Obesity is not associated with increased difficulty placing peripheral IVs in trauma activation patients.

INTRODUCTION: Previous studies have identified obesity as a risk factor for difficult IV access, but this has not been studied in the acute trauma setting. The primary objective was to determine if obesity is associated with increased difficulty placing peripheral IVs in trauma patients. Secondary analysis evaluated IV difficulty and associations with nursing self-competence ratings, trauma experience, and patient demographics. METHODS: Prospective, observational study at academic level I trauma center with 58,000 annual visits. Trauma activation patients between January and October of 2016 were included. Each nurse who attempted IV placement, completed anonymous 7 question survey, including trauma experience (years), self-competence and IV difficulty (Likert scales 1-5), and attempts. Demographic and clinical information was retrospectively collected from the EMR and nursing surveys. Descriptive statistics, chi-square tests, and spearman correlations were used. RESULTS: 200 patients included in the study with 185 BMI calculations. 110 overweight (BMI > 25) and 48 obese (BMI > 30). 70 (35%) female, 149 (75%) white, average age 48. Increased BMI and IV difficulty displayed spearman correlation (ρ) of 0.026 (P = 0.72) suggesting against significant association. Increased trauma experience and self-competence ratings significantly correlated with decreased IV difficulty, ρ = -0.173 and -0.162 (P = 0.010 and 0.014). There was no statistically significant association with IV difficulty in regards to patient race, age, sex, or location of IV placement. CONCLUSION: Obesity was not associated with increased difficulty in placing peripheral IVs in trauma activation patients. Nurses with greater trauma experience and higher self-competence ratings, had less difficulty inserting IVs.

Advance directives, living wills, and futility in perioperative care.

Patient autonomy is preserved through the use of advance directives. A living will defines treatment by establishing parameters under which patients want to be treated. A durable power of attorney for health care establishes a surrogate for patients if they are unable to make decisions for themselves. In the perioperative setting, advance directives are applied with significant variation between surgeons, likely due to surgeons implying from informed consent discussions that patients want to pursue aggressive treatment. Futility is a rare occurrence in patient care that is difficult to define; however, there are some classic surgical conditions in which futility is part of the decision process.

Acute acalculous cholecystitis in the critically ill: risk factors and surgical strategies.

PURPOSE: Acute acalculous cholecystitis (AAC) is characterized by severe gallbladder inflammation without cystic duct obstruction. Critical illness and neurological deficits are often associated with AAC, and early radiologic imaging is necessary for the detection and timely treatment of AAC. In critically ill patients, effective surgical management is difficult. This review examines the three common surgical treatments for AAC (open cholecystectomy (OC), laparoscopic cholecystectomy (LC), or percutaneous cholecystostomy (PC)), their prevalence in current literature, and the perioperative outcomes of these different approaches using a large retrospective database. MATERIALS AND METHODS: This review examined literature gathered from PubMed and Google Scholar to select more than 50 sources with data pertinent to AAC; of which 20 are described in a summary table. Outcomes from our previous research and several updated results were obtained from the University HealthSystem Consortium (UHC) database. RESULTS: LC has proven effective in treating AAC when the risks of general anesthesia and the chance for conversion to OC are low. In critically ill patients with multiple comorbidities, PC or OC may be the only available options. Data in the literature and an examination of outcomes within a national database indicate that for severely ill patients, PC may be safer and met with better outcomes than OC for the healthier set of AAC patients. CONCLUSIONS: We suggest a three-pronged approach to surgical resolution of AAC. Patients that are healthy enough to tolerate LC should undergo LC early in the course of the disease. In critically ill patients, patients with multiple comorbidities, a high conversion risk, or who are poor surgical candidates, PC may be the safest and most successful intervention.

Improvement in gastroesophageal reflux disease symptoms after various bariatric procedures: review of the Bariatric Outcomes Longitudinal Database.

