Implementing a robotics curriculum at an academic general surgery training program: our initial experience

The robotic surgical platform is being utilized by a growing number of hospitals across the country, including academic medical centers. Training programs are tasked with teaching their residents how to utilize this technology. To this end, we have developed and implemented a robotic surgical curriculum, and share our initial experience here. Our curriculum was implemented for all General Surgical residents for the academic year 2014–2015. The curriculum consisted of online training, readings, bedside training, console simulation, participating in ten cases as bedside first assistant, and operating at the console. 20 surgical residents were included. Residents were provided the curriculum and notified the department upon completion. Bedside assistance and operative console training were completed in the operating room through a mix of biliary, foregut, and colorectal cases. During the fiscal years of 2014 and 2015, there were 164 and 263 robot-assisted surgeries performed within the General Surgery Department, respectively. All 20 residents completed the online and bedside instruction portions of the curriculum. Of the 20 residents trained, 13/20 (65 %) sat at the Surgeon console during at least one case. Utilizing this curriculum, we have trained and incorporated residents into robot-assisted cases in an efficient manner. A successful curriculum must be based on didactic learning, reading, bedside training, simulation, and training in the operating room. Each program must examine their caseload and resident class to ensure proper exposure to this platform.     

Full robot-assisted gastrectomy: surgical technique and preliminary experience from a single center

The treatment of gastric cancer requires a multidisciplinary approach in which surgery plays the main role. The diffusion of minimally invasive surgery for gastric cancer treatment is limited by the complexity of performing an extended lymphadenectomy. This surgical step can be facilitated through the use of a robot-assisted system. To date, there are few published articles discussing a full robotic approach that precisely show the different surgical steps. The aim of this study is to describe our experience, surgical techniques and the short-term results of a consecutive series of full robotic gastrectomies using the Da Vinci Surgical System. From November 2011 to January 2015, 17 patients with gastric cancer underwent curative resection by robotic approach for locally advanced tumors. In summary, there were 15 total gastrectomies with a Roux-en-Y esophagojejunostomy, one total gastrectomy with transverse colectomy and one sub-total gastrectomy. Resection margins were negative in all cases. Conversions occurred in two patients. Robot-assisted gastrectomy with extended lymphadenectomy is a safe technique and successfully allows an adequate lymph node harvest and optimal R0-resection rates with low postoperative morbidity. The learning curve appears to be shorter than in laparoscopic surgery. Further follow-up and randomized clinical trials are required to confirm the role of a robotic approach in gastric cancer surgery.     

An increasing proportion of perinephric to subcutaneous fat is associated with adverse perioperative outcomes of robotic partial nephrectomy

To investigate the association of perinephric fat (PF) thickness and the ratio of perinephric to subcutaneous fat (PF:SF) thickness on perioperative outcomes following robotic partial nephrectomy (RPN), 240 patients undergoing RPN with preoperative computed tomography (CT) axial imaging were included. Perinephric and subcutaneous fat thickness was measured at the level of the renal vein and umbilicus, respectively. The association between PF thickness and PF:SF ratio and perioperative outcomes was determined by Spearman correlation and logistic regression. 121 men and 119 women with a median age of 55 years, BMI of 32, tumor size of 2.6 cm, and RENAL nephrometry score of 6 were included. On preoperative imaging, median PF thickness was 2.2 cm, SF thickness was 3.1 cm, and PF:SF ratio was 0.63. There were statistically significant positive correlations between PF thickness (Spearman correlation coefficient = 0.26, p = 0.001) and PF:SF ratio (Spearman correlation coefficient = 0.33, p < 0.0001) with longer operative duration of RPN. In addition, an increasing PF:SF ratio was associated with a greater risk of perioperative complications (OR = 1.82, 95 % CI 1.1–3.0, p = 0.02). No association was observed with respect to ischemia time, blood loss, length of stay, or margin status. PF thickness is associated with longer OR duration, and a greater PF:SF ratio correlated with increased OR duration and complications following RPN. These easily measured indices of fat distribution are likely more accurate in predicting perioperative outcomes after RPN than BMI alone.     

