Benign Finding or Malignancy: von Meyenburg Complexes Found during Laparoscopic Cholecystectomy.

Von Meyenburg complexes are benign bile duct hamartomas that arise as cystic nodules of the liver. Von Meyenburg complexes are often asymptomatic and thus typically discovered incidentally on imaging or autopsy. They can also be encountered at the time of surgery where they often appear as scattered white liver lesions concerning for malignancy. Here, we present a case in which white hepatic nodules were found incidentally during laparoscopic cholecystectomy in a 36 -year-old female. Pathologic analysis confirmed the diagnosis of von Meyenburg complexes. The operating surgeon proceeded with laparoscopic cholecystectomy without complication. We report this case to encourage awareness of this benign entity. The finding of scattered hepatic lesions found intra-operatively can create concern for metastatic neoplastic processes. An awareness of von Meyenburg complexes and their gross appearance can better guide surgeons' intraoperative decision-making when encountering these characteristic hepatic lesions.

Patient experience with electronic health record-integrated postoperative telemedicine visits in an academic endocrine surgery program.

BACKGROUND: In response to the coronavirus 2019 pandemic, telemedicine use has increased throughout the United States. We aimed to measure patient experience with electronic health record-integrated postoperative telemedicine encounters following thyroid and parathyroid surgery. METHODS: In this preliminary study, adult patients receiving postoperative electronic health record-integrated telemedicine video encounters or standard in-person visits after thyroid or parathyroid surgery at a single institution were prospectively enrolled from November 2019 through May 2020. Patients with home zip codes 10 to 75 miles from the medical center were included. Patient experience was assessed using the Consumer Assessment of Health Care Providers and Systems Clinician & Group Visit Survey 2.0 and the Communication Assessment Tool. Top box analysis was performed, defined as the percentage of respondents who chose the most positive response score. RESULTS: The cohort consisted of 45 telemedicine and 32 in-person encounters. Both groups reported similar and excellent patient experience and satisfaction (9.7 of 10 for telemedicine vs 9.8 of 10 for in-person encounters, mean difference 0.02, 95% confidence interval, [-0.25 to 0.29]). Similar surgeon communication performance was observed (mean Communication Assessment Tool top box score 83% telemedicine vs 86% in-person, mean difference 3%, 95% confidence interval [-10% to 17%]). Nonlinear increases in monthly telemedicine encounter volume were observed within the section of endocrine surgery (3-fold increase) and the health system (125-fold increase) from November 2019 to May 2020. CONCLUSION: Patients who underwent cervical endocrine surgery reported similarly high rates of satisfaction and excellent surgeon communication following either telemedicine or in-person postoperative encounters. Electronic health record-integrated telemedicine for a subset of low-risk procedures can act as a suitable replacement for in-person encounters. A surge in telemedicine use, stimulated by the coronavirus 2019 pandemic, was experienced at our institution.

Intraoperative Laparoscopic Near-Infrared Fluorescence Cholangiography to Facilitate Anatomical Identification: When to Give Indocyanine Green and How Much.

Recent technological advances have enabled real-time near-infrared fluorescence cholangiography (NIRFC) with indocyanine green (ICG). Whereas several studies have shown its feasibility, dosing and timing for practical use have not been optimized. We undertook a prospective study with systematic variation of dosing and timing from injection of ICG to visualization. Adult patients undergoing laparoscopic biliary and hepatic operations were enrolled. Intravenous ICG (0.02-0.25 mg/kg) was administered at times ranging from 10 to 180 minutes prior to planned visualization. The porta hepatis was examined using a dedicated laparoscopic system equipped to detect NIRFC. Quantitative analysis of intraoperative fluorescence was performed using a scoring system to identify biliary structures. A total of 37 patients were enrolled. Visualization of the extrahepatic biliary tract improved with increasing doses of ICG, with qualitative scores improving from 1.9 ± 1.2 (out of 5) with a 0.02-mg/kg dose to 3.4 ± 1.3 with a 0.25-mg/kg dose (P < .05 for 0.02 vs 0.25 mg/kg). Visualization was also significantly better with increased time after ICG administration (1.1 ± 0.3 for 10 minutes vs 3.4 ± 1.1 for 45 minutes, P < .01). Similarly, quantitative measures also improved with both dose and time. There were no complications from the administration of ICG. These results suggest that a dose of 0.25 mg/kg administered at least 45 minutes prior to visualization facilitates intraoperative anatomical identification. The dosage and timing of administration of ICG prior to intraoperative visualization are within a range where it can be administered in a practical, safe, and effective manner to allow intraoperative identification of extrahepatic biliary anatomy using NIRFC.

Evaluation of hospital readmissions in surgical patients: do administrative data tell the real story?

