of achalasia relative to laparoscopic Heller myotomy (LHM) and pneumatic dilation (PD). Design, Setting, and Participants This was a retrospective national cohort study of commercially insured patients, aged 18 to 63 years, who underwent index intervention for achalasia with either LHM, PD, or POEM in the US between July 1, 2010, and December 31, 2017. Patient data were obtained from a national commercial claims database. Included in the study were patients with at least 12 months of enrollment after index treatment and a minimum of 6 months of continuous enrollment before their index procedure. Patients 64 years or older were excluded to avoid underestimation of health care claims from enrollment in Medicare supplemental insurance. Data were analyzed from July 1, 2019, to July 1, 2021. Main Outcomes and Measures Changes in the proportion of annual procedures performed for achalasia were evaluated over time. The frequency of severe procedure-related adverse events, including perforation, pneumothorax, bleeding, and death, were compared. Negative binomial regression was used to compare the incidence rates of subsequent diagnostic testing, reintervention, and unplanned hospitalization. Generalized linear models were used to compare differences in 1-year health-related expenditures across procedures. Results This cohort study included a total of 1921 patients (median [IQR] age: LHM group, 48 [37-56] years; 737 men [51%]; PD group, 51 [41-58] years; 168 men [52%]; POEM group, 50 [40-57] years; 80 men [56%]). The use of POEM increased 19-fold over the study period, from 1.1% (95% CI, 0.2%-3.2%) of procedures in 2010 to 18.9% in 2017 (95% CI, 13.6%-25.3%; P = .01). Adverse events were rare and did not differ between procedures. Compared with LHM, POEM was associated with more subsequent diagnostic testing (incidence rate ratio [IRR], 2.2; 95% CI, 1.9-2.6) and reinterventions (IRR, 1.9; 95% CI, 1.1-3.3). When compared with PD, POEM was associated with more subsequent diagnostic testing (IRR, 1.5; 95% CI, 1.3-1.8) but fewer reinterventions (IRR, 0.4; 95% CI, 0.2-0.6). The total 1-year health care costs were similar between POEM and LHM, but significantly lower for PD (mean cost difference, $7674; 95% CI, $657-$14 692). Conclusions and Relevance Results of this cohort study suggest that POEM was associated with higher health care utilization compared with LHM and lower subsequent health care utilization but higher costs compared with PD. The use of POEM is increasing rapidly; payers should recognize the totality of evidence and current treatment guidelines as they consider reimbursement for POEM. Patients should be informed of the trade-offs between approaches when considering treatment.
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Affiliation(s)
- Alex W Lois
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, Seattle
| | - Brant K Oelschlager
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, Seattle
| | - Andrew S Wright
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, Seattle
| | - Adam W Templeton
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle
| | - David R Flum
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, Seattle.,Department of Health Services, University of Washington, Seattle.,Department of Pharmacy, University of Washington, Seattle
| | - Farhood Farjah
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, Seattle.,Department of Health Services, University of Washington, Seattle
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Abstract
Inguinal hernias represent one of the most common pathologic conditions presenting to the general surgeon. In surgical practice, several controversies persist: when to operate, the utility of a laparoscopic versus open approach, the applicability of robotic surgery, the approach to bilateral hernias, management of athletic-related groin pain ("sports hernia"), and the role of tissue-based repairs in modern hernia surgery. Ideally, surgeons should approach each patient individually and tailor their approach based on patient factors and preferences. The informed consent process is critical, especially given increasing recognition of the risk of long-term chronic pain following hernia repair.
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Affiliation(s)
- Veeshal H Patel
- Department of Surgery, University of Washington Medical School, 1959 Northeast Pacific Street Box 356410, Seattle, WA 98195, USA
| | - Andrew S Wright
- Department of Surgery, University of Washington Medical School, 1959 Northeast Pacific Street Box 356410, Seattle, WA 98195, USA; Center for VideoEndoscopic Surgery Endowed Professor, University of Washington.
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10
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Lois AW, Oelschlager BK, Wright AS, Templeton AW, Flum DR, Farjah F. The Use and Safety of POEM and Other Definitive Management Strategies for Achalasia. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.015] [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: 10/20/2022]
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Wright AS. Mitigating Concerns over Virtual Interviews for Surgical Residencies and Fellowships: In Reply to Haley and colleagues. J Am Coll Surg 2021; 233:155-156. [PMID: 34175058 DOI: 10.1016/j.jamcollsurg.2021.02.023] [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] [Received: 01/26/2021] [Accepted: 02/16/2021] [Indexed: 12/01/2022]
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12
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Wright AS. Virtual Interviews for Fellowship and Residency Applications Are Effective Replacements for In-Person Interviews and Should Continue Post-COVID. J Am Coll Surg 2020; 231:678-680. [PMID: 33243397 PMCID: PMC7538117 DOI: 10.1016/j.jamcollsurg.2020.09.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 09/10/2020] [Indexed: 11/26/2022]
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13
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Fennern EB, Hantouli M, Lois AW, Cook SB, Wolff E, Farjah F, Flum DR, Wright AS, Davidson GH. Early Cholecystectomy for Acute Cholecystitis: Does Failure to Follow the Recommendation Cost More? J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.177] [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]
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Abstract
Achalasia manifests as failure of relaxation of the lower esophageal sphincter resulting in dysphagia. Although there are several medical and endoscopic treatment options, laparoscopic Heller myotomy has excellent short- and long-term outcomes. This article describes in detail our surgical approach to this operation. Key steps include extensive esophageal mobilization, division of the short gastric vessels, mobilization of the anterior vagus nerve, an extended gastric myotomy (3 cm as opposed to the conventional 1-2 cm gastric myotomy), a minimum 6 cm esophageal myotomy through circular and longitudinal muscle layers, and a Toupet partial fundoplication. We routinely use intraoperative endoscopy both to check for inadvertent full-thickness injury and to assess completeness of the myotomy and the geometry of the anti-reflux wrap.
