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Robert V Rege

Publications and source records attributed to Robert V Rege.

14 recordsLinked to original sources
PubMed2005

Do resident duty hour restrictions reduce technical complications of emergency laparoscopic cholecystectomy?

BACKGROUND: The impact of resident duty hour restrictions on patient care has not been assessed. STUDY DESIGN: We studied 275 patients undergoing emergency cholecystectomy before and after duty hour regulations instituted by the Accreditation Council for Graduate Medical Education. Operations were stratified into 6-hour intervals from the time in-hospital call began. Procedure-related complications (bile duct injury, cystic duct leak, abdominal hemorrhage, trocar injury, intraabdominal/wound infection, unrecognized retained stone) were the primary outcomes variables. RESULTS: Complications occurred after 7 of 107 (6.5%) operations performed before duty hour restrictions, which was not different from 15 of 168 (8.9%) after duty hour restrictions. In both periods, all complications followed operations that began within the first 18 hours of duty. Patients with complications had longer operative times (p = 0.038) and a higher proportion of operations lasting 120 minutes or longer (p = 0.006). Comparing patients with and without complications, there were no significant differences in patient demographics, operative complexity, or PGY level of the surgeon. Only operative time of 120 minutes or longer retained significance in the multivariable model (p = 0.0023; odds ratio, 4.05; 95% CI, 1.65-9.97). CONCLUSIONS: There was no correlation between imposition of duty hour restrictions and technical complication rates in this study. Duration of operative time of 120 minutes or longer was the only independent marker, suggesting that technical complications are a function of operative complexity, not duration of duty. These data suggest that duty hour restrictions might not have a measurable influence on the surgical complication rate after emergency cholecystectomy.

Adult↗
PubMed2005

Indications for selective intraoperative cholangiography.

The indications for selective intraoperative cholangiography (IOC) include a clinical history of jaundice, pancreatitis, elevated bilirubin level, abnormal liver function test results, increased amylase levels, a high lipase level, or dilated common bile duct on preoperative ultrasonography. Although these clinical features are widely accepted as indications for IOC, they have not been tested for their ability to predict choledocholithiasis. Charts were reviewed for a 6-month time period in 2003 at Parkland Memorial Hospital for all patients undergoing cholecystectomy. Univariate analysis and logistic regression were used to determine which factors predicted choledocholithiasis. Of the 572 patients undergoing cholecystectomies during the study period, 189 underwent IOC and common bile duct stones were found in 57. Only preoperative hyperbilirubinemia or ultrasonograph identification of common bile duct dilation reliably predicted choledocholithiasis. There were 13 cases of choledocholithiasis that would not have been identified by preoperative hyperbilirubinemia or an enlarged common bile duct. However, common bile duct stones were clinically significant in only 2 of the 13 cases. One of these was treated with postoperative endoscopic retrograde cholangiopancreatography, and the other was treated with laparoscopic common bile duct exploration. Preoperative identification of a dilated common bile duct or elevated bilirubin levels can be the sole criteria for performing IOC on a selective basis in patients without malignancy. Reliance on a history of remote jaundice, pancreatitis, elevated liver function test values, or pancreatic enzymes results in unnecessary IOCs.

Adult↗
PubMed2005

Technical complications are rising as common duct exploration is becoming rare.

BACKGROUND: Both hospital and surgeon volume influence outcomes. With introduction of new technologies, some procedures are now performed less frequently. ERCP has replaced the need for common duct exploration (CDE) in most cases of choledocholithiasis. We explored the secular trends and outcomes of CDE and how they have changed relative to introduction of ERCP. STUDY DESIGN: The National Hospital Discharge Survey database was analyzed for the years 1979 to 2001. Procedural frequency of ERCP and CDE was determined. Charlson and Elixhauser comorbidity indices were used to characterize patients' disease burden for the years 1993 to 2001. Length of stay, mortality, and complication rates for each procedure were determined. RESULTS: At the beginning of the study period, an estimated 47,000 CDEs were performed annually. These declined to 7,700 per year as ERCP increased to 42,500 procedures per year at the end of the study period. CDE complication rates increased from 3.4% to 17.4% over the same period. Comorbidity analysis for the years 1993 to 2001 revealed that ERCP and CDE patients had equivalent disease burdens. Technical complication rates rose in parallel to the increased overall CDE complication rate. CONCLUSIONS: ERCP has replaced the need for most but not all CDE. With diminished CDE experience at a national level, the complication rate has markedly increased, at least in part from technical complications. Both choledocholithiasis treatment algorithms and clinical training paradigms need to account for the rarity of CDE and high complication rates associated with it, by incorporation of training modules in surgical residencies and advocating referral to centers having expertise in biliary tract operations from surgeons with little CDE experience.

