Laparoscopic Appendectomy: Minimally Invasive Surgery Training Improves Outcomes in Basic Laparoscopic Procedures

Background

To determine whether minimally invasive surgery (MIS) training improves outcomes in laparoscopic appendectomy, a procedure that is commonly performed in general surgery training.

Methods

Retrospective review was conducted of all patients undergoing laparoscopic appendectomy for suspected acute appendicitis between 2014 and 2015 at a single-center, tertiary-care academic institution. Patients operated on by MIS-trained surgeons (MIS group) were compared to those operated on by general surgeons (GS group). Single-incision and multiport laparoscopic appendectomies were included; open approach, known malignancy, and interval appendectomies were excluded.

Results

A total of 507 patients were included in the study: 181 patients in the MIS group and 326 in the GS group. There were no differences in patient demographics or medical comorbidities between groups and most patients were ASA class 1 or 2. Patients operated on by MIS-trained surgeons had significantly shorter operative time (43 min, IQR 32–60 vs. 58 min, IQR 44–81; p < 0.001) and fewer intra-operative adverse events (0/181 vs. 8/326, 2.5%; p = 0.03). There was no difference in number of postoperative adverse events between groups (6/181, 3.3% vs. 21/326, 6.4%; p = 0.13). In the MIS group, subgroup analysis of single-incision versus multiport appendectomy showed no differences in intra-operative or postoperative adverse events. On multivariable linear regression, lack of MIS training and traditional multiport approach had the greatest effects on prolonging operative time (11.2 and 12.8 min, respectively; p = 0.001).

Conclusions

MIS fellowship improves operative metrics and patient outcomes even in basic laparoscopy.

     

Ein strukturiertes Behandlung- und Schulungsprogramm für Patienten mit Typ-2-Diabetes mellitus, Insulintherapie und verminderter kognitiver Leistungsf?higkeit (DikoL)*

Zusammenfassung. Hintergrund und Ziel:   Über die Hälfte der Patienten mit Typ-2-Diabetes mellitus und verminderter kognitiver Leistungsfähigkeit ist mit den Lerninhalten herkömmlicher strukturierter Behandlungs- und Schulungsprogramme für Patienten mit Insulintherapie überfordert. Folgen sind Probleme beim Diabetes- Selfmanagement (Insulininjektionen, Selbstkontrollen) und die Abhängigkeit von Familienangehörigen und Sozialstationen. Dies führt zu einer verminderten Lebensqualität und erhöhten Kosten für das Gesundheitswesen. Seit 1996 wurde deshalb ein zielgruppenorientiertes strukturiertes Behandlungs- und Schulungsprogramm (DikoL) entwickelt. Wesentliche Unterschiede im Vergleich zu herkömmlichen Programmen sind weniger theoretische Inhalte (z. B. keine Pathophysiologie, keine Insulinwirkkurven, keine komplizierte Berechnung von Kohlenhydrateinheiten) und mehr Zeit für praktische Übungen. Die Effektivität des DikoL-Programms wurde in einer randomisierten, prospektiven Untersuchung evaluiert. Patienten und Methodik:   Alle Patienten mit Typ-2-Diabetes mellitus (n = 106, Alter 68,6 ± 8,7 Jahre, Diabetesdauer im Median 10,3 [0,03–35,4] Jahre, HbA1c 10,3 ± 1,7% [HPLC, Diamat^®, Normbereich 4,5–6,3%], kognitive Leistungsfähigkeit 87,7 ± 12,3 IQ-Punkte), die zwischen April 1999 und Juni 2000 zur Teilnahme an einem strukturierten Behandlungs- und Schulungsprogramm bei Insulintherapie stationär eingewiesen worden waren, wurden untersucht. Patienten mit verminderter kognitiver Leistungsfähigkeit (< 91 IQ-Punkte) wurden randomisiert: Sie nahmen entweder an einem herkömmlichen strukturierten Behandlungs- und Schulungsprogramm nach Berger et al. (Standardgruppe: n = 35) oder am DikoL-Programm (DikoL-Gruppe: n = 33) teil. Unmittelbar nach Teilnahme und 1/2 Jahr später wurden die Stoffwechselqualität, das theoretische Wissen, in einem Handling-Test die Fähigkeit zum Diabetes-Selfmanagement und die Schulungszufriedenheit untersucht. Ergebnisse:   Patienten aus der DikoL-Gruppe zeigten nach Schulung vergleichbare Werte hinsichtlich des HbA1c-Werts (DikoL- vs. Standardgruppe: 8,5 ± 1,3 vs. 8,3 ± 1,4%; p = 0,62) und des theoretischen Wissens (DikoL- vs. Standardgruppe: 9,6 ± 4,4 vs. 10,3 ± 3,8 Punkte; p = 0,52), aber signifikant bessere Ergebnisse hinsichtlich der Fähigkeit zum Diabetes-Selfmanagement (DikoL- vs. Standardgruppe: 15,9 ± 3,1 vs. 12,5 ± 4,1 Punkte; p = 0,001). Zudem benötigten aus der DikoL-Gruppe tendenziell weniger Patienten Fremdhilfe (n = 1 Patient aus der DikoL-Gruppe vs. n = 5 Patienten aus der Standardgruppe; p = 0,13). Akutkomplikationen (Hypoglykämien, Komata und Fußulzera) waren in keiner Gruppe aufgetreten. Patienten der DikoL-Gruppe erreichten nach Schulung einen höheren Punktescore im Fragebogen zur Erfassung der Schulungszufriedenheit (DikoL- vs. Standardgruppe: 52,5 ± 4,5 vs. 44,7 ± 7,6 Punkte; p < 0,001). Schlussfolgerung:   Die Forderungen einer großen Zahl von Schulungsfachkräften, aber auch zahlreicher diabetologisch tätiger Ärzte, insbesondere jedoch die direkten oder indirekten Wünsche der Patienten wurden mit dem zielgruppengerechten strukturierten Behandlungs- und Schulungsprogramm DikoL erfüllt. DikoL ist das erste strukturierte Behandlungs- und Schulungsprogramm für Patienten mit Typ-2-Diabetes mellitus, Insulintherapie und verminderter kognitiver Leistungsfähigkeit, das in einer randomisierten Studie evaluiert wurde. Es wurde nachgewiesen, dass Patienten mit verminderter kognitiver Leistungsfähigkeit eine höhere Kompetenz hinsichtlich des Diabetes- Selfmanagements, somit mehr Selbständigkeit und einen sichereren Umgang mit ihrem Diabetes und der Therapie sowie eine höhere Schulungszufriedenheit besitzen. Seine flächendeckende Umsetzung könnte zu einer deutlichen Verbesserung der Behandlungsqualität der Patienten mit Typ-2-Diabetes mellitus und verminderter kognitiver Leistungsfähigkeit führen.* Das DikoL-Projekt erhielt von der AOK und der Ärztekammer Berlin eine Anerkennung im Rahmen des Berliner Gesundheitspreises 2000.     

