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Frailty is a measure of physiologic reserve associated with increased vulnerability to adverse outcomes following surgery in older adults. The ‘accumulating deficits’ model of frailty has been applied to the NSQIP database, and an 11-item modified frailty index (mFI) has been validated. We developed a condensed 5-item frailty index and used this to assess the relationship between frailty and outcomes in patients undergoing paraesophageal hernia (PEH) repair. The NSQIP database was queried for ICD-9 and CPT codes associated with PEH repair. Subjects ≥60 years who underwent PEH repair between 2011 and 2013 were included. Five of the 11 mFI items present in the NSQIP data on the most consistent basis were selected for the condensed index. Univariate and multivariate logistic regressions were used to determine the validity of the 5-item mFI as a predictor of postoperative mortality, complications, readmission, and non-routine discharge. A total of 3711 patients had data for all variables in the 5-item index, while 885 patients had complete data to calculate the 11-item mFI. After controlling for competing risk factors, including age, ASA score, wound classification, surgical approach, and procedure timing (emergent vs non-emergent), we found the 5-item mFI remained predictive of 30-day mortality and patients being discharged to a location other than home (p

Previous randomized controlled trials have demonstrated that partial fundoplication following Heller myotomy results in less pathologic acid exposure to the esophagus when compared to myotomy without fundoplication. Recent studies have questioned the necessity of a fundoplication, especially when a limited hiatal dissection (LHD) is performed and the angle of His is preserved.This is a retrospective review of prospectively maintained data. All patients underwent primary Heller myotomy for achalasia over a 30-month period. In select patients, an LHD was performed anteriorly. Symptomatic outcomes were assessed up to 2 years postoperation using the Achalasia Severity Questionnaire (ASQ), Gastrointestinal Quality of Life Index (GIQLI), and Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL).A total of 31 patients underwent Heller myotomy during the study interval. The majority of patients underwent Heller myotomy with full hiatal dissection (FHD) (21, 68%). Intraoperative mucosal perforations occurred in 3 (14%) patients undergoing FHD. Patient demographics, surgery details, and baseline symptomatic outcomes did not differ significantly preoperatively. At greater than 1 year postoperation, there was no significant difference between the groups for ASQ, GERD-HRQL, and GIGLI (P = .76, .78, and .33, respectively).Heller myotomy with LHD and no fundoplication and Heller myotomy with FHD and partial fundoplication result in similar GERD-related quality of life outcomes. Further studies (including pH studies) are necessary to determine if fundoplication is a necessary step in selected patients in whom an LHD is possible.

Gastroesophageal reflux disease is a common comorbid medical condition of obesity. Laparoscopic sleeve gastrectomy has been associated with de novo and worsening GERD following surgery. For this reason, patients who suffer from GERD and are considering bariatric surgery are often counseled to undergo gastric bypass. Given this practice, we sought to determine acid reduction medication (ARM) utilization in bariatric surgical patients who undergo one of these procedures prior to surgery and at 1 year following surgery.A retrospective review of prospectively maintained data on patients to undergo gastric bypass or sleeve gastrectomy between November 2012 and December 2014 was conducted after IRB approval. ARM utilization and Gastroesophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL) scores [range 0 (no symptoms)-50 (severe GERD)] were compared prior to surgery and at 1 year postoperatively.334 patients underwent an eligible procedure in the study interval. 147 patients (44 %) had data on both preoperative and 1 year postoperative ARM use (93 gastric bypass and 54 sleeve gastrectomy). ARM utilization prior to surgery in gastric bypass patients did not reach statistical significance when compared to sleeve gastrectomy (40.9 vs. 26 %, p = 0.07). GERD-HRQL scores were greater prior to surgery in gastric bypass patients (GERD-HRQL 8.2 vs. 1.9; p 0.01). At 12 months postoperatively, sleeve gastrectomy patients had a significantly higher rate of overall ARM use (48.1 vs. 16.1 %, p 0.01), new ARM use (35 vs. 7.3 %, p 0.01), and persistent ARM use (78.6 vs. 21.9 %, p 0.01) when compared to gastric bypass patients. GERD-HRQL scores were similar overall at 12 months postoperatively (4.4 bypass vs. 4.8 sleeve; p = 0.72).Laparoscopic sleeve gastrectomy is associated with a significantly increased likelihood that acid reduction medications will be necessary for GERD symptom control 12 months postoperatively when compared to gastric bypass.

