Contemporary Outcomes of Transduodenal Sphincteroplasty: the Importance of Surgical Quality.

BACKGROUND: Sphincter of Oddi dysfunction (SOD) is managed primarily by endoscopic sphincterotomy (ES); however, surgical transduodenal sphincteroplasty (TDS) is a treatment option for select patients. In our high-volume pancreatico-biliary practice, we have observed variable outcomes among TDS patients; therefore, we sought to determine preoperative predictors of durable improvement in quality of life. METHODS: SOD patients treated by TDS between January 2006 and December 2015 were studied. The primary outcome measure was long-term changes in quality of life after sphincteroplasty. The secondary outcome measure examined postoperative outcomes, including postoperative complications, need for repeat procedures, and readmission rates. Perioperative data were abstracted, and the SF-36 quality-of-life (QoL) survey was administered. Standard statistical analysis included non-parametric methods to examine bivariate associations. RESULTS: Eighty-eight patients had an average follow-up duration of 6.7 (± 2.9) years. Thirty (34%) patients were naïve to endoscopic therapy. Patients with prior endoscopy averaged 2.1 procedures (range 1 to 13) prior to surgery. Perioperative morbidity was 27%; one postoperative death was caused by severe acute pancreatitis. Twenty-nine (33%) patients required subsequent biliary-pancreatic procedures. QoL analysis from available patients showed that 66% were improved or much improved. With multivariable analysis including SOD type and prior endoscopic instrumentation, freedom from surgical complication was the only variable that correlated significantly with a good outcome (p < 0.02). CONCLUSION: Surgical transduodenal sphincteroplasty provides durable symptom management for select patients with sphincter of Oddi dysfunction. Minimizing surgical complications optimizes long-term outcomes.

The Kidney Transplant: Maintaining Excellent Outcomes While Increasing Skills Acquisition.

OBJECTIVE/BACKGROUND: Kidney transplantation is a complex operation that incorporates multiple fundamental surgical techniques and is an excellent opportunity for surgical skill development during residency training. We hypothesized that increasing resident competency, measured as anastomosis time, could be demonstrated while maintaining high-quality surgical outcomes during the learning process. METHODS: We performed a retrospective cohort study of surgical resident involvement in kidney transplantation and recorded the anastomosis time. The study population comprised adult, single organ kidney transplants (n = 2052) at a large academic transplant center between 2006 and 2019. Descriptive statistics included frequencies, medians, and means. A mixed model of anastomosis time on number of procedures was fitted. Poisson models were fitted with outcomes of the number of patients with delayed graft function and number of patients that underwent reoperation postoperatively, with the exposure being number of kidney transplants performed by resident. RESULTS: Results from the mixed model suggest that as the number of times a resident performs the surgery increases, the time to conduct the operation decreases with statistical significance. The Poisson regression demonstrated no significant relationship between the operative volume of a resident and postoperative complications. CONCLUSION: This study demonstrated statistical evidence that with an increase in the number of renal transplantations performed by a surgical resident, anastomosis time decreased. It also demonstrated no significant relationship between number of kidney transplants performed by a resident and postoperative complications, suggesting that patient outcomes for this operation are not adversely affected by resident involvement.

Identifying prenatal ultrasound predictors and the ideal neonatal management of closing gastroschisis: the key is prevention.

OBJECTIVE: To evaluate the optimal approaches to initial surgical management and the potential for prenatal ultrasound detection of patients with closing gastroschisis. STUDY DESIGN: We performed a retrospective analysis of patients born with gastroschisis to determine clinical and surgical outcomes and the ability to determine prognosis by prenatal imaging. Data collected included operative findings and postoperative outcome, as well as prenatal imaging features from a subset of cases with and without closing gastroschisis. Statistical analyses were performed as appropriate. RESULTS: We included 197 patients with gastroschisis. No statistical significance was seen in outcomes between closing gastroschisis patients undergoing resection versus intracorporeal parking (n = 18). Ultrasound review was performed on 33 of these patients, 11 with closing gastroschisis, and 22 without. Significantly more closing gastroschisis patients had imaging indicative of progressive defect narrowing and defect diameter ≤8 mm after 30 weeks of gestation versus non-closing patients (p = 0.002). CONCLUSION: Parking of extruded bowel offers potential for intestinal remodeling. In addition, prenatal ultrasound may be useful in detection of closing gastroschisis in utero.