A Randomized,Double-Blind,Placebo-Controlled Trial of Intravenous Acetaminophen on Hospital Length of Stay in Obese Individuals Undergoing Sleeve Gastrectomy

Background

Retrospective studies indicate that acetaminophen iv administration reduces hospital length of stay (LoS) and opiate consumption in patients undergoing bariatric surgery.

Objective

This study sought to determine whether using acetaminophen iv in morbidly obese subjects undergoing sleeve gastrectomy decreased LoS and total hospital charges as compared to patients receiving saline placebo.

Setting

Single-center university hospital

Methods

Using a randomized, double-blind, placebo-controlled design, subjects were assigned to receive either acetaminophen iv (group A) or saline placebo iv (group P). Data were collected between Jan 1 and Dec 31, 2016. Group A received acetaminophen every 6 h for a total of four doses. The first dose was administered following the induction of general anesthesia; group P received saline iv on the same schedule. Anesthetic management and prophylactic antiemetic regimen were standardized in all subjects. Postoperative pain management consisted of hydromorphone via patient-controlled infusion pump. Primary outcomes include hospital LoS and associated hospital costs. Secondary outcomes include patient satisfaction and postoperative nausea and pain scores.

Results

Subject demographics (n?=?127) and intraoperative management were similar in the two groups. Across all subjects, median hospital LoS in group A (n?=?63) was 1.87 vs. 1.97 days in group P (n?=?64) (p?=?0.03, Wilcoxon rank-sum test). Postoperatively, daily quality-of-recovery (QoR-15) scores, narcotic consumption, and the use of rescue antiemetics were not significantly different between groups. Median hospital costs were as follows: group A, $12,885 vs. group P, $12,977 (n?=?64).

Conclusions

Acetaminophen iv may reduce hospital LoS in subjects undergoing sleeve gastrectomy.