Robotic surgical systems have been used at a rapidly increasing rate in general surgery. Many of these procedures have been performed laparoscopically for years. In a surgical encounter, a significant portion of the total costs is associated with consumable supplies. Our hospital system has invested in a software program that can track the costs of consumable surgical supplies. We sought to determine the differences in cost of consumables with elective laparoscopic and robotic procedures for our health care organization. De-identified procedural cost and equipment utilization data were collected from the Surgical Profitability Compass Procedure Cost Manager System (The Advisory Board Company, Washington, DC) for our health care system for laparoscopic and robotic cholecystectomy, fundoplication, and inguinal hernia between the years 2013 and 2015. Outcomes were length of stay, case duration, and supply cost. Statistical analysis was performed using a t-test for continuous variables, and statistical significance was defined as p

The goal of antireflux surgery is to create a competent antireflux valve at the esophagogastric junction (EGJ). The two most common types of fundoplications constructed are the 360° Nissen and the 270° Toupet. We sought to determine whether there was a significant difference in distensibility at the EGJ based on fundoplication geometry (full vs. partial). This is a retrospective review of prospective data. All subjects underwent laparoscopic fundoplication over a 47-month period for primary GERD or failed fundoplication. An endoluminal functional luminal-imaging probe (EndoFLIP®) was used to assess EGJ distensibility intraoperatively. Minimum esophageal diameter (D min), cross-sectional area (CSA), and distensibility index (DI) were measured at 30- and 40-mL balloon distension volumes prior to abdominal insufflation, after hiatal dissection, and following fundoplication. DI is defined as the narrowest CSA divided by the corresponding pressure expressed in mm2/mmHg. Analysis was conducted to compare distensibility metrics based on the type of fundoplication constructed (Nissen or Toupet). As a secondary outcome, we sought to determine whether there was a difference in distensibility of the EGJ prior to surgery in patients with primary GERD as opposed to those with recurrent GERD after a failed fundoplication. A total of 75 patients underwent fundoplications during the study interval. There were 44 primary and 31 reoperative fundoplications. Nissen fundoplication was constructed in 45 and Toupet in 30. Based on the distensibility index, the EGJ distensibility significantly decreased from prior to surgery to following fundoplication in all patients. Patients undergoing reoperative antireflux surgery had an initial DI at the EGJ similar to that of patients with primary GERD. Following Toupet, the EGJ was significantly more distensible than that after Nissen fundoplication. Laparoscopic fundoplication results in decreased EGJ distensibility in patients with GERD. The EGJ following partial fundoplication is significantly more distensible than that after a full fundoplication.

We sought to characterize the changes in esophagogastric junction (EGJ) distensibility during Heller Myotomy with Dor fundoplication using the EndoFLIP device. Intraoperative distensibility measurements on 14 patients undergoing Heller myotomy with Dor fundoplication were conducted over an 18-month period. Minimum esophageal diameter, cross-sectional areas, and distensibility index were measured at 30 and 40 mL catheter volumes before myotomy, postmyotomy, and following Dor fundoplication. Distensibility index is defined as the narrowest cross-sectional area divided by the corresponding pressure expressed in mm/mm Hg. Heller myotomy was found to lead to significant changes in the distensibility characteristics of the EGJ. Minimum esophageal diameter and EGJ distensibility increased significantly with Heller myotomy.

Background Hospital readmissions are a quality indicator in bariatric surgery. In recent years, duration of stay after bariatric surgery has trended down greatly. We hypothesized that a shorter postoperative hospitalization does not increase the likelihood of readmission. Methods The University HealthSystem Consortium (UHC) is an alliance of academic medical centers and affiliated hospitals. The UHC's clinical database contains information on inpatient stay and returns (readmissions) up to 30 days after discharge. A multicenter analysis of outcomes was performed by the use of data from the January 2009 to December 2013 for patients 18 years and older. Patients were identified by bariatric procedure International Classification of Diseases, Ninth Revision, codes and restricted by diagnosis codes for morbid obesity. Results A total of 95,294 patients met inclusion criteria. The mean patient age was 45.4 (±0.11) years, and 73,941 (77.6%) subjects were female. There were 5,423 (5.7%) readmissions within the study period. Patients with hospitalizations of 3 days and more than 3 days were twice and four times as likely to be readmitted than those with hospitalizations of one day, respectively ( P Conclusion Patients with longer postoperative hospitalizations were more likely to be readmitted after bariatric surgery. Early discharge does not appear to be associated with increased readmission rates.

