Robotic excision of atrial myxoma.

BACKGROUND: Advances in optics and instrumentation with the da Vinci S Surgical System have facilitated minimally invasive and robotic cardiac procedures including mitral valve repair and atrial myxoma excision. We report our retrospective data comparing robotically assisted myxoma excision with standard median sternotomy excision. METHODS: Data were collected for cardiac myxoma resection performed between January 2000 and December 2009. The resulting cohort included a total of 57 patients. These patients were grouped into two categories: robotic-assisted (n = 17) surgical procedures and traditional (nonrobotic; n = 40) surgical procedures. Presurgical and surgical risk factors were examined. RESULTS: Univariate analysis comparing the surgical procedure groups and surgical risk factors found a significant difference in 3 of the 14 variables. Cannulation in all patients undergoing robotic-assisted cardiac myxoma excision was performed through cannulating the common femoral artery and vein while cannulation for the traditional procedures was performed using the aorta and atrium except for two patients. For aortic occlusion, 14 of the robotic-assisted cardiac myxoma patients had balloon occlusion and 34 of the traditional cardiac myxoma patients had aortic cross-clamp occlusion. Operating time was significantly shorter for robotic cases (2.7 hours) compared with traditional cases (3.5 hours). CONCLUSION: Robotic excision of atrial myxomas is safe and may be an alternative to traditional open surgery in selected patients.

Near infrared fluorescence imaging with ICG in TECAB surgery using the da Vinci Si surgical system in a canine model.

BACKGROUND: This study assessed the clinical utility of near-infrared fluorescence imaging using indocyanine green in off-pump beating heart total endoscopic and robotic-assisted coronary artery bypass using the fluorescence imaging system for the da Vinci Si on a canine model for vessel identification, graft patency, and correlation of graft patency with ultrasound transit-time flow measurement probe. METHODS: Beating heart total endoscopic robotic-assisted coronary artery bypass was performed on eight canine using indocyanine green and fluorescence imaging to identify the internal mammary artery prior to harvesting, the coronary vessel anatomy, and the patency of the beating heart total endoscopic coronary artery bypass anastomosis. Three to four injections of indocyanine green with a dose of 1.25 mg to 2.5 mg were administered per animal. Transit-time flow was measured in each of the dogs. RESULTS: High definition 3D images were obtained. The camera working distance, indocyanine green dosage, internal mammary artery visualization, coronary artery visualization, patency by indocyanine green injection, and patency by transit-time flow were recorded. Six cases were completed successfully, and all demonstrated correlation between indocyanine green measurements of flow, and the transit-time flow measurement. CONCLUSION: Use of near-infrared fluorescence with indocyanine green was feasible in our study, and would be of great benefit during total endoscopic robotic-assisted coronary artery bypass using the fluorescence imaging-capable da Vinci Si system to help identify the internal mammary artery, delineate the coronary anatomy, and also determine patency of the anastomoses. This procedure correlated well with transit-time flow measurement.

Clinically unsuspected papillary microcarcinomas of the thyroid: a common finding with favorable biology?

BACKGROUND: The purpose of this study was to describe the incidence and clinical/pathologic characteristics of papillary thyroid microcarcinoma (PMC) in a community hospital setting and to evaluate the frequency and characteristics of these lesions when unsuspected preoperatively. METHODS: A total of 723 patients underwent a partial or total thyroidectomy. A retrospective review was performed. RESULTS: A total of 194 of the 723 patients had a final diagnosis of papillary carcinoma. Ninety-six (49%) of these tumors were PMCs defined as being 1.0 cm or less in diameter. One third (32 of 96) of these lesions were multifocal and 16.7% (16 of 96) were found to have regional lymph node metastases. The majority (58%) of PMCs were found on final pathology and were clinically unsuspected (occult). Multifocality was found in 32.1% (18 of 56) of patients with clinically unsuspected PMC, with nodal metastases in 3.6% (2 of 56). The other 40 patients with PMC had surgeries performed for a clinical reason related to that pathologic lesion. This clinically suspected group was comparably multifocal (35%), but more likely to have cervical lymph node metastasis (35%). Sixty-six percent (37 of 56) diagnosed with a clinically unsuspected PMC underwent a partial thyroidectomy at the initial surgery. CONCLUSIONS: The prevalence of clinically unsuspected PMC in our population undergoing thyroidectomy was 7.7% (56 of 723). In our institution, this is more than half of all PMCs. The incidence of cervical lymph node metastasis in clinically unsuspected PMC was only 3.6% compared with 35% in clinically suspected disease, suggesting that the biological behavior (and possibly treatment) may be different. Long-term follow-up evaluation is needed to better evaluate the significance of these differences.

