Objective
The most feared complication during laparoscopic cholecystectomy remains a bile duct injury (BDI). Accurately risk-stratifying patients for a BDI remains difficult and imprecise. This study ...evaluated if the lethal triad of acute cholecystitis, obesity, and steatohepatitis is a prognostic measure for BDI.
Methods
A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) registry was performed. All laparoscopic cholecystectomy cases within the main NSQIP database for 2012–2019 were queried. Two study cohorts were constructed. One with the lethal triad of acute cholecystitis, BMI ≥ 30, and steatohepatitis. The other cohort did not have the full triad present. Multivariate analysis was performed via logistic regression modeling with calculation of odds ratios (OR) to identify independent factors for BDI. An uncontrolled and controlled propensity score match analysis was performed.
Results
A total of 387,501 cases were analyzed. 36,887 cases contained the lethal triad, the remaining 350,614 cases did not have the full triad. 860 BDIs were identified resulting in an overall incidence rate 0.22%. There were 541 BDIs within the lethal triad group with 319 BDIs in the other cohort and an incidence rate of 1.49% vs 0.09% (
P
< 0.001). Multivariate analysis identified the lethal triad as an independent risk factor for a BDI by over 15-fold (OR 16.35, 95%CI 14.28–18.78,
P
< 0.0001) on the uncontrolled analysis. For the controlled propensity score match there were 29,803 equivalent pairs identified between the cohorts. The BDI incidence rate remained significantly higher with lethal triad cases at 1.65% vs 0.04% (
P
< 0.001). The lethal triad was an even more significant independent risk factor for BDI on the controlled analysis (OR 40.13, 95%CI 7.05–356.59,
P
< 0.0001).
Conclusions
The lethal triad of acute cholecystitis, obesity, and steatohepatitis significantly increases the risk of a BDI. This prognostic measure can help better counsel patients and potentially alter management.
Following gastric bypass surgery, up to 30% of patients will visit the emergency room or require admission to the hospital. Postoperatively, the patient was doing well until 10 months after surgery ...when she presented to our emergency department complaining of postprandial upper abdominal pain. The patient was treated twice daily with proton pump inhibitors and discharged.
To review the current literature available and evaluate the efficacy of arthroscopic repair of 270° and 360° labral tears, as well as the complication rates associated with such. In addition, we ...intend to investigate whether consistent clinical findings can be observed in these patients.
This review is registered in the PROSPERO database. The MEDLINE, Cochrane Library, Scopus, and EMBASE databases were queried, and additional searches were performed manually. Studies that reported outcomes after arthroscopic repair of a minimum of 270° of glenoid labrum were included. Technique articles, repairs of less than 270°, studies on atraumatic multidirectional instability, and studies that lacked observable outcomes were excluded.
In total, 3031 studies/documents were identified from database and manual searching. Screening, removal of duplicates, and assessment for inclusion/exclusion criteria resulted in 6 level IV studies for review. History and physical examination, as well as advanced imaging findings, were variable across studies. All studies reported satisfactory outcomes at short- to mid-term follow-up, although there was heterogeneity in type of outcomes used. Return to sport ranged from 75% to 100%. Complication rates ranged from 10% to 30%. Notably, recurrence of instability and need for secondary surgery occurred in up to 15% of patients.
The current literature suggests that although clinical and radiographic variability exist in the diagnosis of 270° and 360° glenoid labrum tears, successful outcomes and return to work/sport can be achieved with arthroscopic management at an average minimum follow-up of 1 year. These figures, however, are limited by heterogenous studies containing small numbers of patients. Complications occur in up to 30% of cases, including an instability recurrence rate of up to 15%.
Systematic review of Level IV evidence.
Introduction
With the advancement of minimally invasive surgical techniques surgeons have moved away from elective open foregut surgeries. Despite studies demonstrating the safety of same day ...discharge in appropriate patient populations, ambulatory surgery has yet to be established as the practice norm for patients undergoing uncomplicated laparoscopic foregut surgery.
Methods
The ACS-NSQIP database was queried from 2005 to 2018 for patients who had undergone elective and non-emergent laparoscopic Heller myotomy, fundoplication, and paraesophageal hernia repairs with and without mesh. The primary endpoints in this study included number and severity of complications as classified by the Clavien–Dindo Classification, readmission, and return to the operating room.
Results
6893 patients who met inclusion criteria were identified, 696 (10.1%) of which were discharged on the day of surgery. Patients who were discharged on post-operative day one were matched at a 3:1 ratio producing 2088 comparisons. There was no difference in overall morbidity (
p
= 0.264), readmission (OR 0.849, 95% CI 0.522–1.419), or return to the operating room (OR 1.15, 95% CI 0.531–2.761) between the two groups.
Conclusion
Same day discharge for patients without life threatening comorbidities undergoing elective minimally invasive Heller myotomy, Nissen and Toupet fundoplication, and paraesophageal hernia repairs is safe and feasible.
The Hirsch Index is a measure of academic productivity which captures both the quantity and quality of an author's output. A well-accepted bibliometric, the Hirsch Index still may be influenced by ...self-citation, which has been assessed in other medical and surgical specialties. This study aims to evaluate research output and self-citation in physiatry, establishing a benchmark for the field, in addition to identifying differences between physical medicine and rehabilitation subspecialties. This study identified physical medicine and rehabilitation residency and fellowship program directors and analyzed the number of publications, citations, self-citations, and h-indices. A total of 169 program directors were identified, and the mean number ± SD of publications, citations, and Hirsch Index for the cohort were 16.7 ± 29.5, 348 ± 753, and 5.7 ± 6.7, respectively. When self-citation was excluded, less than 2% of program directors (3 of 169) had changes in Hirsch Index greater than one integer, and none greater than two integers. The Hirsch Index remained unchanged for 90% (152 of 169). Spinal cord injury fellowship directors had significantly higher mean number of publications (28, P = 0.04), mean number of citations (672, P = 0.03), and Hirsch Index (9.2, P < 0.01; 95% confidence interval). Overall, self-citation is infrequent in physical medicine and rehabilitation, and spinal cord injury directors had more robust academic profiles.
