Evaluation of Quality of Life and Surgical Outcomes for Treatment of Diverticular Disease.

The prevalence of diverticular disease in the Western and industrialized nations has increased over the last century, and our understanding of this disease and its management continues to evolve. In this article, we review the literature regarding the postoperative quality of life (QOL) and functional outcomes following surgical management of diverticulitis, including information regarding bowel function, recurrence of symptoms, and other postoperative sequelae. While objective parameters, such as attacks of diverticulitis, complications, and clinical episodes have been studied, there is a paucity of data on less objective factors, such as overall patient satisfaction after operative management of diverticular disease. The literature shows improvement in QOL following surgical intervention for diverticulitis if preoperative QOL was significantly low, secondary to severe/complicated diverticulitis. However, a subset of patients does continue to have symptoms following surgical intervention for diverticulitis. Often neglected in the literature, there remains a need for prospective data evaluating preoperative function to ascertain the impact of surgery on patients' QOL and postoperative function.

Effectiveness of Liposomal Bupivacaine in Colorectal Surgery: A Pragmatic Nonsponsored Prospective Randomized Double Blinded Trial in a Community Hospital.

BACKGROUND: Prior industry conducted studies have shown that long acting liposomal bupivacaine injection improves pain control postoperatively. OBJECTIVE: To evaluate whether liposomal bupivacaine reduced the use of postoperative opioid (http://links.lww.com/DCR/A253) pain medication as compared to standard bupivacaine following colorectal surgery. DESIGN: A double blinded, prospective, randomized controlled trial comparing liposomal bupivacaine versus standard bupivacaine in patients undergoing elective colon resection. SETTINGS: Community hospital with general surgery residency program with all cases performed by colorectal surgeons. PATIENTS: Fifty-seven patients were randomized and reported as intention-to-treat analysis with 6 protocol violations. Sensitivity analysis excluding these 6 patients demonstrated no change in study results or conclusion. Mean age was 67 ± 2 years and 56% were male. There were 36 patients who underwent minimally invasive surgery, and 21 patients had an open colon resection. INTERVENTIONS: Experimental arm received liposomal bupivacaine while control arm received standard bupivacaine. MAIN OUTCOME MEASURES: Primary outcome measure was intravenous hydromorphone equivalent used via PCA during first 48 hours after operation. RESULTS: There was no significant difference between the two groups in the amount of opioid used orally or intravenously in the postoperative period. The primary outcome measure was PCA hydromorphone consumption during first two postoperative days after operation (hydromorphone equivalent use in standard bupivacaine group 11.3 ± 8.9 mg versus 13.3 ± 11.9 mg in liposomal bupivacaine group, p = 0.58 Mann-Whitney test). LIMITATIONS: Small pragmatic trials typically remain underpowered for secondary analyses. A larger study could help to further delineate other outcomes that are impacted by postoperative pain. CONCLUSIONS: Liposomal bupivacaine did not change the amount of opioid used postoperatively. Based on our study, liposomal bupivacaine does not provide any added benefit over conventional bupivacaine after colon resection. (ClinicalTrials.gov: NCT02052557).

