Perioperative outcomes of surgical procedures for symptomatic fundoplication failure: a retrospective case-control study.

BACKGROUND: Anatomic failure with recurrent gastroesophageal reflux disease (GERD) or related symptoms following fundoplication is a well-described occurrence. Occasionally, reoperative surgery is required. The morbidity of revisional surgery can be quite high, and the clinical outcomes may not be as good as is observed following primary antireflux operations. METHODS: Data were obtained from a prospectively maintained foregut surgery database and via follow-up survey. Patients who underwent surgery for symptomatic failed fundoplication were included. A control group consisting of the same number of patients who underwent a first-time fundoplication for GERD was randomly selected from the same database. Anatomic failure of the original fundoplication was confirmed in all cases with upper endoscopy and an upper-GI series. Perioperative outcomes were compared between study groups. Visick scores were attained via phone follow-up along with satisfaction scores related to the outcome. RESULTS: From January 2003 to January 2010, 38 patients underwent revisional operations for failed fundoplication at our institution. The majority of patients (74%) had one previous failed attempt at fundoplication (range = 1-3). The most common mechanism of failure was hiatal hernia with recurrent GERD (79%). Reoperative patients were similar to their controls (age, sex, and body mass index). Reoperative surgery took longer, patients remained in the hospital longer, and these patients experienced more complications. Despite this fact, satisfaction with the outcomes of surgery was high in each group. The majority of patients in each study group reported Visick scores of grade 1 (no symptoms, resolved) or grade 2 (mild occasional symptoms, easily controlled) after surgery. CONCLUSION: Compared to primary antireflux surgery, revisional operations are associated with longer mean operating times, increased length of hospital stay, and increased morbidity. Despite this fact, the majority of patients are satisfied with the outcomes of revisional surgery for failed fundoplication, and symptomatic outcomes are good.

Preoperative predictors of significant symptomatic response after 1 year of gastric electrical stimulation for gastroparesis.

BACKGROUND: In cases of gastroparesis where significant symptoms fail to respond to standard medical therapy, gastric electrical stimulation (GES) may be of benefit. Unfortunately, not all patients improve with this therapy. Reliable preoperative predictors of symptomatic response to GES may allow clinicians to offer this expensive and invasive treatment to only those patients most likely to benefit. METHODS: Therapy was initiated in 15 patients more than 12 months prior to this retrospective review of our prospectively maintained data. All patients completed a Total Symptom Score (TSS) survey at every encounter as well as the SF-36 quality-of-life instrument prior to surgery. A failure of GES therapy was considered to have occurred when after 1 year of treatment, preoperative TSS had not decreased by at least 20%. RESULTS: Four patients (4 idiopathic) failed to improve more than 20% on multiple assessments after a year of therapy. All diabetic patients experienced a durable symptomatic improvement with GES. Review of individual items of the TSS revealed that nonresponders experienced less severe vomiting preoperatively. CONCLUSIONS: Diabetic gastroparesis patients respond best to GES. Responders tend to have more severe vomiting preoperatively. Patients with idiopathic gastroparesis who do not experience severe vomiting should be cautioned about a potentially higher rate of poor response to GES and may be better served with alternative treatments.

The use of the Ligasure for hemostasis during thyroid lobectomy.

BACKGROUND: The Ligasure electrothermal vessel sealer (Valleylab, Boulder, CO) has been introduced as a new method for hemostasis during thyroidectomy. We hypothesized that the use of Ligasure would potentially reduce operative time during thyroid surgery. METHODS: From 2001 to 2005, 150 patients had a thyroid lobectomy by a single surgeon. Data from these patients were prospectively collected in a database and retrospectively analyzed. RESULTS: Of the 150 patients, 51 underwent thyroid lobectomy with the use of the Ligasure and 99 patients underwent conventional ligation of vessels. There were no differences between groups with regard to demographic factors, thyroid gland pathology, or complications. Operative time was significantly shortened by 40 minutes in patients who had surgery with the Ligasure. CONCLUSION: In patients undergoing thyroid lobectomy, the use of the Ligasure decreases operating room time and is associated with no increase in complications. Thus, we advocate the routine use of this technology during thyroid surgery.

Computed tomography in the diagnosis of acute appendicitis: definitive or detrimental?

OBJECTIVES: Utilization of computed tomography (CT) scans in patients with presumed appendicitis was evaluated at a single institution to determine the sensitivity of this diagnostic test and its effect on clinical outcome. METHODS: Adult patients (age > 17 years) with appendicitis were identified from hospital records. Findings at surgery, including the incidence of perforation, were correlated with imaging results. RESULTS: During a 3-year period, 411 patients underwent appendectomy for presumed acute appendicitis at our institution. Of these patients, 256 (62%) underwent preoperative CT, and the remaining 155 (38%) patients did not have imaging before the surgery. The time interval between arrival in the emergency room to time in the operating room was longer for patients who had preoperative imaging (8.2 +/- 0.3 h) compared to those who did not (5.1 +/- 0.2 h, p < 0.001). Moreover, this possible delay in intervention was associated with a higher rate of appendiceal perforation in the CT group (17 versus 8%, p = 0.017). CONCLUSIONS: Preoperative CT scanning in patients with presumed appendicitis should be used selectively as widespread utilization may adversely affect outcomes. The potential negative impact of CT imaging includes a delay in operative intervention and a potentially higher perforation rate.