Various surgical techniques exist to create the gastrojejunostomy during laparoscopic Roux-en-Y gastric bypasses (LRYGB). A hand-sewn anastomosis (HSA) and circular-stapled anastomosis (CSA) are both common techniques. We hypothesized that the CSA was associated with a greater incidence of anastomotic complications. As a secondary aim, we sought to determine if weight loss varied by technique.This study is a retrospective review of patients who underwent primary LRYGB at the Medical College of Wisconsin from January 2010 to December 2011. Procedures were performed by one of 2 surgeons, each with a preferred gastrojejunostomy technique. Clinical information and patient outcomes were followed up to one year.A total of 190 patients underwent LRYGB during the study interval. The majority of patients underwent HSA. Forty-one of 190 (21.6%) patients experienced one or more complications. Most complications were Clavien Classification Grade III and were experienced within 30 days of surgery in 3 (2.2%) HSA patients and 6 (10.9%) CSA patients (P = .02). Anastomotic complications occurred more frequently with the CSA technique (marginal ulcer 5.5% CSA versus .7% HSA; P = .04 and stenosis 16.4% CSA versus 3% HSA; P = .01). There were no gastrojejunostomy leaks in this series. Operative time was significantly longer in HSA patients (204 minutes HSA versus 166 minutes CSA; P.01), but length of hospital stay did not differ. Weight loss at 12 months was similar between techniques (69.4% percent excess BMI lost (EBMIL) HSA versus 76.6% EBMIL CSA; P = .11). No patients were lost to follow-up at 30 days. Thirty-five patients (19%) were lost to follow-up by one year.The CSA technique of gastrojejunostomy in gastric bypass is associated with a higher rate of nonlife threatening anastomotic complications than the HSA technique. Operative times are significantly longer for HSA, but length of hospital stay (LOS) and long-term weight loss are equivalent.

Objective: Despite widespread use of proton pump inhibitors (PPIs), the incidence of esophageal adenocarcinoma (EAC) continues to rise. PPIs reduce reflux acidity, but only transiently inactivate gastric enzymes. Nonacid reflux, specifically nonacid pepsin, contributes to carcinogenesis in the larynx. Given the carcinogenic potential of pepsin and inefficacy of PPIs to prevent EAC, the presence and effect of pepsin in the esophagus should be investigated. Methods: Normal and Barrett’s biopsies from 8 Barrett’s esophagus patients were collected for pepsin analysis via Western blot and reverse transcriptase-polymerase chain reaction (RT-PCR). Human esophageal cells cultured from healthy patients were treated with pepsin (0.01-1 mg/mL; 1-20 hours), acid (pH 4) ± pepsin (5 minutes); real-time RT-PCR, ELISA, and cell migration were assayed. Results: Pepsin was detected in all 8 Barrett’s and 4 of 8 adjacent normal specimens. Pepsinogen mRNA was observed in 22 Barrett’s, but not in normal adjacent samples. Pepsin induced PTSG2 (COX-2) and IL-1β expression and cell migration in vitro. Conclusions: Pepsin is synthesized by metaplastic, Barrett’s esophageal mucosa. Nonacid pepsin increases metrics of tumorigenicity in esophageal epithelial cells in vitro. These findings implicate refluxed and locally synthesized pepsin in development and progression of EAC and, in part, explain the inefficacy of PPIs in the prevention of EAC.

