"Needlescopic" heller myotomy

MIS continues to evolve with the introduction of new techniques and technology. This report discusses the use of "needlescopic" technology in the surgical management of achalasia. Heller myotomy procedures performed between January 1, 1997, and July 1, 2000, were analyzed and the results of 14 needlescopic procedures were compared with 15 laparoscopic procedures. Demographic and short-term outcome data were compared for each group using chi2, Fisher exact, and Student t tests where appropriate. Both groups were similar in age and gender. However, the needlescopic group weighed less (72.2 vs. 83.5 kg; P = 0.05). Intraoperatively, the needlescopic procedures were shorter (98.2 vs. 131.9 minutes; P = 0.03). There were no conversions to open surgery or differences in the number of intraoperative complications for either group. Postoperatively, the groups had similar complications, time to normal diet, and analgesia requirements. Nonetheless, the needlescopic group had a shorter length of stay in hospital (1.1 vs. 2.0 days; P = 0.04). Needlescopic Heller myotomy appears to be a safe treatment option, resulting in a decreased length of stay and improved wound cosmesis.

Minimally invasive surgery training in Canada: a survey of general surgery

BACKGROUND

The purpose of this study was to assess the state of surgical training in minimally invasive surgery (MIS) within Canadian academic surgical departments.

METHODS

A pretested questionnaire was distributed to the general surgery residents of participating Canadian academic surgical departments.

RESULTS

Fourteen of 16 residency programs participated and 235 of 388 residents (60%) responded to the survey. Residents expect to perform both basic (217/235 [92%]) and advanced (123/234 [53%]) MIS procedures on completion of their residency. However, only 41 of 233 (18%) believed that their advanced MIS training would be adequate. On a Likert scale, the most important factors influencing their training included limited advanced case volume (median, 5), limited opportunity in the operating room (OR) (median, 5), lack of attending surgeon interest (median, 4), limited OR time (median, 4), and a lack of surgical department support (median, 4). Residents were concerned about their ability to acquire these skills once they finished their training (median, 4), and 231 of 234 (99%) thought that there was an important role for a MIS surgeon within the academic setting (median, 5).

CONCLUSION

The rapid development of MIS has generated complex issues for resident training within the present Canadian academic surgical environment.

Laparoscopic splenectomy for idiopathic thrombocytopenic purpura (ITP)

BACKGROUND

Although the short-term benefits of laparoscopic splenectomy (LS) have been well documented, long-term follow-up data of patients who have undergone LS for ITP are scarce. We report our long-term follow-up data in patients who underwent LS for idiopathic thrombocytopenic purpura (ITP).

METHODS

Data were obtained from a prospectively collected computer database of 52 patients who underwent LS between October 1992 and December 2000 for medically refractory ITP. Patients and their referring hematologist were contacted, and follow-up information was obtained for 45 patients.

RESULTS

Fifty-two patients (27 women and 25 men) underwent LS for ITP. Median operative time was 160 min (range, 70-335); and median blood loss was 100 cc (range, 20-1500). There were seven cases of intraoperative hemorrhage (13.7%), resulting in one conversion. A second case was converted due to inadequate working space in a patient with a 26-cm spleen. Accessory spleens were found in 17 patients (32.7%). Postoperative complications occurred in three patients (5.9%). There were no deaths. Median length of hospital stay was 2 days (range, 1-12). Follow-up data were obtained in 45 patients (86.5%), with a median follow-up of 51 months. Six patients did not respond to surgery initially, and another two patients developed recurrent disease, for a remission rate of 82.2%. Nine patients underwent a damaged red blood cell scan. This group included the two patients who suffered recurrences. A positive scan was obtained in three patients (33%), one of whom was a patient with recurrent disease. This patient underwent an uneventful laparoscopic excision of residual splenic tissue but continues to require intermittent steroids to maintain platelet counts. The two other patients with a positive scan remain in remission.

CONCLUSIONS

Laparoscopic splenectomy for ITP is safe and associated with low morbidity and a short hospital stay. Long-term follow-up showed that remission rates of ITP following LS are comparable to those reported in the literature on open surgery.

