Bio

Clinical Focus


  • General Surgery
  • Minimally Invasive Surgery

Administrative Appointments


  • President, Association of Women Surgeons (2001 - 2002)
  • Chair, Committee on Diversity, American College of Surgeons (2002 - 2004)
  • Chair, Awards Committee,, Association of Surgical Education (2003 - 2004)
  • Membership Committee,, Society of University Surgeons (2003 - 2006)
  • Chair, Committee on Resident Education,, American College of Surgeons (2004 - 2008)
  • Program Committee, Association of Surgical Education (2004 - 2007)

Honors & Awards


  • Physician of the Year, Gallup Indian Medical Center (1990)
  • United States Public Health Service Achievement Award, Public Health Service (1991)
  • Navajo Area Indian Health Service Directors Award for Excellence, Indian Health Service (1993)
  • Faculty Teaching Excellence Award,, University of New Mexico (1999)
  • Khatali Award for Excellence in Teaching,, University of New Mexico (2000)
  • Medical Student Teaching Award, Surgery rotation,, Department of Surgery, Stanford University (2002, 2003)
  • The John Austin Collins Memorial Award for Outstanding Resident Teaching,, Department of Surgery, Stanford University (2003)
  • 2003 The Henry J. Kaiser Award for Excellence in Clinical Teaching,, Stanford University School of Medicine (2003)
  • Master Teacher Award, Association for Surgical Education (2006)

Education & Certifications


  • Residency:University of Chicago Hospitals (1989) IL
  • Fellowship:University of New Mexico (1994) NM
  • Board Certification: General Surgery, American Board of Surgery (1990)
  • Internship:University of Chicago Hospitals (1983) IL
  • Medical Education:Harvard Medical School (1982) MA
  • MD, Harvard University, Medicine (1982)

Research & Scholarship

Current Research and Scholarly Interests


My main areas of research interest are in surgical education, laparoscopic surgery, bariatric surgery and robotic surgery

In laparoscopic surgery, I have performed both animal and clinical studies. The animal studies have focused on investigating the safety of pneumoperitoneum and increased intra-abdominal pressure during pregnancy. In clinical studies, I have performed prospective, randomized trials investigating laparoscopic vs open surgery for colon cancer and investigating outpatient vs inpatient management of patients undergoing laparoscopic cholecystectomy. I have a variety of ongoing projects looking at the advantages of laparoscopic surgery for various disease processes.

In the area of surgical education, I am particularly interested in teaching and assessing surgical skills. I initiated a surgical skills curriculum for residents and I am investigating whether teaching surgical skills outside of the operating room translates into improved outcomes (decreased time and complications) in the operating room.

I am also investigating methods of evaluating educational programs and work environment. Fewer and fewer medical students are interested in pursuing surgery as a future career. As a surgeon and program director, I am trying to identify the causes for this decreased interest and methods for correcting it.

I have a very busy bariatric surgery practice. I am actively involved in numerous projects investigating outcomes in bariatric surgery. Some of these have included examining the learning curve for laparoscopic gastric bypass, studying the effect of preoperative weight loss on the results of bariatric surgery and determining factors that will identify successful outcomes postoperatively.

Recently, I performed the first totally robotic laparoscopic gastric bypass with the daVinci robotic system. We are currently studying the use of the robot in bariatric surgery, including comparing this technique to a pure laparosocpic hand-sewn technique, evaluating the learning curve of the robot and investigating the ergonomic benefits of the robot compared to laparoscopic surgery

Publications

All Publications


  • The evolving application of single-port robotic surgery in general surgery JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES Qadan, M., Curet, M. J., Wren, S. M. 2014; 21 (1): 26-33

    View details for DOI 10.1002/jhbp.37

    View details for Web of Science ID 000328792500007

  • The evolving application of single-port robotic surgery in general surgery. Journal of hepato-biliary-pancreatic sciences Qadan, M., Curet, M. J., Wren, S. M. 2014; 21 (1): 26-33

    Abstract

    Advances in the field of minimally invasive surgery have grown since the original advent of conventional multiport laparoscopic surgery. The recent development of single incision laparoscopic surgery remains a relatively novel technique, and has had mixed reviews as to whether it has been associated with lower pain scores, shorter hospital stays, and higher satisfaction levels among patients undergoing procedures through cosmetically-appeasing single incisions. However, due to technical difficulties that arise from the clustering of laparoscopic instruments through a confined working space, such as loss of instrument triangulation, poor surgical exposure, and instrument clashing, uptake by surgeons without a specific interest and expertise in cutting-edge minimally invasive approaches has been limited. The parallel use of robotic surgery with single-port platforms, however, appears to counteract technical issues associated with single incision laparoscopic surgery through significant ergonomic improvements, including enhanced instrument triangulation, organ retraction, and camera localization within the surgical field. By combining the use of the robot with the single incision platform, the recognized challenges of single incision laparoscopic surgery are simplified, while maintaining potential advantages of the single-incision minimally invasive approach. This review provides a comprehensive report of the evolving application single-port robotic surgery in the field of general surgery today.

    View details for DOI 10.1002/jhbp.37

    View details for PubMedID 24124130

  • Single-Port Robotic Cholecystectomy Results From a First Human Use Clinical Study of the New da Vinci Single-Site Surgical Platform ARCHIVES OF SURGERY Wren, S. M., Curet, M. J. 2011; 146 (10): 1122-1127

    Abstract

    To report our results from a first human use clinical study with the da Vinci Surgical single-site instrumentation in patients with gallbladder disease and to perform a retrospective comparison with traditional multiport laparoscopic cholecystectomy.Ten patients underwent robotic single-port cholecystectomy performed with the da Vinci Si robot and novel da Vinci single-site instrumentation. Outcomes and operative times were compared with patients undergoing traditional multiport laparoscopic cholecystectomy during the same period.Tertiary care Veterans Administration hospital.Outpatients older than 18 years with an American Society of Anesthesiologists class of 1 to 3, no prior upper abdominal surgery, and diagnosis of noninflammatory biliary disease.Single-site robotic cholecystectomy.Operative time, complications up to 30 days, pain scores, and overall satisfaction.Nine of 10 patients had completion of robotic single-site cholecystectomy. Average operating room time was 105.3 minutes compared with an average of 106.1 minutes in the standard laparoscopic group. There were no serious adverse events in the robotic surgery group, with an average follow-up of 3 or more months.Robotic single-port cholecystectomy is feasible and comparable with standard laparoscopic cholecystectomy in the Veterans Administration medical center setting.

    View details for DOI 10.1001/archsurg.2011.143

    View details for Web of Science ID 000295942300002

    View details for PubMedID 21690436

  • Clinical Outcomes With Robotic Surgery CURRENT PROBLEMS IN SURGERY Anonymous 2011; 48 (9): 577-656

    View details for DOI 10.1067/j.cpsurg.2011.05.002

    View details for Web of Science ID 000294030300002

    View details for PubMedID 21816267

  • Single-Incision Laparoscopic Surgery Are We Doomed to Repeat the Mistakes of the Past? ARCHIVES OF SURGERY Curet, M. J. 2010; 145 (12): 1191-1192

    View details for Web of Science ID 000285470800019

    View details for PubMedID 21218583

  • Early, Intermediate, and Late Effects of a Surgical Skills "Boot Camp" on an Objective Structured Assessment of Technical Skills: A Randomized Controlled Study Parent, R. J., Plerhoples, T. A., Long, E. E., Zimmer, D. M., Teshome, M., Mohr, C. J., Ly, D. P., Hernandez-Boussard, T., Curet, M. J., Dutta, S. ELSEVIER SCIENCE INC. 2010: 984-989

    Abstract

    Surgical interns enter residency with variable technical abilities and many feel unprepared to perform necessary procedures. We hypothesized that interns exposed to a preinternship intensive surgical skills curriculum would demonstrate improved competency over unexposed colleagues on a test of surgical skills and that this effect would persist throughout internship.We designed a 3-day intensive skills "boot camp" with simulation-based training on 10 topics. Interns were randomized to an intervention group (boot camp) or a control group (no boot camp). All interns completed a survey including demographic information, previous experience, and comfort with basic surgical skills. Both groups completed a clinical skills assessment focused on 4 topics: chest tube insertion, central line placement, wound closure, and the Fundamentals of Laparoscopic Surgery peg transfer task. We assessed both groups immediately (month 0), early postcurriculum (month 1), and late postcurriculum (month 6).Fifteen participants were in the intervention group and 13 were in the control group. Before boot camp, mean comfort levels were similar for the groups. All participants had minimal prior experience. Competency for chest tube insertion and central line placement were considerably higher for the boot camp group at months 0 and 1, although much of this difference disappeared by month 6. There was no substantial difference between the 2 groups in the Fundamentals of Laparoscopic Surgery peg transfer and wound closure skills.A surgical skills boot camp accelerates the learning curve for interns in basic surgical skills as measured by a technical skills examination for some skills, although these improvements diminished over time. This can augment traditional training and translate into fewer patient errors.

    View details for DOI 10.1016/j.jamcollsurg.2010.03.006

    View details for Web of Science ID 000278649100013

    View details for PubMedID 20510808

  • Recovery of Renal Function in a Dialysis-Dependent Patient Following Gastric Bypass Surgery OBESITY SURGERY Tafti, B. A., Haghdoost, M., ALVAREZ, L., Curet, M., Melcher, M. L. 2009; 19 (9): 1335-1339

    Abstract

    There is increasing evidence that obesity, independently from other comorbidities such as diabetes and hypertension, can cause renal dysfunction. While this indolent dysfunction may be asymptomatic, it can render patients more susceptible to renal insufficiency when the kidneys are further injured by other pathological processes. Here, we present a morbidly obese patient whose type-A aortic dissection was complicated by acute renal failure that subsequently progressed into end-stage renal disease. However, his renal function improved dramatically following substantial weight reduction after gastric bypass surgery obviating the need for dialysis and transplantation. The potential mechanisms by which a patient's obesity may lead to renal dysfunction are discussed. This case and other similar reports suggest that obese patients with renal failure can safely undergo bariatric surgery and that bariatric surgery may have a role in treating chronic kidney disease in select morbidly obese patients.

    View details for DOI 10.1007/s11695-009-9907-6

    View details for Web of Science ID 000269153200022

    View details for PubMedID 19693639

  • Endoscopy is accurate, safe, and effective in the assessment and management of complications following gastric bypass surgery. American journal of gastroenterology Lee, J. K., Van Dam, J., Morton, J. M., Curet, M., Banerjee, S. 2009; 104 (3): 575-582

    Abstract

    Roux-en-Y gastric bypass (RYGB) is a common intervention for morbid obesity. Upper gastrointestinal (UGI) symptoms are frequent and difficult to interpret following RYGB. The aim of our study was to examine the role of endoscopy in evaluating UGI symptoms after RYGB and to assess the safety and efficacy of endoscopic therapy.Between 1998 and 2005, a total of 1,079 patients underwent RYGB for clinically severe obesity and were followed prospectively. Patients with UGI symptoms after RYGB who were referred for endoscopy were studied.Of 1,079 patients, 76 (7%) who underwent RYGB were referred for endoscopy to evaluate UGI symptoms. Endoscopic findings included normal surgical anatomy (n=24, 31.6%), anastomotic stricture (n=40, 52.6%), marginal ulcer (n=12, 15.8%), unraveled nonabsorbable sutures causing functional obstruction (n=3, 4%) and gastrogastric fistula (n=2, 2.6%). Patients with abnormal findings on endoscopy presented with UGI symptoms at a mean of 110.7 days from their RYGB, which was significantly shorter than the time of 347.5 days for patients with normal endoscopy (P<0.001). A total of 40 patients with anastomotic strictures underwent 86 endoscopic balloon dilations before complete symptomatic relief. In one patient, a needle knife was used to open a completely obstructed anastomotic stricture. Unraveled, nonabsorbable suture material was successfully removed using endoscopic scissors in three patients.Patients presenting with UGI symptoms less than 3 months after surgery are more likely to have an abnormal finding on endoscopy. Endoscopic balloon dilation is safe and effective in managing anastomotic strictures. Endoscopic scissors are safe and effective in removing unraveled, nonabsorbable sutures contributing to obstruction.

