The effects of using telemedicine for introductory bariatric surgery seminars during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic required immediate systematic change in healthcare delivery. Many institutions relied on telemedicine as an alternative to in-person visits. There is limited data in the bariatric surgery literature to determine how telemedicine impacts patient volume. This study evaluates the effects of using telemedicine for introductory bariatric surgery seminars on patient volume at a single institution. METHODS: A retrospective review was performed before and after implementing virtual introductory seminars for bariatric surgery patients at a comprehensive metabolic and surgery center. The effect on attendance rates for introductory seminars and completion rates of bariatric surgery was evaluated. RESULTS: The introductory seminar attendance rate for the in-person/pre-telemedicine period, April 2019 to February 2020, was compared to that of the virtual/post-telemedicine period, June 2020 to April 2021. A total of 836 patients registered for an introductory seminar during the pre-telemedicine period with a 65.79% attendance rate. In the post-telemedicine period, 806 patients registered with a 67.87% attendance rate, which was not statistically different (p = 0.37, 95% CI - 0.03-0.07). Completion rates of bariatric surgery were analyzed using June 2019 to October 2019 as the pre-telemedicine period and June 2020 to October 2020 as the post-telemedicine period. Similarly, there was no difference between the pre-telemedicine surgery rate of 23.43% and post-telemedicine surgery rate of 19.68% (p = 0.31, 95% CI - 0.11-0.04). CONCLUSION: Despite abruptly transitioning to virtual introductory bariatric seminars, there was no change in attendance rates nor was there a difference in the number of patients progressing through the program and undergoing bariatric surgery at our institution. This demonstrates similar efficacy of telemedicine and in-person introductory seminars for bariatric surgery patients, which supports telemedicine as a promising tool for this patient population in the post-pandemic era.

Laparoscopic-Assisted Intra-Abdominal Section of the Lateral Femoral Cutaneous Nerve for Meralgia Paresthetica Following Anterior Hip Arthroplasty.

BACKGROUND: Meralgia paresthetica, a pain syndrome that is caused by injury to the lateral femoral cutaneous nerve, is a well-documented complication after anterior hip arthroplasty (THA). Traditional treatment of this peripheral nerve entrapment syndrome can be complicated in patients who have had THA via an anterior approach owing to the presence of scar in the postoperative bed. CASE DESCRIPTION: In a 70-year-old man, we performed a novel laparoscopic-assisted intra-abdominal approach to treat meralgia paresthetica in the setting of previous anterior THA. CONCLUSIONS: Minimally invasive intra-abdominal treatment of meralgia paresthetica following anterior THA results in durable pain relief. This approach is a helpful alternative to traditional techniques of decompression or section of the lateral femoral cutaneous nerve below the inguinal ligament.

Cost-effectiveness of prophylactic appendectomy: a Markov model.

BACKGROUND: Appendectomy is the most common emergency surgery performed in the USA. Removal of a non-inflamed appendix during unrelated abdominal surgery (prophylactic or incidental appendectomy) can prevent the downstream risks and costs of appendicitis. It is unknown whether such a strategy could be cost saving for the health system. METHODS: We considered hypothetical patient cohorts of varying ages from 18 to 80, undergoing elective laparoscopic abdominal and pelvic procedures. A Markov decision model using cost per life-year as the main outcome measure was constructed to simulate the trade-off between cost and risk of prophylactic appendectomy and the ongoing risk of developing appendicitis, with downstream costs and risks. Rates, probabilities, and costs of disease, treatment, and outcomes by patient age and gender were extracted from the literature. Sensitivity analyses were conducted using complications and costs of prophylactic appendectomy. RESULTS: With our base-case assumptions, including added cost of prophylactic appendectomy of $660, we find that prophylactic removal of the appendix is cost saving for males aged 18-27 and females aged 18-28 undergoing elective surgery. The margin of cost savings depends on remaining life-years and increases exponentially with age: a 20-year-old female undergoing elective surgery could save $130 over a lifetime by undergoing prophylactic appendectomy, while a 40-year-old female would lose $130 over a lifetime. When the risk of the prophylactic appendectomy exceeds the risk of laparoscopic appendectomy for appendicitis or the cost exceeds $1080, it becomes more cost saving to forego the prophylactic procedure. CONCLUSIONS: Prophylactic appendectomy can be cost saving for patients younger than age thirty undergoing elective laparoscopic abdominal and pelvic procedures.

