[Show abstract][Hide abstract] ABSTRACT: Introduction:
Laparoscopy has become the gold standard for many surgical cases in the developed world. It however, remains a rarity in developing countries for several reasons, a major one being cost. This study aimed to determine the knowledge and attitude of patients attending Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana toward laparoscopic surgery and their willingness to pay for it.
A cross-sectional survey was conducted among patients attending specialist clinics at KATH.
1070 patients participated. Mean age was 40±15years. 54% were city-dwellers. 14% had salary-paying jobs. None had undergone prior laparoscopic surgery. 3% had knowledge of laparoscopy. 95% preferred laparoscopy to open surgery mainly because of faster recovery and less post-op pain. Age >45years (AOR = 0.53, p = 0.03) and higher education (AOR = 2.00, p = 0.04) were significant predictors of patient choice. Among those preferring laparoscopy, 78% were willing to pay more than the baseline cost of open surgery for laparoscopy. A history of previous abdominal surgery (AOR = 0.67, p = 0.02), having a salaried job compared with being unemployed (AOR = 2.36, p < 0.01) and living in the city compared with the village (AOR = 1.78, p = 0.04) were significant predictors of patients' willingness to pay more for laparoscopy.
Knowledge about laparoscopy and its benefits are severely lacking among patients at KATH. Once educated about its benefits, most people prefer laparoscopy even if they needed to pay more for it even in resource-limited countries like Ghana.
Pan African Medical Journal 08/2015; 20. DOI:10.11604/pamj.2015.20.422.6218
[Show abstract][Hide abstract] ABSTRACT: Single-incision laparoscopic cholecystectomy (SILC) may lead to higher patient satisfaction; however, SILC may expose the surgeon to increased workload. The goal of this study was to compare surgeon stress and workload between SILC and conventional laparoscopic cholecystectomy (CLC).
During a double-blind randomized controlled trial comparing patient outcomes for SILC versus CLC (NCT0148943), surgeon workload was assessed by four measures: surgery task load index questionnaire (Surg-TLX), maximum heart rate, salivary cortisol level, and instruments usability survey. The maximum heart rate and salivary cortisol levels were sampled from the surgeon before the random assignment of the surgical procedure, intraoperatively after the cystic duct was clipped, and at skin closure. After each procedure, the surgeon completed the Surg-TLX and an instrument usability survey. Student's t tests, Wilcoxon rank sum test, and Kruskal-Wallis nonparametric ANOVAs on the dependent variables by the technique (SILC vs. CLC) were performed with α = 0.05.
Twenty-three SILC and 25 CLC procedures were included in the intent-to-treat analysis. No significant differences were observed between SILC and CLC for patient demographics and procedure duration. SILC had significantly higher post-surgery surgeon maximum heart rates than CLC (p < 0.05). SILC also had significantly higher mean change in the maximum heart rate between during and post-procedure (p < 0.05) than CLC. Salivary cortisol level was significantly higher during SILC than CLC (p < 0.01). Awkward manipulation of the instruments and limited fine motions were reported significantly more frequently with SILC than CLC (p < 0.01). In the surgeon-reported Surg-TLX, subscale of physical demand was significantly more demanding for SILC than CLC (p < 0.05).
Surgeon heart rate, salivary cortisol level, instrument usability, and Surg-TLX ratings indicate that SILC is significantly more stressful and physically demanding than the CLC. Surgeon stress and workload may impact patients' outcomes; thus, ergonomic improvement on SILC is necessary.
[Show abstract][Hide abstract] ABSTRACT: We tested the responsiveness of the National Institutes of Health-sponsored Patient-Reported Outcomes Measures Information System (PROMIS) global health short form and a linear analog self-assessment for laparoscopy.
From May 2011 through December 2013, patients undergoing laparoscopy responded to patient reported outcome questionnaires perioperatively. Composite and single item scores were compared.
