Surgical Technology International
43rd Edition
December 2023 - ISSN:1090-3941
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Polymer versus Titanium Clips in Laparoscopic Cholecystectomy
Anna Malysz Oyola, DO, John Miller, MD,
Colston Edgerton, MD,
Adjunct Assistant Professor, William Hope, MD,
Adjunct Professor,
Novant Health New Hanover Regional Medical Center
Wilmington, NC
1730
Background: Surgical clips are commonly used during laparoscopic cholecystectomy for cystic duct and artery ligation. Titanium and polymer clips are the two most common types used for this indication. Given the cost-saving potential, design advantages, and decreased incidence of complications associated with polymer clips, we sought to study whether there is a clinically significant difference in outcome between polymer and titanium clips in laparoscopic cholecystectomy.
Methods: Fifty consecutive cases using polymer clips followed by 50 consecutive cases using metal clips over a 6-month period by residents under the direction of a single surgeon were retrospectively reviewed. The following outcomes were evaluated: incidence of bile leak, postoperative bleeding, need for additional procedures, hospital length of stay, and cost.
Results: We found that significantly more misfires occurred with the use of the polymer clips (n=17) than with the titanium clips (n=2, p<.001). Eight cases (16%) required opening of an additional polymer clip cartridge to complete the operation. Despite this additional expense, the total cost as it pertained to clip usage ($30.32 USD) was still lower than that using titanium clips ($139.17 USD). While these numbers were not statistically significant, three cases had bile leaks and required additional procedures, all of which were performed with metal clips. No postoperative bleeds were identified and there was no difference in hospital length of stay; most patients were discharged on the day of the procedure.
Conclusion: These findings demonstrate comparable clinical outcomes between laparoscopic cholecystectomies performed with polymer and titanium clips, though polymer clip usage carries a lower cost.
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Odds of Mortality in Geriatric Patients with Appendicitis is 22 Times Higher than that in Non-Geriatrics: An Analysis of 336,880 Patients from NIS Database
Rahim Hirani, MS, New York Medical College, School of Medicine, Valhalla, New York, Abbas Smiley, MD, PhD, University of Rochester, Rochester, New York, Rifat Latifi, MD, FACS, FICS, FKCS, Adjunct Professor of Surgery, Abrazo West Campus, Phoenix, Arizona
1671
Introduction: Our goal was to identify risk factors for mortality in adult (18–64 years) and geriatric (65+ years) patients admitted with a primary diagnosis of appendicitis.
Materials and Methods: The data was obtained from the National Inpatient Sample for patients admitted emergently with appendicitis (ICD-9 540-542) between 2005–2014, and then retrospectively analyzed using multivariable logistic regression with backward elimination.
Results: A total of 336,880 patients were included in the cohort. Mean age was 37.7 and 73.8 years in adult and elderly patients, respectively. 97.3% of adults and 94.2% of elderly patients underwent an operation. The mortality rate in the elderly patients (1.04%, n=402/38,509) was 22 times higher (p< 0.0001) than that in adult patients (0.047%, n=144/301,408). Mean (SD) hospital length of stay (HLOS) was 2.6 (2.9) days in adults and 4.9 (5.2) days in elderly patients (p<0.0001). Ninety-nine percent of adult and elderly patients were discharged within 11 and 20 days after emergent hospitalization, respectively. In the final regression model, every one year older in age increased the odds of mortality by 5% (OR=1.05, 95%CI: 1.04–1.06, p<0.001), and for every one day longer, HLOS increased the odds of mortality by 1% (OR=1.01, 95%CI: 1.001–1.02, p<0.001). The multivariable logistic regression model was built on 82,006 patients whose HLOS was ≥4 days, the odds ratio for HLOS was 1.05 (95%CI: 1.04–1.06). This means that for every additional day in hospital after day 4, the odds of mortality increase by 5%.
Conclusion: The risk of mortality in elderly patients admitted emergently with appendicitis is approximately 22 times higher than that of non-elderly adults.
