Research Spotlight

Hachem, R. R., M. Kamoun, M. M. Budev, M. Askar, V. N. Ahya, J. C. Lee, D. J. Levine, M. S. Pollack, G. S. Dhillon, D. Weill, K. B. Schechtman, L. E. Leard, J. A. Golden, L. Baxter-Lowe, T. Mohanakumar, D. B. Tyan and R. D. Yusen (2018). “Human leukocyte antigens antibodies after lung transplantation: Primary results of the HALT study.” Am J Transplant 18(9): 2285-2294.

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Donor-specific antibodies (DSA) to mismatched human leukocyte antigens (HLA) are associated with worse outcomes after lung transplantation. To determine the incidence and characteristics of DSA early after lung transplantation, we conducted a prospective multicenter observational study that used standardized treatment and testing protocols. Among 119 transplant recipients, 43 (36%) developed DSA: 6 (14%) developed DSA only to class I HLA, 23 (53%) developed DSA only to class II HLA, and 14 (33%) developed DSA to both class I and class II HLA. The median DSA mean fluorescence intensity (MFI) was 3197. We identified a significant association between the Lung Allocation Score and the development of DSA (HR = 1.02, 95% CI: 1.001-1.03, P = .047) and a significant association between DSA with an MFI >/= 3000 and acute cellular rejection (ACR) grade >/= A2 (HR = 2.11, 95% CI: 1.04-4.27, P = .039). However, we did not detect an association between DSA and survival. We conclude that DSA occur frequently early after lung transplantation, and most target class II HLA. DSA with an MFI >/= 3000 have a significant association with ACR. Extended follow-up is necessary to determine the impact of DSA on other important outcomes.

Gonzalez-Hernandez, J., P. Prajapati, G. Ogola, R. D. Burkart and L. D. Le (2018). “Surgical training in robotic surgery: surgical experience of robotic-assisted transabdominal preperitoneal inguinal herniorrhaphy with and without resident participation.” J Robot Surg 12(3): 487-492.

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Robotic-assisted surgery is becoming more popular in general surgery. Implementation of a robotic curriculum is necessary and will influence surgical training. The aim of this study is to compare surgical experience and outcomes with and without resident participation in robotic inguinal herniorrhaphy. A retrospective review of patients who underwent either unilateral or bilateral robotic-assisted transabdominal preperitoneal (TAPP) inguinal herniorrhaphy, with and without resident participation as console surgeons from January through December 2015, was performed. Patient demographics, procedure-related data, postoperative variables, and follow-up data were analyzed. A total of 104 patients were included. Patients were significantly older in the Resident group (57.5 +/- 14.1 vs 50.6 +/- 13.5 years, p = 0.01). Gender, BMI, and ASA classification were similar between groups. There were similar mean operative times for unilateral (89.9 +/- 19.5 vs 84.8 +/- 22.2 min, p = 0.42) and bilateral (128.4 +/- 21.9 vs 129.8 +/- 50.9 min, p = 0.90) inguinal herniorrhaphy as well as mean robot console times for unilateral (73.2 +/- 18.4 vs 67.3 +/- 29.9 min, p = 0.44) and bilateral (115.5 +/- 24.6 vs 109.3 +/- 55.4 min, p = 0.67) inguinal herniorrhaphy with and without resident participation, respectively. Postoperative complications included urinary retention (11.1 vs 2.0%, p = 0.11), conversion to open repair (0 vs 2%, p = 0.48), and delayed reoperation (0 vs 4%, p = 0.22) with and without resident participation, respectively. Patients’ symptoms/signs at follow-up were similar among groups. Robotic-assisted TAPP inguinal herniorrhaphy with resident participation as console surgeons did not affect the hospital operative experience or patient outcomes. This procedure can be implemented as part of the resident robotic curriculum with rates of morbidity equivalent to those of published studies.Level of evidence 2b.

Gonzalez, G., E. Montemayor, J. M. Sanders, M. Burton, J. M. Tessier and T. M. Duane (2018). “Measuring Provider Compliance with an Institution-Based Clinical Pathway for Diverticulitis Using Radiologic Criteria.” Surg Infect (Larchmt) Sep 4. [Epub ahead of print].