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Affiliation(s)
- Colette S Inaba
- Department of Surgery, Center for Esophageal and Gastric Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Andrew S Wright
- Department of Surgery, Center for Esophageal and Gastric Surgery, University of Washington School of Medicine, Seattle, Washington, USA
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Lois AW, Ehlers AP, Minneman J, Oh JS, Khandelwal S, Wright AS. Disclosure at #SAGES2018: An analysis of physician–industry relationships of invited speakers at the 2018 SAGES national meeting. Surg Endosc 2019; 34:2644-2650. [DOI: 10.1007/s00464-019-07037-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 07/24/2019] [Indexed: 11/28/2022]
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Jackson HT, Young MT, Rodriguez HA, Wright AS. SAGES Foregut Surgery Masters Program: a surgeon’s social media resource for collaboration, education, and professional development. Surg Endosc 2018; 32:2800-2807. [DOI: 10.1007/s00464-017-5983-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 11/12/2017] [Indexed: 11/28/2022]
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Sood RF, Wright AS, Nilsen H, Whitney JD, Lober WB, Evans HL. Use of the Mobile Post-Operative Wound Evaluator in the Management of Deep Surgical Site Infection after Abdominal Wall Reconstruction. ACTA ACUST UNITED AC 2017. [DOI: 10.1089/crsi.2017.0022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Ravi F. Sood
- Department of Surgery, University of Washington, Seattle, Washington
| | - Andrew S. Wright
- Department of Surgery, University of Washington, Seattle, Washington
| | | | - JoAnne D. Whitney
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, Washington
| | - William B. Lober
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, Washington
- Department of Global Health, School of Public Health, University of Washington, Seattle, Washington
- Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, Seattle, Washington
| | - Heather L. Evans
- Department of Surgery, University of Washington, Seattle, Washington
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Ehlers AP, Oelschlager BK, Pellegrini CA, Wright AS, Saunders MD, Flum DR, He H, Farjah F. Achalasia Treatment, Outcomes, Utilization, and Costs: A Population-Based Study from the United States. J Am Coll Surg 2017; 225:380-386. [PMID: 28602724 DOI: 10.1016/j.jamcollsurg.2017.05.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 05/19/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Randomized trials show that pneumatic dilation (PD) ≥30 mm and laparoscopic myotomy (LM) provide equivalent symptom relief and disease-related quality of life for patients with achalasia. However, questions remain about the safety, burden, and costs of treatment options. STUDY DESIGN We performed a retrospective cohort study of achalasia patients initially treated with PD or LM (2009 to 2014) using the Truven Health MarketScan Research Databases. All patients had 1 year of follow-up after initial treatment. We compared safety, health care use, and total and out-of-pocket costs using generalized linear models. RESULTS Among 1,061 patients, 82% were treated with LM. The LM patients were younger (median age 49 vs 52 years; p < 0.01), but were similar in terms of sex (p = 0.80) and prevalence of comorbid conditions (p = 0.11). There were no significant differences in the 1-year cumulative risk of esophageal perforation (LM 0.8% vs PD 1.6%; p = 0.32) or 30-day mortality (LM 0.3% vs PD 0.5%; p = 0.71). Laparoscopic myotomy was associated with an 82% lower rate of reintervention (p < 0.01), a 29% lower rate of subsequent diagnostic testing (p < 0.01), and a 53% lower rate of readmission (p < 0.01). Total and out-of-pocket costs were not significantly different (p > 0.05). CONCLUSIONS In the US, LM appears to be the preferred treatment for achalasia. Both LM and PD appear to be safe interventions. Along a short time horizon, the costs of LM and PD were not different. Mirroring findings from randomized trials, LM is associated with fewer reinterventions, less diagnostic testing, and fewer hospitalizations.
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Affiliation(s)
- Anne P Ehlers
- Division of General Surgery, University of Washington, Seattle, WA.
| | | | | | - Andrew S Wright
- Division of General Surgery, University of Washington, Seattle, WA
| | | | - David R Flum
- Division of General Surgery, University of Washington, Seattle, WA
| | - Hao He
- Department of Surgery, University of Washington, Seattle, WA
| | - Farhood Farjah
- Division of Cardiothoracic Surgery, University of Washington, Seattle, WA
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Abstract
BACKGROUND/PURPOSE Excessive skin hydration from wearing wet undergarments, such as infant diapers and adult incontinence products, has been historically problematic. Skin damage occurs from wetness (urine) and limited product breathability. Evaporative water loss has been measured on adult arms (armband method) or infant torsos (on-baby method), after wearing a saline-insulted diaper product. The current study developed a reliable in vitro method of evaluating diaper and incontinence products for improvements in skin dryness. METHODS A simulated skin substrate was applied to a heated mechanical arm or baby torso. A disposable diaper or incontinence product was wrapped around the arm or baby torso, and loaded with saline. Hydration of the simulated skin was measured by evaporimetry and compared with clinical data from adult armband evaluations. RESULTS The heated mechanical arm and baby torso accurately distinguished products for skin dryness. Eight diaper products were evaluated and compared to human test results. The torso in vitro and mechanical arm evaluations demonstrated strong correlations to human epidermal water loss evaluations, with repeatable results. Additionally, the bench test has been used for adult incontinence products, and it proved to differentiate those products as well as infant products. CONCLUSIONS A rapid and reliable means of evaluation has been developed, and it is predictive of human subject testing.
