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D W Rattner

Publications and source records attributed to D W Rattner.

At least 19 recordsLinked to original sources
PubMed2006

Operative time is a poor surrogate for the learning curve in laparoscopic colorectal surgery.

BACKGROUND: Previous studies have relied on conversion rate and operative time for construction of learning curves in laparoscopic colorectal surgery. The authors hypothesized that conversion rate and operative time were less important than complication and readmission rates in defining good outcomes and hence the learning curve. METHODS: A database of 287 consecutive laparoscopic colorectal resections from a single tertiary referral center was analyzed. Outcome measures included operative time, conversion rate, major and minor complications, length of hospital stay, and the 15- and 30-day hospital readmission rate. Data were analyzed both by surgeons and by quartile case numbers. RESULTS: A total of 151 right colectomies and 136 left colectomies were performed between 1995 and 2005. For both right and left colectomies, the conversion rate decreased in each of the first three quartiles, reaching a nadir of 0% for right colectomies and 3% for left colectomies in the third quartile. The conversion rates increased slightly in the fourth quartile. The operative time remained stable for three quartiles, then increased slightly in the fourth quartile. Two surgeons managed 199 of the 287 cases. Analysis of the two high-volume surgeons demonstrated that for left-sided resections, the surgeon with the shorter operative times had the higher major complication rate (13% vs 2%), overall complication rate (22% vs 2%), 30-day readmission rate (13% vs 0%), and length of stay (3.8 vs 3.1 days) (p < 0.05 for all comparisons). CONCLUSIONS: In this series, operative time failed to decrease with experience, and shorter operative times did not correlate with better clinical outcomes. The failure of operative time to decline with experience often reflects surgeons' willingness to attempt more difficult cases rather than an accurate representation of a "learning curve." Therefore, complication and readmission rates are more important than operative time and conversion rates for evaluating the learning curve and quality of laparoscopic colorectal surgery.

Adult↗
PubMed2006

Evaluating an optimal gastric closure method for transgastric surgery.

BACKGROUND: The transgastric approach is currently being studied as a potentially less invasive alternative to conventional laparoscopy for intra-abdominal surgery. A major obstacle to overcome is the closure of the transgastric incision in a rapid, reproducible, and safe manner. The effectiveness of various techniques for gastrotomy closure were compared by assessing leak pressures in an ex vivo porcine stomach model. METHODS: Whole stomachs from adult white pigs were suspended in a Plexiglas box to facilitate endoscopic technique. Standard gastrotomies were made by needle knife incision and dilation with a controlled radial expansion (CRE) balloon. The first arm used standard QuickClips; the second, a prototype device developed by LSI Solutions; the third, hand-sewn by a senior surgeon; the final, a control with open gastrotomy. Five stomachs were tested per study arm. After closure, each stomach was inflated by an automated pressure gauge. The pressures to achieve air leakage and liquid leakage were recorded. RESULTS: The unclosed controls demonstrated air leakage at a median pressure of 15 mmHg, representing baseline system resistance. The QuickClip closures leaked air at a median pressure of 33 mmHg. The prototype gastrotomy device yielded the highest median air leak pressure of 85 mmHg while dramatically diminishing time for incision and gastrotomy closure to approximately 5 min. The hand-sewn closures leaked air at a median pressure of 47 mmHg. Using Kruskal-Wallis statistical analysis, the comparisons were significant (p = 0.0019). Post hoc paired comparisons using MULTTEST procedure with both Bonferroni and bootstrap adjustments revealed that the difference between prototype and clips was significant; prototype versus hand-sewn was not. Liquid-leak pressures produced similar results. CONCLUSIONS: The prototype device decreases procedure time and yields leak-resistant gastrotomy closures that are superior to clips and rival hand-sewn interrupted stitches.

Animals↗
PubMed2005

Changes in serum ghrelin predict weight loss after Roux-en-Y gastric bypass in rats.

