Faculty Bibliography

Perforated duodenal ulcer following RYGB is an unusual clinical situation that may be a diagnostic challenge. Only 23 cases have previously been reported. We present five cases. The hallmark of visceral perforation, namely pneumoperitoneum, was not seen in three of the four cases that underwent cross sectional imaging. This is perhaps due to the altered anatomy of the RYGB that excludes air from the duodenum. Our cases had more free fluid than expected. The bariatric surgeon should not wait for free intraperitoneal air to suspect duodenal perforation after RYGB.

The Medicare program has transitioned to paying healthcare providers based on the quality of care delivered, not on the quantity. In May 2015, SAGES held its first ever Quality Summit. The goal of this meeting was to provide us with the information necessary to put together a strategic plan for our Society over the next 3-5 years, and to participate actively on a national level to help develop valid measures of quality of surgery. The transition to value-based medicine requires that providers are now measured and reimbursed based on the quality of services they provide rather than the quantity of patients in their care. As of 2014, quality measures must cover 3 of the 6 available National Quality domains. Physician quality reporting system measures are created via a vigorous process which is initiated by the proposal of the quality measure and subsequent validation. Commercial, non-profit, and governmental agencies have now been engaged in the measurement of hospital performance through structural measures, process measures, and increasingly with outcomes measures. This more recent focus on outcomes measures have been linked to hospital payments through the Value-Based Purchasing program. Outcomes measures of quality drive CMS' new program, MACRA, using two formats: Merit-based incentive programs and alternative payment models. But, the quality of information now available is highly variable and difficult for the average consumer to use. Quality metrics serve to guide efforts to improve performance and for consumer education. Professional organizations such as SAGES play a central role in defining the agenda for improving quality, outcomes, and safety. The mission of SAGES is to improve the quality of patient care through education, research, innovation, and leadership, principally in gastrointestinal and endoscopic surgery.

BACKGROUND: Educational and computerized interventions have been shown to reduce red blood cell (RBC) transfusion rates, yet controversy remains surrounding the optimal strategy needed to achieve sustained reductions in liberal transfusions. STUDY DESIGN AND METHODS: The purpose of this study was to assess the impact of clinician decision support (CDS) along with targeted education on liberal RBC utilization to four high-utilizing service lines compared with no education to control service lines across an academic medical center. Clinical data along with associated hemoglobin levels at the time of all transfusion orders between April 2014 and December 2015 were obtained via retrospective chart review. The primary outcome was the change in the rate of liberal RBC transfusion orders (defined as any RBC transfusion when the hemoglobin level is >7.0 g/dL). Secondary outcomes included the annual projected reduction in the number of transfusions and the associated decrease in cost due to these changes as well as length of stay (LOS) and death index. These measures were compared between the 12 months prior to the initiative and the 9-month postintervention period. RESULTS: Liberal RBC utilization decreased from 13.4 to 10.0 units per 100 patient discharges (p = 0.002) across the institution, resulting in a projected 12-month savings of $720,360. The mean LOS and the death index did not differ significantly in the postintervention period. CONCLUSION: Targeted education combined with the incorporation of CDS at the time of order entry resulted in significant reductions in the incidence of liberal RBC utilization without adversely impacting inpatient care, whereas control service lines exposed only to CDS had no change in transfusion habits.

PURPOSE: Documenting surgical complications is limited by multiple barriers and is not fostered in the electronic health record. Tracking complications is essential for quality improvement (QI) and required for board certification. Current registry platforms do not facilitate meaningful complication reporting. We developed a novel web application that improves accuracy and reduces barriers to documenting complications. METHODS: We deployed a custom web application that allows pediatric surgeons to maintain case logs. The program includes a module for entering complication data in real time. Reminders to enter outcome data occur at key postoperative intervals to optimize recall of events. Between October 1, 2014, and March 31, 2015, frequencies of surgical complications captured by the existing hospital reporting system were compared with data aggregated by our application. RESULTS: 780 cases were captured by the web application, compared with 276 cases registered by the hospital system. We observed an increase in the capture of major complications when compared to the hospital dataset (14 events vs. 4 events). CONCLUSIONS: This web application improved real-time reporting of surgical complications, exceeding the accuracy of administrative datasets. Custom informatics solutions may help reduce barriers to self-reporting of adverse events and improve the data that presently inform pediatric surgical QI. TYPE OF STUDY: Diagnostic study/Retrospective study. LEVEL OF EVIDENCE: Level I

