Improving the value of care for appendectomy through an individual surgeon-specific approach.

PURPOSE: Standardized care via a unified surgeon preference card for pediatric appendectomy can result in significant cost reduction. The purpose of this study was to evaluate the impact of cost and outcome feedback to surgeons on value of care in an environment reluctant to adopt a standardized surgeon preference card. METHODS: Prospective observational study comparing operating room (OR) supply costs and patient outcomes for appendectomy in children with 6-month observation periods both before and after intervention. The intervention was real-time feedback of OR supply cost data to individual surgeons via automated dashboards and monthly reports. RESULTS: Two hundred sixteen children underwent laparoscopic appendectomy for non-perforated appendicitis (110 pre-intervention and 106 post-intervention). Median supply cost significantly decreased after intervention: $884 (IQR $705-$1025) to $388 (IQR $182-$776), p<0.001. No significant change was detected in median OR duration (47min [IQR 36-63] to 50min [IQR 38-64], p=0.520) or adverse events (1 [0.9%] to 6 [4.7%], p=0.062). OR supply costs for individual surgeons significantly decreased during the intervention period for 6 of 8 surgeons (87.5%). CONCLUSION: Approaching value measurement with a surgeon-specific (rather than group-wide) approach can reduce OR supply costs while maintaining excellent clinical outcomes. LEVEL OF EVIDENCE: Level II.

Ultrasound-guided gastrostomy tube placement: A case series.

PURPOSE: Gastrostomy tubes (G-tubes) can be placed utilizing a variety of techniques. Here we present a case series to demonstrate feasibility of a novel method, ultrasound-guided G-tube placement (USGTP). METHODS: All cases of USGTP at our institution from September 2015-August 2016 were reviewed. Data included demographics, operative time, complications, time to first feeding, and 30-day readmissions. All steps of the procedure were carried out using ultrasound guidance, resulting in placement of a low-profile G-tube. RESULTS: Twelve patients underwent USGTP. Median age at operation was 2.6years (IQR 0.9-5.3) and median weight 9.9kg (IQR 7.2-18.4). Median operative time was 27min. (IQR 20-44). First feeding occurred 8.8±2.9h after the procedure. The second patient in the series experienced the only operative complication. In this case, a linear probe was used with insufficient gastric distension, resulting in placement of the tube through a fold in the stomach wall. This was recognized and remedied intraoperatively. This prompted successful technique modification for future USGTPs. Only one patient was readmitted within 30days, and this was related to urinary retention, an underlying problem. CONCLUSION: US-guided G-tube placement appears initially to be safe, efficient and effective. Advantages include good anatomical delineation, a single incision, initial placement of a low-profile G-tube, and avoidance of endoscopy, laparoscopy, and radiation. This report illustrates feasibility of USGTP paving the way for further investigation and comparison to other existing gastrostomy insertion methods. LEVEL OF EVIDENCE: IV.

Expansion of intestinal epithelial stem cells during murine development.

Murine small intestinal crypt development is initiated during the first postnatal week. Soon after formation, overall increases in the number of crypts occurs through a bifurcating process called crypt fission, which is believed to be driven by developmental increases in the number of intestinal stem cells (ISCs). Recent evidence suggests that a heterogeneous population of ISCs exists within the adult intestine. Actively cycling ISCs are labeled by Lgr5, Ascl2 and Olfm4; whereas slowly cycling or quiescent ISC are marked by Bmi1 and mTert. The goal of this study was to correlate the expression of these markers with indirect measures of ISC expansion during development, including quantification of crypt fission and side population (SP) sorting. Significant changes were observed in the percent of crypt fission and SP cells consistent with ISC expansion between postnatal day 14 and 21. Quantitative real-time polymerase chain reaction (RT-PCR) for the various ISC marker mRNAs demonstrated divergent patterns of expression. mTert surged earliest, during the first week of life as crypts are initially being formed, whereas Lgr5 and Bmi1 peaked on day 14. Olfm4 and Ascl2 had variable expression patterns. To assess the number and location of Lgr5-expressing cells during this period, histologic sections from intestines of Lgr5-EGFP mice were subjected to quantitative analysis. There was attenuated Lgr5-EGFP expression at birth and through the first week of life. Once crypts were formed, the overall number and percent of Lgr5-EGFP positive cells per crypt remain stable throughout development and into adulthood. These data were supported by Lgr5 in situ hybridization in wild-type mice. We conclude that heterogeneous populations of ISCs are expanding as measured by SP sorting and mRNA expression at distinct developmental time points.

