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COBRA trial takes the long view of absorbable biosynthetic mesh outcomes

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Wed, 01/02/2019 - 09:46

 

Absorbable, biosynthetic surgical mesh used to repair ventral hernia defects may be a good alternative to biologic and permanent synthetic mesh products both in terms of long-term durability and cost, according to a longitudinal cohort study.

The results of the COBRA (Complex Open Bioabsorbable Reconstruction of the Abdominal Wall) study published in the January issue of Annals of Surgery represent the longest follow-up of patients in whom this product was used. Lead author of the study, Michael J. Rosen, MD, professor of surgery at Case Western Reserve University, Cleveland, and his colleagues wrote: “Absorbable synthetic mesh has the prospective advantages of a reduced cost, minimal constraints in manufacturing alternative sizes (lengths, widths, and thicknesses), informed consent in certain religious or cultural groups, and ability to be iterative in generational improvements in mesh constructs based on outcome studies, compared with allogeneic or xenogenic mesh.”

©Dmitrii Kotin/Thinkstock.com
The study adds to the growing literature assessing long-term outcomes and durability of mesh for hernia repair in a contaminated and clean-contaminated operative field. The international, multisite prospective intention-to-treat analysis of 104 patients – primarily obese women in their late 50s – with a hernia defect of at least 9 cm2, investigated surgical repair using a fascial closure and Gore Bio_A Tissue Reinforcement, a mesh made of a bioabsorbable polyglycolide-trimethylene carbonate copolymer. The matrix structure of the biosynthetic material allows it to be absorbed into the body within 6 to 7 months via hydrolysis, and facilitates tissue growth and healing at the wound site.

Contaminated wounds were present in 77% of participants. About one-fourth of patients had concomitant procedures for fistula takedown; a quarter of the cohort also required the removal of infected, previously placed mesh. More than a fifth of patients required a concomitant repair of both a midline and parastomal hernia; the mean size for the hernia defects was 137 cm2, and the average width was 9 cm.

Placement of the biosynthetic mesh was left to the discretion of the surgeon, but 90% chose retrorectus placement. Primary fascial closure using a single unit of the material was successful in all patients, 68 of whom required concomitant component separation; 21 of these had an external oblique release. Another 50 of these had transversus abdominis release.

At 24 months, when 84% of patients completed follow-up, 17% were found to have a hernia recurrence. Intraperitoneal placement of the material was found to significantly increase the risk of hernia recurrence (P less than or equal to .04). Infections at the surgical site were associated with a higher risk of recurrence (P less than .01). Patient-reported physical and mental quality-of-life scores at 24 months improved significantly from baseline (P less than .05), showing sustained improvement at 6 and 12 months post procedure.

While more studies are needed, the COBRA findings suggest absorbable, biosynthetic mesh compares favorably with biologic mesh when it comes to recurrence. “The Repair of Infected and Contaminated Hernias (RICH) trial is the only long-term, multicentered, prospective trial to evaluate biologic mesh in CDC [Centers for Disease Control and Prevention] class II to IV wounds. The RICH trial reported 66% surgical site occurrence and 28% hernia recurrence after 2 years’ follow-up in patients who underwent ventral hernia repair with a non–cross-linked porcine dermis,” the investigators noted.

Cost is another area in which bioabsorbable synthetic mesh compares favorably with the biologics, not only in terms of savings from fewer recurrences but also the cost of the mesh itself. Biologic mesh can cost $10,000 or more while synthetics run about a quarter of that (Clin Colon Rectal Surg. 2014 Dec; 27[4]:140-8).

In conclusion, the investigators commented that despite the lack of a control group and random assignment in the study, the results “should not be underestimated” when considering alternatives to biologic and costlier, permanent synthetic meshes.

The study was funded by W.L. Gore. The authors had no relevant financial disclosures.

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Absorbable, biosynthetic surgical mesh used to repair ventral hernia defects may be a good alternative to biologic and permanent synthetic mesh products both in terms of long-term durability and cost, according to a longitudinal cohort study.

The results of the COBRA (Complex Open Bioabsorbable Reconstruction of the Abdominal Wall) study published in the January issue of Annals of Surgery represent the longest follow-up of patients in whom this product was used. Lead author of the study, Michael J. Rosen, MD, professor of surgery at Case Western Reserve University, Cleveland, and his colleagues wrote: “Absorbable synthetic mesh has the prospective advantages of a reduced cost, minimal constraints in manufacturing alternative sizes (lengths, widths, and thicknesses), informed consent in certain religious or cultural groups, and ability to be iterative in generational improvements in mesh constructs based on outcome studies, compared with allogeneic or xenogenic mesh.”

©Dmitrii Kotin/Thinkstock.com
The study adds to the growing literature assessing long-term outcomes and durability of mesh for hernia repair in a contaminated and clean-contaminated operative field. The international, multisite prospective intention-to-treat analysis of 104 patients – primarily obese women in their late 50s – with a hernia defect of at least 9 cm2, investigated surgical repair using a fascial closure and Gore Bio_A Tissue Reinforcement, a mesh made of a bioabsorbable polyglycolide-trimethylene carbonate copolymer. The matrix structure of the biosynthetic material allows it to be absorbed into the body within 6 to 7 months via hydrolysis, and facilitates tissue growth and healing at the wound site.

Contaminated wounds were present in 77% of participants. About one-fourth of patients had concomitant procedures for fistula takedown; a quarter of the cohort also required the removal of infected, previously placed mesh. More than a fifth of patients required a concomitant repair of both a midline and parastomal hernia; the mean size for the hernia defects was 137 cm2, and the average width was 9 cm.

Placement of the biosynthetic mesh was left to the discretion of the surgeon, but 90% chose retrorectus placement. Primary fascial closure using a single unit of the material was successful in all patients, 68 of whom required concomitant component separation; 21 of these had an external oblique release. Another 50 of these had transversus abdominis release.

At 24 months, when 84% of patients completed follow-up, 17% were found to have a hernia recurrence. Intraperitoneal placement of the material was found to significantly increase the risk of hernia recurrence (P less than or equal to .04). Infections at the surgical site were associated with a higher risk of recurrence (P less than .01). Patient-reported physical and mental quality-of-life scores at 24 months improved significantly from baseline (P less than .05), showing sustained improvement at 6 and 12 months post procedure.

While more studies are needed, the COBRA findings suggest absorbable, biosynthetic mesh compares favorably with biologic mesh when it comes to recurrence. “The Repair of Infected and Contaminated Hernias (RICH) trial is the only long-term, multicentered, prospective trial to evaluate biologic mesh in CDC [Centers for Disease Control and Prevention] class II to IV wounds. The RICH trial reported 66% surgical site occurrence and 28% hernia recurrence after 2 years’ follow-up in patients who underwent ventral hernia repair with a non–cross-linked porcine dermis,” the investigators noted.

Cost is another area in which bioabsorbable synthetic mesh compares favorably with the biologics, not only in terms of savings from fewer recurrences but also the cost of the mesh itself. Biologic mesh can cost $10,000 or more while synthetics run about a quarter of that (Clin Colon Rectal Surg. 2014 Dec; 27[4]:140-8).

In conclusion, the investigators commented that despite the lack of a control group and random assignment in the study, the results “should not be underestimated” when considering alternatives to biologic and costlier, permanent synthetic meshes.

The study was funded by W.L. Gore. The authors had no relevant financial disclosures.

 

Absorbable, biosynthetic surgical mesh used to repair ventral hernia defects may be a good alternative to biologic and permanent synthetic mesh products both in terms of long-term durability and cost, according to a longitudinal cohort study.

The results of the COBRA (Complex Open Bioabsorbable Reconstruction of the Abdominal Wall) study published in the January issue of Annals of Surgery represent the longest follow-up of patients in whom this product was used. Lead author of the study, Michael J. Rosen, MD, professor of surgery at Case Western Reserve University, Cleveland, and his colleagues wrote: “Absorbable synthetic mesh has the prospective advantages of a reduced cost, minimal constraints in manufacturing alternative sizes (lengths, widths, and thicknesses), informed consent in certain religious or cultural groups, and ability to be iterative in generational improvements in mesh constructs based on outcome studies, compared with allogeneic or xenogenic mesh.”

©Dmitrii Kotin/Thinkstock.com
The study adds to the growing literature assessing long-term outcomes and durability of mesh for hernia repair in a contaminated and clean-contaminated operative field. The international, multisite prospective intention-to-treat analysis of 104 patients – primarily obese women in their late 50s – with a hernia defect of at least 9 cm2, investigated surgical repair using a fascial closure and Gore Bio_A Tissue Reinforcement, a mesh made of a bioabsorbable polyglycolide-trimethylene carbonate copolymer. The matrix structure of the biosynthetic material allows it to be absorbed into the body within 6 to 7 months via hydrolysis, and facilitates tissue growth and healing at the wound site.

Contaminated wounds were present in 77% of participants. About one-fourth of patients had concomitant procedures for fistula takedown; a quarter of the cohort also required the removal of infected, previously placed mesh. More than a fifth of patients required a concomitant repair of both a midline and parastomal hernia; the mean size for the hernia defects was 137 cm2, and the average width was 9 cm.

Placement of the biosynthetic mesh was left to the discretion of the surgeon, but 90% chose retrorectus placement. Primary fascial closure using a single unit of the material was successful in all patients, 68 of whom required concomitant component separation; 21 of these had an external oblique release. Another 50 of these had transversus abdominis release.

At 24 months, when 84% of patients completed follow-up, 17% were found to have a hernia recurrence. Intraperitoneal placement of the material was found to significantly increase the risk of hernia recurrence (P less than or equal to .04). Infections at the surgical site were associated with a higher risk of recurrence (P less than .01). Patient-reported physical and mental quality-of-life scores at 24 months improved significantly from baseline (P less than .05), showing sustained improvement at 6 and 12 months post procedure.

While more studies are needed, the COBRA findings suggest absorbable, biosynthetic mesh compares favorably with biologic mesh when it comes to recurrence. “The Repair of Infected and Contaminated Hernias (RICH) trial is the only long-term, multicentered, prospective trial to evaluate biologic mesh in CDC [Centers for Disease Control and Prevention] class II to IV wounds. The RICH trial reported 66% surgical site occurrence and 28% hernia recurrence after 2 years’ follow-up in patients who underwent ventral hernia repair with a non–cross-linked porcine dermis,” the investigators noted.

Cost is another area in which bioabsorbable synthetic mesh compares favorably with the biologics, not only in terms of savings from fewer recurrences but also the cost of the mesh itself. Biologic mesh can cost $10,000 or more while synthetics run about a quarter of that (Clin Colon Rectal Surg. 2014 Dec; 27[4]:140-8).

In conclusion, the investigators commented that despite the lack of a control group and random assignment in the study, the results “should not be underestimated” when considering alternatives to biologic and costlier, permanent synthetic meshes.

The study was funded by W.L. Gore. The authors had no relevant financial disclosures.

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Key clinical point: Biosynthetic surgical mesh had durability and costs comparable with those for biologic mesh for hernia repair.

Major finding: At 24 months, 17% of patients were found to have a hernia recurrence.

Data source: An international, multisite, prospective, intention-to-treat cohort analysis of 104 patients with contaminated or noncontaminated hernia defects of at least 9 cm2 in size.

Disclosures: The study was funded by W.L. Gore. The authors had no relevant financial disclosures.

Interval cholecystectomy may be a risky business

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Fri, 01/18/2019 - 16:29

 

– Interval cholecystectomy remains a challenging procedure, with longer operative times and ICU stays, greater blood loss, more biliary and bowel injuries, and even hints of increased mortality, compared with immediate cholecystectomy, according to the findings from a retrospective study of 404 patients.

The staged procedure, completed after antibiotic therapy and percutaneous cholecystostomy, has been increasing in frequency over the past 10 years, but has not been rigorously studied, James Ackerman, MD, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

Dr. James Ackerman

“Looking at Medicare data over the past decade, we see a 50% increase in this procedure, which is marked by some striking regional variation,” from 5% of acute cholecystitis cases in the Northeast to less than 1% in some other regions. “This shows that as a group, we really don’t know what to do with this procedure.”