Age Factors↗
PubMed2005

Multicenter construct validity for southwestern laparoscopic videotrainer stations.

BACKGROUND: The "Southwestern" videotrainer stations have demonstrated concurrent validity (transferability to the operating room). The purpose of this study was to evaluate the Southwestern stations for construct validity (the ability to discriminate between subjects at different levels of experience). MATERIALS AND METHODS: From two surgical training programs, Institutional Review Board approved protocol data were collected from 142 subjects, including novice (medical students and R1, n = 66), intermediate (R2-R4, n = 67), and advanced (R5 and expert surgeons, n = 9) groups. All participants performed three repetitions on each of five stations. Completion time was scored for each task. Laparoscopic experience was determined from residency case log databases and from expert surgeon personal case logs. Results for the three groups were compared using one-way ANOVA, including relevant pair-wise comparisons. Correlations between number of laparoscopic cases performed and task scores were determined by Pearson's and Spearman's rho-correlation coefficients. RESULTS: The mean number of laparoscopic cases performed prior to completing the five tasks was 0 for novices, 9 for intermediates, and 431 for the advanced group. Significant differences (P < 0.001) were noted between groups for all five tasks and composite score. Task scores and composite scores significantly correlated with laparoscopic experience (P < 0.01). CONCLUSION: These data suggest that differences in laparoscopic ability are detected by performance on the videotrainer; thus, construct validity is demonstrated. Moreover, scores accurately reflect laparoscopic experience. Further validation may allow such simulators to be used for testing and credentialing purposes.

Adult↗
PubMed2004

Health care access and poverty do not explain the higher esophageal cancer mortality in African Americans.

BACKGROUND: Esophageal cancer mortality is increased in African Americans relative to white patients. The reasons for this are unknown but are thought to be related to inadequate access to health care secondary to a higher poverty rate in African American populations. METHODS: The National Health Interview Survey database for years 1986 to 1994 were combined and linked to the National Death Index. Individuals who died from esophageal carcinoma were assessed in the combined database, thus enabling detailed analysis of their socioeconomic status, race, and health care access. RESULTS: Poverty was 4-fold more frequent in African Americans who died from esophageal carcinoma than whites. Despite poverty, African American patients' access to health care was good and was not statistically related to increased mortality. CONCLUSIONS: Although the esophageal carcinoma mortality rate is higher in African Americans than in whites, it is not clearly related to the presence of poverty or to limited health care access. The higher mortality may be related to lifestyle differences, environmental exposure, or difference in disease biology, but it is not related exclusively to socioeconomic factors.

Adult↗
PubMed2004

A nationwide study of conversion from laparoscopic to open cholecystectomy.