Contemporary management of median arcuate ligament syndrome provides early symptom improvement.

OBJECTIVE: Optimal diagnosis and management of median arcuate ligament (MAL) syndrome (MALS) remains unclear in contemporary practice. The advent and evolution of laparoscopic and endovascular techniques has redirected management toward a less invasive therapeutic algorithm. This study examined our contemporary outcomes of patients treated for MALS. METHODS: All patients treated for MALS at Dartmouth-Hitchcock Medical Center from 2000 to 2013 were retrospectively reviewed. Demographics and comorbidities were recorded. Freedom from symptoms and freedom from reintervention were the primary end points. Return to work or school was assessed. Follow-up by clinic visits and telephone allowed quantitative comparisons among the patients. RESULTS: During the study interval, 21 patients (24% male), with a median age of 42 years, were treated for MALS. All patients complained of abdominal pain in the presence of a celiac stenosis, 16 (76%) also reported weight loss at the time of presentation, and 57% had a concomitant psychiatric history. Diagnostic imaging most commonly used included duplex ultrasound (81%), computed tomography angiography (66%), angiography (57%), and magnetic resonance angiography (5%). Fourteen patients (67%) underwent multiple diagnostic studies. All patients underwent initial laparoscopic MAL release. Seven patients (33%) underwent subsequent celiac stent placement in the setting of recurrent or unresolved symptoms with persistent celiac stenosis at a mean interval of 49 days. Two patients required surgical bypass after an endovascular intervention failed. The 6-month freedom from symptoms was 75% and freedom from reintervention was 64%. Eighteen patients (81%) reported early symptom improvement and weight gain, and 66% were able to return to work. CONCLUSIONS: A multidisciplinary treatment approach using initial laparoscopic release and subsequent stent placement and bypass surgery provides symptom improvement in most patients treated for MALS. The potential placebo effect, however, remains uncertain. A significant minority of patients will require reintervention, justifying longitudinal surveillance and prudent patient selection. Patients can anticipate functional recovery, weight gain, and return to work with treatment.

Early morbidity and mortality of laparoscopic sleeve gastrectomy and gastric bypass in the elderly: a NSQIP analysis.

BACKGROUND: Even though the U.S. population is aging, outcomes of bariatric surgery in the elderly are not well defined. Current literature mostly evaluates the effects of gastric bypass (RYGB), with paucity of data on sleeve gastrectomy (SG). The objective of this study was to assess 30-day morbidity and mortality associated with laparoscopic SG in patients aged 65 years and over, in comparison to RYGB. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was queried for all patients aged 65 and over who underwent laparoscopic RYGB and SG between 2010 and 2011. Baseline characteristics and outcomes were compared. P value<.05 was considered significant. Odds ratios (OR) with 95% confidence interval (CI) were reported when applicable. RESULTS: We identified 1005 patients. Mean body mass index was 44 ± 7. SG was performed in 155 patients (15.4%). The American Society of Anesthesiology physical classification of 3 or 4 was similar between the 2 groups (82.6% versus 86.7%, P = .173). Diabetes was more frequent in the RYGB group (43.2% versus 55.6%, P = .004). 30-day mortality (0.6% versus 0.6%, OR 1.1, 95% CI .11-9.49), serious morbidity (5.2% versus 5.6%, OR .91, 95% CI .42-0.96), and overall morbidity (9% versus 9.1%, OR 1.0, 95% CI .55-1.81) were similar. CONCLUSION: In elderly patients undergoing laparoscopic bariatric surgery, SG is not associated with significantly different 30-day outcomes compared to RYGB. Both procedures are followed by acceptably low morbidity and mortality.

