Gallbladder Nonvisualization in Cholecystectomy: A Factor for Conversion.

BACKGROUND AND OBJECTIVES: Many risk factors have been identified in minimally invasive cholecystectomies that lead to higher complications and conversion rates. No study that we encountered looked at nonvisualization of the gallbladder (GB) during surgery as a risk factor. We hypothesized that nonvisualization was associated with an increased risk of complications and could be an early intraoperative identifier of a higher risk procedure. Recognizing this could allow surgeons to be aware of potential risks and to be more likely to convert to open for the safety of the patient. METHODS: We looked at minimally invasive cholecystectomies performed at our institution from January 2015 through April 2016 and had the performing resident fill out a survey after the surgery. Outcomes were conversion rates, intraoperative complications, and blood loss and were analyzed via Pearson χ2 test or Mann-Whitney U test. RESULTS: The primary outcome showed a conversion rate of 37% in nonvisualized GBs versus 0% in visualized (P = .001). Secondary outcomes showed significant differences in GB perforations (74% vs 13%, P = .001), omental vessel bleeding (16% vs. 0%, P = .005), and EBL (46 mL vs 29 mL, P = .001). CONCLUSIONS: Intraoperative nonvisualization of the GB after adequate positioning caused significantly increased risk of intraoperative complications and conversion. This knowledge could be useful during intraoperative assessment, to decide whether a case should be continued as a minimally invasive procedure or converted early to help reduce risk to the patient. Further randomized controlled studies should be performed to further demonstrate the value of this assessment.

Predictors of fatal outcome after colectomy for fulminant Clostridium difficile Colitis: a 10-year experience. dr.markelov@gmail.com.

Surgical treatment of fulminant Clostridium difficile colitis has high mortality rates. Identification of a set of preoperative characteristics that could predict outcome after surgery is necessary to optimize clinical management and guide surgical timing. Data were retrospectively collected on patients operated on for C. difficile colitis between 2000 and 2010 at our institution. Statistical analysis was performed to identify predictors of mortality. We reviewed the records of 13 inpatients diagnosed as having C. difficile colitis and who underwent colectomy during the same admission. The in-hospital mortality rate for patients undergoing colectomy for colitis was 46.2 per cent. Independent predictors of mortality included the following: white blood cell count (34,600/µL or greater), hypoalbuminemia (1.5 g/dL or less), septic shock with requirements of vasopressors, and respiratory failure. Patients who underwent colectomy earlier (mean time from presentation to surgery 2.4 ± 1.5 days) had decreased mortality (P = 0.019).). Longer length of hospital stay to the time of diagnosis was associated with higher rates of fatal outcome (P = 0.031). Parameters without significant difference (P > 0.05) included patient age, presenting symptoms, other comorbidities, creatinine levels, and CT scan findings. Identified factors can predict unfavorable outcomes after colectomy. Aggressive surgical intervention early in the course of the disease might be associated with improved survival.

Innovative technique to reduce incidence of Frey's syndrome after parotid surgery.

Frey's syndrome was first described by Lucia Frey, a Polish neurologist in 1923. It is well accepted that it involves injury to the branches of the auriculotemporal nerve with subsequent aberrant regeneration. Due to this abnormal communication, the skin glands and vessels are always stimulated at the same time as eating and mastication, which results in symptoms such as flushing and sweating. The incidence of Frey's syndrome in the literature has been variously described from 6 to 96 per cent. We analyzed the chart of 18 patients who had parotidectomy from March 2002 to December 2009. All procedures were performed by a single surgeon at the same facility. A total of 16 superficial and three total parotidectomies were done; one patient had bilateral parotidectomy. Oxidized regenerated cellulose (Interceed) was used after 10 surgeries (study group) and no adjuvant was used after nine surgeries (control group). All of the surgeries were done using similar technique. All the patients were followed-up with for a period of about 6 months postoperatively. The absolute risk reduction associated with the placement of an Interceed was 11 per cent. The small number of cases (n = 19) and an empty cell limits statistical analysis (a Fisher's exact test revealed a P value of 0.44). Clearly the low number of procedures restricted the power to test these differences. The development of Frey's syndrome is a very disabling but under-reported complication. The placement of a temporary barrier like Interceed may help in the prevention of Frey's syndrome without increasing any complications.

Local and national trends in general surgery residents' operative experience: do work hour limitations negatively affect case volume in small community-based programs?

The goals of this study were to analyze the impact of work hour restrictions on the operative case volume at a small community-based general surgery residency training program and compare changes with the national level. Annual national resident case log data from Accreditation Council for Graduate Medical Education (ACGME) website and case logs of graduating Easton Hospital residents (years 2002-2009) were used for analysis. Weighted average change in total number of cases in our institution was -1.20 (P = 0.52) vs 1.78 (P = 0.07) for the national program average with statistically significant difference on comparison (P = 0.027). We also found significant difference in case volume changes at the national level compared with our institution for the following ACGME defined subcategories: alimentary tract [8.19 (P < 0.01) vs -1.08 (P = 0.54)], abdomen [8.48 (P < 0.01) vs -6.29 (P < 0.01)], breast [1.91 (P = 0.89) vs -3.6 (P = 0.02)], and vascular [4.03 (P = 0.02) vs -3.98 (P = 0.01)]. Comparing the national trend to the community hospital we see that there is total increase in cases at the national level whereas there is a decrease in case volume at the community hospital. These trends can also be followed in ACGME defined subcategories which form the major case load for a general surgical training such as alimentary tract, abdominal, breast, and vascular procedures. We hypothesize that work hour restrictions have been favorable for the larger programs, as these programs were able to better integrate the night float system, restructure their call schedule, and implement institutional modifications which are too resource demanding for smaller training programs.

Transumbilical laparoscopic cholecystectomy: a novel technique.

OBJECTIVE: To describe a novel technique for performing laparoscopic cholecystectomies using no proprietary or specially designed equipment, while still minimizing the incision and leaving a nearly invisible scar. DESIGN: Retrospective review. SETTING: Community teaching hospital. PATIENTS: Twelve patients having uncomplicated laparoscopic cholecystectomy. MAIN OUTCOME MEASURES: Number and appearance of postoperative scars. RESULTS: Twelve attempts to perform the procedure with our new technique were completed successfully. None of the patients required conversion to the standard technique, which requires additional ports. All of the patients were pleased with their results. No identifiable mark was visible in the right upper quadrant of any of the patients; at the 2-week follow-up, the umbilical incisions were nearly invisible, even to the patients. CONCLUSION: This novel technique can be performed safely and effectively while minimizing the number and extent of incisions.

Significance of the cystic node in preventing major bile duct injuries during laparoscopic cholecystectomy: a technical marker.

Laparoscopic cholecystectomy is associated with an increase in biliary injuries, particularly in acute inflammatory conditions. The cystic lymph node enlarges in most cases of acute cholecystitis. Staying lateral to the node avoids major bile duct injury during dissection of the cystic duct and cystic artery. An enlarged cystic node can thus be used as an endpoint in the dissection of the Calot triangle.