The purpose of this study was to evaluate the value of preoperative electrocardiography in predic... more The purpose of this study was to evaluate the value of preoperative electrocardiography in predicting postoperative cardiac complications. Four hundred eighty-one patients having elective surgery were eligible. The patients' ages and specific ECG findings were recorded preoperatively. The patients had prospective follow-up from admission to discharge for the development of postoperative cardiac complications. The data were analyzed using stepwise logistic regression. Postoperative ischemic events were predicted by ECG findings of ST segment abnormalities and ECG evidence of previous myocardial infarction. Age, P wave abnormalities, and preoperative dysrhythmias were independent predictors of postoperative dysrhythmic events. These specific ECG findings may identify patients at risk of postoperative ischemia or dysrhythmia. These patients may benefit from aggressive preoperative cardiac evaluation or close postoperative cardiac monitoring.
Annals of Laparoscopic and Endoscopic Surgery, Feb 24, 2017
Gastroesophageal reflux disease (GERD) is a common malady. It is a protean disease with many mani... more Gastroesophageal reflux disease (GERD) is a common malady. It is a protean disease with many manifestations. Most patients seek medical attention due to symptoms. When a surgical remedy is contemplated, it is incumbent upon the surgeon to identify those patients in whom antireflux surgery (ARS) will lead to elimination of pathologic reflux and symptomatic improvement. There are many patient-related factors and technical factors which can predict success or failure of ARS. These predictors can be divided into proper diagnosis of GERD-like symptoms, GERD-related patient factors, non-GERD related patient factors, and operation-related factors. Proper diagnosis includes insuring that the GERD-like symptoms are in fact related to pathologic reflux and not some other disease or psychological process. GERD-related patient factors include differentiating between typical and atypical symptoms, as well as upright and supine reflux. This also includes assessing for reflux related complications, such as ulcers, strictures and neoplasia. Non-GERD-related patient factors include other gastrointestinal disorders such as irritable bowel syndrome (IBS), gastroparesis and peptic ulcer disease. Psychological disorders, such as anxiety and depression, can also affect the outcomes of ARS. Lastly, technical aspects, such as the type and geometry of the fundoplication, hiatal closure, division of the short gastric vessels and addition of a pyloroplasty can affect success. Attention to these details will place the surgeon in the best position to insure a favorable outcome of an antireflux operation.
BACKGROUND: Ageism has been suggested as a cause for the undertreatment of elderly breast cancer ... more BACKGROUND: Ageism has been suggested as a cause for the undertreatment of elderly breast cancer patients. The purpose of this study was to determine the rate and causes of elderly patients not receiving standard therapy. STUDY DESIGN: A random sample of 500 patients was reviewed for age, cancer stage, surgical, radiation, cytotoxic or hormonal chemotherapy, number and type of comorbidities, type of therapeutic deficiencies, and their causes. RESULTS: The average age was 59.9Ϯ13.6 years. Of the patients less than 65 years old, 6.0% did not receive standard treatment, compared with 22.2% of patients 65 years or older. Treatment omitted in the less than 65-year-old group: 16.7%, no tumor extirpation; 38.9%, no axillary dissection; 33.3%, no radiation therapy; and 33.3% no chemotherapy. Treatment omitted in the 65-year and older group: 11.4%, no tumor extirpation; 39.1%, no axillary dissection; 47.7%, no radiation therapy; and 18.2%, no chemotherapy. Causes in the less than 65-year-old group were: prohibitive associated medical conditions, 27.8%; favorable primary tumor pathology, 16.7%; and patient treatment refusal, 55.6%. Causes in the 65-year and older group were: prohibitive associated medical conditions, 40.9%; favorable tumor pathology, 13.6%; patient treatment refusal, 31.8%; and unexplainable, 13.6%. The median number of concomitant medical conditions in patients receiving standard therapy was one compared with three in the undertreated patients from prohibitive associated medical conditions or unexplained causes. CONCLUSIONS: Population-based studies of breast cancer treatment do not adequately assess the complex decision making associated with breast cancer in the elderly. Patients do not receive standard care for specific reasons.