The revised Tokyo Guidelines for the management of acute cholangitis and cholecystitis aren’t hugely helpful either, noted Dr. Ackerman of the University of Pittsburgh Medical Center. While the guidelines are fairly straightforward for patients with grade 1 and grade 3 disease, “there’s a lot of gray area in grade 2.”

Treatment for these patients should include biliary drainage with antibiotics, but, he said, the recommendations for surgery, and whether it should be elective, immediate, or delayed, can be confusing for this group.

Dr. Ackerman’s retrospective analysis comprised 177 patients with acute cholecystitis who underwent an interval cholecystectomy (IC) after percutaneous cholecystostomy, and 227 controls who underwent an immediate cholecystectomy. The analysis spanned 2008-2013 and used data from seven hospitals in one health care system.

Patients who had the IC were older (70 vs. 55 years), had a worse American Society of Anesthesiologists class (3 vs. 2.5), and a worse Tokyo Grade (2 vs. 1).

Most of the IC procedures (119) were laparoscopic. There were 43 conversions to open and 15 were planned open surgeries. Among the immediate cholecystectomies, most (192) were laparoscopic. There were 28 conversions to open and six planned open surgeries.

The conversion rate was significantly higher among the IC group (28% vs.13%). The most common reasons for conversion were hostile abdomen (48% vs. 16%) and hostile right upper quadrant (34% vs. 58%).

Operating time was significantly longer in the IC group (121 vs. 90 minutes). Estimated blood loss was also significantly higher (30 vs. 15 cc). Total hospital stay was significantly longer (7 vs. 5 days), as was ICU stay (1 vs. 0.1 day).

There were no biliary tract injuries in the cholecystectomy group, while 5.7% of IC patients sustained such an injury. Bowel injuries, most often serosal, were also more common in the IC group (6% vs. 0.4%). The IC group had more surgical site infections as well (12% vs. 0.44%).

There was no significant difference in 30-day mortality, but at 1 year, IC patients were significantly more likely to have died (15% vs. 0.44%).

The ongoing CHOCOLATE trial (Acute cholecystitis in high risk surgical patients: percutaneous cholecystostomy versus laparoscopic cholecystectomy) may help clarify the issue further, Dr. Ackerman said. The study being conducted in the Netherlands is randomizing high-risk cholecystitis patients to either laparoscopic cholecystectomy or percutaneous drainage.

Dr. Ackerman had no financial disclosures.

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– Interval cholecystectomy remains a challenging procedure, with longer operative times and ICU stays, greater blood loss, more biliary and bowel injuries, and even hints of increased mortality, compared with immediate cholecystectomy, according to the findings from a retrospective study of 404 patients.

The staged procedure, completed after antibiotic therapy and percutaneous cholecystostomy, has been increasing in frequency over the past 10 years, but has not been rigorously studied, James Ackerman, MD, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

Dr. James Ackerman

“Looking at Medicare data over the past decade, we see a 50% increase in this procedure, which is marked by some striking regional variation,” from 5% of acute cholecystitis cases in the Northeast to less than 1% in some other regions. “This shows that as a group, we really don’t know what to do with this procedure.”

The revised Tokyo Guidelines for the management of acute cholangitis and cholecystitis aren’t hugely helpful either, noted Dr. Ackerman of the University of Pittsburgh Medical Center. While the guidelines are fairly straightforward for patients with grade 1 and grade 3 disease, “there’s a lot of gray area in grade 2.”

Treatment for these patients should include biliary drainage with antibiotics, but, he said, the recommendations for surgery, and whether it should be elective, immediate, or delayed, can be confusing for this group.

Dr. Ackerman’s retrospective analysis comprised 177 patients with acute cholecystitis who underwent an interval cholecystectomy (IC) after percutaneous cholecystostomy, and 227 controls who underwent an immediate cholecystectomy. The analysis spanned 2008-2013 and used data from seven hospitals in one health care system.

Patients who had the IC were older (70 vs. 55 years), had a worse American Society of Anesthesiologists class (3 vs. 2.5), and a worse Tokyo Grade (2 vs. 1).

Most of the IC procedures (119) were laparoscopic. There were 43 conversions to open and 15 were planned open surgeries. Among the immediate cholecystectomies, most (192) were laparoscopic. There were 28 conversions to open and six planned open surgeries.

The conversion rate was significantly higher among the IC group (28% vs.13%). The most common reasons for conversion were hostile abdomen (48% vs. 16%) and hostile right upper quadrant (34% vs. 58%).

Operating time was significantly longer in the IC group (121 vs. 90 minutes). Estimated blood loss was also significantly higher (30 vs. 15 cc). Total hospital stay was significantly longer (7 vs. 5 days), as was ICU stay (1 vs. 0.1 day).

There were no biliary tract injuries in the cholecystectomy group, while 5.7% of IC patients sustained such an injury. Bowel injuries, most often serosal, were also more common in the IC group (6% vs. 0.4%). The IC group had more surgical site infections as well (12% vs. 0.44%).

There was no significant difference in 30-day mortality, but at 1 year, IC patients were significantly more likely to have died (15% vs. 0.44%).

The ongoing CHOCOLATE trial (Acute cholecystitis in high risk surgical patients: percutaneous cholecystostomy versus laparoscopic cholecystectomy) may help clarify the issue further, Dr. Ackerman said. The study being conducted in the Netherlands is randomizing high-risk cholecystitis patients to either laparoscopic cholecystectomy or percutaneous drainage.

Dr. Ackerman had no financial disclosures.

 

– Interval cholecystectomy remains a challenging procedure, with longer operative times and ICU stays, greater blood loss, more biliary and bowel injuries, and even hints of increased mortality, compared with immediate cholecystectomy, according to the findings from a retrospective study of 404 patients.

The staged procedure, completed after antibiotic therapy and percutaneous cholecystostomy, has been increasing in frequency over the past 10 years, but has not been rigorously studied, James Ackerman, MD, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

Dr. James Ackerman

“Looking at Medicare data over the past decade, we see a 50% increase in this procedure, which is marked by some striking regional variation,” from 5% of acute cholecystitis cases in the Northeast to less than 1% in some other regions. “This shows that as a group, we really don’t know what to do with this procedure.”

The revised Tokyo Guidelines for the management of acute cholangitis and cholecystitis aren’t hugely helpful either, noted Dr. Ackerman of the University of Pittsburgh Medical Center. While the guidelines are fairly straightforward for patients with grade 1 and grade 3 disease, “there’s a lot of gray area in grade 2.”

Treatment for these patients should include biliary drainage with antibiotics, but, he said, the recommendations for surgery, and whether it should be elective, immediate, or delayed, can be confusing for this group.

Dr. Ackerman’s retrospective analysis comprised 177 patients with acute cholecystitis who underwent an interval cholecystectomy (IC) after percutaneous cholecystostomy, and 227 controls who underwent an immediate cholecystectomy. The analysis spanned 2008-2013 and used data from seven hospitals in one health care system.

Patients who had the IC were older (70 vs. 55 years), had a worse American Society of Anesthesiologists class (3 vs. 2.5), and a worse Tokyo Grade (2 vs. 1).

Most of the IC procedures (119) were laparoscopic. There were 43 conversions to open and 15 were planned open surgeries. Among the immediate cholecystectomies, most (192) were laparoscopic. There were 28 conversions to open and six planned open surgeries.

The conversion rate was significantly higher among the IC group (28% vs.13%). The most common reasons for conversion were hostile abdomen (48% vs. 16%) and hostile right upper quadrant (34% vs. 58%).

Operating time was significantly longer in the IC group (121 vs. 90 minutes). Estimated blood loss was also significantly higher (30 vs. 15 cc). Total hospital stay was significantly longer (7 vs. 5 days), as was ICU stay (1 vs. 0.1 day).

There were no biliary tract injuries in the cholecystectomy group, while 5.7% of IC patients sustained such an injury. Bowel injuries, most often serosal, were also more common in the IC group (6% vs. 0.4%). The IC group had more surgical site infections as well (12% vs. 0.44%).

There was no significant difference in 30-day mortality, but at 1 year, IC patients were significantly more likely to have died (15% vs. 0.44%).

The ongoing CHOCOLATE trial (Acute cholecystitis in high risk surgical patients: percutaneous cholecystostomy versus laparoscopic cholecystectomy) may help clarify the issue further, Dr. Ackerman said. The study being conducted in the Netherlands is randomizing high-risk cholecystitis patients to either laparoscopic cholecystectomy or percutaneous drainage.

Dr. Ackerman had no financial disclosures.

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Key clinical point: Cholecystectomy after percutaneous cholecystostomy was riskier than was immediate surgery.

Major finding: Interval cholecystectomy was associated with greater blood loss, more conversions to open surgery, bowel and biliary injuries, and even higher 1-year mortality (15% vs. 0.44%).

Data source: A retrospective review comparing 177 patients with interval surgery to 227 who had immediate surgery.

Disclosures: Dr. Ackerman had no financial disclosures.

Gastrografin IDs, treats suspected small bowel obstruction

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Fri, 01/18/2019 - 16:28

 

– The radiopaque contrast agent Gastrografin accurately diagnosed the majority of small bowel obstructions, allowing surgeons to identify which patients needed emergent surgery and which could be managed conservatively.

 

When instilled via nasogastric tube, the diatrizoate solution had a 92% positive predictive value for adhesive small bowel obstruction, Martin D. Zielinski, MD, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

Dr. Martin Zielinski
Dr. Martin Zielinski
The agent also exerted a therapeutic effect, Dr. Zielinski noted. Because of its high osmolarity, Gastrogarafin (Bracco Diagnostics) draws water from the bowel wall into the lumen, both decreasing mesenteric edema and promoting movement through the bowel stricture.

Dr. Zielinski of the Mayo Clinic, Rochester, Minn., examined the diagnostic accuracy of the Gastrografin challenge, a small bowel obstruction diagnosis and treatment protocol he developed at the center. The challenge begins with 2 hours of nasogastric suctioning. Patients then receive 100 mL Gastrografin mixed with 50 mL water via the nasogastric tube. The tube is clamped for 8 hours, and then patients have an abdominal x-ray. If the contrast material appears in the colon, or if the patient has a bowel movement in the interim, then the challenge is passed, the tube can be removed, and diet advanced.

If there is no contrast in the colon, or if the patient has no bowel movement, then the surgeon assumes the obstruction remains, and exploratory surgery proceeds.

Dr. Zielinski’s study comprised 316 patients with a suspected adhesive small bowel obstruction. Of these, 173 were managed with the Gastrografin challenge; they were compared to 143 patients who were managed without the contrast agent.

Patients were a mean of 58 years. There were no significant differences in the rate of prior abdominal operations; duration of obstipation; or small bowel feces sign.

The comparator group was managed by a clinical algorithm in which any patient with initial signs of ischemia underwent exploratory surgery, and those without signs of ischemia were managed symptomatically. Patients in the Gastrografin arm who passed the trial were similarly managed, while those who failed it underwent exploratory surgery.

Among those who had the challenge, 130 (75%) passed. Gastrografin had a high diagnostic accuracy for small bowel obstruction, with 87% sensitivity, 71% specificity; and 92% positive predictive value. The negative predictive value was not as good, at 59%.

The Gastrografin protocol was associated with significantly fewer exploratory surgeries (21% vs. 44%), and significantly fewer small bowel resections (7% vs. 21%). That advantage was maintained even among patients in both groups who underwent exploratory surgery, with an ultimate resection rate of 34% vs. 49%. The length of stay was also significantly less in the Gastrografin group, 4 vs. 5 days).

There was no difference in the overall complication rate (12.5% vs. 18%). Complications included acute kidney injury (6% vs. 9%); pneumonia (4% vs. 5%), organ space infection (1% vs. 4%), surgical site infection (3.5% vs. 5%), and anastomotic leak (2% each group).

The rate of missed small bowel strangulation was significantly lower among the Gastrografin group as well (0.6% vs. 7.7%). There were no cases of Gastrografin pneumonitis.