Band removal and conversion to sleeve or bypass: are they equally safe?

INTRODUCTION: Patients who require laparoscopic adjustable gastric band (LAGB) removal are often converted to sleeve gastrectomy (SG) or roux-en-Y gastric bypass (RYGB). The relative safety of these salvage bariatric procedures is unclear. We hypothesized that LAGB removal with conversion to SG (BSG) or RYGB (BRYGB) would be associated with higher morbidity and mortality compared to primary SG or RYGB. METHODS: National Surgical Quality Improvement Project data (2005-2011) were analyzed. Patients undergoing SG, RYGB, BRYGB, and BSG were identified. The incidence of major complications, as well as mortality was compared between groups. Multivariate analysis was performed to identify patient factors and operation types associated with major complications or mortality. Odds ratios (OR) were calculated with 95 % confidence intervals (CI) with p value <0.05 considered statistically significant. RESULTS: A total of 51,609 patients were analyzed, consisting of primary RYGB (n = 46,153), BRYGB (495), primary SG (n = 4,831), and BSG (n = 130) patients. All groups had similar mean age (45 ± 11-years old). Salvage patients were more commonly female (89 vs. 79 %) and with lower body-mass index than primary bariatric patients (BMI 42 ± 8 vs. 46 ± 8 kg/m2). Major complication rates were 5.23 % (RYGB), 4.65 % (BRYGB), 3.95 % (SG) and 6.92 % (BSG), with 30-day mortality of 0.16 % (RYGB), 0.20 % (BRYGB), 0.08 % (SG) and 0.77 % (BSG). Multivariate analysis showed that compared to SG, RYGB, and BSG were independent predictors of major complications. Multivariate analysis of mortality showed BSG was an independent predictor of mortality compared to SG (OR 8.02, 95 % CI 1.08-59.34, p = 0.04). CONCLUSIONS: Band removal with conversion to RYGB is not associated with higher morbidity or mortality compared to primary RYGB. However, band removal with conversion to sleeve gastrectomy appears to be independently associated with a higher rate of major complications and mortality, and thus may not be the salvage procedure of choice.

Laparoscopic paraesophageal hernia repair: advanced age is associated with minor but not major morbidity or mortality.

BACKGROUND: Large studies have documented the safety of laparoscopic paraesophageal hernia (PEH) repair in the general population. Even though this condition affects primarily the elderly, data on the short-term outcomes of this procedure on the oldest-old are lacking. STUDY DESIGN: The NSQIP database was analyzed for all patients undergoing laparoscopic PEH repair in 2010 and 2011. Chi-square, Fisher's exact, and 2-tailed Student's t-test were used to compare baseline characteristics, morbidity, and mortality. Binary logistic regression was used to control for confounding variables. Odds ratios (OR) with 95% confidence intervals (CI) were reported when applicable. RESULTS: A total of 2,681 patients undergoing laparoscopic PEH repair were identified. The mean (±SD) age of the cohort was 63 ± 14 years. We identified 313 patients (11.7%) aged 80 years and older. Using regression analysis, advanced age (OR 1.7, 95% CI 1.1 to 2.7, p = 0.009), American Society of Anesthesiologists class 3 or 4 (OR 1.4, 95% CI 1.0 to 2.1, p = 0.045), gastrostomy placement (OR 2.4, 95% CI 1.3 to 4.7, p = 0.007), and significant recent weight loss (OR 2.1, 95% CI 1.1 to 4.1, p = 0.037) were independently associated with development of overall morbidity. Mortality (1% vs 0.4%, p = 0.16) and serious morbidity (5.8% vs 3.7%, p = 0.083) were not significantly different between the older and younger groups. Minor morbidity was higher in the older group (8.3% vs 3.5%, OR 2.5, 95% CI 1.6 to 3.9, p < 0.001). CONCLUSIONS: In an assessment of modern nationwide practice, laparoscopic PEH repair is performed with minimal morbidity and mortality. Elective repair in patients aged 80 years or older is not associated with significant differences in mortality or major morbidity compared with younger patients.