Background: Recent studies indicate that laparoscopic ventral hernia repair has a lower incidence... more Background: Recent studies indicate that laparoscopic ventral hernia repair has a lower incidence of postoperative surgical site infections (SSI) and length of stay (LOS). There is limited literature evaluating postoperative SSI, LOS, blood loss, and operation time (OT) in obese patients. The objective of this study was to compare postoperative SSI, LOS, blood loss, and OT in obese patients undergoing laparoscopic and open ventral hernia repair (OVHR). Materials and Methods: The American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP) Participant Use File (PUF) from 2011 was used to identify patients with OVHR and laparoscopic ventral hernia repair (LVHR). Postoperative SSI, OT, LOS, and blood loss were analyzed and compared in the different patient groups using univariate and multivariate analyses. Results: A total of 12,004 patients who underwent ventral hernia repair were included in the study. The distribution of repair types were: 6537 (54.5%) reducible OVHR, 2749 (22.9%) incarcerated OVHR, 1767 (14.7%) reducible LVHR, and 763 (6.4%) incarcerated LVHR. Of the patients with body mass index (BMI) >30 kg/m 2 113 (3.4%) developed superficial SSI in the OVHR group compared with 7 (0.72%) of the patients in the LVHR group (P < 0.01). The mean total OT was 77.9 minutes in the OVHR group, compared with 87.9 minutes LVHR for patients with BMI < 25 kg/m 2. In the highest BMI class of >40 kg/m 2 , OT was not significantly different between the groups. The mean LOS increased in OVHR group from 2.4 days in patients with BMI < 25 kg/m 2 to 3.7 days in patients with BMI > 40 kg/m 2. In contrast, in the LVHR group, the LOS was decreased from a mean of 3.2 days in patients with BMI < 25 kg/m 2 to 1.9 days in patients with BMI > 40 kg/m 2. Conclusions: LVHR repair is related to a decreased risk for superficial SSI's and LOS in obese patients, without extending OT.
Surgical Endoscopy and Other Interventional Techniques, Aug 1, 2003
Background: Quality of life as a medical endpoint has become an important measure in clinical res... more Background: Quality of life as a medical endpoint has become an important measure in clinical research. Methods: In this article, we review the recent literature that has examined the impact of gastroesophageal reflux disease (GERD) and its treatment of quality of life. Results: The increasing interest in measuring patients' quality of life as an outcome reflects an increasing awareness that traditional physiological endpoints often do not correlate well with patients' functional status, general well-being, and satisfaction with therapy. It has been shown that GERD has a significant impact on patients' quality of life; therefore, improvement of quality of life is one of the major goals of GERD treatment. This can be achieved by medical as well as surgical treatment. Conclusion: In addition to the patients' perspective, quality of life is one of the major endpoints in medical research that will help provide more selective treatment regimens for our patients.
Helicobacter pylori has been associated with a number of upper gastrointestinal diseases. Treatme... more Helicobacter pylori has been associated with a number of upper gastrointestinal diseases. Treatment directed toward H. pylori promotes ulcer healing and decreases ulcer recurrence. This study reports a longer-term quality of life follow-up in a group of patients treated for H. pylori. Thirty patients who were treated for upper gastrointestinal symptoms at least 2 years (median 32 months) prior to the initiation of this study had the Gastrointestinal Symptom Rating Scale questionnaire mailed to them. 19 patients responded. This scale measures abdominal pain, heartburn, acid regurgitation, sucking sensations in the upper abdomen, nausea and vomiting, borborygmus, abdominal distention, and belching. Three groups of patients were studied: symptomatic patients without H. pylori infection, symptomatic patients with H. pylori infection and successful eradication, and symptomatic patients with H. pylori infections without eradication. The median symptom scores for each group were no more than 1.5. However, there were no statistically significant differences among these three groups in any of the eight items measured by the Gastrointestinal Symptom Rating Scale. The sample size of this study was sufficient to detect a difference between groups of 1.6. Patients treated for H. pylori have no to occasional upper gastrointestinal symptoms in more than 2 years' follow-up. There appears to be no difference in patients treated for the infection and those without the infection.