Early experience with laparoscopic ileal pouch-anal anastomosis for ulcerative colitis

The purpose of this study was to describe our minimally invasive technique and outline perioperative and medium-term outcomes in patients undergoing laparoscopic ileal pouch-anal anastomosis (LIPAA) for ulcerative colitis. Data were obtained from a prospectively collected database of 13 LIPPA procedures performed for ulcerative colitis between May 1994 and November 2000. Medium-term quality-of-life follow-up was obtained by telephone interview. Eight males and five females had an LIPAA performed, all of whom had previously undergone total abdominal colectomy with ileostomy. Median operative time was 255 minutes (range, 200-398 minutes) with one conversion (8%) due to adhesions. There were no deaths or intraoperative complications; however, six patients experienced seven postoperative complications within 30 days of final closure of defunctioning ileostomy (two leaks, two wound infections, one pulmonary embolus, and two reoperations for small bowel obstruction). Median length of stay was 7 days (range, 5-13 days). Median follow-up was 24 months (range, 6-66 months). The median number of day and night bowel movements was 6.0 (range, 3-10) and 1.0 (range, 0-3), respectively, with five patients requiring medication to control frequency. None had incontinence of stool or retrograde ejaculation; however, one had occasional incontinence of gas, three had occasional nocturnal soiling, and one was impotent. Three patients (23%) had pouchitis, all treated successfully with oral antibiotics. All patients were satisfied with the outcome of their operation and all preferred their pouch to previous ileostomy. Patients reported their overall social, emotional, and physical well being to be satisfactory to excellent. Results of the SF-36, a generic quality-of-life survey, were similar to those from studies of patients following an open pelvic pouch procedure. The LIPAA is technically feasible in experienced centers. We believe that the technique is still evolving and that more time and experience is required to refine the procedure.

Laparoscopic splenectomy does the training of minimally invasive surgical fellows affect outcomes?

BACKGROUND

The training of surgeons and residents in laparoscopic surgery has become an important issue. The purpose of this study is to determine if the training of a laparoscopic fellow affects outcomes in patients undergoing laparoscopic splenectomy (LS).

METHODS

Data were obtained from a prospectively collected database of patients who underwent LS from August 1994 to November 1999. Outcomes of the last 25 cases, performed by fellows under supervision, were compared to 25 cases performed by staff surgeons prior to the introduction of fellows.

RESULTS

Patient demographics, preoperative platelet count, and splenic size were similar for the two groups. Outcome measures comparing the staff and the fellows group including operative time (151 vs 178 min, p = 0.055), blood loss (214 vs 162 ml, p = 0.40), intraoperative complications (3 vs 2, p = 1.0), need for transfusion (2 vs 3, p = 1.0), conversions (1 vs 0, p = 1.0), length of hospital stay (3.3 vs 2.5 days, p = 0.13), and postoperative complications (1 vs 2, p = 1.0) were similar for the two groups.

CONCLUSION

When performed by a fellow under supervision, LS has the same outcomes as when the procedure is performed by the teaching staff surgeon.

Needlescopic fundoplication

BACKGROUND

Minimally invasive surgery continues to evolve, with an emphasis on developing new techniques and applying new technology to surgical procedures. The purpose of this study was to compare the short-term outcomes of needlescopic fundoplication with those of conventional laparoscopic fundoplication.

METHODS

Between January 1999 and June 2000, 38 needlescopic fundoplications were performed, and the short-term outcomes for these patients were compared with those for a contemporary matched cohort of patients who had undergone a conventional laparoscopic fundoplication.

RESULTS

There was a nonsignificant trend toward decreased operative time (143.4 to 127 min; p = 0.13), blood loss (54.3 to 48 ml; p = 0.30), narcotic requirements (29.5 to 19.5 morphine equivalents; p = 0.32), and length of hospital stay (1.78 to 1.49 days; p = 0.10) in the needlescopic group. There were no significant differences in intraoperative complications (2.6% vs 2.6%; p = 1.0). Two needlescopic cases were converted to laparoscopic cases because of obesity. Postoperatively, there were no significant differences in rates of early dysphagia (7.9% vs 7.9%), bloating (13.2% vs 5.3%; p = 0.43), or other complications (5.3% vs 5.3%) between the groups. There was a significant reduction in mean operative time for needlescopic fundoplication after the first four cases (166 +/- 44 vs 120 +/- 32 min; p = 0.03).

CONCLUSIONS

Needlescopic fundoplication poses no disadvantage, and it offers the added cosmetic benefit of smaller incisions.

