Early results of a surgeon-led, perioperative surgical home.

BACKGROUND: The Perioperative Surgical Home is a novel care model designed to provide patient-centered, high-quality surgical care. In 2013, we implemented POSH, a pilot Peri-Operative Surgical Home at Phoenix Indian Medical Center (PIMC), an Indian Health Service hospital, as a quality improvement project. After 2 y, we sought to quantify the impact of POSH on the quality of surgical care at PIMC. MATERIALS AND METHODS: We conducted a retrospective review of 33 surgical patients who underwent surgery at PIMC through the POSH process between 2013 and 2015 matched to 64 historical controls with similar operations. Study patients underwent surgery via the POSH treatment process. Primary outcomes were composite measures of (1) care standards and (2) care goals. Success was defined as meeting seven of nine care standards and six of eight care goals. RESULTS AND DISCUSSION: The mean number of care standards met was 8.1 ± 1.0 versus 4.2 ± 1.4 (P < 0.001) and the mean number of care goals met was 6.7 ± 0.8 versus 6.1 ± 1.1 (P = 0.005) for POSH patients and historical controls, respectively. Patients participating in the POSH model were 8.6 (95% confidence interval: 3.5-22.3) and 1.5 (95% confidence interval: 1.2-1.9) times more likely to meet the minimum number of care standards and goals, respectively. Fourteen of the study patients (42%) would not have been offered surgery at PIMC before POSH due to elevated surgical risk. CONCLUSIONS: POSH may have improved quality of surgical care at PIMC while expanding services to more complex patients. POSH may present an opportunity for improved surgical quality in resource-constrained environments.

Orogastric tube complications in laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Recent national efforts have focused on improving patient safety in surgical procedures including examining adverse events. An adverse event in laparoscopic Roux-en-Y gastric bypass (LRYGBP) which has not received much scrutiny involves orogastric tube complications during gastric pouch formation. METHODS: Retrospective review was conducted of all LRYGBPs (n=727) performed by 5 surgeons over 5 years at 2 institutions. Cases with intraoperative orogastric tube (OGT) related complications (n=9) were identified. RESULTS: 9 patients (1.2%) had preventable orogastric tube-related complications. Mean patient demographics were as follows: age 47 years, female 56%, pre-op BMI 52 kg/m(2), co-morbidities 3.5 and mortality 0%. 7 of 9 patients' cases were complicated by stapling of an orogastric tube during gastric pouch formation. The remaining 2 patients had complications involving suturing of the Levacuator tube during gastrojejunostomy formation. All complications required gastric pouch or anastomotic revision. 2 patients required conversion to an open procedure, 2 required re-operation for anastomotic leak, and 1 had respiratory failure and prolonged hospital stay. CONCLUSION: Orogastric tube complications can occur during laparoscopic RYGBP, but are seldom reported and can be associated with significant morbidity. Treatment options are dependent upon the situation. More importantly, prevention strategies must include constant communication with the anesthesiologist and removal or manipulation of an OGT prior to stapling or suturing, use of large bore OGTs for increased visual or tactile recognition, retraction of the OGT proximal to the anastomosis during gastrojejunal construction and employing alternatives to esophageal temperature probes (i.e. Foley temperature probes).

Introducing laparoscopic Roux-en-Y gastric bypass at a Veterans Affairs medical facility.

BACKGROUND: Previous studies have shown that advanced age, diabetes, and male gender are associated with higher morbidity and mortality after bariatric surgery. Those risk factors are characteristic of patients in the Veterans Affairs (VA) health care system. Laparoscopic Roux-en-Y gastric bypass (RYGB) has become an established treatment modality for morbid obesity. Our objective was to review the initial experience with laparoscopic (RYGB) for morbid obesity at our VA facility. METHODS: A retrospective review was used. RESULTS: Between May of 2002 and April of 2004, 40 patients underwent laparoscopic RYGB. All patients met National Institutes of Health consensus statement guidelines for bariatric surgery. There were 30 (75%) male and 10 (25%) female patients, with an average age of 49.9 +/- 8.7 years and an average body mass index (BMI) of 48.1 +/- 8.5 kg/m(2). Preoperative comorbidities included diabetes mellitus (DM) in 59%, hypertension in 79%, and obstructive sleep apnea in 74.4%. The procedure was converted to an open procedure in 3 patients (7.5%). There were no mortalities. Immediate (within 30 days) complications developed in 9 (22.5%) patients, necessitating abdominal re-operation in 3 patients (7.5%). The median length of hospital stay was 3 days. Late complications (>30 days) developed in 8 (20%) patients. Percent excess weight loss at 3, 6, and 12 months was 44% (n = 34), 59% (n = 29), and 70.0% (n = 22), respectively. In 23 patients who were followed-up for more than 3 months, DM resolved in 79% and improved in 21% at a mean follow-up evaluation of 13 months. CONCLUSIONS: Laparoscopic RYGB can be performed with acceptable morbidity and with good short-term results in a VA hospital setting. Morbid obesity is prevalent in the VA patient population and access to bariatric surgery should be an available alternative.

Laparoscopic colon resection for colon cancer.

INTRODUCTION: Laparoscopic colon resection for cancer is as yet an unproven operation. This review article summarizes current data on the topic. METHODS: A Medline review identified articles published since 1990 summarizing patients with potentially curable colon cancer who underwent a laparoscopic-assisted colon resection. Only articles that were randomized or had a control group with historical or matched open cases were used. RESULTS: Very few prospective randomized controls exist. Several clinical trials are under way with one completed. Data thus far support some patient benefits with a laparoscopic approach. No differences in morbidity, oncologic data, or survival appear to exist. CONCLUSIONS: The results of ongoing clinical trials are still needed to further evaluate the role of laparoscopic assisted colon resection in patients with potentially curable colon cancer.

Institutional variations in the management of patients with acute appendicitis.

The purpose of this study was to evaluate institutional differences in preoperative workup, operative approach, complications, and cost in patients with acute appendicitis. A retrospective chart review was performed of all adults operated on for acute appendicitis from June 1999 to November 2000 at the University of New Mexico Hospital (UNMH) and Stanford University Medical Center (SUMC). Variables compared included age, race, sex, duration of symptoms, type of symptoms, results of radiographic evaluation, time from emergency room to operating room, operative approach (open vs. laparoscopic), operative time, length of hospital stay, pathologic findings, and complications. Statistical analysis was performed by means of Fisher's exact test. A total of 154 appendectomies were performed for acute appendicitis at UNMH and 165 at SUMC. Statistically significant differences were found at UNMH vs. SUMC in time from emergency room to operating room (9.1 hours vs. 13.7 hours; P<0.001), operative approach (48% laparoscopic vs. 29% open; P<0.001), and negative appendectomy rate (13% vs. 4.8%; P<0.001). There were no differences in the perforation rate or other complications. Cost analysis showed that $56,744 more was spent at UNMH for the additional negative appendectomy operations, whereas $99,842 more was spent at SUMC for the additional CT scans. Institutional differences in the management of patients with acute appendicitis can result in significant differences in cost without clinically significant differences in outcome. The use of clinical examination and laparoscopy as diagnostic modalities instead of CT scanning resulted in a more cost-effective approach.