Explore the vast range of titles available.

Ulcerative colitis is an idiopathic, chronic inflammatory disorder of the colonic mucosa, which starts in the rectum and generally extends proximally in a continuous manner through part of, or the entire, colon; however, some patients with proctitis or left-sided colitis might have a caecal patch of inflammation. Bloody diarrhoea is the characteristic symptom of the disease. The clinical course is unpredictable, marked by alternating periods of exacerbation and remission. In this Seminar we discuss the epidemiology, pathophysiology, diagnostic approach, natural history, medical and surgical management, and main disease-related complications of ulcerative colitis, and briefly outline novel treatment options. Enhanced understanding of how the interaction between environmental factors, genetics, and the immune system results in mucosal inflammation has increased knowledge of disease pathophysiology. We provide practical therapeutic algorithms that are easily applicable in daily clinical practice, emphasising present controversies in treatment management and novel therapies.

Background The study was designed to examine the epidemiology of appendicitis and risk factors of perforation and appendectomy. Methods Retrospective analysis of the California Office of Statewide Health Planning and Development Patient Discharge Data was performed from 1995 to 2009. Patients with appendicitis were identified by ICD-9 diagnosis code. Population statistics from the RAND Corporation were used to calculate incidence rates. Risk factors of perforation and appendectomy were also calculated. Results A total of 608,116 patients with appendicitis (70 % non-perforated) were included. The incidence increased at an average rate of 0.5 cases/100,000 population/year ( p  < 0.001), with annual incidence peaking during the third quarter. Children age 10–14 had the highest rates of appendicitis (169.6 cases/100,000). The lifetime cumulative incidence rate is 9.0 %. Appendicitis is most common in whites and Hispanics and less common in African Americans and Asians. Risks of perforation include Hispanic or Asian race, young or old age, and non-private insurance. The adjusted odds of appendectomy increased since 1995 in patients with non-perforated appendicitis (OR 1.5, 95 % CI (1.3–1.7); p  < 0.001), but it decreased in patients with perforated appendicitis (OR 0.4, 95 % CI (0.4–0.5); p  < 0.001). Conclusions This is the largest epidemiological study of appendicitis to our knowledge in recent years. Incidence has increased over time and is higher in the summer months. Whites and Hispanics have higher rates of appendicitis, but Hispanics and Asians and patients with non-private insurance, have higher odds of perforation. Surgical management of perforated appendicitis has decreased over time. It is unknown why the incidence has increased, displays seasonality, and varies by race.

BackgroundEvaluation of robotic surgical skill has become increasingly important as robotic approaches to common surgeries become more widely utilized. However, evaluation of these currently lacks standardization. In this paper, we aimed to review the literature on robotic surgical skill evaluation.MethodsA review of literature on robotic surgical skill evaluation was performed and representative literature presented over the past ten years.ResultsThe study of reliability and validity in robotic surgical evaluation shows two main assessment categories: manual and automatic. Manual assessments have been shown to be valid but typically are time consuming and costly. Automatic evaluation and simulation are similarly valid and simpler to implement. Initial reports on evaluation of skill using artificial intelligence platforms show validity. Few data on evaluation methods of surgical skill connect directly to patient outcomes.ConclusionAs evaluation in surgery begins to incorporate robotic skills, a simultaneous shift from manual to automatic evaluation may occur given the ease of implementation of these technologies. Robotic platforms offer the unique benefit of providing more objective data streams including kinematic data which allows for precise instrument tracking in the operative field. Such data streams will likely incrementally be implemented in performance evaluations. Similarly, with advances in artificial intelligence, machine evaluation of human technical skill will likely form the next wave of surgical evaluation.

BackgroundMarginal ulcerations (MU) are a common and concerning complication following Roux-en-Y gastric bypass (RYGB) surgery. The aim of the present study was to examine the progression of MU and identify risk factors for the need for surgical intervention in patients with MU following RYGB.MethodsA New York state longitudinal administrative database was queried to identify patients who underwent RYGB between 2005 and 2010 and who were followed for at least 4 years for the development of MU using ICD-9 and CPT codes. Patients with perforation as their first presentation of MU were excluded. Multivariable Cox proportional hazard model was built to identify risk factors for surgical intervention. Hazard ratios (HR) with 95% confidence intervals (CI) were reported.ResultsWe identified 35,075 patients who underwent RYGB. Mean age was 42.47 ± 10.90 years and most were female (81.08%). There were 2201 (6.28%) patients with MU, of which 204 (9.27% of MU; 0.58% of RYGB overall) required surgery. The estimated cumulative incidence of having surgical intervention 1, 2, 5, and 8 years after MU diagnosis was 6% (95% CI 5–7%), 8% (95% CI 7–9%), 13% (95% CI 11–14%), and 17% (95% CI 13–20%), respectively. At time of MU diagnosis, younger age (HR 0.93 every 5 years, 95% CI 0.87–0.99), white race (HR 1.60, 95% CI 1.15–2.23), and weight loss (HR 2.82, 95% CI 1.62–4.88) were independent risk factors for subsequent surgical intervention for MU. Estimated cumulative incidence of MU recurrence was 15% (95% CI 9–22%) and 24% (95 CI% 15–32%) at 6 and 12 months after surgical intervention.ConclusionsThe need for surgical intervention for MU after RYGB is uncommon. Young age, white race, and marked weight loss are risk factors for surgical intervention. Such patients may benefit from early intensive medical therapy at the time of MU diagnosis.