"Needlescopic" sigmoid resection

Minimally invasive surgical techniques and procedures continue to evolve with the trend toward fewer and smaller instruments. To our knowledge, this is the first reported case of sigmoid colon resection utilizing needlescopic technology. The patient was a 53-year-old woman diagnosed with a malignant lesion in the midsigmoid colon at 30 cm. A subsequent needlescopic sigmoid colon resection was performed and the patient was discharged home after an uneventful postoperative course. This case demonstrates that colon procedures that require major reconstruction may be performed needlescopically in selected patients.

Hip fracture surgery in Nova Scotia: a comparison of treatment provided by "generalist" general surgeons and orthopedic surgeons

OBJECTIVE

To determine quality of hip fracture services provided by "generalist" general surgeons (generalists) in Nova Scotia.

DESIGN

Chart review and postoperative, blinded, random-ordered radiologic analysis.

SETTING

Three community hospitals and 1 tertiary care hospital in Nova Scotia.

PARTICIPANTS

Seven generalists who performed 120 hip fracture repairs and 7 orthopedic surgeons (specialists) who performed 135 hip fracture repairs.

OUTCOME MEASURES

Patient demographics, preoperative, perioperative, postoperative and discharge information, technical quality of reduction as determined through postoperative radiologic assessment.

RESULTS

There were no differences between patients treated by generalists and those treated by specialists with respect to age, sex, American Society of Anesthesiologists' class, level of function and fracture type. Intraoperatively, the patient groups were similar with respect to type of anesthesia, use of antibiotics, number of transfusions and surgical complications. Significant differences were noted in length of operation (54.4 v. 41.1 minutes), use of C-arm imaging (6.7% v. 85.9%) and management of Garden classes 1 and 2 subcapital fractures. Postoperatively, the 2 groups had similar numbers of medical complications, wound complications, reoperations, readmissions and deaths, and a similar level of function on discharge. Significant differences included the number of intensive care unit admissions (5.8% v. 15.6%) and length of stay there (5.7 v. 2.8 days) and of postoperative stay (14.5 v. 10.7 days). The assessment of radiographs did not demonstrate any significant difference in the quality of reduction.

CONCLUSION

In Nova Scotia the outcomes of hip fracture surgery performed by generalists are comparable to those performed by specialists.

Skin necrosis: an unusual complication of hyperphosphatemia during total parenteral nutrition therapy

BACKGROUND

Hyperphosphatemia complicated by calcification of subcutaneous arteries and skin infarcts are very rarely reported in the absence of chronic renal failure (CRF). We describe identical lesions in an obese woman with sepsis. Hyperphosphatemia resulted from an unintended excess of phosphate in her total parenteral nutrition (TPN) formulations. She did not have CRF or hyperparathyroidism.

METHODS

The patient's records during 37 weeks of hospitalization 12 years ago and, subsequently, her outpatient records were reviewed.

RESULTS

During a 7-week period, the total elemental phosphorus infused daily, as divalent phosphate, ranged from 1.8 to 4.2 g, median 3.1, over triple the normal daily requirement. This excess was unintended. This occurred before the current practice of pharmacist-monitoring of TPN formulations, and possibly resulted from misinterpretation of a revised formulation sheet, newly introduced to the nursing units at the start of that period. Serum phosphorus increased to 3.02 mmol/L (normal 0.76 to 1.46 mmol/L). She developed calcification of subcutaneous arteries, which was complicated by widespread infarcts of the anatomically related skin and subcutis, apparently the result of hypoperfusion of these vessels during an episode of septic shock. The infarcts were heralded by unusual, blotchy skin discolorations.

CONCLUSIONS

This report, illustrating a startling cutaneous complication associated with apparent misinterpretation of TPN formulations, demonstrates a pathogenetic relationship between hyperphosphatemia, calcification of subcutaneous arteries, and necrosis of the skin and subcutis in the absence of CRF and hyperparathyroidism and introduces a new differential diagnosis for unusual skin lesions appearing during TPN therapy.

Role of the general practitioner in the delivery of surgical and anesthesia services in rural western Canada

OBJECTIVE

To determine the present role of general practitioners (GPs) in the delivery of surgical and anesthesia services in rural western Canada.

DESIGN

Survey by mailed questionnaire in November 1993, with telephone follow-up of nonresponders.

SETTING

Rural British Columbia, Alberta, the Yukon Territory and the Northwest Territories.