Dr. Zielinski had no financial disclosures.

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– The radiopaque contrast agent Gastrografin accurately diagnosed the majority of small bowel obstructions, allowing surgeons to identify which patients needed emergent surgery and which could be managed conservatively.

 

When instilled via nasogastric tube, the diatrizoate solution had a 92% positive predictive value for adhesive small bowel obstruction, Martin D. Zielinski, MD, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

Dr. Martin Zielinski
Dr. Martin Zielinski
The agent also exerted a therapeutic effect, Dr. Zielinski noted. Because of its high osmolarity, Gastrogarafin (Bracco Diagnostics) draws water from the bowel wall into the lumen, both decreasing mesenteric edema and promoting movement through the bowel stricture.

Dr. Zielinski of the Mayo Clinic, Rochester, Minn., examined the diagnostic accuracy of the Gastrografin challenge, a small bowel obstruction diagnosis and treatment protocol he developed at the center. The challenge begins with 2 hours of nasogastric suctioning. Patients then receive 100 mL Gastrografin mixed with 50 mL water via the nasogastric tube. The tube is clamped for 8 hours, and then patients have an abdominal x-ray. If the contrast material appears in the colon, or if the patient has a bowel movement in the interim, then the challenge is passed, the tube can be removed, and diet advanced.

If there is no contrast in the colon, or if the patient has no bowel movement, then the surgeon assumes the obstruction remains, and exploratory surgery proceeds.

Dr. Zielinski’s study comprised 316 patients with a suspected adhesive small bowel obstruction. Of these, 173 were managed with the Gastrografin challenge; they were compared to 143 patients who were managed without the contrast agent.

Patients were a mean of 58 years. There were no significant differences in the rate of prior abdominal operations; duration of obstipation; or small bowel feces sign.

The comparator group was managed by a clinical algorithm in which any patient with initial signs of ischemia underwent exploratory surgery, and those without signs of ischemia were managed symptomatically. Patients in the Gastrografin arm who passed the trial were similarly managed, while those who failed it underwent exploratory surgery.

Among those who had the challenge, 130 (75%) passed. Gastrografin had a high diagnostic accuracy for small bowel obstruction, with 87% sensitivity, 71% specificity; and 92% positive predictive value. The negative predictive value was not as good, at 59%.

The Gastrografin protocol was associated with significantly fewer exploratory surgeries (21% vs. 44%), and significantly fewer small bowel resections (7% vs. 21%). That advantage was maintained even among patients in both groups who underwent exploratory surgery, with an ultimate resection rate of 34% vs. 49%. The length of stay was also significantly less in the Gastrografin group, 4 vs. 5 days).

There was no difference in the overall complication rate (12.5% vs. 18%). Complications included acute kidney injury (6% vs. 9%); pneumonia (4% vs. 5%), organ space infection (1% vs. 4%), surgical site infection (3.5% vs. 5%), and anastomotic leak (2% each group).

The rate of missed small bowel strangulation was significantly lower among the Gastrografin group as well (0.6% vs. 7.7%). There were no cases of Gastrografin pneumonitis.

Dr. Zielinski had no financial disclosures.

 

– The radiopaque contrast agent Gastrografin accurately diagnosed the majority of small bowel obstructions, allowing surgeons to identify which patients needed emergent surgery and which could be managed conservatively.

 

When instilled via nasogastric tube, the diatrizoate solution had a 92% positive predictive value for adhesive small bowel obstruction, Martin D. Zielinski, MD, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

Dr. Martin Zielinski
Dr. Martin Zielinski
The agent also exerted a therapeutic effect, Dr. Zielinski noted. Because of its high osmolarity, Gastrogarafin (Bracco Diagnostics) draws water from the bowel wall into the lumen, both decreasing mesenteric edema and promoting movement through the bowel stricture.

Dr. Zielinski of the Mayo Clinic, Rochester, Minn., examined the diagnostic accuracy of the Gastrografin challenge, a small bowel obstruction diagnosis and treatment protocol he developed at the center. The challenge begins with 2 hours of nasogastric suctioning. Patients then receive 100 mL Gastrografin mixed with 50 mL water via the nasogastric tube. The tube is clamped for 8 hours, and then patients have an abdominal x-ray. If the contrast material appears in the colon, or if the patient has a bowel movement in the interim, then the challenge is passed, the tube can be removed, and diet advanced.

If there is no contrast in the colon, or if the patient has no bowel movement, then the surgeon assumes the obstruction remains, and exploratory surgery proceeds.

Dr. Zielinski’s study comprised 316 patients with a suspected adhesive small bowel obstruction. Of these, 173 were managed with the Gastrografin challenge; they were compared to 143 patients who were managed without the contrast agent.

Patients were a mean of 58 years. There were no significant differences in the rate of prior abdominal operations; duration of obstipation; or small bowel feces sign.

The comparator group was managed by a clinical algorithm in which any patient with initial signs of ischemia underwent exploratory surgery, and those without signs of ischemia were managed symptomatically. Patients in the Gastrografin arm who passed the trial were similarly managed, while those who failed it underwent exploratory surgery.

Among those who had the challenge, 130 (75%) passed. Gastrografin had a high diagnostic accuracy for small bowel obstruction, with 87% sensitivity, 71% specificity; and 92% positive predictive value. The negative predictive value was not as good, at 59%.

The Gastrografin protocol was associated with significantly fewer exploratory surgeries (21% vs. 44%), and significantly fewer small bowel resections (7% vs. 21%). That advantage was maintained even among patients in both groups who underwent exploratory surgery, with an ultimate resection rate of 34% vs. 49%. The length of stay was also significantly less in the Gastrografin group, 4 vs. 5 days).

There was no difference in the overall complication rate (12.5% vs. 18%). Complications included acute kidney injury (6% vs. 9%); pneumonia (4% vs. 5%), organ space infection (1% vs. 4%), surgical site infection (3.5% vs. 5%), and anastomotic leak (2% each group).

The rate of missed small bowel strangulation was significantly lower among the Gastrografin group as well (0.6% vs. 7.7%). There were no cases of Gastrografin pneumonitis.

Dr. Zielinski had no financial disclosures.

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Key clinical point: The bowel-imaging agent Gastrografin can both diagnose and treat small bowel obstruction.

Major finding: The agent had a 92% positive predictive value; it was associated with fewer bowel resections (7% vs. 21%) and a day shorter length of stay, compared with those who didn’t receive it.

Data source: The prospective study comprised 316 patients, 173 of whom underwent the Gastrografin challenge.

Disclosures: Dr. Zielinski had no financial disclosures.

Scleroligation procedure proposed for gastroesophageal varices

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In the treatment of gastroesophageal varices, scleroligation – a hybrid procedure that combines sclerotherapy and band ligation – performed as well as did band ligation, but required fewer sessions and had a shorter overall treatment duration. Sclerotherapy involves the injection of sclerosant to prompt occlusion of the varices, while ligation involves banding the varices to cut off blood flow.

 
Dr. Paul Y. Kwo
“It’s an interesting approach to a problem that gastroenterologists encounter,” said Paul Y. Kwo, MD, professor of medicine at Stanford (Calif.) University, who was not involved in the study.

He noted that in the United States, band ligation is the standard of therapy, and the new study won’t change that. “These preliminary results from a single center are quite promising, and if they can be confirmed in a larger, multicenter trial, then this is something that can be added to our therapeutic armamentarium,” said Dr. Kwo.

Band ligation replaced sclerotherapy as the preferred treatment for gastroesophageal varices because it has equal efficacy but fewer severe side effects. However, it also suffers from a higher rate of recurrence because the bands cannot destroy deeper varices and perforating veins.

The combination technique, scleroligation, has been demonstrated in the treatment of esophageal varices, which prompted the authors’ investigation into gastroesophageal varices.

At a single center, the researchers recruited 120 patients with cirrhosis and acute gastroesophageal variceal bleeding above the gastroesophageal junction. They were randomized 1:1 to undergo endoscopic band ligation (EBL) or scleroligation (SL).

On average, 15.6 weeks were required to obliterate the varices in the EBL group versus 8.64 weeks in the SL group (P less than .001). The EBL group required an average of 3.43 sessions to reach that endpoint, compared with 2.22 sessions in the SL group (P less than .001). The EBL group required an average of 13.72 bands per patient, compared with 8.88 bands in the SL group (P less than .001). The EBL group also had a higher average number of units of blood transfused (2.30 vs 1.53; P less than .001).

No patients in either group experienced perforation, chest empyema, pericardial effusion, or strictures.

The good safety outcomes may be related to the small volume of sclerosant used, just 2 mL. “It’s probably because of their meticulous approach that they were able to reduce the complications that we have historically seen with sclerotherapy alone,” said Dr. Kwo.

There was no difference in the number of rebleeds or recurrences at follow-up, total cost, mortality due to rebleeding, or 12-month survival.

No funding source was disclosed. The authors reported no financial disclosures.

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In the treatment of gastroesophageal varices, scleroligation – a hybrid procedure that combines sclerotherapy and band ligation – performed as well as did band ligation, but required fewer sessions and had a shorter overall treatment duration. Sclerotherapy involves the injection of sclerosant to prompt occlusion of the varices, while ligation involves banding the varices to cut off blood flow.

 
Dr. Paul Y. Kwo
“It’s an interesting approach to a problem that gastroenterologists encounter,” said Paul Y. Kwo, MD, professor of medicine at Stanford (Calif.) University, who was not involved in the study.

He noted that in the United States, band ligation is the standard of therapy, and the new study won’t change that. “These preliminary results from a single center are quite promising, and if they can be confirmed in a larger, multicenter trial, then this is something that can be added to our therapeutic armamentarium,” said Dr. Kwo.

Band ligation replaced sclerotherapy as the preferred treatment for gastroesophageal varices because it has equal efficacy but fewer severe side effects. However, it also suffers from a higher rate of recurrence because the bands cannot destroy deeper varices and perforating veins.

The combination technique, scleroligation, has been demonstrated in the treatment of esophageal varices, which prompted the authors’ investigation into gastroesophageal varices.

At a single center, the researchers recruited 120 patients with cirrhosis and acute gastroesophageal variceal bleeding above the gastroesophageal junction. They were randomized 1:1 to undergo endoscopic band ligation (EBL) or scleroligation (SL).

On average, 15.6 weeks were required to obliterate the varices in the EBL group versus 8.64 weeks in the SL group (P less than .001). The EBL group required an average of 3.43 sessions to reach that endpoint, compared with 2.22 sessions in the SL group (P less than .001). The EBL group required an average of 13.72 bands per patient, compared with 8.88 bands in the SL group (P less than .001). The EBL group also had a higher average number of units of blood transfused (2.30 vs 1.53; P less than .001).

No patients in either group experienced perforation, chest empyema, pericardial effusion, or strictures.

The good safety outcomes may be related to the small volume of sclerosant used, just 2 mL. “It’s probably because of their meticulous approach that they were able to reduce the complications that we have historically seen with sclerotherapy alone,” said Dr. Kwo.

There was no difference in the number of rebleeds or recurrences at follow-up, total cost, mortality due to rebleeding, or 12-month survival.

No funding source was disclosed. The authors reported no financial disclosures.

In the treatment of gastroesophageal varices, scleroligation – a hybrid procedure that combines sclerotherapy and band ligation – performed as well as did band ligation, but required fewer sessions and had a shorter overall treatment duration. Sclerotherapy involves the injection of sclerosant to prompt occlusion of the varices, while ligation involves banding the varices to cut off blood flow.

 
Dr. Paul Y. Kwo
“It’s an interesting approach to a problem that gastroenterologists encounter,” said Paul Y. Kwo, MD, professor of medicine at Stanford (Calif.) University, who was not involved in the study.

He noted that in the United States, band ligation is the standard of therapy, and the new study won’t change that. “These preliminary results from a single center are quite promising, and if they can be confirmed in a larger, multicenter trial, then this is something that can be added to our therapeutic armamentarium,” said Dr. Kwo.