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Staple Line Reinforcement Using SEAMGUARD® versus Suture Over Sewing During Laparoscopic Sleeve Gastrectomy for Super Morbidly Obese Patients: A Prospective Randomized Clinical Trial
Hosam Elghadban, MD, Associate Professor, Ahmed Negm, MD, Professor, Mohamed Samir, MD, Associate Professor, Magdy Basheer, MD, Associate Professor, Ibrahim Dawoud, MD, Professor, Ashraf Shouma, MD, FRCS, Professor , Elsayed Abdallah, MD, Professor, Faculty of medicine Mansoura University, Mansoura, Egypt, Ahmed Taki-Eldin, MD, Assistant Professor, Faculty of medicine, Horus University-Egypt, New Damietta, Egypt
1704
Itroduction: Although theoretically a simple procedure, laparoscopic sleeve gastrectomy (LSG) can be followed by life-threatening complications. Early postoperative complications include staple line bleeding and leakage. Staple line reinforcement (SLR) has been used to decrease these complications. There are various methods for reinforcement of staple line such as suture over sewing, placing omental flap, using buttressing material, and spraying fibrin glue along the staple line. However, it is controversial whether SLR reduces the rate of staple line complications or not.
Materials and Methods: A prospective randomized clinical trial included 200 super morbidly obese patients randomized into two groups: Group 1 with reinforcement of the staple line by SEAMGUARD® (Gore Medical, Newark, Delaware) and Group 2 with reinforcement of the staple line using suture over sewing.
Results: The mean operative time was significantly shorter in Group 1 than Group 2 (62.6 ± 14.5 vs. 84.7 ±15.8 min, p=0.02). Intraoperative blood loss was significantly lower in Group 1 than Group 2 (17.1± 19.1 vs. 56.8 ± 27.9ml, p=0.00). Staple line hematomas were significantly higher in Group 2. There was no difference in postoperative bleeding between the two groups. No leak was reported in both groups. The cost was higher in Group 1.
Conclusion: Reinforcing the staple line in laparoscopic sleeve gastrectomy using suturing is equal to SEAMGUARD® in all aspects except shorter operative time and lower intraoperative blood loss with SEAMGUARD®.
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The Risk of Mortality in Elderly Patients with Acute Vascular Insufficiency of the Intestine is 2.5-Fold Greater than that in Adult Patients: An Analysis of 36,864 Patients
Maziyah O’garro, BS, New York Medical College, Valhalla, New York, Abbas Smiley, MD, PhD, School of Medicine, University of Rochester, Rochester, New York, Rifat Latifi, MD, FACS, FICS, FKCS, Abrazo West Campus, Phoenix, Arizona
1709
Introduction: Vascular insufficiency of the intestine is difficult to diagnose and it has high mortality rates. Our study aimed to identify risk factors for in-hospital mortality of patients emergently admitted with the primary diagnosis of vascular insufficiency of the intestine.
Materials and Methods: Adult (18–64 years) and elderly (>64 years) patients emergently admitted with the primary diagnosis of vascular insufficiency of the small and large intestine were analyzed using the National Inpatient Sample database from 2005–2014. Using stratified analysis and backward multivariable logistic regression analysis, the relationship between mortality and several risk factors were evaluated.
Results: There were 36,864 patients analyzed of which 4,994 died in hospital. Most patients were elderly, making up 23,052 of the total patients (63.4%). The mean (SD) age for adult males, adult females, elderly males, and elderly females were 50.51 (11.18), 52.12 (10.06), 77.00 (7.50), and 78.44 (7.88) years, respectively. When the data was stratified according to outcome, deceased adult patients accounted for 6.9% of all adult patients, while elderly deceased patients accounted for 17.5% of all elderly patients. Elderly patients had a 2.5 times increase in mortality compared to adult patients. When the data was stratified according to operation status, non-operation patients had 58.6% use of gastrointestinal invasive diagnostic procedures, as opposed to the operative patients with 30.3% use. In the final regression model, age (OR=1.03, 95%CI: 1.02–1.04), male sex (OR=1.12, 95%CI: 1.04–1.21), operation (OR=2.73, 95%CI: 2.50–2.97), bacterial infections (OR=3.12, 95%CI: 2.82–3.44), respiratory diseases, (OR=1.84, 95%CI: 1.71–1.99), cardiac diseases (OR=2.78, 95%CI: 2.09–2.48), liver diseases (OR=2.24, 95%CI: 1.99–2.53), genitourinary system diseases (OR=1.40, 95%CI: 1.30–1.51), fluid and electrolyte disorders (OR=1.48, 95%CI: 1.37–1.60), neurological diseases (OR=1.23, 95%CI: 1.13–1.33), and trauma, burns, and poisons (OR=1.57, 95%CI: 1.43–1.73) were the risk factors for mortality. Gastrointestinal invasive diagnostic procedures (OR=0.31, 95%CI: 0.28–0.34) and hospital length of stay (OR=0.91, 95%CI: 0.90–0.92) were protective factors for mortality in all patients.
