Outcomes of Dexmedetomidine with Local Regional Anesthesia in Carotid Endarterectomy.

BACKGROUND: Adequate sedation to complement regional techniques in carotid endarterectomy (CEA) can be challenging. Dexmedetomidine has both analgesic and amnesic properties and is reported to be a safe and acceptable alternative to conventional general endotracheal anesthesia (GETA). Outcomes observing dexmedetomidine in conjunction with regional anesthesia in CEA are not well described or known. OBJECTIVE: Compare the immediate (during hospitalization) and short-term (within 30 days of hospitalization) postoperative outcomes in patients who underwent CEA using GETA versus local regional anesthesia (LRA) alone versus dexmedetomidine with LRA at a single institution to determine whether dexmedetomidine is a safe adjunct and if there are anesthesia advantages over LRA alone. METHODS: A retrospective cohort study from January 2015 to December 2019 at Saint Joseph Mercy Ann Arbor. Patients were stratified into three groups based on anesthesia type: GETA, LRA, and dexmedetomidine (D) + LRA. Primary outcomes included stroke, myocardial infarction (MI), and death. Patient demographics were characterized and adjusted using propensity score weighting. RESULTS: Three hundred seventy nine patients met inclusion criteria; 182 patients in the GETA group, 66 in the D + LRA, and 131 in LRA. There were no significant differences across anesthesia groups in primary outcomes of stroke, MI, and death during the admission. The GETA group had significantly longer length of stay (LOS) compared to the D + LRA group (LOS = 1.51 days versus 0.85 days; P = 0.011) and the LRA group (LOS = 1.08 days; P = 0.003). However, there was no significant difference in hospital LOS between the D + LRA group and LRA only groups (P = 0.952). There was no significant difference between stroke (LRA 0.87%, GETA 0.85%, and LRA + Dex 3.52%), MI (LRA 0%, GETA 0.49%, LRA + Dex 0%), or death (LRA 5.24%, GETA 1.16%, LRA + Dex 0%), within 30 days between all three of the anesthesia groups. There was no significant difference in postoperative pain scores when comparing the GETA group (mean 1.3, standard deviation [SD] 2.5) to LRA (mean 1.2, SD 2.1) and between LRA and D + LRA (mean 0.9, SD 2.1). Procedure time (time of skin incision to closure) and total room time were comparable among all three anesthesia groups (LRA 2.2 hr, SD 2.2; GETA 2.1 hr, SD 0.5; LRA + Dex 2.1 hr, SD 0.5). CONCLUSIONS: The use of dexmedetomidine in addition to LRA is a safe and acceptable alternative to conventional GETA or LRA alone in CEA with shorter length of hospital stay when compared with GETA, improved patient tolerance based on physician observation, and similar rates of immediate and short-term complications and postoperative pain scores.

Laparoscopic magnetic sphincter augmentation device placement for patients with medically-refractory gastroesophageal reflux after sleeve gastrectomy.

BACKGROUND: The use of the magnetic sphincter augmentation (MSA) in patients with de novo or persistent gastroesophageal reflux disease (GERD) after sleeve gastrectomy has not been thoroughly investigated. OBJECTIVE: The aim of this study is to evaluate the efficacy of MSA device placement in improving GERD symptoms and reducing anti-reflux medication usage in patients with persistent or de novo GERD after sleeve gastrectomy. METHODS: This is a retrospective analysis of patients who underwent laparoscopic MSA device placement between January 2018 and July 2020 after sleeve gastrectomy. RESULTS: A total of twenty-two patients met inclusion criteria. Twenty patients were female (91%) and two patients were male (9%). All patients were taking anti-reflux medications daily to control GERD symptoms prior to MSA device placement. There was a significant improvement in the mean GERD-HRQL survey scores when comparing scores prior to (43.8) and after (16.7) MSA device placement (p < 0.0001). Majority of the patients did well without any post-operative complications (77%). Nearly 82% of patients were no longer taking any anti-acid medications after MSA device placement (p < 0.0485). There were no patients that required MSA device removals. There were no adverse events such as MSA device erosions or device-related mortalities. CONCLUSIONS: MSA device placement in patients with medically refractory GERD after sleeve gastrectomy is a safe and viable alternative to Roux-en-Y gastric bypass without conferring additional risks. We show an improvement in reflux symptoms after MSA device placement as evidenced by decreased post-operative GERD-HRQL scores, decreased anti-acid medication usage, and overall patient satisfaction with the procedure. Further prospective and comparative studies with longer term follow-up are needed to validate the use of MSA in patients who have undergone sleeve gastrectomy.