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Affiliation(s)
- M L Tate
- Kimberly-Clark Corp., Roswell, GA, USA
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20
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Selby LV, Ganai S, Shirley LA, Wright AS, Harzman AE, Ghaferi A, Matthews JB. Research at Academic and Community Surgical Residencies: Results of a National Survey of Surgical Residents. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.06.273] [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: 10/20/2022]
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21
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Sood R, Lipira AB, Louie O, Wright AS, Neligan PC, Gibran NS. Respiratory Complications after Abdominal Wall Reconstruction: Analysis of the Nationwide Inpatient Sample Database. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.06.207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Simianu VV, Sham JG, Wright AS, Stewart SD, Alloosh M, Sturek M, Cummings DE, Flum DR. A Large Animal Survival Model to Evaluate Bariatric Surgery Mechanisms. Surg Sci 2016; 6:337-345. [PMID: 27213116 PMCID: PMC4871691 DOI: 10.4236/ss.2015.68050] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background The impact of Roux-en-Y gastric bypass (RYGB) on type 2 diabetes mellitus is thought to result from upper and/or lower gut hormone alterations. Evidence supporting these mechanisms is incomplete, in part because of limitations in relevant bariatric-surgery animal models, specifically the lack of naturally insulin-resistant large animals. With overfeeding, Ossabaw swine develop a robust metabolic syndrome, and may be suitable for studying post-surgical physiology. Whether bariatric surgery is feasible in these animals with acceptable survival is unknown. Methods Thirty-two Ossabaws were fed a high-fat, high-cholesterol diet to induce obesity and insulin resistance. These animals were assigned to RYGB (n = 8), RYGB with vagotomy (RYGB-V, n = 5), gastrojejunostomy (GJ, n = 10), GJ with duodenal exclusion (GJD, n = 7), or sham operation (n = 2) and were euthanized 60 days post-operatively. Post-operative changes in weight and food intake are reported. Results Survival to scheduled necropsy among surgical groups was 77%, living an average of 57 days post-operatively. Cardiac arrest under anesthesia occurred in 4 pigs. Greatest weight loss (18.0% ± 6%) and food intake decrease (57.0% ± 20%) occurred following RYGB while animals undergoing RYGB-V showed only 6.6% ± 3% weight loss despite 50.8% ± 25% food intake decrease. GJ (12.7% ± 4%) and GJD (1.2% ± 1%) pigs gained weight, but less than sham controls (13.4% ± 10%). Conclusions A survival model of metabolic surgical procedures is feasible, leads to significant weight loss, and provides the opportunity to evaluate new interventions and subtle variations in surgical technique (e.g. vagus nerve sparing) that may provide new mechanistic insights.
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Affiliation(s)
- Vlad V Simianu
- Departments of Surgery, University of Washington, Seattle, USA
| | - Jonathan G Sham
- Departments of Surgery, University of Washington, Seattle, USA
| | - Andrew S Wright
- Departments of Surgery, University of Washington, Seattle, USA
| | - Skye D Stewart
- Departments of Surgery, University of Washington, Seattle, USA
| | - Mouhamad Alloosh
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, USA
| | - Michael Sturek
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, USA
| | | | - David R Flum
- Departments of Surgery, University of Washington, Seattle, USA ; Departments of Health Services, University of Washington, Seattle, USA
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24
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Evans HL, O'Shea DJ, Morris AE, Keys KA, Wright AS, Schaad DC, Ilgen JS. A comparison of Google Glass and traditional video vantage points for bedside procedural skill assessment. Am J Surg 2016; 211:336-42. [DOI: 10.1016/j.amjsurg.2015.07.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 07/30/2015] [Accepted: 07/30/2015] [Indexed: 10/22/2022]
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Wright AS, Khandelwal S. Task performance in standard laparoscopy in comparison with single-incision laparoscopy in a modified skills trainer. Surg Endosc 2016; 30:3591-7. [PMID: 26823059 DOI: 10.1007/s00464-015-4658-z] [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: 04/22/2015] [Accepted: 10/28/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Single-incision laparoscopy (SIL) is similar to conventional laparoscopic surgery (LAP), but carries specific technical challenges due to lack of triangulation, reduced dexterity, conflicts due to inline instrumentation, and impaired visualization. This study was designed to evaluate technical skill performance of SIL versus LAP surgery in a simulated environment. METHODS We developed a modified laparoscopic skills trainer for SIL based upon the fundamentals of laparoscopic surgery (FLS) model. This includes a standard laparoscopic tower for visualization, allowing replication of the conflicts between scope and instruments. It also has a modified trainer box allowing use of different access devices and instruments for SIL. Sixteen subjects at different levels of training (novice through expert) completed four FLS tasks with standard LAP techniques. They then practiced the same tasks using SIL technique until they reached a steady state of performance. The first and last SIL trials were recorded. RESULTS Baseline SIL peg transfer was worse than FLS (254 ± 157 s vs 99 ± 27, p < 0.0002). Final SIL time was still significantly worse than FLS (173 ± 130, p < 0.02). FLS, baseline SIL, and final SIL circle cutting were not significantly different (p = 0.058). Final SIL loop ligation was significantly faster than FLS (48 ± 19 vs 70 ± 42, p < 0.05). FLS suturing was faster than SIL suturing (281 ± 188 vs. 526 ± 105, p < 0.01). There was substantial dropout due to frustration with SIL, and only two surgeons were able to successfully complete SIL suturing. CONCLUSIONS There are technical challenges with SIL that vary depending on task. Peg transfer and suturing were significantly impaired in SIL, while circle cutting was not significantly affected, and ligating loop was faster with SIL than LAP. These challenges may impact clinical outcomes of SIL and should influence training in SIL as well as future product development.
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Affiliation(s)
- Andrew S Wright
- University of Washington, 1959 NE Pacific ST, Seattle, WA, 98115, USA.
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26
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Lu K, Gandhi S, Qureshi MA, Wright AS, Kantathut N, Noeller TP. Approach to Management of Intravascular Missile Emboli: Review of the Literature and Case Report. West J Emerg Med 2015; 16:489-96. [PMID: 26265959 PMCID: PMC4530905 DOI: 10.5811/westjem.2015.5.25553] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 04/26/2015] [Accepted: 05/07/2015] [Indexed: 11/11/2022] Open
Affiliation(s)
- Kevin Lu
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Sanjay Gandhi
- MetroHealth Medical Center, Heart and Vascular Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | - Andrew S Wright
- MetroHealth Medical Center, Department of Emergency Medicine, Cleveland, Ohio
| | - Narongrit Kantathut
- Cleveland Clinic Foundation, Thoracic and Cardiovascular Surgery, Cleveland, Ohio
| | - Thomas P Noeller
- MetroHealth Medical Center, Department of Emergency Medicine, Cleveland, Ohio
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27
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Sham JG, Simianu VV, Wright AS, Stewart SD, Alloosh M, Sturek M, Cummings DE, Flum DR. Evaluating the mechanisms of improved glucose homeostasis after bariatric surgery in Ossabaw miniature swine. J Diabetes Res 2014; 2014:526972. [PMID: 25215301 PMCID: PMC4158302 DOI: 10.1155/2014/526972] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [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] [Received: 06/06/2014] [Revised: 07/29/2014] [Accepted: 08/07/2014] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) is the most common bariatric operation; however, the mechanism underlying the profound weight-independent effects on glucose homeostasis remains unclear. Large animal models of naturally occurring insulin resistance (IR), which have been lacking, would provide opportunities to elucidate such mechanisms. Ossabaw miniature swine naturally exhibit many features that may be useful in evaluating the anti diabetic effects of bariatric surgery. METHODS Glucose homeostasis was studied in 53 Ossabaw swine. Thirty-two received an obesogenic diet and were randomized to RYGB, gastrojejunostomy (GJ), gastrojejunostomy with duodenal exclusion (GJD), or Sham operations. Intravenous glucose tolerance tests and standardized meal tolerance tests were performed prior to, 1, 2, and 8 weeks after surgery and at a single time-point for regular diet control pigs. RESULTS High-calorie-fed Ossabaws weighed more and had greater IR than regular diet controls, though only 70% developed IR. All operations caused weight-loss-independent improvement in IR, though only in pigs with high baseline IR. Only RYGB induced weight loss and decreased IR in the majority of pigs, as well as increasing AUCinsulin/AUCglucose. CONCLUSIONS Similar to humans, Ossabaw swine exhibit both obesity-dependent and obesity-independent IR. RYGB promoted weight loss, IR improvement, and increased AUCinsulin/AUCglucose, compared to the smaller changes following GJ and GJD, suggesting a combination of upper and lower gut mechanisms in improving glucose homeostasis.