IntroductionPercutaneous cholecystostomy tube (PCT) placement is often the initial management approach to severe acute cholecystitis in the unstable patient. However, the timing of cholecystectomy after PCT has not been carefully examined. The purpose of this study was to compare outcomes of early versus late cholecystectomy following PCT placement.MethodsThe New York SPARCS administrative database was searched for all patients undergoing PCT placement between 2000 and 2012. Patients were followed for subsequent cholecystectomy (CCX) procedures up to 2014. Subsequent cholecystectomies were divided into early (≤ 8 weeks) versus late (> 8 weeks) groups. Outcomes included overall complications, 30-day readmissions, 30-day Emergency Department (ED) visits, and length of stay (LOS). Multivariable regression models were used to examine the differences in clinical outcomes between these two groups, after adjusting for possible confounding factors.ResultsThere were 9728 patients who underwent PCT placement identified during the time period, as early subsequent cholecystectomy was performed in 1211 patients (40.4%), while 1787 (59.6%) patients had a late cholecystectomy. Average time to cholecystectomy was 38 days in the early group, versus 203 days in the late group. After adjusting for other confounding factors, patients with early CCX had a significantly higher risk of overall complications and longer LOS compared to the late CCX group (P = 0.01 and P = 0.0004, respectively). There were no significant differences in 30-day readmissions and 30-day ED visits. Furthermore, there was no significant difference in the risk of CBD injury between the two groups (n = 21, 1.7% in the early cholecystectomy group and n = 26, 1.5% in the late cholecystectomy group).ConclusionEarly cholecystectomy (≤ 8 weeks) is associated with a higher risk of complications and longer hospital LOS compared to cholecystectomy performed at > 8 weeks. Surgeons should be aware and should delay cholecystectomy beyond 8 weeks to improve outcomes.

Introduction Here, we report the first series of patients with 1-year implantation of a novel, endoluminal, endoscopically delivered and retrieved gastro-duodeno-jejunal bypass sleeve (GJBS) (ValenTx, Inc. Carpinteria, CA, USA). In this report, we present the safety, feasibility of the device, weight loss, and changes in comorbidities. Methods and procedures A prospective, single-center, 12-month trial was designed. The patients are morbidly obese individuals who meet the NIH criteria for bariatric surgery. The GJBS is a 120-cm sleeve secured at the esophago-gastric junction with endoscopic and laparoscopic techniques that is designed to create an endoluminal gastro-duodeno-jejunal bypass. The device was implanted and, at the completion of the trial, retrieved with an endoscopic technique. The primary endpoints were safety and incidence of adverse events. The secondary outcomes included the percentage of excess weight loss (EWL) and changes in comorbidities, specifically glucose control, use of antihyperglycemics, and changes in hemoglobin A1C levels. Results From July 2009 until October 2009, 13 patients were prospectively enrolled for the 1-year trial. The study included five men and eight women with a mean preoperative BMI of 42 kg/m 2 . One patient was excluded, at the time of endoscopic evaluation, due to inflammation at the GE junction. Two additional patients required early explantation of the device, within the first 4 weeks, due to patient intolerance. Upon explant of the device, both patients’ symptoms improved. In the remaining ten patients, the device was implanted, left in situ for 12 months, and then retrieved endoscopically. Safe delivery of the cuff at the gastro-esophageal junction was seen in all ten patients whom had device implants, without complication. No esophageal leak was seen immediately post-procedure or during follow-up. The sleeve device was well tolerated within the bowel lumen during the 12-month study, specifically, no bowel erosions, ulceration, or pancreatitis was observed. All ten patients reached the 1-year mark. Of the ten, six had fully attached and functional devices throughout the follow-up, verified by endoscopy. The mean percentage EWL, at 1 year, in this group was 54 %. In the remaining four patients, partial cuff detachment was observed at follow-up endoscopy. The percentage EWL was lower in this group. Of the six patients that reached a year with a fully attached device, five were followed at an average of 14-months post-explant (26 months from the time of device implant). These five maintained an average percentage EWL of 30 % at the 14-month post-explant follow-up. Co-morbidites measured included diabetes mellitus, hypertension, hyperlipidemia, and use of antihyperglycemics. Each of the measured comorbidities showed improvement during the 12-month trial. Discussion The endoluminal, GJBS can be safely placed and retrieved. The short-term data show it is well tolerated with a good safety profile. It achieves excellent weight loss results with over 70 % of all comorbidities resolved or significantly improved.