Inflammation enhances resection-induced intestinal adaptive growth in IL-10 null mice.

BACKGROUND: Surgical resection of the ileum, cecum, and proximal right colon (ICR) is common in the management of Crohn's disease, yet little is known about the effect of active inflammation on the adaptive response following intestinal loss. We recently developed a surgical model of ICR in germ-free (GF) IL-10 null mice that develop small intestinal inflammation only when mice undergo conventionalization with normal fecal microflora (CONV) before surgical intervention. In this study, we examined the effects of postsurgical small bowel inflammation on adaptive growth after ICR. METHODS: GF 129SvEv IL-10 null mice, 8-10 wk old, were allocated to GF or CONV groups. Nonoperated GF and CONV mice provided baseline controls. Two wk later, GF and CONV mice were further allocated to ICR or sham operation. Small intestine and colon were harvested 7 d after surgery for histological analysis. RESULTS: All mice within the gnotobiotic facility maintained GF status and did not develop small intestinal or colonic inflammation. CONV resulted in colitis in all groups, whereas small intestinal inflammation was only observed following ICR. Resection-induced small intestinal inflammation in CONV mice was associated with increases in proliferation, crypt depth, and villus height compared with GF mice after ICR. Resection-induced increases in crypt fission only occurred in CONV mice. CONCLUSION: ICR-dependent small intestinal inflammation in CONV IL-10 null mice dramatically enhances early adaptive growth of the small intestine. Additional studies utilizing our model may provide clinical insight leading to optimal therapies in managing IBD patients after surgical resection.

Outcome of a clinical pathway for discharge within 48 hours after laparoscopic gastric bypass.

BACKGROUND: The benefits of laparoscopic gastric bypass (LGB) include decreased pain, quicker recovery, and shorter hospital stay. Our hypothesis was that a clinical pathway for 48-hour discharge after LGB can be implemented safely. METHODS: Charts of patients undergoing LGB were retrospectively reviewed to assess our prospectively placed clinical pathway. Patients were discharged within 48 hours if they met the criteria of the pathway. RESULTS: There were 104 patients who underwent LGB with no intraoperative conversions. Complications included 5 leaks, 5 reoperations, and no mortality. In our series, 76% (n=79) of patients were discharged within 48 hours. Gender and body mass index (BMI) did not differ between those who were discharged in 48 hours and those who were not (P=not significant). No patient who was discharged in 48 hours required return before their scheduled appointment. CONCLUSIONS: A majority of patients after LGB can be discharged safely in 48 hours. A formal clinical pathway helps decrease hospital stay without adverse patient outcome.

Laparoscopic lumbar hernia repair.

Lumbar hernias are rare clinical entities that often pose a challenge for repair. Because of the surrounding anatomy, adequate surgical herniorraphy is often difficult. Minimally invasive surgery has become an option for these hernias. Herein, we describe two patients with lumbar hernias (one with a recurrent traumatic hernia and one with an incisional hernia). Both of these hernias were successfully repaired laparoscopically.

Internet use in the bariatric surgery patient population.

