Introduction
Surgical procedures in patients with cirrhosis and associated ascites carry significant morbidity and mortality. However, these patients often undergo non-emergent but necessary ...procedures such as laparoscopic cholecystectomy. The purpose of this study is to determine the impact of cirrhosis with ascites on non-emergent laparoscopic cholecystectomy.
Methods
The ACS-NSQIP database was queried from 2005 to 2017 for patients undergoing non-emergent laparoscopic cholecystectomy with or without intra-operative cholangiogram. Groups were propensity score matched for age, sex, BMI, smoking, inpatient status, ASA Class, presence of pre-operative SIRS/sepsis, and the individual components of the 5-item modified frailty index.
Results
346,105 patients were identified, 591 of which who had liver-related ascites. Patients without ascites were matched at a 5:1 ratio, producing 2955 controls. Patients with ascites had significantly higher rates of overall morbidity (15.6% vs. 11.3%,
p
= 0.0039), mortality (3.6% vs. 1.5%,
p
= 0.0020), and longer hospitalizations (7.4 vs. 4.4 days,
p
< 0.0001). Patients with ascites and a MELD score less than or equal to 9 had no difference in morbidity (
p
= 0.1124) or mortality (
p
= 0.6021) when compared to patients without ascites. Patients with ascites and a MELD score greater than 9 had significantly higher rates of both morbidity (25.8%,
p
= 0.0056) and mortality (7.1%,
p
= 0.0333).
Conclusion
Patients with cirrhosis and ascites have many comorbidities in addition to their liver disease. These patients are at significant risk for both morbidity and mortality related to non-emergent laparoscopic cholecystectomy. Surgeons should proceed with caution for patients with ascites and MELD scores greater than 9. These cases should only be performed by surgeons comfortable with difficult gallbladders at facilities equipped to take care of cirrhotic patients.
Introduction
Percutaneous Endoscopic Gastrostomy (PEG) is an infrequent adjunct in elective paraesophageal hernia repair (PEHR). Guidelines denote that PEG “may facilitate postoperative care in ...selected patients.” Though there is sparse literature defining which patients may benefit. The purpose of this study is to determine factors associated with simultaneous PEG placement during PEHR and their subsequent outcomes.
Methods
The NSQIP database was queried from 2011 to 2016 for patients undergoing elective laparoscopic PEHR. Cases were excluded if PEHR or fundoplasty was not the primary procedure, a concomitant bariatric procedure was performed, or if the primary surgeon was not a general or cardiothoracic surgeon. Groups were Propensity Score Matched for age, BMI, and ASA Class.
Results
15700 patients were identified, 371 who underwent simultaneous PEG placement (2.4%). Non-PEG patients were matched at a 5:1 ratio, producing 1855 controls. PEG patients had higher rates of pre-operative dyspnea (OR 1.45,
p
= 0.0110), pre-operative weight loss (OR 2.87,
p
= 0.0001), and lower pre-operative albumin (3.92 vs. 4.01,
p
= 0.0129). PEG patients had more intra-operative contamination (mean Wound Classification 1.54 vs. 1.38,
p
< 0.0001) and longer case durations (170 vs. 148 min,
p
< 0.0001). PEG patients had longer lengths of stay (3.4 vs. 2.5 days,
p
= 0.0001), rates of superficial SSI (OR 5.82,
p
= 0.0012), peri-operative transfusions (OR 2.68,
p
= 0.0197), and pulmonary emboli (OR 3.61,
p
= 0.0359).
Conclusion
Patients undergoing simultaneous PEG during PEHR are more likely to have respiratory symptoms, markers of malnutrition, and intra-operative factors indicative of more technically challenging cases. These patients have longer hospitalizations, higher rates of superficial SSI, and more pulmonary emboli.
The purpose of this study is to assess how the Hirsch Index (h-index) and other academic metrics change over time for academic minimally invasive surgeons (MIS).
Through the Fellowship Council's ...website, MIS program-directors and associate program-directors were identified in 2017 and again in 2018. Using the Scopus database, the number of publications, citations, self-citations, and h-indices were calculated.