Introduction The spleen provides a unique immune function in its production of opsins directed ag... more Introduction The spleen provides a unique immune function in its production of opsins directed against encapsulated bacteria. Splenectomy, therefore, increases the risk of infections in patients as well as post-operative complications. This study aims to assess the risk of post-operative complications within 5 years of splenectomy by indication for splenectomy: trauma, disease, or in association with a distal pancreatectomy for pancreatic disease. The relationship between vaccination and infectious outcomes was also investigated. Methods This study is a review of splenectomy cases between June 2005 and June 2015 at a single institution. Infection, splenectomy indication, and vaccination history were identified from electronic medical records and lab test confirmations. Data was analyzed using Student's t test for continuous variables, the Mann-Whitney U test for ordinal variables, and a Chi-square/Fisher exact test for categorical variables. Results A total of 106 splenectomy patients were included: 35 traumatic (74% male) and 71 non-traumatic causes (42% male) with no significant difference in age. There were no statistical differences in complications during splenectomy and vaccination administration between the splenectomy indication groups: trauma, disease, and with distal pancreatectomy. There was a statistically significant higher infection rate within 5 years post-splenectomy in the non-traumatic vs traumatic group (42% vs 14.0%, p = 0.0040) with majority gastrointestinal (7/38) and respiratory (5/38) and surgical wound infections (3/38) observed in non-traumatic versus traumatic, respectively. Conclusion Results from data analysis show a statistically significant difference in rates of infection within 5 years postoperatively between traumatic versus non-traumatic indications for splenectomies, with the non-traumatic group experiencing a higher rate of infectious outcomes. The non-traumatic group included patients with disease and distal pancreatectomy indications. This suggests that patients who have non-traumatic causes may be at a higher risk of developing infections following splenectomy procedure. Additionally, vaccinations did not appear to have a protective effect.
Gastroesophageal reflux disease (GERD) and its many manifestations are common in North America an... more Gastroesophageal reflux disease (GERD) and its many manifestations are common in North America and Europe. Although less common in Asia, Middle East, Caribbean, and African countries, its prevalence is increasing in these regions as well. Although the incidence of new cases is relatively low, the disease persists over long periods of time, thereby leading to an overall high prevalence. Risk factors include age, gender, ethnicity, obesity, physiologic/anatomic conditions, and lifestyle. GERD is an economic burden to patients, healthcare systems, employers, and society. Barrett’s esophagus is one of the more serious consequences of GERD. Its primary importance is as a risk factor for esophageal adenocarcinoma. Although prevalence and incidence of Barretts is difficult to determine, it is probably more common than initially believed. Risk factors are similar to GERD, although diet may play an additional role.
AIM: To compare the laparoscopic and the open gastrectomy approaches for short term morbidity, le... more AIM: To compare the laparoscopic and the open gastrectomy approaches for short term morbidity, length of hospital stay and also long term gastrointestinal symptoms. METHODS: Patients who have undergone gastrectomy had their medical records reviewed for demographic data, type of gastrectomy, short term morbidity, and length of hospital stay. Patients were contacted and asked to complete the Gastrointestinal Symptom Rating Scale (GSRS). The GSRS measures three domains of GI symptoms: Dyspepsia Syndrome (DS) for the foregut (best score 0, worse score 15), indigestion syndrome (IS) for the midgut (best score 0, worse score 12), and bowel dysfunction syndrome (BDS) for the hindgut (best score 0, worse score 16). Statistical analysis was done using the Mann-Whitney U-test. RESULTS: We had complete data on 32 patients: 7 laparoscopic and 25 open. Of these, 25 had a gastroenteric anastomosis and 6 did not. The table shows the results as medians with interquartile range. Laparoscopic gastrectomy had a better score than open gastrectomy in the DS domain (0 vs 1, P = 0.02), while gastrectomy without anastomosis had a better score than gastrectomy with anastomosis in the IS domain (0 vs 1, P = 0.05). CONCLUSION: Patients have little adverse gastrointestinal symptoms and preserve good gastrointestinal function after undergoing any type of gastrectomy. Laparoscopic approach had better dyspepsia and foregut symptoms. Performing an anastomosis led to mild adverse midgut and indigestion effects