IMPORTANCE: The Centers for Medicare & Medicaid Services has developed an all-cause readmission measure that uses administrative data to measure readmission rates and financially penalize hospitals with higher-than-expected readmission rates. OBJECTIVES: To examine the accuracy of administrative codes in determining the cause of readmission as determined by medical record review, to evaluate the readmission measure's ability to accurately identify a readmission as planned, and to document the frequency of readmissions for reasons clinically unrelated to the original hospital stay. DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of all consecutive patients discharged from general surgery services at a tertiary care, university-affiliated teaching hospital during 8 consecutive quarters (quarter 4 [October through December] of 2009 through quarter 3 [July through September] of 2011). Clinical readmission diagnosis determined from direct medical record review was compared with the administrative diagnosis recorded in a claims database. The number of planned hospital readmissions defined by the readmission measure was compared with the number identified using clinical data. Readmissions unrelated to the original hospital stay were identified using clinical data. MAIN OUTCOMES AND MEASURES: Discordance rate between administrative and clinical diagnoses for all hospital readmissions, discrepancy between planned readmissions defined by the readmission measure and identified by clinical medical record review, and fraction of hospital readmissions unrelated to the original hospital stay. RESULTS: Of the 315 hospital readmissions, the readmission diagnosis listed in the administrative claims data differed from the clinical diagnosis in 97 readmissions (30.8%). The readmission measure identified 15 readmissions (4.8%) as planned, whereas clinical data identified 43 readmissions (13.7%) as planned. Unrelated readmissions comprised 70 of the 258 unplanned readmissions (27.1%). CONCLUSIONS AND RELEVANCE: Administrative billing data, as used by the readmission measure, do not reliably describe the reason for readmission. The readmission measure accounts for less than half of the planned readmissions and does not account for the nearly one-third of readmissions unrelated to the original hospital stay. Implementation of this readmission measure may result in unwarranted financial penalties for hospitals.

Annular pancreas in the adult: management with laparoscopic gastrojejunostomy.

Annular pancreas is an uncommon congenital anomaly associated with duodenal atresia in neonates. Rarely, the condition may manifest later in life. These symptoms include abdominal pain, nausea, and vomiting and usually arise due to obstruction to gastric emptying. Abdominal CT scan with high resolution and angiography protocol and magnetic resonance imaging are useful in confirming the presence of annular pancreas. Operative management involves bypassing the obstructed duodenum. Duodenoduodenostomy is routinely performed in neonates with annular pancreas. In adults, the duodenum is less mobile, and duodenojejunostomy or gastrojejunostomy are recommended. We report two cases of annular pancreas in adults treated with laparoscopic gastrojejunostomy.

Inpatient surgery in California: 1990-2000.

BACKGROUND: The practice environment for surgery is changing. However, little is known regarding the trends or current status of inpatient surgery at a population level. HYPOTHESIS: Inpatient surgical care has changed significantly over the last 10 years. DESIGN: Longitudinal analysis of California inpatient discharge data (January 1, 1990, through December 31, 2000). SETTING: All 503 nonfederal acute care hospitals in California. PATIENTS: All inpatients undergoing general, vascular, and cardiothoracic surgery in California from January 1, 1990, through December 31, 2000, were obtained. MAIN OUTCOME MEASURES: Volume, mean age, comorbidity profile, length of hospital stay, and in-hospital mortality were obtained for inpatient general, vascular, and cardiothoracic surgical procedures performed during the period 1990 to 2000. Rates of change and trends were evaluated for the 10-year period. RESULTS: Between January 1, 1990, and December 31, 2000, 1.64 million surgical procedures were performed. The number of surgical procedures increased 20.4%, from 135,795 in 1990 to 163,468 in 2000. Overall, patients were older and had more comorbid disease in 2000 compared with 1990. Both crude and adjusted (by type of operation) in-hospital mortality decreased from 3.9% in 1990 to 2.75% (P<.001) and 2.58% (P<.001), respectively, in 2000. Length of hospital stay decreased over the period for all operations analyzed. CONCLUSIONS: The total number of inpatient general, vascular, and cardiothoracic surgical procedures has increased over the past decade. Furthermore, our findings indicate that the outcomes of care (eg, in-hospital mortality and length of hospital stay) for patients who undergo general, vascular, and cardiothoracic surgical procedures have improved. However, continued evaluations at the population level are needed.

Laparoscopic Nissen fundoplication improves quality of life in patients with atypical symptoms of gastroesophageal reflux.

Laparoscopic Nissen fundoplication has been shown to improve overall quality of life (QOL) in patients with gastroesophageal reflux, but most studies have not addressed patients with atypical symptoms. We investigated the effect of laparoscopic Nissen fundoplication on QOL using the Gastrointestinal Quality of Life Index (GIQLI) survey modified to address both typical (heartburn, regurgitation, dysphagia) and atypical (hoarse voice, chronic cough, adult-onset asthma, vocal cord polyps) symptoms. One-hundred forty-eight patients underwent laparoscopic Nissen fundoplication for gastroesophageal reflux disease (GERD) at UCLA Medical Center from January 1, 1995 to May 1, 2002. Surveys evaluating pre- and postoperative QOL were administered after surgery: 55 per cent of patients responded (82/148). Forty-eight per cent of all patients (72/148) had atypical symptoms. Perioperative morbidity and mortality were 8.8 per cent and 0.7 per cent, respectively. Mean length of postoperative stay was 2.96 +/- 1.5 days. Mean follow-up for the entire cohort was 18.5 months. Postoperative dysphagia not present before surgery occurred in 4.7 per cent of patients. Eighty per cent of patients were medication-free following surgery. QOL scores for all participants increased significantly from 52.5 +/- 15.3 preoperatively to 72.0 +/- 14.9 postoperatively (P < 0.0001). Patients with atypical symptoms or typical symptoms alone showed significant mean QOL score increases from 48.3 +/- 17.6 preoperatively to 71 +/- 15.7 postoperatively (P < 0.0001) and from 55.7 +/- 12.6 to 72.8 +/- 14.4 (P < 0.0001), respectively. Laparoscopic Nissen fundoplication can effectively improve overall QOL for patients with GERD. Patients with atypical GERD symptoms can experience increases in QOL similar to those with only typical gastrointestinal symptoms.