Faculty Bibliography

INTRODUCTION/BACKGROUND:Minimally invasive surgery (MIS) is widely considered to be the standard of care for paraesophageal hernia (PEH) repairs, yet a subset of cases still require unplanned conversion to open surgery due to factors such as poor visualization and intraoperative complications. Although both laparoscopic and robotic approaches are routinely used, few studies have compared conversion rates as a primary outcome. This study aims to evaluate conversion to open surgery and associated short-term outcomes between surgical approaches for PEH repairs. METHODS:This retrospective cohort study used the 2022-2023 American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) registry to identify elective laparoscopic and robotic PEH repairs in patients aged 18-90 years. Concomitant procedures were excluded and 1:1 propensity score matching was performed to control for baseline characteristics and comorbidities. The primary outcome was unplanned conversion to open surgery. Secondary outcomes included 30-day postoperative complications, return to OR, readmission, and hospital length of stay. RESULTS:A total of 8325 patients met inclusion criteria, of which 40% (n=3364) underwent robotic repair. After matching, 3335 patients were included in each group with balanced covariates (standardized mean difference < 0.05). The robotic group had zero conversions to open, while the laparoscopic group had a conversion rate of 0.2% (p = 0.031). Operative times were longer in the robotic group (133 vs 115 minutes, p < 0.001). No differences were observed in 30-day postoperative complications, readmission, return to OR, or median length of stay. Rates of specific complications including infections, thromboembolic events, and cardiopulmonary issues were comparable between groups. CONCLUSION/CONCLUSIONS:In this large national cohort, there was a growing trend of robot usage for elective PEH repair. Additionally, robotic repairs were associated with fewer conversions to open but longer operative time. Further studies are needed.

Humankind's historical footprint on the continent of Antarctica now spans nearly 130 years. Since the first expedition, surgical care has remained both a necessity and a challenge. Residence in Antarctica is made difficult by unforgiving terrain and a long, isolating winter season. Survival requires strategic allocation of resources and personnel. Surgical emergencies and consultations on residential bases arise in the forms of traumatic injuries and atraumatic illnesses. Medical evacuation is considered dangerous and therefore reserved for critical cases. As such, medical professionals (both surgeons and non-surgeons) must be prepared to provide life-saving surgical care.

BACKGROUND:The National Surgical Quality Improvement Program (NSQIP) American College of Surgeons (ACS) risk calculator is a validated method of predicting postoperative complications that was recently updated to a machine-learning structure. The objective of this study was to measure the accuracy of this calculator in our institution on paraoesophageal hernia (PEH) repair. METHOD/METHODS:Procedures performed between 2019 and 2023 were retrospectively collected regarding demographics, operative variables, and outcomes with a 30-day follow-up. Thirteen outcomes measured by NSQIP-ACS calculator were measured. Observed and predicted rates were compared by receiver operating curves (ROC) and length of stay was compared by Wilcoxon signed rank test. RESULTS:A total of 203 paraoesophageal hernia repairs on patients with a median age of 68 (IQR 61-75) and 70.9% (n = 144) predominantly female. The size of the paraoesophageal hernia (PEH) was large or giant in 59.1% (n = 120) and mesh was placed in 70.4% (n = 143). The predicted risk was consistently higher than observed events on all but discharge destinations. Eight outcomes had no event to measure; however, the calculator accurately predicted a risk of ≤ 1% on all of these. The area under the curve (AUC) was fair (0.6-0.79) on discharge to nursing or rehabilitation facilities and failed in the rest of the measurable outcomes. CONCLUSION/CONCLUSIONS:The ACS-NSQIP risk calculator correctly predicted a low occurrence of postoperative outcomes in patients undergoing robotic paraoesophageal hernia repair.

Despite the paucity of evidence on robotic ventral hernia repair (RVHR) in patients with obesity, the robotic platform is being used more frequently in hernia surgery. The impact of obesity on RVHR outcomes has not been thoroughly studied. Obesity is considered a major risk factor for the development of recurrent ventral hernias and postoperative complications; however, we hypothesize that patients undergoing robotic repairs will have similar complication profiles despite their body mass index (BMI). We performed a retrospective analysis of patients aged 18-90 years who underwent RVHR between 2013 and 2023 using data from the Abdominal Core Health Quality Collaborative registry. Preoperative, intraoperative, and postoperative characteristics were compared in non-obese and obese groups, determined using a univariate and logistic regression analysis to compare short-term outcomes. The registry identified 9742 patients; 3666 were non-obese; 6076 were classified as obese (BMI > 30 kg/m²). There was an increased odds of surgical site occurrence in patients with obesity, mostly seroma formation; however, obesity was not a significant factor for a complication requiring a procedural intervention after RVHR. In contrast, the hernia-specific quality-of-life scores significantly improved following surgery for all patients, with those with obesity having more substantial improvement from baseline. Obesity does increase the risk of certain complications following RVHR in a BMI-dependent fashion; however, the odds of requiring a procedural intervention are not significantly increased by BMI. Patients with obesity have a significant improvement in their quality of life, and RVHR should be carefully considered in this population.