BACKGROUND: Recommended procedure numbers for upper endoscopy (UE) and colonoscopy (C) are 35 and... more BACKGROUND: Recommended procedure numbers for upper endoscopy (UE) and colonoscopy (C) are 35 and 50 for surgical residents, and 130 and 140 for gastroenterology fellows, respectively. The purpose of this study was to challenge the methods used to determine proficiency in flexible endoscopy. METHODS: Global assessment of gastrointestinal endoscopic skills (GAGES) was used to evaluate 139 procedures. Scores for UE were compared using self-reported case numbers and grouped according to requirements for each discipline. C scores were compared using the requirements to define novice and experienced endoscopists. Procedure volumes were plotted against GAGES scores. RESULTS: Three groups were compared for UE based on case volumes: fewer than 35 cases (group 1), 35 to 130 cases (group 2), and more than 130 cases (group 3). There was no difference between group 2 (17.8 Ϯ 1.8) and group 3 (19.1 Ϯ 1.1), but both scored higher than group 1 (14.4 Ϯ 3.7; P Ͻ .05). For C, the scores were 11.8 Ϯ 3.8 (novices) and 18.8 Ϯ 1.34 (experienced; P Ͻ .001) at a 50-case minimum and 12.4 Ϯ 4.2 and 18.8 Ϯ 1.3 (P Ͻ .001) for a 140-case proficiency cutoff level, respectively. The curve of procedures versus GAGES plateaued at 50 (UE) and 75 (C). CONCLUSIONS: The surgical and gastroenterology case recommendations may not represent the experience needed to achieve proficiency. GAGES scores could help define proficiency in basic endoscopy.
The relationship of the upper esophageal sphincter (UES) and gastroesophageal reflux is not well ... more The relationship of the upper esophageal sphincter (UES) and gastroesophageal reflux is not well established. The phenomenon of refluxate violation of the UES has been well documented. Laryngopharyngeal reflux (LPR) which occurs when the refluxate has breached the UES has been linked to various atypical reflux symptoms, including laryngitis, hoarseness, chronic cough, asthma, aspiration pneumonia, and globus. This paper aims to review existing research on both physiologic and pathological UES functions related to reflux. The vagally mediated esophago-upper sphincter contraction reflex prevents oropharyngeal reflux while the esophago-upper sphincter relaxation reflex (EURR) allows gas venting. The UES responds to liquid refluxate with a contractile response in healthy, supine subjects. This mechanism serves to protect the respiratory tract and is distinct from the UES belch relaxation reflex. This response is innate and likely diminishes with age. Deficient esophago-upper sphincter contraction reflex and hyperattenuated EURR have been linked with symptoms of supra-esophageal reflux disease (SERD). When this type of reflux leads to symptoms and other pharyngeal, laryngeal or airway pathology, it is considered SERD. Artificial augmentation of UES pressure has been proposed as a therapeutic option for the prevention of SERD. These findings have been reproduced in subsequent studies and correlate with a reduction in regurgitation and extraesophageal symptoms.
Antireflux surgery was originally developed as an open operation. With the advent of laparoscopic... more Antireflux surgery was originally developed as an open operation. With the advent of laparoscopic cholestectomy, fundoplications have been modified to the laparoscopic approach. There have been at least 11 non-randomized comparisons and 6 randomized clinical trials comparing laparoscopic and open antireflux surgery. Overall, these studies have shown that symptomatic relief is similar between these approaches. Short-term quality of life appears superior for the laparoscopic approach. However, the laparoscopic approach may also have a slightly higher complication and side effect rate. Nevertheless, patient satisfaction appears dependent of symptomatic relief, not the type of approach. Therefore, type of approach should be determined by patient and surgeon factors, not dogmatically applied to all patients. Rudolph Nissen published in 1956 the landmark article pertaining to the fundoplication which now bears his name [1]. Since that time the Nissen fundoplication has become the standard by which all other anti-reflux operations are compared. Most variations of anti-reflux operations have some component of either a partial or complete fundoplication. Up until recently, the two main approaches have been the trans-abdominal approach, through some type of laparotomy, or a trans-thoracic approach, through a left posterior lateral thoracotomy. 1991 ushered in a new era of anti-reflux surgery with the first Nissen fundoplication performed through a laparoscopic approach [2]. Although the laparoscopic fundoplication has rightfully taken its place as a standard of care for gastroesophageal reflux disease, the open approach is still a valuable alternative to the minimally invasive approach. The purpose of this chapter will be to review the comparative data pertaining to laparoscopic and open anti-reflux surgery, and to make recommendations with respect to these approaches.