Predictors and outcomes of prolonged ventilation after coronary artery bypass graft surgery.

This study investigated and compared the risk factors and outcomes of patients undergoing coronary artery bypass graft surgery with and without the occurrence of prolonged mechanical ventilation. Data in a cardiac surgery database were examined retrospectively. Data selected included any isolated coronary artery bypass graft surgery performed by the surgical group from August 2005 to June 2009. The resulting cohort included a total of 2933 patients which was comprised of 116 patients with a ventilation time of greater than 72 hours (prolonged ventilation) and 2817 patients with a ventilation time of 72 hours or less (no prolonged ventilation). Patients with a prolonged ventilation time were matched (1:3 ratio) to patients not requiring a prolonged ventilation time by year of surgery resulting in our study cohort of 464 patients. To generate the unadjusted risks of each factor, χ(2) and t test analysis were performed. Logistic regression analysis was then used to investigate the adjusted risk between cases and controls and each of the significant variables. χ(2) and t tests were conducted comparing cases and controls with the outcome variables. Patients undergoing coronary artery bypass graft that experienced a prolonged ventilation time (cases) were more likely female, had a New York Hospital Association functional class of III or IV, and had a longer perfusion time. There was no significant difference between cases and controls with diabetes, chronic obstructive pulmonary disease, left ventricular ejection fraction, or body mass index while controlling for all significant risk factors. Careful patient selection and preparation during preoperative evaluation may help identify patients at risk for prolonged mechanical ventilation and thus help prevent the added morbidity and mortality associated with it.

Improving satisfaction ratings of surgical patients from referral to follow-up in the faculty medical center clinic.

OBJECTIVE: The objective of this study was to evaluate patient satisfaction in an outpatient community-based surgical clinic to seek opportunities for improvement. METHODS: A paper survey was distributed to patients at the Faculty Medical Center Clinic over a 12-week period. The survey allowed patients to rate their experience on a 5-point scale from "very dissatisfied" to "very satisfied." The survey addressed referral to the clinic, appointment scheduling, visit experience, wait times, laboratory testing, and satisfaction with surgery. Separate from the surveys, data were collected regarding wait time in clinic prior to being placed in an examining room, time spent waiting for the physician, time spent with the physician, overall time spent in clinic, and appointment time to surgery. RESULTS: During the 12-week time period, 87 surveys were returned from patients in the surgery clinic for a 69% response rate. Most patients were referred to the surgery clinic from the emergency department or their primary care physicians at 44% and 43%, respectively. Just over half of the patients responded that they were "very satisfied" with their overall experience. Of those surveyed, 40% of patients were "very satisfied" with their wait time for the first visit to the clinic, 52% with time in waiting room, 43% with time in examining room, and 47% with time spent with physician. Only 16.4% of patients were "very dissatisfied" or "mostly dissatisfied" with time waiting for appointment, 17.9% with time available for appointment, 14.3% with time in waiting room, 18.2% in time waiting in examination room for the physician, and 20.9% of time wait to schedule surgery. Data were also collected on 203 surgical clinic patients during this time. Of the 203 patients, 55% were new patients, 31% were postoperative patients, and 14% were in the clinic for another type of visit. CONCLUSIONS: Overall patient satisfaction was good for the clinic, yet there were areas to improve. Efficiency of scheduling patients, improving wait time for waiting room, examining room, and time prior to scheduling surgery are areas that need improvement. Modification of the current practice at the surgery clinic could result in improvement of patient satisfaction in future evaluation.

Operative decision-making for follicular thyroid lesions: a community hospital system experience.