Introduction: Morbidity in giant abdominal wall reconstruction may be significant in the early postoperative period from pain and wound complications, and from hernia recurrences long term. To improve outcomes, botulinum toxin A was applied to the oblique muscles to reduce postoperative incisional tension. The initial findings are reported from seven abdominal wall reconstructions in which botulinum toxin was used. Methods: Patients undergoing abdominal wall reconstruction gave signed consent for the off-label use of botulinum toxin A. Retrospective chart review was performed. Three patients had hernias secondary to major trauma. One patient had a multiply recurrent parastomal hernia. One had an incisional hernia from emergent surgery for diverticulitis. One had multiple failed hernia repairs with exposed mesh. One had a large incisional hernia following hysterectomy. BMI ranged from 23.1 to 62.4 with a median of 28. Loss of domain was present in all due to multiple loops of herniated intestine. In six patients, 50 units intramuscular botulinum toxin A was delivered preincision into the oblique muscles bilaterally under ultrasound guidance. In one, 50 units were injected bilaterally without ultrasound guidance. Preoperative elliptical defect surface area as measured on CT scan ranged from 22.5 to 466.5 cm2, with a median of 200 cm2; the widest transverse defect measured 22 cm. Results: Primary defect closure was achieved in all using posterior rectus fascia advancement. In two patients an external oblique release was also used. A composite polyester and cellulose mesh was placed in the retro-rectus position for clean cases and porcine dermal matrix was used in the three cases involving bowel incision or infected mesh. There were no pulmonary complications in any patients. Four of seven patients noted decreased abdominal tightness on day 4 or 5, consistent with the pharmacodynamics of botulinum toxin. Major wound complications occurred in one patient requiring debridement and removal of biologic!

A recently convened Consortium at the Cleveland Clinic agreed on the term Laparo-Endoscopic Single-Site (LESS) surgery to describe minimally invasive techniques that use a single incision to accomplish laparoscopic procedures. These procedures are done by using either a single port through one fascial incision or multiple ports placed through separate fascial incisions. Because of cost containment issues and the lack of widespread availability of a single port, we currently use multiple reusable ports placed through three separate fascial incisions via a transumbilical incision. As opposed to standard laparoscopic cholecystectomy, a deflecting laparoscope and one articulating instrument are utilized to improve the safety and ease of this procedure. Presented in this video are the steps necessary to perform a LESS cholecystectomy via a transumbilical incision with commercially available instruments

INTRODUCTION: Without ongoing practice, acquired motor skills may deteriorate over time. The purpose of this study is to document the level of retention of laparoscopic skills over time. METHODS: Thirty-three general-surgery PGY 1, 2, and 3 residents trained to established criteria and passed an exam for each of seven technical skills (camera navigation, instrument navigation, camera/instrument coordination, grasping, lifting and grasping, cutting, and clip applying) on a virtual simulator (LapSim Surgical Science Ltd., Goteborg, Sweden). Six months later, the residents again completed the exam for each of the seven skills. During the 6 months, the simulators were available, but additional practice was not required. The retesting process consisted of three attempts, the first of which was acclimatization. The results of the subsequent two exams were compared with baseline data. RESULTS: At retest, the number of residents who passed clip applying (7, 21%) and cutting tasks (18, 55%) was significantly lower than for the other five tasks (p < 0.05). In failed tests, instrument wandering and tissue damage were more common than increases in task time. Upper-level residents were significantly more likely to pass than first-year residents were (p < 0.01). Time of day did not influence passing rates. CONCLUSION: Six months after training to criteria, instrument and tissue-handling skills deteriorated more than the speed with which a task is completed. Evidence of skill retention was present for some but not all tasks. Fine motor skills, required to perform more difficult tasks, deteriorated more than skills needed for easier tasks

BACKGROUND: The thyroid gland is one of the most vascular organs in the body and surgical resection mandates meticulous surgical technique and hemostasis. The aim of this study was to assess the safety and efficacy of the electrothermal bipolar vessel sealing system in permitting ambulatory thyroid surgery under local anesthesia. METHODS: From January 1, 2004, to December 31, 2005, 224 consecutive patients underwent thyroid surgery using the LigaSure for hemostasis. Whenever possible, local/regional anesthesia with conscious sedation was utilized during the procedure. A descriptive analysis was performed to evaluate patient characteristics and outcome measures. RESULTS: Eighty-two percent (n = 184) of all unselected patients presenting for thyroid surgery had their procedure performed under local/regional anesthesia with conscious sedation whereas 18% (n = 40) received general anesthesia. When comparing these two groups, the local anesthesia patients were more likely to be female (85% vs. 68%, p < or = 0.05) and younger (mean age = 50 vs. 61 years, p < or= 0.05). Forty percent of the local anesthesia patients underwent a total thyroidectomy compared to 58% in the general anesthesia group (p < or = 0.05). The mean duration of surgery was shorter in the local anesthesia patients (71 minutes vs. 101 minutes, p < or = 0.05) and the mean gland weight was also less (26.9 g vs. 63.9 g, p < or = 0.05). There was one hematoma in the local anesthesia group, but overall the morbidity was not different. Eighty-eight percent of the local anesthesia patients were discharged same day of surgery compared to 45% of the general anesthesia patients. CONCLUSIONS: The electrothermal bipolar vessel sealing system permits safe, same day discharge in patients undergoing thyroid surgery with a low complication rate irrespective of the type of anesthesia