The purpose of this study was to evaluate the value of preoperative electrocardiography in predic... more The purpose of this study was to evaluate the value of preoperative electrocardiography in predicting postoperative cardiac complications. Four hundred eighty-one patients having elective surgery were eligible. The patients&#39; ages and specific ECG findings were recorded preoperatively. The patients had prospective follow-up from admission to discharge for the development of postoperative cardiac complications. The data were analyzed using stepwise logistic regression. Postoperative ischemic events were predicted by ECG findings of ST segment abnormalities and ECG evidence of previous myocardial infarction. Age, P wave abnormalities, and preoperative dysrhythmias were independent predictors of postoperative dysrhythmic events. These specific ECG findings may identify patients at risk of postoperative ischemia or dysrhythmia. These patients may benefit from aggressive preoperative cardiac evaluation or close postoperative cardiac monitoring.
Annals of Laparoscopic and Endoscopic Surgery, Feb 24, 2017
Gastroesophageal reflux disease (GERD) is a common malady. It is a protean disease with many mani... more Gastroesophageal reflux disease (GERD) is a common malady. It is a protean disease with many manifestations. Most patients seek medical attention due to symptoms. When a surgical remedy is contemplated, it is incumbent upon the surgeon to identify those patients in whom antireflux surgery (ARS) will lead to elimination of pathologic reflux and symptomatic improvement. There are many patient-related factors and technical factors which can predict success or failure of ARS. These predictors can be divided into proper diagnosis of GERD-like symptoms, GERD-related patient factors, non-GERD related patient factors, and operation-related factors. Proper diagnosis includes insuring that the GERD-like symptoms are in fact related to pathologic reflux and not some other disease or psychological process. GERD-related patient factors include differentiating between typical and atypical symptoms, as well as upright and supine reflux. This also includes assessing for reflux related complications, such as ulcers, strictures and neoplasia. Non-GERD-related patient factors include other gastrointestinal disorders such as irritable bowel syndrome (IBS), gastroparesis and peptic ulcer disease. Psychological disorders, such as anxiety and depression, can also affect the outcomes of ARS. Lastly, technical aspects, such as the type and geometry of the fundoplication, hiatal closure, division of the short gastric vessels and addition of a pyloroplasty can affect success. Attention to these details will place the surgeon in the best position to insure a favorable outcome of an antireflux operation.
BACKGROUND: Ageism has been suggested as a cause for the undertreatment of elderly breast cancer ... more BACKGROUND: Ageism has been suggested as a cause for the undertreatment of elderly breast cancer patients. The purpose of this study was to determine the rate and causes of elderly patients not receiving standard therapy. STUDY DESIGN: A random sample of 500 patients was reviewed for age, cancer stage, surgical, radiation, cytotoxic or hormonal chemotherapy, number and type of comorbidities, type of therapeutic deficiencies, and their causes. RESULTS: The average age was 59.9Ϯ13.6 years. Of the patients less than 65 years old, 6.0% did not receive standard treatment, compared with 22.2% of patients 65 years or older. Treatment omitted in the less than 65-year-old group: 16.7%, no tumor extirpation; 38.9%, no axillary dissection; 33.3%, no radiation therapy; and 33.3% no chemotherapy. Treatment omitted in the 65-year and older group: 11.4%, no tumor extirpation; 39.1%, no axillary dissection; 47.7%, no radiation therapy; and 18.2%, no chemotherapy. Causes in the less than 65-year-old group were: prohibitive associated medical conditions, 27.8%; favorable primary tumor pathology, 16.7%; and patient treatment refusal, 55.6%. Causes in the 65-year and older group were: prohibitive associated medical conditions, 40.9%; favorable tumor pathology, 13.6%; patient treatment refusal, 31.8%; and unexplainable, 13.6%. The median number of concomitant medical conditions in patients receiving standard therapy was one compared with three in the undertreated patients from prohibitive associated medical conditions or unexplained causes. CONCLUSIONS: Population-based studies of breast cancer treatment do not adequately assess the complex decision making associated with breast cancer in the elderly. Patients do not receive standard care for specific reasons.