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Affiliation(s)
- Jonathan G. Sham
- Department of Surgery, University of Washington, Seattle, WA 98195, USA
- *Jonathan G. Sham:
| | - Vlad V. Simianu
- Department of Surgery, University of Washington, Seattle, WA 98195, USA
| | - Andrew S. Wright
- Department of Surgery, University of Washington, Seattle, WA 98195, USA
| | - Skye D. Stewart
- Department of Surgery, University of Washington, Seattle, WA 98195, USA
| | - Mouhamad Alloosh
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Michael Sturek
- Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - David E. Cummings
- Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - David R. Flum
- Department of Surgery, University of Washington, Seattle, WA 98195, USA
- Department of Health Services, University of Washington, Seattle, WA 98195, USA
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Wright AS, McKenzie J, Tsigonis A, Jensen AR, Figueredo EJ, Kim S, Horvath K. A structured self-directed basic skills curriculum results in improved technical performance in the absence of expert faculty teaching. Surgery 2012; 151:808-14. [DOI: 10.1016/j.surg.2012.03.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Accepted: 03/15/2012] [Indexed: 11/28/2022]
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Jensen AR, Wright AS, Kim S, Horvath KD, Calhoun KE. Educational feedback in the operating room: a gap between resident and faculty perceptions. Am J Surg 2012; 204:248-55. [PMID: 22537472 DOI: 10.1016/j.amjsurg.2011.08.019] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2011] [Revised: 08/19/2011] [Accepted: 08/19/2011] [Indexed: 11/28/2022]
Abstract
BACKGROUND Immediate feedback regarding performance in the operating room remains a key component of resident education. The aim of this study was to assess resident and faculty perceptions regarding postoperative feedback. METHODS Anonymous surveys were distributed to residents and faculty members. Questions addressed the timing, amount, and specificity of feedback; satisfaction; and the definition and importance of feedback. Additional questions regarded the importance and frequency of feedback in 7 specific areas of surgical competency. RESULTS Resident satisfaction with timing, amount, and specificity of feedback was significantly lower than faculty satisfaction. Perceptions of the importance of feedback for each of the 7 specific areas did not differ. Faculty members' perceptions on the frequency of feedback were higher than residents' perception in all competencies of feedback (5-point scale, all P values = .001). CONCLUSIONS There are significant differences between resident and faculty perceptions regarding postoperative feedback. Although faculty members believed they delivered appropriate amounts of timely, quality feedback, this perception was not shared by residents.
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Affiliation(s)
- Aaron R Jensen
- Institute for Simulation and Interprofessional Studies and Division of Surgical Education, Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA
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Khandelwal S, Wright AS, Figueredo E, Pellegrini CA, Oelschlager BK. Single-incision laparoscopy: training, techniques, and safe introduction to clinical practice. J Laparoendosc Adv Surg Tech A 2011; 21:687-93. [PMID: 21882993 DOI: 10.1089/lap.2011.0238] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Single-incision laparoscopy is an emerging technique that brings new challenges to laparoscopy and introduces new skills that a surgeon must learn. The learning needs for single-incision skills acquisition are unknown and no current guidelines exist for training or for its safe adoption. METHODS We developed an approach to adoption of new surgical techniques and applied it to single-incision laparoscopy. It is based on the following principles: a defined training algorithm, dry and wet-laboratory practice, a graded clinical introduction, and careful review of early outcomes. We analyzed its impact in our initial 40 patients. RESULTS Our training paradigm consisted of the following: attending a formal course, developing a simulation model, and animal laboratory training, followed by graduated clinical adoption. A 20% conversion rate to standard laparoscopy or open surgery occurred. CONCLUSION Introducing a new surgical technique may not only offer potential advantages but also present significant risks. We developed a thoughtful approach to adoption that includes simulation-based training, progressive clinical adoption, and early review of outcomes. This approach may be applied to various new clinical applications.
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Affiliation(s)
- Saurabh Khandelwal
- Department of Surgery, The Center for Videoendoscopic Surgery, The Institute for Simulation and Interprofessional Studies, University of Washington, Seattle, Washington, USA.
