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Patients with coagulopathy requiring emergent appendectomy constitute a challenging patient population. It is unclear whether laparoscopic appendectomy (LA) is as safe as open appendectomy (OA) in these patients.We queried the ACS-NSQIP database for adults with coagulopathy undergoing emergent appendectomy from 2014 to 2017. Demographic characteristics and operative outcomes were compared between the two groups. Propensity weighting for LA versus OA was estimated using augmented inverse probability of treatment weights (AIPW).A total of 137,429 patients were included, of which 7049 (5%) had coagulopathy. In patients with coagulopathy, LA was the most common approach (89%). After AIPW, there was no difference in the adjusted risk of either postoperative transfusion or 30-day reoperation between OA and LA. LA was associated with reduced operative time (56 versus 75 min), length of stay (3.5 versus 7.0 d), and surgical site infection rate (6% versus 13%) compared to OA.Patients with coagulopathy represent a significant proportion of those undergoing an appendectomy. The majority of patients with coagulopathy who require appendectomy undergo LA, and this approach appears to be safe with regard to transfusion requirement and reoperation.

Volumetric analysis is being increasingly utilized in the preoperative evaluation of complex incisional hernias. Three-dimensional (3D) reconstruction of abdominal computed tomography (CT) scan has been used to obtain surface area (SA) and volume (Vol.) measurements, while others have used simple mathematical formulas to obtain SA and Vol. estimates without 3D reconstruction. Our objective was to assess the correlation of SA and Vol. measurements and estimates of complex incisional hernias. We conducted a retrospective agreement study of adults who underwent abdominal wall reconstruction from 2007 to 2018. Demographics, hernia characteristics, and operative data were collected from the medical record. SA and Vol. measurements were obtained after 3D CT reconstruction. Linear CT variables were obtained independently by two surgeons and SA and Vol. estimates were calculated. Because both surgeons reported similar results, only lead author values are reported in the abstract. We used Pearson’s correlation coefficient (r) to assess inter-rater agreement and the agreement between SA and Vol. measurements and estimates. A total of 108 patients were eligible for analysis. The mean age was 57 ± 11 years and 53 (49%) were female. 42 (39%) hernias were recurrent, 10 (9%) patients had a stoma, and 9 (8%) had a history of open abdomen. The mean defect width was 11 ± 4 cm and mean defect surface area (DSA) was 150 ± 95 cm2. Inter-rater agreement of SA and Vol. estimates was high (r ≥ 0.80). There was high correlation between SA and Vol. measurements and estimates for DSA, hernia sac volume (HSV), abdominal cavity volume (ACV), and HSV/ACV ratio (r = 0.81, 0.89, 0.94 and 0.91, respectively). SA and Vol. estimates demonstrated high level of agreement with SA and Vol. measurements using 3D reconstruction. SA and Vol. estimates can be obtained using simple mathematical formulas using easily obtained linear variables negating the need for the time and effort consuming 3D reconstruction.

Improved outcomes of abdominal wall reconstruction (AWR) have been shown when tension-free fascial closure (TFFC) is achieved. Our objective was to determine the clinical and radiologic predictors of TFFC in patients undergoing AWR. We conducted a single institution retrospective cohort study of adults who underwent AWR between 2007 and 2018. Demographics, hernia characteristics and operative data were collected. Linear and volumetric variables were obtained from preoperative abdominal CT scans, the latter following 3D reconstruction. Logistic regression was used to evaluate predictors of TFFC. Area under the curve (AUC) ≥ 0.70 was considered to have acceptable discrimination. A total of 108 patients were eligible for analysis. The mean age was 57 ± 11 years and 53 (49%) were female. 42 (39%) hernias were recurrent, 10 (9%) patients had a stoma and 9 (8%) had a history of open abdomen. The mean defect width was 11 ± 4 cm and mean defect surface area was 150 ± 95 cm2. The most common AWR technique was endoscopic component separation 75 (69%). TFFC was achieved in 90 (83%) patients. No demographics or 3D volumetric measures were predictive of TFFC (all AUC

