Reducing retraction forces with tactile feedback during robotic total mesorectal excision in a porcine model

Excessive tissue-instrument interaction forces during robotic surgery have the potential for causing iatrogenic tissue damages. The current in vivo study seeks to assess whether tactile feedback could reduce intraoperative tissue-instrument interaction forces during robotic-assisted total mesorectal excision. Five subjects, including three experts and two novices, used the da Vinci robot to perform total mesorectum excision in four pigs. The grip force in the left arm, used for retraction, and the pushing force in the right arm, used for blunt pelvic dissection around the rectum, were recorded. Tissue-instrument interaction forces were compared between trials done with and without tactile feedback. The mean force exerted on the tissue was consistently higher in the retracting arm than the dissecting arm (3.72 ± 1.19 vs 0.32 ± 0.36 N, p < 0.01). Tactile feedback brought about significant reductions in average retraction forces (3.69 ± 1.08 N vs 4.16 ± 1.12 N, p = 0.02), but dissection forces appeared unaffected (0.43 ± 0.42 vs 0.37 ± 0.28 N, p = 0.71). No significant differences were found between retraction and dissection forces exerted by novice and expert robotic surgeons. This in vivo animal study demonstrated the efficacy of tactile feedback in reducing retraction forces during total mesorectal excision. Further research is required to quantify the clinical impact of such force reduction.

Screen-Based Simulation for Training and Automated Assessment of Teamwork Skills: Comparing 2 Modes With Different Interactivity

INTRODUCTION

The need for teamwork training is well documented; however, teaching these skills is challenging given the logistics of assembling individual team members together to train in person. We designed 2 modes of screen-based simulation for training teamwork skills to assess whether interactivity with nonplayer characters was necessary for in-game performance gains or for player satisfaction with the experience.

METHODS

Mixed, randomized, repeated measures study with licensed healthcare providers block-stratified and randomized to evaluation-participant observes and evaluates the team player in 3 scenarios-and game play-participant is immersed as the leader in the same 3 scenarios. Teamwork construct scores (leadership, communication, situation monitoring, mutual support) from an ontology-based, Bayesian network assessment model were analyzed using mixed randomized repeated measures analyses of variance to compare performance, across scenarios and modes. Learning was measured by pretest and posttest quiz scores. User experience was evaluated using χ2 analyses.

RESULTS

Among 166 recruited and randomized participants, 120 enrolled in the study and 109 had complete data for analysis. Mean composite teamwork Bayesian network scores improved for successive scenarios in both modes, with evaluation scores statistically higher than game play for every teamwork construct and scenario (r = 0.73, P = 0.000). Quiz scores improved from pretest to posttest (P = 0.004), but differences between modes were not significant.

CONCLUSIONS

For training teamwork skills using screen-based simulation, interactivity of the player with the nonplayer characters is not necessary for in-game performance gains or for player satisfaction with the experience.

Analysis of Early Job Market Experiences and Perceptions Among Bariatric Surgery Fellowship Graduates and Bariatric Surgery Program Directors

PURPOSE

Over the past decade, an increasing number of bariatric surgeons are trained in fellowships annually despite only a modest increase in nationwide bariatric surgery volume. The study surveys the bariatric surgery job market trend in order to inform better career-choice decisions for trainees interested in this field.

MATERIALS AND METHODS

A national retrospective cohort survey over an 11-year period was conducted. Bariatric surgery fellowship graduates from 2008 to 2019 and program directors (PDs) were surveyed electronically. Univariate analysis was performed comparing responses between earlier (2008-2016) and recent graduates (2017-2019).

RESULTS

We identified a total of 996 graduates and 143 PDs. Response rates were 9% and 20% respectively (n = 88, 29). Sixty-eight percent of graduates felt there are not enough bariatric jobs for new graduates. Seventy-nine percent of PDs felt that it is more difficult to find a bariatric job for their fellows now than 5-10 years ago. Forty-eight percent of PDs felt that we are training too many bariatric fellows. Seventy-seven percent of all graduates want the majority of their practice to be comprised bariatric cases; however, only 42% of them reported achieving this. In the univariate analysis, recent graduates were less likely to be currently employed as a bariatric surgeon (64% vs. 86%, p = 0.02) and were less satisfied with their current case volume (42% vs. 66%, p = 0.01).

CONCLUSIONS

The temporal increase in bariatric fellowship graduates over the past decade has resulted in a significant decline in the likelihood of employment in a full-time bariatric surgical practice and a decline in surgeons' bariatric case volumes.

Trends in Diverting Loop Ileostomy vs Total Abdominal Colectomy as Surgical Management for Clostridium difficile Colitis

Importance

Diverting loop ileostomy and colonic lavage has generated much interest since it was first reported as a potential alternative to total abdominal colectomy for treating Clostridium difficile colitis in 2011. To our knowledge, few studies have validated the benefit reported in the initial description, and the association of this new approach with practice patterns has not been described.

Objective

To examine the national adoption pattern and outcomes of diverting loop ileostomy vs total abdominal colectomy as treatment for fulminant C difficile colitis.

Design, Setting, and Participants

This retrospective cohort study used data from hospitals participating in the National Inpatient Sample database across the United States from January 2011 to September 2015 and included 3021 adult patients who underwent surgery for C difficile colitis during the study period, comprising 2408 subtotal colectomies and 613 loop ileostomies. The data were analyzed between November 2018 and April 2019.

