A Novel Patient-oriented Tool for Evaluating Quality Measurements.

Quality measurements (QMs) have emerged as quantitative tools for measuring "quality", an elusive term that has been historically difficult to define and quantify. However, current literature has demonstrated that these measurements are flawed. The purpose of this study was to identify the strengths and weaknesses of quality measurements and provide a novel scorecard for evaluating quality measurements. In this retrospective analysis, 246 quality measurements that are integrated into the most significant payer-provider contracts within our institution were analyzed. Each measurement was dissected based on type of measurement, evidence, precision, data exchange, alignment, and how patient-oriented. Our research showed a significant lack of quality measurement alignment across payer-provider contracts. As such, we developed and proposed a Quality Measurement Evaluation Tool (QMET) that scores a quality measurement's ability to 1) reflect population health and 2) promote patient-oriented goals. Our research demonstrated the majority of quality measurements scored in the inadequate range (i.e., QMET score <6) and only few in the optimal range (i.e., QMET score 10-12). QMET provides a standardized and comprehensive method for appraising quality measurements, promoting continued use of QMs that accurately reflect population health and promote patient-oriented measurements. Future research into the application and reliability of QMET is needed.

Advances in the Diagnosis and Treatment of Barrett's Esophagus and Early Esophageal Cancer; Summary of the Kelly and Carlos Pellegrini SSAT/SAGES Luncheon Symposium.

BACKGROUND: Patients with Barrett's esophagus (BE) are at increased risk of developing esophageal adenocarcinoma (EAC). The incidence of EAC is rising faster than any other cancer. DISCUSSION: Patients with BE have a 30- to 40-fold increased risk of EAC. In the past 20 years, there have been dramatic advances in our understanding of the incidence and natural history of BE. Endoscopic treatment of BE is evolving. Even early EAC has been treated without esophagectomy and good oncologic results in the modern era.

Near-infrared fluorescent cholangiography facilitates identification of biliary anatomy during laparoscopic cholecystectomy.

BACKGROUND: Intraoperative cholangiography (IOC) is the current gold standard for biliary imaging during laparoscopic cholecystectomy (LC). However, utilization of IOC remains low. Near-infrared fluorescence cholangiography (NIRF-C) is a novel, noninvasive method for real-time, intraoperative biliary mapping. Our aims were to assess the safety and efficacy of NIRF-C for identification of biliary anatomy during LC. METHODS: Patients were administered indocyanine green (ICG) prior to surgery. NIRF-C was used to identify extrahepatic biliary structures before and after partial and complete dissection of Calot's triangle. Routine IOC was performed in each case. Identification of biliary structures using NIRF-C and IOC, and time required to complete each procedure were collected. RESULTS: Eighty-two patients underwent elective LC with NIRF-C and IOC. Mean age and body mass index (BMI) were 42.6 ± 13.7 years and 31.5 ± 8.2 kg/m(2), respectively. ICG was administered 73.8 ± 26.4 min prior to incision. NIRF-C was significantly faster than IOC (1.9 ± 1.7 vs. 11.8 ± 5.3 min, p < 0.001). IOC was unobtainable in 20 (24.4 %) patients while NIRF-C did not visualize biliary structures in 4 (4.9 %) patients. After complete dissection, the rates of visualization of the cystic duct, common bile duct, and common hepatic duct using NIRF-C were 95.1, 76.8, and 69.5 %, respectively, compared to 72.0, 75.6, and 74.3 % for IOC. In 20 patients where IOC could not be obtained, NIRF-C successfully identified biliary structures in 80 % of the cases. Higher BMI was not a deterrent to visualization of anatomy with NIRF-C. No adverse events were observed with NIRF-C. CONCLUSIONS: NIRF-C is a safe and effective alternative to IOC for imaging extrahepatic biliary structures during LC. This technique should be evaluated further under a variety of acute and chronic gallbladder inflammatory conditions to determine its usefulness in biliary ductal identification.

Impact of transoral incisionless fundoplication (TIF) on subjective and objective GERD indices: a systematic review of the published literature.