Locally advanced perforated appendiceal cancer: Case report and review.

Appendiceal cancers may be difficult to diagnose even after comprehensive investigation. This report of locally advanced perforated appendiceal adenocarcinoma attached to the terminal ileum, cecum, and rectosigmoid illustrates the management challenges that require comprehensive knowledge of pathologic variations and range from simple appendectomy to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

A Single Institution Propensity Score Weighted Analysis of Time to Chemotherapy After Minimally Invasive Versus Open Colorectal Surgery.

BACKGROUND: Oncologic outcomes for colon cancer are optimal when chemotherapy is started within 6 to 8 weeks after surgery. The study objective was to investigate the impact of operative modality and urgency on the time interval from surgery to adjuvant chemotherapy. METHODS: This is a retrospective institutional tumor registry cohort study of open and laparoscopic/robotic colorectal resections for stage II-IV cancer between April 2010 and January 2018. Primary outcome was time from surgery to chemotherapy. Predictor variables were adjusted for imbalances by propensity score weighting. RESULTS: A total of 220 patients met inclusion criteria: 171 elective (108 laparoscopic/robotic and 63 open) and 49 urgent colectomies. After propensity score weighting, there was no significant difference in time to chemotherapy between elective minimally invasive and open surgical approaches (48 days vs. 58 days, P = .187). Only 68.9% of minimally invasive and 50.8% of open colectomy patients started chemotherapy within 8 weeks of surgery. There was a significant difference (P = .037) among surgical sites with rectal resections having the longest (55 days), and right colectomies having the shortest (46 days), time to chemotherapy. Patients who had urgent operations had significantly longer hospital length of stay (P < .001) and higher post-discharge emergency department visit rates (P < .001) than the elective operation group. However, there was no significant difference in time to chemotherapy. DISCUSSION: Neither operative modality nor operative urgency resulted in a significant difference in postoperative time to initiating chemotherapy. Future efforts should be focused on identifying postoperative recovery criteria and optimum multidisciplinary communication methods that allow recovered patients to start chemotherapy sooner.

Recurrence of Acute Right Colon Diverticulitis Following Nonoperative Management: A Systematic Review and Meta-analysis.

BACKGROUND: There are currently no guidelines on the management of right colon diverticulitis. Treatment options have been extrapolated from the management of left-sided diverticulitis. Gaining knowledge of the risk and morbidity of diverticulitis recurrence is integral to weighing the benefit of elective surgery for right-sided diverticulitis. OBJECTIVE: The purpose of this study was to summarize the recurrence rate and the morbidity of recurrence of Hinchey classification I/II, right-sided diverticulitis following nonoperative management. DATA SOURCES: PubMed, EMBASE, and Cochrane Database of Collected Reviews were searched up to June 2019. STUDY SELECTION: Observational cohort studies evaluating outcomes following nonoperative management were reviewed. No randomized controlled trials were available. INTERVENTIONS: Intravenous antibiotics with or without percutaneous drainage of associated abscess were administered. MAIN OUTCOME MEASURES: The primary outcomes measured were the recurrence rate and morbidity associated with recurrence. Two independent investigators extracted data. The rates of recurrence were pooled by using a random-effects model. RESULTS: There were 1584 adult participants from a total of 11 studies (9 retrospective cohort and 2 prospective cohort studies) included in the analysis. Over a median follow-up period of 34.2 months, the pooled recurrence rate was 12% (95% CI, 10%-15%). Twenty of 202 patients (9.9%) required urgent surgery at the time of first recurrence. There was no mortality. Subset analysis excluding 3 studies that included percutaneous drainage as a nonoperative treatment option did not change the recurrence rate (12% (95% CI, 9%-15%)) or heterogeneity. Funnel plot assessment revealed no publication bias. LIMITATIONS: There were no randomized controlled trials available. The statistical heterogeneity was moderate (I = 46%). CONCLUSIONS: Nonoperative management of Hinchey I/II right-sided diverticulitis is safe and feasible. The recurrence rate is relatively low, and complications that require urgent operation are uncommon. PROSPERO: CRD42019131673.