BACKGROUND: Although Roux-en-Y gastric bypass (RYGB) is an effective and widely used therapy for severe obesity, the mechanisms by which it induces weight loss are not well understood. Several studies have shown that RYGB in human patients causes a decrease in circulating levels of ghrelin, a gastric hormone that strongly stimulates food intake. Substantial variation in the effect of RYGB on serum ghrelin has been reported in different studies and among individual patients, suggesting that regulation of this hormone is complex and subject to genetic and other patient-specific factors. To control for these factors and to enable more detailed study of physiologic mechanisms, we have recently developed a clinically relevant rat model of RYGB. In this study, we used this model to examine the effect of RYGB on serum ghrelin levels. METHODS: Fifteen Sprague-Dawley rats that had received a high-fat diet to induce moderate obesity underwent RYGB. The operation closely resembled the procedure in humans. Serum samples were collected 1 month before and 3 months after RYGB, and serum ghrelin levels were measured. The primary outcomes of the study were the changes in body weight, food intake, and circulating ghrelin levels after RYGB. A multiple linear regression model was developed to examine the relationship between ghrelin levels and weight change after RYGB. RESULTS: Three months after the procedure, RYGB-treated rats weighed 20 +/- 5% less than they would have, had they not undergone the procedure. Despite the weight loss, serum ghrelin levels were 38 +/- 6% lower than before surgery. There was appreciable variation in the weight loss in individual animals, and preoperative weight and pre- and postoperative ghrelin levels were the best predictors of postoperative weight loss. Thus, the animals who had the greatest weight loss were those that were heaviest before surgery. These rats had the highest preoperative and lowest postoperative ghrelin levels. CONCLUSIONS: Using our recently developed rat model of RYGB, we found that postoperative weight loss is correlated with the magnitude of the decrease in circulating ghrelin levels. This correlation provides the strongest evidence to date that altered ghrelin signaling contributes to weight loss after this operation. The lower level of circulating ghrelin after RYGB likely blunts the appetitive drive, leading to decreased food intake in these animals.

Animals↗
PubMed2004

Computer-enhanced laparoscopic training system (CELTS): bridging the gap.

BACKGROUND: There is a large and growing gap between the need for better surgical training methodologies and the systems currently available for such training. In an effort to bridge this gap and overcome the disadvantages of the training simulators now in use, we developed the Computer-Enhanced Laparoscopic Training System (CELTS). METHODS: CELTS is a computer-based system capable of tracking the motion of laparoscopic instruments and providing feedback about performance in real time. CELTS consists of a mechanical interface, a customizable set of tasks, and an Internet-based software interface. The special cognitive and psychomotor skills a laparoscopic surgeon should master were explicitly defined and transformed into quantitative metrics based on kinematics analysis theory. A single global standardized and task-independent scoring system utilizing a z-score statistic was developed. Validation exercises were performed. RESULTS: The scoring system clearly revealed a gap between experts and trainees, irrespective of the task performed; none of the trainees obtained a score above the threshold that distinguishes the two groups. Moreover, CELTS provided educational feedback by identifying the key factors that contributed to the overall score. Among the defined metrics, depth perception, smoothness of motion, instrument orientation, and the outcome of the task are major indicators of performance and key parameters that distinguish experts from trainees. Time and path length alone, which are the most commonly used metrics in currently available systems, are not considered good indicators of performance. CONCLUSION: CELTS is a novel and standardized skills trainer that combines the advantages of computer simulation with the features of the traditional and popular training boxes. CELTS can easily be used with a wide array of tasks and ensures comparability across different training conditions. This report further shows that a set of appropriate and clinically relevant performance metrics can be defined and a standardized scoring system can be designed.

Clinical Competence↗
PubMed2002

A cost--utility analysis of treatment options for inguinal hernia in 1,513,008 adult patients.

