This genetic blistering disease is the result of mutations in
COL7A1
, which encodes type VII collagen. Topical HSV-1 gene therapy delivering
COL7A1
resulted in greater wound healing at 6 months than ...placebo.
Background
Few studies have examined robotic surgery from a programmatic standpoint, yet this is how hospitals evaluate return on investment clinically and fiscally. This study examines the 10-year ...experience of a robotic program at a single academic institution.
Study design
All robotic operations performed at our institution from August 2005 to December 2016 were reviewed. Data were collected from the robotic system and hospital databases.
Results
A total of 3485 robotic operations were performed. Yearly case volume nearly quadrupled. There have been 37 robotic-trained surgeons in 5 specialties performing 53 different operations. Rate of conversion to open was 4.2%. American Society of Anesthesiologists (ASA) class increased over time, with ASA class 3 increasing from 20% of patients to 45% of patients.
Average case time in 2005 was 453 min, but decreased by 46% to 246 min by 2007, then remained relatively stable (range 226–247). Operating efficiency improved, with room time and case time decreasing by 9% in the past 4 years.
Average cost for robotic supplies was $1519 per case. Additional costs per case related to equipment and contracts totaled an average of $11,822.
Average length of stay (LOS) for robotic cases was 3.3 days, compared to 3.0 days for laparoscopic and 7.0 for open. Cost per day for admission after robotic surgery was 1.7 times greater than the cost of open or laparoscopic surgery. Total admission costs of robotic operations were 1.5 times those of laparoscopic surgery, but less than open operations. Readmissions following robotic cases were lower than open (15% v 26%,
p
< 0.0001).
Conclusions
Over 10 years, the use of robotic technology has grown significantly at our institution, with good fiscal and clinical outcomes. Operating room costs are high; however, efficiency has improved, LOS is shorter, admission costs are lower than open operations, and readmission rates are lower.
Background
The use of the surgical robot has increased annually since its introduction, especially in general surgery. Despite the tremendous increase in utilization, there are currently no validated ...curricula to train residents in robotic surgery, and the effects of robotic surgery on general surgery residency training are not well defined. In this study, we aim to explore the perceptions of resident and attending surgeons toward robotic surgery education in general surgery residency training.
Methods
We performed a qualitative thematic analysis of in-person, one-on-one, semi-structured interviews with general surgery residents and attending surgeons at a large academic health system. Convenient and purposeful sampling was performed in order to ensure diverse demographics, experiences, and opinions were represented. Data were analyzed continuously, and interviews were conducted until thematic saturation was reached, which occurred after 20 residents and seven attendings.
Results
All interviewees agreed that dual consoles are necessary to maximize the teaching potential of the robotic platform, and the importance of simulation and simulators in robotic surgery education is paramount. However, further work to ensure proper access to simulation resources for residents is necessary. While most recognize that bedside-assist skills are essential, most think its educational value plateaus quickly. Lastly, residents believe that earlier exposure to robotic surgery is necessary and that almost every case has a portion that is level-appropriate for residents to perform on the robot.
Conclusions
As robotic surgery transitions from novelty to ubiquity, the importance of effective general surgery robotic surgery training during residency is paramount. Through in-depth interviews, this study provides examples of effective educational tools and techniques, highlights the importance of simulation, and explores opinions regarding the role of the resident in robotic surgery education. We hope the insights gained from this study can be used to develop and/or refine robotic surgery curricula.
Background
Rectal neuroendocrine tumors comprise 20% of neuroendocrine tumors in the alimentary tract, but there is controversy surrounding the optimal management of this disease. The purpose of this ...study is to better define treatment for patients with rectal neuroendocrine tumors.
Methods
Using the National Cancer Database, we analyzed patients with rectal neuroendocrine tumors between 2004 and 2015. Patients with metastatic disease and missing treatment data were excluded. We examined overall survival stratified by tumor size, treatment type, and presence of positive lymph nodes using Kaplan-Meier analysis with log-rank test. Cox proportional hazard regression model was performed to identify factors associated with overall survival.
Results
In total, 17,448 patients with rectal neuroendocrine tumors were identified; 16,531 of these patients met inclusion criteria. The majority of patients had tumors ≤ 10 mm (9216 patients, 79.8%), and approximately 90% underwent local excision. The probability of 5-year overall survival was significantly higher for patients with smaller tumors (≤ 10 mm: 94.1% 11–20 mm: 85.7%, > 20 mm: 71.8%;
p
< 0.001) and those with no positive lymph nodes (91.4% versus 53.3%,
p
< 0.001). The probability of 5-year overall survival differed based on treatment modality (local excision: 93.6%, radical resection: 79.1%, observation alone: 77.1%;
p
< 0.001). On multivariable Cox regression, when compared to local excision, radical resection was not associated with a difference in overall survival but observation alone was associated with significantly worse OS (HR = 2.750,
p
< 0.001).
