Postoperative Outcomes Between Positive and Negative Electrodiagnosis in Patients With Tarsal Tunnel Syndrome: A Retrospective Comparative Study

BACKGROUND

The sensitivity of diagnosing tarsal tunnel syndrome with an electrodiagnostic study is just over 50%. Given this low reliability, many surgeons prefer to make a diagnosis solely from a physical examination, despite reported electrodiagnostic findings. Thus, to understand the clinical ramifications between these 2 methods of diagnosis, this investigation compared the postoperative outcomes following a tarsal tunnel release between patients with positive and negative preoperative electrodiagnosis (EDx).

METHODS

This study retrospectively reviewed 53 consecutive patients who underwent tarsal tunnel release by a single surgeon between 2015 and 2022. The primary outcome was pain level using visual analog scale (VAS) whereas the secondary outcomes were 36-Item Short Form Health Survey questionnaire, Foot and Ankle Ability Measure, recovery times (time to return to activities of daily living, work, and sports), and complications. Pre- and postoperative functional outcomes were compared within each EDx group using a paired sample t test. Postoperative outcomes between groups were compared using a generalized linear model adjusted for potential confounders.

RESULTS

Both EDx groups (positive studies = 31 patients and negative studies = 22 patients) demonstrated significant improvement of all functional outcomes (P < .001). We found no significant difference in recovery time or postoperative outcomes between the 2 groups (P > .05). Multivariable analysis showed diabetes (risk ratio [RR] = 1.79, 95% CI 1.11-2.90) and longer duration of symptoms before surgery (RR = 1.02, 95% CI 1.00-1.04) as prognostic factors for residual pain following tarsal tunnel release.

CONCLUSION

In our series, we found that preoperative electrodiagnostic results did not prognosticate postoperative functional outcomes or recovery times after tarsal tunnel release.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Impact of Assistant Experience on Perioperative Outcomes of Simple and Radical Laparoscopic Nephrectomy: Does It Really Matter?

Background and Objectives: While systematic reviews highlight the advantages of laparoscopic nephrectomy over traditional open surgery, the impact of an assistant's experience on surgical outcomes remains unclear. This study aims to evaluate whether the level of assistant expertise influences laparoscopic nephrectomy outcomes. Materials and Methods: Retrospective data from our institutional database were analyzed for patients who underwent laparoscopic nephrectomy between January 2018 and December 2022. Procedures were performed by a highly experienced surgeon, including postgraduate year (PGY)-3 to PGY-5 residents as assistants. Senior-level assistants had completed at least 10 procedures. Patient characteristics, surgical outcomes, and postoperative details were collected. Multivariable linear and logistic regression models were performed to test the effect of assistant experience (low vs. high) on estimated blood loss (EBL), length of stay (LOS), operative time (OT), and postoperative complications. Results: 105 patients were included, where 53% had highly experienced assistants and 47% had less experienced ones. Low assistant experience and higher BMI predicted longer operative time (OT), confirmed by multivariable regression (β = 40.5, confidence interval [CI] 18.7-62.3, p < 0.001). Assistant experience did not significantly affect EBL or LOS after adjusting for covariates (β = -14.2, CI -91.8-63.3, p = 0.7 and β = -0.83, CI -2.7-1.02, p = 0.4, respectively). There was no correlation between assistant experience and postoperative complications. Conclusions: Assistant experience does not significantly impact complications, EBL, and LOS in laparoscopic nephrectomy. Surgeries with less experienced assistants had longer OT, but the overall clinical impact seems limited. Trainee involvement remains safe, guided by experienced surgeons.

