Population-based comparison of open vs laparoscopic esophagogastric fundoplication in children: application of the Agency for Healthcare Research and Quality pediatric quality indicators

Background/Purpose

Increasing national focus on patient safety has promoted development of the pediatric quality indicators (PDIs), which screen for preventable events during provision of health care for children. Our objective is to apply these safety metrics to compare 2 surgical procedures in children, specifically laparoscopic and open esophagogastric fundoplication for gastroesophageal reflux.

Methods

A retrospective analysis using 20 years of data from national representative state inpatient databases through the Healthcare Cost and Utilization Project was conducted. Patients younger than 18 years with International Classification of Diseases, Ninth Revision, Clinical Modification, codes for open or laparoscopic esophagogastric fundoplication were included. Pediatric quality indicators were linked to each patient's profile. Demographics, comorbidities, outcomes, and 8 selected PDIs between open and laparoscopic fundoplications were compared using Pearson χ² tests and t tests.

Results

Of 33,533 patients identified, 28,141 underwent open and 5392 underwent laparoscopic fundoplication. Comorbidities occurred more frequently in open surgery. In-hospital mortality, length of stay, and hospital charges were less in laparoscopic surgery. Of the 8 PDIs evaluated, decubitus ulcer (P = .04) and postoperative sepsis (P = .003) had decreased rates with laparoscopic surgery compared with open.

Conclusion

Laparoscopic fundoplication for gastroesophageal reflux in children can be performed safely compared with the open approach with equivalent or improved rates of PDIs.     

Outcomes of laparoscopic colorectal surgery in obese and nonobese patients: a case-matched study of 180 patients

Background

Because it has been suggested that obese patients may be at higher risk of morbidity and mortality after surgery, we conducted a prospective case-matched study to compare outcomes of elective laparoscopic colorectal surgery in obese and nonobese patients.

Methods

Sixty-two consecutive nonselected obese patients (body mass index ≥30 kg/m²) were matched with 118 nonobese patients. Postsurgical mortality and morbidity were defined as in-hospital death and complications.

Results

Cardiopulmonary comorbidities were significantly more frequent in obese compared with nonobese patients (44% vs 24%, P < .01). Obesity was significantly associated with increased mean operating time (268 ± 74 min vs 232 ± 59 min, P < .001), and conversion rate (32% vs 14%, P < .01). The mortality rate was nil. The overall postsurgical morbidity rate (31% vs 19%, P = not significant) and mean hospital stay (11 ± 10 days vs 9 ± 8 days, P = not significant) were similar in obese and nonobese patients.

Conclusions

The results of this large case-matched study suggest that laparoscopic approach for colorectal surgery is feasible and safe in obese patients.     

The effect of laparoscopic excision vs open excision in children with choledochal cyst: a midterm follow-up study

Purpose

Cyst excision with hepaticojejunostomy has been the classic procedure for treating choledochal cysts. Recently, laparoscopic treatment of the disease has gained popularity worldwide. The aim of this study is to evaluate whether laparoscopic management of choledochal cysts is as feasible and safe as conventional open surgery in children with this disease.

Methods

A retrospective study comparing the laparoscopic and the open procedures was performed in 77 consecutive patients with choledochal cyst in our hospital. Thirty-nine patients operated on between June 2001 and September 2003 were in the laparoscopic group, whereas 38 patients in the open group were operated on between February 1999 and May 2001.

Results

Patient demographics were similar between the 2 groups. The duration of operation was significantly longer in the laparoscopic group than in the open group (median, 230 vs 190 minutes; P < .001). In contrast, the durations of delayed oral feeding and hospital stay postoperatively were significantly shorter in the laparoscopic group (median, 4 vs 5 days [P < .01] and median, 5 vs 7 days [P < .01], respectively.) There were no differences in the early and late complication rates between the 2 groups.

Conclusions

Laparoscopic treatment of choledochal cyst in children is feasible and safe. For experienced centers, this procedure can be recommended.     

Pediatric appendicitis in New England: epidemiology and outcomes

Background

Acute appendicitis is among the most common indications for surgery in children in the Western world. The epidemiology of acute appendicitis in the United States has not been recently analyzed in a population-based cohort study.