Inguinal hernia repair, laparoscopic or open, is one of the most frequently performed operations in general surgery. Postoperative urinary retention (POUR) can occur in 0.2-35 % of patients after inguinal hernia repair. The primary objective of this study was to determine the incidence of POUR after inguinal hernia repair. As a secondary goal, we sought to determine whether perioperative and patient factors predicted urinary retention.This study is a retrospective review of patients who underwent inguinal hernia repair with synthetic mesh at the Medical College of Wisconsin from January 2007 to June 2012. Procedures were performed by four surgeons. Clinical information and perioperative outcomes were collected up to hospital discharge. Urinary retention was defined as need for urinary catheterization postoperatively.A total of 192 patients were included in the study (88 bilateral, 46 %) and (104 unilateral, 54 %). The majority of subjects (76 %) underwent laparoscopic repair. The overall POUR rate was 13 %, with 25 of 192 patients requiring a Foley catheter prior to discharge. POUR was significantly associated with bilateral hernia repairs (p = 0.04), BMI ≥ 35 kg/m(2) (p = 0.05) and longer operative times (p = 0.03). Based on odds ratio (OR) estimates, for every 10-min increase in operative time, an 11 % increase in the odds of urinary retention is expected (OR 1.11, CI 1.004-1.223; p = 0.04). For every 10-min increase in operative time, an 11 % increase in POUR is expected.Bilateral hernia repairs, BMI ≥ 35 kg/m(2), and operative time are significant predictors of POUR. These factors are important to determine potential risk to patients and interventions such as strict fluid administration, use of catheters, and potential premedication.

Background Average costs associated with common procedures can vary by surgeon without a corresponding variation in outcome or case complexity. Methods De-identified cost and equipment utilization data were collected from our hospital for elective laparoscopic cholecystectomy performed by 17 different surgeons over a 6-month period. A group of surgeons used this data to design a standardized equipment pick list that became optional (not mandated) for laparoscopic cholecystectomy. Cost and consumable surgical supply utilization data were collected for six months prior to and following the creation of the standardized pick-list. Results 280 elective laparoscopic cholecystectomies were performed during the study interval. In the 6 months after standardized pick list creation, the cost of disposable supplies utilized per case decreased by 32%. Conclusions Surgical cost savings can be achieved with standardized procedure pick lists and attention to the cost of consumable surgical supplies.

General Surgery is currently the fastest growing specialty with regards to robotic surgical system utilization. Contrary to the experience in laparoscopy, simulator training for robotic surgery is not widely employed partly because robotic surgical simulators are expensive. We sought to determine the effect of a robotic simulation curriculum and whether robotic surgical skills could be derived from those psychomotor skills attained in laparoscopic training. Twenty-seven trainees with no prior robotic experience and limited laparoscopy exposure were randomly assigned to one of three training groups: no simulator training, training on a fundamentals of laparoscopic surgery (FLS™) standard box trainer, and training on a robotic computer based simulator (da Vinci Skills Simulator™). Baseline robotic surgical skills were assessed on the clinical robot docked to a standard FLS trainer box on two tasks—intracorporeal knot tying and peg transfer. Subjects subsequently underwent four 1-h long training sessions in their assigned training environment over a course of several weeks. Robotic surgical skills were reassessed on the robot on the same two tasks used to assess skills prior to training. FLS training resulted in a greater score improvement than no training for both knot and peg scores. FLS training was also determined to result in greater score improvement than robotic simulator training for knot tying. There was no significant difference in peg transfer or knot tying scores when comparing robotic simulator training and no training. Robotic surgical skills can be in part derived from psychomotor skills developed in a laparoscopic trainer, especially for complex skills such as intracorporeal knot tying. Acquisition of robotic surgical skills may be enhanced by practice on a laparoscopic simulator using the FLS curriculum. This may be especially helpful when a robotic simulator is not available or is poorly accessible.

Over 300,000 ventral hernia repairs (VHRs) are performed each year in the US. We sought to assess the economic burden related to ventral hernia recurrences with a focused comparison of those with the initial open versus laparoscopic surgery. The Premier Alliance database from 2009 to 2014 was utilized to obtain patient demographics and comorbid indices, including the Charlson comorbidity index (CCI). Total hospital cost and resource expenses during index laparoscopic and open VHRs and subsequent recurrent repairs were also obtained. The sample was separated into laparoscopic and open repair groups from the initial operation. Adjusted and propensity score matched cost outcome data were then compared amongst groups. One thousand and seventy-seven patients were used for the analysis with a recurrence rate of 3.78 %. For the combined sample, costs were significantly higher during recurrent hernia repair hospitalization ($21,726 versus $19,484, p