Follicular neoplasms of the thyroid are a frequent indication for surgery of the thyroid gland. We evaluated the use of frozen sections on intraoperative decision-making, possible avoidance of reoperative surgery, and histologic findings in a retrospective cohort. A database was created of all thyroid operations from 2001 to 2007. Data collected included age, gender, preoperative cytology, indication for surgery, surgeon, intraoperative decision-making, and histologic findings. Of the 723 thyroidectomies, 203 were performed for follicular neoplasms diagnosed by fine needle aspiration. Of these, 135 had cytology reports available within our electronic medical record; 44 per cent (59 of 135) of these patients had an intraoperative frozen section. Only two of 59 (3.4%) were positive for carcinoma, both of which were papillary carcinomas. One was interpreted as "suspicious" for carcinoma by the pathologist. In these three cases, the surgeon proceeded with total thyroidectomy at the time of initial surgery. The results of frozen section altered the operation in only three of 59 cases (5.1%). Intraoperative frozen section rarely impacts the conduct of thyroidectomy for follicular neoplasms.

Differences in public belief and reality in the care of operative patients in a teaching hospital.

OBJECTIVE: The accreditation Council for Graduate Medical Education (ACGME) restricts residents from working more than 80 hours per week averaged over a 4-week period. No such restriction exists, however, for attending surgeons. Little exploration has been done of the public's perception of the number of hours that surgeons work and how residents work with the staff surgeons at a teaching institution. METHODS: A survey was designed to study the public's belief on surgeon work hours and habits. The survey also asked their opinion on resident involvement. All patients and accompanying persons arriving through the Surgicare Center for elective procedures older than age 18 were surveyed. The overall survey responses were calculated, and the results then were stratified by sex, age, race, and education. RESULTS: Of the 1516 surveys distributed, 370 were completed and returned (24.4%). Of those responding, 91% believed that a work hour limit should be in place for surgeons, and 77% believed the limit should be 12 consecutive hours or less. Eighty-four percent of the population believed that limit should be in place on the hours/week that a surgeon works, and 68% believe that it should be 60 hours or less. Although 82% would reschedule if they knew their surgeon had less than 4 hours of sleep the night before their procedure, 79% trust their surgeon's judgment to cancel if he/she were too tired. Only 28% of those surveyed were aware whether a resident was involved in their care, and 14% were against resident involvement. Respondents also were asked if the attending surgeon deemed a resident capable, then what percent of the procedure should the resident be able to perform? Ninety-one percent of those surveyed believed that the attending should be present for the entire case, and 78% believed that they should not be able to schedule more than 1 procedure at any given time. CONCLUSIONS: These findings illustrate a difference between the public's beliefs in regard to the hours a surgeon should be permitted to work and the reality of a surgeon's work life. Although the public may not be aware of the surgeon's schedule at a given time, they do trust the surgeon would cancel if too fatigued. The majority surveyed were not aware of resident involvement, but they trusted the attending surgeon's judgment with deciding how much of the actual procedure he/she could perform. With work-hour restrictions and resident involvement continuing to evolve, keeping the public informed should be a priority.

Changes in ghrelin levels following bariatric surgery: review of the literature.

Obesity is a severe health issue that is a global epidemic. Bariatric surgery is an accepted, popular, and effective therapy for weight loss. Ghrelin, a peptide secreted primarily by the fundus cells of the stomach, has been found to impact body weight by its influence on appetite. Although numerous studies have investigated serum ghrelin levels following bariatric surgery, there is no solid agreement yet as to the direction or magnitude of its change, or even its impact on weight loss. Some studies have found an increase in ghrelin, some have found a decrease, and others have found no change in ghrelin following bariatric surgery. The purpose of this review was to establish the impact of ghrelin changes following bariatric surgery.

The influence of gender on adults admitted for asthma.