PARTICIPANTS

Administrators of 148 rural hospitals; of the 121 who completed it 101 represented hospitals that met the inclusion criteria (fewer than 51 beds and serving a population of 15,000 or less).

OUTCOME MEASURES

Hospital characteristics, type of practitioners providing surgical and anesthesia services, length and location of GPs', surgical and anesthesia training, types of surgical procedures performed by GPs and opinions of administrators regarding the delivery of surgical services in their community.

RESULTS

Surgical services were provided by 56 (55%) of the 101 hospitals; at 45 (80%) they were provided by GPs, and at 33 (59%) they were provided by GPs with limited additional surgical training. Fifteen (27%) of the 56 hospitals were said to rely solely on GPs with limited surgical training for surgical services. At 45 (80%) of the 56 hospitals anesthesia services were provided by GPs, all of whom had limited additional training in anesthesia; 36 (64%) were said to rely solely on GPs for anesthesia services. Just over three quarters (76% [74/98]) of the administrators felt that their community's surgical needs were well met.

CONCLUSION

GPs with limited specialty training continue to play a role in providing surgical and anesthesia services in rural western Canada. This has implications for postgraduate training programs in Canada.

Predicting Bariatric Surgical Outcomes: Does Preoperative Weight Gain Correlate with Lesser Postoperative Weight Loss?

BACKGROUND: This study is a retrospective analysis of 76 patients who underwent vertical banded gastroplasty (VBG), in order to determine whether preoperative weight gain correlates with lesser postoperative weight loss. METHODS: Patients were divided into two groups: those patients who did not gain a significant amount of weight during the preoperative period (group 1), and those patients who gained greater than 2.5% of their preoperative BMI during the preoperative period (group 2). There were 59 patients in group 1 and 17 patients in group 2. RESULTS: Patients in group I had an average follow-up of 374 days and lost an average of 37.5 kg. The patients in group 2 had an average follow-up of 379 days with an average weight loss of 39.3 kg. CONCLUSION: Linear regression analysis was performed and supported the finding that preoperative weight gain is not predictive of lesser postoperative weight loss.

Initial Experience with the Surgical Management of Morbid Obesity Associated with Symptomatic Gastro-esophageal Reflux: A Comparison between Gastroplasty Alone and Gastroplasty with Anterior Fundoplication

The optimal management of patients with morbid obesity and gastro-esophageal reflux disease (GERD) remains an unresolved issue. We have performed a vertical banded gastroplasty combined with an anterior fundoplication (VBG + AF) in 28 selected morbidly obese patients with moderate or severe heartburn. The patients who underwent VBG +/- AF are compared to patients who had similar heartburn symptoms and underwent gastroplasty alone during this period. In the VBG + AF group there were two treatment failures (7%). In the gastroplasty group there were 63 patients with 15 treatment failures (24%). These differences were independent of demographic and weight loss variables. These results suggest that VBG +/- AF may provide a superior option for the management of morbidly obese patients with GERD.

General surgical practice patterns in Nova Scotia: the role of the "generalist" general surgeon

OBJECTIVE

To determine the role of traditional "generalist" general surgeons in Nova Scotia.

DESIGN

An anonymous mail survey.

SETTING

The Province of Nova Scotia.

PARTICIPANTS

Sixty-two active general surgeons listed on the Nova Scotia Provincial Medical Board Registry.

INTERVENTIONS

A questionnaire to compare the practice patterns of community surgeons, regional surgeons and tertiary care surgeons.

MAIN OUTCOME MEASURES

The availability of non-general-surgery subspecialty colleagues in the hospital setting, the extent of non-general-surgery subspecialty practices of the participating surgeons, the types of procedures they commonly perform and the adequacy of their general surgery training to meet their present practice requirements.

RESULTS

The questionnaire response rate was 79%. Community surgeons had few non-general-surgery subspecialty colleagues, and the majority maintained broad "generalist" general surgical practices. Regional surgeons had more non-general-surgery subspecialty colleagues, but many still had surgical practices that included the non-general-surgery subspecialties. Tertiary surgeons had adequate non-general-surgery subspecialty colleagues and maintained narrow general surgery practices.

CONCLUSIONS

In Nova Scotia, "generalist" general surgeons presently provide non-general-surgery subspecialty services in both regional and community hospital settings.