Exposures

Loop ileostomy as surgery of choice.

Main Outcomes and Measures

In-hospital mortality.

Results

Of 2408 participants, 1416 (58.8%) were women, 1781 (78.4%) were white, and 627 (21.6%) were individuals of color and the mean (SD) age was 68.2 (14.8) years. During the overall study period, 613 patients (20.28%) underwent diverting loop ileostomy without total abdominal colectomy. The annual proportion of patients undergoing only diversion increased from 11.16% in 2011 to 25.30% in 2015. Significantly more loop ileostomies were performed within the first day of hospitalization, in contrast to subtotal colectomies (23.31% vs 12.21%; P < .01). There was no significant difference in in-hospital mortality rates between the 2 groups (25.98% vs 31.18%; P = .28).

Conclusions and Relevance

This study demonstrates the adoption of diverting loop ileostomy to treat C difficile colitis across the United States. While fulminant C difficile colitis remains a condition with high mortality rates, no significant difference in this outcome was observed between loop ileostomy and total abdominal colectomy. Loop ileostomy may represent a viable surgical alternative to total abdominal colectomy, although the grounds for selection of treatment need to be clarified.

Complete Impact of Care Fragmentation on Readmissions Following Urgent Abdominal Operations

BACKGROUND

Urgent abdominal operations commonly occurred in low-volume hospitals with high failure-to-rescue rates. Recent studies have demonstrated a survival benefit associated with readmission to the original hospital after operation, presumably due to improved continuity of care. It is unclear if this survival benefit persists in low-volume hospitals. We seek to evaluate differences in mortality between readmission to the original hospital and a higher-volume hospital after urgent abdominal operations.

METHODS

A retrospective cohort study using the National Readmissions Database from 2010 to 2014 was performed. Propensity score-weighted multilevel regression analysis was used to examine the association between readmission destination and mortality after accounting for hospital volume.

RESULTS

A total of 71,551 adult patients who experienced 30-day readmission following urgent abdominal operations were identified, among whom 10,368 (14.5%) were readmitted to a different hospital. Patients with higher baseline comorbidity scores, lower income, less comprehensive insurance coverage, systemic complications, prolonged length of stay, or non-home disposition were more likely to experience readmission to a different hospital. Following stratification by readmission hospital volume and propensity score weighting to adjust for baseline mortality risk differences, readmission to a different hospital is still associated with higher mortality rates than the original hospital.

CONCLUSIONS

The adverse outcomes associated with case fragmentation are present even after adjusting for readmission hospital volume. Patients who received urgent abdominal operations at low-volume hospitals should return to the original hospital for concern of care fragmentation.

Trends in Readmission and Costs After Transcatheter Implantation Versus Surgical Aortic Valve Replacement in Patients With Renal Dysfunction

Patients with renal dysfunction are at increased risk for developing aortic valve pathology. In the present era of value-based healthcare delivery, a comparison of transcatheter and surgical aortic valve replacement (SAVR) readmission performance in this population is warranted. All adult patients who underwent transcatheter or SAVR from 2011 to 2014 were identified using the Nationwide Readmissions Database, containing data for nearly 50% of US hospitalizations. Patients were further stratified as chronic kidney disease stage 1 to 5 as well as end-stage renal disease requiring dialysis. Kaplan-Meier, Cox Hazard, and multivariable regression models were generated to identify predictors of readmission and costs. Of the 350,609 isolated aortic valve replacements, 4.7% of patients suffered from chronic kidney disease stages 1 to 5 or end-stage renal disease. Transcatheter aortic valve patients with chronic kidney disease stages 1 to 5/or end-stage renal disease were older (81.9 vs 72.9 years, p <0.0001) with a higher prevalence of heart failure (15.2 vs 4.3%, p = 0.04), and peripheral vascular disease (31.1 vs 22.8%, p <0.0001) compared to their SAVR counterparts. Transcatheter aortic valve replacement in chronic kidney disease stage 1 to 3 patients had a higher rate of readmission due to heart failure and pacemaker placement than SAVR. Transcatheter aortic valve replacement was associated with increased costs compared with SAVR for all renal failure patients. In conclusion, in this national cohort of chronic and end-stage renal disease patients, transcatheter aortic valve implantation was associated with increased mortality, readmissions for chronic kidney disease stages1 to 3, and index hospitalization costs.

Multi-Modal Haptic Feedback for Grip Force Reduction in Robotic Surgery

Minimally invasive robotic surgery allows for many advantages over traditional surgical procedures, but the loss of force feedback combined with a potential for strong grasping forces can result in excessive tissue damage. Single modality haptic feedback systems have been designed and tested in an attempt to diminish grasping forces, but the results still fall short of natural performance. A multi-modal pneumatic feedback system was designed to allow for tactile, kinesthetic, and vibrotactile feedback, with the aims of more closely imitating natural touch and further improving the effectiveness of HFS in robotic surgical applications and tasks such as tissue grasping and manipulation. Testing of the multi-modal system yielded very promising results with an average force reduction of nearly 50% between the no feedback and hybrid (tactile and kinesthetic) trials (p < 1.0E-16). The multi-modal system demonstrated an increased reduction over single modality feedback solutions and indicated that the system can help users achieve average grip forces closer to those normally possible with the human hand.