Fundamentals of endoscopic surgery: creation and validation of the hands-on test.

BACKGROUND: The Fundamentals of Endoscopic Surgery™ (FES) program consists of online materials and didactic and skills-based tests. All components were designed to measure the skills and knowledge required to perform safe flexible endoscopy. The purpose of this multicenter study was to evaluate the reliability and validity of the hands-on component of the FES examination, and to establish the pass score. METHODS: Expert endoscopists identified the critical skill set required for flexible endoscopy. They were then modeled in a virtual reality simulator (GI Mentor™ II, Simbionix™ Ltd., Airport City, Israel) to create five tasks and metrics. Scores were designed to measure both speed and precision. Validity evidence was assessed by correlating performance with self-reported endoscopic experience (surgeons and gastroenterologists [GIs]). Internal consistency of each test task was assessed using Cronbach's alpha. Test-retest reliability was determined by having the same participant perform the test a second time and comparing their scores. Passing scores were determined by a contrasting groups methodology and use of receiver operating characteristic curves. RESULTS: A total of 160 participants (17 % GIs) performed the simulator test. Scores on the five tasks showed good internal consistency reliability and all had significant correlations with endoscopic experience. Total FES scores correlated 0.73, with participants' level of endoscopic experience providing evidence of their validity, and their internal consistency reliability (Cronbach's alpha) was 0.82. Test-retest reliability was assessed in 11 participants, and the intraclass correlation was 0.85. The passing score was determined and is estimated to have a sensitivity (true positive rate) of 0.81 and a 1-specificity (false positive rate) of 0.21. CONCLUSIONS: The FES hands-on skills test examines the basic procedural components required to perform safe flexible endoscopy. It meets rigorous standards of reliability and validity required for high-stakes examinations, and, together with the knowledge component, may help contribute to the definition and determination of competence in endoscopy.

Ventral hernia repairs in the oldest-old: high-risk regardless of approach.

BACKGROUND: Ventral hernia repairs (VHR) are among the most common procedures performed by general surgeons. Even though the US population is aging, outcomes of VHR in the elderly and oldest-old (≥80 years) are not well documented. Our study aims to evaluate the short-term outcomes of VHR in the oldest-old patients. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was queried for all patients who underwent VHR based on Current Procedural Terminology codes between 2005 and 2011. Chi square, Fisher's exact and two-tailed Student's t test were used to compare baseline characteristics and outcomes. Binary logistic regression was used to control for confounding variables. Odds ratios (OR) with 95 % confidence intervals (CI) were reported when applicable. RESULTS: We identified 123,151 patients who underwent a VHR; 4,917 (4 %) were ≥80 years of age. The incidence of laparoscopy increased from 19.8 % in 2009-23.2 % in 2011 (p < 0.001). 30-day unadjusted mortality was 1.7 versus 0.1 % for younger patients (p < 0.001). After controlling for baseline differences, age ≥80 years was an independent predictor of overall morbidity (OR 1.4, 95 % CI 1.3-1.6, p < 0.001), serious morbidity (OR 1.6, 95 % CI 1.4-1.8, p < 0.001) and mortality (OR 3.5, 95 % CI 2.5-4.6, p < 0.001). Oldest-old patients undergoing laparoscopic VHR had a lower incidence of surgical site infection (SSI) compared with patients with open repair (1 vs. 3.4 %, p = 0.001). Mortality, serious morbidity and overall morbidity were not significantly different. CONCLUSIONS: VHR in the oldest-old carried significantly higher 30-day overall morbidity, serious morbidity and mortality, compared with younger patients. The use of laparoscopy was associated with improved SSI. Mortality and morbidity were associated with emergency surgery, wound classification and baseline comorbidities, but not surgical approach.