Methods

Here, we describe the epidemiology of acute appendicitis in the pediatric population in New England from 2000 to 2006.

Results

Our results show that there is clustering of perforated and nonperforated appendicitis by hospital catchment area (Moran I index 0.01 and 0.03, respectively). The overall incidence of nonperforated appendicitis decreased over our study period by 9.7% (P < .05), the proportion of perforated appendicitis did not change significantly over our study period, and there was a 38% decrease in the proportion of negative appendectomies (P < .05).

Conclusions

There were trends toward increased operative volume for pediatric surgeons as well as sharp increases in the use of laparoscopy and early discharge with home health services. Our results demonstrate that the epidemiology, outcomes, and trends in treatment of acute appendicitis continue to change.     

Laparoscopic versus open reduction of intussusception in children: a single-institution comparative experience

Background

The role of laparoscopic surgery in treating intussusception has been controversial. This study reviews our institution's experience with the laparoscopic approach (LAP) compared to the open surgical approach (OPEN).

Methods

Retrospective analysis of all patients undergoing surgery for intussusception at our center from January 2002 to February 2006. Statistical assessment included Student's t test and χ² analysis.

Results

A total of 41 patients required operation for intussusception (18 LAP, 23 OPEN). Mean age was 22 months for LAP and 11 months for OPEN (P = .17). In the LAP group, 28% (5/18) were converted to an open procedure. Operative times and complications were not significantly different. Pathologic lead points were found in 33% (6/18) LAP and 35% (8/23) OPEN patients (P = 1.0). Time to full feeds was significantly shorter (LAP vs OPEN: 3.4 ± 2.7 vs 5.6 ± 3.4 days, P = .02). Length of stay was shorter (LAP vs OPEN: 4.8 ± 3.5 vs 9.1 ± 7.5 days, P = .03).

Conclusions

Intussusception can be treated safely and effectively using a LAP with a significant decrease in time to full feeds and length of stay. The LAP should be considered as the initial approach for stable patients with intussusception requiring operative intervention.     

Thirteen cases of isolated tubal torsions associated with hydrosalpinx in children and adolescents, proposal for conservative management: retrospective review and literature survey

Background/Purpose

Isolated tubal torsion associated with hydrosalpinx is a rare pathology. Our goal was to analyze the clinical and imaging features and discuss the different treatment options available.

Methods

We retrospectively reviewed all the cases of adnexal torsion treated in our department of pediatric surgery over a 10-year period. We searched 2 electronic databases (Medline and Sciencedirect) and targeted reports published during the same period using the key words tubal torsion and hydrosalpinx.

Results

A total of 13 cases, 6 from our hospital and 7 in the medical literature, were identified and analyzed. In 9 (69%) of 13 cases (n = 9/13), torsion and hydrosalpinx occurred on the left fallopian tube. Salpingectomy was performed in 11 of the patients. The resected tubes showed the persistence of ciliated cells associated with signs of moderate ischemic infarction in 50% (n = 3/6) of the cases.

Conclusions

Isolated tubal torsion associated with hydrosalpinx is too often misdiagnosed and treated by salpingectomy regardless of the negative impact on the future reproductive potential of our young patients. As is commonly advocated for ovarian salvage in adnexal torsions, tubal conservation should be favored when possible.     

Intravenous landiolol, a novel β(1)-adrenergic blocker, reduces the minimum alveolar concentration of sevoflurane in women

Study Objective

To investigate the effect of intravenous (IV) landiolol, a novel β₁-adrenergic blocker, on the minimum alveolar concentration (MAC) of sevoflurane in adult women.

Design

Prospective, randomized study.

Setting

University hospital.

Patients

42 ASA physical status 1 and 2 women, aged 24-57 years, who were scheduled to undergo elective abdominal surgery.

Interventions

Anesthesia was induced in all patients by vital capacity rapid inhalation induction of sevoflurane. In the landiolol group, administration of landiolol began when patients took a vital-capacity breath: 0.125 mg/kg/min for one minute and then 0.04 mg/kg/min. Normal saline was administered in the control group.