Background Improvements in percutaneous drainage techniques combined with the recognized advantages of avoiding surgery in critically ill patients have rendered cholecystostomy an attractive treatment option, particularly in those patients with acute acalculus cholecystitis. However, robust data to guide surgeons in choosing cholecystostomy versus cholecystectomy have been lacking. Methods Retrospective analysis of the Nationwide Inpatient Sample (NIS) database from 1998–2010 was performed. Patients identified as having acute cholecystitis (calculus and acalculus) were identified by ICD-9 diagnosis codes and further classified as having undergone cholecystostomy or cholecystectomy. Patients with both procedures were included in the cholecystectomy group. Patients with neither procedure and those younger than age 18 years were excluded. Multivariate analyses examined mortality, length of stay, total charges, gallbladder/gastrointestinal complications, or any complication. Results were adjusted for age, race, gender, Charlson comorbidity index, and teaching-hospital status. Subset analyses were performed among patients who survived and patients who died. Results A total of 248,229 calculus and 58,518 acalculus acute cholecystitis patients were analyzed. On unadjusted analysis, mortality, length of stay, and total charges were higher, but complication rates were lower, in patients with a cholecystostomy. Adjusted analysis showed lower odds of complications [calculus: odds ratio (OR) 0.3, p  < 0.001; acalculus: OR 0.4, p  < 0.001] but higher odds of mortality, total charges, and LOS (calculus: mortality OR 5.2, p  < 0.001, $29,113, p  < 0.001, +5.1 days, p  < 0.001; acalculus: mortality OR 3.7, p  < 0.001; $43,771, p  < 0.001, +6.2 days, p  < 0.001) among patients who received cholecystostomy. Results were similar in subset analyses. Conclusions Patients receiving cholecystostomy were more likely to be older and have more comorbidities. Among patients with calculus or acalculus cholecystitis, patients with cholecystostomy had decreased complication rates compared with patients with cholecystectomy. However, patients who received cholecystostomy had increased odds of death, longer length of stay, and higher total charges.

Background Since the introduction of laparoscopic cholecystectomy (LC), there has been continued evolution in technique, instrumentation and postoperative management. With increased experience, LC has migrated to the outpatient setting. We asked whether increased availability and experience has impacted incidence of and indications for LC. Methods The New York (NY) State Planning and Research Cooperative System longitudinal administrative database was utilized to identify patients who underwent cholecystectomy between 1995 and 2013. ICD-9 and CPT procedure codes were extracted corresponding to laparoscopic and open cholecystectomy and the associated primary diagnostic codes. Data were analyzed as relative change in incidence (normalized to 1000 LC patients) for respective diagnoses. Results From 1995 to 2013, 711,406 cholecystectomies were performed in NY State: 637,308 (89.58 %) laparoscopic. The overall frequency of cholecystectomy did not increase (1.23 % increase with a commensurate population increase of 6.32 %). Indications for LC during this time were: 72.81 % for calculous cholecystitis ( n  = 464,032), 4.88 % for biliary colic ( n  = 31,124), 8.98 % for acalculous cholecystitis ( n  = 57,205), 3.01 % for gallstone pancreatitis ( n  = 19,193), and 1.59 % for biliary dyskinesia ( n  = 10,110). The incidence of calculous cholecystitis declined (−20.09 %, p  < 0.0001) between 1995 and 2013; meanwhile, other diagnoses increased in incidence: biliary colic (+54.96 %, p  = 0.0013), acalculous cholecystitis (+94.24 %, p  < 0.0001), gallstone pancreatitis (+107.48 %, p  < 0.0001), and biliary dyskinesia (+331.74 %, p  < 0.0001). Outpatient LC incidence catapulted to 48.59 % in 2013, from 0.15 % in 1995, increasing >320-fold. Analysis of LC through 2014 revealed increasing rates of digestive, infectious, respiratory, and renal complications, with overall cholecystectomy complication rates of 9.29 %. Conclusion A shifting distribution of operative indications and increasing rates of complications should prompt careful consideration prior to surgery for benign biliary disease. For what is a common procedure, LC carries substantial risk of complications, thus requiring the patient to be an active participant and to share in the decision-making process.