Outcomes of Laparoscopic Suture vs Mesh Rectopexy for Complete Rectal Prolapse

Objective To compare outcomes of laparoscopic suture and laparoscopic mesh rectopexy for the treatment of complete rectal prolapse in adults. Materials and methods This study was conducted between December 2020 to December 2022, involving 75 patients (Group A: 34; Group B: 41). Inclusion criteria encompassed confirmed complete rectal prolapse. Preoperative measures included comprehensive assessments, mechanical bowel cleansing, prophylactic antibiotics, and rectal irrigation. Surgical techniques involved laparoscopic suture rectopexy for Group A and laparoscopic mesh rectopexy for Group B. Postoperative care and follow-up evaluations were conducted. Results Group A demonstrated advantages in terms of shorter operative times, quicker bowel activity resumption, and reduced hospital stays. Intraoperative bleeding was absent in Group A, while wound-related complications were higher in Group B. Recurrence rates were lower in Group A (2.9%) compared to Group B (9.8%). Both groups exhibited improvements in incontinence grades postoperatively. Constipation increased in both groups. Conclusion Both techniques are effective in treating complete rectal prolapse, each with its advantages and considerations. Group A showed potential benefits in terms of operative efficiency and fewer complications, albeit with a potential for increased recurrence. The study emphasizes the need for individualized patient care, considering factors such as operative characteristics, postoperative outcomes, and patient preferences.

Association of Complications during and after Carotid Body Tumor Resection with Tumor Size and Distance to the Base of Skull

OBJECTIVE

Depending on the size and location of the tumor, carotid body tumor (CBT) resection can come with various complications, mostly intraoperative bleeding, and cranial nerve injuries. In the present study, we aim to evaluate two fairly new variables, tumor volume, and distance to the base of the skull (DTBOS), with operative complications of carotid body tumor (CBT) resection.

METHOD

Patients who underwent carotid body tumor surgery in Namazi hospital from 2015 to 2019 were studied using standard databases. Tumor characteristics and distance to the base of the skull were measured via computed tomography or Magnetic resonance imaging. Outcomes, including intraoperative bleeding and cranial nerve injuries, along with perioperative data were collected.

RESULTS

A total of 42 cases of CBT were evaluated with an average age of 53.21±12.8 and mostly female (85.7%). Based on Shamblin scoring, 2 (4.8%) were classified as group I, 25 (59.5%) as group II, and 15 (35.7%) as group III. The amount of bleeding significantly increased with an increase in the Shamblin scores (P=0.031; median: I: 45cc; II: 250cc, III: 400cc). Also, there was a significant positive correlation between the size of the tumor and the estimated amount of bleeding (Correlation Coefficient = 0.660; P<0.001), and also a significant reverse correlation with between bleeding and DTBOS (Correlation Coefficient= -0.345; P=0.025). During the follow-up of the patients, six (14.3%) had abnormalities in their neurological evaluation. Receiver operating characteristic curve analysis revealed the size of tumor cutoff level 32.7 cm³ (3.2cm radius) to be most predictive of post-op neurological complication with an area under the curve=0.83, sensitivity=83.3%, specificity=80.6%, a negative predictive value= 96.7%, and positive predictive value of 41.7%, and an accuracy of 81.0%. Furthermore, based on the predictive power of the models in our study, we demonstrated that a combination model including the tumor size, DTBOS, along with the Shamblin score had the most predictive power for neurological complications.

CONCLUSION

By evaluating CBT size and distance to the base of the skull, paired with the use of the Shamblin classification, a better, more insightful understanding of possible risks and complications of CBT resection can be obtained, leading to deserved levels of patient care.

Application of the advance incision in robotic-assisted laparoscopic rectal anterior resection

Background

The incidence of rectal cancer is increasing each year. Robotic surgery is being used more frequently in the surgical treatment of rectal cancer; however, several problems associated with robotic surgery persist, such as docking the robot repeatedly to perform auxiliary incisions and difficulty exposing the operative field of obese patients. Herein we introduce a new technology that effectively improves the operability and convenience of robotic rectal surgery.

Objectives

To simplify the surgical procedure, enhance operability, and improve healing of the surgical incision, we developed an advance incision (AI) technique for robotic-assisted laparoscopic rectal anterior resection, and compared its safety and feasibility with those of intraoperative incision.

Methods

Between January 2016 and October 2021, 102 patients with rectal cancer underwent robotic-assisted laparoscopic rectal anterior resection with an AI or intraoperative incision (iOI) incisions. We compared the perioperative, incisional, and oncologic outcomes between groups.