    View details for DOI 10.1038/ajg.2008.102

    View details for PubMedID 19262516

  • Benefits to Patients Choosing Preoperative Weight Loss in Gastric Bypass Surgery: New Results of a Randomized Trial JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Solomon, H., Liu, G. Y., Alami, R., Morton, J., Curet, M. J. 2009; 208 (2): 241-245

    Abstract

    Historically, preoperative weight loss has been encouraged for patients undergoing gastric bypass surgery to decrease liver mass, technically facilitating the procedure. In an earlier prospective randomized trial investigating effects of preoperative weight loss on patients' clinical outcomes, we reported no differences in postoperative complications or weight-loss profiles at 6-month followup. This article demonstrates results of the same study, with 1-year followup.One hundred consecutive patients in an 18-month period preparing to undergo gastric bypass surgery at Stanford University Medical Center were selected. Fifty patients were randomly assigned to lose 10% or more of their excess body weight preoperatively, and 50 patients were assigned to no preoperative weight-loss requirements. After 1 year, patient demographics and data on postoperative complications, cure or improvement of comorbidities, and differences in weight-loss profiles were collected.At 1 year, the 2 groups had similar preoperative demographics and body mass indexes (BMIs). Patients in the weight-loss group, on average, lost 8.2% of their excess body weight preoperatively compared with the nonweight-loss group, which gained 1.1% (p = 0.007). After a year, the patients in both arms of the study showed no difference in weight, BMI, excess weight-loss, and number of remaining comorbidites. But when patients were divided according to those who had lost at least 5% of their excess body weight preoperatively, the 1-year results for excess weight-loss, weight, and BMI were much lower for the weight-loss group.Preoperative weight loss in patients undergoing gastric bypass surgery is safe and feasible. It should be encouraged, because it will markedly improve longterm weight loss.

    View details for DOI 10.1016/j.jamcollsurg.2008.09.028

    View details for Web of Science ID 000263387500010

    View details for PubMedID 19228536

  • Resident Work Hour Restrictions: Where Are We Now? JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Curet, M. J. 2008; 207 (5): 767-776
  • Preoperative endoscopic screening for laparoscopic Roux-en-Y gastric bypass has a low yield for anatomic findings OBESITY SURGERY Mong, C., Van Dam, J., Morton, J., Gerson, L., Curet, M., Banerjee, S. 2008; 18 (9): 1067-1073

    Abstract

    Patients undergoing laparoscopic Roux-en-Y bariatric surgery undergo screening esophagoduodenoscopy (EGD) during preoperative evaluation. The hypothesis is to examine the utility of this examination. The purpose of this study was to evaluate the prevalence of clinically significant upper gastrointestinal (UGI) tract findings at screening EGD in patients undergoing laparoscopic Roux-en-Y bariatric surgery. A secondary aim was to determine whether preprocedure symptoms could predict findings at EGD.We evaluated records of patients undergoing EGD prior to bariatric surgery between 2000 and 2005 at the Stanford University Medical Center. Clinical, endoscopic, and pathological data were analyzed. The prevalence of endoscopic findings of clinical significance was determined.Two hundred seventy two complete patient records were identified and included in the study. Of these, 237 (87%) were female and 197 (72%) were Caucasian. The mean age was 43 +/- 9.68 years and mean body mass index was 48 +/- 7.95 kg/m(2). Of the 272 patients, 33 (12%) had EGD findings of clinical significance including erosive esophagitis (3.7%), Barrett's esophagus (3.7%), gastric ulcers (2.9%), erosive gastritis (1.8%), duodenal ulcers (0.7%), and gastric carcinoid (0.3%). No patients had malignancy. Of these 33 patients, 22 (67%) had UGI symptoms.Significant findings at screening EGD were found in 12% of patients. While EGD may be low-yield, the findings could be useful in guiding clinical decision making.

    View details for DOI 10.1007/s11695-008-9600-1

    View details for Web of Science ID 000258456400003

    View details for PubMedID 18574642

  • Use of flexible endoscopic scissors to cut obstructing suture material in gastric bypass patients OBESITY SURGERY Patel, C., Van Dam, J., Curet, M., Morton, J. M., Banerjee, S. 2008; 18 (3): 336-339

    Abstract

    With the epidemic increase in obesity in the USA and consequent increased demand for bariatric surgery, new complications of the surgery are being described. The most common surgery practiced is the Roux-en-Y gastric bypass (RYGBP). Unraveling of suture material at the gastrojejunal anastomosis may occur, which may be troublesome if nonabsorbable suture is employed. We describe, for the first time, two patients who developed obstructive symptoms as a consequence of food matter/bezoars entrapped within a mesh of unraveled nonabsorbable suture material at their anastomoses. One of these patients also developed ulceration, presumably as a result of pressure necrosis from the entrapped bezoar. We describe a third patient where the placement of nonabsorbable sutures led to obstructive symptoms by limiting distensibility at an otherwise satisfactory anastomosis. We also describe for the first time, the use of a new endoscopic scissors in cutting luminal suture material with subsequent resolution of the clinical problem.

    View details for DOI 10.1007/s11695-007-9283-z

    View details for Web of Science ID 000253627700017

    View details for PubMedID 18197458

  • Retrievable inferior vena cava filters may be safely applied in gastric bypass surgery SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES Schuster, R., Hagedorn, J. C., Curet, M. J., Morton, J. M. 2007; 21 (12): 2277-2279

    Abstract

    Pulmonary embolus (PE) is a potentially devastating and fatal postoperative complication in morbidly obese patients. This study was undertaken to review the safety and efficacy of retrievable prophylactic inferior vena cava (IVC) filters in high-risk morbidly obese patients undergoing gastric bypass.Patients who underwent gastric bypass surgery and preoperative insertion of retrievable IVC filters had their records reviewed. Indications for IVC filter insertion were: history of deep venous thrombosis (DVT) or PE, long-standing sleep apnea, venous stasis disease, and/or weight > 400 pounds.24 patients underwent IVC filter placement before gastric bypass surgery. There were 10 women and 14 men with an average age of 50 +/- 6.3 years (range 39 to 59) and average body mass index (BMI) of 57 +/- 7.5 kg/m(2) (range 49 to 74). BMI greater then 50 kg/m(2) was present in 21 of 24 patients (88%). All patients had successful IVC filter placement. IVC filter retrieval postoperatively was performed in 20 of 24 patients (83%) with three left for clinical reasons and one (4%) left due to technical inability to retrieve. There was one complication directly attributable to IVC filter retrieval. There were no deaths. Five patients (21%) developed DVT or PE postoperatively. Follow-up was 16 +/- 7.6 months (range 8 to 33).Prophylactic IVC filter placement and retrieval can be safely undertaken in high-risk gastric bypass patients. We recommend preoperative IVC filter placement in selected patients.

    View details for DOI 10.1007/s00464-007-9370-1

    View details for Web of Science ID 000250923200033

    View details for PubMedID 17440780

  • Innovative introduction to surgery in the preclinical years AMERICAN JOURNAL OF SURGERY Riboh, J., Curet, M., Krummel, T. 2007; 194 (2): 227-230

    Abstract

    Lack of exposure to surgery in the preclinical years of medical school contributes to students' negative opinions of the field and to low application rates to categorical surgical programs.Forty preclinical medical students attended a series of 16 seminars and practice sessions covering the gamut of surgical specialties and basic technical skills. Students were given a Likert format survey before and after taking the course.Students gave high ratings to course content (4.26/5) and lecturers (4.54/5). Students' confidence in their surgical skills doubled (1.45/5 to 3/5, P < .0001), and their perceived readiness for the surgical clerkship increased by 73% (1.63/5 to 2.82/5, P = .007).The preclinical years offer a promising venue for improving medical student interest and performance in surgery.

    View details for DOI 10.1016/j.amjsurg.2006.12.038

    View details for Web of Science ID 000248110900019

    View details for PubMedID 17618810

  • Transnasal small-caliber esophagogastroduodenoscopy for preoperative evaluation of the high-risk morbidly obese patient SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES Alami, R. S., Schuster, R., Friedland, S., Curet, M. J., Wren, S. M., Soetikno, R., Morton, J. M., Safadi, B. Y. 2007; 21 (5): 758-760

    Abstract

    Esophagogastroduodenoscopy (EGD) is an important facet of the preoperative evaluation for bariatric surgery. Morbidly obese patients are at high risk for airway complications during this procedure, and an attractive alternative is transnasal EGD. This report describes a series of patients evaluated successfully using this technique.All patients undergoing preoperative transnasal small-caliber EGD for morbid obesity surgery between September 2004 and June 2005 at a Veterans Affairs Hospital were included in the analysis. The variables assessed were the adequacy of the examination, patient tolerance, the need for sedation, and the ability to perform interventions.The study enrolled 25 patients (17 men and 8 women) with an average age of 55 years (range, 44-63 years) and an average body mass index (BMI) of 47 kg/m2 (range, 38-69 kg/m2). All the patients met the 1991 National Institutes of Health (NIH) Consensus Conference Criteria for bariatric surgery and were undergoing preoperative evaluation. The most common comorbidities were hypertension (82%), diabetes mellitus (80%), and obstructive sleep apnea (68%). All 25 patients had successful cannulation of the duodenum's second portion with excellent tolerance. There were no sedation requirements for 23 (92%) of the 25 patients. Significant pathology was found in 14 (56%) of the 25 patients, including hiatal hernia (28%), gastritis (16%), esophageal intestinal metaplasia (16%), esophagitis (12%), gastric polyps (8%), gastric ulcer (4%) and esophageal varices (4%). Biopsies were indicated for 12 patients and successful for all 12 (100%).Transnasal small-caliber EGD is a feasible and safe alternative to conventional EGD for the preoperative evaluation of patients undergoing bariatric surgery. It requires minimal to no sedation in a population at high risk for complications in this setting. In addition, this technique is effective in identifying pathology that requires preoperative treatment and offers a complete examination with biopsy capabilities. This technique should be considered for all morbidly obese patients at high risk for airway compromise during EGD.