Implementation of General Surgery Care into a Student-Run Free Clinic.

BACKGROUND: Student-run free clinics (SRFCs) provide medical care to uninsured, and surgical issues are often outside the normal scope of care of these clinics. The Shade Tree Clinic (STC) is an SRFC serving 300 patients with complex medical conditions. This study describes the implementation and efficacy of a General Surgery Specialty Clinic in this setting. METHODS: This descriptive study examines the demographics and referral patterns of patients seen in two pilot Specialty Clinics and other patients evaluated for general surgical issues from December 2017 to January 2020. Providers were surveyed regarding their experience in clinic. RESULTS: Twenty patients were evaluated by six general surgeons during 22 separate encounters (n = 20). Nine patients were seen in two pilot Specialty Clinics for biliary colic, hernia, hemorrhoids, anal mass, toenail lesion, surgical weight loss, and venous insufficiency. Referrals from these clinics to affiliated Vanderbilt University Medical Center included six ultrasounds; referrals to vascular surgery and podiatry clinics; and referrals for laparoscopic cholecystectomy and anal mass excision. STC also directly referred eight patients for colonoscopies and five patients for major operations through primary care clinic. Hundred percent of care was cost-free to patients. Providers reported a median satisfaction score of five with the Specialty Clinics (Very Satisfied; [4, 5]). Hundred percent of providers felt that the concerns of patients were addressed. CONCLUSIONS: A surgery specialty clinic in the setting of an SRFC is an effective way to provide surgical care to underserved populations with the potential to reduce unplanned hospital utilization.

Placement of Subcutaneous Central Venous Ports in Breast Cancer Patients: Does Side Matter?

BACKGROUND: Central venous ports placed for breast cancer treatment have traditionally been placed contralateral to the disease. This is done out of concern for the possibility of an increased risk of complications with ipsilateral port placement. There have been only a few small studies evaluating complication rates between ports placed ipsilateral versus contralateral to the breast cancer. We sought to determine if there was a difference in port complications or lymphedema rates by location. METHODS: A single institution retrospective review was conducted of adult (aged >18 y) females undergoing central venous port placement for breast cancer treatment from 2012 to 2016. RESULTS: A total of 581 females were identified with a mean age of 52.9 ± 11.7 y. Ipsilateral ports were placed in 41 patients (7.1%). Ipsilateral ports were more likely to be placed via the internal jugular vein (56.1%), whereas contralateral ports were more likely to be placed in the subclavian vein (67.2%; P = 0.002). There was no difference between stage at diagnosis (P = 0.059), type of breast surgery (P = 0.999), axillary surgery (P = 0.087), or administration of radiation therapy (P = 0.684) between the groups. Ipsilateral ports were more likely to be on the right side, 73.2% versus 51.1% (P = 0.006). Port complications requiring intervention occurred in 3 patients (7.3%) with ipsilateral port and 33 patients (6.1%) with contralateral ports (P = 0.73). Lymphedema occurred in 8 patients (20%) with ipsilateral ports and 118 patients (21.9%) with contralateral ports (P = 0.639). On multivariable analysis, the type of axillary surgery (P = 0.003) was associated with upper extremity lymphedema, whereas port sidedness (P = 0.26) was not. CONCLUSIONS: There was no difference in port complications or lymphedema rates between patients who had ports placed on the ipsilateral side compared with the contralateral side for breast cancer treatment.