Results

No significant differences in the operating time, blood loss, time to first passage of flatus, time to first passage of stool, duration of hospitalization, and rate of overall postoperative complications were observed between groups. The mean time to perform auxiliary incisions was shorter in the AI group than in the iOI group (14.14 vs. 19.77 min; p < 0.05). The average incision length was shorter in the AI group than in the iOI group (6.12 vs. 7.29 cm; p < 0.05). Postoperative incision pain (visual analogue scale) was lower in the AI group than in the iOI group (2.5 vs. 2.9 p = 0.048). No significant differences in incision infection, incision hematoma, incision healing time, and long-term incision complications, including incision hernia and intestinal obstruction, were observed between groups. The recurrence (AI group vs. iOI group = 4.0% vs. 5.77%) and metastasis rates (AI group vs. iOI group = 6.0% vs. 5.77%) of cancer were similar between groups.

Conclusion

The advance incision is a safe and effective technique for robotic-assisted laparoscopic rectal anterior resection, which simplifies the surgical procedure, enhances operability, and improves healing of the surgical incision.

Obesity-associated sleep hypoventilation and increased adverse postoperative bariatric surgery outcomes in a large clinical retrospective cohort

STUDY OBJECTIVES

Although obesity hypoventilation syndrome (OHS) is associated with increased morbidity and mortality, post-bariatric surgery OHS risk remains unclear due to often nonsystematic OHS assessments.

METHODS

We leverage a clinical cohort with nocturnal CO2 monitoring during polysomnography to address the hypothesis that patients with obesity-associated sleep hypoventilation (OaSH; ie, stage II OHS) have increased adverse postoperative bariatric surgery outcomes. We retrospectively analyzed data from patients undergoing pre-bariatric surgery polysomnography at the Cleveland Clinic from 2011-2018. OaSH was defined by body mass index ≥ 30 kg/m2 and either polysomnography-based end-tidal CO2 ≥ 45 mmHg or serum bicarbonate ≥ 27 mEq/L. Outcomes considered were as follows: intensive care unit stay, intubation, tracheostomy, discharge disposition other than home or 30-day readmission individually and as a composite, and all-cause mortality. Two-sample t test or Wilcoxon rank-sum test for continuous variables and chi-square or Fisher's exact test for categorical variables were used for OaSH vs non-OaSH comparisons. All-cause mortality was compared using Kaplan-Meier estimation and Cox proportional hazards models.

RESULTS

The analytic sample (n = 1,665) was aged 45.2 ± 12 years, 20.4% were male, had a body mass index of 48.7 ± 9 kg/m2, and 63.6% were White. OaSH prevalence was 68.5%. OaSH patients were older and more likely to be male with a higher BMI, apnea-hypopnea index, and glycated hemoglobin. The composite outcome was higher in OaSH vs non-OaSH patients (18.9% vs 14.3%, P = .021). Although some individual outcomes were respectively higher in OaSH vs non-OaSH patients, differences were not statistically significant: intubation (1.5% vs 1.3%, P = .81) and 30-day readmission (13.8% vs 11.3%, P = .16). Long-term mortality (median follow-up: 22.9 months) was not significantly different between groups, likely due to overall low event rate (hazard ratio = 1.39, 95% confidence interval: 0.56, 3.42).

CONCLUSIONS

In this largest sample to date of systematically phenotyped OaSH in a bariatric surgery cohort, we identify increased postoperative morbidity in those with sleep-related hypoventilation in stage II OHS when a composite outcome was considered, but individual contributors of intubation, intensive care unit admission, and hospital length of stay were not increased. Further study is needed to identify whether perioperative treatment of OaSH improves post-bariatric surgery outcomes.

CITATION

Chindamporn P, Wang L, Bena J, et al. Obesity-associated sleep hypoventilation and increased adverse postoperative bariatric surgery outcomes in a large clinical retrospective cohort. J Clin Sleep Med. 2022;18(12):2793-2801.