Laparoscopic repair of hiatal hernia after esophagectomy.

BACKGROUND: Herniation of abdominal contents via the diaphragmatic hiatus is a potentially life-threatening complication of esophagectomy. Mounting evidence suggests that hiatal hernias are more common following minimally invasive esophagectomy. Therefore, post-esophagectomy hiatal hernia and its treatment bear increasing significance. METHODS: We retrospectively reviewed the records of five patients with hiatal hernia following esophagectomy over a 5-year period. RESULTS: Successful laparoscopic reduction of a post-esophagectomy hiatal hernia was done without mesh reinforcement in three patients. One patient underwent mesh reinforcement. One patient was found to have carcinomatosis upon laparoscopic inspection, and repair of the hiatal hernia was abandoned. There were no perioperative deaths or complications. One patient developed a recurrent hiatal hernia 14 months after repair of the initial hiatal hernia. Patients were discharged within a mean of 1.75 days after surgical repair. DISCUSSION: We have successfully used laparoscopy to treat hiatal hernias after esophagectomy. The benefits conferred by laparoscopy, including better visualization of the right gastroepiploic artery supplying the gastric conduit, minimally invasive evaluation of the field for metastasis, and shorter recovery time, make it our favored approach. Here, we describe our experience with hiatal hernia following esophagectomy and our operative technique.

Transgastric-assisted endoscopic fundoplication.

Gastroesophageal reflux disease (GERD) is a common entity in the United States. Surgical fundoplication can be performed safely with well-established long-term results. In selected patients with GERD, endoluminal therapy has a potential role. We report on a patient with recurrent GERD after two prior fundoplications who wished to pursue endoscopic treatment. The presence of a gastrostomy tube allowed for the performance of a transgastric-assisted endoluminal fundoplication using the EndoCinch (TM) device and standard pediatric laparoscopic instruments. Symptomatic relief of GERD with EndoCinch (TM) is common but the long-term outcomes are limited. Nevertheless, the EndoCinch (TM) device remains a method for endoscopic suturing in certain settings. In patients with gastrostomy access, the use of laparoscopic instruments may further enable the performance of advanced endoscopic therapies.

Laparoendoscopic transgastric resection of a submucosal mass at the gastroesophageal junction.

INTRODUCTION: Traditional management of gastric submucosal lesions usually involves wedge resection. However, lesions close to the gastroesophageal junction are difficult to manage with wedge resection without compromising the lower esophageal sphincter. This video highlights an interesting combined laparoscopic and endoscopic technique for safe resection of a submucosal lesion adjacent to the gastroesophageal junction. METHODS: A 66-year-old male was evaluated by gastroenterology for melena. Upper endoscopy with subsequent endoscopic ultrasound demonstrated a 2-cm submucosal lesion adjacent to the gastroesophageal junction. Biopsies were indeterminate, and the remainder of his workup was negative. A combined laparoendoscopic technique was utilized to safely resect the lesion while protecting the gastroesophageal junction. This was accomplished using three 5-mm trocars placed directly through the abdominal wall into the stomach using endoscopic guidance. All muscle layers were resected en bloc with the specimen, leaving the serosa intact. RESULTS: The patient did well and was discharged home on postoperative day 1. Final pathology demonstrated a leiomyoma with negative margins. CONCLUSION: Submucosal lesions adjacent to the gastroesophageal junction can be safely and effectively managed using a laparoendoscopic approach. This technique provides improved visualization and facilitates an adequate resection compared to endoscopy or laparoscopy alone.

The certifying examination of the american board of surgery: the effect of improving communication and professional competency: twenty-year results.

