Can Laparoscopic Pancreaticoduodenectomy Be Safely Implemented?

Introduction  

The implementation of laparoscopic pancreaticoduodenectomy (LPD) has been appropriately met with apprehension, and concerns exist regarding outcomes early in a program’s experience. We reviewed our early experience and outcomes of LPD.     

Who Should Be Doing Laparoscopic Bariatric Surgery?

Background: The training and credentialing of surgeons for laparoscopic bariatric surgery is controversial. We sought to determine if there is an association between surgeons' practice and choice of open or laparoscopic bariatric surgery. Methods: Members of the ASBS were surveyed via email. Associations were tested with Cochran-Mantel-Haenszel or Pearson's chi-square. Results: 104/472 members responded; 65% were in private practice; 47% did 1-5 operations/week, 48% offered open procedures only, and 76% undertook gastric bypass. Respondents believe that laparoscopic procedures: should mimic open ones (77%), are safe (63%), should be evaluated by clinical trials (48%), and that expertise in bariatric surgery is more important than laparoscopic experience. 75% believe that courses and preceptorships are important. Regarding laparoscopic operations, surgeons doing only open procedures believe that: 1) the ASBS should be the main credentialing body; 2) surgeons should do >25 open before laparoscopic ones; and 3) clinical trials are needed (P<0.02, all). Surgeons with laparoscopic training or practices believe that laparoscopic surgery is safe and effective (P<0.002). Both laparoscopic and open surgeons believe bariatric surgeons should be the only surgeons doing laparoscopic bariatric procedures (P<0.008). Conclusions:There is consensus that laparoscopic bariatric surgery should be undertaken only by surgeons with strong interest in bariatric surgery. Laparoscopic bariatric surgeons should incorporate lessons learned from open surgery. Both laparoscopic and open bariatric surgeons should seek added expertise via courses and preceptorships.The skepticism of surgeons with 'open' practices could be addressed by clinical trials. The ASBS should maintain its leadership position and foster emerging technologies.     

Can Postoperative Nausea and Vomiting Be Predicted?

Background: Retrospective [1] studies fail to identify predictors of postoperative nausea and vomiting (PONV). The authors prospectively studied 17,638 consecutive outpatients who had surgery to identify these predictors.

Methods: Data on medical conditions, anesthesia, surgery, and PONV were collected in the post-anesthesia care unit, in the ambulatory surgical unit, and in telephone interviews conducted 24 h after surgery. Multiple logistic regression with backward stepwise elimination was used to develop a predictive model. An independent set of patients was used to validate the model.

Results: Age (younger or older), sex (female or male), smoking status (nonsmokers or smokers), previous PONV, type of anesthesia (general or other), duration of anesthesia (longer or shorter), and type of surgery (plastic, orthopedic shoulder, or other) were independent predictors of PONV. A 10-yr increase in age decreased the likelihood of PONV by 13%. The risk for men was on third that for women. A 30-min increase in the duration of anesthesia increased the likelihood of PONV by 59%. General anesthesia increased the likelihood of PONV 11 times compared with other types of anesthesia. Patients with plastic and orthopedic shoulder surgery had a sixfold increase in the risk for PONV. The model predicted PONV accurately and yielded an area under the receiver operating characteristic curve of 0.785 +/- 0.011 using an independent validation set.     

Magnetic Resonance Imaging of the Breast as a Problem‐solving Method: To Be or Not to Be?

The use of dynamic magnetic resonance imaging (MRI) of the breast as a complementary problem‐solving tool was explored in a heterogeneous population sample. A total of 3,076 patients that underwent breast MRI examination between January 2008 and June 2012 in our center were screened retrospectively. Of these, 868 met the following inclusion criteria and were considered eligible for the study: available data on clinical signs, symptoms and on the results of mammography and ultrasound examinations in medical records; at least 1 year of follow‐up; and documented pathology findings. Lesions with a stable course over a follow‐up period of at least 12 months were considered benign. MRI was suggestive of a suspicious abnormality (BI‐RADS 4) or highly suggestive of malignancy (BI‐RADS 5) in 129 (15%) of 868 patients, leading to a biopsy examination in these cases. On the other hand, MRI findings were considered normal in 739 (85%) subjects based on normal (BI‐RADS 1), benign (BI‐RADS 2) or probably benign (BI‐RADS 3) findings. Of the 129 patients undergoing a histopathologic examination based on MRI findings, 63 were diagnosed with cancer, and in 66, the biopsy proved to be benign. Forty of the 63 patients (40/63) with a diagnosis of malignancy and 34 of the 66 patients (34/66) with a benign diagnosis had been categorized as BI‐RADS 4 with conventional methods. A total of 23 patients with BI‐RADS category of 0 to 3 according to conventional methods were diagnosed as having cancer with MRI. In six of these, the family history was positive. The sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of MRI for the detection of cancer were 100%, 92%, 52%, and 100%, respectively. In cases with inconclusive findings on conventional imaging studies or in patients with clinical/radiological suspicion of malignancy, MRI should be more effectively used as a problem‐solving approach owing to its high sensitivity and NPV in this condition. Use of MRI as a problem‐solving method in such cases may decrease rather than increase unnecessary biopsy procedures and patient anxiety.     