    View details for DOI 10.1007/s00464-006-9101-z

    View details for Web of Science ID 000246351800013

    View details for PubMedID 17235723

  • Is there a benefit to preoperative weight loss in gastric bypass patients? A prospective randomized trial SURGERY FOR OBESITY AND RELATED DISEASES Alami, R. S., Morton, J. M., Schuster, R., Lie, J., Sanchez, B. R., Peters, A., Curet, M. J. 2007; 3 (2): 141-145

    Abstract

    Roux-en-Y gastric bypass surgery is the leading surgical treatment of morbid obesity in the United States. The role of preoperative weight loss in gastric bypass surgery remains controversial. We performed a prospective randomized trial to determine whether preoperative weight loss results in better outcomes after laparoscopic gastric bypass.A total of 100 patients undergoing laparoscopic gastric bypass surgery from May 2004 to October 2005 were randomized preoperatively to either a weight loss group with a 10% weight loss requirement or a group that had no weight loss requirements. The patients were followed prospectively. The variables analyzed included perioperative complications, operative time, postoperative weight loss, and resolution of co-morbidities.Data were available for 26 patients in the weight loss group and 35 in the nonweight loss group. The 2 groups had similar preoperative characteristics, conversion and complication rates, and resolution of co-morbidities. The initial body mass index was 48.7 kg/m(2) and 49.3 kg/m(2) for the weight loss group and nonweight loss group, respectively (P = NS). The preoperative body mass index was 44.5 kg/m(2) and 50.7 kg/m(2) for the weight loss group and nonweight loss group, respectively (P = 0.0027). The operative time was 220.2 and 257.6 minutes for the 2 groups (P = 0.0084). The percentage of excess weight loss at 3 and 6 months for the weight loss group and nonweight loss group was 44.1% and 33.1% (P = 0.0267) and 53.9% and 50.9% (P = NS), respectively. The interval to surgery from the initial consultation was 5.4 months and 5.2 months for the 2 groups (P = NS).Preoperative weight loss before laparoscopic Roux-en-Y gastric bypass was associated with a decrease in the operating room time and an improved percentage of excess weight loss in the short term. Preoperative weight loss, however, did not affect the major complication or conversion rates, and its long-term effects were not apparent through this study. Also, preoperative weight loss did not have any bearing on the resolution of co-morbidities.

    View details for DOI 10.1016/j.soard.2006.11.006

    View details for Web of Science ID 000261097100006

    View details for PubMedID 17331803

  • Abnormal findings on routine upper GI series following laparoscopic Roux-en-Y gastric bypass OBESITY SURGERY Raman, R., Raman, B., Raman, P., Rossiter, S., Curet, M. J., Mindelzun, R., Morton, J. M. 2007; 17 (3): 311-316

    Abstract

    The use of postoperative upper GI series (UGIS) after laparoscopic Roux-en-Y gastric bypass (LRYGBP) varies among bariatric surgeons. The authors describe the findings and impact of UGIS after LRYGBP.From July 2003 to January 2006, 487 patients undergoing primary LRYGBP at a single academic institution had a single-contrast Gastrografin UGIS performed on the first postoperative day, without complication. Patient and operative demographics were: mean age 43 years, mean BMI 47 kg/m2, female 84%, and laparoscopic 100%.Of the 487 patients, the UGIS revealed 14 (2.9%) major and 88 (15.2%) minor abnormalities. Among the major UGIS abnormalities, 6 (1.2%) demonstrated a gastrojejunal anastomotic (GJA) leak, 8 (1.4%) confirmed complete obstruction at the GJA, and 1 (0.2%) disclosed a communication with the bypassed stomach. For the minor UGIS abnormalities, 45 (9.2%) displayed significant delay in contrast passage through the GJA, 23 (5.0%) had evidence of dilated loops of small and/or large bowel, and 6 (1.2%) verified miscellaneous abnormal findings (malrotation, lower esophageal dysmotility, jejunal clots). Patients with UGIS abnormalities necessitated additional procedures, delayed oral intake and/or longer length of stay (LOS).UGIS on postoperative day 1 is a useful means of evaluating postoperative LRYGBP anatomy and influenced postoperative care.

    View details for Web of Science ID 000245043900005

    View details for PubMedID 17546837

  • Gastric bypass reduces biochemical cardiac risk factors SURGERY FOR OBESITY AND RELATED DISEASES Williams, D. B., Hagedorn, J. C., Lawson, E. H., Galanko, J. A., Safadi, B. Y., Curet, M. J., Morton, J. M. 2007; 3 (1): 8-13

    Abstract

    Coronary artery disease (CAD) is the leading cause of death in the United States, with obesity as a leading preventable risk factor for CAD. Certain biochemical markers have demonstrated strong prediction for cardiovascular events. We hypothesized that in addition to weight reduction, gastric bypass will also induce a salutary effect on the biochemical cardiac risk factors.At a single academic institution, from 2003 to 2004, we measured the biochemical cardiac risk factors in gastric bypass patients preoperatively and at 3, 6, and 12 months postoperatively. These risk factors included total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein cholesterol, total cholesterol/HDL cholesterol ratio, triglyceride/HDL cholesterol ratio, triglycerides, lipoprotein A, high-sensitivity C-reactive protein, and homocysteine. The data were analyzed using the Wilcoxon signed rank test.The mean age of the 356 patients was 43 years; 84% were women; the mean body mass index was 47 kg/m(2); 33% were diabetic; 50% were hypertensive; 23% were taking lipid-lowering medications; and 2% had known CAD. Significant improvement occurred in the biochemical cardiac factors from preoperatively to 12 months. The beneficial changes were as follows: total cholesterol, 192 mg/dL preoperatively to 166 mg/dL at 12 months; HDL cholesterol, 46 mg/dL preoperatively to 54 mg/dL at 12 months; low-density lipoprotein, 125 mg/dL preoperatively to 88 mg/dL at 12 months; total cholesterol/HDL cholesterol ratio, 4 preoperatively to 3 at 12 months; triglyceride/HDL cholesterol ratio, 3 preoperatively to 2 at 12 months; triglycerides, 133 mg/dL preoperatively to 92 mg/dL at 12 months; lipoprotein A, 14 mg/dL preoperatively to 13 mg/dL at 12 months; high-sensitivity C-reactive protein, 8 mg/L preoperatively to 1 mg/L; and homocysteine, 10 mumol/L preoperatively to 8 mumol/L at 12 months.The results of our study have shown that gastric bypass significantly improves all biochemical markers of CAD risk, particularly C-reactive protein, which had an 80% reduction. As a result, gastric bypass decreases the cardiac risk by both weight loss and advantageous alterations of biochemical cardiac risk factors.

    View details for DOI 10.1016/j.soard.2006.10.003

    View details for Web of Science ID 000261052900004

    View details for PubMedID 17196442

  • Attitude of prospective surgical residents regarding surgery for morbid obesity OBESITY SURGERY Schuster, R., Morton, J. M., Liu, G. Y., Alami, R. S., Curet, M. J. 2006; 16 (11): 1464-1468

    Abstract

    Obesity and associated co-morbidities have become an epidemic in the United States. As surgery for obesity becomes more common, surgical training programs need to address this growing demand. We conducted this study to assess prospective surgery trainees' attitudes and knowledge regarding surgery for morbid obesity.An anonymous and voluntary questionnaire was given to prospective surgical residency applicants to complete during their interview. The questionnaire included basic demographic information and addressed the applicants' attitudes and basic knowledge about surgery for obesity.57 applicants to the surgical residency program completed the survey. Demographic information included: 51% male, 36% from the Northeast, 32% with obese family members, and 93% applying for a categorical surgery position. 81% of applicants had been exposed to bariatric surgery. Although 70% of applicants would perform bariatric surgery as part of their practice, only 44% would make this their career. Reasons for reluctance to treat bariatric surgery patients included: more complications (46%), non-compliant patients (33%), and technically demanding surgery (18%). 89% responded that they would recommend bariatric surgery to a family member, but only 77% would consider it for themselves. Overall correct answers regarding bariatric surgery knowledge were 74%.Attitudes and knowledge about surgery for morbid obesity were generally positive in prospective surgical trainees. Medical school curriculum and surgical training programs should continue to expose trainees to information from this ever-growing field.

    View details for Web of Science ID 000241926700011

    View details for PubMedID 17132412

  • Concurrent gastric bypass and repair of anterior abdominal wall hernias OBESITY SURGERY Schuster, R., Curet, M. J., Alami, R. S., Morton, J. M., Wren, S. M., Safadi, B. Y. 2006; 16 (9): 1205-1208

    Abstract

    Many patients seeking surgical treatment for morbid obesity present with anterior abdominal wall hernias. Although principles of hernia repair involve a tension-free repair with the use of prosthetic mesh, there is concern about the use of mesh in gastric bypass surgery due to potential contamination with the contents of the gastrointestinal tract and resultant mesh infection. We report our series of patients undergoing Roux-en-Y gastric bypass (RYGBP) and simultaneous anterior abdominal wall hernia repair.All patients who underwent simultaneous RYGBP surgery and anterior abdominal wall hernia repair were reviewed.12 patients underwent concurrent RYGBP and anterior wall hernia repair. There were 5 women and 7 men with average age 54.9 +/- 8.5 years (range 35 to 64) and average body mass index (BMI) 50.4 +/- 10.3 kg/m(2) (range 38 to 70). Two open and 10 laparoscopic RYGBP operations were performed. Nine patients (75%) underwent incisional hernia repairs and 3 patients (25%) underwent umbilical hernia repair concurrent with gastric bypass. Average size of defect was 14.7 +/- 13.4 cm(2). One patient had primary repair and 11 patients had prosthetic mesh repair: polypropylene in 3 patients (25%) and polyester in 8 patients (67%). With a 14.1 +/- 9.3 month follow-up, there have been no mesh infections and 2 recurrences, one in the patient who underwent primary repair and one in a patient repaired with polyester mesh but with two previous failed incisional hernia repairs.Concurrent RYGBP and repair of anterior abdominal wall hernias is safe and feasible. In order to optimize success, tension-free principles of hernia repair with the use of prosthetic mesh should be followed since no mesh infections occurred in our series.

    View details for Web of Science ID 000240355400015

    View details for PubMedID 16989705

  • Intra-operative fluid volume influences postoperative nausea and vomiting after laparoscopic gastric bypass surgery OBESITY SURGERY Schuster, R., Alami, R. S., Curet, M. J., Paulraj, N., Morton, J. M., Brodsky, J. B., Brock-Utne, J. G., Lemmens, H. J. 2006; 16 (7): 848-851

    Abstract

    Laparoscopic Roux-en-Y gastric bypass (RYGBP) is a commonly performed operation for morbid obesity. A significant number of patients experience postoperative nausea and vomiting (PONV) following this procedure. The aim of this study was to determine the effect, if any, of intra-operative fluid replacement on PONV.Patients who underwent laparoscopic (RYGBP) for morbid obesity during a 12-month period were included in this retrospective analysis. Demographic data including age, gender, and body mass index (BMI) were collected. Perioperative data also included total volume of intra-operative fluids administered, rate of administration, urine output, length of surgery, and incidence of PONV as determined by nursing or anesthesia records in the postanesthesia care unit (PACU). Data were analyzed by t-test.The table below depicts demographic and perioperative data, comparing patients who experienced PONV (n=125) in the PACU with those who did not (n=55). Values are mean +/- standard deviation.PONV is a common complication after laparoscopic RYGB. Patient who did not experience PONV received a larger volume of intravenous fluid at a faster rate than similar patients who complained of PONV.