Band ligation replaced sclerotherapy as the preferred treatment for gastroesophageal varices because it has equal efficacy but fewer severe side effects. However, it also suffers from a higher rate of recurrence because the bands cannot destroy deeper varices and perforating veins.

The combination technique, scleroligation, has been demonstrated in the treatment of esophageal varices, which prompted the authors’ investigation into gastroesophageal varices.

At a single center, the researchers recruited 120 patients with cirrhosis and acute gastroesophageal variceal bleeding above the gastroesophageal junction. They were randomized 1:1 to undergo endoscopic band ligation (EBL) or scleroligation (SL).

On average, 15.6 weeks were required to obliterate the varices in the EBL group versus 8.64 weeks in the SL group (P less than .001). The EBL group required an average of 3.43 sessions to reach that endpoint, compared with 2.22 sessions in the SL group (P less than .001). The EBL group required an average of 13.72 bands per patient, compared with 8.88 bands in the SL group (P less than .001). The EBL group also had a higher average number of units of blood transfused (2.30 vs 1.53; P less than .001).

No patients in either group experienced perforation, chest empyema, pericardial effusion, or strictures.

The good safety outcomes may be related to the small volume of sclerosant used, just 2 mL. “It’s probably because of their meticulous approach that they were able to reduce the complications that we have historically seen with sclerotherapy alone,” said Dr. Kwo.

There was no difference in the number of rebleeds or recurrences at follow-up, total cost, mortality due to rebleeding, or 12-month survival.

No funding source was disclosed. The authors reported no financial disclosures.

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Key clinical point: Scleroligation equaled band ligation in efficacy, but required fewer sessions.

Major finding: Scleroligation required 2.22 sessions on average, compared with 3.43 for endoscopic band ligation.

Data source: Single-center randomized trial of 120 patients.

Disclosures: No funding source was disclosed. The authors reported no financial disclosures.

‘Negative’ appendectomy = longer LOS, higher morbidity

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Among adults, “negative” appendectomy, or appendectomy in which the surgeon discovers there is no appendicitis, is associated with a prolonged hospital stay, greater morbidity, and higher costs than is curative nonperforated appendectomy, according to a report in the American Journal of Surgery.

“Many argue that negative appendectomy is justified to decrease the risk of perforated appendicitis, as it has been accepted that an inverse relationship exists between the rates of negative appendectomy and perforated appendicitis. However, with the increasing prevalence of preoperative imaging, the rate of negative appendectomy has been decreasing, whereas the rate of perforated appendicitis has remained largely the same,” said Kyle Mock, MD, of the department of surgery, Harbor-University of California Los Angeles Medical Center, and his associates (Am J Surg. 2016;212[6]:1076-82). The study found that the prevalence of negative appendectomy decreased from 4.5% to 2.8% in California from 2005 to 2011, while the prevalence of perforated appendicitis decreased from 23.1% to 21.7%

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In addition, negative appendectomy “was also justified as it is believed to be associated with minimal morbidity and cost. However, the clinical and economic burden associated with negative appendectomy has not been recently studied,” the researchers noted.

To examine this issue, Dr. Mock and his associates analyzed information from a statewide California inpatient database, focusing on 180,958 adult appendectomy admissions during a 6-year period. Compared with nonperforated appendectomy, negative appendectomy required an additional 0.8 days in length of stay, was associated with greater morbidity, and cost approximately $1,063 more per patient. Rates of negative appendectomy also did not correlate with rates of appendiceal perforation, so negative appendectomy cannot be said to prevent what otherwise would have been a ruptured appendix.

“Consequently, negative appendectomy should no longer be thought of as a benign procedure,” the investigators said.

It is important to note that patients who undergo negative appendectomy likely have other disease processes underlying their signs and symptoms, and they likely require longer hospitalization and incur greater morbidity and costs to identify and treat these alternative disorders. In contrast, patients who undergo routine appendectomy usually are discharged home the same day, Dr. Mock and his associates added.

This researchers had no financial relationships or sources of support in the form of grants, equipment, or drugs. Dr. Mock and his associates reported having no relevant conflicts of interest.

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Among adults, “negative” appendectomy, or appendectomy in which the surgeon discovers there is no appendicitis, is associated with a prolonged hospital stay, greater morbidity, and higher costs than is curative nonperforated appendectomy, according to a report in the American Journal of Surgery.

“Many argue that negative appendectomy is justified to decrease the risk of perforated appendicitis, as it has been accepted that an inverse relationship exists between the rates of negative appendectomy and perforated appendicitis. However, with the increasing prevalence of preoperative imaging, the rate of negative appendectomy has been decreasing, whereas the rate of perforated appendicitis has remained largely the same,” said Kyle Mock, MD, of the department of surgery, Harbor-University of California Los Angeles Medical Center, and his associates (Am J Surg. 2016;212[6]:1076-82). The study found that the prevalence of negative appendectomy decreased from 4.5% to 2.8% in California from 2005 to 2011, while the prevalence of perforated appendicitis decreased from 23.1% to 21.7%

copyright decade3d/Thinkstock
In addition, negative appendectomy “was also justified as it is believed to be associated with minimal morbidity and cost. However, the clinical and economic burden associated with negative appendectomy has not been recently studied,” the researchers noted.

To examine this issue, Dr. Mock and his associates analyzed information from a statewide California inpatient database, focusing on 180,958 adult appendectomy admissions during a 6-year period. Compared with nonperforated appendectomy, negative appendectomy required an additional 0.8 days in length of stay, was associated with greater morbidity, and cost approximately $1,063 more per patient. Rates of negative appendectomy also did not correlate with rates of appendiceal perforation, so negative appendectomy cannot be said to prevent what otherwise would have been a ruptured appendix.

“Consequently, negative appendectomy should no longer be thought of as a benign procedure,” the investigators said.

It is important to note that patients who undergo negative appendectomy likely have other disease processes underlying their signs and symptoms, and they likely require longer hospitalization and incur greater morbidity and costs to identify and treat these alternative disorders. In contrast, patients who undergo routine appendectomy usually are discharged home the same day, Dr. Mock and his associates added.

This researchers had no financial relationships or sources of support in the form of grants, equipment, or drugs. Dr. Mock and his associates reported having no relevant conflicts of interest.

 

Among adults, “negative” appendectomy, or appendectomy in which the surgeon discovers there is no appendicitis, is associated with a prolonged hospital stay, greater morbidity, and higher costs than is curative nonperforated appendectomy, according to a report in the American Journal of Surgery.

“Many argue that negative appendectomy is justified to decrease the risk of perforated appendicitis, as it has been accepted that an inverse relationship exists between the rates of negative appendectomy and perforated appendicitis. However, with the increasing prevalence of preoperative imaging, the rate of negative appendectomy has been decreasing, whereas the rate of perforated appendicitis has remained largely the same,” said Kyle Mock, MD, of the department of surgery, Harbor-University of California Los Angeles Medical Center, and his associates (Am J Surg. 2016;212[6]:1076-82). The study found that the prevalence of negative appendectomy decreased from 4.5% to 2.8% in California from 2005 to 2011, while the prevalence of perforated appendicitis decreased from 23.1% to 21.7%

copyright decade3d/Thinkstock
In addition, negative appendectomy “was also justified as it is believed to be associated with minimal morbidity and cost. However, the clinical and economic burden associated with negative appendectomy has not been recently studied,” the researchers noted.

To examine this issue, Dr. Mock and his associates analyzed information from a statewide California inpatient database, focusing on 180,958 adult appendectomy admissions during a 6-year period. Compared with nonperforated appendectomy, negative appendectomy required an additional 0.8 days in length of stay, was associated with greater morbidity, and cost approximately $1,063 more per patient. Rates of negative appendectomy also did not correlate with rates of appendiceal perforation, so negative appendectomy cannot be said to prevent what otherwise would have been a ruptured appendix.

“Consequently, negative appendectomy should no longer be thought of as a benign procedure,” the investigators said.

It is important to note that patients who undergo negative appendectomy likely have other disease processes underlying their signs and symptoms, and they likely require longer hospitalization and incur greater morbidity and costs to identify and treat these alternative disorders. In contrast, patients who undergo routine appendectomy usually are discharged home the same day, Dr. Mock and his associates added.

This researchers had no financial relationships or sources of support in the form of grants, equipment, or drugs. Dr. Mock and his associates reported having no relevant conflicts of interest.

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Key clinical point: In adults, “negative” appendectomy – appendectomy in which the surgeon discovers there is no appendicitis – is associated with longer length of stay, higher morbidity, and higher costs than curative appendectomy.

Major finding: Compared with nonperforated appendectomy, negative appendectomy required an additional 0.8 days in length of stay, was associated with greater morbidity, and cost approximately $1,063 more per patient.

Data source: An analysis of information regarding 180,958 appendectomies performed during a 6-year period and detailed in a state (California) inpatient database.

Disclosures: The researchers had no financial relationships or sources of support in the form of grants, equipment, or drugs. Dr. Mock and his associates reported having no relevant conflicts of interest.

Do fellowship programs help prepare general surgery residents for board exams?

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Thu, 03/28/2019 - 14:59

WASHINGTON – Pass rates on the general surgery board exams were significantly higher for programs in which residents trained alongside surgical fellows, according to a retrospective study presented at the annual clinical congress of the American College of Surgeons.

The study adds another perspective to the ongoing debate about the impact of fellowships on general surgery residency and residency programs. Mohammed J. Al Fayyadh, MD, of the University of Texas Health Science Center at San Antonio and his associates investigated the impact of fellowships on program pass rates for general surgery boards. They reviewed American Board of Surgery exam data for the classes of 2010-2014, which included 242 programs (a total of 5,191 resident examinees), of which 148 had fellows participating (3,767 resident examinees).

Dr. Mohammed Al Fayyadh
The investigators focused on comparing pass rates between general surgery residents who trained with and without fellows in the program. The investigators also looked at the relationship between pass rates and the program fellow to general surgery resident (Fel:Res) ratio.

The findings suggest that having fellows in a program has a positive impact on the pass rates of those taking the ABS general surgery exam. Pass rates were significantly higher for general surgery programs with fellows. This trend held for all measures studied: Qualifying (written) exam (88% vs. 86%), certifying (oral) exam (83% vs. 80%), and combined exams (74% vs. 69%). Differences between the groups were statistically significant.

The pass rates tended to be higher in programs with higher Fel:Res ratios. For example, programs with a 1.5:1 Fel:Res ratio had the highest pass rates for the qualifying, certifying, and combined exams.

The impact of subspecialty fellowships on general surgery residencies has been the subject of research and debate in recent years. Some studies have suggested that subspecialty training for fellows has meant that general surgery residents have less opportunity to operate in areas such as trauma (“Trauma operative training declining for general surgery residents,” ACS Surgery News, Oct. 4, 2016) and vascular surgery (Ann Vasc Surg. 2016;33;98-102).

Taken in this context, it is possible that the programs with more fellows simply recruit more competitive residents who tend to do better on exams. However, this could also reflect more resources in fellowship programs that are available to all trainees or better mentorship opportunities, said Dr. Al Fayyadh. He concluded that more research is needed to tease out the impact of fellowship programs on general surgery resident education.

Dr. Al Fayyadh had no disclosures.

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WASHINGTON – Pass rates on the general surgery board exams were significantly higher for programs in which residents trained alongside surgical fellows, according to a retrospective study presented at the annual clinical congress of the American College of Surgeons.

The study adds another perspective to the ongoing debate about the impact of fellowships on general surgery residency and residency programs. Mohammed J. Al Fayyadh, MD, of the University of Texas Health Science Center at San Antonio and his associates investigated the impact of fellowships on program pass rates for general surgery boards. They reviewed American Board of Surgery exam data for the classes of 2010-2014, which included 242 programs (a total of 5,191 resident examinees), of which 148 had fellows participating (3,767 resident examinees).

Dr. Mohammed Al Fayyadh
The investigators focused on comparing pass rates between general surgery residents who trained with and without fellows in the program. The investigators also looked at the relationship between pass rates and the program fellow to general surgery resident (Fel:Res) ratio.