Measurements

MAC was determined by a technique adapted from the conventional up-down method.

Main Results

The MAC of sevoflurane was 2.2% ± 0.2% in the control group and 1.7% ± 0.2% in the landiolol group, a statistically significant difference (P = 0.0005).

Conclusions

IV landiolol reduces the MAC of sevoflurane in women by approximately 20%.     

Emergency laparoscopic colectomy: does it measure up to open?

Background

Laparoscopic colectomy has become the standard of care for elective resections; however, there are few data regarding laparoscopy in the emergency setting.

Methods

By using a database with prospectively collected data, we identified 94 patients who underwent an emergency colectomy between August 2005 and July 2008. Laparoscopic surgeries were performed in 42 patients and were compared with 25 patients who were suitable for laparoscopy but received open colectomy.

Results

The groups had similar demographics with no differences in age, sex, or surgical indications. Blood loss was lower (118 vs 205 mL; P < 0.01) and the postoperative stay was shorter (8 vs 11 d; P = 0.02) in the laparoscopic patients, and perioperative mortality rates were similar between the 2 groups (1 vs 3; P = 0.29).

Conclusions

With increasing experience, laparoscopic colectomy is a feasible option in certain emergency situations and is associated with shorter hospital stay, less morbidity, and similar mortality to that of open surgery.     

Does type of mesh used have an impact on outcomes in laparoscopic inguinal hernia?

Background

Theoretically, a lighter and softer mesh may decrease nerve entrapment and chronic pain by creating less fibrosis and mesh contracture in laparoscopic inguinal hernia repair.

Methods

We performed a telephone survey of patients who underwent laparoscopic inguinal hernia surgery between 2001 and 2007. We recorded patient responses for chronic pain, foreign body sensation, recurrence, satisfaction, and return to work, and then studied the effect of type of mesh (polypropylene vs polyester) on these factors.

Results

Of 109 consecutive patients surveyed (mean age, 54.5 y), 67 eligible patients underwent 84 transabdominal extraperitoneal procedures and 2 transabdominal preperitoneal procedures. Patients with polypropylene mesh had a 3 times higher rate of chronic pain (P = .05), feeling of lump (P = .02), and foreign body perception (P = .05) than the polyester mesh group. Our overall 1-year recurrence rate was 5.9%. The recurrence rate was 9.3% for the polypropylene group and 2.9% for the polyester group (P = .26).

Conclusions

A lightweight polyester mesh has better long-term outcomes for chronic pain and foreign body sensation compared with a heavy polypropylene mesh in laparoscopic inguinal hernia repair. We also saw a trend toward higher recurrence in the polypropylene group.     

Contemporary outcomes of open thoracic aortic surgery in a veteran population: do risk models exaggerate mortality?

Background

We evaluated contemporary outcomes of open thoracic aortic surgery at a Veterans Affairs (VA) medical center affiliated with a major academic aortic program and examined the predictive value of 2 established cardiac risk models.

Methods

We retrospectively reviewed all open thoracic aortic operations performed between April 1998 and April 2008 (n = 100). Both the EuroSCORE and the VA Continuous Improvement in Cardiac Surgery Program (CICSP) scores were evaluated.

Results

Procedures included ascending aortic repair (n = 74, 15 with arch repair), descending thoracic repair (n = 11, 1 with arch repair), and thoracoabdominal aortic repair (n = 15). Emergency surgery was necessary in 15 cases, and 19 procedures were reoperations. The patients' logistic EuroSCORE and the CICSP scores were similar (18.7% and 18.2%, respectively), but both scores significantly exceeded the observed operative mortality rate (8.0%, P = .008).

Conclusions

Good outcomes can be achieved when thoracic aortic surgery is performed at an experienced VA center. The cardiac risk models we examined overpredicted operative mortality.     

Single-incision laparoscopic appendectomy vs multiport laparoscopic appendectomy in children: a retrospective comparison

Background

Minimally invasive surgery is commonly used to treat appendicitis. Single-incision laparoscopic surgery is an attractive modality to treat a commonly occurring problem with the advantage of minimal or possibly no scarring. We sought to compare our results of single-incision laparoscopic appendectomy (SILA) with those of patients undergoing traditional multiport laparoscopic appendectomy (MPLA).