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Islam A, Castellvi AO, Tesfay ST, Castellvi AD, Wright AS, Scott DJ. Early surgeon impressions and technical difficulty associated with laparoendoscopic single-site surgery: a Society of American Gastrointestinal and Endoscopic Surgeons Learning Center study. Surg Endosc 2011; 25:2597-603. [PMID: 21359887 DOI: 10.1007/s00464-011-1594-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Accepted: 10/24/2010] [Indexed: 12/12/2022]
Abstract
BACKGROUND Interest in laparoendoscopic single-site surgery (LESS) is growing rapidly among surgeons. This study aimed to characterize current surgeon impressions about LESS and to determine the relative difficulty of performing a simulated LESS task using a multiport access device. METHODS This study was conducted at the 2009 Society of Gastrointestinal Endoscopic Surgeons (SAGES) Learning Center. The 56 study participants were asked to complete pre- and post-test questionnaires regarding their level of training, prior clinical experience, and opinions about LESS. Technical skill performance was evaluated using the standardized fundamentals of laparoscopic surgery Peg Transfer task scored according to time and error metrics. The participants completed three repetitions: conventional laparoscopy (LAP), LESS with nonarticulated instruments (LESS Straight), and LESS with articulated instruments (LESS Articulating). RESULTS Complete data were collected for 45 (80%) of the 56 participants, which included 27 practicing surgeons, nine minimally invasive surgery (MIS) fellows, seven residents, and two allied health professionals. Five surgeons (LESS experienced) had managed at least one LESS case in the preceding 6 months. Participants rated their comfort with LESS as 2.0 ± 1.2 (5-point scale, 1 = very uncomfortable). Compared with conventional laparoscopy, the participants indicated that LESS had 97% better cosmesis, 25% decreased postoperative pain, 18% faster recovery, 97% more demanding, 73% increased rate of complications, and 82% anticipated wide adoption. They all indicated a readiness to offer LESS to their patients if appropriately trained. Peg Transfer performance was significantly worse for LESS than for LAP (40-65% performance decline), and for LESS Articulating than for LESS Straight (44% performance decline). Construct validity for the LESS simulated tasks was supported because the LESS-experienced scores were significantly better than the LESS-nonexpert scores. CONCLUSION Despite the increased technical difficulty associated with the LESS approach, surgeons are enthusiastic about offering these techniques and seeking additional training. Robust simulation-based methods that foster skill acquisition through repetitive practice and verification of proficiency are needed such that safe adoption may be fostered.
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Affiliation(s)
- Arsalla Islam
- Department of Surgery, Southwestern Center for Minimally Invasive Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9156, USA
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Wright AS, Kim S, Ross B, Pellegrini C. ISIS: The Institute for Simulation and Interprofessional Studies at the University of Washington. J Surg Educ 2011; 68:94-96. [PMID: 21292226 DOI: 10.1016/j.jsurg.2010.05.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Accepted: 05/27/2010] [Indexed: 05/30/2023]
Affiliation(s)
- Andrew S Wright
- ISIS, University of Washington, Seattle, Washington 98195, USA.
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Tsigonis AM, Jensen A, McKenzie J, Kim S, Wright AS. Validation of novel self- and expert-administered assessment tools for basic open technical skills. J Am Coll Surg 2010. [DOI: 10.1016/j.jamcollsurg.2010.06.305] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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RamjeeSingh D, Wright AS, McDavid H. An intense influenza pandemic--possible subtype of H5N1: its implications for Jamaica. W INDIAN MED J 2010; 59:76-81. [PMID: 20931919] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Using two different attack rates, 20% and 30%, the paper attempts to project several possible outcomes for the Jamaican economy in the event of a severe pandemic. In addition to forecasting the possible loss in man hours for the economy, the study uses the Monte Carlo modelling technique to provide estimates of the death and hospitalization rates among the 0-19, 20-64 and 65(+)-year age cohorts while extra-polating the demand for healthcare providers.
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Affiliation(s)
- D RamjeeSingh
- Department of Management Studies, The University of the West Indies, Mona Campus, Kingston 7, Jamaica.
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Lum MJH, Rosen J, Lendvay TS, Wright AS, Sinanan MN, Hannaford B. TeleRobotic fundamentals of laparoscopic surgery (FLS): effects of time delay--pilot study. Annu Int Conf IEEE Eng Med Biol Soc 2009; 2008:5597-600. [PMID: 19163986 DOI: 10.1109/iembs.2008.4650483] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Within the area of telerobotic surgery no standardized means of surgically relevant performance evaluation has been established. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Fundamentals of Laparoscopic Surgery (FLS) program provides a set of standardized tasks that are considered the 'gold standard' in surgical skill assessment. We present a methodology for using one of the SAGES FLS tasks for surgical robotic performance evaluation. The TeleRobotic FLS methodology is extendable to two other FLS tasks. Time delay in teleoperation in general and telesurgery in particular is one of the fundamental effects that limits performance in telerobotic surgery. In this pilot study the effect of time delay on the Block Transfer task performance was investigated. The RAVEN Surgical Robot was used in a master/slave configuration in which time delays of 0, 250, 500, and 1000 ms were introduced by a network emulator between the master (Surgeon Site) and the slave (Patient Site). The study included three subjects, each of whom was presented with three of the four conditions. The results show that one subject had a lower error rate with increasing time delay, whereas the other subjects had a higher error rate with increased delay. The subject with the longest average completion time suffered the least performance decrease under time delay.
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Lum MJH, Rosen J, King H, Friedman DCW, Lendvay TS, Wright AS, Sinanan MN, Hannaford B. Teleoperation in surgical robotics--network latency effects on surgical performance. Annu Int Conf IEEE Eng Med Biol Soc 2009; 2009:6860-6863. [PMID: 19964184 DOI: 10.1109/iembs.2009.5333120] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
A teleoperated surgical robotic system allows surgical procedures to be conducted across long distances while utilizing wired and wireless communication with a wide spectrum of performance that may affect the outcome. An open architecture portable surgical robotic system (Raven) was developed for both open and minimally invasive surgery. The system has been the subject of an intensive telesurgical experimental protocol aimed at exploring the boundaries of the system and surgeon performance during a series of field experiments in extreme environments (desert and underwater) teleportation between US, Europe, and Japan as well as lab experiments under synthetic fixed time delay. One standard task (block transfer emulating tissue manipulation) of the Fundamentals of Laparoscopic Surgery (FLS) training kit was used for the experimental protocol. Network characterization indicated a typical time delay in the range of 16-172 ms in field experiments. The results of the lab experiments showed that the completion time of the task as well as the length of the tool tip trajectory significantly increased (alpha< 0.02) as time delay increased in the range of 0-0.5 sec increased. For teleoperation with a time delay of 0.25s and 0.5s the task completion time was lengthened by a factor of 1.45 and 2.04 with respect to no time delay, whereas the length of the tools' trajectory was increased by a factor of 1.28 and 1.53 with respect to no time delay. There were no statistical differences between experienced surgeons and non-surgeons in the number of errors (block drooping) as well as the completion time and the tool tip path length at different time delays.