BACKGROUND: The controversial issue of the cost-effectiveness of laparoscopic inguinal hernia repair is examined, employing a decision analytic method. MATERIALS AND METHODS: The NSAS, NHDS (National Center for Health Statistics), HCUP-NIS (Agency for Healthcare Research and Quality) databases and 51 randomized controlled trials were analyzed. The study group constituted of a total of 1,513,008 hernia repairs. Projection of the clinical, economic, and quality-of-life outcomes expected from the different treatment options was done by using a Markov Monte Carlo decision model. Two logistic regression models were used to predict the probability of hospital admission after an ambulatory procedure and the probability of death after inguinal hernia repair. Four treatment strategies were modeled: (1) laparoscopic repair (LR), (2) open mesh (OM), (3) open non-mesh (ONM), and (4) expectant management. Costs were expressed in US dollars and effectiveness in quality-adjusted life years (QALYs). The main outcome measures were the average and the incremental cost-effectiveness (ICER) ratios. RESULTS: Compared to the expectant management, the incremental cost per QALY gained was 605 dollars (4086 dollars, 9.04 QALYs) for LR, 697 dollars (4290 dollars, 8.975 QALYs) for OM, and 1711 dollars (6200 dollars, 8.546 QALYs) for ONM. In sensitivity analysis the two major components that affect the cost-effectiveness ratio of the different types of repair were the ambulatory facility cost and the recurrence rate. At a LR ambulatory facility cost of 5526 dollars the ICER of LR compared to OM surpasses the threshold of 50,000 dollars/QALY. CONCLUSIONS: On the basis of our assumptions this mathematical model shows that from a societal perspective laparoscopic approach can be a cost-effective treatment option for inguinal hernia repair.

Adult↗
PubMed2002

Measurement of in-vivo force response of intra-abdominal soft tissues for surgical simulation.

The lack of data on in-vivo material properties of soft tissues has been a significant impediment in the development of virtual reality based surgical simulators that can provide the user with realistic visual and haptic feedback. As a first step towards characterizing the mechanical behavior of organs, this work presents in-vivo force response of the liver and lower esophagus of pigs when subjected to ramp and hold, and sinusoidal indentations delivered using a haptic feedback device, Phantom, employed as a mechanical stimulator. The results show that pulse significantly affects the reaction forces and that the lower esophagus is 2 to 2.5 times stiffer than the liver.

Abdomen↗
PubMed2001

Robotically assisted minimally invasive biliary surgery in a porcine model.

BACKGROUND: A robotic surgery system has the potential both to reduce the effects of tremor and fatigue and to enhance dexterity in the performance of complex, fine endosurgical tasks. We report a prospective study of robotically assisted minimally invasive biliary surgery in a porcine model using the Zeus robotic surgical system (Computer Motion, Goleta, Ca, USA). METHODS: For this study, 50-kg domestic swine were used. Minimally invasive robotically assisted cholecystectomy was performed in 16 animals, either longitudinal or transverse common bile duct incision, T-tube placement, and suture repair of the common bile duct. Retrieval of 12 simulated bile duct calculi was attempted. Eight animals were monitored for 6 weeks postoperatively. Liver function tests and cholangiography were performed 2 and 6 weeks after surgery. RESULTS: The median setup time for the robotic system was 45 min (range, 10-120 min). The median operative time was 40 min (range, 25-60 min) for cholecystectomy and 80 min (range, 40-165 min) for bile duct dissection, exploration, and repair. Of 12 bile duct calculi, 11 were retrieved successfully. Cholangiography demonstrated no leaks, and the anastomotic stenotic index (diameter of the proximal bile duct divided by the diameter of distal bile duct) at 6 weeks was 0.98. The results of the liver function tests remained normal in all animals. One postoperative death unrelated to operative technique occurred. Complications included one minor splenic laceration and two intraoperative gallbladder perforations. CONCLUSIONS: Robotically assisted minimally invasive biliary surgery in this animal model is both feasible and safe. The Zeus system provides enhanced dexterity, which facilitates precise laparoscopic suture repair of small bile ducts.

Animals↗
PubMed2001

Obesity adversely affects the outcome of antireflux operations.