A total of 222 surgeons were included. The median increase of publications, citations, and h-index were 4, 134, and 1, respectively. 75% of surgeons (166/222) saw their h-index increase. In 2017, 26% of surgeons (57/222) had an increase of their h-index due to self-citation. One-year later, 35% of those surgeons (20/57) no longer demonstrated that change.
Self-citation remains infrequent within MIS. The h-index of most surgeons will increase over one-year. Many surgeons demonstrating an increase in h-index due to self-citation will see that change eliminated over time.
•The academic profiles of 222 MIS surgeons were analyzed over the course of a year.•The median increase of publications, citations, and h-index were 4, 134, and 1.•The self-citation rate was no different for new citations.•Over the course of one year, 75% of surgeons saw their h-index increase.•Increases in h-index from self-citation one year may disappear over time.
The h-index is a widely utilized academic metric that measures both productivity and citation impact. The purpose of this study is to define the impact of self-citation among minimally invasive ...surgery (MIS) fellowship program directors.
Through the Fellowship Council's website, all program directors and associate program directors from the 148 MIS fellowship programs were identified. Using the Scopus database, we calculated the number of publications, citations, self-citations, and h-index for each surgeon.
A total of 274 surgeons were identified. The mean number±SD of publications, citations, and h-index for the cohort were 60.5 ± 77.2, 1765 ± 4024, and 16.0 ± 15.0, respectively. The self-citation rate for the entire cohort was 3.23%. Excluding self-citations reduces the mean number of citations to 1708 ± 3887 and h-index to 15.8 ± 14.6. The h-index remained unchanged for 77% (210/274) of surgeons. Only 5% (15/274) of surgeons had a change in h-index of greater than one integer and no surgeon had a change greater than three integers.
Self-citation is infrequent and has a minimal impact on the academic profile of program directors of MIS fellowships.
•The academic profiles of 274 surgeons from 148 MIS fellowships were analyzed.•The self-citation rate for the entire cohort was 3.23%.•The h-index remained unchanged for 77% (210/274) of surgeons.•Only 5% (15/274) of surgeons had a change in h-index of more than one integer.•No surgeon had a change in h-index greater than three integers.
Simply put, the h-index is defined as "the number of papers with a citation number > or = h."1 The h-index is now considered an important marker for the process of tenure and promotion at academic ...medical programs as it is an easily computable index that can be used as a yardstick to compare the importance, significance, and broad impact of an individual's cumulative research contributions. Scatter plot analysis and linear regression were used to determine correlation between the number of published articles and the change in the h-index or self-citation. Scatter plot analysis showed there was a low positive correlation between the number of publications and the change in the h-index (R2 = 0.3234) and a moderate positive correlation between the number of publications and the number of self-citations (R2 = 0.5897). Within the entire cohort and the subgroups of chairpersons and full professors, the average h-index change with selfcitation was an increase of 0.44, 0.42, and 0.44, respectively. ...for the large majority of academic general surgeons, the inclusion of self-citations did not change the h-index by a full integer or significantly impact their academic profile.
Polycystic ovary syndrome (PCOS) is a common disease among the bariatric population. However, there are limited data regarding the impact of laparoscopic sleeve gastrectomy (SG) on these patients. ...The study was conducted at University Hospital, United States. The purpose of this study was to examine per cent excess body weight loss (%EWL) and diabetes control in patients who have PCOS compared with those without PCOS. A total of 550 female patients underwent SG between December 2011 and October 2016. Retrospective analysis was completed to include follow-up data at 1, 3, 6, and 12 months and yearly after that. Outcomes measured were %EWL and hemoglobin A1c (HgbA1c). The mean and median follow-up for the entire cohort was 21 and 15 months, respectively. Seventy-eight per cent of patients completed at least 12 months of follow-up for %EWL, although only 21 per cent had similar follow-up for HgbA1c. PCOS patients had similar age (36.3 vs 36.2 years, P = 0.90), preoperative BMI (47.2 vs 47.2, P = 0.99), preoperative HgbA1c (6% vs 5.8%, P = 0.31), conversion rate to gastric bypass, and other associated comorbidities compared with non-PCOS comparisons. There was no difference in %EWL at 12-month (49.7% vs 53.1%, P = 0.53) or 24-month (43% vs 49.8%, P = 0.46) postoperative intervals. There was no difference in absolute change of HgbA1c at 12 months (-0.47% vs -0.67%, P = 0.39). SG has equivalent short-term results in %EWL and reduction in HgbA1c for patients who have PCOS and those who do not.