PURPOSE: In 1985, a small research group identified variables affecting applicant success on the oral Certifying Examination (CE) of the American Board of Surgery (ABS). This led to the design of an oral examination course first taught in 1991. The success of and need for this program led to its continuation. The results from the first 10 years were presented at the 2001 Association of Program Directors in Surgery annual meeting.(1) We now report the outcomes for the course of the second 10 years as measured by success on the CE. METHODS: Thirty-six courses were held over 20 years. There were 57 invited faculty from 27 general surgery programs throughout the United States and Canada. The participant-to-faculty ratio ranged from 16:7 to 5:1 in the newer 3-day format (2007). Courses were offered at sites that replicated the actual examination setting. Each course included (1) pretest and posttest examinations, (2) analysis of case presentation skills, (3) measurement of communication apprehension, (4) 1:1 faculty feedback, (5) small-group practice sessions, (6) individual videotaping, (7) didactic review of specific behaviors on examinations, (8) a debrief session with two faculty members, and (9) a written evaluative summary that included an improvement strategy. RESULTS: There were 36 courses with 326 participants (30-54 years). Follow-up data are available for 225 participants. Trends were analyzed between 1991-2001 and 2002-2011. As resident performance on the CE increased in importance, applicant profiles changed from those who had previously failed (1991-2001) to residents identified by program directors as needing assistance (52%). Since 2002, most course participants (69%) who had failed the CE had completed at least 1 other review course. Participants reported more significant stressors (2002-2011) 9%, but communication apprehension remained the same. As a result, individual counseling for anger and family stressors was integrated into the course. The perception of knowledge deficits was associated with those who enrolled in fellowship training and delayed their examination. The recent groups exhibited more professionalism and articulation issues related to performance. Five surgeons (2002-2011) were asked not to return to the course because of severe knowledge deficiencies or ethical/behavioral issues based on faculty evaluations. Although complete follow-up of all participants was not possible (only 225/326), the success rate among those providing follow-up was 97% for those who followed their remediation plan, giving 218/326, a worse-case pass rate of 67%. CONCLUSION: Communication and professionalism deficits are still common in those struggling with the CE, Early identification of those at risk of failing by program directors who are documenting the competencies may promote earlier interventions and thus lead to success. This program continues to be effective at identifying behaviors that interfere with success on the CE of the ABS.

Safety and effectiveness of Realize adjustable gastric band: 3-year prospective study in the United States.

BACKGROUND: The effectiveness and safety of bariatric surgery using laparoscopic adjustable gastric bands have been demonstrated in numerous published studies. We present the results of the first U.S. multicenter trial of the Realize adjustable gastric band, a laparoscopic adjustable gastric band previously available only outside the United States as the Swedish adjustable gastric band. METHODS: A total of 405 morbidly obese patients were screened at 12 different centers from May to November 2003 to participate in a prospective, single-arm study of the safety and effectiveness of the laparoscopically implanted Realize band. Changes in excess body weight, the parameters of diabetes and dyslipidemia, and the incidence of complications were assessed at 3 years of follow-up. RESULTS: Of the 405 patients, 276 (78.3% women and 61.2% white) qualified for the study. The average age was 38.6 + or - 9.4 years (range 18-61), and the preoperative body mass index was 44.5 + or - 4.7 kg/m(2). The mean hospital stay was 1.2 + or - 1.3 days. At 3 years, the average excess weight loss was 41.1% + or - 25.1% or a decrease in the body mass index of 8.2 kg/m(2) (18.6%) (P < .001). In diabetic patients with a baseline elevated hemoglobin A(1)c level, the level decreased by 1% (P < .001). The total cholesterol, low-density lipoprotein cholesterol, and triglycerides decreased by 9%, 16%, and 50%, respectively (P < .001), and the high-density lipoprotein cholesterol increased by 25% (P < .001) in patients with abnormal baseline values. One patient required conversion to an open surgical technique. No 30-day mortality occurred. The complication frequencies were generally low and included esophageal dysmotility in 0.4%, late balloon failure in 0.4%, band erosion in 0.4%, slippage in 3.3%, esophageal dilation in 3.3%, pouch dilation in 3.6%, catheter kinking in 1.1%, port displacement in 2.5%, and port disconnection in 4.3%. Reoperations were required in 15.2% of the patients and involved 2 band replacements, 9 band revisions, 5 port replacements, 22 port revisions, and 4 explants. CONCLUSION: The results of our study have shown that the Realize adjustable gastric band is safe and effective in a diverse U.S. population of morbidly obese patients. Significant weight loss was achieved throughout the 3 years of follow-up, with corresponding improvements in the indicators of diabetes and dyslipidemia.