    View details for Web of Science ID 000239131000007

    View details for PubMedID 16839481

  • Laparoscopic-assisted colectomy for colon cancer EXPERT REVIEW OF MEDICAL DEVICES Tedesco, M. M., Curet, M. J. 2006; 3 (4): 415-419

    Abstract

    Laparoscopic-assisted colectomy (LAC) for colon cancer was first described in 1991. Unlike other laparoscopic procedures used to treat benign disease, the LAC for colon cancer has been slow to gain acceptance for a variety of reasons. Recently, several large, randomized controlled trials have demonstrated that LACs are comparable with open colectomies with respect to oncological issues such as survival, port-site metastases and tumor recurrence. Moreover, there are significant patient benefits with the use of LAC including duration of analgesic use, return of bowel function, length of stay and return to normal activity.

    View details for DOI 10.1586/17434440.3.4.415

    View details for Web of Science ID 000242101900007

    View details for PubMedID 16866638

  • Totally Robotic Laparoscopic Roux-en-Y Gastric Bypass: Results from 75 patients OBESITY SURGERY Mohr, C. J., Nadzam, G. S., Alami, R. S., Sanchez, B. R., Curet, M. J. 2006; 16 (6): 690-696

    Abstract

    A technique for Totally Robotic Laparoscopic Roux-en-y Gastric Bypass (TRL-RYGBP) has been reported previously. In this paper, we report our experience with our first 75 TRLRYGBP operations, including the training of three laparoscopic fellows. We describe changes in technique that have evolved with more experience, lessons learned, and the results from a larger series.A retrospective review was conducted of the first 75 TRLRYGBP procedures performed at our institution using the da Vinci surgical robot. We recorded demographics including patient age, gender, preoperative BMI, and numbers of NIH-defined co-morbidities. Data were collected on operative time, length of stay, complications, and postoperative weight loss. Results were compared between the three fellows to examine learning curves.The average patient age was 44 years (23-61), average BMI was 46.1 kg/m(2) (34.3-65.5), and the median number of NIH defined co-morbidities was 1 (0-3). Median operative time was 140 minutes (80-312) with mean operative time per BMI of 3.1 minutes (1.6-5.7). Excess weight loss was 48% at 3 months, 64% at 6 months, and 82% at 1 year. The overall complication rate was 22.6% (5.3% intraoperative, 8.0% major, and 9.3% minor including a 2.9% stricture rate and 0% leak rate). Each fellow demonstrated a learning curve of 10-15 cases.The authors' continued experience with the TRLRYGBP has confirmed our early results that the use of the da Vinci robot for laparoscopic gastric bypass is a superior alternative to the standard laparoscopic RYGBP, and that the learning curve is significantly faster.

    View details for Web of Science ID 000238156200002

    View details for PubMedID 16756726

  • Refractory hematuria from amyloidosis successfully treated by splenectomy UROLOGY Ma, J. F., Coutre, S. E., Curet, M. J., Brooks, J. D. 2006; 67 (5)

    Abstract

    Systemic amyloidosis can result in a coagulopathy that is associated with low levels of factor X. We present a case of intractable, life-threatening hematuria that was successfully managed with activated recombinant human factor VII and splenectomy.

    View details for DOI 10.1016/j.urology.2005.11.048

    View details for Web of Science ID 000238390800059

    View details for PubMedID 16698382

  • Alphanumeric paging in an academic hospital setting AMERICAN JOURNAL OF SURGERY Nguyen, T. C., Battat, A., Longhurst, C., Peng, P. D., Curet, M. J. 2006; 191 (4): 561-565

    Abstract

    To determine whether implementation of an alphanumeric-paging system would improve physician work environment.Surveys were distributed to all general surgery residents, faculty, and nurses before and after implementation of an alphanumeric-paging system. Housestaff also kept a detailed log of paging activity before and after the intervention.User satisfaction with the paging system was measured using a Likert format survey. Interruptions to patient care and pages requiring a call back were tracked using paging logs.Physician perceptions of the capability of text paging before the intervention were high and did not differ significantly postintervention. For nursing staff, postintervention perceptions of the text-paging system were significantly more positive than preintervention, especially with regard to perceived improvements in patient care (54.1% versus 81.6%, P < .05). Residents' paging logs reflected significantly decreased interruptions to patient care after the intervention (28.2% versus 46.9%, P < .05), with less pages requiring a call back (100% versus 73.6%, P < .05).Study participants rated the alphanumeric-paging system highly. Text-paging technology has the potential to reduce interruptions in patient care and improve physician work efficiency and satisfaction.

    View details for DOI 10.1016/j.amjsurg.2005.06.037

    View details for Web of Science ID 000236508800024

    View details for PubMedID 16531156

  • Laparoscopic repair for recurrent abdominal wall hernia after TRAM flap breast reconstruction - Case report of 2 patients ANNALS OF PLASTIC SURGERY Shaw, R. B., Curet, M. J., Kahn, D. M. 2006; 56 (4): 447-450

    Abstract

    The transverse rectus abdominis musculocutaneous (TRAM) flap is an appealing option for women choosing between various breast reconstructive techniques as it results in an autologous reconstructed breast that is soft and mimics a natural breast. Despite these benefits, there are complications with this procedure, such as pain at the donor site, longer scars, and most frequently the occurrence of abdominal wall hernia or bulge, which has been reported in up to 20%-40% of patients.In this case report, we share our experience with 2 patients who had multiple open hernia repairs, 5 between the 2 of them, after their TRAM flap surgery. Each of these 5 repairs was performed with a Prolene mesh overlay, but not one lasted for more than 6 months. After reviewing our patients' records and our surgical options, we decided to proceed with laparoscopic repair of their recurrent hernias.The patients are now at postoperative follow-up of 12 months and 15 months, with no evidence of recurrence.Laparoscopic surgery has many benefits, such as shorter hospitalization and decreased pain. For our patients, it also resulted in a more beneficial and longer-lasting repair. We believe that this is partly due to the mechanics of the repair, which allows the abdominal contents to buttress the mesh against the abdominal wall. In addition, we believe that this technique reinforces the posterior sheath, which may not be accomplished in an open repair. This is important as most hernias after TRAM flap surgery occur below the arcuate line. From our experience with these 2 patients, we now advocate the use of laparoscopic repair as a treatment option for those who present with recurrent abdominal wall hernia or bulge after their TRAM flap surgery and believe with more experience it will become a first-line treatment.

    View details for DOI 10.1097/01.sap.0000200281.24169.1f

    View details for Web of Science ID 000236376900025

    View details for PubMedID 16557083

  • Orogastric tube complications in Laparoscopic Roux-en-Y gastric bypass OBESITY SURGERY Sanchez, B. S., Safadi, B. Y., Kieran, J. A., Hsu, G. P., Brodsky, J. B., Curet, M. J., Morton, J. M. 2006; 16 (4): 443-447

    Abstract

    Recent national efforts have focused on improving patient safety in surgical procedures including examining adverse events. An adverse event in laparoscopic Roux-en-Y gastric bypass (LRYGBP) which has not received much scrutiny involves orogastric tube complications during gastric pouch formation.Retrospective review was conducted of all LRYGBPs (n=727) performed by 5 surgeons over 5 years at 2 institutions. Cases with intraoperative orogastric tube (OGT) related complications (n=9) were identified.9 patients (1.2%) had preventable orogastric tube-related complications. Mean patient demographics were as follows: age 47 years, female 56%, pre-op BMI 52 kg/m(2), co-morbidities 3.5 and mortality 0%. 7 of 9 patients' cases were complicated by stapling of an orogastric tube during gastric pouch formation. The remaining 2 patients had complications involving suturing of the Levacuator tube during gastrojejunostomy formation. All complications required gastric pouch or anastomotic revision. 2 patients required conversion to an open procedure, 2 required re-operation for anastomotic leak, and 1 had respiratory failure and prolonged hospital stay.Orogastric tube complications can occur during laparoscopic RYGBP, but are seldom reported and can be associated with significant morbidity. Treatment options are dependent upon the situation. More importantly, prevention strategies must include constant communication with the anesthesiologist and removal or manipulation of an OGT prior to stapling or suturing, use of large bore OGTs for increased visual or tactile recognition, retraction of the OGT proximal to the anastomosis during gastrojejunal construction and employing alternatives to esophageal temperature probes (i.e. Foley temperature probes).

    View details for Web of Science ID 000236566000166

    View details for PubMedID 16608608

  • Robotic-assisted laparoscopic Roux-en-Y gastric bypass in a patient with midgut malrotation. Surgery for obesity and related diseases Alami, R. S., Schuster, R., Morton, J. M., Curet, M. J. 2006; 2 (2): 222-225

    View details for PubMedID 16925348

  • Incidental finding of gastrointestinal stromal tumors (GISTs) during laparoscopic gastric bypass OBESITY SURGERY Sanchez, B. R., Morton, J. M., Curet, M. J., Alami, R. S., Safadi, B. Y. 2005; 15 (10): 1384-1388

    Abstract

    Gastrointestinal stromal tumors (GISTs) are rare tumors, accounting for <1% of all neoplasms of the alimentary tract. GISTs have not been previously reported in association with gastric bypass surgery.This study is a retrospective review of 517 consecutive morbidly obese patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGBP) between January 2002 and August 2005. Incidental intraoperative findings of gastric GIST were recorded.4 patients (0.8%) were noted to have GISTs intra-operatively upon inspection of the stomach prior to partition. All GISTs were identified along the anterior aspect of the upper third of the stomach and were removed by laparoscopic wedge excision with at least a 1 cm margin. The 4 tumors were <1 cm in size and all had immunohistochemical analysis positive for CD117 (c-kit). None of the tumors had determinants of malignant behavior (high mitotic rate, necrosis or pleomorphism).We have found a 0.8% incidence of gastric GISTs in our morbidly obese patients undergoing LRYGBP. All of these small, benign tumors were found incidentally in asymptomatic patients. This case series underscores the need to fully assess the stomach prior to gastric pouch formation. Without the ability to grossly determine the benign or malignant behavior of GISTs, all these tumors found incidentally should be resected with adequate margins.

    View details for Web of Science ID 000233506900005

    View details for PubMedID 16354516

  • Laparoscopic Roux-en-Y gastric bypass at a Veterans Affairs and high-volume academic facilities: a comparison of institutional outcomes AMERICAN JOURNAL OF SURGERY Alami, R. S., Morton, J. M., Sanchez, B. R., Curet, M. J., Wren, S. M., Safadi, B. Y. 2005; 190 (5): 821-825

    Abstract

    Outcomes of bariatric surgery have been linked to institutional case volume. The objective of our study was to compare outcome of laparoscopic Roux-en-y gastric bypass (RYGB) in 2 settings: a low-volume Veterans Affairs (VA) and a high-volume university hospital (UH).Over a period of 27 months, 140 patients underwent RYGB (137 laparoscopic, 3 open) performed by 1 surgeon. Fifty-five were performed at a VA and 85 at a UH with an annual caseload close to 300.The body mass index in both groups was similar, but patients at the VA were older, mostly men, and more likely to have hypertension (HTN), obstructive sleep apnea, and diabetes mellitus (DM). Operative and anesthesia times were significantly longer at the VA. There were no differences in 30-day mortality (none), major morbidity, conversion rates, or reoperation rates.Laparoscopic RYGB can be performed safely at a VA facility despite a higher risk population and low annual volume.