BACKGROUND:Scrotal inguinal hernias represent a challenging surgical pathology. Although some advanced laparoscopists can repair these hernias through a minimally invasive approach, open repair is ...considered the technique of choice for most surgeons. The purpose of this study is to show our results of robotic-assisted laparoscopic repair of scrotal inguinal hernias.
PATIENTS AND METHODS:We reviewed the charts of 14 patients with inguinoscrotal hernias who underwent robotic-assisted transabdominal preperitoneal (TAPP) hernia repair. Mean follow-up was 7 months. The European Registry for Abdominal Wall Hernia Quality of Life score, a 90-point scale, was utilized to quantify patient reported outcomes.
RESULTS:Robotic TAPP repair was successful in all 14 patients. Average case duration was 100 minutes (78 to 140 min) for unilateral hernias and 208 minutes (166 to 238 min) for bilateral hernias. Trainees were involved in 93% (13/14) of cases. There were no recurrences. Three patients developed postoperative seromas. The mean European Registry for Abdominal Wall Hernia Quality of Life score was 3.7 (0 to 10).
CONCLUSIONS:Scrotal hernias can be safely repaired using robotic-assisted TAPP methods with low morbidity and favorable patient reported outcomes.
Introduction The Accreditation Council for Graduate Medical Education (ACGME) case log captures resident operative experience based on Current Procedural Terminology (CPT) codes and is used to track ...operative experience during residency. With increasing emphasis on resident operative experiences, coding is more important than ever. It has been shown in other surgical specialties at similar institutions that the residents’ ACGME case log may not accurately reflect their operative experience. What barriers may influence this remains unclear. As the only objective measure of resident operative experience, an accurate case log is paramount in representing one’s operative experience. This study aims to determine the accuracy of procedural coding by general surgical residents at a single institution. Methods Data were collected from 2 consecutive graduating classes of surgical residents’ ACGME case logs from 2008 to 2014. A total of 5799 entries from 7 residents were collected. The CPT codes entered by residents were compared to departmental billing records submitted by the attending surgeon for each procedure. Assigned CPT codes by institutional American Academy of Professional Coders certified abstract coders were considered the “gold standard.” A total of 4356 (75.12%) of 5799 entries were identified in billing records. Excel 2010 and SAS 9.3 were used for analysis. In the event of multiple codes for the same patient, any match between resident codes and billing record codes was considered a “correct” entry. A 4-question survey was distributed to all current general surgical residents at our institution for feedback on coding habits, limitations to accurate coding, and opinions on ACGME case log representation of their operative experience. Results All 7 residents had a low percentage of correctly entered CPT codes. The overall accuracy proportion for all residents was 52.82% (range: 43.32%-60.07%). Only 1 resident showed significant improvement in accuracy during his/her training (p = 0.0043). The survey response rate was 100%. Survey results indicated that inability to find the precise code within the ACGME search interface and unfamiliarity with available CPT codes were by far the most common perceived barriers to accuracy. Survey results also indicated that most residents (74%) believe that they code accurately most of the time and agree that their case log would accurately represent their operative experience (66.6%). Conclusion This is the first study to evaluate correctness of residents’ ACGME case logs in general surgery. The degree of inaccuracy found here necessitates further investigation into the etiology of these discrepancies. Instruction on coding practices should also benefit the residents after graduation. Optimizing communication among attendings and residents, improving ACGME coding search interface, and implementing consistent coding practices could improve accuracy giving a more realistic view of residents’ operative experience.
