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1. Robotic Subtotal Cholecystectomy in a Geriatric Acute Care Surgery Patient with Super Obesity

Author

Diane Bronikowski, Dominic Lombardo, Connie DeLa’O, and Nova Szoka

Subjects
Surgery, RD1-811
Abstract

Introduction. Unique challenges exist with conventional laparoscopic operations in patients with super obesity (BMI>50). Limited literature is available regarding use of the robotic platform to treat patients with super obesity or acute care surgery patients. This case describes an interval robotic subtotal cholecystectomy in an elderly patient with super obesity and multiple comorbidities. Case Description. A 74-year-old male with a BMI of 59.9 developed acute cholecystitis. He was deemed excessively high risk for operative intervention due to concurrent comorbid conditions and underwent percutaneous cholecystostomy. After a few months, a cholangiogram demonstrated persistent cystic duct occlusion. The patient expressed interest in tube removal and elective interval cholecystectomy. After preoperative risk stratification and optimization, he underwent a robotic subtotal cholecystectomy with near infrared fluorescence cholangiography. The patient was discharged on postoperative day one and recovered without complications. Discussion. Obesity is a risk factor for acute cholecystitis, which is most commonly treated with conventional laparoscopy (CL). CL is technically restraining and difficult to perform in patients with super obesity. The body habitus of patients with super obesity can impair proper instrumentation and increase perioperative morbidity. In this case, robotic assisted cholecystectomy console improved surgeon ergonomics and provided support for proper instrumentation. Robotic, minimally invasive cholecystectomy approaches may reduce perioperative morbidity in patients with super obesity. Further studies are necessary to address the role of robotic surgery in acute care surgery patients with super obesity.

Published
2021
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2. Trauma and nontrauma damage-control laparotomy: The difference is delirium (data from the Eastern Association for the Surgery of Trauma SLEEP-TIME multicenter trial)

Author

Sigrid Burruss, Xian Luo-Owen, Zoltan H. Nemeth, James M. Bardes, Heidi Kemmer, Nina E. Glass, Areg Grigorian, Alexa Dorricott, Meghan Cochran-Yu, Adam Gutierrez, Samantha Toscano, Nicholas T. Duletzke, Cassandra C. Krause, Connie Dela'O, Eugenia Kwon, David Turay, Leon Naar, Jade Nunez, Haytham Kaafarani, Kaitlin McArthur, Grace Chang, Kyle Leneweaver, Oscar D. Guillamondegui, Kaushik Mukherjee, Mark J. Lieser, Aimee Lariccia, Simon Moradian, Ahsan Butt, Eric J. Ley, Salina M. Wydo, Chloe Krasnoff, Jeffry Nahmias, Michelle Kincaid, Joseph A. Posluszny, Michele Fiorentino, Sarah R. Lombardo, and Lourdes Swentek

Subjects
Male, medicine.medical_treatment, damage-control laparotomy, Abdominal Injuries, Cardiorespiratory Medicine and Haematology, Critical Care and Intensive Care Medicine, law.invention, 0302 clinical medicine, Postoperative Complications, Injury Severity Score, law, Risk Factors, Laparotomy, education.field_of_study, Analgesics, Abbreviated Injury Scale, Incidence, Middle Aged, Intensive care unit, Analgesics, Opioid, Intensive Care Units, Infectious Diseases, sedation, Anesthesia, Female, Patient Safety, medicine.symptom, nontrauma, Adult, Physical Injury - Accidents and Adverse Effects, Sedation, Population, Clinical Trials and Supportive Activities, Clinical Sciences, Opioid, Nursing, Trauma, Article, 03 medical and health sciences, Young Adult, delirium, Clinical Research, Multicenter trial, medicine, Humans, education, Dialysis, Traumatic Head and Spine Injury, Retrospective Studies, business.industry, Delirium, 030208 emergency & critical care medicine, Length of Stay, Emergency & Critical Care Medicine, United States, Linear Models, Surgery, business, Sleep
Abstract

BackgroundDamage-control laparotomy (DCL) has been used for traumatic and nontraumatic indications. We studied factors associated with delirium and outcome in this population.MethodsWe reviewed DCL patients at 15 centers for 2 years, including demographics, Charlson Comorbidity Index (CCI), diagnosis, operations, and outcomes. We compared 30-day mortality; renal failure requiring dialysis; number of takebacks; hospital, ventilator, and intensive care unit (ICU) days; and delirium-free and coma-free proportion of the first 30 ICU days (DF/CF-ICU-30) between trauma (T) and nontrauma (NT) patients. We performed linear regression for DF/CF-ICU-30, including age, sex, CCI, achievement of primary fascial closure (PFC), small and large bowel resection, bowel discontinuity, abdominal vascular procedures, and trauma as covariates. We performed one-way analysis of variance for DF/CF-ICU-30 against traumatic brain injury severity as measured by Abbreviated Injury Scale for the head.ResultsAmong 554 DCL patients (25.8% NT), NT patients were older (58.9 ± 15.8 vs. 39.7 ± 17.0 years, p < 0.001), more female (45.5% vs. 22.1%, p < 0.001), and had higher CCI (4.7 ± 3.3 vs. 1.1 ± 2.2, p < 0.001). The number of takebacks (1.7 ± 2.6 vs. 1.5 ± 1.2), time to first takeback (32.0 hours), duration of bowel discontinuity (47.0 hours), and time to PFC were similar (63.2 hours, achieved in 73.5%). Nontrauma and T patients had similar ventilator, ICU, and hospital days and mortality (31.0% NT, 29.8% T). Nontrauma patients had higher rates of renal failure requiring dialysis (36.6% vs. 14.1%, p < 0.001) and postoperative abdominal sepsis (40.1% vs. 17.1%, p < 0.001). Trauma and NT patients had similar number of hours of sedative (89.9 vs. 65.5 hours, p = 0.064) and opioid infusions (106.9 vs. 96.7 hours, p = 0.514), but T had lower DF/CF-ICU-30 (51.1% vs. 73.7%, p = 0.029), indicating more delirium. Linear regression analysis indicated that T was associated with a 32.1% decrease (95% CI, 14.6%-49.5%; p < 0.001) in DF/CF-ICU-30, while achieving PFC was associated with a 25.1% increase (95% CI, 10.2%-40.1%; p = 0.001) in DF/CFICU-30. Increasing Abbreviated Injury Scale for the head was associated with decreased DF/CF-ICU-30 by analysis of variance (p < 0.001).ConclusionNontrauma patients had higher incidence of postoperative abdominal sepsis and need for dialysis, while T was independently associated with increased delirium, perhaps because of traumatic brain injury.Level of evidenceTherapeutic study, level IV.

Published
2021

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