BACKGROUND: In the United States, the prevalence of asthma is not only higher than in most other countries, it also varies greatly between diverse populations. Only limited data exist that examine the variation of outcomes by gender in patients admitted to a hospital for asthma. OBJECTIVE: This study assessed outcome differences based on gender in adults who were admitted nationally with the primary diagnosis of asthma. METHODS: A retrospective cohort study was conducted of all patients who were admitted to a hospital with the primary diagnosis of asthma in 2002-2005 and were reported in the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Patients were excluded if they were aged <18 years or had an additional diagnosis of chronic obstructive pulmonary disease. RESULTS: A total of 590,410 patients (439,991 women, 150,419 men) were included in the study. Patients admitted for asthma were significantly more likely to be female (P < 0.05). Women were significantly older compared with men (mean [SD], 48.5 [17.4] vs 44.6 [17.0] years, respectively), had a longer length of stay (3.44 vs 2.84 days), were more likely to be white (37.9% vs 34.2%), and had a higher total cost of admission ($10,575 vs $9390) (all, P < 0.05). Women were more likely than men to need a tracheostomy (adjusted odds ratio [AOR] = 2.04; 95% CI, 1.77-2.35) and to have a bronchoscopy (AOR =1.12; 95% CI, 1.05-1.21). Men were significantly more likely than women to have arterial blood gases performed (AOR = 1.15; 95% Cl, 1.05-1.27) and to be intubated (AOR = 1.18; 95% Cl, 1.10-1.26) (both, P < 0.05). Men were significantly more likely to be admitted as an emergency admission (AOR = 1.10; 95% Cl, 1.04-1.18) and to die during hospitalization (AOR =1.69; 95% CI, 1.41-2.03). CONCLUSION: Although they were less likely to be admitted to a hospital, men were more likely to be admitted as an emergency and to experience worse outcomes compared with women, in this study of adults with asthma in the United States.

Does participation in graduate medical education contribute to improved patient outcomes as outlined by Surgical Care Improvement Project guidelines?

BACKGROUND: Patient quality outcomes are a major focus of the health care industry. It is unknown what effect involvement in graduate medical education (GME) has on patient outcomes. The purpose of this study is to begin to examine whether GME involvement in postoperative care impacts patient quality outcomes. METHODS: The retrospective cohort included all patients who underwent a nonemergent colectomy from January 1, 2007 to January 1, 2008 at a 2-hospital system. Data collected included patient demographics, patient quality outcomes, complications, and GME involvement. Patient quality outcomes were based on compliance with the Surgical Care Improvement Project (SCIP) guidelines. RESULTS: A total of 159 nonemergent colectomies were analyzed. The GME group accounted for 116 (73%) patients. A significant difference was found in several SCIP process-based measures of quality when comparing the GME group with the non-GME group. Postoperative antibiotics were more likely to be stopped within 24 hours (p = 0.010), and preoperative heparin and postoperative deep vein thrombosis (DVT) prophylaxis were more likely to be administered (p < 0.001). Additionally, patients in the GME group showed improved quality outcomes as there were significantly fewer postoperative complications (p < 0.001) and a shorter duration of stay (p = 0.008). The use of gastrointestinal prophylaxis was more common in the non-GME group (p = 0.002). No significant differences were observed between the 2 groups in respect to age, sex, diabetes, preoperative antibiotics, antibiotics, 1 hour before surgery, postoperative antibiotics, and continuation of home beta blockade. CONCLUSIONS: GME at teaching institutions has a positive impact on patient quality outcomes. At our institution, many of the SCIP measurable outcomes had improved compliance if an attending physician participated in the GME program.

Does an obese body mass index affect hospital outcomes after coronary artery bypass graft surgery?

BACKGROUND: More than one third of adults in the United States are obese. Coronary artery bypass graft surgery (CABG) has become necessary for many obese persons. We evaluated the effect of this procedure on in-hospital mortality and morbidity of patients based on their body mass index (BMI). METHODS: Data in a cardiac surgery database were examined retrospectively. Data selected from the database included CABG surgery from January 2003 to December 2007. The resulting cohort included a total of 10,590 patients. The BMI was grouped into four categories: underweight (BMI < or = 19), normal weight (BMI 20 to 29), obese (BMI 30 to 39), and morbidly obese (BMI > or = 40). Regression analysis was conducted to determine whether BMI was an independent predictor of morbidity and mortality after CABG. RESULTS: Our results indicate that patients with an obese BMI are not at greater risk for morbidity or mortality after CABG. Logistic regression analysis found that CABG patients in the underweight body mass index group had the greatest risk of mortality, prolonged ventilation, reoperation for bleeding, and renal failure. Linear regression indicated length of hospital stay and intensive care unit stay after surgery were the longest for patients with an underweight BMI. CONCLUSIONS: Despite the comorbidities that are often present with obesity, an obese BMI was not found to be an independent predictor of morbidity or mortality after CABG. On the contrary, the underweight patients are at greater risk for mortality and complications after CABG surgery.