BACKGROUND: The prevalence of gastroesophageal reflux disease (GERD) in the morbidly obese population is as high as 45%. The objective of this study was to compare the efficacy of various bariatric procedures in the improvement of GERD. METHODS: The Bariatric Outcomes Longitudinal Database is a prospective database of patients who undergo bariatric surgery by a participant in the American Society of Metabolic and Bariatric Surgery Center of Excellence program. GERD is graded on a 6-point scale, from 0 (no history of GERD) to 5 (prior surgery for GERD). Patients with GERD severe enough to require medications (grades 2, 3, and 4) from June 2007 to December 2009 are identified; the resolution of GERD is noted based on 6-month follow-up. RESULTS: Of a total of 116,136 patients, 36,938 patients had evidence of GERD preoperatively. After excluding patients undergoing concomitant hiatal hernia repair or fundoplication, there were 22,870 patients with 6-month follow-up. Mean age was 47.6±11.1 years, with an 82% female population. Mean BMI was 46.3±8.0 kg/m(2). Mean preoperative GERD score for patients with Roux-en-Y gastric bypass (RYGB) was 2.80±.56, and mean postoperative score was 1.33±1.41 (P<.0001). Similarly, adjustable gastric banding (AGB, 2.77±.57 to 1.63±1.37, P<.0001) and sleeve gastrectomy (SG, 2.82±.57 to 1.85±1.40, P<.0001) had significant improvement in GERD score. GERD score improvement was best in RYGB patients (56.5%; 7955 of 14,078) followed by AGB (46%; 3773 of 8207) and SG patients (41%; 240 of 585). CONCLUSION: All common bariatric procedures improve GERD. Roux-en-Y gastric bypass is superior to adjustable gastric banding and sleeve gastrectomy in improving GERD. Also, the greater the loss in excess weight, the greater the improvement in GERD score.

Emergent cholecystostomy is superior to open cholecystectomy in extremely ill patients with acalculous cholecystitis: a large multicenter outcome study.

BACKGROUND: Morbidity and mortality are very high for critically ill patients who develop acute acalculous cholecystitis (AAC). The aim of this study was to compare outcomes in extremely ill patients with AAC treated with percutaneous cholecystostomy (PC), laparoscopic cholecystectomy (LC), or open cholecystectomy (OC), which were also analyzed together in the LC-plus-OC (LO) group. METHODS: Discharge data from the University HealthSystem Consortium database were accessed using International Classification of Diseases codes. The University HealthSystem Consortium's Clinical Data Base/Resource Manager allows member hospitals to compare patient-level, risk-adjusted outcomes. Multivariate regression models for extremely ill patients undergoing PC or LO for the diagnosis of AAC were created and analyzed. RESULTS: A total of 1,725 extremely ill patients were diagnosed with AAC between October 2007 and June 2011. Patients undergoing PC (n = 704) compared with the LO group (n = 1,021) showed decreased morbidity (5.0% with PC vs 8.0% with LO, P < .05), fewer intensive care unit admissions (28.1% with PC vs 34.6% with LO, P < .05), decreased length of stay (7 days with PC vs 8 days with LO, P < .05), and lower costs ($40,516 with PC vs $53,011 with LO, P < .05). Although perioperative outcomes of PC compared with LC were statistically similar, PC had lower costs compared with LC ($40,516 vs 51,596, P < .005). Multivariate regression analysis showed that LC (n = 822), compared with OC (n = 199), had lower mortality (odds ratio [OR], .3; 95% confidence interval [CI], .1 to .6), lower morbidity (OR, .4; 95% CI, .2 to .7), reduced intensive care unit admission (OR, .3; 95% CI, .2 to .5), and similar 30-day readmission rates (OR, 1.0; 95% CI, .6 to 1.5). Also, decreased length of stay (7 days with LC vs 8 days with OC) and costs ($51,596 with LC vs $61,407 with OC) were observed, with a 26% conversion rate to an open procedure. CONCLUSIONS: On the basis of this experience, extremely ill patients with AAC have superior outcomes with PC. LC should be performed in patients in whom the risk for conversion is low and in whom medical conditions allow. These results show PC to be a safe and cost-effective bridge treatment strategy with perioperative outcomes superior to those of OC.

Impact of advanced laparoscopy courses on present surgical practice.