PURPOSE: To determine the national incidence and risk factors for conversion from laparoscopic to open cholecystectomy. BACKGROUND: Most series reporting the rates at which laparoscopic cholecystectomies are performed, relative to the open procedure, have come from centers specializing in laparoscopic surgery. The rates at which conversions occur from these centers may not reflect those in community practice. We sought to determine the actual, and therefore acceptable, conversion rate by examining nationally representative discharge data. METHODS: The National Hospital Discharge database for 1998 to 2001 was acquired from the Centers for Disease Control. All gallbladder disease related admissions were extracted, and the cholecystectomies (ICD-9-CM codes 51.2X) were analyzed using the SAS package. Stepwise logistic regression was used to determine what factors were associated with the risk of conversion from laparoscopic to open cholecystectomy. RESULTS: Approximately 25% of all cholecystectomies are performed by the open technique. Of the remaining 75%, there is an approximately 5% to 10% conversion rate. The major risk factors for conversion included male sex, obesity, and cholecystitis. Concurrent choledocholithiasis, cholelithiasis, and cholecystitis were associated with a conversion rate of 25%. Length of stay (LOS) was reduced for laparoscopic operations and although conversion added 2 to 3 days to the LOS, for most cases the LOS was still less than for primary open operations. CONCLUSIONS: Three quarters of all cholecystectomies are performed laparoscopically, and the national conversion rate is 5% to 10%. Cholecystitis, choledocholithiasis, male sex, and obesity are major predictors for conversion. The data presented in terms of conversion rates and LOS were derived from population-adjusted hospital discharge data and represent the current U.S. experience for cholecystectomy. From these data the community experience for conversion rates, risk factors, and LOS can be derived.

Cholecystectomy↗
PubMed2004

Why should the VA continue academic affiliations?

Academic affiliations between VA medical centers and medical schools have made an important contribution to the healthcare of veterans and the education of physicians over the last 60 years. The rationale for these affiliations and their establishment following World War II is discussed. The circumstances leading to affiliations and the benefit they afford veterans remain pertinent today.

Academic Medical Centers↗
PubMed2004

Rebleeding and survival after acute lower gastrointestinal bleeding.

BACKGROUND: Previous studies of acute lower gastrointestinal bleeding (LGIB) have focused on evaluation and therapy. Measurement of long-term outcome has been rare. The purpose of this study was to document rebleeding and survival rates in patients with acute LGIB. METHODS: A retrospective review of all patients undergoing technetium-labeled red blood cell scans for LGIB from January of 1997 to December of 2002 was performed. Rebleeding was defined as identification of enteric bleeding requiring a transfusion 2 or more weeks after the initial bleeding episode. RESULTS: A total of 119 patients met inclusion criteria. Rebleeding was documented in 14 of 102 patients surviving for more than 2 weeks. The actuarial rebleeding rate was 15% at 2 years. No factors were identified that portended a higher likelihood of rebleeding. The 30-day mortality was 18% and the median survival was 60 months for the entire cohort. Of the 36 patients in whom cause of death was documented, 4 died of surgical complications and a single patient died as a direct result of hemorrhage. CONCLUSIONS: Rebleeding after an initial episode of LGIB occurs in a small percentage of individuals. Although survival is poor for patients with LGIB, few patients die as a direct consequence of hemorrhage.

Age Distribution↗
PubMed2003

Effect of sleep deprivation on the performance of simulated laparoscopic surgical skill.

BACKGROUND: Resident work hours may impact patient care. We hypothesized that "call-associated" acute sleep deprivation has no effect on technical dexterity as measured on a minimally invasive surgery trainer, virtual reality (MIST VR) surgical simulator. METHODS: Thirty-five surgical residents were prospectively evaluated pre-call (rested), on-call (rested), and post-call (acutely sleep deprived). Participants completed questionnaires regarding sleep hours and level of fatigue. Technical skill was assessed using the MIST VR. Speed, errors, and economy of motion were automatically recorded by the MIST VR computer simulator. Data were analyzed by paired Student t test and analysis of variance. RESULTS: Estimated hours of sleep and subjective indicators of fatigue were different between rested and sleep-deprived residents. The number of errors and time to complete all tasks increased at the post-call assessment. CONCLUSIONS: Resident work schedules lead to sleep deprivation and fatigue. Call-associated sleep deprivation and fatigue are associated with increased technical errors in the performance of simulated laparoscopic surgical skills.

Adult↗
PubMed2003

Laparoscopic Heller myotomy with bolstering partial posterior fundoplication for achalasia.