A Prospective Study in Comparison of Ambulatory Phlebectomy and Duplex Guided Foam Sclerotherapy in the Management of Varicosities with Isolated Perforator Incompetence

Perforators are those which connect the superficial and deep venous system either directly to main veins or indirectly through the muscular and soleal venous plexus. The emergence of minimally invasive techniques like ambulatory phlebectomy (AP) and foam sclerotherapy (FS) has led to increasing interest about the appropriate therapy for the treatment of isolated perforator incompetence. There have been no studies which have compared the effectiveness of these in-office procedures in isolated perforator incompetence due to the low prevalence of cases. The primary goal of this study is to compare the clinical parameters (return to normal activity, primary symptom relief), functional parameters (procedure time, change in disease severity, course of venous ulcer), and duplex parameters (recurrence in treated veins, complete occlusion of treated veins) in the management of leg varicosities having isolated primary perforator incompetence by ambulatory phlebectomy and duplex guided foam sclerotherapy. Though the procedure time was shorter with FS than AP, the other parameters of primary symptom relief such as change in disease severity, faster healing of venous ulcer, complete occlusion of treated veins in follow-up duplex examination, and lower recurrence of treated veins are better with AP than FS. In conclusion, the interruption of perforators is effective in decreasing the symptoms of chronic venous insufficiency and for the rapid healing of ulcers. The interruption of the incompetent perforating veins appears to be essential to decrease ambulatory venous hypertension. It is apparent from this study that ambulatory phlebectomy stands distinct with enormous benefits and serves as a superior alternative to foam sclerotherapy in treating patients with isolated perforator incompetence.     

Morbidity and Mortality After Gastrectomy: Identification of Modifiable Risk Factors

Background

Morbidity after gastrectomy remains high. The potentially modifiable risk factors have not been well described. This study considers a series of potentially modifiable patient-specific and perioperative characteristics that could be considered to reduce morbidity and mortality after gastrectomy.

Methods

This retrospective cohort study includes adults in the ACS NSQIP PUF dataset who underwent gastrectomy between 2011 and 2013. Sequential multivariable models were used to estimate effects of clinical covariates on study outcomes including morbidity, mortality, readmission, and reoperation.

Results

Three thousand six hundred and seventy-eight patients underwent gastrectomy. A majority of patients had distal gastrectomy (N?=?2,799, 76.1 %) and had resection for malignancy (N?=?2,316, 63.0 %). Seven hundred and ninety-eight patients (21.7 %) experienced a major complication. Reoperation was required in 290 patients (7.9 %). Thirty-day mortality was 5.2 %. Age (OR?=?1.01, 95 % CI?=?1.01–1.02, p?=?0.001), preoperative malnutrition (OR?=?1.65, 95 % CI?=?1.35–2.02, p?<?0.001), total gastrectomy (OR?=?1.63, 95 % CI?=?1.31–2.03, p?<?0.001), benign indication for resection (OR?=?1.60, 95 % CI?=?1.29–1.97, p?<?0.001), blood transfusion (OR?=?2.57, 95 % CI?=?2.10–3.13, p?<?0.001), and intraoperative placement of a feeding tubes (OR?=?1.28, 95 % CI?=?1.00–1.62, p?=?0.047) were independently associated with increased risk of morbidity. Association between tobacco use and morbidity was statistically marginal (OR?=?1.23, 95 % CI?=?0.99–1.53, p?=?0.064). All-cause postoperative morbidity had significant associations with reoperation, readmission, and mortality (all p?<?0.001).

Conclusions

Mitigation of perioperative risk factors including smoking and malnutrition as well as identified operative considerations may improve outcomes after gastrectomy. Postoperative morbidity has the strongest association with other measures of poor outcome: reoperation, readmission, and mortality.

     

Impact of Delta Hemoglobin on Provider Transfusion Practices and Post-operative Morbidity Among Patients Undergoing Liver and Pancreatic Surgery

Background

Delta hemoglobin (ΔHb) is defined as the difference between the preoperative Hb and the lowest post-operative Hb level. We sought to define the impact of ΔHb relative to nadir Hb levels on the likelihood of transfusion, as well as characterize the impact of ΔHb and nadir Hb on morbidity among a large cohort of patients undergoing complex hepatopancreatobiliary (HPB) surgery.