    View details for DOI 10.1016/j.amjsurg.2005.07.027

    View details for Web of Science ID 000232935200030

    View details for PubMedID 16226965

  • Comparison of totally robotic laparoscopic Roux-en-Y gastric bypass and traditional laparoscopic Roux-en-Y gastric bypass. Surgery for obesity and related diseases Sanchez, B. R., Mohr, C. J., Morton, J. M., Safadi, B. Y., Alami, R. S., Curet, M. J. 2005; 1 (6): 549-554

    Abstract

    Laparoscopic gastric bypass is a technically demanding operation, especially when hand-sewing is required. Robotics may help facilitate the performance of this difficult operation. This study was undertaken to compare a single surgeon's results using the daVinci Surgical System with those using traditional laparoscopic Roux-en-Y gastric bypass (LRYGB) when the techniques were learned simultaneously.From July 2004 to April 2005, the new laparoscopic fellow's first 50 patients were randomized to undergo either LRYGB or totally robotic laparoscopic Roux-en-Y gastric bypass (TRRYGB). Data were collected on patient age, gender, body mass index (BMI), co-morbidities, operative time, complication rates, and length of stay. Student's t test with unequal variances was used for statistical analysis.No significant differences in age, gender, co-morbidities, complication rates, or length of stay were found between the two groups. The mean operating time was significantly shorter for TRRYGB than for LRYGB (130.8 versus 149.4 minutes; P = 0.02), with a significant difference in minutes per BMI (2.94 versus 3.47 min/BMI; P = 0.02). The largest difference was in patients with a BMI >43 kg/m(2), for whom the difference in procedure time was 29.6 minutes (123.5 minutes for TRRYGB versus 153.2 minutes for LRYGB; P = 0.009) and a significant difference in minutes per BMI (2.49 versus 3.24 min/BMI; P = 0.009).Our data indicate that the use of the daVinci Surgical System for TRRYGB is safe and feasible. The operating room time is shorter with the use of the robotic system during a surgeon's learning curve, and that decrease is maximized in patients with a larger BMI. TRRYGB may be a better approach to gastric bypass when hand-sewing is required, especially early in a surgeon's experience.

    View details for PubMedID 16925289

  • The impact of preoperative weight loss in patients undergoing Laparoscopic Roux-en-Y gastric bypass OBESITY SURGERY ALVARADO, R., Alami, R. S., Hsu, G., Safadi, B. Y., Sanchez, B. R., Morton, J. M., Curet, M. J. 2005; 15 (9): 1282-1286

    Abstract

    Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a widely performed bariatric operation. Preoperative factors that predict successful outcomes are currently being studied. The goal of this study was to determine if preoperative weight loss was associated with positive outcomes in patients undergoing LRYGBP.A retrospective analysis was performed of all patients undergoing LRYGBP at our institution between July 2002 (when a policy of preoperative weight loss was instituted) and August 2003. Outcome measures evaluated at 1 year postoperatively included percent excess weight loss (EWL) and correction of co-morbidities. Statistical analysis was performed by multiple linear regression. P<0.05 was considered significant.The study included 90 subjects. Initial BMI ranged from 35.4 to 63.1 (mean 48.1). Preoperative weight loss ranged from 0 to 23.8% (mean 7.25). At 12 months, postoperative EWL ranged from 40.4% to 110.9 % (mean 74.4%). Preoperative loss of 1% of initial weight correlated with an increase of 1.8% of postoperative EWL at 1 year. In addition, initial BMI correlated negatively with EWL, so that an increase of 1 unit of BMI correlated with a decrease of 1.34% of EWL. Finally, preoperative weight loss of >5% correlated significantly with shorter operative times by 36 minutes. Preoperative weight loss did not correlate with postoperative complications or correction of co-morbidities.Preoperative weight loss resulted in higher postoperative weight loss at 1 year and in shorter operative times with LRYGBP. No differences in correction of co-morbidities or complication rates were found with preoperative weight loss in this study. Preoperative weight loss should be encouraged in patients undergoing bariatric surgery.

    View details for Web of Science ID 000233014200014

    View details for PubMedID 16259888

  • Laparoscopic Roux-en-Y gastric bypass: Differences in outcome between attendings and assistants of different training backgrounds OBESITY SURGERY Hsu, G. P., Morton, J. M., Jin, L., Safadi, B., Satterwhite, T. S., Curet, M. J. 2005; 15 (8): 1104-1110

    Abstract

    Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is associated with a significant learning curve. We hypothesize that differences in surgeon and assistant training backgrounds may significantly impact outcomes during the learning curve.Retrospective analysis was performed on patients undergoing LRYGBP at an academic medical center between January 1998 and August 2003. Operations were performed by surgeons with different training backgrounds: without formal laparoscopic fellowship (S1, n=95); immediately following laparoscopic fellowship (S2, n=100); and with extensive laparoscopic experience post fellowship (S3, n=88). First assistants were attendings, fellows, or residents. The variables analyzed included demographics, operative times, estimated blood loss (EBL), rate of conversion, length of stay (LOS), ICU stay, re-operation/re-admission rate, and complications. Results were analyzed by ANOVA and Fisher's exact test.There were significant differences among surgeons of different training backgrounds in EBL, LOS, rate of ICU admission, and intraoperative and late complications rates. Among assistants of different training levels, there were significant differences in operative time, EBL, intraoperative complication rates and re-admission rates.Differences in training background of the surgeons resulted in significant differences in outcome, including EBL, LOS, ICU admission and intraoperative and late complication rates. Lower assistant training levels significantly impacted efficiency through lengthened operative times and increased EBL, as well as increased intraoperative complication rates and re-admission rates. Our results suggested that participating in a laparoscopic fellowship and operating with a more experienced assistant may improve outcomes during the learning curve.

    View details for Web of Science ID 000232592700004

    View details for PubMedID 16197780

  • Totally robotic Roux-en-Y gastric bypass ARCHIVES OF SURGERY Mohr, C. J., Nadzam, G. S., Curet, M. J. 2005; 140 (8): 779-785

    Abstract

    We hypothesized that we could develop a safe and effective technique for performing a totally robotic laparoscopic Roux-en-Y gastric bypass procedure using the da Vinci surgical system. We anticipated that the learning curve for this totally robotic procedure could be shorter than the learning curve for standard laparoscopic bariatric surgery.Retrospective case comparison study.Academic tertiary care center.Consecutive samples of patients who met National Institutes of Health (NIH) criteria for morbid obesity and who completed the Stanford Bariatric Surgery Program evaluation process.A port placement and robot positioning scheme was developed so that the entire case could be performed robotically. The first 10 patients who underwent a totally robotic laparoscopic Roux-en-Y gastric bypass were compared with a retrospective sample of 10 patients who had undergone laparoscopic Roux-en-Y gastric bypass surgery.Patient age, gender, body mass index (BMI), numbers of NIH-defined comorbidities, operative time, length of stay, and complications.No significant differences existed between the 2 patient series with regard to age, gender, or BMI. The median surgical times were significantly lower for the robotic procedures (169 vs 208 minutes; P = .03), as was the ratio of procedure time to BMI (3.8 vs 5.0 minutes per BMI for the laparoscopic cases; P = .04).This study details the first report, to our knowledge, of a totally robotic laparoscopic Roux-en-Y gastric bypass and demonstrates the feasibility, safety, and potential superiority of such a procedure. In addition, the learning curve may be significantly shorter with the robotic procedure. Further experience is needed to understand the long-term advantages and disadvantages of the totally robotic approach.

    View details for Web of Science ID 000230948300019

    View details for PubMedID 16103289

  • Laparoscopic-assisted resection of colorectal carcinoma LANCET Curet, M. J. 2005; 365 (9472): 1666-1668

    View details for Web of Science ID 000229082300005

    View details for PubMedID 15894083

  • Comparison of training on two laparoscopic simulators and assessment of skills transfer to surgical performance JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Youngblood, P. L., Srivastava, S., Curet, M., Heinrichs, W. L., Dev, P., Wren, S. M. 2005; 200 (4): 546-551

    Abstract

    Several studies have investigated the transfer of surgical trainees' skills acquired on surgical simulators to the operating room setting. The purpose of this study was to compare the effectiveness of two laparoscopic surgery simulators by assessing the transfer of skills learned on simulators to closely matched surgical tasks in the animal laboratory.In this post-test-only Control group study design, 46 surgically naive medical student volunteers were randomly assigned to one of three groups: Tower Trainer group (n = 16), LapSim group (n = 17), and Control group (n = 13). Outcomes measures included both time and accuracy scores on three laparoscopic tasks (Task 1: Grasp and Place; Task 2: Run the Bowel; Task 3: Clip and Cut) performed on live anesthetized pigs, and a global rating of overall performance as judged by four experienced surgeons.The Tower Trainer group performed significantly better than the Control group on 1 of 7 outcomes measures-Task 3: Time (p < 0.032), although the LapSim group performed significantly better than the Control group on 2 of 7 measures-Task 3: Time (p < 0.008) and Global score (p < 0.005). In comparing the two simulators, the LapSim group performed significantly better than the Tower Trainer group on 3 of 7 outcomes measures-Task 2: Time (p < 0.032), Task 2: Accuracy (p < 0.030) and Global score (p < 0.005), although the Tower Trainer group did not perform significantly better than the LapSim group on any measure.This study demonstrated that naive subjects trained on a virtual-reality part-task trainer performed better on live surgical tasks in a porcine model as compared with those trained with a traditional box trainer. These findings could aid in selection of appropriate training methodologies.

    View details for DOI 10.1016/j.jamcollsurg.2004.11.011

    View details for Web of Science ID 000228085200007

    View details for PubMedID 15804468

  • Nitrous oxide and laparoscopic bariatric surgery OBESITY SURGERY Brodsky, J. B., Lemmens, H. J., Collins, J. S., Morton, J. M., Curet, M. J., Brock-Utne, J. G. 2005; 15 (4): 494-496

    Abstract

    Nitrous oxide (N2O) is frequently used to supplement more potent anesthetic agents. One side-effect of N2O is its ability to expand an air-containing space. We investigated if N2O adversely affected operating conditions by distending normal bowel during laparoscopic bariatric procedures.50 morbidly obese patients were divided into 2 study groups. Group 1 patients were ventilated with a halogenated anesthetic/oxygen/air mixture, while Group 2 received a halogenated anesthetic/oxygen/N2O mixture. At 30, 60, and 90 min intervals during the operation, the surgeon was asked if N2O was being used.The surgeons responded correctly only 42% (30 min), 50% (60 min), and 48% (90 min) of the time. In Group 2 (N2O) patients, they incorrectly answered that N2O was not being used 88% (30 min), 68% (60 min), and 68% (90 min); and in Group 1 (air) patients, they incorrectly answered that N2O was being used 28% (30 min), 32% (60 min), and 36% (90 min) of the time.We found that using N2O did not cause noticeable bowel distention during laparoscopic bariatric procedures of relatively short duration.