Learning curve analysis of single-site incision laparoscopic adnexal surgery performed by a single surgeon

OBJECTIVES

Due to the development of laparoscopy techniques, single-site incision laparoscopic surgery (SILS) has recently been performed at many institutes using only a single-incision transumbilical port. We aimed to carry out a learning curve analysis for SILS for adnexal surgery and validate the short-term surgical outcomes.

MATERIAL

AND METHODS: In total, 214 patients were enrolled in this study. The medical records of patients who underwent SILS for adnexal surgery by an expert surgeon from October 2008 to September 2018 were reviewed and analyzed.

RESULTS

The mean age and parity were 33.9 ± 11.5 years and 1.0 ± 1.1, respectively. The mean operation duration was 77.5 ± 22.3 min. In the analysis of the learning curve for single-site incision laparoscopic adnexal surgery, surgical proficiency was defined as the point at which the slope of the learning curve became less steep, which was evident after the 24th operation. No operative complications, conversions to laparotomy or additional trocar insertions were observed.

CONCLUSIONS

Single-site incision laparoscopic surgery (SILS) for adnexal surgery is a safe technique and does not increase the risk of peri- or postoperative complications. For safe performance of SILS, a certain training period for learning the technique should be required.

Initial experience with and surgical outcomes of da Vinci single-port system in general thoracic surgery

Background

The da Vinci single-port system (SPS) (Model SP1098, Intuitive Surgical Inc., Sunnyvale, CA, USA) has been used in genitourinary and general surgical procedures; however, its clinical application in general thoracic surgery has not been attempted. This retrospective study investigated the clinical outcomes of SPS in general thoracic surgery.

Methods

After approval from the Ministry of Food and Drug Safety in Korea, the surgical details of SPS in simple thoracic surgeries at two independent institutions were collected and retrospectively reviewed.

Results

Overall, 17 surgeries were performed using SPS without conversion to multiport surgery. The patients included six males, and the overall median age was 52 years (range, 28–83 years). The commonest pathological diagnoses were thymoma (8 cases) and benign cystic lesions (6 cases). The approach for SPS was subxiphoid, subcostal, and intercostal in 11, 4, and 2 cases, respectively. All patients underwent the surgeries without complications. The median operation time and peak pain score were 120 minutes (range, 58–250 minutes) and 3 (range, 2–4). The median duration of in situ chest tube and hospital stay was 1 day (range, 1–2 days) and 3 days (range, 2–7 days), respectively. SPS showed a shorter duration of in situ chest tube and hospital stay than robotic single-site surgeries.

Conclusions

The application of SPS in the field of general thoracic surgery is feasible and can be successful. Although this study reported preliminary data and the cases were relatively simple, advanced and complex procedures should be attempted with the SPS in the near future.

Analysis of robot-assisted nipple-sparing mastectomy using the da Vinci SP system

BACKGROUND

As patients tend to be diagnosed with breast cancer at an early stage, the demand for better cosmetic outcomes has increased. Several studies revealed that robot-assisted nipple-sparing mastectomy (RNSM) shows favorable outcomes. The aim of the study was to reveal the feasibility of RNSM using the da Vinci single-port (SP) system with a minimal incision, hidden in the arm.

METHODS

From 2018 to 2021, 81 cases (70 patients) were retrospectively reviewed. Clinicopathologic characteristics, operative outcomes, and postoperative complications were evaluated. The operative outcomes were analyzed using the Mann-Whitney U test.

RESULTS

The median age was 42 years (range, 26-60 years). Bilateral RNSM was performed in 11 (27.2%) patients. The median size of the initial skin incision was 40 mm (range, 20-55 mm). Immediate reconstruction with direct-to-implant was performed in 54 (66.7%) patients and deep inferior epigastric perforator (DIEP) flaps in 15 (18.5%) patients. Postoperative complications of Clavien-Dindo Classification III occurred in six (7.5%) patients. Patients reconstructed with a DIEP flap had large breasts with more severe ptosis, yet grade III complications did not occur.

CONCLUSIONS

RNSM using the SP system can be applied for curative and risk-reducing mastectomy, regardless of breast size or ptosis grade.