How Can Prognosis for Diabetic ESRD Be Improved?

Although the prognosis of patients who have diabetes and are receiving renal replacement therapy has greatly improved, survival and medical rehabilitation rates continue to be significantly worse than those of nondiabetic patients, mainly because of pre‐existing severely compromised cardiovascular conditions. In this scenario, the nephrology community had to do its best in order to offer the best treatment options to these patients using a multifaceted approach. The most common RRT modality in patients with diabetes is still hemodialysis, but it gives rise to a number of clinical problems, in particular difficulties in the management of the vascular access and high frequency of intradialytic hypotension. Recent data suggest that efficient high‐flux treatments have the potential of improving morbidity and mortality of diabetics with ESRD. Sodium profiling during the dialysis session may be also of importance in reducing intradialytic hypotension and helping in achieving the prescribed body weight. Patients who have diabetes and are on peritoneal dialysis have to face a progressive increase in peritoneal permeability, loss of ultrafiltration, and peritoneal fibrosis, all phenomena being accelerated in patients with diabetes and ultimately leading to an increased technique failure. However, the two dialytic modalities are comparable in terms of outcomes in the short term.     

Should Initial Surveillance of Vestibular Schwannoma Be Abandoned?

Early diagnosis of vestibular schwannoma (VS) has increased in recent years because of increased longevity and availability of magnetic resonance imaging (MRI). Initial conservative radiological surveillance is often requested by patients and physicians to establish whether these tumors are growing before embarking on intervention. Initial observation of at least 1 year in all small VS was therefore recommended by some authors. We evaluated our prospective skull base database of VSs that were managed with initial radiological surveillance to establish when this policy should be abandoned and what predicts future growth. Fifty-four consecutive patients with VS in our institution who were managed by initial yearly MRI scanning were studied. The MRI data were collected prospectively and analyzed by Kodak CareStream viewing software where VS maximum diameters in three perpendicular planes and volume were calculated. One patient was excluded from the analysis as he had only one MRI follow-up. The median age of the 53 patients was 59 years (range, 26 to 86 years), 25 were males and 28 were females, and 33 were under 65 years of age; 18 VSs were extracanalicular, 18 were intracanalicular, and 17 extended both inside and outside the canal; 21 VSs were 1.2 cm³ or less, 22 were 1.2 to 4 cm³, and the rest were >4 cm³. Using volumetric analysis, 29.72% of conservatively managed VS grew by at least 2 mm per year, and 70.82% did not grow in 5 years. Age, gender, symptoms, and side did not predict future growth. However, growth in the first year was a strong predictor of future growth (p < 0.001) and initial volume was also a strong predictor of future growth (p < 0.05). Twenty-nine percent of observed VSs grew by at least 2 mm per year in the first 5 years of surveillance. As the growth rate is slow, initial radiological surveillance is justified in elderly patients and patients with small VSs and nonserviceable hearing. Growth in the first year was a strong predictor of future growth. The reported treatment effect should be interpreted in the light of 70.24% of VSs that either shrink or do not change in the first 5 years.     

Should Depression Be Treated Before Lower Extremity Arthroplasty?

Background

Patient optimization is becoming increasingly important before arthroplasty to ensure outcomes. It has been suggested that depression is a modifiable risk factor that should be corrected preoperatively. It remains to be determined whether psychological intervention before surgery will improve outcomes. We theorized that the use of preoperative depression scales to predict postoperative outcomes may be influenced by the pain and functional disability of arthritis. To determine whether depression is a modifiable risk factor that should be corrected preoperatively we asked the following questions: (1) What is the prevalence of depression in arthroplasty patients preoperatively? (2) Do depressive symptoms improve after surgery? (3) Is preoperative depression associated with outcome?