    View details for Web of Science ID 000228911000006

    View details for PubMedID 15946427

  • Introducing laparoscopic Roux-en-Y gastric bypass at a Veterans Affairs medical facility AMERICAN JOURNAL OF SURGERY Safadi, B. Y., Kieran, J. A., Hall, R. G., Morton, J. M., Bellatorre, N., Shinoda, E., Johnson, P. J., Curet, M. J., Wren, S. M. 2004; 188 (5): 606-610

    Abstract

    Previous studies have shown that advanced age, diabetes, and male gender are associated with higher morbidity and mortality after bariatric surgery. Those risk factors are characteristic of patients in the Veterans Affairs (VA) health care system. Laparoscopic Roux-en-Y gastric bypass (RYGB) has become an established treatment modality for morbid obesity. Our objective was to review the initial experience with laparoscopic (RYGB) for morbid obesity at our VA facility.A retrospective review was used.Between May of 2002 and April of 2004, 40 patients underwent laparoscopic RYGB. All patients met National Institutes of Health consensus statement guidelines for bariatric surgery. There were 30 (75%) male and 10 (25%) female patients, with an average age of 49.9 +/- 8.7 years and an average body mass index (BMI) of 48.1 +/- 8.5 kg/m(2). Preoperative comorbidities included diabetes mellitus (DM) in 59%, hypertension in 79%, and obstructive sleep apnea in 74.4%. The procedure was converted to an open procedure in 3 patients (7.5%). There were no mortalities. Immediate (within 30 days) complications developed in 9 (22.5%) patients, necessitating abdominal re-operation in 3 patients (7.5%). The median length of hospital stay was 3 days. Late complications (>30 days) developed in 8 (20%) patients. Percent excess weight loss at 3, 6, and 12 months was 44% (n = 34), 59% (n = 29), and 70.0% (n = 22), respectively. In 23 patients who were followed-up for more than 3 months, DM resolved in 79% and improved in 21% at a mean follow-up evaluation of 13 months.Laparoscopic RYGB can be performed with acceptable morbidity and with good short-term results in a VA hospital setting. Morbid obesity is prevalent in the VA patient population and access to bariatric surgery should be an available alternative.

    View details for DOI 10.1016/j.amjsurg.2004.07.021

    View details for Web of Science ID 000225208600032

    View details for PubMedID 15546580

  • Port site metastases AMERICAN JOURNAL OF SURGERY Curet, M. J. 2004; 187 (6): 705-712

    Abstract

    Concerns about port site metastases have limited the application of minimally invasive surgery for intra-abdominal malignancies. The purpose of this review article was to summarize the current literature regarding port site metastases.A Medline search identified >100 articles in English published during the last 15 years regarding the history, incidence, etiology, and prevention of port site metastases. These articles were reviewed and are summarized.The incidence of port site metastases, initially thought to be as high as 21%, is now thought to be closer to the incidence of wound metastases after open surgery. Multiple etiologic factors have been studied including direct wound contamination, surgical technique, effects of carbon dioxide pneumoperitoneum, and changes in host immune response. Various preventive measures have been proposed.Port site metastases are a well-documented and devastating complication after laparoscopic resection of intra-abdominal malignancies. Although the etiology is not yet understood, a number of factors are contributory. All efforts should be made to prevent port site metastases.

    View details for DOI 10.1016/j.amjsurg.2003.10.015

    View details for Web of Science ID 000222121100008

    View details for PubMedID 15191862

  • Laparoscopic colon resection for colon cancer JOURNAL OF SURGICAL RESEARCH Kieran, J. A., Curet, M. J. 2004; 117 (1): 79-91

    Abstract

    Laparoscopic colon resection for cancer is as yet an unproven operation. This review article summarizes current data on the topic.A Medline review identified articles published since 1990 summarizing patients with potentially curable colon cancer who underwent a laparoscopic-assisted colon resection. Only articles that were randomized or had a control group with historical or matched open cases were used.Very few prospective randomized controls exist. Several clinical trials are under way with one completed. Data thus far support some patient benefits with a laparoscopic approach. No differences in morbidity, oncologic data, or survival appear to exist.The results of ongoing clinical trials are still needed to further evaluate the role of laparoscopic assisted colon resection in patients with potentially curable colon cancer.

    View details for DOI 10.1016/j.jss.2003.11.025

    View details for Web of Science ID 000220182100012

    View details for PubMedID 15013718

  • Improving resident work environment: Evaluation of a novel cooperative program SURGERY Curet, M. J., McAdams, T. R. 2003; 134 (2): 158-163

    Abstract

    Improving the resident work environment is a major concern for surgery faculty. This study evaluated the ability of a cooperative program with nurses and interns to decrease the number of nonurgent pages and consistently generate a 4-hour block of time at night without nonurgent pages.Multiple discussions with interns and with nurses on 2 nursing floors identified ways to improve nurse/resident communication. These included use of a notebook by nurses to record nonurgent issues and having on-call interns check with the night nurses after night shift report. For the week before and after institution of the program, interns logged each page received. Pretest and posttest data were compared by use of t testing.Interns logged fewer pages after intervention compared with preintervention (P <.01). In addition, the interns had a 4-hour block of time on call nights without pages more frequently during the posttest period (100% vs 25%, P <.01). The percent of necessary calls increased from 50% to 70% during day shifts (P <.01).A cooperative program that focused on decreasing nonurgent pages and maximizing efficient communication led to a decrease in the number of nonurgent pages received by interns and increased the number of call nights in which a 4-hour block of sleep or study time was generated, thereby improving residents' work environment.

    View details for DOI 10.1067/msy.2003.266

    View details for Web of Science ID 000185184900008

    View details for PubMedID 12947313

  • Institutional variations in the management of patients with acute appendicitis JOURNAL OF GASTROINTESTINAL SURGERY Kieran, J. A., Curet, M. J., Schermer, C. R. 2003; 7 (4): 523-528

    Abstract

    The purpose of this study was to evaluate institutional differences in preoperative workup, operative approach, complications, and cost in patients with acute appendicitis. A retrospective chart review was performed of all adults operated on for acute appendicitis from June 1999 to November 2000 at the University of New Mexico Hospital (UNMH) and Stanford University Medical Center (SUMC). Variables compared included age, race, sex, duration of symptoms, type of symptoms, results of radiographic evaluation, time from emergency room to operating room, operative approach (open vs. laparoscopic), operative time, length of hospital stay, pathologic findings, and complications. Statistical analysis was performed by means of Fisher's exact test. A total of 154 appendectomies were performed for acute appendicitis at UNMH and 165 at SUMC. Statistically significant differences were found at UNMH vs. SUMC in time from emergency room to operating room (9.1 hours vs. 13.7 hours; P<0.001), operative approach (48% laparoscopic vs. 29% open; P<0.001), and negative appendectomy rate (13% vs. 4.8%; P<0.001). There were no differences in the perforation rate or other complications. Cost analysis showed that $56,744 more was spent at UNMH for the additional negative appendectomy operations, whereas $99,842 more was spent at SUMC for the additional CT scans. Institutional differences in the management of patients with acute appendicitis can result in significant differences in cost without clinically significant differences in outcome. The use of clinical examination and laparoscopy as diagnostic modalities instead of CT scanning resulted in a more cost-effective approach.

    View details for DOI 10.1016/S1091-255X(03)00044-1

    View details for Web of Science ID 000183209100017

    View details for PubMedID 12763410

  • The effect of longterm vs shortterm tutors on the quality of the tutorial process and student performance ADVANCES IN HEALTH SCIENCES EDUCATION Curet, M. J., Mennin, S. P. 2003; 8 (2): 117-126

    Abstract

    Small-group, problem- based learning can require a significant amount of individual faculty time when groups last as long as 10 weeks. One solution is to use two short-term (3-5 weeks) tutors instead of a single long-term (6-10 weeks) tutor. This study was performed to evaluate whether having short-term instead of a long-term tutors affected student performance and/or the quality of the tutorial process. The grade point averages for first and second year medical students in the classes of 2001 and 2002 were stratified by how many long-term tutors students had (2, 3, 4, 5, or 6) over a period of 17 months. In addition, students completed anonymously a 24-item tutor evaluation questionnaire utilizing a 5 point Likert scale (outstanding, good, satisfactory, marginal or unsatisfactory) at the mid-point and at the end of each tutorial. The evaluations were stratified by whether the tutor was short-term or long-term (to the mid-point or end of the tutorial, respectively). Statistical analysis was performed using analysis of variance. Grade point averages did not correlate with the number of long-term tutors that students had. Long-term tutors were rated significantly higher than short-term tutors in 17 of the 24 categories evaluated by the questionnaire, including development of students' critical thinking, information skills and self-learning skills; encouraging students to express themselves freely and to take responsibility for their own learning; helping students to balance basic science and clinical applications; and overall assessment. Short-term vs long-term tutors do not affect objective student performance as measured by grade point average. However, long-term tutors are ranked significantly higher by students in numerous areas related to the perceived quality of the tutorial process. Short-term tutoring may be less of a demand on an individual faculty's time, but may lessen the students' perceived quality of the tutorial process.

    View details for Web of Science ID 000184412500004

    View details for PubMedID 12913371

  • Laparoscopic cholecystectomy - Outpatient vs inpatient management SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES Curet, M. J., Contreras, M., Weber, D. M., Albrecht, R. 2002; 16 (3): 453-457

    Abstract

    This study was undertaken to determine if patients undergoing laparoscopic cholecystectomy may be discharged home 4 h postoperatively with similar outcomes as patients admitted overnight.Patients were randomized to an outpatient group (OP), consisting of patients who were discharged after a 4-h stay in the Post Anesthesia Care Unit (PACU), or to an inpatient group. Variables compared between the two groups included patient demographics; degree of postoperative pain, nausea, vomiting, and patient satisfaction; amount of pain and nausea medication taken; and number of phone calls, readmissions, or complications. Statistical analysis was performed with students t-test, Fisher's exact test, and Wilcoxon's signed rank and rank sums tests as appropriate.Eighty patients were initially enrolled. Two were converted and 4 required admission after being randomized to the OP group. Patients in the OP group received more oral pain medication prior to PACU discharge. Degree of pain, number of phone calls, readmission and complication rates, and patient satisfaction were similar between both groups. Of the 4 unexpected admissions, all were identified within the 4-h PACU stay.Patients undergoing laparoscopic cholecystectomy who are discharged home 4 h postoperatively will experience the same satisfaction with no increase in complications as patients admitted overnight.

    View details for DOI 10.1007/s00464-001-8129-3

    View details for Web of Science ID 000174894800018

    View details for PubMedID 11928027

  • Effects of helium pneumoperitoneum in pregnant ewes SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES Curet, M. J., Weber, D. M., Sae, A., Lopez, J. 2001; 15 (7): 710-714

    Abstract

    Previous animal studies have demonstrated that a carbon dioxide (CO(2)) pneumoperitoneum in pregnant ewes causes maternal and fetal acidosis, decreased uterine blood flow (UtBF), and fetal hypertension. This study was undertaken to determine whether helium (He) produces these same effects when used as an insufflating gas.Six gravid ewes, at 116 to 120 days gestation, underwent catheterization of the maternal femoral artery and vein and the fetal hindlimb artery and vein, as well as insertion of a uterine artery flow probe. After a 6-day recovery period, the animals were anesthetized; a Hasson trocar was placed; and an He pneumoperitoneum was established (10 mmHg for 30 min followed by 15 mmHg for 30 min). The following parameters were recorded at baseline and at preset time points: maternal and fetal heart rate (HR), blood pressure (BP), arterial blood gasses, maternal end-tidal CO(2) (EtCO2), and UtBF. The percentage of change over time was determined for each variable. The results were compared with results previously obtained in control animals and in animals undergoing CO(2) pneumoperitoneum. Statistical significance was determined by repeated measures analysis of variance (ANOVA).The following statistically significant changes were found.Like CO(2), He used for pneumoperitoneum resulted in decreased UtBF and fetal hypertension because of increased intra-abdominal pressure. Unlike a CO(2), He used for pneumoperitoneum does not cause maternal or fetal acidosis, indicating that the metabolic effects seen with CO(2) are the result of the specific gas used. Therefore, He may be a safer gas than CO(2) to use for laparoscopic procedures in pregnant patients.