One hundred fifteen patients, mean age 55 years, 58 % female, were enrolled. Visual analog pain scores differed significantly from baseline (mean 1.7 ± 2.3) to postoperative day 1 (mean 4.8 ± 2.6) and 7 (mean 2.5 ± 2.1) (p < 0.0001). PROMIS physical subscale and total physical component subscore differed significantly from baseline (14.4 ± 3.0/47.4 ± 8.3) to postoperative day 1 (12.7 ± 3.2/42.1 ± 8.8) (p = 0.0007/0.0003), due to everyday physical activities (p = 0.0001). Linear analog self-assessment scores differed from baseline for pain frequency (p < 0.0001), pain severity (p < 0.0001), and social activity (p = 0.0052); 40 % of subjects reported worsening in PROMIS physical T-score to postoperative day 1 and 25 % to postoperative day 7. Linear analog self-assessment mental well-being scores were worse in 32 % of patients at postoperative day 7, emotional well-being in 28 %, social activity in 24 %, and fatigue in 20 % of patients.
Single items and change from baseline are responsive perioperative quality of life assessments for laparoscopy.
Journal of Gastrointestinal Surgery 03/2015; 19(5). DOI:10.1007/s11605-015-2789-0 · 2.80 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Our previous work revealed significantly less acidosis in swine undergoing natural orifice translumenal endoscopic surgery (NOTES) using endoscopic air insufflation than swine undergoing standard laparoscopy. We wanted to evaluate the differential effects of CO2 versus intra-abdominal pressure as source for this finding. In addition, we investigated the endocrine stress response between swine undergoing NOTES peritoneoscopy with CO2 insufflation and animals undergoing standard diagnostic laparoscopy with CO2.
Twenty-eight (28) female 50-kg domestic pigs were randomly assigned to one of four groups using a permuted block randomization table: Group 1: NOTES using CO2 insufflation, Group 2: NOTES using air insufflation, Group 3: laparoscopy max pressure 12 mmHg and Group 4: laparoscopy with max pressure 7 mmHg. Invasive monitoring lines were placed. Pneumoperitoneum was established by the respective method and maintained for 90 min, visualizing liver, spleen and colon. Arterial blood gas was obtained at baseline and four additional time points. Serum TNF-α for POD (postoperative day) 1 and cumulative urine adrenaline for the procedure were determined by ELISA. ANOVA and t test were used for statistical comparison. The study was Institutional Animal Care and Use Committees approved.
All experiments were completed as outlined. Blood pH showed a significant difference between groups. Serum TNF-α revealed higher levels for NOTES CO2 on POD 1 than standard laparoscopy (p = 0.03).
NOTES animals with CO2 insufflation initially experienced similar pH compared to standard laparoscopy but recovered to levels seen in low-pressure laparoscopy and NOTES with air. NOTES with CO2 appears to elicit a stronger stress response in this study than standard or low-pressure laparoscopy or NOTES with air.
[Show abstract][Hide abstract] ABSTRACT: Background:
Decreased survival after colon cancer surgery has been reported in patients with deficient preoperative quality of life. We hypothesized that deficits in preoperative quality of life are associated with postoperative complications.
Patient and methods:
A secondary analysis of the Clinical Outcomes Surgical Therapy trial NCCTG 93-46-53 (INT 0146, Alliance) was performed. Quality of life deficit was defined as overall quality of life score <50 on a 100-point scale and used for univariate and multivariate analysis.
Of 431 patients enrolled in the quality of life portion of the trial, 81 patients (19%) experienced complications including two deaths (0.5%). Fifty-five patients (13%) had a preoperative quality of life score <50. Patients with a preoperative deficit were more likely to have a serious early complication (16 vs 6%, p = 0.023). Using stepwise logistic model, the variables significantly associated with having any early complications (yes/no) were age, ASA III and change in "activity" from baseline to day 14. Patients with an early complication experienced a 3.5-day longer hospital stay (p = 0.0001). Gender, race, tumor stage, and laparoscopic or open approach were not associated with an increased frequency of complications. After adjusting for demographics, tumor stage, ASA, and operative approach, significant predictors for readmission were preoperative pain (odds ratio (OR) 1.61, confidence interval (CI) 1.11-2.34, p = 0.0125), and changes from baseline to day 2 in fatigue (OR 1.34, CI 1.03-1.74, p = 0.032).