An Innovative Approach for Familiarizing Surgeons with Malpractice Litigation

OBJECTIVE

Familiarize surgery residents with medicolegal knowledge and skills required when facing the prospect of being sued through a simulation session.

DESIGN

The general surgery residency, hospital risk management, and malpractice attorneys collaboratively organized an educational intervention, consisting of an introductory lecture followed by a mock lawsuit. Two medical malpractice attorneys acted as defense and plaintiff attorneys while an attending surgeon experienced in litigation acted as defendant. Experience, attitudes, and preintervention/postintervention competency were evaluated via retrospective self-assessment.

SETTING

Weekly departmental educational conference.

PARTICIPANTS

Forty residents and attending surgeons.

RESULTS

Among the participants, 27.5% had been named in a law suit before. Most surgeons (70.0%) are worried about malpractice. Physicians who had been sued were no more likely to worry about malpractice (18.6 vs 25.0%, p = 0.82) than their colleagues who had never been sued. Results from the retrospective preintervention/postintervention competency assessments demonstrated significant improvement in all measured competencies after the mock lawsuit. In comparison with attending faculty, residents obtained greater improvements in understanding the essential elements of a medical claim (1.9 vs 1.1, p = 0.03), gaining confidence doing a deposition for medical litigation (1.9 vs 0.9, p < 0.01) and understanding the do's and don'ts when named in a lawsuit (2.0 vs 1.1, p = 0.01).

CONCLUSIONS

The novel educational format effectively familiarized surgery faculty and residents with the process of litigation and improved their confidence and mental preparedness when facing the prospect of a lawsuit. It is a valuable educational tool that can be incorporated in residency training and faculty development curricula.

Mixed-Method Evaluation of a Cadaver Dissection Course for General Surgery Interns: An Innovative Approach for Filling the Gap Between Gross Anatomy and the Operating Room

OBJECTIVE

To evaluate an innovative whole cadaver dissection curriculum designed to focus on teaching procedure-relevant anatomy and surgical skills to surgery interns.

DESIGN

A mixed methods explanatory sequential design incorporating both quantitative and qualitative evaluations was used to evaluate the cadaver dissection course. Quantitative data were prospectively collected and retrospectively reviewed in order to compare anatomy knowledge and operative skills before and after the course. In the qualitative phase, open-ended telephone interviews were conducted in order to explore the major strengths and weaknesses of the course and gain a more in-depth understanding of resident perceptions and attitudes toward the course.

SETTING

All UCLA categorical surgery interns who have undergone the cadaver dissection curriculum between the years 2010 to 2016 were recruited for evaluation and interview.

PARTICIPANTS

From 2010 to 2016, 6 to 7 categorical surgery interns were enrolled in the cadaver dissection course each year.

RESULTS

Anatomy practical examination scores increased following implementation of the course from 50.5% to 83.5% (p < 0.01). Faculty ratings of operative skills improved as well (average Likert scale rating for technical skills improved from 4.1 ± 0.4 to 4.4 ± 0.3, p = 0.06). Almost all interviewees (96%) reported that the course improved their knowledge of anatomy, and 78% of respondents believed the course was conducive to improving technical skills.

CONCLUSIONS

We believe that cadaver dissection courses offer a superior educational model for teaching clinically relevant anatomy as well as surgical skills. We found improvements in anatomy knowledge and technical skills, and trainees expressed strongly favorable views of the program.

Readmissions after Ileostomy Creation Using a Nationwide Database

Readmissions occur frequently in patients undergoing ostomy creation, ranging from 12 per cent to more than 30 per cent. The objective of this study was to compare the reasons for early versus intermediate readmissions after surgical procedures involving formation of ileostomies at a national level. Patients receiving a new ileostomy were identified in the 2010 to 2014 Nationwide Readmission Database. Patients were categorized into Early, Intermediate, and Late cohorts (0–7, 8–30, 31–90 days, respectively), based on discharge-to-readmission interval. Of the 76,590 patients undergoing ileostomy creation, 28 per cent were nonelectively rehospitalized within 90 days after discharge: 10 per cent Early, 12 per cent Intermediate, and 7 per cent Late. Compared with the Intermediate cohort, the Early readmissions were more frequently because of anastomotic complications (20% vs 12%, P < 0.001) and gastrointestinal obstruction (10% vs 5%, P < 0.001), whereas Intermediate readmissions were because of renal failure (17% vs 9%, P < 0.001). In the Late group, the most common reason for readmission was renal failure (14%), followed by anastomotic complications (11%), and stoma reversal (8%). In this nationwide study, all-cause 90-day non-elective readmissions after ileostomy procedures occurred in nearly 30 per cent of patients. Although early rehospitalizations were mainly because of surgical complications and gastrointestinal complications, late readmissions were because of ileostomy reversal.