Confocal laser endomicroscopy (CLE) is a novel endoscopic adjunct that allows real-time in vivo histological examination of mucosal surfaces. By using intravenous or topical fluorescent agents, CLE highlights certain mucosal elements that facilitate an optical biopsy in real time. CLE technology has been used in different organ systems including the gastrointestinal tract. There has been numerous studies evaluating this technology in gastrointestinal endoscopy, our aim was to evaluate the safety, value, and efficacy of this technology in the gastrointestinal tract. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Technology and Value Assessment Committee (TAVAC) performed a PubMed/Medline database search of clinical studies involving CLE in May of 2018. The literature search used combinations of the keywords: confocal laser endomicroscopy, pCLE, Cellvizio, in vivo microscopy, optical histology, advanced endoscopic imaging, and optical diagnosis. Bibliographies of key references were searched for relevant studies not covered by the PubMed search. Case reports and small case series were excluded. The manufacturer’s website was also used to identify key references. The United States Food and Drug Administration (U.S. FDA) Manufacturer And User facility and Device Experience (MAUDE) database was searched for reports regarding the device malfunction or injuries. The technology offers an excellent safety profile with rare adverse events related to the use of fluorescent agents. It has been shown to increase the detection of dysplastic Barrett’s esophagus, gastric intraepithelial neoplasia/early gastric cancer, and dysplasia associated with inflammatory bowel disease when compared to standard screening protocols. It also aids in the differentiation and classification of colorectal polyps, indeterminate biliary strictures, and pancreatic cystic lesions. CLE has an excellent safety profile. CLE can increase the diagnostic accuracy in a number of gastrointestinal pathologies.

Wide-area transepithelial sampling of the esophagus with computer-assisted three-dimensional analysis (WATS3D, CDx Diagnostics, Suffern, NY) is an adjunctive technique to random biopsies for early detection of Barrett’s esophagus. The aim of the SAGES Technology and Value Assessment Committee aims is to evaluate the efficacy, value, and safety of WATS3D. Clinical studies involving WATS3D were identified via a search of the PubMed/Medline databases ( www.ncbi.nlm.nih.gov/pubmed ) conducted in March of 2019 using search terms, such as wide-area transepithelial sampling, three-dimensional (3D) computer-assisted analysis, WATS-3D, Barrett’s esophagus and WATS-3D, Barrett’s esophagus and wide-area transepithelial sampling with three-dimensional computer-assisted analysis, Barrett’s esophagus, and emerging technology. Bibliographies of key references were searched for relevant studies not covered by the PubMed search. Case reports and small case series were excluded. No significant morbidity or mortality was reported within the literature associated with the WATS3D technology. WATS3D increases diagnostic yield by 38–150% for Barrett’s Esophagus, by 40–150% for Low Grade Dysplasia; and by 420% for High Grade Dysplasia; when compared to forceps biopsy alone. WATS3D technique has very high inter-observer agreement for the pathological diagnosis of non-dysplastic and dysplastic Barrett’s Esophagus. Increased detection of pre-malignant diseases of the esophagus by the adjunctive use of WATS3D supports screening and surveillance by the adjunctive use of WATS3D during upper endoscopy in appropriate patients. Wide-area transepithelial sampling with three-dimensional computer-assisted analysis (WATS3D, CDx Diagnostics) is a safe and effective adjunct to forcep biopsies in the evaluation of Barrett’s Esophagus, Low Grade Dysplasia, and High Grade Dysplasia.

There are a paucity of data regarding the safety of laparoscopic inguinal hernia repair in patients on antiplatelet and anticoagulant therapy (APT/ACT). We aim to compare the postoperative outcomes of laparoscopic (LIHR) vs. open repair of inguinal hernias (OIHR) in patients on APT/ACT.We conducted a retrospective cohort study using the Vizient Clinical DataBase. We included adults receiving APT/ACT who underwent outpatient, elective, and primary inguinal hernia repair between 2017 and 2019. Subgroup analysis was performed on patients receiving aspirin, non-aspirin antiplatelet, and anticoagulant therapy. Mixed-effects logistic regression was used to assess both the effect of APT/ACT on the probability of receiving LIHR vs OIHR and their respective outcomes.A total of 142,052 repairs were included, of which 21,441 (15%) were performed on patients receiving APT/ACT. Mean age was 69 years (± 10.5) and 93% were male. 19% of hernias were bilateral. 40% of operations were performed at teaching hospitals. On multivariable analysis, patients on non-aspirin antiplatelet or anticoagulant therapy were more likely to receive an open procedure (Odds Ratio (OR) = 1.2; 95% Confidence Intervals (CI) [1.1, 1.4] and OR = 1.4; CI [1.3, 1.5], respectively). LIHR was associated with a lower rate of length of stay 1 day (OR = 0.65; CI [0.5, 0.9]). Rates of 30-day postoperative hematoma, transfusions, stroke, myocardial infarction, deep venous thrombosis, pulmonary embolism, readmission, and emergency department visits were similar between the two operative approaches.Patients on APT/ACT represent a substantial proportion of those undergoing inguinal hernia repair. Non-aspirin antiplatelet or anticoagulant therapy are independent predictors of choosing an open repair. Laparoscopic repair appears to be safe in patients receiving APT/ACT under current perioperative management patterns.