Patients and Methods

A retrospective review of all patients who underwent a minimally invasive appendectomy from September 2009 to February 2010 was performed. The patients were divided into 2 groups based on if they had a SILA or a traditional MPLA. Outcomes including demographics, diagnosis, operative time, length of stay, narcotic usage, and complications were evaluated.

Results

A total of 110 patients underwent appendectomy. There were 50 patients who underwent SILA and 46 patients who underwent MPLA. Fourteen patients with perforated appendicitis were excluded. Mean age (11.1 vs 11.7 years, P = .43), weight (43.3 vs 50.9 kg, P = .27), and length of stay (1.1 vs 1.2 days, P = .56) were comparable between both groups. Operative time for SILA was slightly longer (33.8 vs 26.8 minutes, P = .01). Overall intravenous narcotic use was lower in the SILA group (0.9 vs 1.4 doses, P = .01), but there was no difference in the patients who also received ketorolac (0.8 vs 1.0 doses, P = .6). Four patients in the SILA group developed superficial wound infections and 1 patient in the SILA group was admitted for postoperative abscess.

Conclusions

Single-incision laparoscopic appendectomy is safe and effective in the pediatric population. Further studies should be performed to determine the impact on operative time and postoperative narcotic requirements.     

Typical carcinoids and neuroendocrine carcinomas of the stomach: differing clinical courses and prognoses

Background

Gastric endocrine tumors are usually classified as 3 types of well-differentiated endocrine tumors (typical carcinoids or carcinoids) and poorly differentiated carcinomas (neuroendocrine carcinomas [NECs]).

Methods

From 1993 to 2008, 97 patients (73 men and 24 women) were diagnosed with gastric neuroendocrine tumors at the Asan Medical Center.

Results

Of the 45 patients with typical carcinoids, 37 underwent surgery (eg, endoscopic resection). Of the 52 patients with NECs, 43 underwent surgery (eg, radical gastrectomy). One patient died of recurrence of the typical carcinoids, whereas 26 patients with NECs died of related diseases (P < .05). The rates of survival and recurrence did not significantly differ by type of typical carcinoid (P > .05).

Conclusions

Regardless of the type, carcinoids that are not yet advanced can be effectively treated with minimal endoscopic or laparoscopic surgery. However, all NECs and advanced carcinoids should be treated with radical gastrectomy.     

Gamma probe identification of normal parathyroid glands during central neck surgery can facilitate parathyroid preservation

Background

We evaluated gamma probe identification (GPI) of sestamibi-labeled normal parathyroid glands during central neck surgery.

Methods

GPI was judged to be helpful if it resulted in the identification of parathyroid glands not identified by direct inspection.

Results

GPI was performed in 54 patients and was helpful in 20, including 9 patients in whom GPI identified intact parathyroid glands in vivo and 11 patients in whom GPI identified incidentally excised parathyroid glands ex vivo in the central neck dissection (CND) specimen. GPI was more commonly helpful in patients who underwent reoperation (9/16, 56%) compared with primary surgery (11/38, 29%; P = .04) and was more commonly helpful in patients who underwent CND (17/28, 61%) compared with thyroidectomy without CND (2/26, 8%; P < .0001). In 11 patients, normal parathyroid glands were salvaged by GPI from the ex vivo CND specimens and autografted.

Conclusions

GPI is a relatively simple and effective technique that may help maximize parathyroid preservation.     

Oncologic outcomes after resection of rectal cancer: Laparoscopic versus open approach

Background

This study examined outcomes of laparoscopic and open rectal cancer surgery in a community hospital setting.

Methods

A community health care system cancer registry was reviewed retrospectively (2004-2007) for rectal cancer patients undergoing surgical treatment. Primary end points were rates of recurrence and survival.

Results

Both open and laparoscopic resection groups had similar demographic, treatment, and tumor characteristics. Most patients in the open resection and laparoscopic resection populations experienced no recurrence (79% vs 83%, respectively; P = .5). Overall, the groups had similar mean (88% vs 96%, respectively; P = .4) and disease-free (21 and 23 months, respectively; P = .5) survival.