    View details for Web of Science ID 000169664100017

    View details for PubMedID 11591973

  • Laparoscopically assisted colon resection for colon carcinoma - Perioperative results and long-term outcome SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES Curet, M. J., Putrakul, K., Pitcher, D. E., Josloff, R. K., Zucker, K. A. 2000; 14 (11): 1062-1066

    Abstract

    The role of laparoscopic colon resection in the management of colon cancer is unclear. The aims of this study were to compare perioperative results and long-term outcomes in patients randomized to either open (O) or laparoscopically assisted (LA) colon resection for colon cancer.A prospective randomized trial comparing O to LA colon resection was conducted from January 1993 to November 1995. Preoperative workup, intraoperative results, complications, length of stay, pathologic findings, and long-term outcomes were compared between the two groups. Statistical analysis was performed with t-test. Follow-up periods ranged from 3.5 to 6.3 years (mean, 4.9 years).No port-site or abdominal wall recurrences were noted in any patients. [table: see text]These results suggest that laparoscopically assisted colon resection for malignant disease can be performed safely, with morbidity, mortality, and en bloc resections comparable with those of open laparotomy. Long-term (5-year) follow-up assessment shows similar outcomes in both groups of patients, demonstrating definite perioperative advantages with LA surgery and no perioperative or long-term disadvantages.

    View details for Web of Science ID 000165706100020

    View details for PubMedID 11116420

  • Predictors of outcome in trauma during pregnancy: Identification of patients who can be monitored for less than 6 hours JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE Curet, M. J., Schermer, C. R., Demarest, G. B., Bieneik, E. J., Curet, L. B. 2000; 49 (1): 18-24

    Abstract

    The first objective of this study was to identify risk factors in pregnant patients suffering blunt trauma predictive for uterine contractions, preterm labor, or fetal loss. The second objective was to identify patients who can safely undergo fetal monitoring for 6 hours or less after blunt trauma by selecting out those patients demonstrating the identified risk factors.A retrospective chart review was performed from January 1, 1990, through December 31, 1998. Charts were reviewed for numerous possible risk factors for adverse outcomes. Statistical analysis was performed by using logistic regression.A total of 271 pregnant patients admitted after blunt trauma were identified. Risk factors significantly predictive of fetal death included ejections, motorcycle and pedestrian collisions, maternal death, maternal tachycardia, abnormal fetal heart rate, lack of restraints, and Injury Severity Score > 9. Risk factors significantly predictive of contractions or preterm labor included gestational age >35 weeks, assaults, and pedestrian collisions.Pregnant patients who present after blunt trauma with any of the identified risk factors for contractions, preterm labor, or fetal loss should be monitored for at least 24 hours. Patients without these risk factors can safely be monitored for 6 hours after trauma before discharge.

    View details for Web of Science ID 000088244600005

    View details for PubMedID 10912853

  • Special Problems in Laparoscopic Surgery: Previous Abdominal Surgery, Obesity and Pregnancy Surgical Clinics of North America Curet, M. 2000; 80: 1093-1110
  • Predictors of Outcome in Trauma During Pregnancy: Identificatin of Patients who can be Monitored for Less than Six Hours Journal of Trauma Curet MJ, Schermer CR, Demarest GB, Bieneik EJ, Curet LB 2000; 49: 18-25
  • Surgical Practice Patterns of Primary Care Physicians in a Rural State: Implications for Curriculum Design Family Medicine Curet MJ, McGrew M 2000; 32: 97-101
  • Laparoscopic management of gastric diverticula JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES-PART A Vogt, D. M., Curet, M. J., Zucker, K. A. 1999; 9 (5): 405-410

    Abstract

    Gastric diverticular are rare and usually are diagnosed incidentally on radiographic examination. Surgical treatment, consisting of simple excision or inversion of the diverticulum, has been reserved for patients with proven symptoms or complications. These procedures have typically required laparotomy, but with the development of advanced endoscopic techniques, a minimally invasive approach may be appropriate. The authors report two cases of gastric diverticula managed laparoscopically and review the literature related to this entity. Between 1993 and 1996, two patients were evaluated for dyspepsia-like gastrointestinal complaints. Both patients were found to have a gastric diverticulum on a contrast study, and one diverticulum was also seen on upper endoscopy. Laparoscopic resection was undertaken in both cases. Flexible gastroscopy was performed intraoperatively to help localize the diverticulum, which was resected with an endoscopic stapling device. Nissen fundoplication was performed in conjunction with the diverticulectomy in the second patient for gastroesophageal reflux. Both procedures were completed laparoscopically without complications. The postoperative course was uneventful in both patients. At long-term follow-up, the patients are asymptomatic. This experience indicates that laparoscopic resection of symptomatic gastric diverticula is a feasible alternative to laparotomy. A prospective analysis to verify the safety and efficacy of this procedure should be done.

    View details for Web of Science ID 000083049900005

    View details for PubMedID 10522535

  • University and practice based physicians' input on the content of a surgical curriculum AMERICAN JOURNAL OF SURGERY Curet, M. J., DaRosa, D., Mennin, S. 1999; 178 (1): 78-84

    Abstract

    The specific knowledge and skills students learn during surgical rotations are reconsidered in light of recent changes in medical school curricula. The purpose of this study was to determine the priorities of a surgical curriculum based on input from three groups; surgical faculty (SF), primary care faculty (PCF), and community-based , practicing primary care physicians (PCP).A questionnaire was developed in which SF (n=54), PCF (n=85), and PCP (n=876) were asked to rank the importance of 145 areas of knowledge and 48 areas of clinical skills on a 5-point Likert-type scale. Responses were rank ordered by the mean of importance ratings for each group. Differences among groups were evaluated using ANOVA.Response rates were best for faculty (100%) SF, 88% PCF, 61% PCP). All three groups were best considered general surgery related topics and general skills very important. Primary care physicians and PCF consistently ranked otolaryngology, ophthalmology, and orthopedic topics and skills higher than did SF. Surgery faculty ranked invasive surgical procedures higher than did PCP while PCP ranked orthopedic procedural skills more highly.There is significant overlap among physicians about what medical students should learn during surgical rotation. Differences between groups centered on surgical subspecialty knowledge and clinical skills. These results provide a broad perspective about required subjects for a core surgical clerkship curriculum, which should include surgical subspecialty training.

    View details for Web of Science ID 000081838600021

    View details for PubMedID 10484757

  • Laparoscopic reoperation for failed antireflux procedures ARCHIVES OF SURGERY Curet, M. J., Josloff, R. K., Schoeb, O., Zucker, K. A. 1999; 134 (5): 559-563

    Abstract

    Laparoscopic fundoplication has become the criterion standard for the surgical treatment of gastroesophageal reflux disease. Recently, several patients were referred with recurrent symptoms of gastroesophageal reflux disease or severe dysphagia following previous antireflux surgery for possible laparoscopic reoperation.To determine the safety and efficacy of this procedure.Case series, consecutive sample.University-affiliated and community tertiary care hospitals.Prospective study of 27 consecutive patients undergoing attempted laparoscopic reoperation for symptoms of recurrent gastroesophageal reflux disease or intractable dysphagia following antireflux surgery. Patients were available for follow-up for 1 to 60 months postoperatively.All patients underwent preoperative workup and attempted laparoscopic reoperation for treatment of symptoms.Data were collected on preoperative symptoms and evaluation, operative time, blood loss, time to regular diet, length of hospitalization, morbidity, mortality, and long-term results.Twenty-six patients underwent successful laparoscopic operations, with no mortality and minimal morbidity. One patient underwent conversion to open laparotomy and then developed a proximal gastric leak, which was treated conservatively. Twenty-four patients began a liquid diet by postoperative day 1, and most were discharged from the hospital by postoperative day 3. One patient required dilation for postoperative dysphagia. The remaining patients are doing well and none have required treatment with acid-reducing medication.Although technically challenging, laparoscopic reoperation for recurrent gastroesophageal reflux disease can be performed safely and with excellent results. In the hands of experienced endoscopic surgeons, patients who have undergone unsuccessful antireflux surgery should be offered laparoscopic reoperation.

    View details for Web of Science ID 000080173400020

    View details for PubMedID 10323431

  • University and Practice-based Physicians' Perspectives on the Content of a Surgical Curriculum American Journal of Surgery Curet MJ, DaRosa D, Mennin S 1999; 178: 78-84
  • Laparoscopic intraperitoneal onlay inguinal herniorrhaphy AMERICAN JOURNAL OF SURGERY Kingsley, D., Vogt, D. M., Nelson, M. T., Curet, M. J., Pitcher, D. E. 1998; 176 (6): 548-552

    Abstract

    This study presents intermediate follow-up data on a randomized prospective series of patients undergoing either a modified laparoscopic intraperitoneal onlay mesh herniorrhaphy (IPOM) or conventional anterior inguinal herniorrhaphy (CH).All patients from two university affiliated hospitals with primary or recurrent inguinal hernias were recruited for randomization to either the IPOM technique utilizing a meshed expanded polytetrafluorethylene (ePTFE) soft tissue patch or CH. Follow-up data were gathered from postoperative clinic visits and telephone and mail surveys.Previously reported early recurrence and complication rates at a mean follow-up of 8 months were 1 of 30 (3%) and 5 of 30 (17%) for IPOM, and 2 of 28 (7%) and 5 of 28 (18%) for CH. Intermediate follow-up with 50 (23 IPOM and 27 CH) of the original 58 patients (86%) at a mean of 41 months reveals a recurrence rate of 10 of 23 (43%) for the IPOM group and 4 of 27 (15%) for the CH group (P = 0.053). Five delayed complications occurred in 4 IPOM patients (port site hernia 4, painful neuroma 1), while 2 delayed complications (unilateral testicular atrophy 2) occurred in 2 patients in the CH group. One IPOM versus 5 CH patients subsequently developed previously unrecognized contralateral hernias. There was 1 death unrelated to previous herniorrhaphy in each group.IPOM recurrence rates (43%) at a mean follow-up of 41 months are excessively high when compared with CH (15%) or with preliminary results of IPOM at 8 months of follow-up (3%). Despite reduced perioperative pain and disability and promising preliminary results in the IPOM group, these intermediate follow-up data strongly suggest that the IPOM technique should not be used for repair of inguinal hernias.

    View details for Web of Science ID 000078160800033

    View details for PubMedID 9926788

  • Successful treatment of esophageal achalasia with laparoscopic Heller myotomy and Toupet fundoplication Vogt, D., Curet, M., Pitcher, D., JOSLOFF, R., Milne, R. L., Zucker, K. EXCERPTA MEDICA INC-ELSEVIER SCIENCE INC. 1997: 709-714

    Abstract

    Recently, investigators have reported the use of endoscopic myotomy in the treatment of esophageal achalasia. As with the open operation, considerable disagreement exists regarding the appropriate length of the myotomy and the need for a concomitant antireflux procedure.Patients presenting with symptomatic achalasia between 1993 and 1997 were included in this prospective study. Preoperative studies included barium upper gastrointestinal study, endoscopy, and esophageal manometry. Laparoscopic myotomy was completed in all 20 patients; 18 had concomitant Toupet fundoplication.Operative times ranged from 95 to 345 minutes (mean 216). Blood loss ranged from 50 to 300 cc (mean 100 cc). There were 7 minor complications (5 mucosal injuries repaired laparoscopically, 1 bile leak and 1 splenic capsular tear). Nine patients began a liquid diet on the first day postoperatively; 19 were tolerating liquids by postoperative day 3. Hospital stay ranged from 2 to 20 days (mean 5). Eighteen patients had complete relief of dysphagia, with less than one reflux episode per month. One individual continues to have mild persistent solid food dysphagia. Another patient initially did well but subsequently developed mild recurrent dysphagia and reflux. One patient required laparoscopic take-down of the wrap because of recurrent dysphagia and now has no problems swallowing, but does complain of mild reflux. Two other patients also have mild reflux, 1 of whom did not undergo fundoplication.Laparoscopic Heller myotomy can be performed safely with excellent results in patients with achalasia. Adding a partial fundoplication appears to help control postoperative symptoms of reflux. This procedure should be considered the procedure of choice in patients with symptomatic esophageal achalasia.