Methods

Patients who underwent pancreatic or hepatic resection between January 1, 2009 and June 30, 2015 at Johns Hopkins Hospital were identified. Data on the perioperative ΔHb, nadir Hb, as well as blood utilization were obtained and analyzed. Multivariable logistic regression models were used to identify the factors associated with ΔHb and the impact of ΔHb on perioperative morbidity. A Bayesian model was used to evaluate the correlation of ΔHb and nadir Hb with the likelihood of transfusion, as well as the impact on morbidity.

Results

A total of 4363 patients who underwent hepatobiliary (n?=?2200, 50.4 %) or pancreatic (n?=?2163, 49.6 %) surgery were identified. More than one quarter of patients received at least one unit of packed red blood cells (PRBC) (n?=?1187, 27.2 %). The median nadir Hb was 9.2 (IQR 7.9–10.5)?g/dL resulting in an average ΔHb of 3.4 mg/dL (IQR 2.2–4.7) corresponding to 26.3 %. Both ΔHb and nadir Hb strongly influenced provider behavior with regards to use of transfusion. Among patients with the same nadir Hb, ΔHb was strongly associated with use of transfusion; among patients who had a nadir Hb ≤6 g/dL, the use of transfusion was only 17.9 % when the ΔHb?=?10 % versus 49.1 and 80.9 % when the ΔHb was 30 or 50 %, respectively. Perioperative complications occurred in 584 patients (13.4 %) and were more common among patients with a higher value of ΔHb, as well as patients who received PRBC (both P?<?0.001).

Conclusions

The combination of the Hb trigger with ΔHb was associated with transfusion practices among providers. Larger ΔHb values, as well as receipt of transfusion, were strongly associated with risk of perioperative complication following HPB surgery.

     

Prospektive 1‑Jahres-Ergebnisse der arthroskopischen Arthrolyse des Ellenbogens

Background

Arthroscopic arthrolysis is a minimally invasive but technically demanding treatment option for elbow stiffness. Prospective clinical data are limited thus far.

Objectives

The aim was to analyze the clinical short-term results of arthroscopic elbow arthrolysis and to evaluate factors predictive of the outcome.

Materials and methods

28 patients (16 men, 12 women) following arthroscopic arthrolysis were enrolled in this study. The VAS (visual analogue scale) score, range of motion (ROM), and DASH score were obtained preoperatively as well as 6 weeks and 12 months after surgery. Posttraumatic elbow stiffness was present in 15 cases, elbow stiffness was due to primary osteoarthritis in 10 cases and due to other reasons in 3 cases. Osteoarthritis was absent in 1 case, grade 1 osteoarthritis was present in 7 cases, grade 2 in 9 cases and grade 3 in 11 cases according to the Broberg and Morrey classification.

Results

The VAS score was 5.3 ± 2.4 points preoperatively and decreased to 2.8 ± 2.7 points after 6 weeks and 1.6 ± 1.8 points after 12 months (p ≤ 0.001). The ROM increased from 86± 30° to 106± 28° after 6 weeks and to 121± 18° 12 months postoperatively (p ≤ 0.01). The DASH score improved from 39.3 ± 17.8 points to 23.8 ± 15.7 points after 6 weeks and to 11.3 ± 8.7 points 12 months postoperatively (p ≤ 0.001). Sex, age, grade of osteoarthritis and cause of elbow stiffness were not predictive of the clinical outcome. Complications were seen in 2 patients (7?%).

Conclusions

Arthroscopic arthrolysis represents an effective treatment method for elbow stiffness, which increases the range of motion, decreases pain levels and thus improves the functionality of the affected extremity regardless of sex, age, severity of osteoarthritis and etiology of elbow stiffness.

     

Elipse™, a Procedureless Gastric Balloon for Weight Loss: a Proof-of-Concept Pilot Study

Background

Endoscopic gastric balloons have been used effectively as weight loss devices for decades, but the requirement for endoscopy and sedation poses several limitations. The goal of this pilot study was to evaluate the safety and performance of a prototype version of Elipse?, a procedureless gastric balloon.