Background: Recent studies indicate that laparoscopic ventral hernia repair has a lower incidence... more Background: Recent studies indicate that laparoscopic ventral hernia repair has a lower incidence of postoperative surgical site infections (SSI) and length of stay (LOS). There is limited literature evaluating postoperative SSI, LOS, blood loss, and operation time (OT) in obese patients. The objective of this study was to compare postoperative SSI, LOS, blood loss, and OT in obese patients undergoing laparoscopic and open ventral hernia repair (OVHR). Materials and Methods: The American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP) Participant Use File (PUF) from 2011 was used to identify patients with OVHR and laparoscopic ventral hernia repair (LVHR). Postoperative SSI, OT, LOS, and blood loss were analyzed and compared in the different patient groups using univariate and multivariate analyses. Results: A total of 12,004 patients who underwent ventral hernia repair were included in the study. The distribution of repair types were: 6537 (54.5%) reducible OVHR, 2749 (22.9%) incarcerated OVHR, 1767 (14.7%) reducible LVHR, and 763 (6.4%) incarcerated LVHR. Of the patients with body mass index (BMI) >30 kg/m 2 113 (3.4%) developed superficial SSI in the OVHR group compared with 7 (0.72%) of the patients in the LVHR group (P < 0.01). The mean total OT was 77.9 minutes in the OVHR group, compared with 87.9 minutes LVHR for patients with BMI < 25 kg/m 2. In the highest BMI class of >40 kg/m 2 , OT was not significantly different between the groups. The mean LOS increased in OVHR group from 2.4 days in patients with BMI < 25 kg/m 2 to 3.7 days in patients with BMI > 40 kg/m 2. In contrast, in the LVHR group, the LOS was decreased from a mean of 3.2 days in patients with BMI < 25 kg/m 2 to 1.9 days in patients with BMI > 40 kg/m 2. Conclusions: LVHR repair is related to a decreased risk for superficial SSI's and LOS in obese patients, without extending OT.
Surgical Endoscopy and Other Interventional Techniques, Aug 1, 2003
Background: Quality of life as a medical endpoint has become an important measure in clinical res... more Background: Quality of life as a medical endpoint has become an important measure in clinical research. Methods: In this article, we review the recent literature that has examined the impact of gastroesophageal reflux disease (GERD) and its treatment of quality of life. Results: The increasing interest in measuring patients' quality of life as an outcome reflects an increasing awareness that traditional physiological endpoints often do not correlate well with patients' functional status, general well-being, and satisfaction with therapy. It has been shown that GERD has a significant impact on patients' quality of life; therefore, improvement of quality of life is one of the major goals of GERD treatment. This can be achieved by medical as well as surgical treatment. Conclusion: In addition to the patients' perspective, quality of life is one of the major endpoints in medical research that will help provide more selective treatment regimens for our patients.
Helicobacter pylori has been associated with a number of upper gastrointestinal diseases. Treatme... more Helicobacter pylori has been associated with a number of upper gastrointestinal diseases. Treatment directed toward H. pylori promotes ulcer healing and decreases ulcer recurrence. This study reports a longer-term quality of life follow-up in a group of patients treated for H. pylori. Thirty patients who were treated for upper gastrointestinal symptoms at least 2 years (median 32 months) prior to the initiation of this study had the Gastrointestinal Symptom Rating Scale questionnaire mailed to them. 19 patients responded. This scale measures abdominal pain, heartburn, acid regurgitation, sucking sensations in the upper abdomen, nausea and vomiting, borborygmus, abdominal distention, and belching. Three groups of patients were studied: symptomatic patients without H. pylori infection, symptomatic patients with H. pylori infection and successful eradication, and symptomatic patients with H. pylori infections without eradication. The median symptom scores for each group were no more than 1.5. However, there were no statistically significant differences among these three groups in any of the eight items measured by the Gastrointestinal Symptom Rating Scale. The sample size of this study was sufficient to detect a difference between groups of 1.6. Patients treated for H. pylori have no to occasional upper gastrointestinal symptoms in more than 2 years' follow-up. There appears to be no difference in patients treated for the infection and those without the infection.