The findings suggest that having fellows in a program has a positive impact on the pass rates of those taking the ABS general surgery exam. Pass rates were significantly higher for general surgery programs with fellows. This trend held for all measures studied: Qualifying (written) exam (88% vs. 86%), certifying (oral) exam (83% vs. 80%), and combined exams (74% vs. 69%). Differences between the groups were statistically significant.

The pass rates tended to be higher in programs with higher Fel:Res ratios. For example, programs with a 1.5:1 Fel:Res ratio had the highest pass rates for the qualifying, certifying, and combined exams.

The impact of subspecialty fellowships on general surgery residencies has been the subject of research and debate in recent years. Some studies have suggested that subspecialty training for fellows has meant that general surgery residents have less opportunity to operate in areas such as trauma (“Trauma operative training declining for general surgery residents,” ACS Surgery News, Oct. 4, 2016) and vascular surgery (Ann Vasc Surg. 2016;33;98-102).

Taken in this context, it is possible that the programs with more fellows simply recruit more competitive residents who tend to do better on exams. However, this could also reflect more resources in fellowship programs that are available to all trainees or better mentorship opportunities, said Dr. Al Fayyadh. He concluded that more research is needed to tease out the impact of fellowship programs on general surgery resident education.

Dr. Al Fayyadh had no disclosures.

WASHINGTON – Pass rates on the general surgery board exams were significantly higher for programs in which residents trained alongside surgical fellows, according to a retrospective study presented at the annual clinical congress of the American College of Surgeons.

The study adds another perspective to the ongoing debate about the impact of fellowships on general surgery residency and residency programs. Mohammed J. Al Fayyadh, MD, of the University of Texas Health Science Center at San Antonio and his associates investigated the impact of fellowships on program pass rates for general surgery boards. They reviewed American Board of Surgery exam data for the classes of 2010-2014, which included 242 programs (a total of 5,191 resident examinees), of which 148 had fellows participating (3,767 resident examinees).

Dr. Mohammed Al Fayyadh
The investigators focused on comparing pass rates between general surgery residents who trained with and without fellows in the program. The investigators also looked at the relationship between pass rates and the program fellow to general surgery resident (Fel:Res) ratio.

The findings suggest that having fellows in a program has a positive impact on the pass rates of those taking the ABS general surgery exam. Pass rates were significantly higher for general surgery programs with fellows. This trend held for all measures studied: Qualifying (written) exam (88% vs. 86%), certifying (oral) exam (83% vs. 80%), and combined exams (74% vs. 69%). Differences between the groups were statistically significant.

The pass rates tended to be higher in programs with higher Fel:Res ratios. For example, programs with a 1.5:1 Fel:Res ratio had the highest pass rates for the qualifying, certifying, and combined exams.

The impact of subspecialty fellowships on general surgery residencies has been the subject of research and debate in recent years. Some studies have suggested that subspecialty training for fellows has meant that general surgery residents have less opportunity to operate in areas such as trauma (“Trauma operative training declining for general surgery residents,” ACS Surgery News, Oct. 4, 2016) and vascular surgery (Ann Vasc Surg. 2016;33;98-102).

Taken in this context, it is possible that the programs with more fellows simply recruit more competitive residents who tend to do better on exams. However, this could also reflect more resources in fellowship programs that are available to all trainees or better mentorship opportunities, said Dr. Al Fayyadh. He concluded that more research is needed to tease out the impact of fellowship programs on general surgery resident education.

Dr. Al Fayyadh had no disclosures.

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Study shows NJ tube and PEG-J on par for enteral nutrition, but each has complications

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CORONADO, CALIF. – Percutaneous gastrostomy with jejunal extension (PEG-J) is an appealing and effective method for delivery of enteral nutrition in necrotizing pancreatitis patients, without the mechanical issues and discomfort associated with nasojejunal (NJ) tube, results from a single-center retrospective study showed.

“The advantages of PEG-J route for enteral nutrition in necrotizing pancreatitis patients must be weighed carefully against the potentially severe complication profile,” study author Alexandra M. Roch, MD, said at the annual meeting of the Western Surgical Association.

Dr. Alexandra M. Roch

Historically, the preferred way to manage patients with necrotizing pancreatitis was via parenteral nutrition with a lack of pancreatic stimulation, said Dr. Roch, of the department of surgery at Indiana University, Indianapolis. However, parenteral nutrition is associated with increased permeability, a lack of peristaltic stimulation, changes in intestinal flora, and an increased risk of infection.

 


“More recently, enteral nutrition has been used, despite a potential for pancreatic stimulation,” she said. “From 16 randomized, controlled trials with 847 patients, it was associated with decreased mortality, decreased infectious complications, decreased length of hospital stay, and a trend toward decreased rate of organ failure. Based on those findings, enteral nutrition has become the standard of care in acute pancreatitis. The optimal enteral nutrition route, however, is still debated. The traditional route is the nasojejunal [NJ] tube. Its placement is noninvasive, but it is associated with discomfort for the patient, dislodgement in 16%-63% of cases, and potentially sinusitis. Conversely, percutaneous gastrostomy with jejunal extension [PEG-J] is beneficial for patient comfort but has the drawbacks of being an invasive procedure with the risk of cellulitis and more severe complications.”

The aim of the current study was to compare the safety and efficacy of NJ tube and PEG-J enteral nutrition delivery before surgical debridement in patients with necrotizing pancreatitis. Dr. Roch and her associates hypothesized that NJ tube and PEG-J would have a similar complication profile. They retrospectively reviewed the medical records of all patients who underwent surgical debridement for necrotizing pancreatitis at Indiana University Medical Center between 2005 and 2015. Patients with exclusive total parenteral nutrition were excluded from the study, as were those who had incomplete data.

Dr. Roch reported results from 242 patients with a mean age of 54 years. More than half (64%) were men and the main etiology was biliary (47%), followed by alcohol (16%). The median duration of preoperative enteral nutrition was 29 days. Of the 242 patients, 187 had an NJ tube only, 25 had PEG-J only, and 30 patients had an NJ tube followed by PEG-J. More than half of PEG-Js were placed under fluoroscopic guidance, while the remaining 41% were placed endoscopically.

In terms of safety, patients in the NJ tube group had a significantly higher rate of all complications, compared with those in the PEG-J group (52% vs. 27%, respectively; P = .0015). Conversely, there was a significantly higher rate of serious complications among patients in the PEG-J group, compared with the NJ group (11% vs. 0%; P less than .0001). The researchers also found that compared with patients in the PEG-J group, those in the NJ group were more prone to mechanical complications such as difficulty to place (5% vs. 0%, respectively), replacement (30% vs. 5.5%), and repositioning (30% vs. 2%), while PEG-J patients were more prone to infectious complications such as skin infections/cellulitis (4% vs. 0%) and perforation/leakage/peritonitis (11% vs. 0%). When they limited the analysis to grade III or IV complications, the mechanism was always the same: early dislodgement from the GI tract. “The presentation ranged from asymptomatic patients to severe peritonitis,” Dr. Roch said. “Two patients out of the six with severe complications required emergent laparotomy.”

In terms of efficacy, the NJ and PEG-J groups were equivalent in achieving enteral nutrition (67% vs. 68%, respectively). There were also no differences between the two groups in nutritional status when assessed by an increase of serum albumin (38% vs. 36%; P = .87), normalization of serum albumin (9% vs. 16%; P = .14), or in the prevalence of infected necrosis (53% vs. 49%; P = .64).

Dr. Roch acknowledged certain limitations of the study, including its single-center, retrospective design. “Furthermore, we are a tertiary care center, and most patients are referred to us late in the course of their disease,” she said. “Finally, no PEG-Js were placed outside of our institution, raising the question of a selection bias. She reported having no financial disclosures.

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CORONADO, CALIF. – Percutaneous gastrostomy with jejunal extension (PEG-J) is an appealing and effective method for delivery of enteral nutrition in necrotizing pancreatitis patients, without the mechanical issues and discomfort associated with nasojejunal (NJ) tube, results from a single-center retrospective study showed.

“The advantages of PEG-J route for enteral nutrition in necrotizing pancreatitis patients must be weighed carefully against the potentially severe complication profile,” study author Alexandra M. Roch, MD, said at the annual meeting of the Western Surgical Association.

Dr. Alexandra M. Roch

Historically, the preferred way to manage patients with necrotizing pancreatitis was via parenteral nutrition with a lack of pancreatic stimulation, said Dr. Roch, of the department of surgery at Indiana University, Indianapolis. However, parenteral nutrition is associated with increased permeability, a lack of peristaltic stimulation, changes in intestinal flora, and an increased risk of infection.

 


“More recently, enteral nutrition has been used, despite a potential for pancreatic stimulation,” she said. “From 16 randomized, controlled trials with 847 patients, it was associated with decreased mortality, decreased infectious complications, decreased length of hospital stay, and a trend toward decreased rate of organ failure. Based on those findings, enteral nutrition has become the standard of care in acute pancreatitis. The optimal enteral nutrition route, however, is still debated. The traditional route is the nasojejunal [NJ] tube. Its placement is noninvasive, but it is associated with discomfort for the patient, dislodgement in 16%-63% of cases, and potentially sinusitis. Conversely, percutaneous gastrostomy with jejunal extension [PEG-J] is beneficial for patient comfort but has the drawbacks of being an invasive procedure with the risk of cellulitis and more severe complications.”

The aim of the current study was to compare the safety and efficacy of NJ tube and PEG-J enteral nutrition delivery before surgical debridement in patients with necrotizing pancreatitis. Dr. Roch and her associates hypothesized that NJ tube and PEG-J would have a similar complication profile. They retrospectively reviewed the medical records of all patients who underwent surgical debridement for necrotizing pancreatitis at Indiana University Medical Center between 2005 and 2015. Patients with exclusive total parenteral nutrition were excluded from the study, as were those who had incomplete data.

Dr. Roch reported results from 242 patients with a mean age of 54 years. More than half (64%) were men and the main etiology was biliary (47%), followed by alcohol (16%). The median duration of preoperative enteral nutrition was 29 days. Of the 242 patients, 187 had an NJ tube only, 25 had PEG-J only, and 30 patients had an NJ tube followed by PEG-J. More than half of PEG-Js were placed under fluoroscopic guidance, while the remaining 41% were placed endoscopically.

In terms of safety, patients in the NJ tube group had a significantly higher rate of all complications, compared with those in the PEG-J group (52% vs. 27%, respectively; P = .0015). Conversely, there was a significantly higher rate of serious complications among patients in the PEG-J group, compared with the NJ group (11% vs. 0%; P less than .0001). The researchers also found that compared with patients in the PEG-J group, those in the NJ group were more prone to mechanical complications such as difficulty to place (5% vs. 0%, respectively), replacement (30% vs. 5.5%), and repositioning (30% vs. 2%), while PEG-J patients were more prone to infectious complications such as skin infections/cellulitis (4% vs. 0%) and perforation/leakage/peritonitis (11% vs. 0%). When they limited the analysis to grade III or IV complications, the mechanism was always the same: early dislodgement from the GI tract. “The presentation ranged from asymptomatic patients to severe peritonitis,” Dr. Roch said. “Two patients out of the six with severe complications required emergent laparotomy.”

In terms of efficacy, the NJ and PEG-J groups were equivalent in achieving enteral nutrition (67% vs. 68%, respectively). There were also no differences between the two groups in nutritional status when assessed by an increase of serum albumin (38% vs. 36%; P = .87), normalization of serum albumin (9% vs. 16%; P = .14), or in the prevalence of infected necrosis (53% vs. 49%; P = .64).

Dr. Roch acknowledged certain limitations of the study, including its single-center, retrospective design. “Furthermore, we are a tertiary care center, and most patients are referred to us late in the course of their disease,” she said. “Finally, no PEG-Js were placed outside of our institution, raising the question of a selection bias. She reported having no financial disclosures.

 

CORONADO, CALIF. – Percutaneous gastrostomy with jejunal extension (PEG-J) is an appealing and effective method for delivery of enteral nutrition in necrotizing pancreatitis patients, without the mechanical issues and discomfort associated with nasojejunal (NJ) tube, results from a single-center retrospective study showed.