Effective surgical residents strongly influence medical students to pursue surgical careers.

BACKGROUND: There is a paucity of data about the influence of surgical residents on the career choices of medical students. We hypothesized that medical students exposed to effective surgical residents would be more likely to pursue careers in surgery. STUDY DESIGN: From 1998 to 2003, 108 surgical residents were evaluated by medical students rotating on the third-year clerkship. Residents were scored on a 4-point scale (1 = outstanding to 4 = poor). The career choices of all medical students were also tabulated. RESULTS: We examined 2,632 evaluations on 108 residents. Medical students who eventually pursued surgical residency training were exposed to surgical residents who were more effective clinical teachers, role models, and overall residents. In addition, medical students exposed to the highest-rated residents were more likely to pursue surgical residency training compared with students exposed to the least effective residents (12% versus 4.9%, p = 0.022). CONCLUSIONS: These data suggest that surgical residents who are effective educators and mentors influence medical students to pursue surgical careers. Efforts to provide more leadership and teaching workshops to surgical residents may not only create better future surgeon educators, but may also increase the number of students pursuing surgical training.

Metastatic neuroendocrine hepatic tumors: resection improves survival.

BACKGROUND: The optimal treatment for hepatic metastases from neuroendocrine tumors remains controversial because of the often indolent nature of these tumors. We sought to determine the effect of 3 major treatment modalities including medical therapy, hepatic artery embolization, and surgical resection, ablation, or both in patients with liver-only neuroendocrine metastases, with the hypothesis that surgical treatment is associated with improvement in survival. DESIGN: Retrospective study. SETTING: Tertiary care center. PATIENTS: Patients with metastatic liver-only neuroendocrine tumors were identified from hospital records. INTERVENTIONS: Patients were subdivided into those receiving medical therapy, hepatic artery embolization, or surgical management. MAIN OUTCOME MEASURES: Effect of treatment on survival and palliation of symptoms was analyzed. RESULTS: From January 1996 through May 2004, 48 patients with liver-only neuroendocrine metastases were identified (median follow-up, 20 months), including 36 carcinoid and 12 islet cell tumors. Seventeen patients were treated conservatively, which consisted of octreotide (n = 7), observation (n = 6), or systemic chemotherapy (n = 4). Hepatic artery embolization was performed in 18 patients. Thirteen patients underwent surgical therapy, including anatomical liver resection (n = 6), ablation (n = 4), or combined resection and ablation (n = 3). No difference was noted in the percentage of liver involved with tumor between the 3 groups. An association of improved survival was noted in patients treated surgically, with a 3-year survival of 83% for patients treated by surgical resection, compared with 31% in patients treated with medical therapy or embolization (P = .01). No difference in palliation of symptoms was noted among the 3 treatment groups (P = .2). CONCLUSION: In patients with liver-only neuroendocrine metastases, surgical therapy using resection, ablation, or both is associated with improved survival.

A mouse model of carcinoid syndrome and heart disease.

BACKGROUND: Carcinoid heart disease occurs in over 65% of patients with the carcinoid syndrome and is characterized by fibrous thickening of cardiac valves, leading to heart failure. Whether serotonin is directly responsible for these cardiac abnormalities is unknown. Therefore, to further understand the etiology and pathophysiology of carcinoid heart disease, we developed an animal model of the carcinoid syndrome. MATERIALS AND METHODS: Seventeen nude mice underwent intrasplenic injection of human pancreatic carcinoid BON cells (10(7)) and then were euthanized 9 weeks later. Murine livers were analyzed by immunohistochemistry. Murine hearts were sectioned and the surface area of the right heart valves determined. Blood was also collected and analyzed for platelet serotonin by ELISA. RESULTS: Sixty-five percent of the mice developed gross carcinoid liver metastases demonstrated by chromogranin-A-staining lesions within the liver. Mice with carcinoid liver metastases had elevated platelet serotonin levels (1058 +/- 529 ng/ml versus 123 +/- 52 ng/ml, P = 0.002) when compared to the controls. Animals with carcinoid liver metastases also had a trend toward greater tricuspid valvular surface areas (242 +/- 24 versus 174 +/- 25 microm, P = 0.08). On histological examination, this increase in tricuspid surface area in mice with liver metastases appeared to be due to fibrosis of the valvular tissues, consistent with the pathologic findings of carcinoid heart disease. CONCLUSIONS: Using this novel animal model of carcinoid syndrome, the tricuspid valve thickening resembling carcinoid heart disease could be due to exposure to factors such as serotonin secreted by carcinoid tumor cells.