Introduction The spleen provides a unique immune function in its production of opsins directed ag... more Introduction The spleen provides a unique immune function in its production of opsins directed against encapsulated bacteria. Splenectomy, therefore, increases the risk of infections in patients as well as post-operative complications. This study aims to assess the risk of post-operative complications within 5 years of splenectomy by indication for splenectomy: trauma, disease, or in association with a distal pancreatectomy for pancreatic disease. The relationship between vaccination and infectious outcomes was also investigated. Methods This study is a review of splenectomy cases between June 2005 and June 2015 at a single institution. Infection, splenectomy indication, and vaccination history were identified from electronic medical records and lab test confirmations. Data was analyzed using Student's t test for continuous variables, the Mann-Whitney U test for ordinal variables, and a Chi-square/Fisher exact test for categorical variables. Results A total of 106 splenectomy patients were included: 35 traumatic (74% male) and 71 non-traumatic causes (42% male) with no significant difference in age. There were no statistical differences in complications during splenectomy and vaccination administration between the splenectomy indication groups: trauma, disease, and with distal pancreatectomy. There was a statistically significant higher infection rate within 5 years post-splenectomy in the non-traumatic vs traumatic group (42% vs 14.0%, p = 0.0040) with majority gastrointestinal (7/38) and respiratory (5/38) and surgical wound infections (3/38) observed in non-traumatic versus traumatic, respectively. Conclusion Results from data analysis show a statistically significant difference in rates of infection within 5 years postoperatively between traumatic versus non-traumatic indications for splenectomies, with the non-traumatic group experiencing a higher rate of infectious outcomes. The non-traumatic group included patients with disease and distal pancreatectomy indications. This suggests that patients who have non-traumatic causes may be at a higher risk of developing infections following splenectomy procedure. Additionally, vaccinations did not appear to have a protective effect.
Gastroesophageal reflux disease (GERD) and its many manifestations are common in North America an... more Gastroesophageal reflux disease (GERD) and its many manifestations are common in North America and Europe. Although less common in Asia, Middle East, Caribbean, and African countries, its prevalence is increasing in these regions as well. Although the incidence of new cases is relatively low, the disease persists over long periods of time, thereby leading to an overall high prevalence. Risk factors include age, gender, ethnicity, obesity, physiologic/anatomic conditions, and lifestyle. GERD is an economic burden to patients, healthcare systems, employers, and society. Barrett’s esophagus is one of the more serious consequences of GERD. Its primary importance is as a risk factor for esophageal adenocarcinoma. Although prevalence and incidence of Barretts is difficult to determine, it is probably more common than initially believed. Risk factors are similar to GERD, although diet may play an additional role.
AIM: To compare the laparoscopic and the open gastrectomy approaches for short term morbidity, le... more AIM: To compare the laparoscopic and the open gastrectomy approaches for short term morbidity, length of hospital stay and also long term gastrointestinal symptoms. METHODS: Patients who have undergone gastrectomy had their medical records reviewed for demographic data, type of gastrectomy, short term morbidity, and length of hospital stay. Patients were contacted and asked to complete the Gastrointestinal Symptom Rating Scale (GSRS). The GSRS measures three domains of GI symptoms: Dyspepsia Syndrome (DS) for the foregut (best score 0, worse score 15), indigestion syndrome (IS) for the midgut (best score 0, worse score 12), and bowel dysfunction syndrome (BDS) for the hindgut (best score 0, worse score 16). Statistical analysis was done using the Mann-Whitney U-test. RESULTS: We had complete data on 32 patients: 7 laparoscopic and 25 open. Of these, 25 had a gastroenteric anastomosis and 6 did not. The table shows the results as medians with interquartile range. Laparoscopic gastrectomy had a better score than open gastrectomy in the DS domain (0 vs 1, P = 0.02), while gastrectomy without anastomosis had a better score than gastrectomy with anastomosis in the IS domain (0 vs 1, P = 0.05). CONCLUSION: Patients have little adverse gastrointestinal symptoms and preserve good gastrointestinal function after undergoing any type of gastrectomy. Laparoscopic approach had better dyspepsia and foregut symptoms. Performing an anastomosis led to mild adverse midgut and indigestion effects