Specific biomarkers of intestinal injury associated with necrotizing enterocolitis (NEC) are needed to diagnose and monitor intestinal mucosal injury and recovery. This study aims to develop and test a modified enzyme-linked immunosorbent assay (ELISA) protocol to detect the total keratin 8 (K8) in the stool of newborns with NEC and investigate the clinical value of fecal K8 as a marker of intestinal injury specifically associated with NEC. We collected fecal samples from five newborns with NEC and five gestational age-matched premature neonates without NEC at the Lucile Packard Children's Hospital Stanford and Washington University School of Medicine, respectively. Fecal K8 levels were measured using a modified ELISA protocol and Western blot, and fecal calprotectin was measured using a commercial ELISA kit. Clinical data, including gestational age, birth weight, Bell stage for NEC, feeding strategies, total white blood cell (WBC) count, and other pertinent clinical variables, were collected and analyzed. Fecal K8 levels were significantly higher in the pre-NEC group (1-2 days before diagnosis of NEC) and NEC group than those in the non-NEC group (p = 0.013, p = 0.041). Moreover, fecal K8 was relatively higher at the onset of NEC and declined after the resolution of the disease (p = 0.019). Results with similar trends to fecal K8 were also seen in fecal calprotectin (p = 0.046), but not seen in total WBC count (p = 0.182). In conclusion, a modified ELISA protocol for the total K8 protein was successfully developed for the detection of fecal K8 in the clinical setting of premature newborns with NEC. Fecal K8 is noted to be significantly increased in premature newborns with NEC and may, therefore, serve as a noninvasive and specific marker for intestinal epithelial injury associated with NEC.

BACKGROUND/PURPOSE/OBJECTIVE:Distraction enterogenesis with intraluminal spring technology has been successfully used to lengthen segments of murine small intestine. We hypothesized that biocompatible springs could also be used to lengthen murine large intestine. METHODS:Age and weight matched C57BL/6 mice underwent surgical insertion of nitinol spring-loaded capsules into the cecum. Segment lengths were measured at initial spring placement and at euthanasia after 7 and 14 days. Histologic adaptations were evaluated at scarification. RESULTS:Cecal segments loaded with compressed springs lengthened an average of 150%, which was significantly longer than control segments loaded with either empty capsules or uncompressed springs. Muscularis layers tended to be thicker in the compressed spring groups compared to control groups. CONCLUSIONS:Insertion of a compressed nitinol spring into the cecum results in significant colonic lengthening in a mouse model. The ability to increase cecum length serves as proof of concept that distraction enterogenesis technology may be feasibly applied to large intestinal models. The use of distraction enterogenesis technology shows promise for application to clinical models in the treatment of pediatric intestinal disease.

Pediatric firearm-related injuries pose a significant public health problem in the United States, yet the associated financial burden has not been well described. This is the first study examining national data on the cost of initial hospitalization for pediatric firearm-related injuries. In this retrospective review, the Healthcare Cost and Utilization Project Kids' Inpatient Database from the years 2003, 2006, 2009, and 2012 was used to identify all patients 18 years of age and under who were admitted with firearm-related injuries. We compared demographic and discharge-level data including injury severity score, hospital length of stay, income quartile, injury intent, and inflation-adjusted hospital costs across age groups (0-5, 6-9, 10-15, 16-18 years). There were approximately 4,753 pediatric firearm-related admissions each year, with a median hospitalization cost of $12,984 per patient. Annual initial hospitalization costs for pediatric firearm injuries were approximately $109 million during the study period. Pediatric firearm-related injuries predominately occured among older teenagers (74%, 16-18 years), males (89%), black individuals (55%), and those from the lowest income quartile (53%). We found significant cost variation based on patient race, income quartile, injury severity score, intent, hospital length of stay, disposition, and hospital region. Inflation-adjusted hospitalization costs have increased significantly over the study period (p < 0.001). Pediatric firearm-related injuries are a large financial burden to the United States healthcare system. There are significant variations in cost based on predictable factors like hospital length of stay and injury severity score; however, there are also substantial discrepancies based on hospital region, patient race, and income quartile that require further investigation.

BACKGROUND:Ultrasound-guided (US) transversus abdominis plane (TAP) block is commonly utilized as part of a multi-modal approach for postoperative pain management. This study seeks to determine whether laparoscopic-guided TAP blocks are as effective as US-guided TAP blocks among pediatric patients. METHOD/METHODS:In this prospective, randomized controlled trial, pediatric patients undergoing laparoscopic procedures were randomly assigned to one of two treatment arms: US-guided TAP block (US-arm) or laparoscopic-guided TAP block (LAP-arm). Primary outcome was PACU pain scores. Secondary outcomes included PACU opioid consumption, block completion time and block accuracy. RESULTS:Twenty-five patients were enrolled in each arm. In the LAP-arm, 59% of blocks were in the transversus abdominis plane compared to 74% of TAP blocks in the US-arm (p = 0.18). Blocks were completed faster in the LAP-arm (2.1 ± 1.9 vs. 7.9 ± 3.4 min, p<0.001). The average highest PACU pain score was 3.4 ± 3.1 for the LAP-arm and 4.3 ± 3.8 for the US-arm (p = 0.37). Overall PACU pain scores and opioid consumption were similar between the groups (1.2 ± 1.3 vs. 1.6 ± 1.6, p = 0.24; 2.2 ± 5.8 vs. 0.9 ± 1.4MME, p = 0.26). CONCLUSION/CONCLUSIONS:Laparoscopic TAP blocks have equivalent efficacy in post-operative pain scores, narcotic use, and tissue plane accuracy as compared to US-guided TAP blocks. They are also completed faster and may result in less operating room and general anesthetic time for the pediatric patient.