Gender differences in outcomes following aortic valve replacement surgery.

OBJECTIVE: The objective of this study was to assess outcome differences in aortic valve replacement based on gender. METHODS: A study from a ten-year hospitalization cohort with prospective data collection was conducted. Included in the study were patients undergoing aortic valve replacement surgery between March 1997 and July 2003 (N=406). There were 223 males and 183 females included in the study. The study examined 41 potential confounding risk factors and 16 outcome variables. RESULTS: Univariate analysis on potential confounding risk factors revealed a significant difference between males and females on 12 factors. Co-morbid disease, hypertension, current vascular disease, aortic insufficiency, body surface area, blood added on pump, and annulus size significantly correlated with age. The correlation resulted in five confounding risk factors: age, tobacco history, obesity, left ventricular hypertrophy, and creatinine level. Logistic regression analysis found that after controlling for age, tobacco history, obesity, left ventricular hypertrophy, and creatinine level, there is no difference between males and females on outcomes following aortic valve replacement. Additionally, choice of vascular prosthesis had no impact on post-operative outcomes. CONCLUSION: After controlling for confounding variables, similar outcomes were observed for males and females undergoing aortic valve replacement.

Predictors of type II neurologic complications after coronary artery bypass graft surgery.

The study objective was to determine predictors, and adverse outcomes of postoperative type II neurologic complications. An 11-year cohort (N=12,706) study with 595 coronary artery bypass graft (CABG) patients with a neurologic complication, and 7793 patients without any neurologic complications was conducted. This study examined 26 potential risk factors and 13 outcome variables. Logistic regression analysis found that patients were more likely to experience a neurologic complication after CABG if they were older than 70 years of age [odds ratio (OR), 3.8; 95% confidence interval (CI), 3.1-4.5; P < 0.001], had a previous intervention within 10 days before surgery (OR, 3.4; 95% CI, 1.4-8.3; P = 0.008), or had a higher creatinine level (OR, 0.9; 95% CI, 0.95-0.99; P = 0.013). Additionally, there was a significant difference between CABG patients with and without neurologic complications on 12 outcome variables. Type II neurologic complications after CABG are common and associated with an increased risk of postoperative morbidity and mortality.

The influence of diabetes mellitus in patients undergoing coronary artery bypass graft surgery: a prospective cohort study.

This study was conducted to prospectively assess if there are any outcome differences between patients undergoing coronary artery bypass graft surgery with and without diabetes. This is an 11-year, prospective, hospitalization cohort study. Data were collected on 225 variables. A total of 8935 patients were available for our analysis (6023 nondiabetics, 319 diet-controlled diabetics, 1636 diabetics on oral medications, 957 insulin-controlled diabetics). Compared with nondiabetics, diet-treated diabetics possessed four significant comorbidities, diabetics treated with oral medications possessed 12 significant comorbidities, and insulin-treated diabetics possessed 13 significant comorbidities (P < 0.05). There was no significant difference between diet-treated diabetics and nondiabetics for all outcomes. Diabetics treated with oral medications possessed a longer length of stay [relative risk (RR), 1.09; CI, 1.08-1.10], longer intensive care unit length of stay (RR, 1.56; CI, 1.12-2.00), and more intraoperative complications (RR, 1.42; CI, 1.12-1.66). Insulin-treated diabetics possessed more neurological complications (RR, 2.39; CI, 1.52-3.77), wound complications (RR, 2.42; CI, 1.19-4.95), and renal complications (RR, 2.43; CI, 1.70-3.49), longer length of stay (RR, 1.20; CI, 1.14-1.27), and longer intensive care unit length of stay (RR, 1.33; CI, 1.16-1.48). In diabetics undergoing coronary artery bypass graft surgery, as their diabetes progresses from diet treated with oral medications to insulin-dependent, this is associated with more comorbidities at surgical presentation and more morbidity after surgery.

