The effects of using telemedicine for introductory bariatric surgery seminars during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic required immediate systematic change in healthcare delivery. Many institutions relied on telemedicine as an alternative to in-person visits. There is limited data in the bariatric surgery literature to determine how telemedicine impacts patient volume. This study evaluates the effects of using telemedicine for introductory bariatric surgery seminars on patient volume at a single institution. METHODS: A retrospective review was performed before and after implementing virtual introductory seminars for bariatric surgery patients at a comprehensive metabolic and surgery center. The effect on attendance rates for introductory seminars and completion rates of bariatric surgery was evaluated. RESULTS: The introductory seminar attendance rate for the in-person/pre-telemedicine period, April 2019 to February 2020, was compared to that of the virtual/post-telemedicine period, June 2020 to April 2021. A total of 836 patients registered for an introductory seminar during the pre-telemedicine period with a 65.79% attendance rate. In the post-telemedicine period, 806 patients registered with a 67.87% attendance rate, which was not statistically different (p = 0.37, 95% CI - 0.03-0.07). Completion rates of bariatric surgery were analyzed using June 2019 to October 2019 as the pre-telemedicine period and June 2020 to October 2020 as the post-telemedicine period. Similarly, there was no difference between the pre-telemedicine surgery rate of 23.43% and post-telemedicine surgery rate of 19.68% (p = 0.31, 95% CI - 0.11-0.04). CONCLUSION: Despite abruptly transitioning to virtual introductory bariatric seminars, there was no change in attendance rates nor was there a difference in the number of patients progressing through the program and undergoing bariatric surgery at our institution. This demonstrates similar efficacy of telemedicine and in-person introductory seminars for bariatric surgery patients, which supports telemedicine as a promising tool for this patient population in the post-pandemic era.

Dysautonomia following breast surgery: Disproportionate response to postoperative hematoma.

Background: Up to 10% of patients undergoing breast surgery suffer from bleeding complications. Some experience severe hypotension and bradycardia of unclear etiology. Similar to the vasovagal hyperstimulation provoked by abdominal insufflation during laparoscopic surgery, we hypothesize that chest wall stretch from postoperative breast hematoma may mechanically stretch the vagus nerve, triggering dysautonomia disproportionate to the degree of blood loss. Methods: A single-institution retrospective review of patients requiring reoperation for hematoma evacuation following breast surgery between 2011 and 2021 was performed. The relationship between hematoma volume and hemodynamic instability, as well as hematoma volume and vasovagal symptoms, was measured. Results: Sixteen patients were identified. Average hematoma volume was 353 mL, and average minimum mean arterial pressure was 64 mm Hg (range: 34-102 mm Hg). Fifty-six percent of patients reported symptoms including dizziness, somnolence, and/or syncope. Accounting for body surface area, patients with larger hematomas had similar minimum mean arterial pressures compared to those with smaller hematomas, 55 and 73 mm Hg, respectively (P = .0943). However, patients in the large hematoma group experienced over 3 times as many vasovagal symptoms, 88% and 25%, respectively (P = .0095). Conclusion: Patients with large hematomas reported significantly more vagal symptoms compared to those with small hematomas despite similar mean arterial pressures. In addition, the trend of lower mean arterial pressures and heart rates more closely resembles vagal hyperstimulation than hypovolemic shock. Early hematoma evacuation to relieve vagal nerve stretch and parasympatholytics to reverse dysautonomia are targeted interventions to consider in this patient population rather than fluids, vasopressors, and blood products that are used in cases of hemodynamic instability due to hypovolemia alone.

Using telemedicine on an acute care surgery service: improving clinic efficiency and access to care.

BACKGROUND: Telemedicine has been shown to improve patient access to medical care while potentially improving overall healthcare efficiency. It has not been consistently explored on an acute care surgery service as a method of increasing clinic availability and efficiency within a safety-net hospital system. Socioeconomic hardships associated with an in-person clinic visit can deter patients with limited resources. A virtual clinic for post-operative laparoscopic cholecystectomy patients was developed. We hypothesized that a virtual follow-up increases clinic efficiency and availability for new patients without compromising patient safety. METHODS: A retrospective review of patient and clinic outcomes before and after implementing virtual post-op visits for uncomplicated laparoscopic cholecystectomy patients on an acute care surgery service was performed. Providers called post-operative patients using a standardized questionnaire. Data included outpatient clinic composition (new vs. post-operative patients), elective operations scheduled, emergency department visits, and loss to follow-up rates. RESULTS: February to March 2017 was the baseline pre-intervention period, while February to March 2019 was post-intervention. Pre-intervention clinics consisted of 17% new and 50% post-op visits, in comparison to 31% new and 27% post-op visits in the post-intervention group (p < 0.01). Elective operations scheduled increased slightly from 8.4 to 11.5 per 100 patient visits, but was not statistically significant (p = 0.09). There was no change in the number of post-operative patients returning to the emergency department (p = 0.91) or loss to follow-up (p = 0.30) rates. CONCLUSIONS: Through the implementation of virtual post-operative visits for laparoscopic cholecystectomy patients, clinic efficiency improved by increasing new patient encounters, decreasing post-operative volume, and trending towards increased operations scheduled. This change did not compromise patient safety. Further implementation of telemedicine on an acute care surgery service is a promising method to expand services offered to an at-risk population and increase efficiency in a resource-limited environment.

Extramedullary plasmacytoma mimicking colon carcinoma: an unusual presentation and review of the literature.

A 72-year-old woman presented to outpatient clinic with fatigue, light-headedness, dyspnoea and dark stool suggestive of lower gastrointestinal bleeding. She was previously diagnosed with multiple myeloma and completed 9 cycles of chemotherapy with bortezomib, lenalidomide and dexamethasone. She had very good partial response. A CT scan of the abdomen revealed a 9 cm mass at the hepatic flexure of the large intestine with an apple core deformity causing a marked narrowing of the lumen. Colonoscopy confirmed a large, nearly obstructing ulcerative mass in the distal right colon. The patient underwent a right hemicolectomy, distal ileal resection and lymph node dissection. Histopathology confirmed the mass as a plasmacytoma. Postoperatively, the patient was started with bortezomib and liposomal doxorubicin followed by carfilzomib. She showed excellent response to the chemotherapy.