Primary Arthrodesis Versus Open Reduction and Internal Fixation Outcomes for Lisfranc Injuries: An Analysis of Conflicting Meta-analyses Results

INTRODUCTION

The superiority of primary arthrodesis (PA) versus open reduction and internal fixation (ORIF) in Lisfranc injuries has been debated. Meta-analyses comparing these surgical options have reached contradicting conclusions. The goal of this article is to determine why different conclusions were reached and provide clarity on the comparable outcomes of PA and ORIF in Lisfranc injuries.

METHODS

A systematic literature review was conducted by searching for "meta-analysis" AND "Lisfranc" with keywords such as "ORIF" OR "open reduction" OR "arthrodesis" OR "fusion." Five meta-analysis articles discussing PA and ORIF in Lisfranc injuries were identified. Study outcomes were extracted from each article, and contradicting conclusions were identified for analysis.

RESULTS

PA had lower rates of hardware removal. There was no difference between PA and ORIF when considering revision surgery, anatomic reduction, postoperative infection, total complications, and patient satisfaction. However, contradicting conclusions were reached for return to duty, the American Orthopaedic Foot and Ankle Society (AOFAS) score, and visual analogue scale (VAS) score. Conclusions. There was no difference in PA and ORIF for return to work and VAS score. Repeat meta-analysis with truly equivocal outcomes would be necessary to reach a valid conclusion for return to full activity and AOFAS midfoot scores.

LEVELS OF EVIDENCE

Level II: Therapeutic studies.

Operative Outcomes of Minimally Invasive Esophagectomy versus Open Esophagectomy for Resectable Esophageal Cancer

Background There is a recent rise in the incidence of esophageal carcinoma in India. Surgical resection with or without neoadjuvant chemoradiation is the current treatment modality of choice. Postoperative complications, especially pulmonary complications, affect many patients who undergo open esophagectomy for esophageal cancer. Minimally invasive esophagectomy (MIE) could reduce the pulmonary complications and reduce the postoperative stay.

Methodology We performed a retrospective analysis of prospectively collected data of 114 patients with esophageal cancer in the department of surgical oncology at a tertiary cancer center in South India between January 2019 and March 2020. We included patients with resectable cancer of middle or lower third of the esophagus, and gastroesophageal junction tumors (Siewert I). MIE was performed in 27 patients and 78 patients underwent open esophagectomy (OE). The primary outcome measured was postoperative complications of Clavien–Dindo grade II or higher within 30 days. Other outcomes measured include overall mortality within 30 days, intraoperative complications, operative duration and the length of hospital stay.

Results A postoperative complication rate of 18.5% was noted in the MIE group, compared with 41% in the OE group ( p = 0.034). Pulmonary complications were noted in 7.4% in the MIE group compared to 25.6% in the OE group ( p = 0.044). Postoperative mortality rates, intraoperative complications, and other nonpulmonary postoperative complications were almost similar with MIE as with open esophagectomy. Although the median operative time was more in the MIE group (260 minutes vs. 180 minutes; p < 0.0001), the median length of hospital stay was shorter in patients undergoing MIE (9 days vs. 12 days; p = 0.0001).

Conclusions We found that MIE resulted in lower incidence of postoperative complications, especially pulmonary complications. Although, MIE was associated with prolonged operative duration, it resulted in shorter hospital stay.

Operative Complications and Outcomes Comparing Small and Large Uterine Weight in Case of Laparoscopic Hysterectomy for a Benign Indication

Study Objective: This study was performed to evaluate the association between uterine weight and operative outcomes in women undergoing laparoscopic hysterectomy for a benign indication.

Methods: This is a secondary analysis of a randomized trial with data collected prospectively and retrospectively. The data of 159 women undergoing laparoscopic hysterectomy for a benign indication were analyzed. Women were divided in two groups according to the postoperative uterine weight: small uterus group (<250 grams) and large uterus group (≥250 grams). Operative complications were compared between the two groups. Operative outcomes (need for uterine morcellation, operative duration, estimated blood loss), postoperative pain, and hospital length of stay were also analyzed.