“The advantages of PEG-J route for enteral nutrition in necrotizing pancreatitis patients must be weighed carefully against the potentially severe complication profile,” study author Alexandra M. Roch, MD, said at the annual meeting of the Western Surgical Association.

Dr. Alexandra M. Roch

Historically, the preferred way to manage patients with necrotizing pancreatitis was via parenteral nutrition with a lack of pancreatic stimulation, said Dr. Roch, of the department of surgery at Indiana University, Indianapolis. However, parenteral nutrition is associated with increased permeability, a lack of peristaltic stimulation, changes in intestinal flora, and an increased risk of infection.

 


“More recently, enteral nutrition has been used, despite a potential for pancreatic stimulation,” she said. “From 16 randomized, controlled trials with 847 patients, it was associated with decreased mortality, decreased infectious complications, decreased length of hospital stay, and a trend toward decreased rate of organ failure. Based on those findings, enteral nutrition has become the standard of care in acute pancreatitis. The optimal enteral nutrition route, however, is still debated. The traditional route is the nasojejunal [NJ] tube. Its placement is noninvasive, but it is associated with discomfort for the patient, dislodgement in 16%-63% of cases, and potentially sinusitis. Conversely, percutaneous gastrostomy with jejunal extension [PEG-J] is beneficial for patient comfort but has the drawbacks of being an invasive procedure with the risk of cellulitis and more severe complications.”

The aim of the current study was to compare the safety and efficacy of NJ tube and PEG-J enteral nutrition delivery before surgical debridement in patients with necrotizing pancreatitis. Dr. Roch and her associates hypothesized that NJ tube and PEG-J would have a similar complication profile. They retrospectively reviewed the medical records of all patients who underwent surgical debridement for necrotizing pancreatitis at Indiana University Medical Center between 2005 and 2015. Patients with exclusive total parenteral nutrition were excluded from the study, as were those who had incomplete data.

Dr. Roch reported results from 242 patients with a mean age of 54 years. More than half (64%) were men and the main etiology was biliary (47%), followed by alcohol (16%). The median duration of preoperative enteral nutrition was 29 days. Of the 242 patients, 187 had an NJ tube only, 25 had PEG-J only, and 30 patients had an NJ tube followed by PEG-J. More than half of PEG-Js were placed under fluoroscopic guidance, while the remaining 41% were placed endoscopically.

In terms of safety, patients in the NJ tube group had a significantly higher rate of all complications, compared with those in the PEG-J group (52% vs. 27%, respectively; P = .0015). Conversely, there was a significantly higher rate of serious complications among patients in the PEG-J group, compared with the NJ group (11% vs. 0%; P less than .0001). The researchers also found that compared with patients in the PEG-J group, those in the NJ group were more prone to mechanical complications such as difficulty to place (5% vs. 0%, respectively), replacement (30% vs. 5.5%), and repositioning (30% vs. 2%), while PEG-J patients were more prone to infectious complications such as skin infections/cellulitis (4% vs. 0%) and perforation/leakage/peritonitis (11% vs. 0%). When they limited the analysis to grade III or IV complications, the mechanism was always the same: early dislodgement from the GI tract. “The presentation ranged from asymptomatic patients to severe peritonitis,” Dr. Roch said. “Two patients out of the six with severe complications required emergent laparotomy.”

In terms of efficacy, the NJ and PEG-J groups were equivalent in achieving enteral nutrition (67% vs. 68%, respectively). There were also no differences between the two groups in nutritional status when assessed by an increase of serum albumin (38% vs. 36%; P = .87), normalization of serum albumin (9% vs. 16%; P = .14), or in the prevalence of infected necrosis (53% vs. 49%; P = .64).

Dr. Roch acknowledged certain limitations of the study, including its single-center, retrospective design. “Furthermore, we are a tertiary care center, and most patients are referred to us late in the course of their disease,” she said. “Finally, no PEG-Js were placed outside of our institution, raising the question of a selection bias. She reported having no financial disclosures.

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Key clinical point: In necrotizing pancreatitis, NJ tube and PEG-J both delivered enteral nutrition effectively.

Major finding: In terms of efficacy, the NJ and PEG-J groups were equivalent in achieving enteral nutrition (67% vs. 68%, respectively).

Data source: A retrospective review of 242 patients who underwent surgical debridement for necrotizing pancreatitis at Indiana University Medical Center between 2005 and 2015.

Disclosures: Dr. Roch reported having no financial disclosures.

Open, laparoscopic, robotic approaches all sound for distal pancreatectomy

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– The three approaches to distal pancreatectomy – open, laparoscopic, and robotic – are equally safe and oncologically sound methods in properly selected patients, findings from a NSQIP database study show.

“The three approaches have specific indications for use and advantages in well-selected patients; therefore, demonstrating the superiority of one technique over another remains challenging,” said Dimitrios Xourafas, MD, in his presentation at the annual clinical congress of the American College of Surgeons.

Dr. Dimitrios Xourafas


Laparoscopic surgeries are more likely to result in open conversions than are robotic surgeries – but robotic surgeries take more time to complete. Open surgeries may be best for advanced disease. But all in all, there are no overriding advantages or disadvantages to any of them, reported Dr. Xourafas, a research fellow in surgery at Brigham and Women’s Hospital, Boston.

He and his colleagues used the American College of Surgeons National Surgical Quality Improvement (NSQIP) database for detailed information on 1,815 distal pancreatectomies performed in 2014. These they separated into three groups: open (921), laparoscopic (694) and robotic (200).

There were no differences in baseline characteristics. Mean age of the patients was 62 years. More than 70% of each group had serious comorbidities. Significantly more in the open surgery group had lost 10% or more of their body weight since diagnosis; this was probably related to a higher rate of preoperative chemotherapy in this group, Dr. Xourafas said. Patients having open surgery also were more likely to have undergone radiation therapy.

There were significant, but mixed, differences in operative outcomes. Surgery was longest in the robotic group (243 minutes vs. 205 minutes in the laparoscopic group and 222 minutes in the open group.) Laparoscopic procedures were more likely to convert to open than were robotic (16% vs. 8%). Blood loss was significantly greater in the open group, with 21% needing transfusion vs. 5% laparoscopic and 6% robotic. Close to 100% of patients in the robotic and open groups needed no vascular resection and no reconstruction. In the open group, fewer patients (88%) had no vascular resection, and 84% required no reconstruction, suggesting that these cases were more advanced disease. This finding was also borne out by the larger percentage of tumors that staged at T3 or higher (34% in the open group vs. about 20% in the other groups). However, about half of each group had a malignant tumor subtype and lesion sizes were similar.

Surgical site infections were more common in the open group (10% vs. 7% of the other groups). The length of stay was longest in the open group (7 days vs. 5 in the other groups). The robotic group had the highest rate of pancreatic fistula (21%) although this was not significantly different from the open and laparoscopic rates (16% and 17%, respectively).

Overall morbidity was 45% in the open group, 36% in the laparoscopic group, and 37% in the robotic group. Mortality was 1.5% in the open group, 1% in the laparoscopic group, and 0.5% in the robotic group – not significantly different.

Dr. Xourafas had no financial disclosures.

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– The three approaches to distal pancreatectomy – open, laparoscopic, and robotic – are equally safe and oncologically sound methods in properly selected patients, findings from a NSQIP database study show.

“The three approaches have specific indications for use and advantages in well-selected patients; therefore, demonstrating the superiority of one technique over another remains challenging,” said Dimitrios Xourafas, MD, in his presentation at the annual clinical congress of the American College of Surgeons.

Dr. Dimitrios Xourafas


Laparoscopic surgeries are more likely to result in open conversions than are robotic surgeries – but robotic surgeries take more time to complete. Open surgeries may be best for advanced disease. But all in all, there are no overriding advantages or disadvantages to any of them, reported Dr. Xourafas, a research fellow in surgery at Brigham and Women’s Hospital, Boston.

He and his colleagues used the American College of Surgeons National Surgical Quality Improvement (NSQIP) database for detailed information on 1,815 distal pancreatectomies performed in 2014. These they separated into three groups: open (921), laparoscopic (694) and robotic (200).

There were no differences in baseline characteristics. Mean age of the patients was 62 years. More than 70% of each group had serious comorbidities. Significantly more in the open surgery group had lost 10% or more of their body weight since diagnosis; this was probably related to a higher rate of preoperative chemotherapy in this group, Dr. Xourafas said. Patients having open surgery also were more likely to have undergone radiation therapy.

There were significant, but mixed, differences in operative outcomes. Surgery was longest in the robotic group (243 minutes vs. 205 minutes in the laparoscopic group and 222 minutes in the open group.) Laparoscopic procedures were more likely to convert to open than were robotic (16% vs. 8%). Blood loss was significantly greater in the open group, with 21% needing transfusion vs. 5% laparoscopic and 6% robotic. Close to 100% of patients in the robotic and open groups needed no vascular resection and no reconstruction. In the open group, fewer patients (88%) had no vascular resection, and 84% required no reconstruction, suggesting that these cases were more advanced disease. This finding was also borne out by the larger percentage of tumors that staged at T3 or higher (34% in the open group vs. about 20% in the other groups). However, about half of each group had a malignant tumor subtype and lesion sizes were similar.

Surgical site infections were more common in the open group (10% vs. 7% of the other groups). The length of stay was longest in the open group (7 days vs. 5 in the other groups). The robotic group had the highest rate of pancreatic fistula (21%) although this was not significantly different from the open and laparoscopic rates (16% and 17%, respectively).

Overall morbidity was 45% in the open group, 36% in the laparoscopic group, and 37% in the robotic group. Mortality was 1.5% in the open group, 1% in the laparoscopic group, and 0.5% in the robotic group – not significantly different.

Dr. Xourafas had no financial disclosures.

 

– The three approaches to distal pancreatectomy – open, laparoscopic, and robotic – are equally safe and oncologically sound methods in properly selected patients, findings from a NSQIP database study show.

“The three approaches have specific indications for use and advantages in well-selected patients; therefore, demonstrating the superiority of one technique over another remains challenging,” said Dimitrios Xourafas, MD, in his presentation at the annual clinical congress of the American College of Surgeons.

Dr. Dimitrios Xourafas


Laparoscopic surgeries are more likely to result in open conversions than are robotic surgeries – but robotic surgeries take more time to complete. Open surgeries may be best for advanced disease. But all in all, there are no overriding advantages or disadvantages to any of them, reported Dr. Xourafas, a research fellow in surgery at Brigham and Women’s Hospital, Boston.

He and his colleagues used the American College of Surgeons National Surgical Quality Improvement (NSQIP) database for detailed information on 1,815 distal pancreatectomies performed in 2014. These they separated into three groups: open (921), laparoscopic (694) and robotic (200).

There were no differences in baseline characteristics. Mean age of the patients was 62 years. More than 70% of each group had serious comorbidities. Significantly more in the open surgery group had lost 10% or more of their body weight since diagnosis; this was probably related to a higher rate of preoperative chemotherapy in this group, Dr. Xourafas said. Patients having open surgery also were more likely to have undergone radiation therapy.

There were significant, but mixed, differences in operative outcomes. Surgery was longest in the robotic group (243 minutes vs. 205 minutes in the laparoscopic group and 222 minutes in the open group.) Laparoscopic procedures were more likely to convert to open than were robotic (16% vs. 8%). Blood loss was significantly greater in the open group, with 21% needing transfusion vs. 5% laparoscopic and 6% robotic. Close to 100% of patients in the robotic and open groups needed no vascular resection and no reconstruction. In the open group, fewer patients (88%) had no vascular resection, and 84% required no reconstruction, suggesting that these cases were more advanced disease. This finding was also borne out by the larger percentage of tumors that staged at T3 or higher (34% in the open group vs. about 20% in the other groups). However, about half of each group had a malignant tumor subtype and lesion sizes were similar.

Surgical site infections were more common in the open group (10% vs. 7% of the other groups). The length of stay was longest in the open group (7 days vs. 5 in the other groups). The robotic group had the highest rate of pancreatic fistula (21%) although this was not significantly different from the open and laparoscopic rates (16% and 17%, respectively).