Frailty is a measure of physiological reserve that has been used to predict outcomes after surgical procedures in the elderly. We hypothesized that frailty would be associated with outcomes after paraesophageal hernia (PEH) repair.The National Surgical Quality Improvement Program database (2011-2013) was queried for International Classification of Diseases, Version 9 and Current Procedural Terminology codes associated with PEH repair in patients aged ≥ 60 y. A previously described modified frailty index (mFI), based on 11 clinical variables in National Surgical Quality Improvement Program was used to quantify frailty. Multivariate logistic regression was used to determine the relationship between frailty, complications, and mortality.Of the 4434 PEH repairs that met inclusion criteria, 885 records were included in the final analysis (20%). Excluded patients were missing one or more variables in the mFI. The rate of complications that were Clavien-Dindo Grade ≥ 3 was 6.1%. Mortality was 0.9%. The readmission rate was 8.2%, and 10.9% of patients were discharged to a facility other than home. Relative to mFI scores of 0, 1, 2, and ≥3, the respective occurrence percentages were as follows; Grade ≥3 complication: 3.2%, 4.7%, 9.8%, and 23.3% (P 0.0001; odds ratio [OR] 3.51; confidence interval [CI] 1.46-8.46); mortality: 0.0%, 0.9%, 1.8%, and 2.3% (P = 0.0974); discharge to facility other than home: 4.4%, 10.9%, 15.7%, and 31.7% (P 0.0001; OR 4.07; CI 1.29-12.82); and readmission: 8.9%, 6.8%, 8.5%, and 16.3% (P = 0.1703; OR 1.01; CI 0.36-2.84). Complications and discharge destination were significantly correlated with the mFI.Frailty, as assessed by the mFI, is correlated with postoperative complications and discharge to a facility other than home after PEH repair.

We sought to evaluate the feasibility, safety, and difficulty of performing the per-oral endoscopic myotomy (POEM) procedure in the setting of a prior Heller myotomy using a survival porcine model.Four pigs underwent laparoscopic Heller myotomy with Dor partial anterior fundoplication followed by the POEM performed 4 weeks later. Two additional pigs served as controls, undergoing only the POEM.All procedures were completed without complications. The revisional POEM was not significantly more difficult than POEM controls based on procedure time, POEM procedure components, or procedure difficulty scores. Revisional POEM had a longer mean operative time when compared with Heller myotomy (126.0 vs. 83.8 min; P0.01) but had a lower total difficulty score (28.6 vs. 52.1; P≪0.01).A POEM after previous Heller myotomy is safe and feasible in the porcine model and has potential as an option for patients suffering from recurrent or persistent symptoms after failed surgical myotomy.

Worldwide, the annual number of robotic surgical procedures continues to increase. Robotic surgical skills are unique from those used in either open or laparoscopic surgery. The acquisition of a basic robotic surgical skill set may be best accomplished in the simulation laboratory. We sought to review the current literature pertaining to the use of virtual reality (VR) simulation in the acquisition of robotic surgical skills on the da Vinci Surgical System.A PubMed search was conducted between December 2014 and January 2015 utilizing the following keywords: virtual reality, robotic surgery, da Vinci, da Vinci skills simulator, SimSurgery Educational Platform, Mimic dV-Trainer, and Robotic Surgery Simulator. Articles were included if they were published between 2007 and 2015, utilized VR simulation for the da Vinci Surgical System, and utilized a commercially available VR platform.The initial search criteria returned 227 published articles. After all inclusion and exclusion criteria were applied, a total of 47 peer-reviewed manuscripts were included in the final review.There are many benefits to utilizing VR simulation for robotic skills acquisition. Four commercially available simulators have been demonstrated to be capable of assessing robotic skill. Three of the four simulators demonstrate the ability of a VR training curriculum to improve basic robotic skills, with proficiency-based training being the most effective training style. The skills obtained on a VR training curriculum are comparable with those obtained on dry laboratory simulation. The future of VR simulation includes utilization in assessment for re-credentialing purposes, advanced procedural-based training, and as a warm-up tool prior to surgery.