Main Results: Operative complications were not significantly different between the two groups (37% in the large uterus group versus 41% in the small uterus group). Operative outcomes showed a significantly increased use of uterine morcellation in the large uterus group (61% in the large uterus group versus 10% in the small uterus group). The operative duration was 150 min in the small uterus group and 176 min in the large uterus group, which corresponds to an increase of 17% in the large uterus group. The mean pain score on the day of surgery was identical in both groups (VAS pain score 5), but significantly in favor of the large uterus group on day 1 postoperatively (VAS pain score 4 in the small uterus group and 3 in the large uterus group). There was no statistical difference between groups in the mean hospital stay (62 ± 37 hours in the small uterus group versus 54 ± 21 hours in the large uterus group). In terms of surgical indication, the small uterus group comprised more patients with endometriosis/adenomyosis (36%) and the large uterus group more patients with leiomyoma (93%).

Conclusion: The results from this study show that, even if a large uterine weight is associated with increased uterine morcellation requirement and operative duration, a laparoscopic approach is safe and does not increase operative complications nor pain and/or length of hospital stay in women undergoing hysterectomy for a benign indication.

Operative Outcomes of Single-Incision Laparoscopic Hysterectomy vs Conventional Laparoscopic Total Hysterectomy: A Prospective Randomized Controlled Study

Background. Over time, there was an emerging need to shift from laparotomy to minimally invasive laparoscopic surgery, with the success of laparoscopic surgery in the last decade in gyne-oncology. Patients and Methods. This is a prospective randomized controlled trial conducted in Surgical Oncology Unit, Oncology Centre, Mansoura University, in the period between February 2016 and October 2019. Fifty female patients planned for total hysterectomy were randomized into two equal groups; the first underwent conventional laparoscopic hysterectomy (CLH), while the second underwent single-incision laparoscopic hysterectomy (SILH). Results. The mean operative time in the SILH group was 120.00 ± 28.72 minutes vs 103.20 ± 23.04 minutes in the CLH group (P= .027). Median hospital stay in the SILH group was 1 day (range: 1-3 days), the same as that in the CLH group, with no statistical significance (P= .384). Postoperative pain assessment using the Visual Analogue Scale (VAS) after 6 hours had a median score of 6 (2-8) in the SILH group and 6 (4-7) in the CLH group with significant increase in experienced pain in the SILH group (P= .004), while no significant difference was noted after 12 hours and 24 hours in both SILH and CLH groups. Conclusion. Single-incision laparoscopic hysterectomy (SILH) has similar outcomes when compared to conventional laparoscopic hysterectomy as regard blood loss, hospital stay, conversion to laparotomy, intraoperative and postoperative complications with the disadvantages of longer operative time, increased surgeon's workload, and relatively more postoperative pain.

The feasibility and safety of radical esophagectomy in patients receiving neoadjuvant chemoradiotherapy with pembrolizumab for esophageal squamous cell carcinoma

Background

Immune checkpoint inhibitors have been tried for several thoracic malignancies; however, their application as a neoadjuvant therapy in esophageal squamous cell carcinoma (ESCC) has not been studied. We evaluated the feasibility and safety of esophagectomy and total lymphadenectomy after neoadjuvant chemoradiation therapy with pembrolizumab.

Methods

Between 2017 and 2018, 38 patients who received the neoadjuvant therapy followed by radical esophagectomy and total lymphadenectomy for ESCC were analyzed. Twenty-two patients received conventional neoadjuvant chemoradiation therapy (Group 1), and sixteen patients received neoadjuvant chemoradiation therapy with pembrolizumab in clinical trial (Group 2). Two groups were compared retrospectively.

Results

The basic characteristics of age, clinical stage, location and methods of operation were not different between the two groups. The pathologic stages were higher in Group 2, but the difference was not statistically significant. The operative outcomes, i.e., operation time, blood loss, and numbers of dissected lymph nodes in the thorax, neck, and abdomen were comparable. Complications, including pulmonary complications and anastomotic leakage, were also comparable. The rate of recurrent laryngeal nerve palsy was also comparable between the two groups (31.8% vs. 18.8%, P=0.469). Operative mortalities developed in 2 patients [0 vs. 2 (12.5%), P=0.171] due to acute respiratory distress syndrome (ARDS).