This study suggests that quality of life can provide an early indicator for patients at risk of complications. Further studies should evaluate how perioperative quality of life assessment may assist to improve outcomes.
Journal of Gastrointestinal Surgery 08/2014; 19(1). DOI:10.1007/s11605-014-2613-2 · 2.80 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Differentiation between patients with acute cholecystitis and patients with severe biliary colic can be challenging. Patients with undiagnosed acute cholecystitis can incur repeat emergency department (ED) visits, which is resource intensive.
Billing records from 2000-2013 of all adults who visited the ED in the 30 d preceding their cholecystectomy were analyzed. Patients who were discharged from the ED and underwent elective cholecystectomy were compared with those who were discharged and returned to the ED within 30 d. T-tests, chi-square tests, and multivariable analysis were used as appropriate.
From 2000-2013, 3138 patients (34%) presented to the ED within 30 d before surgery, 63% were women, mean age 51 y, and of those 1625 were directly admitted from the ED for cholecystectomy, whereas 1513 patients left the ED to return for an elective cholecystectomy. Patients who were discharged were younger (mean age 49 versus 54 y, P < 0.001) and had shorter ED stays (5.9 versus 7.2 h, P < 0.001) than the patients admitted immediately. Of the discharged patients, 303 (20%) returned to the ED within 30 d to undergo urgent cholecystectomy. Compared with patients with successful elective cholecystectomy after the ED visit, those who failed the pathway were more likely to have an American Society of Anesthesiologists score ≥3 and were <40 or ≥60 compared with the successful group.
One in five patients failed the elective cholecystectomy pathway after ED discharge, leading to additional patient distress and use of resources. Further risk factor assessment may help design efficient care pathways.
Journal of Surgical Research 06/2014; 193(1). DOI:10.1016/j.jss.2014.06.023 · 1.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Patient benefits from natural orifice transluminal endoscopic surgery (NOTES) are of interest in acute-care surgery. This review provides an overview of the historical development of NOTES procedures, and addresses their current uses and limitations for intra-abdominal emergency conditions.
A PubMed search was carried out for articles describing NOTES approaches for appendicectomy, percutaneous gastrostomy, hollow viscus perforation and pancreatic necrosectomy. Pertinent articles were reviewed and data on available outcomes synthesized.
Emergency conditions in surgery tax the patient's cardiovascular and respiratory systems, and fluid and electrolyte balance. The operative intervention itself leads to an inflammatory response and blood loss, thus adding to the physiological stress. NOTES provides a minimally invasive alternative access to the peritoneal cavity, avoiding abdominal wall incisions. A clear advantage to the patient is evident with the implementation of an endoscopic approach to deal with inadvertently displaced percutaneous endoscopic gastrostomy tubes and perforated gastroduodenal ulcer. The NOTES approach appears less invasive for patients with infected pancreatic necrosis, in whom it allows surgical debridement and avoidance of open necrosectomy. Transvaginal appendicectomy is the second most frequently performed NOTES procedure after cholecystectomy. The NOTES concept has provided a change in perspective for intramural and transmural endoscopic approaches to iatrogenic perforations during endoscopy.
NOTES approaches have been implemented in clinical practice over the past decade. Selected techniques offer reduced invasiveness for patients with intra-abdominal emergencies, and may improve outcomes. Steady future development and adoption of NOTES are likely to follow as technology improves and surgeons become comfortable with the approaches.