Conclusions

In a community hospital setting, laparoscopic resection of rectal cancer was found to be as safe and effective as open resection in selected patients.     

Laparoscopic nephrectomy, ex vivo excision and autotransplantation for complex renal tumors

Purpose:

In many patients partial nephrectomy is the preferred alternative to radical nephrectomy for upper urinary tract cancers. We describe the use of laparoscopic nephrectomy, ex vivo excision and reconstruction, and autotransplantation to expand the realm of minimally invasive, nephron sparing surgery to the most complex renal tumors.

Materials and Methods:

In our cohort undergoing renal surgery 2 patients had a solitary kidney with renal tumors not considered amenable to in situ partial nephrectomy. After transperitoneal laparoscopic nephrectomy ex vivo tumor excision and renorrhaphy were performed. The kidney was transplanted to the ipsilateral iliac vessels through the Gibson extraction incision.

Results:

Indications for surgery were high grade urothelial carcinoma within a caliceal diverticulum and a central 5 cm renal cell carcinoma. Mean nephrectomy, cold ischemic and transplantation times were 4.5, 2 and 3.7 hours, respectively. No intraoperative or postoperative complications were noted. Hospitalization was 12 and 6 days, respectively. At 20 and 12 months of followup each patient remained off dialysis without evidence of recurrence.

Conclusions:

Despite experience with conventional nephron sparing surgery some cases may be more appropriate for ex vivo excision and reconstruction. In these situations the minimally invasive approach provides a kidney suitable for renal autotransplantation, while simultaneously decreasing patient morbidity. This novel approach to complex renal tumors is feasible when one applies principles of laparoscopic donor nephrectomy and possesses experience with renal transplantation.     

Implications of laparoscopy on surgery residency training

Background

With the advent of laparoscopy, many traditional junior-level cases now require advanced laparoscopic skill. We sought to ascertain the implications of laparoscopy on residency training through the use of a large national database.

Methods

American College of Surgeons National Surgical Quality Improvement Program data were gathered for patients undergoing elective open and laparoscopic inguinal herniorrhaphy, appendectomy, and partial colectomy during 2005 and 2006. Cases were stratified by resident level and compared using univariate analysis.

Results

A total of 14,729 cases were performed during the study period. For inguinal hernia repair, 72% of open repairs were performed by postgraduate year 3 residents or below versus 41% of laparoscopic repairs (P < .0001). Similarly, 61% of open appendectomies were performed by postgraduate year 3 residents or below compared with 48% of laparoscopic appendectomies (P < .0001). Forty-six percent of open colectomies were performed by postgraduate year 3 and postgraduate year 4 residents versus 33% of laparoscopic resections (P < .0001).

Conclusions

These data show an upward shift in cases traditionally performed by junior-level residents. The implications of this shift are unknown but may lead to decreased surgical experience during the early years of training.     

Laparoscopic improves perioperative outcomes of antireflux surgery at US academic centers

Background

Open and laparoscopic antireflux surgeries are standard for the treatment of gastroesophageal reflux disease (GERD). The in-hospital outcomes of laparoscopic and open antireflux procedures were analyzed and compared at US academic medical centers.

Methods

Using International Classification of Diseases, Ninth Revision, Clinical Modification codes for 5,737 patients with GERD that underwent open (n = 1,377) or laparoscopic (n = 4,360) antireflux surgery were identified from the University Health-System Consortium Database over a 3-year period (2004-2007). Demographic and outcome data measured included length of stay, overall complications, in-hospital mortality, observed-to-expected mortality ratio (risk-adjusted mortality), and hospital costs.

Results

Laparoscopic antireflux procedures offered significantly lower mean length of stay, in-hospital morbidity, and hospital costs. Both procedures had a low observed to expected in-hospital mortality. Open surgery was associated with significantly higher procedure-related and pulmonary complications.