Readmissions after Ileostomy Creation Using a Nationwide Database

Readmissions occur frequently in patients undergoing ostomy creation, ranging from 12 per cent to more than 30 per cent. The objective of this study was to compare the reasons for early versus intermediate readmissions after surgical procedures involving formation of ileostomies at a national level. Patients receiving a new ileostomy were identified in the 2010 to 2014 Nationwide Readmission Database. Patients were categorized into Early, Intermediate, and Late cohorts (0-7, 8-30, 31-90 days, respectively), based on discharge-to-readmission interval. Of the 76,590 patients undergoing ileostomy creation, 28 per cent were nonelectively rehospitalized within 90 days after discharge: 10 per cent Early, 12 per cent Intermediate, and 7 per cent Late. Compared with the Intermediate cohort, the Early readmissions were more frequently because of anastomotic complications (20% vs 12%, P < 0.001) and gastrointestinal obstruction (10% vs 5%, P < 0.001), whereas Intermediate readmissions were because of renal failure (17% vs 9%, P < 0.001). In the Late group, the most common reason for readmission was renal failure (14%), followed by anastomotic complications (11%), and stoma reversal (8%). In this nationwide study, all-cause 90-day nonelective readmissions after ileostomy procedures occurred in nearly 30 per cent of patients. Although early rehospitalizations were mainly because of surgical complications and gastrointestinal complications, late readmissions were because of ileostomy reversal.

Suture Breakage Warning System for Robotic Surgery

As robotic surgery has increased in popularity, the lack of haptic feedback has become a growing issue due to the application of excessive forces that may lead to clinical problems such as intraoperative and postoperative suture breakage. Previous suture breakage warning systems have largely depended on visual and/or auditory feedback modalities, which have been shown to increase cognitive load and reduce operator performance. This work catalogues a new sensing technology and haptic feedback system (HFS) that can reduce instances of suture failure without negatively impacting performance outcomes including knot quality. Suture breakage is common in knot-tying as the pulling motion introduces prominent shear forces. A shear sensor mountable on the da Vinci robotic surgical system's Cadiere grasper detects forces that correlate to the suture's internal tension. HFS then provides vibration feedback to the operator as forces near a particular material's failure load. To validate the system, subjects tightened a total of four knots, two with the Haptic Feedback System (HFS) and two without feedback. The number of suture breakages were recorded and knot fidelity was evaluated by measuring knot slippage. Results showed that instances of suture failure were significantly reduced when HFS was enabled (p = 0.0078). Notably, knots tied with HFS also showed improved quality compared to those tied without feedback (p = 0.010). The results highlight the value of HFS in improving robotic procedure outcomes by reducing instances of suture failures, producing better knots, and reducing the need for corrective measures.

Impact of New-Onset Postoperative Depression on Readmission Outcomes After Surgical Coronary Revascularization

BACKGROUND

Depression affects between 10% and 40% of cardiac surgery patients and is associated with significantly worse outcomes. The incidence and impact of new-onset depression beyond acute follow-up remain ill-defined. The present study aimed to evaluate the incidence, risk factors, and prognostic implication of depression on 90-d readmission rates after coronary artery bypass grafting (CABG) surgery.

METHODS

A retrospective cohort study was performed identifying adult patients without prior depression who underwent CABG surgery using the 2010-2014 National Readmissions Database. CABG patients who were readmitted more than 2 wk but within 90 d of discharge were categorized based on the presence of new-onset depression. Association between the development of new-onset depression and rehospitalization were morbidity, mortality, costs, and length of stay (LOS) and were examined using multivariable regression.

RESULTS

During the study period, 1,001,945 patients underwent CABG. Of these, 11.7% of patients were readmitted after 14 d but within 90 d of discharge with 5.1% of these patients having a diagnosis of new-onset depression. Postoperative new-onset depression was not associated with increased readmission morbidity, costs, or LOS. Mortality in new-onset depression readmissions was 1.2%, compared with 2.3% in all readmitted patients (P = 0.014). Depression was associated with lower odds of mortality (OR = 0.56, P = 0.02).

CONCLUSIONS

New-onset depression following CABG discharge was not associated with increased odds of mortality, morbidity, costs, or increased LOS on readmission. Rather, new-onset depression is associated with decreased odds of readmission mortality. Overall, CABG readmissions are decreasing, whereas the rate of new-onset depression is slightly increasing. Implementation of routine depression screening tools in postoperative CABG care may aid in early detection and management of depression to enhance postoperative recovery and quality of life.

Efficacy of video-based education program in improving metabolic surgery perception among patients with obesity and diabetes

BACKGROUND

Metabolic surgery remains underutilized despite its efficacy and safety. Poor perception of surgery has been cited as one of the major reasons.

OBJECTIVES

Evaluate current patient perceptions about metabolic surgery and measure the impact a video-based education program has on changing the perceptions of patients diagnosed with obesity and type 2 diabetes.

SETTING

A university hospital in the United States.

METHODS

A prospective interventional study was performed at an endocrinology clinic. Patients were asked to complete surveys evaluating their perception of metabolic surgery before and after watching a short educational video.

RESULTS

A total of 51 patients were recruited; almost all patients (98%) attempted weight loss in the past, and approximately 90.1% voiced dissatisfaction with their current weight. The video-based education program was effective in improving the patient's perception of the efficacy and safety with regard to surgery. In addition, the proportion of patients with overall positive impression toward metabolic surgery increased from 22.5% to 53.1% (P < .01) and those willing to undergo surgical consultation increased from 41.7% to 51.0% (P < .01). Among those that remained unwilling, fear of surgery in general was the most commonly voiced reason (31.4%), with safety (27.5%) and cost of metabolic surgery (27.5%) being equally concerning.

CONCLUSIONS

Most patients with obesity and type 2 diabetes held negative impressions of metabolic surgery due to its perceived risk profile. A video-based educational intervention may improve patients' perception and increase their willingness for surgical referral. Future trials with a broader sample and longer follow-up could provide answers to its efficacy in increasing metabolic surgery accessibility.