Conclusions

Radical esophagectomy for esophageal squamous cell carcinoma after neoadjuvant chemoradiation therapy with pembrolizumab may not increase the operative risk or reduce the quality of radical dissection including lymphadenectomy. The risk of ARDS after neoadjuvant neoadjuvant chemoradiation therapy with pembrolizumab has to be studied in the further analysis.

Incidence and risk factors of readmission after esophagectomy for esophageal cancer

Background

The Esophageal Complications Consensus Group (ECCG) recommends that readmission to a primary or secondary hospital within 30 days of discharge after esophagectomy is an important quality outcome indicator for esophagectomy. This retrospective study was performed to investigate the incidence and risk factors for readmission after esophagectomy.

Methods

We retrospectively reviewed 291 patients who received an esophagectomy and mediastinal lymphadenectomy for curative purposes from January 2006 to June 2017.

Results

The mean age was 63.02±8.02 years, and there were 264 (90.7%) male patients. Thirty-nine (13.4%) patients were re-admitted within 30 days after discharge. The mean interval from discharge to the readmission was 13.46±9.36. Common causes of readmission were anastomotic stricture that required ballooning (12, 30.7%), wound problem (7, 17.9%), pneumonia (6, 15.4%), and poor oral intake (4, 10.2%). Other causes of readmission were delayed gastric emptying [3], jejunostomy tube problem [2], ileus [2], pain [1], pneumothorax [1], and pleural effusion [1]. On multivariable analysis, anastomotic leakage (odd ratio =2.884, P=0.026) was significantly related to readmission, whereas age, pathologic stage, vocal cord palsy, and neoadjuvant therapy were not related to readmission.

Conclusions

Readmission within 30 days after esophagectomy was determined to be related to postoperative anastomotic leakage and wound problems whereas the vocal cord palsy was not.

Variation in prostate surgery costs and outcomes in the USA: robot-assisted versus open radical prostatectomy

AIM

To compare perioperative complications, inpatient cost and length of stay between robot-assisted radical prostatectomy (RARP) and open radical prostatectomy (ORP) using National Inpatient Sample data from 2010 to 2015.

PATIENTS & METHODS

A total of 69,009 records with RARP or ORP were analyzed using multivariate logistic regression and generalized linear models.

RESULTS

The RARP had superior perioperative outcomes at a higher cost (adjusted mean difference = 2956; 95% CI: $2822-$3090) and shorter length of stay (mean difference = 0.85; 95% CI: 0.81-0.89) compared with ORP. Mean cost of RARP was lowest in urban teaching, private invest-own, high volume and northeast region hospitals and highest for black men.

CONCLUSION

Compared with ORP, RARP had significantly better perioperative outcomes at a higher cost.

Learning curve for the transsphenoidal endoscopic endonasal approach to pituitary tumors

INTRODUCTION

The transsphenoidal endoscopic approach is a relatively new procedure compared to the microscopic approach in pituitary adenoma resection. The endoscopic approach has shown to significantly decrease the rate of complications, time in the operating room and hospital, and patient post-op discomfort. However, this procedure requires the surgeon to make use of different visual and tactile clues that must be developed with experience. Therefore, it is important to understand the learning curve that the surgeon must overcome to become proficient with the endoscopic approach.

METHODS

Retrospective review of a single-surgeon consecutive series of 78 patients undergoing endoscopic pituitary tumor surgery from 2006 to 2012 at Rush University Medical Center has been used in this study. Patients were grouped according to an early (n = 9) and late group (n = 68) determined by a significant difference in outcomes. Our primary outcome measures were: duration of operation, CSF leak, hospital length of stay, visual field improvement, diabetes insipidus, panhypopituitarism, and subtotal resection.