Background
Minimally invasive distal pancreatectomy (MIDP) is gaining popularity due to improved perioperative outcomes over open distal pancreatectomy (ODP). The purpose of this study is to compare ...outcomes of MIDP and ODP using patients within a nationwide cohort.
Methods
The American College of Surgeons’ National Quality Improvement Program (2014–2018) was used to evaluate incidence of post-operative pancreatic fistula (POPF) as well as 30-day composite major morbidity for patients undergoing MIDP vs. ODP. Matching was performed with a Mahalanobis-distance model for demographic characteristics, preoperative risk factors, and benign versus malignant pathology. Outcomes were assessed via weighted multiple logistic regression.
Results
A total of 3940 patients underwent distal pancreatectomy (1978 MIDP, 1962 ODP). After matching, 2985 patients were included (1978 MIDP, 1007 ODP). The rates of major morbidity (8.65% MIDP vs. 9.76% ODP,
p
= 0.37) were similar between groups. The MIDP group was found to have significantly decreased length of stay (5.6 vs. 7 days,
p
≤ 0.001), but greater rates (12.54% MIDP vs. 9.35% ODP,
p
= 0.02) of post-operative fistula.
Conclusions
When matched for baseline patient characteristics, MIDP was associated with shorter length of hospitalization with similar rates of morbidity compared to ODP. However, MIDP was associated with significantly increased rates of POPF. Further studies are needed to investigate this difference in POPF rate, and determine how to optimize MIDP surgical technique to reduce this risk.
There is a lack of literature describing how competitive surgical fellowships are, especially across specialties. Such information would be valuable to prospective candidates, especially as immediate ...postresidency subspecialty training becomes the norm for general surgery. Match-rates alone may be misleading indicators as programs may not fill positions with unqualified applicants. We propose a simple metric to analyze the competitiveness of various surgical subspecialties to each other and themselves over time.
Retrospective cohort study. The Competitive Index is defined as the percentage of filled programs within each specialty divided by the match-rate for that specialty. For ease of comparison, a Normalized Competitive Index (NCI) was developed, normalizing the metric for all specialties in that year to a value of 1.
The National Resident Matching Program, The Fellowship Council, and the San Francisco Match publicly available match data from 2009 to 2018.
General Surgery Associated Fellowship Applicants (Abdominal Transplant, Colorectal, Surgical Oncology, Minimally Invasive Surgery, Pediatric, Plastic, Critical Care, Thoracic, and Vascular).
The overall match rate for all specialties was 74.6% and 84.0% of all programs were filled. Over the past decade, pediatric surgery was significantly more competitive than other specialties (NCI 1.67, p < 0.0001), while surgical critical care (NCI 0.58, p < 0.0001) and vascular (NCI 0.90, p < 0.0492) were significantly less competitive. When comparing the NCI within each specialty from the first 5 years (2009-2013) to the last 5 years, (2014-2018), surgical critical care (NCI 0.54 vs. 0.62, p = 0.0462) and thoracic (NCI 0.74 vs. 1.08, p=0.0025) became significantly more competitive, while transplant (NCI 1.10 vs. 0.92, p = 0.0343) and colorectal (NCI 1.32 vs. 1.09, p = 0.0021) became significantly less competitive.
The NCI is a metric which might be useful to prospective applicants and which could be provided annually by organizations sponsoring fellowship matching processes. Further research must be performed to establish what defines a qualified applicant in each specialty.
Objectives/Hypothesis
To better understand the causes and outcomes of lawsuits involving otolaryngologists in the past decade by analyzing malpractice litigation trends to prevent future litigation ...and improve physician education.
Study Design
Analysis of a national database for all US civil trials.
Methods
The Westlaw database was reviewed from 2001 to 2011. Data were compiled on the demographics of the plaintiffs, use of expert witnesses, procedures, nature of the injury, legal allegations, verdicts, and indemnities.
Results
One hundred ninety‐eight cases met inclusion criteria. Verdicts for the defendant/otolaryngologist predominated (58%), whereas the average award when the verdict favored the plaintiff was $1,782,514. When otolaryngologists were used as expert witnesses by the defense, the verdict outcome statistically favored the defendant. Two of the most commonly cited legal allegations were improper performance and failure to diagnose and treat. Fifty‐one cases involved allegations of wrongful death, with the overall outcome favoring the plaintiffs (51%). The average indemnities in these cases were significantly higher for plaintiff verdicts at $2,552,580 versus settlements at $992,896. Forty‐two cases involved malignancy, with the two most common allegations being failure to diagnose and treat (79%) and delay in diagnosis (74%).
Conclusions
Our study reveals that in the past decade, in significant malpractice litigations, overall outcomes favored otolaryngologists. The average awards was significantly higher when cases involved malignancy. Our analysis reveals the importance of meticulous surgical techniques and thorough preoperative evaluations. Last, when otolaryngologists are defendants in litigation, our review reiterates the value of the otolaryngologist as the defense's expert witnesses. Laryngoscope, 124:896–901, 2014
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