Overall morbidity was 45% in the open group, 36% in the laparoscopic group, and 37% in the robotic group. Mortality was 1.5% in the open group, 1% in the laparoscopic group, and 0.5% in the robotic group – not significantly different.

Dr. Xourafas had no financial disclosures.

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Key clinical point: Each approach has its unique advantages and disadvantages in distal pancreatectomy.

Major finding: Surgery was longest in the robotic group (243 minutes), but more patients in the open group needed transfusions (21% vs. 5% of the other groups).

Data source: The database review comprised 1,815 patients.

Disclosures: Dr. Xourafas had no financial disclosures.

Discharging select diverticulitis patients from the ED found to be acceptable

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CORONADO, CALIF. – Among patients diagnosed with diverticulitis via CT scan in the emergency department who were discharged home, only 13% required a return visit to the hospital, results from a long-term retrospective analysis demonstrated.

“In select patients whose assessment includes a CT scan, discharge to home from the emergency department with treatment for diverticulitis is safe,” study author Anne-Marie Sirany, MD, said at the annual meeting of the Western Surgical Association.

Dr. Anne Marie Sirany
Dr. Anne Marie Sirany
According to Dr. Sirany, a general surgery resident at Hennepin County Medical Center, Minneapolis, diverticulitis accounts for about 150,000 hospital admissions per year in the United States, and only 15% of cases require surgical intervention. However, between 2006 and 2011, emergency department visits for diverticulitis increased by 21%, and the annual direct medical cost related to the condition is estimated to exceed $1.8 billion. At the same time, medical literature regarding uncomplicated diverticulitis is scarce. “Most of the literature focuses on complicated diverticulitis, which includes episodes associated with extraluminal air, free perforation, abscess, fistula, obstruction, and stricture,” Dr. Sirany said.

A few years ago, researchers conducted a randomized trial to evaluate the treatment of uncomplicated diverticulitis (Ann Surg. 2014;259[1]:38-44). Patients were diagnosed with diverticulitis in the emergency department and randomized to either hospital admission or outpatient management at home. The investigators found no significant differences between the readmission rates of the inpatient and outpatient groups, but the health care costs were three times lower in the outpatient group. Dr. Sirany and her associates set out to compare the outcomes of patients diagnosed with and treated for diverticulitis in the emergency department who were discharged to home, versus those who were admitted to the hospital. They reviewed the medical records of 240 patients with a primary diagnosis of diverticulitis by CT scan who were evaluated in the emergency department at one of four hospitals and one academic medical center from September 2010 to January 2012. The primary outcome was hospital readmission or return to the emergency department within 30 days, while the secondary outcomes were recurrent diverticulitis or surgical resection for diverticulitis.

The mean age of the 240 patients was 59 years, 45% were men, 22% had a Charlson Comorbidity Index (CCI) of greater than 2, and 7.5% were on steroids or immunosuppressant medications. More than half (62%) were admitted to the hospital, while the remaining 38% were discharged home on oral antibiotics. Compared with patients discharged home, those admitted to the hospital were more likely to be older than age 65 (43% vs. 24%, respectively; P = .003), have a CCI of 2 or greater (28% vs. 13%; P = .007), were more likely to be on immunosuppressant or steroid medications (11% vs. 1%; P = .003), show extraluminal air on CT (30% vs. 7%; P less than .0001), or show abscess on CT (19% vs. 1%; P less than .0001). “Of note: We did not have any patients who had CT scan findings of pneumoperitoneum who were discharged home, and 48% of patients admitted to the hospital had uncomplicated diverticulitis,” she said.

After a median follow-up of 37 months, no significant differences were observed between patients discharged to home and those admitted to the hospital in readmission or return to the emergency department (13% vs. 14%), recurrent diverticulitis (23% in each group), or in colon resection at subsequent encounter (16% vs. 19%). “Among patients discharged to home, only one patient required emergency surgery, and this was 20 months after their index admission,” Dr. Sirany said. “We think that the low rate of readmission in patients discharged home demonstrates that this is a safe approach to management of patients with diverticulitis, when using information from the CT scan.”

Closer analysis of patients who were discharged home revealed that six patients had extraluminal air on CT scan, three of whom returned to the emergency department or were admitted to the hospital. In addition, 11% of those with uncomplicated diverticulitis returned to the emergency department or were admitted to the hospital.

Dr. Sirany acknowledged certain limitations of the study, including its retrospective design, a lack of complete follow-up for all patients, and the fact that it included patients with recurrent diverticulitis. “Despite the limitations, we recommend that young, relatively healthy patients, with uncomplicated findings on CT scan, can be discharged to home and managed as an outpatient,” she said. “In an era where there’s increasing attention to health care costs, we need to think more critically about which patients need to be admitted for management of uncomplicated diverticulitis.” She reported having no financial disclosures.

[email protected]

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CORONADO, CALIF. – Among patients diagnosed with diverticulitis via CT scan in the emergency department who were discharged home, only 13% required a return visit to the hospital, results from a long-term retrospective analysis demonstrated.

“In select patients whose assessment includes a CT scan, discharge to home from the emergency department with treatment for diverticulitis is safe,” study author Anne-Marie Sirany, MD, said at the annual meeting of the Western Surgical Association.

Dr. Anne Marie Sirany
Dr. Anne Marie Sirany
According to Dr. Sirany, a general surgery resident at Hennepin County Medical Center, Minneapolis, diverticulitis accounts for about 150,000 hospital admissions per year in the United States, and only 15% of cases require surgical intervention. However, between 2006 and 2011, emergency department visits for diverticulitis increased by 21%, and the annual direct medical cost related to the condition is estimated to exceed $1.8 billion. At the same time, medical literature regarding uncomplicated diverticulitis is scarce. “Most of the literature focuses on complicated diverticulitis, which includes episodes associated with extraluminal air, free perforation, abscess, fistula, obstruction, and stricture,” Dr. Sirany said.

A few years ago, researchers conducted a randomized trial to evaluate the treatment of uncomplicated diverticulitis (Ann Surg. 2014;259[1]:38-44). Patients were diagnosed with diverticulitis in the emergency department and randomized to either hospital admission or outpatient management at home. The investigators found no significant differences between the readmission rates of the inpatient and outpatient groups, but the health care costs were three times lower in the outpatient group. Dr. Sirany and her associates set out to compare the outcomes of patients diagnosed with and treated for diverticulitis in the emergency department who were discharged to home, versus those who were admitted to the hospital. They reviewed the medical records of 240 patients with a primary diagnosis of diverticulitis by CT scan who were evaluated in the emergency department at one of four hospitals and one academic medical center from September 2010 to January 2012. The primary outcome was hospital readmission or return to the emergency department within 30 days, while the secondary outcomes were recurrent diverticulitis or surgical resection for diverticulitis.

The mean age of the 240 patients was 59 years, 45% were men, 22% had a Charlson Comorbidity Index (CCI) of greater than 2, and 7.5% were on steroids or immunosuppressant medications. More than half (62%) were admitted to the hospital, while the remaining 38% were discharged home on oral antibiotics. Compared with patients discharged home, those admitted to the hospital were more likely to be older than age 65 (43% vs. 24%, respectively; P = .003), have a CCI of 2 or greater (28% vs. 13%; P = .007), were more likely to be on immunosuppressant or steroid medications (11% vs. 1%; P = .003), show extraluminal air on CT (30% vs. 7%; P less than .0001), or show abscess on CT (19% vs. 1%; P less than .0001). “Of note: We did not have any patients who had CT scan findings of pneumoperitoneum who were discharged home, and 48% of patients admitted to the hospital had uncomplicated diverticulitis,” she said.

After a median follow-up of 37 months, no significant differences were observed between patients discharged to home and those admitted to the hospital in readmission or return to the emergency department (13% vs. 14%), recurrent diverticulitis (23% in each group), or in colon resection at subsequent encounter (16% vs. 19%). “Among patients discharged to home, only one patient required emergency surgery, and this was 20 months after their index admission,” Dr. Sirany said. “We think that the low rate of readmission in patients discharged home demonstrates that this is a safe approach to management of patients with diverticulitis, when using information from the CT scan.”

Closer analysis of patients who were discharged home revealed that six patients had extraluminal air on CT scan, three of whom returned to the emergency department or were admitted to the hospital. In addition, 11% of those with uncomplicated diverticulitis returned to the emergency department or were admitted to the hospital.

Dr. Sirany acknowledged certain limitations of the study, including its retrospective design, a lack of complete follow-up for all patients, and the fact that it included patients with recurrent diverticulitis. “Despite the limitations, we recommend that young, relatively healthy patients, with uncomplicated findings on CT scan, can be discharged to home and managed as an outpatient,” she said. “In an era where there’s increasing attention to health care costs, we need to think more critically about which patients need to be admitted for management of uncomplicated diverticulitis.” She reported having no financial disclosures.

[email protected]

CORONADO, CALIF. – Among patients diagnosed with diverticulitis via CT scan in the emergency department who were discharged home, only 13% required a return visit to the hospital, results from a long-term retrospective analysis demonstrated.

“In select patients whose assessment includes a CT scan, discharge to home from the emergency department with treatment for diverticulitis is safe,” study author Anne-Marie Sirany, MD, said at the annual meeting of the Western Surgical Association.

Dr. Anne Marie Sirany
Dr. Anne Marie Sirany
According to Dr. Sirany, a general surgery resident at Hennepin County Medical Center, Minneapolis, diverticulitis accounts for about 150,000 hospital admissions per year in the United States, and only 15% of cases require surgical intervention. However, between 2006 and 2011, emergency department visits for diverticulitis increased by 21%, and the annual direct medical cost related to the condition is estimated to exceed $1.8 billion. At the same time, medical literature regarding uncomplicated diverticulitis is scarce. “Most of the literature focuses on complicated diverticulitis, which includes episodes associated with extraluminal air, free perforation, abscess, fistula, obstruction, and stricture,” Dr. Sirany said.

A few years ago, researchers conducted a randomized trial to evaluate the treatment of uncomplicated diverticulitis (Ann Surg. 2014;259[1]:38-44). Patients were diagnosed with diverticulitis in the emergency department and randomized to either hospital admission or outpatient management at home. The investigators found no significant differences between the readmission rates of the inpatient and outpatient groups, but the health care costs were three times lower in the outpatient group. Dr. Sirany and her associates set out to compare the outcomes of patients diagnosed with and treated for diverticulitis in the emergency department who were discharged to home, versus those who were admitted to the hospital. They reviewed the medical records of 240 patients with a primary diagnosis of diverticulitis by CT scan who were evaluated in the emergency department at one of four hospitals and one academic medical center from September 2010 to January 2012. The primary outcome was hospital readmission or return to the emergency department within 30 days, while the secondary outcomes were recurrent diverticulitis or surgical resection for diverticulitis.

The mean age of the 240 patients was 59 years, 45% were men, 22% had a Charlson Comorbidity Index (CCI) of greater than 2, and 7.5% were on steroids or immunosuppressant medications. More than half (62%) were admitted to the hospital, while the remaining 38% were discharged home on oral antibiotics. Compared with patients discharged home, those admitted to the hospital were more likely to be older than age 65 (43% vs. 24%, respectively; P = .003), have a CCI of 2 or greater (28% vs. 13%; P = .007), were more likely to be on immunosuppressant or steroid medications (11% vs. 1%; P = .003), show extraluminal air on CT (30% vs. 7%; P less than .0001), or show abscess on CT (19% vs. 1%; P less than .0001). “Of note: We did not have any patients who had CT scan findings of pneumoperitoneum who were discharged home, and 48% of patients admitted to the hospital had uncomplicated diverticulitis,” she said.

After a median follow-up of 37 months, no significant differences were observed between patients discharged to home and those admitted to the hospital in readmission or return to the emergency department (13% vs. 14%), recurrent diverticulitis (23% in each group), or in colon resection at subsequent encounter (16% vs. 19%). “Among patients discharged to home, only one patient required emergency surgery, and this was 20 months after their index admission,” Dr. Sirany said. “We think that the low rate of readmission in patients discharged home demonstrates that this is a safe approach to management of patients with diverticulitis, when using information from the CT scan.”