Readmission and resource utilization after orthotopic heart transplant versus ventricular assist device in the National Readmissions Database, 2010-2014

BACKGROUND

As the technology of ventricular assist devices continues to improve, the morbidity and mortality for patients with a ventricular assist device is expected to approach that of orthotopic heart transplantation. The present study was performed to compare perioperative outcomes, readmission, and resource utilization between ventricular assist device implantation and orthotopic heart transplantation, using a national cohort.

METHODS

Patients who underwent either orthotopic heart transplantation or ventricular assist device implantation from 2010 to 2014 in the National Readmission Database were selected.

RESULTS

Of the 12,111 patients identified during the study period, 5,440 (45%) received orthotopic heart transplantation, while 6,671 (55%) received ventricular assist devices. Readmissions occurred frequently after ventricular assist device implantation and orthotopic heart transplantation, with greater rates at 30 days (29% versus 24%, P=.005) and 6 months (62% versus 46%, P < .001) for the ventricular assist device cohort. Cost of readmission was greater among ventricular assist device patients at 30 days ($29,115 versus $21,586, P=.0002) and 6 months ($34,878 versus $20,144, P = .0106).

CONCLUSION

Readmission rates and costs for patients with a ventricular assist device remain greater than their orthotopic heart transplantation counterparts. Given the projected increases in ventricular assist device utilization and limited transplant donor pool, further emphasis on cost containment and decreased readmissions for patients undergoing a ventricular assist device is essential to the viability of such therapy in the era of value-based health care delivery.

Robotic-assisted spleen preserving distal pancreatectomy: a technical review

Minimally-invasive spleen-preserving distal pancreatectomy is indicated for benign or borderline malignant lesions confined to the pancreatic body and tail. With the introduction of the da Vinci robotic system, preliminary case series have suggested an improved spleen preservation rate, higher rate of margin negative resections and improved lymph node yield versus the standard laparoscopic approach. In this article, we described our approach to robotic-assisted distal pancreatectomy with both vessel-conserving (Kimura) and vessel-sacrificing (Warshaw) variations.

Obesity Is Associated with Early Onset of Gastrointestinal Cancers in California

BACKGROUND

Although it is well known that obesity is a risk factor for gastrointestinal (GI) cancer, it is not well established if obesity can cause earlier GI cancer onset.

METHODS

A cross-sectional study examining the linked 2004-2008 California Cancer Registry Patient Discharge Database was performed to evaluate the association between obesity and onset age among four gastrointestinal cancers, including esophageal, gastric, pancreatic, and colorectal cancers. Regression models were constructed to adjust for other carcinogenic factors.

RESULTS

The diagnosis of obesity (BMI > 30) was associated with a reduction in diagnosis age across all four cancer types: 3.25 ± 0.53 years for gastric cancer, 4.56 ± 0.18 years for colorectal cancer, 4.73 ± 0.73 years for esophageal cancer, and 5.35 ± 0.72 for pancreatic cancer. The diagnosis of morbid obesity (BMI > 40) was associated with a more pronounced reduction in the age of diagnosis: 5.48 ± 0.96 years for gastric cancer, 7.75 ± 0.30 years for colorectal cancer, 7.67 ± 1.26 years for esophageal cancer, and 8.19 ± 1.25 years for pancreatic cancer. Both morbid obesity and obesity remained strongly associated with earlier cancer diagnosis for all four cancer types even after adjusting for other available cancer risk factors.

CONCLUSIONS

The diagnosis of obesity, especially morbid obesity, was associated with a significantly earlier gastrointestinal cancer onset in California. Further research with prospective cohort data may be required to establish the causal relationship between obesity and cancer onset age.

Incidence of Myocardial Infarction After High-Risk Vascular Operations in Adults

Importance

Advances in perioperative cardiac management and an increase in the number of endovascular procedures have made significant contributions to patients and postoperative myocardial infarction (POMI) risk following high-risk vascular procedures. Whether these changes have translated into real-world improvements in POMI incidence remain unknown.

Objective

To examine the temporal trends of myocardial infarction (MI) following high-risk vascular procedures.

Design, Setting, and Participants

A retrospective cohort study was performed using data collected from January 1, 2005, to December 31, 2013, in the American College of Surgeons National Surgery Quality Improvement Program database, to which participating hospitals across the United States report their preoperative, operative, and 30-day outcome data. A total of 90 303 adults who underwent a high-risk vascular procedure-open aortic surgery or infrainguinal bypass-during the study period were identified. Patients were divided into cohorts based on their year of operation, and their baseline cardiac risk factors and incidence of POMI were compared. Cases from 2005 to 2014 in the database were eligible for inclusion if one of their Current Procedural Terminology codes matched any of the operations identified as a high-risk vascular procedure. Data analysis took place from August 1, 2016, to November 15, 2016.

Exposures

The main exposure was the year of the operation. Other variables of interest included demographics, comorbidities, and other risk factors for MI.

Main Outcomes and Measures

Primary outcome of interest was the incidence of POMI.