Conclusion: For elderly patients emergently admitted for intestinal vascular insufficiency, the odds of mortality were 2.5 times greater than in adult patients. Age, male sex, operation, and several comorbidities were risk factors for mortality; whereas, invasive diagnostic procedures and longer hospital stay were the protective factors against mortality.
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Surgical Technique for Sphinkeeper® Implantation
Christopher Dawoud, MD, Moritz Daniel Felsenreich, MD, PhD, Associate Professor, Felix Harpain, MD, Stefan Riss, MD, FRCS, Associate Professor, Department of General Surgery, Division of Visceral Surgery, Medical University Vienna, Austria
1712
Fecal incontinence is a distressing condition characterized by the involuntary loss of solid and liquid stool and gas, It affects a significant proportion of the general population, with a reported prevalence ranging from 1% to 20%. Despite its considerable impact on quality of life, therapeutic options for fecal incontinence remain limited.
Current treatment modalities for fecal incontinence include conservative approaches such as dietary modifications, pelvic floor exercises, and pharmacotherapy. Surgical interventions, including sphincteroplasty or sacral nerve stimulation, may be considered in more severe cases.
Recently, THD Labs (THD S.p.A. Correggio (RE), Italy) introduced the Gatekeeper® as a novel device that supports the implantation of up to four solid prostheses into the intersphincteric groove. Early data were promising, with success rates above 50% and only a few perioperative complications.
Subsequently, Gatekeeper® was modified by increasing the length and number (up to 10) of prostheses, and renamed Sphinkeeper® (THD). With this device, nine to 10 small incisions measuring 2 mm are made at a distance of 2-3 cm from the anus. The intersphincteric space is accessed using the delivery system, and positioning is verified through endoanal ultrasound. This procedure is repeated for all 10 prostheses placed around the entire circumference. The Sphinkeeper® offers the potential to improve the management of fecal incontinence, and offers patients a less-invasive alternative to traditional surgical approaches.
Use of Indocyanine Green Fluorescence During Total Thyroidectomy to Identify Parathyroid Glands and Prevent Hypoparathyroidism
Daqi Zhang, MD, Professor, Hui Sun, MD , Professor, China-Japan Union Hospital of Jilin University, Changchun City, Jilin Province, China, Francesco Frattini, MD, Andrea Cestari, MD, Simona Bertoli, MD, Gianlorenzo Dionigi, MD, Professor, Istituto Auxologico Italiano IRCCS, Milan, Italy, Hoon Yub Kim, MD, Professor, Korea University Hospital, Korea University College of Medicine, Seoul, Republic of Korea , Che Wei Wu, MD, Professor, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, Gianluca Donatini, MD, Professor, CHU Poitiers, University of Poitiers, Poitiers, France, Diego Barbieri, MD, Mario Bussi, MD, Professor, IRCCS San Raffaele Scientific Institute, Milan, Italy
1741
Introduction: Total thyroidectomy is associated with a high rate of transient or permanent hypoparathyroidism. During surgery, indocyanine green (ICG) fluorescein angiography can be used to detect and preserve well-vascularized parathyroid glands. This technique has been introduced as an intraoperative support to prevent postoperative hypoparathyroidism.