The degree of gallbladder wall thickness and its impact on outcomes after laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy is the gold-standard procedure for management of symptomatic gallstone disease. Increased rates of conversion to an open procedure, increased postoperative complications, and longer lengths of stay are seen in thick-walled gallbladders. Previous studies have only evaluated gallbladder walls as being thick or not thick, without looking at the degree of thickness. We hypothesized that, the more severe the wall thickening, the greater the chance of conversions and complications, and the longer the lengths of stay. METHODS: All attempted laparoscopic cholecystectomies in our institution between 2006 and 2009 were retrospectively reviewed. Patients undergoing cholecystectomy for reasons other than gallstones (e.g., polyps or cancer) and those without preoperative ultrasounds were excluded. Patients were divided into four groups based on the degree of gallbladder wall thickness: normal (1-2 mm), mildly thickened (3-4 mm), moderately thickened (5-6 mm), and severely thickened (7 mm and above). Outcomes were compared amongst the groups. RESULTS: 874 patients were included in the study. There were 68 conversions (7.8 %) and 58 complications (6.6 %). The incidence of conversions was 3.1, 5.1, 14.9, and 16.8 % in the four groups, respectively (p < 0.001, χ (2)), and the incidence of complications was 1.8, 6.7, 9.1, and 13.1 %, respectively (p = 0.001, χ (2)). The mean (± standard deviation, SD) length of stay in days was 1.09 ± 1.42, 1.83 ± 3.24, 2.54 ± 3.40 and 3.54 ± 4.61, respectively [p < 0.001, analysis of variance (ANOVA)]. CONCLUSIONS: A greater degree of gallbladder wall thickness is associated with an increased risk of conversion, increased postoperative complications, and longer lengths of stay. Classifying patients according to degree of gallbladder wall thickness gives more accurate assessment of the risk of surgery, as well as potential outcomes.

Robotic adrenalectomy by an open surgeon: are outcomes different?

Our objective is to demonstrate the feasibility of robotic adrenalectomy by a traditional open surgeon using the da Vinci Robotic Surgical System and to analyze our outcomes. All patients who underwent robotic adrenalectomy by a single surgeon from July 2001 to April 2011 were included in the study. Vascular inflow control was obtained early on to facilitate dissection and handling of the adrenal gland. Forty adrenalectomies were performed during the study period in 39 patients (15 males; 25 left sided; 1 bilateral). Four patients underwent conversion to complete the procedure. The mean tumor size was 6.97 ± 2.4 cm. The mean operating room (OR) time was 117 ± 50.4 min. Comparing the OR time between da Vinci and da Vinci S robotic systems showed that the OR time was significantly less (169 ± 46 vs. 94.25 ± 32 min; P = 0.002) while blood loss, length of stay, size and weight were not different. The mean length of stay was 3 days. There were no mortalities in our study. Benign neoplasms formed a majority of the tumors removed. Robotic adrenalectomy is an option for surgeons without extensive training in advanced laparoscopic techniques provided they have adequate open experience.

Endolumenal revision obesity surgery results in weight loss and closure of gastric-gastric fistula.

BACKGROUND: Approximately 20-50% of patients regain weight 3-5 years after Roux-en-Y gastric bypass (RYGB) surgery. Gastric-gastric fistulas and dilation of the gastrojejunostomy and gastric pouch have been reported in these patients. Traditional revision surgery after RYGB has greater morbidity and mortality compared with the index bariatric procedure. We studied our initial results with revision of obesity surgery using an endoscopic platform in a community hospital setting. METHODS: A retrospective review was performed of patients who had undergone this endoscopic revisional procedure secondary to significant weight regain with or without gastric-gastric fistula. All patients underwent revision of the gastrojejunostomy and/or closure of the gastric-gastric fistula using this minimally invasive approach. RESULTS: A total of 37 consecutive patients (36 women) with a mean age of 45 years and mean weight regain of 15.1 ± 10.0 kg were included in the present study. The mean interval between RYGB and revision was 5.2 years (range 1-11). The mean preoperative and postoperative stomal size was 21.5 and 10 mm, respectively. Anchors were successfully placed in all patients. The mean follow-up period was 4.69 months (range 2-10). The mean percentage of excess body weight loss was 23.5% ± 66.4%. No immediate complications developed. Two patients underwent endoscopic dilation of the stoma because of persistent meal intolerance. Three gastric-gastric fistulas were successfully closed. CONCLUSION: Revision of gastrojejunostomy after RYGB can be safely undertaken using this endoscopic platform. The short-term follow-up results showed clinically significant weight loss. Long-term follow-up is needed. Closure of gastric-gastric fistulas can also be achieved using this procedure.