Carbonic acid accumulation, which results from CO2 insufflation, can produce visceral and referred pain in the postoperative setting. Acetazolamide inhibits carbonic anhydrase, an enzyme that accelerates carbonic acid formation. We hypothesized that preoperative administration of acetazolamide would decrease postoperative pain in patients undergoing laparoscopic inguinal herniorrhaphy. A retrospective review was conducted of patients who underwent laparoscopic preperitoneal inguinal herniorrhaphy at the Medical College of Wisconsin between October 2012 and September 2014. Beginning in January 2014, patients began receiving 250 mg of acetazolamide preoperatively; patients prior to that time did not. The visual analog scale (range 0–10) was used to assess both preoperative pain and postoperative pain. A total of 66 patients underwent laparoscopic inguinal herniorrhaphy during the study interval. Of these, 22 (33 %) patients received acetazolamide preoperatively, and 44 (67 %) were included as controls. Overall mean pain scores were lower in the acetazolamide group (1.9 ± 1.45 vs 2.9 ± 1.5, p = 0.04). Specifically, patients who received acetazolamide reported lower pain scores immediately after surgery (0.6 ± 1.2 vs 1.9 ± 2.3, p = 0.01) and on post-op day one (2.3 ± 0.9 vs 4.0 ± 2.1, p = 0.04). Total morphine equivalents administered to manage postoperative pain were significantly less for the acetazolamide group (4.3 ± 4.8 mg) when compared to the control group (8.9 ± 8.4 mg), p = 0.04. Perioperative complications did not differ between the groups (p = 0.16). Acetazolamide appears to reduce pain in the immediate postoperative setting. Patients who received acetazolamide had lower pain scores postoperatively and required fewer narcotics for pain management prior to discharge.

Patients who present emergently with hernia-related concerns may experience increased morbidity with repair when compared with those repaired electively. We sought to characterize the outcomes of patients who undergo elective and nonelective ventral hernia (VH) repair using a large population-based data set.The Nationwide Inpatient Sample was queried for primary International Classification of Diseases, Ninth Revision codes associated with VH repair (years 2008-2011). Outcomes were inhospital mortality and the occurrence of a preidentified complication. Multivariable analysis was performed to determine the risk factors for complications and mortality after both elective and nonelective VH repair.We identified 74,151 VH repairs performed during the study interval. Of these procedures, 67.3% were elective and 21.6% were performed laparoscopically. Nonelective repair was associated with a significantly higher rate of morbidity (22.5% versus 18.8%, P 0.01) and mortality (1.8% versus 0.52, P 0.01) than elective repair. Elective repairs were more likely to occur in younger patients, Caucasians, and were more likely to be performed laparoscopically. Logistic modeling revealed that female gender, Caucasian race, elective case status, and laparoscopic approach were independently associated with a lower probability of complications and mortality. Minority status and Medicaid payer status were associated with increased probability of nonelective admission.Patients undergoing elective VH repair in the United States tend to be younger, Caucasian, and more likely to have a laparoscopic repair. Nonelective VH is associated with a substantial increase in morbidity and mortality. We recommend that patients consider elective repair of VHs because of the increased morbidity and mortality associated with nonelective repair.

Background: Electronic consent for research has shown success in clinical trial models, but has not been rigorously evaluated as an alternative to conventional paper consent. We sought to design a 21 CFR Part 11 compliant iPad-based electronic Informed Consent Form (eICF) with Research Electronic Data Capture (REDCap). As a secondary aim, we sought to compare subject workload between eICF and paper consent groups.Methods: This is a prospective, randomized study of subjects who completed an iPad-based eICF versus paper consent for research. The eICF was designed with REDCap and presented on an iPad. Subject workload was measured with the NASA Task Load Index (NASA-TLX) and subjective feedback in regards to consent process was collected.Results: A total of 116 subjects were screened for consent. Of which, 51 (44%) subjects provided informed consent and completed all study related procedures. Twenty-five (49%) eICF and 26 (51%) paper consents were completed. The eICF group rated a significantly greater preference to use the eICF for future research studies (6.4±1.5) compared to the paper consent group (5.0±1.9), pConclusion: In summary, we have demonstrated that an iPad-based eICF designed with REDCap is both 21 CFR Part 11 compliant and feasible in the clinical research setting. The eICF does not appear to be more technically difficult or demanding than conventional paper consent.