RESULTS

There was a significant reduction in OR time and intraoperative CSF leaks between the early and late groups. There was no difference in hospital LOS or visual field improvement between the groups. With regards to complication rates, there was no difference found for DI, panhypopituitarism, lumbar drain placement, sinusitis, or subtotal resection between the two groups.

CONCLUSION

This study indicates that there may be a learning curve of approximately 9 cases before a surgical team can decrease OR times and reduce the rate of intraoperative CSF leaks for the endonasal endoscopic approach to pituitary adenoma resection.

Patient expectation and satisfaction as measures of operative outcome in end-stage ankle arthritis: a prospective cohort study of total ankle replacement versus ankle fusion

BACKGROUND

Current operative outcome scales are based on pain and function, such as the Ankle Osteoarthritis Scale (AOS). Outcomes based on patient expectation and satisfaction may be more useful. The purpose of this prospective cohort study was to evaluate associations between patient expectation, satisfaction, and outcome scores for ankle fusion and total ankle replacement (TAR).

METHODS

In total, 654 ankles in 622 patients were analyzed at a mean of 61 months. Patient expectation and satisfaction with symptoms were quantified pre- and postoperatively using the Musculoskeletal Outcomes Data Evaluation and Management Scale questionnaires from the American Academy of Orthopaedic Surgeons, while function was quantified using the AOS.

RESULTS

Patients undergoing ankle replacement had a higher preoperative expectation score (79; 95% confidence interval [CI], 77-81) compared with those undergoing ankle fusion (72; 95% CI, 68-75). Preoperative expectation scores correlated weakly with AOS scores (R (2) = 0.02) and with the "expectations met" score for ankle fusion (R (2) = 0.07) but not for ankle replacement (R (2) < 0.01). Satisfaction scores were similar for ankle fusion and ankle replacement at follow-up, but a greater number of ankle replacement patients showed improvement in satisfaction (84% vs 74%, P < .005). Higher satisfaction at final follow-up was associated with better expectations met and greater improvement in AOS outcome scores for both ankle fusion and ankle replacement. Expectations met and AOS scores at follow-up correlated for ankle fusion (R (2) = 0.38, P < .0001) and ankle replacement (R (2) = 0.31, P < .0001).

CONCLUSIONS

Patients undergoing TAR had higher expectation scores prior to surgery than those undergoing ankle fusion. Expectations may be more likely to be met by ankle replacement compared with ankle fusion. Ankle replacement patients were more likely to report improved satisfaction scores after surgery. Preoperative expectation scores showed little correlation with preoperative AOS scores, indicating that expectation is independent of pain and function. However, postoperative expectations met and satisfaction scores were strongly associated with AOS scores at follow-up. Better preoperative patient education may change expectations and requires study.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Staging laparoscopy for the management of early-stage ovarian cancer: a metaanalysis

OBJECTIVE

We sought to perform a quantitative analysis on operative outcomes of laparoscopic staging surgery in patients with presumed early-stage ovarian cancer using a metaanalysis.

STUDY DESIGN

Electronic searches for studies of laparoscopic staging surgery in patients with ovarian cancer were performed within 3 electronic databases (Medline, Embase, and the Cochrane Library) using the key words "ovarian cancer," "early stage," "laparoscopy," "staging surgery," "staging laparoscopy," and "recurrence." Two authors independently screened articles, and those meeting the defined inclusion/exclusion criteria were included in the metaanalysis.

RESULTS

We identified 11 observational studies. The combined results of 3 retrospective studies showed that the estimated blood loss in laparoscopy was significantly lower than that for laparotomy (P < .001). The overall upstaging rate after laparoscopic surgery was 22.6% (95% confidence interval [CI], 18.1-27.9%) without significant heterogeneity among all study results. The overall incidence of conversion from laparoscopy to laparotomy was 3.7% (95% CI, 2.0-6.9%). The overall rate of recurrence in studies with a median follow-up period of ≥19 months was 9.9% (95% CI, 6.7-14.4%).

CONCLUSION

Through our quantitative analysis, we concluded that the operative outcomes of a laparoscopic approach in patients with early-stage ovarian cancer could be compatible with those of laparotomy. In the future, further randomized controlled trials may be needed.