Emergency subtotal colectomy in a Jehovah's Witness with massive lower gastrointestinal bleeding: challenges encountered and lessons learned.

A 66-year-old woman who was a Jehovah's Witness had massive lower gastrointestinal bleeding and subsequent hypovolemic shock, necessitating a subtotal colectomy. During the postoperative period, her hemoglobin level decreased to a low of 2.6 g/dL, prolonging her dependence on mechanical ventilation. Prudent perioperative care resulted in a successful outcome. Blood-conserving techniques are indispensable in the management of Jehovah's Witnesses who have massive blood loss. Maximizing oxygen transport, minimizing blood loss, using a cell saver when permissible, providing optimal ventilatory support, performing tracheostomy early if prolonged mechanical ventilation is expected, and augmenting hemoglobin production with administration of iron and erythropoietin are techniques that can facilitate successful outcome in patients who refuse blood transfusion.

Does transumbilical single incision laparoscopic adjustable gastric banding result in decreased pain medicine use? A case-matched study.

BACKGROUND: We report on our initial experience of laparoscopic adjustable gastric banding performed through a single transumbilical incision of approximately 2.5 cm. All single incision bands were placed using the Covidien SILS Port™ and the Allergan Lap-Band(®). The purpose of the present study was to report on the analgesic use after single-incision laparoscopic surgery (SILS) adjustable gastric banding versus that after conventional laparoscopic gastric banding at a community hospital. METHODS: A retrospective review of postoperative pain medication use and the time to return to work was conducted of 24 consecutive SILS adjustable gastric banding procedures compared with 24 traditional 5-incision laparoscopic adjustable gastric banding procedures. RESULTS: The patients in both groups were evenly matched for age, body mass index, and co-morbidities. All patients were discharged home on postoperative day 1. No complications developed. The mean patient-controlled analgesia morphine use during hospitalization for the SILS group was 33 ± 19.22 mg versus 49 ± 23.78 mg in the traditional group (P <.05). The mean period of postoperative pain medication use for the SILS group was 2 days versus 5 days for the traditional group (P <.05). However, the mean period to return to work was 9.5 days for the SILS group versus 11 days for the traditional group (P = NS). CONCLUSION: Transumbilical single-incision laparoscopic adjustable gastric banding with mechanical port fixation resulted in significantly decreased postoperative pain medication use compared with traditional laparoscopic gastric banding with suture fixation of the band port. Also, the patients tended to return to work earlier after SILS gastric banding.

Colocutaneous fistula after suction lipoplasty: case report and literature review.

Suction lipoplasty is considered to be a relatively safe procedure but is not without complications, some of which are lethal. Colonic injury after liposuction has not been reported so far, although small intestinal perforations are known to occur. We present a case of colocutaneous fistula after suction lipoplasty that was successfully managed nonoperatively. A 56-year-old man with history of abdominoplasty presented with feculent discharge from the abdominal wall 7 days after liposuction. A computed tomography scan of the abdomen showed free intraperitoneal air, with a suspected transverse colonic fistula to the skin. After drainage of abdominal wall abscess, he recovered and the fistula spontaneously closed. Abdominal wall hernias, abdominal operations, and immunosuppression are risk factors for abdominal and intestinal perforations after lipoplasty. Low output colocutaneous fistulae after lipoplasty may close spontaneously unlike small intestinal perforations.

Well leg compartment syndrome after robotic prostatectomy: a word of caution.

Compartment syndrome of the lower extremity is a rare complication that can occur following prolonged surgery in the lithotomy position. We report the case of a 45-year-old man who developed compartment syndrome in the post-operative period after radical robotic prostatectomy. Four-compartment fasciotomy helped prevent serious sequelae from the injury. Young males with a high body mass index undergoing prolonged surgery in the lithotomy position are particularly at risk for developing this complication. The early diagnosis and implementation of preventive measures will facilitate timely management.