Initial experience with laparoscopic inferior epigastric vessel ligation for delayed transverse rectus abdominus musculocutaneous flap breast reconstruction.

HYPOTHESIS: Transverse rectus abdominus musculocutaneous (TRAM) flap breast reconstruction provides excellent cosmetic results. Pedicle flap viability is greatly enhanced by prereconstruction inferior epigastric vessel ligation, which encourages collateral arterial flow (delayed TRAM). We report our initial experience with laparoscopic inferior epigastric vessel ligation. DESIGN: Prospective case series. SETTING: Tertiary academic center. PATIENTS: Female patients with breast cancer who chose pedicle TRAM reconstruction. INTERVENTIONS: Vessel ligations were performed 7 to 14 days prior to reconstruction. Abdominal access was achieved with a 3-mm umbilical trocar. A 5-mm trocar was placed lateral to the rectus sheath in the right lower quadrant. Five-millimeter Teflon clips were used to ligate the vessels near their origin. MAIN OUTCOME MEASURES: Complications of surgery and subsequent flap viability. RESULTS: From January 2001 to July 2006, 130 patients had laparoscopic inferior epigastric vessel ligation, of whom 123 patients had bilateral ligation. Additional procedures in conjunction with vessel ligation were performed in 38 patients (sentinel node biopsy [27], bilateral oophorectomy [7], liver biopsy [2], breast biopsy [1], and Nissen fundoplication [1]). Median operative time for those patients undergoing ligation only was 32.6 minutes (range, 14-121 minutes). The inferior epigastric vessels were not identified in 2 patients. Metastatic breast cancer involving the liver was found in 1 patient. There were no conversions or complications. Subsequent TRAM flap viability was excellent in most cases, with 1 complete flap necrosis in a high-risk, morbidly obese patient. CONCLUSION: Laparoscopic inferior epigastric vessel ligation for delayed TRAM flap breast reconstruction is a safe, effective procedure.

Determining an appropriate threshold for referral to surgery for gastroesophageal reflux disease.

BACKGROUND: Persistent symptomatic gastroesophageal reflux disease (GERD) can be treated with medication or surgery. The purposes of this study were (1) to determine how poor the quality of life on medication would need to be to justify assuming the risks of surgery, and (2) to estimate the proportion of patients currently on medication whose quality of life is below this value. METHODS: We developed a Markov decision analysis model to simulate health outcomes (measured in quality adjusted life years [QALY]) over 10 years for medication and surgery in patients with typical GERD symptoms. We included probabilities of events obtained from a systematic literature review. Quality of life adjustments, expressed as utilities, were drawn from a survey of 131 patients 1 to 5 years after antireflux surgery. By using this model, we calculated what quality of life on medications would change the optimal strategy from medication to surgery (threshold). To determine the proportion of patients below this value, we prospectively surveyed 40 medically treated GERD patients at our hospital. RESULTS: Surgery resulted in more QALYs than medical therapy when the utility with medication use was below 0.90. Sensitivity analysis showed this value to be relatively insensitive to reasonable variations in surgical risks (mortality, failures, reoperation) and quality of life after surgery. Among those surveyed on medications, 48% fell below this threshold and would be predicted to benefit from surgery. CONCLUSION: Our model suggests that surgery would likely benefit a high proportion of medically treated GERD patients. Individual assessment of quality of life with GERD should be considered to aid clinical decision making.