BACKGROUND: Many patients rely on the Internet for gathering medical information. Bariatric patients appear to explore the Internet for information regarding weight loss surgery. This investigation studied the hypothesis that Internet use is common among the bariatric population. METHODS: From Oct 1 to Dec 31, 2003, every patient who visited our bariatric clinic was asked to fill out a questionnaire. This survey contained questions concerning use of the Internet and E-mail. RESULTS: Of the 127 respondents, 89% owned a computer, had Internet access, and had an E-mail address. 85% of the patients had searched the Internet for bariatric information, and 98% of these patients (91/93) found the information useful. Of the patients who had access to the Internet, 36% searched for information about the hospital, 40% about the clinic, and 54% about the surgeon. Most of the patients believed that all doctors and all clinics should be available via E-mail (88% and 92% respectively). CONCLUSIONS: Most patients who come to a bariatric clinic are Internet savvy. It is helpful for bariatric surgeons and clinics to post information about themselves on the Internet and to be available via E-mail.

Inpatient pain medication requirements after laparoscopic gastric bypass.

INTRODUCTION: One of the benefits of laparoscopic Roux-en-Y gastric bypass (RYGBP) includes decreased pain, possibly resulting in decreased narcotic use, quicker recovery of bowel function, and shorter hospital stay. We utilize a pain management strategy for our patients undergoing laparoscopic RYGBP. We investigated this strategy as well as narcotic use and incidence of ileus. METHODS: Inpatient data for patients who underwent laparoscopic RYGBP were collected. Our pain management strategy included a standing dose of ketorolac, morphine sulphate as needed, and propoxyphene hydrochloride/acetaminophen as needed after liquids were initiated. No PCAs were utilized. RESULTS: There were 104 patients in this study. 12 patients did not undergo our pain management strategy due to reoperation (5), postoperative hemorrhage (2), and allergies (5). 2 patients required no pain medications other than ketorolac. Only 2 patients had a delay of discharge (postoperative day [POD] 3 and 5) due to lack of bowel function. An average of 11.2 mg of morphine and an average of 170 mg of propoxyphene (1.7 pills) were given by the end of POD 2. In addition, 74% of patients required no morphine on POD 2 and 48% of patients required no propoxyphene on POD 2. Bowel movements were reported in 65% patients on POD 1. CONCLUSIONS: After laparoscopic RYGBP, only a minimal amount of narcotic use is necessary. Few patients have an ileus when utilizing this pain management strategy after laparoscopic RYGBP.

Routine preoperative upper endoscopy for laparoscopic gastric bypass: is it necessary?

Upper endoscopy is often performed in patients undergoing bariatric procedures. Various pathologies may be found during upper endoscopy that may change treatment plans for these patients. This study tested the hypothesis that routine use of upper endoscopy is necessary before laparoscopic gastric bypass. All patients in a 6-month period who underwent laparoscopic gastric bypass for the treatment of morbid obesity were reviewed. Demographic data, body mass index (BMI), operative reports, upper endoscopies, and Helicobacter pylori results were reviewed. Documentation of polyps, ulcerations, and hiatal hernias were noted. Hiatal hernias were further classified as small (3.5 to 4.0 cm), medium (4.0 to 4.5 cm), and large (>4.5 cm). All patients (N = 102) had preoperative upper endoscopy. There were 87 female and 15 male patients. BMI ranged from 38.2 to 63.2 (mean, 48.2) and weight ranged from 93 to 232 kg (mean, 133 kg). Hiatal hernia incidences were small, 36.3 per cent; medium, 27.5 per cent; and large, 26.5 per cent. All of these hernias were verified and repaired at time of surgery. Distal esophagitis was noted in 24 per cent of patients. Other pathology (gastric polyps, duodenitis, Schatzki ring) was observed in 5 per cent of patients. Overall, 91 per cent of patients had some type of pathology seen on upper endoscopy. Of the patients tested, 20 per cent were positive for H. pylori and were medically treated. Routine use of preoperative upper endoscopy revealed significant pathology in many patients before laparoscopic gastric bypass. The pathology found modified treatment in many cases. Bariatric surgeons should adopt the routine use of preoperative upper endoscopy during the workup for bariatric surgery.