Conclusions
There is a significant difference in overall survival between patients who underwent local excision versus observation alone. Excision of the tumor should be offered to all patients with rectal neuroendocrine tumors who are appropriate surgical candidates, regardless of the tumor size.
Background
Autologous fat grafting (AFG) has shown promise in the treatment of complex wounds, with trials reporting good healing rates and safety profile. We aim to investigate the role of AFG in ...managing complex anorectal fistulas.
Methods
This was a retrospective review of a prospectively maintained IRB-approved database. We examined the rates of symptom improvement, clinical closure of fistula tracts, recurrence, complications, and worsening fecal incontinence. Perianal disease activity index (PDAI) was obtained for patients undergoing combination of AFG and fistula plug treatment.
Results
In total, 52 unique patients underwent 81 procedures, of which Crohn’s was present in 34 (65.4%) patients. The majority of patients previously underwent more common treatments such as endorectal advancement flap or ligation of intersphincteric fistula tract. Fat-harvesting sites and processing technique were selected by the plastic surgeons based on availability of trunk fat deposits. When analyzing patients by their last procedure, 41 (80.4%) experienced symptom improvement, and 29 (64.4%) experienced clinical closure of all fistula tracts. Recurrence rate was 40.4%, and complication rate was 15.4% (7 postoperative abscesses requiring I&D and 1 bleeding episode ligated at bedside). The abdomen was the most common site of lipoaspirate harvest at 63%, but extremities were occasionally used. There were no statistically significant differences in outcomes when comparing single graft treatment to multiple treatments, Crohn’s and non-Crohn’s, different methods of fat preparation, and diversion.
Conclusion
AFG is a versatile procedure that can be done in conjunction with other therapies and does not interfere with future treatments if recurrence occurs. It is a promising and affordable method to safely address complex fistulas.
Background
Anorectal fistulae resultant from Crohn’s disease (CD) is a clinical challenge. The advent of immune therapy (IT) has altered the way in which fistulae have responded to treatment. ...Endorectal advancement flap (ERAF) is a surgical procedure that is used to treat complex fistulae. We have employed ERAF as our second stage treatment of choice in this patient population. Our aim was to determine the success of ERAF in treating perianal fistulas in patients with CD in an era of IT.
Methods
Multicenter retrospective review from 2007 to 2017 of all patients with CD and a perianal fistulae who underwent ERAF.
Results
Forty-one flaps were performed in 39 patients with perianal CD with an average follow-up of 797 days. There were no significant differences in patient demographics; however, all patients who were diverted at the time of surgery had successful healing. Of patients, 73.2% were on IT at an average of 380 days prior to surgery. The duration of single-agent therapy was associated with better healing rates (
p
= 0.03). The overall failure rate was 19.5% (
n
= 8). Six patients underwent secondary techniques for fistulae closure; five were successful. In combination with the patients who did not initially fail, the overall healing rate was 92.6%.
Conclusions
This study demonstrates several factors that may improve fistulae closure for CD patients. Patients who were diverted prior to surgery did not have a fistulae recurrence. Patients who were on IT longer prior to ERAF were more likely to achieve successful closure.
Background
The rectum is a common site for neuroendocrine tumours of the gastrointestinal tract. Diagnosis of these tumours has been increasing in recent years, highlighting the need to better define ...treatment options for patients with rectal neuroendocrine tumours (rNETs).
Methods
We performed a retrospective analysis using the National Cancer Database (2004–2014) to compare overall survival (OS) between local excision (LE) and radical resection (RR). To minimize bias, we performed three propensity score‐matched comparisons stratified by tumour size: <10 mm, 10–20 mm, >20 mm. We compared OS by Kaplan–Meier analysis. We also examined margin status and postoperative outcomes for each comparison.
Results
A total of 12 996 patients underwent surgical treatment for rNET. There was no significant difference in probability of 10‐year OS between LE and RR for patients with tumours <10 mm (88.6% versus 83.8%, P = 0.631, respectively) and tumours 10‐20 mm (69.5% versus 69.3%, P = 0.226, respectively). In patients with tumours >20 mm, probability of 10‐year OS was significantly longer in the LE group (76.5% versus 37.0%, P < 0.001). For all tumour sizes <10 mm and >20 mm, RR had significantly higher rates of 30‐day readmission and negative margins. In subset analysis, there was no difference in OS for patients with positive margins after LE versus negative margins after RR for all tumour size groups.
Conclusions
Our findings suggest that LE is a reasonable treatment option in patients with rNETs, especially for patients with high perioperative risk. Limitations to this study include its retrospective nature and inability to analyse surgeon decision‐making.