BACKGROUND: We hypothesized that obesity was associated with long-term failure of antireflux procedures, and that in obese patients antireflux operations were easier to perform via thoracotomy, and therefore likely to have a higher success rate than transabdominal (laparoscopic or open) antireflux procedures. The aims of this study was to determine the impact of obesity on the success of antireflux operations, and to compare the success rates of transthoracic and laparoscopic approaches in obese patients with gastroesophageal reflux. METHODS: The records of 224 consecutive patients undergoing antireflux surgery by two surgeons in a university-based tertiary care center were reviewed and patients contacted for follow-up assessment. The patients were classified into groups based on the type of operation performed and the calculated body mass index (BMI): normal (BMI 30). Recurrences were documented by symptoms responsive to acid-suppressive medication and radiologic or pH probe studies. RESULTS: Among the 224 patients included in this study, 187 underwent laparoscopic Nissen fundoplications (LNF) and 37 underwent Belsey Mark IV(BM4) procedures. The mean follow-up period was 37 months. The three groups included 89 (39.7%) patients classified as having normal weight, 87 (38.8%) as overweight and 48 (21.4%) as obese. Normal, overweight, and obese patients were similar in terms of age, gender, hiatal hernia size, degree of esophagitis, and comorbid conditions. A total of 26 recurrences occurred, giving an overall recurrence rate of 11.6%. There were 4 recurrences in the normal group (4.5%), 7 in the overweight group (8.0%; p not significant vs normal), and 15 in the obese group (31%; p < 0.001 vs normal; p <.001 vs overweight). The recurrence rate was similar between LNF and BM4 in each BMI subgroup, although in aggregate, the recurrence rate after BMW was greater than after LNF (10/37 vs 16/187; p < 0.02). CONCLUSIONS: Obesity adversely affects the long-term success of antireflux operations. Although athoracotomy provides optimal exposure of the hiatal structures in obese patients, a transthoracic approach was associated with a higher recurrence rate than LNF. Given the high failure rate of antireflux operations in obese patients, intensive efforts at sustained weight loss should be made before consideration of surgery.

Body Mass Index↗
PubMed2001

Long-term results of intraoperative electron beam radiotherapy for primary and recurrent retroperitoneal soft tissue sarcoma.

PURPOSE: This study assesses the long-term outcome of patients with retroperitoneal sarcoma treated by preoperative external beam radiotherapy, resection, and intraoperative electron beam radiation (IOERT). METHODS AND MATERIALS: From 1980 to 1996, 37 patients were treated with curative intent for primary or recurrent retroperitoneal soft tissue sarcoma. All patients underwent external beam radiotherapy with a median dose of 45 Gy. This was followed by laparotomy, resection, and IOERT, if feasible. Twenty patients received 10-20 Gy of IOERT with 9-15 MeV electrons. These patients were compared to a group of 17 patients receiving preoperative irradiation without IOERT. RESULTS: The 5-yr actuarial overall survival (OS), disease-free survival, local control (LC), and freedom from distant disease of all 37 patients was 50%, 38%, 59%, and 54%, respectively. After preoperative irradiation, 29 patients (78%) underwent gross total resection. For 16 patients undergoing gross total resection and IOERT, OS and LC were 74% and 83%, respectively. In contrast, these results were less satisfactory for 13 patients undergoing gross total resection without IOERT. For these patients, OS and LC were 30% and 61%, respectively. Four patients experienced treatment-related morbidity. CONCLUSIONS: In selected patients, IOERT results in excellent local control and disease-free survival with acceptable morbidity.

Adolescent↗
PubMed2001

Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization.