     

A Trial-Based Economic Evaluation Comparing Spinal Cord Stimulation With Best Medical Treatment in Painful Diabetic Peripheral Neuropathy

The objective was to perform an economic evaluation comparing spinal cord stimulation (SCS) in combination with best medical treatment (BMT) with BMT in painful diabetic peripheral neuropathy patients. Alongside a prospective 2-center randomized controlled trial, involving 36 painful diabetic peripheral neuropathy patients with severe lower limb pain not responding to conventional therapy, an economic evaluation was performed. Incremental cost-effectiveness ratios were based on: 1) societal costs and quality-adjusted life years (QALYs), and 2) direct health care costs and the number of successfully treated patients, respectively, both with a time horizon of 12 months. Bootstrap and secondary analyses were performed to address uncertainty. Total societal cost amounted to €26,539.18 versus €5,313.45 per patient in the SCS and BMT group, respectively. QALYs were .58 versus .36 and the number of successfully treated patients was 55% versus 7% for the SCS and BMT group, respectively. This resulted in incremental cost-effectiveness ratios of €94,159.56 per QALY and €34,518.85 per successfully treated patient, respectively. Bootstrap analyses showed that the probability of SCS being cost-effective ranges from 0 to 46% with willingness to pay threshold values ranging between €20,000 and €80,000 for a QALY. Secondary analyses showed that cost-effectiveness of SCS became more favorable after correcting for baseline cost imbalance between the 2 groups, extending the depreciation period of SCS material to 4 years, and extrapolation of the data up to 4 years. Although SCS was considerably more effective compared with BMT, the substantial initial investment that is required resulted in SCS not being cost-effective in the short term. Cost-effectiveness results were sensitive to baseline cost imbalances between the groups and the depreciation period of the SCS material.

Long‐term results of a multicenter study on subthalamic and pallidal stimulation in Parkinson's disease

We report the 5 to 6 year follow‐up of a multicenter study of bilateral subthalamic nucleus (STN) and globus pallidus internus (GPi) deep brain stimulation (DBS) in advanced Parkinson's disease (PD) patients. Thirty‐five STN patients and 16 GPi patients were assessed at 5 to 6 years after DBS surgery. Primary outcome measure was the stimulation effect on the motor Unified Parkinson's Disease Rating Scale (UPDRS) assessed with a prospective cross‐over double‐blind assessment without medications (stimulation was randomly switched on or off). Secondary outcomes were motor UPDRS changes with unblinded assessments in off‐ and on‐medication states with and without stimulation, activities of daily living (ADL), anti‐PD medications, and dyskinesias. In double‐blind assessment, both STN and GPi DBS were significantly effective in improving the motor UPDRS scores (STN, P < 0.0001, 45.4%; GPi, P = 0.008, 20.0%) compared with off‐stimulation, regardless of the sequence of stimulation. In open assessment, both STN‐ and GPi‐DBS significantly improved the off‐medication motor UPDRS when compared with before surgery (STN, P < 0.001, 50.5%; GPi, P = 0.002, 35.6%). Dyskinesias and ADL were significantly improved in both groups. Anti‐PD medications were significantly reduced only in the STN group. Adverse events were more frequent in the STN group. These results confirm the long‐term efficacy of STN and GPi DBS in advanced PD. Although the surgical targets were not randomized, there was a trend to a better outcome of motor signs in the STN‐DBS patients and fewer adverse events in the GPi‐DBS group. © 2010 Movement Disorder Society     

Causality between local field potentials of the subthalamic nucleus and electromyograms of forearm muscles in Parkinson’s disease

Deep brain stimulation of the subthalamic nucleus is an effective treatment for Parkinson’s disease, although its precise mechanisms remain poorly understood. To gain further insight into the mechanisms underlying deep brain stimulation, we analysed the causal relationship between forearm muscle activity and local field potentials derived from the subthalamic nucleus. In 19 patients suffering from Parkinson’s disease of the akinetic‐rigid subtype, we calculated the squared partial directed coherence between muscles of the contralateral forearm and the subthalamic nucleus or zona incerta during both a rest and a hold condition of the arm. For both recording regions, data analysis revealed that, during the rest condition, electromyographic activity was significantly more often ‘Granger‐causal’ for the local field potentials than the opposite causation. In contrast, during the hold condition, no significant difference was found in the occurrence of causalities. Contrary to the existing basal ganglia model and the current concept of Parkinson’s disease pathophysiology, we found the subthalamic nucleus to receive more ‘afferences’ than it emitted ‘efferences’, suggesting that its role is more complex than a simple driving nucleus in the basal ganglia loop. Therefore, the effect of deep brain stimulation in the subthalamic nucleus could, at least in part, result from a blockade of pathological afferent input.