Results

Of the 90 303 patients included in the study, 22 836 (25.3%) had undergone open aortic surgery and 67 467 (74.7%) had had infrainguinal bypass. The open aortic cohort comprised 16 391 men (71.9%), had a mean (SD) age of 69.1 (11.5) years, and was predominantly white (18 440 patients [80.8%] self-identified as white race/ethnicity). The infrainguinal bypass cohort included 41 845 men (62.1%), had a mean (SD) age of 66.7 (11.7) years, and had 51 043 patients (75.7%) who self-identified as white race/ethnicity. During the study period, patients who underwent open aortic procedures were more likely to be classified as American Society of Anesthesiologists class IV (7426 patients [32.6%] vs 15 683 [23.3%] for the infrainguinal bypass cohort) or class V (1131 [5.0%] vs 206 [0.3%]; P < .001) and to undergo emergency procedures (4852 [21.3%] vs 4954 [7.3%]; P < .001). The open aortic procedure cohort also experienced significantly higher actual incidence of POMI (464 [3.0%] vs 1270 [1.9%]; P < .001). From 2009 to 2014, the incidence of POMI demonstrated no substantial temporal change (2.7% in 2009 to 3.1% in 2014; P = .64 for trend). Postoperative MI was consistently associated with poor prognosis, with a 3.62-fold (95% CI, 2.25-5.82) to 11.77-fold (95% CI, 6.10-22.72) increased odds of cardiac arrest and a 3.01-fold (95% CI, 2.08-4.36) to 6.66-fold (95% CI, 4.66-9.52) increased odds of mortality.

Conclusions and Relevance

The incidence of MI did not significantly decrease in the past decade and has been consistently associated with worse clinical outcomes. Further inquiry into why advanced perioperative care did not reduce cardiac complications is important to quality improvement efforts.

Comparative Analysis of Simulated versus Live Patient-Based FAST (Focused Assessment With Sonography for Trauma) Training

OBJECTIVE

To investigate whether simulated patient (SP)-based training has comparable efficacy as live patient (LP)-based training in teaching Focused Abdominal Sonography for Trauma (FAST) knowledge and skill competencies to surgical residents.

DESIGN

A randomized pretest/intervention/posttest controlled study design was employed to compare the participants' performance in written and practical examinations regarding FAST examination after SP-based versus LP-based training.

SETTING

University-based general residency program at a single institution.

PARTICIPANTS

A total of 29 general surgery residents of various training levels and sonographic experience were recruited by convenience sampling.

RESULTS

There was no correlation between subjects' baseline training level or sonographic experience with either the posttest-pretest score difference or the percentage of subjects getting all 4 windows with adequate quality. There was no significant difference between the improvement in written posttest-pretest scores for SP and LP group, which were 33 ± 9.6 and 31 ± 6.8 (p = 0.40), respectively. With regard to performance-based learning efficacy, a statistically higher proportion of subjects were able to obtain all 4 windows with adequate quality among the LP than the SP group (6/8 vs 1/8, p = 0.01).

CONCLUSION

SP- and LP-based FAST training for surgical residents were associated with similar knowledge-based competency acquisition, but residents receiving LP-based training were better at acquiring adequate FAST windows on live patients. Simulation training appeared to be a valid adjunct to LP practice but cannot replace LP training. Future investigations on how to improve simulation fidelity and its training efficacy for skill-based competencies are warranted.

Does Travel Distance Affect Readmission Rates after Cardiac Surgery?

With emphasis on value-based health care, empiric models are used to estimate expected readmission rates for individual institutions. The aim of this study was to determine the relationship between distance traveled to seek surgical care and likelihood of readmission in adult patients undergoing cardiac operations at a single medical center. All adults undergoing major cardiac surgeries from 2008 to 2015 were included. Patients were stratified by travel distance into regional and distant travel groups. Multivariable logistic regression models were developed to assess the impact of distance traveled on odds of readmission. Of the 4232 patients analyzed, 29 per cent were in the regional group and 71 per cent in the distant. Baseline characteristics between the two groups were comparable except mean age (62 vs 61 years, P < 0.01) and Caucasian race (59 vs 73%, P < 0.01). Distant travel was associated with a significantly longer hospital length of stay (11.8 vs 10.5 days, P < 0.01) and lower risk of readmission (9.5 vs 13.4%, P < 0.01). Odds of readmission was inversely associated with logarithm of distance traveled (odds ratio 0.75). Travel distance in patients undergoing major cardiac surgeries was inversely associated with odds of readmission.

Innominate Artery Stenosis Presenting With Migratory Digital Ischemia

Background:

Atherosclerotic lesions of the supra-aortic trunk vessels, including the innominate artery, subclavian artery, or the common carotid artery, tend to present either as low-flow state distal to the lesion or as embolic events. The risk of embolic cerebrovascular event complicates the management of this condition via a pure endovascular approach. A combined operative–endovascular intervention may be a valuable approach in order to reduce the risk of intraoperative stroke and prevent future embolic events.

Case Presentation:

An 84-year-old female presented at the emergency department (ED) with a 4-month history of migratory digital cyanotic lesions across various fingers on her right hand. The lesion eventually progressed into dry gangrene on her right middle finger. Selective angiography of the aortic arch vessels demonstrated significant atherosclerotic plaque burden throughout her supra-aortic vessels and a segmental stenosis at the proximal innominate artery. A right carotid cut down was performed to allow clamping of the carotid artery so as to minimize the risk of intraoperative stroke from plaque manipulation. Retrograde balloon angioplasty was performed, and stent was placed across the stenotic segment. The patient tolerated the procedure well and had an uneventful postoperative course. She was discharged on postoperative day 3. At 2-week follow-up, she has had no progression of her digital ischemia nor other focal cranial nerve deficits.