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Jensen AR, Klein MB, Ver Halen JP, Wright AS, Horvath KD. Skin flaps and grafts: a primer for the National Technical Skills Curriculum advanced tissue-handling module. J Surg Educ 2008; 65:191-199. [PMID: 18571132 DOI: 10.1016/j.jsurg.2008.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2007] [Revised: 03/11/2008] [Accepted: 03/25/2008] [Indexed: 05/26/2023]
Affiliation(s)
- Aaron R Jensen
- Division of Surgical Education, Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195, USA.
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Flum DR, Devlin A, Wright AS, Figueredo E, Alyea E, Hanley PW, Lucas MK, Cummings DE. Development of a porcine Roux-en-Y gastric bypass survival model for the study of post-surgical physiology. Obes Surg 2008; 17:1332-9. [PMID: 18098400 DOI: 10.1007/s11695-007-9237-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [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: 12/26/2022]
Abstract
BACKGROUND Rodents have been used to examine physiologic changes after bariatric surgery, but differences in gastric/vagal anatomy may limit their utility. Swine may be a more appropriate animal model because of anatomic and physiologic similarities to humans. The aim of this study was to establish a survival model of Roux-en-Y gastric bypass (RYGBP) in swine and to evaluate its potential in studies of physiology. METHODS 13 miniature swine, 5 Yucatan [26.4 +/- 1.6 kg], 4 Hanford [28.3 +/- 0.6 kg] and 4 other breed [54.9 +/- 6.2 kg] underwent open RYGBP, and were kept alive to 30 (n=4), 60 (n=1) or 90 (n=2) postoperative days. RESULTS 4 early animals had staple-line leakage within 7 days from surgery and 1 animal experienced unmanageable pain at 42 days after surgery. One animal experienced immediate cardiopulmonary collapse. 58% of animals survived to their projected endpoint. Necropsy of 1 animal at its 90-day endpoint revealed a gastro-gastric fistula. Anatomic features in swine that differ from humans, such as thick perigastric membranes, required adjustment to the standard RYGBP technique used in humans to achieve satisfactory results. Caloric intake decreased in some but not all animals, and was linked to feeding regimen. By postoperative day 30, animals weighed 5.7-29.1% less than their projected, non-operative weight. Serum assays of ghrelin and PYY were conducted, with results consistent with the procedure. CONCLUSIONS The use of swine as a model for bariatric surgery has promise, but also has associated pitfalls that must be addressed for this to be an effective model.
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Affiliation(s)
- David R Flum
- Department of Surgery, University of Washington, Seattle, WA 98195-7183, USA.
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Jensen AR, Wright AS, Lance AR, O’Brien KC, Pratt CD, Anastakis DJ, Pellegrini CA, Horvath KD. The emotional intelligence of surgical residents: a descriptive study. Am J Surg 2008; 195:5-10. [DOI: 10.1016/j.amjsurg.2007.08.049] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2007] [Revised: 08/10/2007] [Accepted: 08/10/2007] [Indexed: 11/30/2022]
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Wright AS, Williams CW, Pellegrini CA, Oelschlager BK. Long-term outcomes confirm the superior efficacy of extended Heller myotomy with Toupet fundoplication for achalasia. Surg Endosc 2007; 21:713-8. [PMID: 17332964 DOI: 10.1007/s00464-006-9165-9] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.1] [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: 10/04/2006] [Revised: 10/04/2006] [Accepted: 10/16/2006] [Indexed: 01/27/2023]
Abstract
BACKGROUND The standard Heller myotomy (SM) for achalasia extends 1 to 2 cm on to the stomach. The authors perform an extended myotomy (EM) (>3 cm) with the goal of reducing postoperative dysphagia. This study examines the long-term efficacy and durability of EM compared with SM. METHODS Patients with achalasia who underwent a laparoscopic Heller myotomy were identified from a prospective database that includes symptom evaluation and results of esophageal functional studies. From September 1994 to August 1998, the authors performed SM with Dor fundoplication, and from September 1998 through 2003, they performed EM with Toupet fundoplication. In 2001, they performed a telephone survey of all available patients. This was repeated in 2005 for the EM group. The survey included scales of symptom frequency (0 [never], 1 [once per month], 2 [once per week], 3 [once per day], 4 [more than once per day]) and severity (0 [no symptoms] to 10 [symptoms equal to preoperative state]) as well as the need to undergo postoperative intervention for dysphagia. RESULTS For this study, 52 patients underwent SM with Dor fundoplication (median follow-up period, 46 +/- 24 months), and 63 patients underwent EM with Toupet fundoplication (median follow-up period, 45 +/- 17 months. Postoperative dysphagia severity was significantly better in the EM group (4.8 +/- 2.3 vs 3.1 +/- 2.6; p < 0.005). There was no significant difference in postoperative heartburn frequency, esophageal acid exposure, or lower esophageal sphincter pressure. In the SM group, 9 patients (17%) required reintervention for dysphagia: 14 endoscopic interventions for 5 patients (10%) and reoperation for 4 patients. Three patients (5%) in the EM group required reintervention for dysphagia: one endoscopic intervention each and no reoperations (p < 0.05). A total of 30 patients in the EM group were contacted in both 2001 (median follow-up period, 19 +/- 11 months) and 2005 (median follow-up period, 63 +/- 10 months). There was no significant change over time in dysphagia severity (2.6 +/- 1.9 vs 3.7 +/- 2.0; p = 0.19). CONCLUSIONS For the treatment of achalasia, EM with Toupet fundoplication provides excellent durable dysphagia relief that is superior to SM with Dor fundoplication.
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Affiliation(s)
- A S Wright
- Department of Surgery, University of Washington Hospital, 1959 NE Pacific Street, Mailbox 356410, Seattle, WA 98195-6410, USA.