HYPOTHESIS: Experience with pancreatic resection for the last 10 years has resulted in new trends in patient characteristics and, for pancreaticoduodenectomy (PD), a decrease in the length of stay (LOS). This decrease is due in part to the implementation of case management and clinical pathways. DESIGN: Retrospective case series of patients undergoing pancreatic resection. SETTING: A university-affiliated, tertiary care referral center. PATIENTS: The study comprised 733 consecutive patients undergoing pancreatic resection for benign or malignant disease at the Massachusetts General Hospital in Boston from April 1990 to March 2000. INTERVENTIONS: Of the 733 pancreatic resections, 489 were PD; 190, distal pancreatectomy; 40, total pancreatectomy; and 14, middle-segment pancreatectomy. MAIN OUTCOME MEASURES: Length of stay; occurrence of delayed gastric emptying, pancreatic fistula, reoperation, readmission, or other complications; mortality; and comparison of patients in 3 periods according to the implementation of case management (July 1995) and clinical pathways (September 1998). RESULTS: For PD, patients in group 1 (April 1990 to June 1995) were significantly younger (mean +/- SD, 57 +/- 15 years) than those in group 2 (July 1995 to August 1998; mean +/- SD, 62 +/- 13 years) and group 3 (September 1998 to October 2000; mean +/- SD, 65 +/- 13 years)(P <.01). Over time, the proportion of PD for cystic tumors increased from 9.9% to 20% (P =.01), and the proportion of PD for chronic pancreatitis decreased from 23% to 10% (P <.01). Use of pylorus-preserving PD decreased from 45% to 0% (P <.001). Delayed gastric emptying decreased from 17% to 6.1% (P <.01). Pancreatic fistula, reoperation, and mortality were unchanged. Length of stay for PD decreased from 16.1 +/- 0.6 to 9.5 +/- 0.4 days (mean +/- SE) (P <.001). Multivariate analysis showed that period, case volume, pylorus-preserving PD, and presence of complications are all independent predictors of LOS (P <.05 for all). For distal pancreatectomy, patients in groups 2 and 3 were older than those in group 1 (mean +/- SD, 57 +/-14 vs 52 +/- 17 years) (P <.05). Resections for cystic tumors increased from 26% to 52% (P <.05), and resections for chronic pancreatitis decreased from 32% to 14% (P =.06). Median LOS decreased from 9 days to 6. For total pancreatectomy, resections for cystic tumors increased from 18% to 43%. Median LOS decreased from 14.5 days to 11. For all resections, case volume increased from 4 resections per month in 1990 to 5.8 in 1995 and 12 in 2000 (r = 0.83; P <.001). CONCLUSIONS: Older patients are increasingly being selected for pancreatic resection. This reflects an increasing frequency of operations performed for cystic tumors and fewer for chronic pancreatitis. With the exception of delayed gastric emptying, complications and mortality have remained the same or decreased slightly during the past 10 years. However, there has been a significant decrease in LOS; this is the result of implementation of case management and clinical pathways, increasing case volume, decreasing incidence of delayed gastric emptying, and decreasing use of pylorus-preserving PD.

Adenocarcinoma↗
PubMed2001

The need for training opportunities in advanced laparoscopic surgery.

BACKGROUND: There is controversy regarding the amount of training necessary to safely perform advanced laparoscopic surgery. General surgical residency often provides only a low volume of advanced laparoscopic cases and there is growing interest in nonaccredited fellowships focused on laparoscopic surgery. OBJECTIVE: To assess surgical residents' perception of the need for training in advanced laparoscopic surgery in addition to that provided in a standard general surgical residency. METHODS: A 15-item questionnaire was mailed to 985 physicians who either were Society of American Gastrointestinal Endoscopic Surgeons (SAGES) candidate members or had attended a SAGES resident course in 1998 or 1999. For the purposes of the survey, laparoscopic Nissen fundoplication, laparoscopic herniorrhaphy, laparoscopic splenectomy, and laparoscopic colectomy were chosen as advanced procedures. RESULTS: Of the 85 responses obtained, 81% were from respondents who were at the postgraduate fourth-year (PG4) level or higher. Furthermore, 58% of the respondents had taken a course in advanced laparoscopic surgery outside their residency program. The respondents believed that to perform the procedures safely and with confidence on entering practice, they needed to do at least eight each of the selected laparoscopic procedures. As reported, 45% of the respondents had performed three or fewer laparoscopic hernias; 60% had performed three or fewer laparoscopic Nissen fundoplications; 81% had performed three or fewer laparoscopic colectomies; and 86% had performed three or fewer splenectomies. Only 32% of the residents expected to perform more than 10 laparoscopic Nissen fundoplications, only 10% expected to perform more than 10 colectomies, and only 4% expected to perform more than 10 splenectomies before completing their residency. Many respondents (65%) said they would pursue an additional year of advanced laparoscopic training if it were available. In programs unaffiliated with a fellowship in advanced laparoscopic surgery, 65% of the residents were concerned that such a fellowship would interfere with residency training in laparoscopic surgery. In comparison, only 24% of the residents in programs affiliated with a fellowship in advanced laparoscopic surgery believed that the fellowship interfered with their training, whereas 47% of the residents in programs affiliated with a fellowship in advanced laparoscopic surgery thought that the fellowship had no impact on their training. CONCLUSIONS: Residents clearly perceive a need for additional training in advanced laparoscopic surgery. Residents from programs without a laparoscopic fellowship are concerned about a negative impact on their experience from a laparoscopic fellow, but residents from programs with a laparoscopic fellowship are neutral about the impact of a fellow.