BACKGROUND: Recommended procedure numbers for upper endoscopy (UE) and colonoscopy (C) are 35 and... more BACKGROUND: Recommended procedure numbers for upper endoscopy (UE) and colonoscopy (C) are 35 and 50 for surgical residents, and 130 and 140 for gastroenterology fellows, respectively. The purpose of this study was to challenge the methods used to determine proficiency in flexible endoscopy. METHODS: Global assessment of gastrointestinal endoscopic skills (GAGES) was used to evaluate 139 procedures. Scores for UE were compared using self-reported case numbers and grouped according to requirements for each discipline. C scores were compared using the requirements to define novice and experienced endoscopists. Procedure volumes were plotted against GAGES scores. RESULTS: Three groups were compared for UE based on case volumes: fewer than 35 cases (group 1), 35 to 130 cases (group 2), and more than 130 cases (group 3). There was no difference between group 2 (17.8 Ϯ 1.8) and group 3 (19.1 Ϯ 1.1), but both scored higher than group 1 (14.4 Ϯ 3.7; P Ͻ .05). For C, the scores were 11.8 Ϯ 3.8 (novices) and 18.8 Ϯ 1.34 (experienced; P Ͻ .001) at a 50-case minimum and 12.4 Ϯ 4.2 and 18.8 Ϯ 1.3 (P Ͻ .001) for a 140-case proficiency cutoff level, respectively. The curve of procedures versus GAGES plateaued at 50 (UE) and 75 (C). CONCLUSIONS: The surgical and gastroenterology case recommendations may not represent the experience needed to achieve proficiency. GAGES scores could help define proficiency in basic endoscopy.
The relationship of the upper esophageal sphincter (UES) and gastroesophageal reflux is not well ... more The relationship of the upper esophageal sphincter (UES) and gastroesophageal reflux is not well established. The phenomenon of refluxate violation of the UES has been well documented. Laryngopharyngeal reflux (LPR) which occurs when the refluxate has breached the UES has been linked to various atypical reflux symptoms, including laryngitis, hoarseness, chronic cough, asthma, aspiration pneumonia, and globus. This paper aims to review existing research on both physiologic and pathological UES functions related to reflux. The vagally mediated esophago-upper sphincter contraction reflex prevents oropharyngeal reflux while the esophago-upper sphincter relaxation reflex (EURR) allows gas venting. The UES responds to liquid refluxate with a contractile response in healthy, supine subjects. This mechanism serves to protect the respiratory tract and is distinct from the UES belch relaxation reflex. This response is innate and likely diminishes with age. Deficient esophago-upper sphincter contraction reflex and hyperattenuated EURR have been linked with symptoms of supra-esophageal reflux disease (SERD). When this type of reflux leads to symptoms and other pharyngeal, laryngeal or airway pathology, it is considered SERD. Artificial augmentation of UES pressure has been proposed as a therapeutic option for the prevention of SERD. These findings have been reproduced in subsequent studies and correlate with a reduction in regurgitation and extraesophageal symptoms.
Antireflux surgery was originally developed as an open operation. With the advent of laparoscopic... more Antireflux surgery was originally developed as an open operation. With the advent of laparoscopic cholestectomy, fundoplications have been modified to the laparoscopic approach. There have been at least 11 non-randomized comparisons and 6 randomized clinical trials comparing laparoscopic and open antireflux surgery. Overall, these studies have shown that symptomatic relief is similar between these approaches. Short-term quality of life appears superior for the laparoscopic approach. However, the laparoscopic approach may also have a slightly higher complication and side effect rate. Nevertheless, patient satisfaction appears dependent of symptomatic relief, not the type of approach. Therefore, type of approach should be determined by patient and surgeon factors, not dogmatically applied to all patients. Rudolph Nissen published in 1956 the landmark article pertaining to the fundoplication which now bears his name [1]. Since that time the Nissen fundoplication has become the standard by which all other anti-reflux operations are compared. Most variations of anti-reflux operations have some component of either a partial or complete fundoplication. Up until recently, the two main approaches have been the trans-abdominal approach, through some type of laparotomy, or a trans-thoracic approach, through a left posterior lateral thoracotomy. 1991 ushered in a new era of anti-reflux surgery with the first Nissen fundoplication performed through a laparoscopic approach [2]. Although the laparoscopic fundoplication has rightfully taken its place as a standard of care for gastroesophageal reflux disease, the open approach is still a valuable alternative to the minimally invasive approach. The purpose of this chapter will be to review the comparative data pertaining to laparoscopic and open anti-reflux surgery, and to make recommendations with respect to these approaches.
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