Conclusion:

Migratory digital ischemia is a rare presentation of atherosclerotic disease of the supra-aortic vessels. It represents a challenging situation for endovascular intervention due to concern about plaque dislodgment during the procedure. A retrograde balloon-stent angioplasty following distal carotid control with an open approach may be safe and effective in selected patients.

Laparoscopic versus open ventral hernia repair in patients with chronic liver disease

BACKGROUND

Previous studies demonstrated laparoscopic ventral hernia repair (LVHR) to be associated with fewer short-term complications than open ventral hernia repair (OVHR). Little literature is available comparing LVHR and OVHR in chronic liver disease (CLD) patients.

METHODS

Patients with model for end-stage liver disease score ≥9 who underwent elective ventral hernia repair in the National Surgical Quality Improvement Program Database were included. 30-day outcomes were compared between LVHR and OVHR after adjusting for hernia disease severity, baseline comorbidities and demographic factors.

RESULTS

A total of 3594 ventral hernia repairs were included, 536 (14.9 %) of which were LVHR. After adjusting for other confounders, LVHR was associated with a lower incidence of wound-related complications (0.23, 95 % CI 0.07-0.74, p = 0.01), shorter length of stay (mean 3.7 vs. 5.0 days, p < 0.01) than OVHR, but similar systemic complications (p = 0.77), bleeding complications (p = 0.69), unplanned reoperation (p = 0.74) or readmission (p = 0.40). Propensity score-matched comparison showed similar conclusions. Five hundred and sixty-two patients had ascites, among whom 35 (6.2 %) underwent LVHR. In this subcohort, LVHR was associated with higher mortality (OR 5.36, 95 % CI 1.00-28.60, p = 0.05), systemic complications (OR 7.03, 95 % CI 2.06-24.00, p < 0.01), and unplanned reoperation (OR 6.03, 95 % CI 1.51-24.12, p = 0.01) than OVHR.

CONCLUSIONS

In comparison with OVHR, LVHR is associated with similar short-term outcomes except for lower wound-related complications and shorter length of stay in CLD patients. However, when patients have ascites, LVHR is associated with higher mortality, systemic complications, and unplanned reoperation.

Epigenetic therapy for solid tumors: from bench science to clinical trials

The cancer epigenome is characterized by global DNA methylation and chromatin changes, such as the hypermethylation of specific CpG island promoters. Epigenetic agents like DNA methyltransferase or histone deacetylase inhibitors induce phenotype changes by reactivation of epigenetically silenced tumor suppressor genes. Despite initial promise in hematologic malignancies, epigenetic agents have not shown significant efficacy as monotherapy against solid tumors. Recent trials showed that epigenetic agents exert favorable modifier effects when combined with chemotherapy, hormonal therapy, or other epigenetic agents. Due to the novel nature of their mechanism, it is important to reconsider the optimal patient selection, drug regimen, study design, and outcome measures when pursuing future trials in order to discover the full potential of this new therapeutic modality.

Single-incision robotic colectomy (SIRC): Current status and future directions

By combining laparo-endoscopic single-site surgery (LESS) techniques with the da Vinci robotic platform, single-incision robotic colectomy (SIRC) aims to further minimize incision-related complications and improve cosmetic outcomes from the current standard of care, laparoscopic colectomy. While there is limited literature on SIRC, all available reports suggest SIRC to be a safe and feasible procedure in terms of perioperative outcomes. Future research should focus on further clarification of proposed benefits of SIRC such as cosmetics, ergonomics, incidence of incision-related complications, and long-term oncologic outcomes.

Single-Incision Robotic Colectomy (SIRC) case series: initial experience at a single center

BACKGROUND

Laparoscopic colectomy has been associated with favorable outcomes when compared to open colectomy. Single-Incision Robotic Colectomy (SIRC) is a novel procedure hypothesized to improve upon conventional three-port laparoscopic colectomy. We hereby present and analyze our institution's initial experience with SIRC.

METHODS

We performed a retrospective review of 59 patients who underwent SIRC between May 2010 and September 2013, attempting to identify factors associated with conversion rate and postoperative complication rate.

RESULTS

Our study included 34 males (57.6%) and 25 females (42.4%). The mean age was 60.3 years (range 29-92 years), and the mean BMI was 26.6 kg/m(2) (range 14.9-39.7 kg/m(2)). We identified 31 right hemicolectomies (53.4%), 20 sigmoid colectomies (34.5%), 5 left hemicolectomies (1.7%), 2 low anterior resections (3.5%), and 1 total colectomy (1.7%). The overall median operative time was 188 min with an interquartile range of 79 min. Surgical indications included diverticulitis (n = 23, 39.0%), benign colonic mass (n = 18, 30.5%), colon cancer (n = 16, 27.1%), familial adenomatous polyposis (n = 1, 1.7%), and Crohn's disease (n = 1, 1.7%). There were four conversions to open procedure (6.8%), three conversions to multiport robotic procedure (5.1%), and one conversion to single-port laparoscopic procedure (1.7%). Reasons for conversions include difficulty mobilizing the colon and robotic equipment malfunction. Conversions were associated with both higher complication rates (62.5 vs 25.5%, p = 0.035) and longer LOS (7.4 vs 4.0 days, p = 0.0003). Postoperative complications occurred in 16 of the 59 cases (27.1%). Higher BMI was the only significant risk factor for postoperative complications. The overall median LOS was 4 ± 2 days, while the median estimated blood loss was 100 ± 90 ml.