Is it cost-effective to require recreational ice hockey players to wear face protection?

OBJECTIVE: The purpose of this study was to determine the cost-effectiveness of requiring all recreational hockey players to wear facial protection. METHODS: The authors randomly surveyed recreational hockey players at two indoor hockey rinks in Evendale, Ohio. Data were collected on face protection, injuries, demographic variables and attitudes about protective gear from 11/2005 to 03/2006. RESULTS: We surveyed 190 players. The mean age was 34 +/- 8.7 years and 99% were male. The average hockey experience was 17 years. Forty-six percent of respondents reported at least one serious hockey injury in the last five years. Twenty-four percent of the surveyed population chose to not wear face protection (46/190). The average cost of face protection was $48. The cost to purchase two shields for the 46 players would be $4416. Individuals with face protection reported significantly more sprains and strains that resulted in significantly more physician office visits and specialty physician visits. The extra physician visits would add approximately $4590 for the 46 people needing face protection. Those with face protection reported significantly fewer facial lacerations and facial bone fractures. Requiring face protection should prevent seven facial lacerations and three facial bone fractures over five years. The savings would be approximately $15,000. The net savings by requiring face protection would be $6,000/5 years. In our population, with 24% choosing to not wear face protection, requiring face protection would save $250/5 years/person needing protection. CONCLUSION: It is cost-effective to require facial protection in all recreational hockey players.

Predictors and outcomes associated with intraoperative aortic dissection in cardiac surgery.

OBJECTIVE: Although rare, aortic dissection is one of the most devastating, but least studied, intraoperative complications. The objective of this study was to assess risk factors of aortic dissection and assess outcomes in patients with aortic dissection experience. METHODS: A study from a 10-year hospitalization cohort (N = 12,907) with prospective data collection was conducted. Patients without aortic dissection were matched to 33 aortic dissection patients 3:1 on the type of procedure. The study examined 24 potential confounding risk factors and 12 outcome variables. RESULTS: Univariate analysis on potential confounding risk factors revealed two significant risk factors. There was a significant difference between aortic dissection and nonaortic dissection patients with New York Heart Association (NYHA) functional class (p = 0.03). Patients with aortic dissection were more likely to be in Class I or II. Patients with aortic dissection had significantly longer perfusion time (p = 0.008). There was a significant difference between patients with and without aortic dissection on four outcome variables. Patients with an aortic dissection were more likely to need prolonged ventilation (p = 0.046), have renal failure (p = 0.005), require intraaortic balloon pump (IABP) (0.043), and have a higher mortality rate (p < 0.001). CONCLUSION: Aortic dissection occurs infrequently during coronary artery bypass grafting, but is a devastating complication and greatly increases morbidity. Although few patients dissect intraoperatively, this study attempted to identify predictors that may label a patient as high risk for possible aortic dissection. Although two factors in this study were statistically significant, they are not reliable preoperative predictors of high-risk patients that can be used to screen patients and help prevent aortic dissection and its sequela.

Residents' perspective on the impact of the 80-hour workweek policy.

BACKGROUND: The 80-hour workweek was initiated in 2003 to reduce the resident workweek and subsequently improve the safety and quality of patient care. PURPOSE: The purpose is to assess the impact of the 80-hr workweek from a resident's perspective. METHOD: We surveyed residents with experience before and after the 80-hr workweek policy. The survey assessed residents' perspective on the impact of the 80-hr workweek on 4 areas: patient care/safety, training experience, resident team functioning, and personal life. RESULTS: There were 111 respondents (57% female, 65% married, average age = 32 years, 66% primary care residents). We found the 80-hr workweek had the greatest impact in personal self-care and sleep hygiene. Primary care residents reported a significantly more positive impact of the 80-hr workweek on quality of the training compared to specialty residents. There was no difference between the primary care residents and specialty residents for patient care/safety, resident team functioning, and personal life. Gender, marital status, and having children did not impact how residents' evaluated the 80-hr workweek. CONCLUSION: Residents, with pre- and post-80-hr workweek experience, reported the policy change as having the greatest benefit on their self-care and personal life significantly more than any other area.