Clinical Competence↗
PubMed2000

Impact of laparoscopic staging in the treatment of pancreatic cancer.

HYPOTHESIS: Staging laparoscopy in patients with pancreatic cancer identifies unsuspected metastases, allows treatment selection, and helps predict survival. DESIGN: Inception cohort. SETTING: Tertiary referral center. PATIENTS: A total of 125 consecutive patients with radiographic stage II to III pancreatic ductal adenocarcinoma who underwent staging laparoscopy with peritoneal cytologic examination between July 1994 and November 1998. Seventy-eight proximal tumors and 47 distal tumors were localized. INTERVENTIONS: Based on the findings of spiral computed tomography (CT) and laparoscopy, patients were stratified into 3 groups. Group 1 patients had unsuspected metastases found at laparoscopy and were palliatedwithout further operation. Group 2 patients had no demonstrable metastases, but CT indicated unresectability due to vessel invasion. This group underwent external beam radiation with fluorouracil chemotherapy followed in selected cases by intraoperative radiation. Patients in group 3 had no metastases or definitive vessel invasion and were resection candidates. MAIN OUTCOME MEASURE: Survival. RESULTS: Staging laparoscopy revealed unsuspected metastases in 39 patients (31.2%), with 9 having positive cytologic test results as the only evidence of metastatic disease (group 1). Fifty-five patients (44.0%) had localized but unresectable carcinoma (group 2), of whom 2 (3.6%) did not tolerate treatment, 20 (36.4%) developed metastatic disease during treatment, and 21 (38.2%) received intraoperative radiation. Of 31 patients with potentially resectable tumors (group 3), resection for cure was performed in 23 (resectability rate, 74.2%). Median survival was 7.5 months for patients with metastatic disease, 10.5 months for those receiving chemoradiation, and 14.5 months for those who underwent tumor resection (P = .01 for group 2 vs. group 1; P<.001 for group 3 vs group 1). CONCLUSIONS: Staging laparoscopy, combined with spiral CT, allowed stratification of patients into 3 treatment groups that correlated with treatment opportunity and subsequent survival. Among the 125 patients, laparoscopy obviated 39 unnecessary operations and irradiation in patients with metastatic disease not detectable by CT. Laparoscopic staging can help focus aggressive treatment on patients with pancreatic cancer who might benefit.

Aged↗
PubMed2000

Measuring improved quality of life after laparoscopic Nissen fundoplication.

BACKGROUND: While the correction of pathologic gastroesophageal reflux by means of laparoscopic Nissen fundoplication (LNF) has been well documented, the psychological profiles of patients with this disease and the impact on their quality of life are less well understood. We obtained a baseline psychological profile and measured the impact of LNF on patients' quality of life with 2 standardized instruments: the psychological general well-being index (PGWB) and the gastrointestinal symptoms rating scale (GSRS). The study included 34 consecutive patients with typical symptoms of gastroesophageal reflux who underwent LNF in 1995 at a tertiary care university medical center. METHODS: Patients filled out PGWB and GSRS surveys preoperatively and at 2 weeks, 2 months, and 12 months postoperatively. Data were collected in a blinded fashion by a study nurse and analyzed after completion of the study. Data are expressed as mean +/- standard deviation. RESULTS: The mean preoperative PGWB score (69.6 +/- 17.3) of study patients with gastroesophageal reflux disease was lower than that expected for a healthy population. This was primarily attributable to low scores in the general health domain of the questionnaire, although LNF patients also had low scores in the vitality and positive well-being domains of the PGWB scale. LNF improved the PGWB score to a normal level (78.7 +/- 19.3) (P = .05 vs the preoperative PGWB score) at 12 months post surgery. The GSRS also showed improvement from 34.7 +/- 7.8 to 28.1 +/- 10 (P = .008). The improvement in GSRS was attributed to improvement in the heartburn (7.12 +/- 2.4 to 2.72 +/- 1.2, P < .001) and abdominal pain (6.58 +/- 2.5 to 4.92 +/- 1.6, P = .006) domains of the scale. LNF had no impact on the diarrhea, indigestion, and obstipation domains of the GSRS. CONCLUSIONS: Patients with gastroesophageal reflux disease who are candidates for LNF have low psychological and general well-being scores that are restored to normal levels by successful LNF. When compared with baseline measurements, LNF effectively relieved heartburn and did not cause significant new gastrointestinal complaints.