Confocal laser endomicroscopy (CLE) is a novel endoscopic adjunct that allows real-time in vivo histological examination of mucosal surfaces. By using intravenous or topical fluorescent agents, CLE highlights certain mucosal elements that facilitate an optical biopsy in real time. CLE technology has been used in different organ systems including the gastrointestinal tract. There has been numerous studies evaluating this technology in gastrointestinal endoscopy, our aim was to evaluate the safety, value, and efficacy of this technology in the gastrointestinal tract.The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Technology and Value Assessment Committee (TAVAC) performed a PubMed/Medline database search of clinical studies involving CLE in May of 2018. The literature search used combinations of the keywords: confocal laser endomicroscopy, pCLE, Cellvizio, in vivo microscopy, optical histology, advanced endoscopic imaging, and optical diagnosis. Bibliographies of key references were searched for relevant studies not covered by the PubMed search. Case reports and small case series were excluded. The manufacturer's website was also used to identify key references. The United States Food and Drug Administration (U.S. FDA) Manufacturer And User facility and Device Experience (MAUDE) database was searched for reports regarding the device malfunction or injuries.The technology offers an excellent safety profile with rare adverse events related to the use of fluorescent agents. It has been shown to increase the detection of dysplastic Barrett's esophagus, gastric intraepithelial neoplasia/early gastric cancer, and dysplasia associated with inflammatory bowel disease when compared to standard screening protocols. It also aids in the differentiation and classification of colorectal polyps, indeterminate biliary strictures, and pancreatic cystic lesions.CLE has an excellent safety profile. CLE can increase the diagnostic accuracy in a number of gastrointestinal pathologies.

Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure that, in the United States, is traditionally performed by gastroenterologists. We hypothesized that when performed by well-trained surgeons, ERCP can be performed safely and effectively. The objectives of the study were to assess the rate of successful cannulation of the duct of interest and to assess the 30-day complication and mortality rates. We retrospectively reviewed the charts of 1858 patients who underwent 2392 ERCP procedures performed by five surgeons between August 2003 and June 2016 in two centers. Demographic and historical data, indications, procedure-related data and 30-day complication and mortality data were collected and analyzed. The mean age was 53.4 (range 7–102) years and 1046 (56.3%) were female. 1430 (59.8%) of ERCP procedures involved a surgical endoscopy fellow. The most common indication was suspected or established uncomplicated common bile duct stones (n = 1470, 61.5%), followed by management of an existing biliary or pancreatic stent (n = 370, 15.5%) and acute biliary pancreatitis (n = 173, 7.2%). A therapeutic intervention was performed in 1564 (65.4%), a standard sphincterotomy in 1244 (52.0%), stent placement in 705 (29.5%) and stone removal in 638 (26.7%). When cannulation was attempted, the rate of successful cannulation was 94.1%. When cannulation was attempted during the patient’s first ERCP the cannulation rate was 92.4%. 94 complications occurred (5.4%); the most common complication was post-ERCP pancreatitis in 75 (4.2%), significant gastrointestinal bleeding in 7 (0.4%), ascending cholangitis in 11 (0.6%) and perforation in 1 (0.05%). 11 mortalities occurred (0.5%) but none of which were ERCP-related. When performed by well-trained surgical endoscopists, ERCP is associated with high success rate and acceptable complication rates consistent with previously published reports and in line with societal guidelines.