BACKGROUND: The ideal antireflux procedure following laparoscopic Heller myotomy for achalasia is controversial. We present a novel laparoscopic technique of partial posterior fundoplication to bolster the myotomy. METHODS: Between August 1998 and March 2002, eight patients (five females and three males; median age, 40 years) underwent a laparoscopic Heller myotomy with bolstering partial posterior fundoplication. Results of barium swallow and manometry studies were consistent with achalasia. Failed medical treatments included balloon dilation, botulinum injection, and calcium channel blockers. RESULTS: The preoperative weight loss was 33 lb (range, 10-50) with a mean duration of symptoms of 29 months (range, 12-72). Seventy-one percent of the patients had reflux. Myotomy was confirmed with endoscopic guidance. Partial posterior fundoplication was performed with the edges of the myotomy on the right and left sides sutured to the stomach, which covered the myotomy. No conversion was required. In one patient, a perforation was recognized, repaired, and bolstered. The mean operative blood loss was 72 mL (range, 30-150). The mean operative time was 4 hours. Patients resumed solids at 2.5 days (range, 2-5). Postoperative complications included subcutaneous emphysema (n = 1), pneumothorax (n = 1), and umbilical port hernia (n = 1). None of the patients had reflux symptoms at 3 to 18 months of follow-up. CONCLUSION: Laparoscopic Heller myotomy with partial posterior fundoplication is technically feasible and effectively prevents reflux symptoms. Bolstering the myotomy may help heal small esophageal perforations.

Adult↗
PubMed2002

The role of biliary calcium in gallstone pathogenesis.

Calcium is an element that is extremely important in the pathogenesis of gallstones. It is present in bile in large quantities since components of bile bind the calcium avidly. Precipitated calcium salts with the calcium sensitive ions, bilirubinate, carbonate and phosphate are major components of pigment gallstones and are present in high concentrations in the centers and rims of cholesterol gallstones. An understanding of the solubility of calcium in bile is thus essential if one is to understand the process that leads to gallstone formation. In addition, calcium also has a very important role in the function of the gallbladder epithelial cell. This manuscript discusses what is known about biliary calcium, the factors that regulate total and free calcium concentrations in bile, the solubility of calcium in both normal and lithogenic bile, and the role calcium plays in epithelial cell function during gallstone formation.

Animals↗
PubMed2002

Risk factors for conversion of laparoscopic to open cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy (LC) has become the treatment of choice for symptomatic gallstones; however conversion to open cholecystectomy (OC) remains a possibility. Unfortunately, preoperative factors indicating risk of conversion are unclear. Therefore, we aimed to identify risk factors associated with conversion of LC to OC. PATIENTS AND MATERIALS: Records of 564 patients undergoing LC in 1995 and 1996 were reviewed. Patients were assigned to one of two groups: (1) acute cholecystitis defined by the presence of gallstones, fever, leukocyte count >10(4), and inflammation on ultrasound or histology; (2) chronic cholecystitis that included all other symptomatic patients. Demographics, history, and physical, laboratory, and radiology data, operative note, and the pathology report were reviewed. RESULTS: 161 of 564 patients, had acute and 403 patients had chronic cholecystitis; 16 acute cholecystitis patients (10%) were converted from LC to OC and 17 chronic cholecystitis patients (4%) had LC converted to OC. Patients having open conversion were significantly older, had greater prevalence of cardiovascular disease, and were more likely to be males. LC conversion to OC in acute cholecystitis patients was associated with a greater leukocyte count; in gangrenous cholecystitis patients, 29% had open conversion. CONCLUSIONS: Importantly, these risk factors-older men, presence of cardiovascular disease, male gender, acute cholecystitis, and severe inflammation-are determined preoperatively, permitting the surgeon to better inform patients about the conversion risk from LC to OC. While acute cholecystitis was associated with more than a twofold increased conversion rate, only 10% of these patients could not be completed laparoscopically. Therefore, acute cholecystitis alone should not preclude an attempt at laparoscopic cholecystectomy.

Acute Disease↗
PubMedDate not supplied

Biliary pancreatitis.

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Biliary Tract Diseases↗