BACKGROUND AND OBJECTIVES: The introduction of new surgical techniques has made training in laparoscopic procedures a necessity for the practicing surgeon, but acquisition of new surgical skills is a formidable task. This study was conducted to assess the impact of advanced laparoscopic workshops on caseload patterns of practicing surgeons. METHODS: After we obtained institutional review board approval, a survey of practicing surgeons who participated in advanced laparoscopic courses was distributed; the results were analyzed for statistical significance. The courses were held at the University of Nebraska Medical Center between January 2002 and December 2010. Questionnaires were mailed, faxed, and e-mailed to surgeons. RESULTS: Of the 109 surgeons who participated in the advanced laparoscopy courses, 79 received surveys and 30 were excluded from the survey because of their affiliation with the University of Nebraska Medical Center. A total of 47 responses (59%) were received from 41 male and 6 female surgeons. The median response time from completion of the course to completion of the survey was 13.2 months (range, 6.8-19.1 months). The mean age of participating surgeons was 39.2 years (range, 29-51 years). The mean time since residency was 8.4 years (range, 0.8-21 years). Eleven surgeons had completed a minimal number of laparoscopic cases in residency (<50), 17 surgeons had completed a moderate number of laparoscopic procedures in residency (50-200), and 21 surgeons had completed a significant number of cases during residency (>200). Of the surgeons who responded, 94% were in private practice. Fifty-seven percent of the participating surgeons who responded reported a change in laparoscopic practice patterns after the courses. Of these surgeons, 24% had a limited residency laparoscopy exposure of <50 cases. Surgeons who were exposed to ≥50 laparoscopic cases during their residency showed a statistically significant increase in the number of laparoscopic procedures performed after their class compared with surgeons who did not receive ≥50 laparoscopic cases in residency (P = .03). In addition, regardless of the procedures learned in a specific class, surgeons with ≥50 laparoscopic cases in residency had a statistically significant increase in their laparoscopic colectomy and laparoscopic hernia procedure caseload (P < .01). However, there was no statistically significant difference in laparoscopic caseload between surgeons who had completed 50 to 200 laparoscopic residency cases and those who had completed greater than 200 laparoscopic residency cases (P = .31). Furthermore, the participant's age (P = .23), practice type (P = .61), and years in practice (P = .22) had no statistical significance with regard to the adoption of laparoscopic procedures after courses taken. This finding is congruent with the findings of other researchers. Future interest in advanced laparoscopy courses was noted in 70% of surgeons and was more pronounced in surgeons with ≥50 cases in residency. CONCLUSION: Advanced laparoscopic workshops provide an efficacious instrument in educating surgeons on minimally invasive surgical techniques. Participating surgeons significantly increased the number of course-specific procedures that they performed but also increased the number of other laparoscopic surgeries, suggesting that a certain proficiency in laparoscopic skills is translated to multiple surgical procedures. Laparoscopy experience of ≥50 cases during residency is a strong predictor of an increase in the number of advanced laparoscopic cases after attending courses.

Differences in outcomes of laparoscopic gastric bypass.

BACKGROUND: Although several risk factors affecting weight loss outcomes with bariatric procedures have been identified, the effect of age, gender, race, and illness severity on postoperative outcomes of laparoscopic gastric bypass has not been extensively examined. METHODS: The University HealthSystem Consortium database is an administrative and financial database that provides information on the inpatient stay. A retrospective analysis of patient outcomes was performed using 4-year discharge data from the University HealthSystem Consortium database. RESULTS: A total of 37,765 patients underwent laparoscopic gastric bypass. The women exhibited significantly reduced mortality, morbidity, intensive care unit (ICU) admissions (9.87% male versus 6.73% female; P <.001), duration of hospitalization (2.72 ± 4.03 d for men versus 2.59 ± 2.88 d for women; P <.001), and hospital costs ($17,346 ± $15,397 for men versus $14,383 ± $11,170 for women; P <.001). Blacks demonstrated significantly greater 30-day readmission rates, duration of hospitalization, and costs compared with whites. Hispanics had lower ICU admission and hospital costs compared with whites. With increasing age, an increased risk of overall morbidity, ICU admissions, duration of hospitalization, and costs was observed. Compared with the minor severity group, the major/extreme severity group had significantly greater observed mortality, overall morbidity, ICU admissions, duration of hospitalization, and hospital costs. CONCLUSION: The present study identified gender, race, age, and illness severity as risk factors affecting postoperative outcomes after laparoscopic gastric bypass. Male gender and increasing age were overall associated with an increased risk of complications. Significant racial disparities in the outcome measures were observed with blacks having an increased risk of adverse events. Illness severity was shown to adversely affect the surgical outcomes in laparoscopic gastric bypass.