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BACKGROUND: Diverticulitis remains a common disease encountered in the acute care setting. Management strategies have been developed to guide treatment decisions based on imaging. By using a multi-faceted clinical pathway approach, a standardized method of diagnosing and categorizing disease severity can be performed in order to guide appropriate management. This study evaluated provider compliance with an institutional clinical pathway designed to guide management of diverticulitis. METHODS: An institutional clinical pathway was developed to manage diverticulitis, including radiologic classification, primary service line assignment, interventional strategies, and antimicrobial treatment. To assess provider compliance with the algorithm, we queried the institutional acute diverticulitis database for patients admitted from May 19, 2016 to February 8, 2017, which identified 83 patients. Provider compliance with the pathway was assessed using subgroup analysis of radiologic documentation (modified Neff [mNeff] classification), primary service assignment, and interventions (i.e., interventional radiology [IR] and antimicrobial agents). RESULTS: The cohort represented a diverse group of mNeff classifications, predominantly Stage 0. Surgical interventions occurred in 10.8% of the cohort. Antimicrobial agents were administered to 88.0% and 78.3% of the outpatients and inpatients, respectively. Patients received a total duration of antimicrobial therapy (mean +/- standard deviation [SD]) of 10.2 +/- 5.1 days. Overall compliance occurred in 10% of the patients. Compliance with radiologic documentation, antimicrobial choice, and antimicrobial duration were 90.4%, 20.5%, and 69.9%, respectively. CONCLUSIONS: Overall compliance with the clinical pathway was poor, except as it related to compliance with radiologic documentation, appropriate assignment to surgical service line, and antimicrobial duration. These results suggest areas for future improvement to augment compliance with the clinical pathway.

Gomez-Hoyos, J., R. L. Martin and H. D. Martin (2018). “Current Concepts Review: Evaluation and Management of Posterior Hip Pain.” J Am Acad Orthop Surg 26(17): 597-609.

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Understanding the etiology of and evolving research on intra- and extra-articular hip complaints requires comprehensive diagnosis and management of the spectrum of posterior hip diseases. Interest in posterior hip disorders has increased in recent years as new studies and theories have emerged regarding the disease process. Although most of the differential diagnoses around the posterior hip have traditionally been considered uncommon, recent reports suggest that these complaints have instead been commonly overlooked. Failure to identify the cause of posterior hip pain in a timely manner can increase pain perception, deteriorate the patient’s hope, and consequently affect quality of life. Posterior hip pain could be differentiated as intrapelvic and extrapelvic, and differential diagnosis is made based on a comprehensive history, physical examination, and imaging studies. Plain radiography, CT, MRI, 3T MRI, and imaging-guided injection tests are usually necessary for accurate diagnosis. Surgical intervention, whether endoscopic or open, is required for patients with long-standing symptoms for whom nonsurgical treatment has been unsuccessful and who have experienced temporary relief of their symptoms after injection. Orthopedic surgeons are uniquely trained in understanding the anatomy, biomechanics, clinical evaluation and treatment of all five layers of the hip.

Garrett, J. S., C. Berry, H. Wong, H. Qin and J. A. Kline (2018). “The effect of vertical split-flow patient management on emergency department throughput and efficiency.” Am J Emerg Med 36(9): 1581-1584.

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BACKGROUND: To address emergency department overcrowding operational research seeks to identify efficient processes to optimize flow of patients through the emergency department. Vertical flow refers to the concept of utilizing and assigning patients virtual beds rather than to an actual physical space within the emergency department to care of low acuity patients. The aim of this study is to evaluate the impact of vertical flow upon emergency department efficiency and patient satisfaction. METHODS: Prospective pre/post-interventional cohort study of all intend-to-treat patients presenting to the emergency department during a two-year period before and after the implementation of a vertical flow model. RESULTS: In total 222,713 patient visits were included in the analysis with 107,217 patients presenting within the pre-intervention and 115,496 in the post-intervention groups. The results of the regression analysis demonstrate an improvement in throughput across the entire ED patient population, decreasing door to departure time by 17min (95% CI 15-18) despite an increase in patient volume. No statistically significant difference in patient satisfaction scores were found between the pre- and post-intervention. CONCLUSIONS: Initiation of a vertical split flow model was associated with improved ED efficiency.