Conclusions

In the context of US academic centers, approximately three quarters of antireflux procedures are being performed using the laparoscopic approach. These data suggest that laparoscopy has improved in-hospital outcomes when compared with open surgery and is preferred for the surgical treatment of GERD.     

Single-incision laparoscopic surgery in children: initial single-center experience

Background

In continued efforts to further improve the advantages of minimally invasive surgery to patients, surgeons have developed single-incision laparoscopic techniques. We report our initial experience in children with a variety of single-site procedures.

Method

A retrospective chart review was performed on patients who underwent a single-site procedure from April 2009 to April 2010.

Results

There were 142 consecutive procedures: 24 cholecystectomies, 103 appendectomies for nonperforated appendicitis, 2 splenectomies, 1 combined splenectomy/cholecystectomy, 8 ileocecectomies, 2 Meckel diverticulectomies, 1 small bowel duplication resection, and 1 jejunal stricture resection. There were 12 conversions to conventional laparoscopy: 10 during appendectomy and 2 during cholecystectomy. Mean operative time was 34 minutes for appendectomy, 73 minutes for cholecystectomy, 90 minutes for splenectomy, 116 minutes for combined splenectomy/cholecystectomy, 86 minutes for ileocecectomy, and 43 minutes for the small bowel procedures. The only complications were umbilical surgical site infections after appendectomy in 6 patients.

Conclusion

This institution's preliminary experience suggests that single-incision laparoscopic surgery in children has at least comparable outcomes to conventional laparoscopic surgery. However, prospective data are needed to prove that single-incision laparoscopic surgery is superior to conventional laparoscopy.     

Pepsin in bronchoalveolar lavage fluid: a specific and sensitive method of diagnosing gastro-oesophageal reflux-related pulmonary aspiration

Objectives

Gastro-oesophageal reflux (GOR)-related aspiration is associated with respiratory disease, but the current “gold standard” investigation, the lipid-laden macrophage index (LLMI), is flawed. A specific marker of GOR-related aspiration should originate in the stomach, but not the lung. An assay to detect gastric pepsin in the bronchoalveolar lavage (BAL) of children was developed and validated.

Methods

Gastro-oesophageal reflux was diagnosed in 33 children using intra-oesophageal pH monitoring. Thirteen asymptomatic negative controls requiring endotracheal intubation for elective surgery and 5 positive control patients with observed aspiration were recruited. All subjects received a BAL; the fluid obtained was analysed for the pepsin content and the LLMI.

Results

All subjects in the negative control group were negative for pepsin. The positive control group had a significantly greater median pepsin level (P < .01) compared with negative controls. Patients with proximal oesophageal GOR and chronic cough also had significantly elevated pepsin levels (P = .04). The LLMI was not significantly elevated by the presence of cough or GOR.

Conclusions

This study suggests that GOR-related aspiration plays a role in chronic cough in children with known GOR. Detecting pepsin in BAL fluid may therefore become an important adjunct in patient selection for antireflux surgery.     

Predictors of complete pathological response after neoadjuvant systemic therapy for breast cancer

Background

The aim of the current study was to identify predictors of pathologic complete response (pCR) following neoadjuvant therapy.

Methods

From 2000 to 2007, 518 breast cancer patients received neoadjuvant therapy. Data were compared using χ² and Fisher's exact tests and multivariate analysis of variance, as appropriate.

Results

Of 518 breast cancer patients receiving neoadjuvant therapy, 81 (16%) had pCR (77 of 456 [17%] with chemotherapy, 4 of 62 [6%] with endocrine therapy; P < .05). Four factors were associated with pCR: higher tumor grade (P = .015), lack of estrogen receptor (ER) and progesterone receptor (PR) expression (P < .0001), HER2/neu amplification (P = .025), and negative lymph node status (P < .0001). On multivariate analysis, ER and PR negativity, HER2/neu amplification, and negative lymph node status were found to significantly correlate with pCR.

Conclusions

Patients with ER-negative and PR-negative and HER2/neu-amplified breast cancer phenotypes are more likely to experience pCR to neoadjuvant therapy. Although pCR is more frequently observed following neoadjuvant chemotherapy, it is rare following neoadjuvant endocrine therapy.