Background It is expected that graduating general surgery residents be confident in performing common abdominal wall hernia repairs. The objective of our study was to assess the confidence of senior surgical residents in these procedures and to identify factors that correlate with confidence. Methods We performed a cross-sectional survey of PGY-4 and PGY-5 general surgery residents at ACGME-accredited programs in the United States in the spring of 2019. Respondents rated their confidence level in 12 hernia procedures on a Likert scale from 1 (not confident) to 5 (extremely confident). Respondents were classified as “Not Confident” (Not Confident, Minimally Confident, Neutral responses) or “Confident” (Confident, Extremely Confident responses). Resident characteristics, program characteristics, and operative experience were collected, and we calculated the area under the curve to screen which factors discriminated between those confident versus not. Multivariable Poisson regression was used to estimate prevalence ratios (PR) and 95% confidence intervals (CI) to identify which factors were most predictive. Results A total of 93 surveys were completed. Respondents reported low confidence rates (25%-60%) in the following hernia repairs: minimally invasive (MIS) inguinal, femoral, tissue (nonmesh) inguinal, pediatric inguinal, and abdominal wall reconstruction. High confidence rates (>80%) were reported for open umbilical, open ventral, and MIS ventral hernia repairs. For MIS inguinal hernia repair, PGY-5 level was associated with a twofold increase in confidence (PR = 2.01; 95% CI = 1.34-3.30), and dedicated research years were associated with low confidence (PR = 0.67; 95% CI = 0.43-1.04). In general, higher operative volumes of a specific repair were associated with increased confidence in that procedure. Conclusions Senior surgical residents reported low confidence in performing a variety of essential hernia repairs (particularly MIS inguinal, femoral, and tissue inguinal). Addressing factors associated with low confidence may help increase resident confidence.

Esophageal peptic stricture is a manifestation of long-standing gastroesophageal reflux disease. It usually involves the distal esophagus and results from chronic exposure of the lower esophagus to the acidic gastric fluid. Dysphagia is the most common presenting symptom. Gastric acid suppression with mechanical dilation (bougienage) or balloon dilation is the mainstay of therapy. Both forms of dilation are highly effective in treating the stricture and resolving the dysphagia. Recalcitrant strictures can be treated by intramucosal steroid injection or esophageal stent placement.

Various adjuncts to common bile duct exploration exist, including biliary drains, stents, papillary balloon dilation, and sphincterotomy. These adjuncts will be reviewed in detail, with a discussion of techniques, outcomes, and potential complications. A proper understanding and utilization of these adjuncts will help increase the chance of success in difficult or unusual cases of choledocholithiasis.

Background We evaluated the incidence and presentations of internal hernias (IH) after laparoscopic antecolic Roux-en-Y gastric bypass (RYGB) at our institution. Methods We retrospectively reviewed the records of 594 patients who underwent laparoscopic antecolic RYGB at our institution between December 2004 and December 2010. Results Five hundred ninety-four patients underwent laparoscopic antecolic RYGB with a mean follow-up of 50.5 months. Thirty-six patients developed 37 IH (6.2 %) requiring surgical intervention. Mean age of IH patients was 36.9 years. Thirty-one out of 36 were female. Mean preoperative BMI was 44.3 Kg/m(2). The mean time of presentation after their RYGB was 25.9 months. The mean % excess body weight loss at time of presentation was 54.0 %. Twenty-five out of 37 of IH occurred at Petersen's space; 9/37 IH occurred under the jejunojejunostomy; three patients had hernias at both locations. Mesenteric swirling was the most common CT scan finding in 20/36 (55.6 %). Six out of 36 CT were initially read as normal; however, on retrospective review by a radiologist, abnormalities indicating IH were found in 4/6. Patients presented with different degrees of acuity: 6/37 with chronic abdominal pain and 28/37 with acute abdominal pain. Bowel necrosis was found in 3/37. Conclusion IH is a serious and potentially fatal complication of RYGB. Presentation can vary from chronic abdominal pain to bowel necrosis. CT is helpful in providing diagnosis; however, careful attention to the specific signs of small bowel volvulus, such as mesenteric swirl sign, should be given. IH should be considered in RYGB patients who present with even vague symptoms.