Methods

Eight patients (mean BMI?=?31.0 kg/m²) participated in this study. Each patient swallowed one Elipse? balloon intended to remain in the stomach for 6 weeks, self-empty, and then pass. Each balloon was filled with 450 mL of filling fluid. Patients returned every 2 weeks for abdominal ultrasound. No specific diet or exercise plan was prescribed.

Results

All eight patients successfully swallowed the device. The most common adverse events were nausea and vomiting. There were no serious adverse events, and all balloons were excreted safely. Despite not being prescribed a diet or exercise plan, all eight patients lost weight. In 6/8 patients, the balloon remained full through 6 weeks, self-emptied, and passed. In one patient, the balloon appeared partially collapsed on ultrasound after 11 days and was endoscopically punctured. One asymptomatic patient elected to have the balloon endoscopically punctured after 19 days. Both balloons passed in the stool after 4 days. In both cases, endoscopic examination of the upper GI tract showed no abnormalities.

Conclusions

This pilot study demonstrates the safety and performance of Elipse?, a procedureless gastric balloon for weight loss. Future studies will test a commercial design filled to 550 mL intended to last in the stomach for at least 12 weeks.

     

External fixation reconstruction of the residual problems of benign bone tumours

The mechanical features of and biologic response to using distraction osteogenesis with the circular external fixator are the unique aspects of Ilizarov’s contribution that allows deformity correction and reconstruction of bone defects. We present a retrospective study of 20 patients who suffered from a variety of benign tumours for which external fixators (EF) were used to treat deformity, bone loss, and limb-length discrepancy. A total of 26 bony segments in twenty patients (10 males, 10 females; mean age 17 years; range 7–58 years) were treated with EF for residual problems from the tumour itself (primary treatment) in 8 patients and for complications related to the primary surgery (secondary treatment) in 12 patients. Histological diagnoses were Ollier’s disease (n = 4), Fibrous Dysplasia (n = 5), Congenital multiple exostosis (n = 5), giant cell tumour (n = 2) and one case for chondromyxoid fibroma, desmoid fibroma, chondroma and unicameral bone cyst. Various types of external fixators used to treat these problems. These were Ilizarov, unilateral fixator, multiaxial correction frame (Biomet, Parsippany, NJ), Taylor spatial frame (Memphis, TN) and smart correction multiaxial frame. The mean follow-up time was 69.5 months (range 35–108 months). The mean external fixation time was 159.5 days (range 27–300 days). The mean external fixation index was 67.4 days/cm (12–610) in 26 limbs who underwent distraction osteogenesis. The mean length of distraction was 4.9 cm (range 0.2–14 cm). At final follow-up, all patients had returned to normal activities. Complications were in the form of knee arthrodesis in one patient, pin tract infection in six and residual shortening in eight patients. The use of EF and the principles of distraction osteogenesis, in the management of problems associated with benign bone tumours and related surgery yields successful results especially in young patients. With this approach, the risk for recurrence of shortening and deformity may be minimized with overcorrection or over-lengthening as dictated by preoperative planning.     

Intramedullary nailing versus external fixation in Gustilo type III open tibial shaft fractures: a meta-analysis of randomised controlled trials

Open tibial shaft fractures are the most common of long-bone open fractures. Management of the fracture is either by intramedullary nailing (IMN) or by external fixation (EF). Since the literature does not indicate clearly which is more effective, a meta-analysis was conducted to establish which approach is more suitable to treat Gustilo type III fractures. MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE and CINAHL databases were searched for randomised controlled trials (RCT) describing IMN and EF treatment of Gustilo type III fractures. As of 15 November 2012, five RCT involving 239 patients had been published; the outcomes examined in this study are their surgical complications. Data analysis led complications to be grouped into infection, fracture healing problems (non-union, malunion) and “other complications” (vascular injury, revision surgery, soft tissue damage, mechanical failure and tibial malalignment). IMN was associated with lower rates of infection and fracture healing problems; the differences between the two approaches for “other complications” were not significant. The data indicate that IMN is the treatment of choice for Gustilo type III fractures.