Adult↗
PubMed2000

Physicians' choice for their own hernia repairs.

BACKGROUND AND PURPOSE: While the optimal method of inguinal herniorrhaphy is controversial, there is growing acceptance that laparoscopic hernia repair is a legitimate alternative to conventional techniques. This study sought to determine if physicians as patients had different preferences for their own hernia repairs than nonphysician patients. PATIENTS AND METHODS: Total endoscopic preperitoneal (TEP) herniorrhaphy was introduced into the author's practice in 1995. Open herniorrhaphies (OH) were performed under local anesthesia and were almost all tension-free repairs. Patients were given the option of surgical technique after a discussion with the author, although patients with primary unilateral hernias were encouraged to undergo a tension-free OH. A prospective database was kept and subsequently analyzed. RESULTS: In the 3 years from June 1, 1995, to June 1, 1998, a total of 138 OH and 77 TEP repairs were performed. There were 19 physicians among the 215 patients. During the 3-year period, the annual percentage of laparoscopic herniorrhaphies increased from 27% (21/79) to 46% (32/70) (P = 0.024). The shift in physician preference for TEP from 16% (1/6) in 1995 to 75% (6/8) in 1997 was more dramatic than the shift in the population at large: 22% (20/73) to 42% (26/62). All patients undergoing TEP repair for recurrent hernias stated their recovery was easier than after their original OH. Four of seven physicians with recurrent hernias also had bilateral hernias. None required hospitalization. The median time to return to work was 4 days in the TEP physician group and 7 days in the physician OH group. The median time to return to work was 10 days in the TEP nonphysician group and 16 days in the OH nonphysician group. CONCLUSIONS: Physicians cared for by the author are increasingly choosing a laparoscopic approach for their hernia repairs even when they have primary unilateral hernias. Patients return to work more rapidly after TEP repairs than after OH.

Hernia, Inguinal↗
PubMed2000

Outcome of pancreaticoduodenectomy with pylorus preservation or with antrectomy in the treatment of chronic pancreatitis.

OBJECTIVE: To compare the short- and long-term results of pancreaticoduodenectomy with pylorus preservation (PPPD) or with antrectomy (Whipple procedure) in the treatment of selected patients with chronic pancreatitis. BACKGROUND: PPPD may be preferred over Whipple because of its purported nutritional advantages and the reduced likelihood of postgastrectomy syndromes. METHODS: A retrospective review was performed of 72 consecutive patients undergoing pancreaticoduodenectomy for chronic pancreatitis between 1991 and 1997. RESULTS: PPPD was performed in 39 patients and Whipple in 33. The two patient populations had similar characteristics. Short-term complications included (PPPD vs. Whipple): pancreatic or biliary fistulas (5.1% vs. 15%), delayed gastric emptying (33% vs. 12%), cholangitis (2.6% vs. 6.1%), and death (0 vs. 3%). Delayed gastric emptying was not associated with other complications and resulted in longer hospital stays for PPPD than for Whipple patients (15 vs. 12 days). The duration of follow-up averaged 41 +/- 24 months. Long-term weight status was similar, with body-mass indices of 22.1 and 22.9 after PPPD and Whipple, respectively. Postoperative enzyme supplementation (63% vs. 77%) and new-onset diabetes (10% vs. 12%) did not differ significantly between the PPPD and Whipple groups. Dumping, bile gastritis, or peptic ulcer disease occurred in three patients after PPPD and in three after Whipple. Complete or partial pain relief was attained in 60% and 70% of patients after PPPD and Whipple, respectively. Multivariate analysis of preoperative variables revealed that site-specific pathology in the head of the pancreas was the only independent factor associated with successful pain relief after pancreatic resection. CONCLUSION: PPPD results in higher frequencies of postoperative delayed gastric emptying compared with the Whipple procedure. Both operations achieve comparable long-term nutritional results, cause new insulin dependence in surprisingly few patients, and provide equivalent pain relief to 65% of selected patients. Patients with disproportionate pathology in the head of the pancreas have a higher likelihood of successful pain relief.

Adult↗