Closer analysis of patients who were discharged home revealed that six patients had extraluminal air on CT scan, three of whom returned to the emergency department or were admitted to the hospital. In addition, 11% of those with uncomplicated diverticulitis returned to the emergency department or were admitted to the hospital.

Dr. Sirany acknowledged certain limitations of the study, including its retrospective design, a lack of complete follow-up for all patients, and the fact that it included patients with recurrent diverticulitis. “Despite the limitations, we recommend that young, relatively healthy patients, with uncomplicated findings on CT scan, can be discharged to home and managed as an outpatient,” she said. “In an era where there’s increasing attention to health care costs, we need to think more critically about which patients need to be admitted for management of uncomplicated diverticulitis.” She reported having no financial disclosures.

[email protected]

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Key clinical point: In select patients whose assessment includes a CT scan, discharge to home from the emergency department with treatment for diverticulitis is safe.

Major finding: After a median follow-up of 37 months, no significant differences were observed between patients discharged to home and those admitted to the hospital in readmission or return to the emergency department (13% vs. 14%, respectively).

Data source: A retrospective review of 240 patients with a primary diagnosis of diverticulitis by CT scan who were evaluated in the emergency department at one of four hospitals and one academic medical center from September 2010 to January 2012.

Disclosures: Dr. Sirany reported having no financial disclosures.

Continue DMARDs, biologics in RA surgery patients

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– The perioperative use of disease-modifying antirheumatic drug monotherapy or combined therapy with methotrexate and a tumor necrosis factor (TNF) inhibitor is not associated with increased rates of postoperative infectious complications or wound infections in patients with rheumatoid arthritis, according to findings from a retrospective review of more than 9,000 surgeries.

With respect to monotherapy, treatment was continued in 1,951 of 2,601 surgeries among patients receiving methotrexate, in 1,496 of 2,012 surgeries among patients receiving hydroxychloroquine, and in 508 of 652 surgeries among patient receiving leflunomide. The odds ratios for postoperative infection (including urinary tract, pneumonia, or sepsis) and postoperative wound infection, respectively, were 0.79 and 0.77 with methotrexate continuation, 0.93 and 0.86 with hydroxychloroquine continuation, and 0.78 and 0.87 with leflunomide continuation, Hsin-Hsuan Juo, MD, reported at the annual meeting of the American College of Rheumatology.

Dmitrii Kotin/Thinkstock
With respect to combination therapy, treatment was continued in 196 of 386 surgeries among patients receiving methotrexate and TNF inhibitors, treatment with the TNF inhibitors alone was continued in 59 surgeries, and methotrexate alone was continued in 72 surgeries. The odds ratios for postoperative infection and postoperative wound infection, respectively, were 0.35 and 0.38 with continuation of both drugs, 0.15 and 0.19 with continuation of only TNF inhibitors, and 0.80 and 1.18 with continuation of methotrexate alone, said Dr. Juo of the University of Washington, Seattle.

Data for this study were derived from the U.S. Department of Veterans Affairs administrative database and surgical quality registry. Rheumatoid arthritis patients who underwent a surgical procedure and who were on at least one disease-modifying antirheumatic drug (DMARD) or one biologic agent in the perioperative period during the study period of Oct. 1, 1999, through Sept. 30, 2009, were included. Subjects had a mean age of 67 years, and 91% were men.

The finding that the continuation of DMARD monotherapy or the combination of methotrexate and TNF inhibitor therapy for RA in the perioperative setting was not associated with increased rates of overall postoperative infectious complications and wound infections is important, because many patients are advised to stop taking these drugs prior to surgery because of concerns about increased susceptibility to infection. Discontinuing RA medication can increase the risk of disease flares requiring treatment with prednisone, which can further increase the risk of postsurgical complications, Dr. Juo said.

Clear, consistent guidance on the continuation of treatment among RA patients undergoing surgery has been lacking, she said, noting that guidelines over the years from the ACR, the British Society for Rheumatology, and the Canadian Rheumatology Association have differed in their recommendations.

A new draft guideline reported the morning of Dr. Juo’s presentation at the ACR annual meeting recommended continuing DMARDs but discontinuing biologics prior to surgery, but that guideline is limited to orthopedic surgery among patients with various rheumatic diseases.

“With literature review, the results are conflicting as well; some recommend continuing medication, and others recommend discontinuing medications prior to surgery,” she said.

The current findings, though limited by the study’s observational design and generally older, male population, suggest that continuing antirheumatic medications during the perioperative period is not associated with increased rates of postoperative complications.

“Our study results suggest that discontinuing DMARDs and biologic agents prior to surgery may not be necessary. Therefore, being on DMARDs or biologic agents should not preclude patients from receiving urgent surgeries,” Dr. Juo concluded.

Dr. Juo reported having no disclosures.

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– The perioperative use of disease-modifying antirheumatic drug monotherapy or combined therapy with methotrexate and a tumor necrosis factor (TNF) inhibitor is not associated with increased rates of postoperative infectious complications or wound infections in patients with rheumatoid arthritis, according to findings from a retrospective review of more than 9,000 surgeries.

With respect to monotherapy, treatment was continued in 1,951 of 2,601 surgeries among patients receiving methotrexate, in 1,496 of 2,012 surgeries among patients receiving hydroxychloroquine, and in 508 of 652 surgeries among patient receiving leflunomide. The odds ratios for postoperative infection (including urinary tract, pneumonia, or sepsis) and postoperative wound infection, respectively, were 0.79 and 0.77 with methotrexate continuation, 0.93 and 0.86 with hydroxychloroquine continuation, and 0.78 and 0.87 with leflunomide continuation, Hsin-Hsuan Juo, MD, reported at the annual meeting of the American College of Rheumatology.

Dmitrii Kotin/Thinkstock
With respect to combination therapy, treatment was continued in 196 of 386 surgeries among patients receiving methotrexate and TNF inhibitors, treatment with the TNF inhibitors alone was continued in 59 surgeries, and methotrexate alone was continued in 72 surgeries. The odds ratios for postoperative infection and postoperative wound infection, respectively, were 0.35 and 0.38 with continuation of both drugs, 0.15 and 0.19 with continuation of only TNF inhibitors, and 0.80 and 1.18 with continuation of methotrexate alone, said Dr. Juo of the University of Washington, Seattle.

Data for this study were derived from the U.S. Department of Veterans Affairs administrative database and surgical quality registry. Rheumatoid arthritis patients who underwent a surgical procedure and who were on at least one disease-modifying antirheumatic drug (DMARD) or one biologic agent in the perioperative period during the study period of Oct. 1, 1999, through Sept. 30, 2009, were included. Subjects had a mean age of 67 years, and 91% were men.

The finding that the continuation of DMARD monotherapy or the combination of methotrexate and TNF inhibitor therapy for RA in the perioperative setting was not associated with increased rates of overall postoperative infectious complications and wound infections is important, because many patients are advised to stop taking these drugs prior to surgery because of concerns about increased susceptibility to infection. Discontinuing RA medication can increase the risk of disease flares requiring treatment with prednisone, which can further increase the risk of postsurgical complications, Dr. Juo said.

Clear, consistent guidance on the continuation of treatment among RA patients undergoing surgery has been lacking, she said, noting that guidelines over the years from the ACR, the British Society for Rheumatology, and the Canadian Rheumatology Association have differed in their recommendations.

A new draft guideline reported the morning of Dr. Juo’s presentation at the ACR annual meeting recommended continuing DMARDs but discontinuing biologics prior to surgery, but that guideline is limited to orthopedic surgery among patients with various rheumatic diseases.

“With literature review, the results are conflicting as well; some recommend continuing medication, and others recommend discontinuing medications prior to surgery,” she said.

The current findings, though limited by the study’s observational design and generally older, male population, suggest that continuing antirheumatic medications during the perioperative period is not associated with increased rates of postoperative complications.

“Our study results suggest that discontinuing DMARDs and biologic agents prior to surgery may not be necessary. Therefore, being on DMARDs or biologic agents should not preclude patients from receiving urgent surgeries,” Dr. Juo concluded.

Dr. Juo reported having no disclosures.

 

– The perioperative use of disease-modifying antirheumatic drug monotherapy or combined therapy with methotrexate and a tumor necrosis factor (TNF) inhibitor is not associated with increased rates of postoperative infectious complications or wound infections in patients with rheumatoid arthritis, according to findings from a retrospective review of more than 9,000 surgeries.

With respect to monotherapy, treatment was continued in 1,951 of 2,601 surgeries among patients receiving methotrexate, in 1,496 of 2,012 surgeries among patients receiving hydroxychloroquine, and in 508 of 652 surgeries among patient receiving leflunomide. The odds ratios for postoperative infection (including urinary tract, pneumonia, or sepsis) and postoperative wound infection, respectively, were 0.79 and 0.77 with methotrexate continuation, 0.93 and 0.86 with hydroxychloroquine continuation, and 0.78 and 0.87 with leflunomide continuation, Hsin-Hsuan Juo, MD, reported at the annual meeting of the American College of Rheumatology.

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With respect to combination therapy, treatment was continued in 196 of 386 surgeries among patients receiving methotrexate and TNF inhibitors, treatment with the TNF inhibitors alone was continued in 59 surgeries, and methotrexate alone was continued in 72 surgeries. The odds ratios for postoperative infection and postoperative wound infection, respectively, were 0.35 and 0.38 with continuation of both drugs, 0.15 and 0.19 with continuation of only TNF inhibitors, and 0.80 and 1.18 with continuation of methotrexate alone, said Dr. Juo of the University of Washington, Seattle.

Data for this study were derived from the U.S. Department of Veterans Affairs administrative database and surgical quality registry. Rheumatoid arthritis patients who underwent a surgical procedure and who were on at least one disease-modifying antirheumatic drug (DMARD) or one biologic agent in the perioperative period during the study period of Oct. 1, 1999, through Sept. 30, 2009, were included. Subjects had a mean age of 67 years, and 91% were men.

The finding that the continuation of DMARD monotherapy or the combination of methotrexate and TNF inhibitor therapy for RA in the perioperative setting was not associated with increased rates of overall postoperative infectious complications and wound infections is important, because many patients are advised to stop taking these drugs prior to surgery because of concerns about increased susceptibility to infection. Discontinuing RA medication can increase the risk of disease flares requiring treatment with prednisone, which can further increase the risk of postsurgical complications, Dr. Juo said.

Clear, consistent guidance on the continuation of treatment among RA patients undergoing surgery has been lacking, she said, noting that guidelines over the years from the ACR, the British Society for Rheumatology, and the Canadian Rheumatology Association have differed in their recommendations.

A new draft guideline reported the morning of Dr. Juo’s presentation at the ACR annual meeting recommended continuing DMARDs but discontinuing biologics prior to surgery, but that guideline is limited to orthopedic surgery among patients with various rheumatic diseases.

“With literature review, the results are conflicting as well; some recommend continuing medication, and others recommend discontinuing medications prior to surgery,” she said.

The current findings, though limited by the study’s observational design and generally older, male population, suggest that continuing antirheumatic medications during the perioperative period is not associated with increased rates of postoperative complications.

“Our study results suggest that discontinuing DMARDs and biologic agents prior to surgery may not be necessary. Therefore, being on DMARDs or biologic agents should not preclude patients from receiving urgent surgeries,” Dr. Juo concluded.

Dr. Juo reported having no disclosures.

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Key clinical point: Observational data suggest that continuing DMARDs and biologics in RA patients undergoing surgery does not increase postoperative infection risk.

Major finding: Odds ratios for postoperative infection and postoperative wound infection, respectively, were 0.79 and 0.77 with methotrexate continuation, 0.93 and 0.86 with hydroxychloroquine continuation, 0.78 and 0.87 with leflunomide continuation, and 0.35 and 0.38 with combined methotrexate/TNF inhibitor continuation.

Data source: A retrospective review of more than 9,000 surgeries.

Disclosures: Dr. Juo reported having no disclosures.