Material and methods: One-hundred consecutive patients who had undergone total thyroidectomy were included in this study. Autofluoroscopy was used on the first dominant side of thyroidectomy and to identify the contralateral parathyroid glands. An intravenous bolus of 5 mg ICG (VERDYE, Diagnostic Green GmbH, Aschheim‐Dornacht, Germany) was administered once. ICG fluorescein angiography was used as a "bridge" at the end of the first dominant hemithyroidectomy and after exposure of the parathyroid glands on the second side. This allowed us to (i) determine the vascularization of the first two parathyroid glands and (ii) define the blood vessels and thus the line of dissection of the parathyroid glands of the second resection side. Finally, autofluoroscopy was then applied outside the surgical area on the surgical specimen to assess forgotten parathyroid glands, which should therefore be re-implanted. Autofluoroscopy and ICG fluorescein angiography were evaluated in real time using the same technology, i.e., FLUOBEAM® LX (EUROPE – Fluoptics Grenoble, France; USA – Fluoptics Imaging Inc., Cambridge, MA, USA). The study was approved by the local ethics committee.
Results: Autofluorescence and ICG fluorescein angiography were performed without any problems in all cases. A total of 370 parathyroid glands were detected in this series. ICG changed the surgical strategy for the first-side parathyroid glands in 5% of cases, i.e,. they were not well-vascularized and were re-implanted. The rate of transient hypoparathyroidism was 19%. The percentage of parathyroids in the surgical specimen was 3.5% and all were re-implanted during the same surgery. There was no case of postoperative definitive hypoparathyroidism when at least one parathyroid gland with a high fluorescence intensity was preserved on the first side of resection.
Conclusion: Use of ICG fluorescein angiography may contribute to predicting and thus preventing postoperative definitive hypoparathyroidism after total thyroidectomy. The results of this case series confirm recent studies. Caution is advised when weakly perfused parathyroid glands are discovered.
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Endoscopic Gastric Plication: A Flexible and Tailored Alternative to Bariatric Surgery
Francesco Frattini, MD, Andrea Gambetti, MD, Giuseppe Cordaro, MD, Jerry Spisani, MD, Gianlorenzo Dionigi, MD, Prof., IRCCS Istituto Auxologico Italiano, Milan, Italy, Georgios Lianos, MD, PhD, Ioannina University Hospital, Ioannina, Greece, Bertoli Simona, MD, Prof., Istituto Auxologico Italiano, IRCCS, Milan, Italy
1745
Introduction: Endoscopic procedures are expanding and have been evolving in recent years, increasing their volume along with the development of new devices. This is due to the low morbidity and complication rate, the reversibility of the procedures, and the positive impact on patients. Among the endoscopic procedures gaining interest is sleeve gastroplasty. It emerged as a feasible and safe alternative to traditional bariatric surgery. There are no guidelines available on the indications and use of endoscopic gastroplasty. The aim of this study is to present preliminary results of a case series of endoscopic gastric plication procedures performed for different options: as a primary endoscopic sleeve, as revision for sleeve gastrectomy, and as revision for gastric bypass.
Materials and Methods: A retrospective analysis was performed on a prospective database collecting data on all patients with obesity treated with endoscopic gastroplasty with the Overstitch™ (Apollo Endosurgery, Inc., Austin, Texas) device from 2022 to 2023 in the bariatric surgery unit.
Results: Twenty-three patients were treated from May 2022 to July 2023 with endoscopic gastric plication. Ten patients (43%) were submitted to primary endoscopic sleeve gastroplasty, three patients to revision of sleeve gastrectomy, one patient to revision of one anastomosis gastric bypass, and eight patients received a revision of Roux-en-Y gastric bypass. The body mass index (BMI) of patients submitted to primary ESG ranged from 33 to 42kg/m2, with a mean BMI of 37kg/m2. The age of the patients ranged from 22 to 70 years, with a mean age of 45. In one case, we registered a Clavien-Dindo 2 complication—an inflammatory perigastric reaction without a collection occurred 15 days after a primary ESG.
Conclusion: Endoscopic gastric plication is emerging as a safe, mini-invasive, and effective procedure alternative to sleeve gastrectomy in patients with I or II class obesity or for those unfit for bariatric surgery. The endoscopic suturing device can be used both as a primary procedure or as a revisional option after failure of the primary surgery, thus proving to be a versatile option to provide to bariatric patients.
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