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Wright AS, Anderson BO. Interactive clinical anatomy: axillary surgery CD-ROM. Lancet Oncol 2006. [DOI: 10.1016/s1470-2045(06)70856-7] [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: 10/24/2022]
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Wright AS, Akintonwa DA, Crowne RS, Hathway DE. The metabolism of 2,6-di-tert.-butyl-4-hydroxymethylphenol (Ionox 100) in the dog and rat. Biochem J 2006; 97:303-10. [PMID: 16749118 PMCID: PMC1264575 DOI: 10.1042/bj0970303] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
1. A single oral dose of [(14)C]Ionox 100 to rats is almost entirely eliminated in 11 days: 89.1-107.2% of the (14)C is excreted and 0.29+/-0.02% of the dose is present in the carcass plus viscera after removal of the gut. Rats exhibit an individual variation in the elimination pattern, 15.6-70.8% of (14)C being excreted in the urine and 75.2-27.0% in the faeces during 11 days. 2. After the oral administration of [(14)C]Ionox 100 to dogs, 87.1-90.3% of the (14)C is excreted in the faeces and urine during 4 days. 3. Dogs and rats do not show a species difference in this pattern of elimination. 4. The rate of elimination from dogs and rats given a single dose of Ionox 100 is not affected by the size of the dose and the presence of triglyceride fat in the diet. 5. Ionox 100 is completely metabolized in dogs and rats: unchanged Ionox 100 is absent from the urine and faeces, and from the carcass when elimination is complete. In rats, 3,5-di-tert.-butyl-4-hydroxybenzoic acid accounts for 50-85% of a dose of Ionox 100 and (3,5-di-tert.-butyl-4-hydroxybenzoyl beta-d-glucopyranosid)uronic acid for 47-10%; in dogs, the unconjugated acid accounts for 85% and the ester glucuronide for 10-12%. 3,5-Di-tert.-butyl-4-hydroxyhippuric acid is not formed. Other metabolites, which have been detected in small quantity in the faeces and urine of animals dosed with Ionox 100, have not been identified. 6. 3,5-Di-tert.-butyl-4-hydroxybenzoic acid and (3,5-di-tert.-butyl-4-hydroxybenzoyl beta-d-glucopyranosid)uronic acid are also the major metabolites of Ionol (2,6-di-tert.-butyl-p-cresol) in rats. 7. The elimination of Ionox 100 metabolites from rats is faster than that of Ionol and its metabolites. Unlike Ionol, unchanged Ionox 100 could not be detected in the bodies of these animals.
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Affiliation(s)
- A S Wright
- Tunstall Laboratory, Shell Research Ltd., Sittingbourne, Kent
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Abstract
Portal hypertension can lead to life-threatening hemorrhage, ascites, and encephalopathy. This paper reviews the pathophysiology and multidisciplinary management of portal hypertension and its complications, including the indications for and techniques of the various surgical shunts. Variceal bleeding is the most dreaded complication of portal hypertension. It may occur once the portal-systemic gradient increases above 12 mm Hg, occurs in 30% of patients with cirrhosis, and carries a 30-day mortality of 20%. Treatment of acute variceal bleeding includes resuscitation followed by upper endoscopy for sclerosis or band ligation of varices, which can control bleeding in up to 85% of patients. Medical therapies such as vasopressin and somatostatin can also be useful adjuncts. Shunt therapy, preferably the placement of a TIPS, is indicated for refractory acute variceal bleeding. Recurrent variceal bleeding is common and is associated with a high mortality. Therapies to prevent recurrent variceal bleeding include chronic endoscopic therapy, nonselective beta-blockade, operative or nonoperative (TIPS) shunts, devascularization operations, and liver transplantation. Recommendations and a treatment algorithm are provided, taking into account both the etiology and the manifestations of portal hypertension.
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Affiliation(s)
- Andrew S Wright
- Department of Surgery, University of Wisconsin Medical School, Madison, Wisconsin 53792, USA
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Abstract
PURPOSE To compare microwave (MW) and radiofrequency (RF) ablation in a hepatic porcine model. MATERIALS AND METHODS Institutional animal research committee approval was obtained. Nineteen pigs were divided into groups based on time of sacrifice (group A, immediate; group B, 2 days; group C, 28 days; group D, 28 days). Groups A, B, and C each underwent a combination of RF and MW ablation. Group D underwent either four MW or four RF ablations. Ablation was performed with a prototype MW device (915 Mhz, 40 W, 10 minutes) and a commercial RF system (150 W, 10 minutes, 3-cm deployment). Computed tomography (CT) was performed in groups B and C at 2 days and in group C at 28 days. Group D underwent serial laboratory testing. Specimens were serially sectioned, and short-axis diameter and length of each were measured. The percentage deflection caused by local blood vessels (heat-sink effect) was also measured in group A. Likelihood ratio tests and unpaired t tests were used for statistical analyses as appropriate. RESULTS MW ablation zones were longer at days 0, 2, and 28 (P < .05), but short-axis diameter was not different from that with RF ablation at any time point (P > .05). Local blood vessels caused 3.5% +/- 5.3 (standard deviation) deflection at MW ablation compared with 26.2% +/- 27.9 at RF ablation (P < .05). MW and RF ablation zones were indistinguishable at CT or pathologic evaluation. Laboratory test results were similar between RF ablation-only animals and MW ablation-only animals, with the exception of a slightly higher alkaline phosphatase levels at day 2 in RF ablation-only animals (P < .02). CONCLUSION MW and RF ablation zones are similar in pathologic appearance and imaging characteristics. Increased length with MW ablation is likely caused by the length of the radiating segment of the antenna. MW ablation may be less affected by the heat-sink effect that is thought to contribute to local recurrence after RF ablation.
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Affiliation(s)
- Andrew S Wright
- Department of Surgery, University of Wisconsin, 600 Highland Ave, Madison, WI 53792-3252, USA
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Wright JH, Wright AS, Albano AM, Basco MR, Goldsmith LJ, Raffield T, Otto MW. Computer-assisted cognitive therapy for depression: maintaining efficacy while reducing therapist time. Am J Psychiatry 2005; 162:1158-64. [PMID: 15930065 DOI: 10.1176/appi.ajp.162.6.1158] [Citation(s) in RCA: 164] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aim of this investigation was to compare the efficacy of computer-assisted cognitive therapy against standard cognitive therapy and a control group without treatment for outpatients with nonpsychotic major depressive disorder. METHOD Medication-free participants (N=45) with major depressive disorder were randomly assigned to cognitive therapy (N=15), computer-assisted cognitive therapy (N=15), or a wait list (N=15). Both active treatments consisted of nine sessions over 8 weeks. Therapist time was reduced after the first visit for computer-assisted cognitive therapy, with 25-minute sessions rather than 50-minute sessions. Assessments were completed pretreatment, after 4 and 8 weeks of therapy, and 3 and 6 months posttreatment. RESULTS Computer-assisted cognitive therapy and standard cognitive therapy were superior to the wait list control group for treatment of depression and did not differ from each other on the primary outcome variables. Very large between-group effect sizes were observed. Improvement in depression for both computer-assisted cognitive therapy and standard cognitive therapy was maintained at the 3- and 6-month follow-up evaluations. Computer-assisted cognitive therapy had more robust effects, relative to being wait-listed, than standard cognitive therapy in reducing measures of cognitive distortion and in improving knowledge about cognitive therapy. CONCLUSIONS A multimedia, computer-assisted form of cognitive therapy with reduced therapist contact was as efficacious as standard cognitive therapy. Computer-assisted therapy could decrease costs and improve access to cognitive therapy for depression.