British Journal of Surgery 01/2014; 101(1). DOI:10.1002/bjs.9352 · 5.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The Institute of Medicine lists investigations of the comparative effectiveness for minimally invasive surgical procedures as a research priority. As new minimally invasive procedures are developed, comparisons of the resulting workload contribute valuable information about the impact of the new procedures. Recent reports suggest that surgeon workload can influence patient outcomes. Measurements of stress and fatigue for the surgical team participating in a randomized NIH supported trial of single incision versus traditional laparoscopic cholecystectomy were obtained. These stress measures showed that the SURG-TLX was sensitive to the difficulty of the surgery. The SURG-TLX and a surgical difficulty score was obtained from the surgical team for 16 laparoscopic surgeries by surgical approach (8 SILC and 8 4-port) showed that for this small sample size, there were no statistically significant differences in length of surgery, degree of difficulty, nor patient considerations such as post-operative pain scores. In addition, no statistically significant differences in the individual Surg-TLX subscale scores or Surg-TLX total for the surgical team overall or for the surgeon alone by surgical platform. This is likely due to the small sample size reducing the power of the tests.
[Show abstract][Hide abstract] ABSTRACT: Staging peritoneoscopy is typically done by laparoscopy in the operating room. Natural orifice transluminal endoscopic surgery peritoneoscopy is an appealing alternative to the current approach. Transcolonic submucosal endoscopy with mucosal flap (SEMF) may provide natural orifice transluminal endoscopic surgery peritoneoscopy.
The aim was to verify the feasibility and safety of transcolonic peritoneoscopy with SEMF (TCPS) in a porcine survival model.
Animal research unit.
Seven target beads were placed in the peritoneal cavity by laparoscopy in each of 6 animals, and TCPS was performed to identify and touch beads to simulate biopsy. Animals were euthanized after 1 week, at which time, laparotomy was performed and the SEMF site was resected for histological analysis.
The number of beads identified and touched during peritoneoscopy, rate of successful completion of TCPS, procedure time, mortality equivalent 1 week after TCPS, adverse event rate, histological assessment of SEMF site.
All 7 beads in all 6 pigs were identified and touched during TCPS. The success rate of TCP was 100%. No major adverse events occurred during the procedure. The median procedure times for the creation of a submucosal tunnel, peritoneoscopy, closure of mucosal incision, and entire procedure were 19.5, 17, 9.5, and 45 minutes, respectively. All pigs survived until euthanasia, and there was no evidence of peritonitis or severe infection.
Animal study, single endoscopist, small sample size.
Results of this study indicate that TCPS is feasible and safe in a porcine survival model.
[Show abstract][Hide abstract] ABSTRACT: Aim:
Patients prefer minimally invasive procedures with fast recovery, minimal pain and good cosmesis. Single-port cholecystectomy may decrease the need for narcotic pain medication and thus shorten recovery. Outcome-based evidence for this procedure is still being assembled.
Single-port cholecystectomy patients were matched based on age and gender with control patients undergoing four-port cholecystectomy during the same time. The primary endpoint was in hospital use of narcotic pain medication, measured by morphine equivalents. Secondary endpoints were operative time and length of stay. Statistical analysis was done by Student's t-test.
Fifty patients (36 women, 14 men) underwent single port cholecystectomy between 11/2009-7/2012 and 50 patients underwent traditional cholecystectomy during the same time period. All patients were matched within 10 years of age. Morbidity was 4% for the single port group, 0% for the traditional cholecystectomy. There were no conversions to open cholecystectomy. The single-port group required a median of 29.0 mg (range, 8.7-180 mg) morphine equivalents of pain medication and the control group required a median of 33.2 mg (range, 0-185.7 mg) morphine equivalents (P=0.04). Single port cholecystectomy operative times were longer (median, 85 vs. 77 minutes, P=0.03).
In this small study, there is a statistically significant difference in narcotic use during the initial hospital stay was measured between the two groups. After the initial ten cases, the operative time for single-port cholecystectomy approximated the standard four-port cholecystectomy. Prospective randomized controlled trials are necessary to investigate differences in outcomes between the two approaches.