In our propensity score match analysis of patients with rectal neuroendocrine tumours, we show that radical resection may not be associated with improved overall survival and that local excision is a reasonable treatment option for patients.
To determine barriers associated with the transition from bedside assistant to console surgeon for general surgery residents in the era of robotic surgery in general surgery training.
Qualitative ...thematic analysis using one-on-one interviews of general surgery residents and attendings conducted between June 2018 and February 2019.
An urban, academic, multihospital general surgery residency program with a robust robotic surgery program.
Convenient and purposeful sampling was performed to ensure a variety of resident graduate-years and attending subspecialties were represented. Sample size was determined by data saturation, which occurred after 20 resident and 7 attending interviews.
Residents identified the low volume of general surgery robotic cases, the infrequency of exposure to robotic surgery, and attending comfort with robotic surgery (and with teaching on the robot) as potential barriers in the transition from bedside assistant to console surgeon. Residents had to find a replacement bedside assistant in order to be the console surgeon, which was challenging. In addition, residents felt that the current culture surrounding robotic surgery is very hierarchal, limiting their exposure. Attendings’ trust in the residents’ console skills was a major determining factor in allowing residents on the console.
Most robotic surgery education curricula are sequential, requiring the resident to progress from bedside assistant to console surgeon. Unfortunately, there are many potential barriers for residents in the transition from bedside assistant to console surgeon. Some barriers apply to general surgery training overall, but are amplified in robotic surgery, while others are unique to robotic surgery education. Recognition of, and rectifying, these barriers may increase resident participation as the console surgeon.
Terminal complement pathway inhibition at the level of C5 alleviates symptoms of several diseases associated with complement overactivation. However, C5 blockade is associated with an increased risk ...of invasive meningococcal disease despite immunization. Targeting specific complement pathways proximal to C5 provides the theoretical advantage of leaving the other pathways (including the terminal pathway) intact for immune surveillance. We aimed to address the risk of
and
infections when inhibiting the classical pathway (CP) using a specific C1s inhibitor (TNT005). Addition of TNT005 to 20% normal human serum that contained anti-meningococcal capsular Ab decreased C4 deposition 8-fold and abrogated killing of
, despite leaving C3 deposition intact. TNT005 impaired killing of
in 78% nonimmune human plasma and 78% whole blood but permitted killing in both when specific anti-capsular Ab was added. Simultaneously inhibiting both the CP and alternative pathway (AP) blocked killing of Ab-coated
in whole blood. Blocking the AP alone abrogated C3 deposition, whereas TNT005 only partially inhibited (∼40% decrease) C3 deposition on
coated with anti-capsular Ab. Blocking either the CP or AP alone did not impair killing of pneumococci in whole blood containing specific Ab (<10% survival at 3 h); however, blocking both pathways resulted in ∼35% bacterial survival. These data suggest that killing of
or
in whole blood containing specific anti-capsular Abs is unimpeded by TNT005. Meningococcal and pneumococcal capsular conjugate vaccines may mitigate risk of these infections in patients receiving C1s inhibitors.
•Measurement of testosterone, DHEA and androstenedione in human meconium.•Testosterone was more abundant in meconium from male newborns.•Dehydroepiandrosterone was more abundant in meconium from ...female newborns.
Prenatal metabolism exerts profound effects on development. The first stool of the newborn, meconium, provides a window into the prenatal metabolic environment. The objective of this study was to examine the feasibility of meconium as a novel matrix to quantify prenatal steroid levels. We quantified parameters of analytical interest regarding the use of meconium, including sample stability. We hypothesized that meconium steroid content would differ by sex, prompting analysis of meconium to test effects of prenatal steroid metabolism. Meconium from 193 newborns enrolled in the Early Autism Risk Longitudinal Investigation (EARLI) study, including 107 males, and 86 females, were analyzed by isotope dilution-liquid chromatography-high resolution mass spectrometry (ID–LC–HRMS) while blinded to identity for testosterone (T), androstenedione (AD), and dehydroepiandrosterone (DHEA). Steroid levels were compared by sex, and investigations of potential trends resulting from sample storage or processing was conducted. The unconjugated steroid content of meconium in ng/g (mean, standard deviation) was for males: T (2.67, 8.99), AD (20.01, 28.12), DHEA (13.96, 23.57) and for females: T (0.82, 1.63), AD (22.32, 24.38), DHEA (21.06, 43.49). T was higher in meconium from males (p=0.0333), and DHEA was higher in meconium from females (p=0.0202). 6 female and 3 male T values were below the limit of detection. No extreme variability in hydration or trend in steroid levels by storage time was detected. Sexually dimorphic levels of hormones may reflect gestational differentiation, and future studies should consider meconium analysis.
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