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Affiliation(s)
- Jesse H Wright
- Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY 40232, USA.
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Wright AS, Mahvi DM. Liver directed therapies for colorectal cancer. ACTA ACUST UNITED AC 2004; 21:831-43. [PMID: 15338777 DOI: 10.1016/s0921-4410(03)21040-1] [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] [Indexed: 04/30/2023]
Affiliation(s)
- Andrew S Wright
- Division of General Surgery, H4/724 Clinical Science Center, Madison, WI 53792-7375, USA
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Wright AS, Gould JC, Melvin WS. Computer-assisted robotic antireflux surgery. MINERVA GASTROENTERO 2004; 50:253-60. [PMID: 15729200] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Robotic surgical systems are relatively new technical devices designed to address several of the limitations inherent to standard laparoscopy. Since the 1(st) report of a computer-assisted fundoplication in 1997, numerous authors have reported their experiences with these devices in antireflux surgery. While there are several advantages to robotic when compared to standard laparoscopic antireflux surgery, there are also some distinct drawbacks. Robotic surgical systems allow the surgeon to perform more complex maneuvers with increased precision and accuracy, and without tremor. The image is high-definition and the surgeon operates in a more ergonomic position. These systems are also costly to purchase and maintain, they are large and may limit access to the patient during surgery, they provide a narrower field of view of the operative site, and they provide the surgeon with essentially no tactile feedback. Clinical outcomes of robotic fundoplication seem to be very similar to those of standard laparoscopic fundoplication, although the operating times in many series are increased when using the robot. The role of computer-assisted fundoplication in general practice, at least at the current level of robotic technology, remains to be defined.
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Affiliation(s)
- A S Wright
- Department of Surgery, University of Wisconsin Medical School, WI, USA
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Wright AS, Mahvi DM, Haemmerich DG, Lee FT. Minimally invasive approaches in management of hepatic tumors. Surg Technol Int 2004; 11:144-53. [PMID: 12931296] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Traditionally, the only curative option for patients with liver tumors has been hepatic resection. Unfortunately, only 10%-20% of patients with liver tumors can undergo surgical resection due to limited hepatic reserve, high surgical risk, or unfavorable tumor location. Ablation of liver tumors is currently the main alternative to formal liver resection. Tumor cell death is achieved through a number of technologies, which may be separated into three categories: chemical (percutaneous ethanol injection), cold-based (cryotherapy), and heat-based (radiofrequency and microwave ablation or laser hyperthermia). Although long-term data are limited, ablation may be curative in some patients with a three- and five-year survival rate approaching that of resection. The main factors to success include proper patient selection, excellent diagnostic and procedural imaging, and careful post-procedure management and follow up. Long-term success following tumor ablation will be most dependent on the underlying tumor biology and the ability to achieve a negative margin. Future directions in ablation will include the use of adjunctive agents such as chemotherapeutics, further advances in energy delivery, improved imaging and lesion targeting, and continued refinements of current technology and technique.
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Affiliation(s)
- Andrew S Wright
- Department of Radiology, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
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Shock SA, Meredith K, Warner TF, Sampson LA, Wright AS, Winter TC, Mahvi DM, Fine JP, Lee FT. Microwave Ablation with Loop Antenna: In Vivo Porcine Liver Model. Radiology 2004; 231:143-9. [PMID: 14990816 DOI: 10.1148/radiol.2311021342] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.5] [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: 01/07/2023]
Abstract
PURPOSE To determine the effectiveness of tissue ablation with a loop microwave antenna in various configurations in porcine liver tissue. MATERIALS AND METHODS Microwave energy was applied for 7 minutes at 60 W in six porcine livers (mean weight, 68.2 kg) by using single (n = 7) or dual 2.7-cm loop microwave probes in parallel (n = 9) or orthogonal (n = 9) configurations. Volume, diameter, shape, and temperature of the zone of necrosis and the presence of viable tissue inside the loop were determined and compared by means of factorial analysis of variance. RESULTS Mean lesion volume and maximum diameter, respectively, were 32.2 cm(3) +/- 14.4 (SD) and 4.6 cm +/- 1.4 for lesions ablated with parallel probes (parallel lesions), 29.5 cm(3) +/- 8.1 and 4.3 cm +/- 0.6 for lesions ablated with orthogonal probes (orthogonal lesions), and 6.4 cm(3) +/- 1.9 and 3.4 cm +/- 0.62 for lesions ablated with single probes (single lesions) (P <.05, single vs parallel and orthogonal lesions). Mean minimum diameter was greatest for orthogonal lesions (3.5 cm +/- 0.53; P =.017, parallel vs orthogonal lesions). Orthogonal lesions had the highest mean internal temperature (97.2 degrees C) versus parallel (91.9 degrees C) and single (60.0 degrees C) lesions. All orthogonal lesions heated to 60 degrees C in comparison to eight of nine parallel and four of seven single lesions. The mean time to reach 60 degrees C was shortest for orthogonal lesions (93.3 seconds) versus parallel (123.8 seconds) and single (263.0 seconds) lesions. Orthogonal lesions were the most spherical. Viable tissue was present in the center of five of seven single, six of nine parallel, and zero of nine orthogonal lesions. CONCLUSION Loop microwave antennas allow precise control and effective ablation of targeted tissue, particularly in the orthogonal configuration.
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Affiliation(s)
- Sarah A Shock
- Department of Radiology, University of Wisconsin Hospitals and Clinics, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792, USA
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