Miniature in vivo robot for laparoendoscopic single-site surgery.

BACKGROUND: The aim of this study was to develop a multidexterous robot capable of generating the required forces and speeds to perform surgical tasks intra-abdominally. Current laparoscopic surgical robots are expensive, bulky, and fundamentally constrained by a small entry incision. A new approach to minimally invasive surgery places the robot completely within the patient. Miniature in vivo robots may allow surgeons to overcome current laparoscopic constraints such as dexterity, orientation, and visualization. METHODS: A collaborative research group from the Department of Surgery at the University of Nebraska Medical Center and the College of Engineering at the University of Nebraska-Lincoln designed and built a surgical robot prototype capable of performing specific surgical tasks within the peritoneal cavity. RESULTS: The basic robotic design consists of two arms each connected to a central body. Each arm has three degrees of freedom and rotational shoulder and elbow joints. This combination allows a surgeon to grasp, manipulate, cauterize, and perform intracorporeal suturing. The robot's workspace is a hollow hemisphere with an inner radius of 75 mm and an outer radius of 205 mm. Its versatility was demonstrated in four procedures performed in a porcine model: cholecystectomy, partial colectomy, abdominal exploration, and intracorporeal suturing. CONCLUSIONS: Miniature in vivo robots have the potential to address the limitations of using articulated instrumentation to perform advanced laparoscopic surgical procedures. Once inserted into the peritoneal cavity, the robot provides a stable platform for visualization with sufficient dexterity and speed to perform surgical tasks from multiple orientations and workspaces.

Dexterous miniature robot for advanced minimally invasive surgery.

This study demonstrates the feasibility of using a miniature robot to perform complex, single-incision, minimal access surgery. Instrument positioning and lack of triangulation complicate single-incision laparoscopic surgery, and open surgical procedures are highly invasive. Using minimally invasive techniques with miniature robotic platforms potentially offers significant clinical benefits. A miniature robot platform has been designed to perform advanced laparoscopic surgery with speed, dexterity, and tissue-handling capabilities comparable to standard laparoscopic instruments working through trocars. The robotic platform includes a dexterous in vivo robot and a remote surgeon interface console. For this study, a standard laparoscope was mounted to the robot to provide vision and lighting capabilities. In addition, multiple robots could be inserted through a single incision rather than the traditional use of four or five different ports. These additional robots could provide capabilities such as tissue retraction and supplementary visualization or lighting. The efficacy of this robot has been demonstrated in a nonsurvival cholecystectomy in a porcine model. The procedure was performed through a single large transabdominal incision, with supplementary retraction being provided by standard laparoscopic tools. This study demonstrates the feasibility of using a dexterous robot platform for performing single-incision, advanced laparoscopic surgery.

Primary and revisional laparoscopic adjustable gastric band placement in patients with hiatal hernia.

BACKGROUND: Limited evidence exists regarding the outcomes of patients undergoing laparoscopic adjustable band placement (LAGB) with hiatal hernia (HH) and concomitant hiatal hernia repair (HHR). The present study evaluated the safety, efficacy, and cost-effectiveness of primary LAGB (pLAGB) and revisional LAGB (rLAGB) in patients with HH. METHODS: The University HealthSystem Consortium is an alliance of >100 academic medical centers and nearly 200 affiliate hospitals. The University Health System Consortium database was queried for patients undergoing LAGB with and without HH from 2006 through 2009. RESULTS: The patients undergoing rLAGB had a significantly greater prevalence of HH than patients undergoing pLAGB (18.9% for pLAGB with HH versus 26.3% for rLAGB with HH; P <.001). The mortality (.04% for pLAGB without HH versus 0% for pLAGB with HHR; P >.05), morbidity (3.39% pLAGB without HH versus 2.63% for pLAGB HHR; P >.05), and length of stay (1.33 ± 2.25 days for pLAGB without HH versus 1.17 ± 0.56 days for pLAGB with HHR; P >.05) were comparable in the patients undergoing pLAGB with or without HHR. A trend was seen toward increased morbidity in patients undergoing rLAGB HHR than in those undergoing pLAGB HHR (2.63% for pLAGB HHR versus 13.33% for rLAGB HHR; P = .08). The length of stay (1.17 ± 0.56 days for pLAGB HHR versus 1.73 ± 1.49 days for rLAGB HHR; P <.01) and hospital costs ($12,178 ± 4451 for pLAGB HHR versus $14,616 ± 3538 for rLAGB HHR; P = .04) were increased for the rLAGB HHR group compared with the pLAGB HHR group. CONCLUSION: The results of the present study have demonstrated the safety of HHR concomitant with pLAGB. In addition, rLAGB was associated with increased morbidity and cost. These data suggest the safety, efficacy, and cost-effectiveness of crural repair of HH simultaneously with pLAGB.