CONCLUSIONS

Our experience has shown that SIRC can be a safe and feasible procedure for both benign and malignant disease. Patient selection is the key to improving surgical outcomes in SIRC.

Robot-assisted single-incision total colectomy: a case report

BACKGROUND

Literature reports shows that robots provide an opportunity for meeting technical challenges associated with Laparo-endoscopic Single Site Surgery (LESS). Following previous success with robot-assisted single-incision right hemicolectomy, this paper reports experience with robot-assisted single-incision total colectomy.

METHODS

Through a single incision around the umbilicus, three robotic ports and a laparoscopic port were placed through the GelPOINT. With one intraoperative redocking of the robot, it was possible to access both right and left sides of the colon. The entire colon was externalized through the GelPOINT and the umbilical incision closed in layers.

RESULTS

The entire procedure took 227 minutes. There was minimal blood loss. The patient was discharged on post-operative day four with no complications. No wound site complications were observed in clinic one week after discharge.

CONCLUSIONS

Robot-assisted single-incision total colectomy is a feasible procedure associated with little increase in operative time.

Is minimally invasive colon resection better than traditional approaches?: First comprehensive national examination with propensity score matching

IMPORTANCE

Minimally invasive colectomies are increasingly popular options for colon resection.

OBJECTIVE

To compare the perioperative outcomes and costs of robot-assisted colectomy (RC), laparoscopic colectomy (LC), and open colectomy (OC).

DESIGN, SETTING, AND PARTICIPANTS

The US Nationwide Inpatient Sample database was used to examine outcomes and costs before and after propensity score matching across the 3 surgical approaches. This study involved a sample of US hospital discharges from 2008 to 2010 and all patients 21 years of age or older who underwent elective colectomy. MAIN OUTCOMES AND MEASURES In-hospital mortality, complications, ostomy rates, conversion to open procedure, length of stay, discharge disposition, and cost.

RESULTS

Of the 244129 colectomies performed during the study period, 126284 (51.7%) were OCs, 116261 (47.6%) were LCs, and 1584 (0.6%) were RCs. In comparison with OC, LC was associated with a lower mortality rate (0.4% vs 2.0%), lower complication rate (19.8% vs 33.2%), lower ostomy rate (3.5 vs 13.0%), shorter median length of stay (4 vs 6 days), a higher routine discharge rate (86.1% vs 68.4%), and lower overall cost than OC ($11742 vs $13666) (all P<.05). Comparison between RC and LC showed no significant differences with respect to in-hospital mortality (0.0% vs 0.7%), complication rates (14.7% vs 18.5%), ostomy rates (3.0% vs 5.1%), conversions to open procedure (5.7% vs 9.9%), and routine discharge rates (88.7% vs 88.5%) (all P>.05). However, RC incurred a higher overall hospitalization cost than LC ($14847 vs $11966, P<.001).

CONCLUSIONS AND RELEVANCE

In this nationwide comparison of minimally invasive approaches for colon resection, LC demonstrated favorable clinical outcomes and lower cost than OC. Robot-assisted colectomy was equivalent in most clinical outcomes to LC but incurred a higher cost.

Prognostic value of CpG island methylator phenotype among colorectal cancer patients: a systematic review and meta-analysis

BACKGROUND

Divergent findings regarding the prognostic value of CpG island methylator phenotype (CIMP) in colorectal cancer (CRC) patients exist in current literature. We aim to review data from published studies in order to examine the association between CIMP and CRC prognosis.

MATERIALS AND METHODS

A comprehensive search for studies reporting disease-free survival (DFS), overall survival (OS), or cancer-specific mortality of CRC patients stratified by CIMP is carried out. Study findings are summarized descriptively and quantitatively, using adjusted hazard ratios (HRs) as summary statistics.

RESULTS

Thirty-three studies reporting survival in 10 635 patients are included for review. Nineteen studies provide data suitable for meta-analysis. The definition of CIMP regarding gene panel, marker threshold, and laboratory method varies across studies. Pooled analysis shows that CIMP is significantly associated with shorter DFS (pooled HR estimate 1.45; 95% confidence interval (CI) 1.07-1.97, Q = 3.95, I(2) = 0%) and OS (pooled HR estimate 1.43; 95% CI 1.18-1.73, Q = 4.03, I(2) = 0%) among CRC patients irrespective of microsatellite instability (MSI) status. Subgroup analysis of microsatellite stable (MSS) CRC patients also shows significant association between shorter OS (pooled HR estimate 1.37; 95% CI 1.12-1.68, Q = 4.45, I(2) = 33%) and CIMP. Seven studies have explored CIMP's value as a predictive factor on stage II and III CRC patient's DFS after receiving adjuvant 5-fluorouracil (5-FU) therapy: of these, four studies showed that adjuvant chemotherapy conferred a DFS benefit among CIMP(+) patients, one concluded to the contrary, and two found no significant correlation. Insufficient data was present for statistical synthesis of CIMP's predictive value among CRC patients receiving adjuvant 5-FU therapy.

CONCLUSION

CIMP is independently associated with significantly worse prognosis in CRC patients. However, CIMP's value as a predictive factor in assessing whether adjuvant 5-FU therapy will confer additional survival benefit to CRC patients remained to be determined through future prospective randomized studies.