BACKGROUND: Gastroesophageal reflux disease (GERD) remains a significant problem for the medical community. Many endoluminal treatments for GERD have been developed with little success. Currently, transoral incisionless fundoplication (TIF) attempts to recreate a surgical fundoplication through placement of full-thickness polypropylene H-fasteners. This, the most recent procedure to gain FDA approval, has shown some promise in the early data. However, questions of its safety profile, efficacy, and durability remain. METHODS: The Cochrane Library and MEDLINE through PubMed were searched to identify published studies reporting on subjective and objective GERD indices after TIF. The search was limited to human studies published in English from 2006 up to March 2012. Data collected included GERD-HRQL and RSI scores, PPI discontinuation and patient satisfaction rates, pH study metrics, complications, and treatment failures. Statistical analysis was performed with weighted t tests. RESULTS: Titles and abstracts of 214 papers were initially reviewed. Fifteen studies were found to be eligible, reporting on over 550 procedures. Both GERD-HRQL scores (21.9 vs. 5.9, p < 0.0001) and RSI scores (24.5 vs. 5.4, p ≤ 0.0001) were significantly reduced after TIF. Overall patient satisfaction was 72 %. The overall rate of PPI discontinuation was 67 % across all studies, with a mean follow-up of 8.3 months. pH metrics were not consistently normalized. The major complication rate was 3.2 % and the failure rate was 7.2 % across all studies. CONCLUSION: TIF appears to provide symptomatic relief with reasonable levels of patient satisfaction at short-term follow-up. A well-designed prospective clinical trial is needed to assess the effectiveness and durability of TIF as well as to identify the patient population that will benefit from this procedure.

Gastric ischemic conditioning increases neovascularization and reduces inflammation and fibrosis during gastroesophageal anastomotic healing.

BACKGROUND: The incidence of anastomotic leak and stricture after esophagectomy remains high. Gastric devascularization followed by delayed esophageal resection has been proposed to minimize these complications. We investigated the effect of ischemic conditioning duration on anastomotic wound healing in an animal model of esophagogastrectomy. METHODS: North American opossums were randomized to four study groups. Group A underwent immediate resection and gastroesophageal anastomosis. Groups B, C, and D were treated with delayed resection and anastomosis after a gastric ischemic conditioning period of 7, 30, and 90 days, respectively. Gastric conditioning was performed by ligating the left, right, and short gastric vessels. An intraabdominal esophagogastric resection and anastomosis was performed, followed by euthanasia 10 days later. Outcome variables included anastomotic bursting pressure, microvessel concentration, tissue inflammation, and collagen deposition. RESULTS: Twenty-four opossums were randomized to groups A (n = 7), B (n = 8), C (n = 5), and D (n = 4). Subclinical anastomotic leak was discovered at necropsy in 5 animals: 3 in group A, and 1 each in groups B and C (p = 0.295). The anastomotic bursting pressure did not differ significantly between groups (p = 0.545). A 7 day ischemic conditioning time did not produce increased neovascularity (p = 0.900), but animals with a 30 day conditioning time showed significantly increased microvessel counts compared to unconditioned animals (p = 0.016). The degree of inflammation at the healing anastomosis decreased significantly as the ischemic conditioning period increased (p = 0.003). Increasing delay interval was also associated with increased muscularis propria preservation (p = 0.001) and decreased collagen deposition at the healing anastomosis (p = 0.020). CONCLUSIONS: Animals treated with 30 days of gastric ischemic conditioning showed significantly increased neovascularity and muscularis propria preservation and decreased inflammation and collagen deposition at the healing anastomosis. These data suggest that an ischemic conditioning period longer than 7 days is required to achieve the desired effect on wound healing.

Omental patch repair effectively treats perforated marginal ulcer following Roux-en-Y gastric bypass.

BACKGROUND: Marginal ulcer formation remains a significant complication of Roux-en-Y gastric bypass (RYGB). Up to 1 % of all RYGB patients will develop free perforation of a marginal ulcer. Classically, this complication has required anastomotic revision; however, this approach is associated with significant morbidity. Several small series have suggested that omental patch repair may be effective. The aim of this study was to examine the management of perforated marginal ulcers following RYGB. METHODS: All patients who underwent operative intervention for perforated ulcers between 2003 and 2011 were reviewed. Those with a history of RYGB with perforation of a marginal ulcer were included in the analysis. Data collected included operative approach, operative time, blood loss, length of hospital stay, complications, smoking history, and steroid or NSAID use. RESULTS: From January 2003 to December 2011, a total of 1,760 patients underwent RYGB at our institution. Eighteen (0.85 %) developed perforation of a marginal ulcer. Three patients' original procedure was performed at another institution. Eight patients (44 %) had at least one risk factor for ulcer formation. Treatment included omental patch repair (laparoscopic, n = 7; open, n = 9) or anastomotic revision (n = 2). Compared to anastomotic revision, omental patch repair had shorter OR time (101 ± 57 vs. 138 ± 2 min), decreased estimated blood loss (70 ± 72 vs. 250 ± 71 mL), and shorter total length of stay (5.6 ± 1.4 vs. 11.0 ± 5.7 days). CONCLUSIONS: Perforated marginal ulcer represents a significant complication of RYGB. Patients should be educated to reduce risk factors for perforation, as prolonged proton pump inhibitor therapy may not prevent this complication in a patient with even just one risk factor. In our sample population we found laparoscopic or open omental patch repair to be a safe and effective treatment for this condition and it was associated with decreased operative time, blood loss, and length of stay.