Multipurpose surgical robot as a laparoscope assistant.

BACKGROUND: This study demonstrates the effectiveness of a new, compact surgical robot at improving laparoscope guidance. Currently, the assistant guiding the laparoscope camera tends to be less experienced and requires physical and verbal direction from the surgeon. Human guidance has disadvantages of fatigue and shakiness leading to inconsistency in the field of view. This study investigates whether replacing the assistant with a compact robot can improve the stability of the surgeon's field of view and also reduce crowding at the operating table. METHODS: A compact robot based on a bevel-geared "spherical mechanism" with 4 degrees of freedom and capable of full dexterity through a 15-mm port was designed and built. The robot was mounted on the standard railing of the operating table and used to manipulate a laparoscope through a supraumbilical port in a porcine model via a joystick controlled externally by a surgeon. The process was videotaped externally via digital video recorder and internally via laparoscope. Robot position data were also recorded within the robot's motion control software. RESULTS: The robot effectively manipulated the laparoscope in all directions to provide a clear and consistent view of liver, small intestine, and spleen. Its range of motion was commensurate with typical motions executed by a human assistant and was well controlled with the joystick. CONCLUSIONS: Qualitative analysis of the video suggested that this method of laparoscope guidance provides highly stable imaging during laparoscopic surgery, which was confirmed by robot position data. Because the robot was table-mounted and compact in design, it increased standing room around the operation table and did not interfere with the workspace of other surgical instruments. The study results also suggest that this robotic method may be combined with flexible endoscopes for highly dexterous visualization with more degrees of freedom.

Does type of mesh used have an impact on outcomes in laparoscopic inguinal hernia?

BACKGROUND: Theoretically, a lighter and softer mesh may decrease nerve entrapment and chronic pain by creating less fibrosis and mesh contracture in laparoscopic inguinal hernia repair. METHODS: We performed a telephone survey of patients who underwent laparoscopic inguinal hernia surgery between 2001 and 2007. We recorded patient responses for chronic pain, foreign body sensation, recurrence, satisfaction, and return to work, and then studied the effect of type of mesh (polypropylene vs polyester) on these factors. RESULTS: Of 109 consecutive patients surveyed (mean age, 54.5 y), 67 eligible patients underwent 84 transabdominal extraperitoneal procedures and 2 transabdominal preperitoneal procedures. Patients with polypropylene mesh had a 3 times higher rate of chronic pain (P = .05), feeling of lump (P = .02), and foreign body perception (P = .05) than the polyester mesh group. Our overall 1-year recurrence rate was 5.9%. The recurrence rate was 9.3% for the polypropylene group and 2.9% for the polyester group (P = .26). CONCLUSIONS: A lightweight polyester mesh has better long-term outcomes for chronic pain and foreign body sensation compared with a heavy polypropylene mesh in laparoscopic inguinal hernia repair. We also saw a trend toward higher recurrence in the polypropylene group.

Catheter-related bloodstream infection.

Catheter-related bloodstream infections (CR-BSIs) are a common, frequently preventable complication of central venous catheterization. CR-BSIs can be prevented by strict attention to insertion and maintenance of central venous catheters and removing unneeded catheters as soon as possible. Antiseptic- or antibiotic-impregnated catheters are also an effective tool to prevent infections. The diagnosis of CR-BSI is made largely based on culture results. CR-BSIs should always be treated with antibiotics, and except in rare circumstances the infected catheter needs to be removed.