    View details for Web of Science ID A1997YK92000028

    View details for PubMedID 9409602

  • Adhesion formation in laparoscopic inguinal hernia repair SURGICAL ENDOSCOPY-ULTRASOUND AND INTERVENTIONAL TECHNIQUES Vader, V. L., Vogt, D. M., Zucker, K. A., Thilstead, J. P., Curet, M. J. 1997; 11 (8): 825-829

    Abstract

    In laparoscopic inguinal hernia repair controversy exists concerning the most appropriate repair method and implant material to use if intraabdominal adhesions are to be minimized.In 108 pigs, we implanted three different types of mesh by both the TAPP (transabdominal preperitoneal) and Onlay (prosthesis placed directly upon the peritoneum) methods. Specimens were harvested in three time periods and adhesion formation was compared.Average adhesions at 3 days were TAPP 18% and Onlay 49% (p < 0.001). At 3 weeks average adhesions were TAPP 8% and Onlay 23% (p < 0.04). Three-month figures were TAPP 1% and Onlay 13% (p < 0.001). In contrast, there were no differences in adhesion formation due to material type in any of the three time periods (all p > 0.17).A peritoneal covering over a laparoscopic inguinal implant significantly reduced adhesions. Prosthetic material type did not affect adhesion formation in this study.

    View details for Web of Science ID A1997XN75400009

    View details for PubMedID 9266644

  • Successful Treatment of Esophageal Achalasia with Laparoscopic Heller Myotomy and Toupet Fundoplication American Journal of Surgery Vogt DM, Curet MJ, Pitcher DE, Josloff RK, Zucker KA 1997; 174: 709-714
  • A comparison of the pathophysiologic effects of carbon dioxide, nitrous oxide, and helium pneumoperitoneum on intracranial pressure AMERICAN JOURNAL OF SURGERY Schob, O. M., Allen, D. C., Benzel, E., Curet, M. J., Adams, M. S., Baldwin, N. G., Largiader, F., Zucker, K. A. 1996; 172 (3): 248-252

    Abstract

    Previous studies have suggested that diagnostic laparoscopy may be contraindicated in multiple trauma patients with closed head injuries because of the detrimental effects of carbon dioxide (CO2) pneumoperitoneum on intracranial pressure (ICP). In this study we compared the effects of two alternative inflation gases, helium (He) and nitrous oxide (N2O), against the standard agent used in most hospitals, CO2. ICP was monitored in experimental animals both with and without a space occupying intracranial lesion designed to simulate a closed head injury.Twenty-four domestic pigs (mean, 30 kg) were divided into four groups (6 CO2, 6 He, 6 N2O, and 6 control animals without insufflation). All animals were monitored for ICP, intraabdominal pressure, mean arterial pressure, end-tidal CO2 (ETCO2), and arterial blood gases. These parameters were measured for 30 minutes prior to introducing a pneumoperitoneum and then for 80 minutes thereafter. The measurements were repeated after artificially elevating the ICP with a balloon placed in the epidural space.The mean ICP increased significantly in all groups during peritoneal insufflation compared with the control group (P < 0.005). The CO2-insufflated animals also showed a significant increase in PaCO2 (P < 0.05) and ETCO2 (P < 0.05), as well as a decrease in pH (P < 0.05). After inflating the epidural balloon the ICP remained significantly higher in animals inflated with CO2 as compared with the He and N2O groups (P < 0.05).Peritoneal insufflation with He and N2O resulted in a significantly less increase in ICP as compared with CO2. That difference was most likely due to a metabolically mediated increase in cerebral perfusion (PaCO2) in the CO2 group. Further studies need to be conducted to determine the safety and efficacy of using He and N2O as inflation agents prior to attempting diagnostic or therapeutic laparoscopy in patients with potential closed head injuries.

    View details for Web of Science ID A1996VK09500008

    View details for PubMedID 8862077

  • Effects of CO2 pneumoperitoneum in pregnant ewes Curet, M. J., Vogt, D. A., Schob, O., Qualls, C., Izquierdo, L. A., Zucker, K. A. ACADEMIC PRESS INC JNL-COMP SUBSCRIPTIONS. 1996: 339-344

    Abstract

    Laparoscopy has been considered a relative contraindication in pregnant patients because the CO2 pneumoperitoneum may cause maternal and/or fetal hypotension, acidosis, hypercarbia, hypoxia, changes in cardiac output, or uterine artery blood flow. These potential changes were studied in an established animal pregnancy model. Twelve gravid ewes (116-120 days gestation) underwent catheterization of maternal femoral artery and vein, fetal hindlimb artery and vein, insertion of a uterine artery flow probe, and pulmonary artery catheter. Six animals underwent creation of a CO2 pneumoperitoneum (10 mm Hg for 30 min; 15 mm Hg for 30 min). Six control animals were studied without a pneumoperitoneum. The following parameters were recorded at baseline and at preset time points: cardiac output (CO), uterine blood flow (UtBF), amniotic cavity pressure (ACP), end-tidal CO, (Et CO2), maternal and fetal heart rate (HR), blood pressure (BP), and lactate, glucose, and arterial blood gasses. Percent change at each time point compared to baseline was determined for each variable. Statistical significance was determined by repeated measures analysis of variance. No changes were found between study and control animals in maternal BP; CO; lactate, glucose, oxygenation, or fetal HR; oxygenation, lactate, or glucose. Statistically significant differences (P < 0.01) between study and control animals were noted in ACP, Et CO2, MHR, UtBF, FBP, and Maternal/fetal pH, PCO2. All ewes delivered healthy lambs at full gestation. A CO2 pneumoperitoneum up to 15 mm Hg pressure in gravid ewes causes increased intrauterine pressure, decreased UtBF, and induces maternal and fetal acidosis. Despite these intraoperative deleterious effects, long-term fetal well being was not effected.

    View details for Web of Science ID A1996UU47100061

    View details for PubMedID 8661222

  • Laparoscopy during pregnancy Curet, M. J., Allen, D., Josloff, R. K., Pitcher, D. E., Curet, L. B., MISCALL, B. G., Zucker, K. A. AMER MEDICAL ASSOC. 1996: 546-550

    Abstract

    To compare the safety and efficacy of laparoscopic surgery with that of open laparotomy in pregnant patients.Six-year case-control study.Tertiary care, university and community hospitals.Population-based sample. From 1990 through 1995, 16 pregnant patients underwent laparoscopic surgery (study group) and 18 underwent open laparotomy (control group) during the first or second trimester. Follow-up ranged from 1 month to 6 years.In the study group, 4 patients underwent appendectomies and 12 underwent cholecystectomies. The control group included 7 appendectomies and 11 cholecystectomies.The 2 groups were compared for age, trimester, surgical time, oxygen saturation, end-tidal carbon dioxide, return of gastrointestinal tract function, duration of intravenous or intramuscular narcotics, postoperative stay, gestational age of delivery, 1- and 5-minute Apgar scores, birth weights, and complications.Age, trimester, oxygenation, end-tidal CO2, gestational age at delivery, Apgar scores, and birth weights were not different between the 2 groups. The patients who underwent laparoscopy had significantly longer operative times 82 vs 49 minutes), shorter stay (1.5 vs 2.8 days), earlier resumption of regular diet (1.0 vs 2.4 days), and shorter duration of intravenous or intramuscular narcotics (1.2 vs 2.6 days) (all P < .01). Four complications were found in the laparotomy group vs 6 in the laparoscopy group.Laparoscopic surgery in pregnant women significantly decrease hospitalization, decreases narcotic use, and quickens return to a regular diet when compared with open laparotomy in pregnant women. No significant differences between the 2 groups in perioperative morbidity or mortality were present. These data suggest that therapeutic laparoscopy during pregnancy in the first or second trimester is safe.

    View details for Web of Science ID A1996UK35400028

    View details for PubMedID 8624203

  • Laparoscopy During Pregnancy Archives of Surgery Curet, M., Allen DC, Josloff RK, Pitcher DE, Curet LB, Miscall BG, Zucker KA 1996; 131: 546-551
  • SUCCESSFUL LAPAROSCOPIC REPAIR OF PARAESOPHAGEAL HERNIA Pitcher, D. E., Curet, M. J., Martin, D. T., Vogt, D. M., Mason, J., Zucker, K. A. AMER MEDICAL ASSOC. 1995: 590-596

    Abstract

    To evaluate prospectively the safety and efficacy of laparoscopic surgical techniques in the repair of types II and III paraesophageal hernias.Case series.Tertiary-care, university-affiliated hospitals.Twelve consecutive patients undergoing elective laparoscopic repair of type II or type III paraesophageal hernias. Patients were available for follow-up for 1 to 17 months postoperatively.All patients underwent laparoscopic paraesophageal hernia reduction and repair. Eight patients with gastroesophageal reflux disease underwent concurrent laparoscopic Nissen fundoplication.Operative times, operative complications, and estimated blood loss were recorded. Postoperative outcome measurements included length of hospital stay, postoperative complications, postoperative gastrointestinal tract symptoms, and patient satisfaction.All patients had successful completion of paraesophageal hernia repair laparoscopically with no recurrences, and with an overall minor morbidity rate of 25%, major morbidity rate of 8%, and no deaths. Eight of 12 patients with concomitant reflux disease underwent successful laparoscopic Nissen fundoplication with complete control of reflux symptoms. The average hospital stay for patients with uncomplicated courses was 2.5 days. Long-term (> 6 weeks) postfundoplication symptoms occurred in 13% of those patients who underwent fundoplication. Eleven (92%) of 12 patients described good to excellent results with complete or near complete control of all preoperative symptoms.Laparoscopic repair of types II and III paraesophageal hernias can be performed under elective circumstances by experienced laparoscopic surgeons, with acceptable morbidity and comparable short-term efficacy. Addition of a concomitant antireflux procedure should be reserved for those patients with clear preoperative evidence of reflux disease secondary to a mechanically defective lower esophageal sphincter. Patients with a normal lower esophageal antireflux barrier do not need a concomitant antireflux procedure.

    View details for Web of Science ID A1995RB45700005

    View details for PubMedID 7763166

  • LAPAROSCOPIC ANTEGRADE SPHINCTEROTOMY - A NEW TECHNIQUE FOR THE MANAGEMENT OF COMPLEX CHOLEDOCHOLITHIASIS ANNALS OF SURGERY Curet, M. J., Pitcher, D. E., Martin, D. T., Zucker, K. A. 1995; 221 (2): 149-155

    Abstract

    Laparoscopic antegrade sphincterotomy represents a new technique that expands the ability of the surgeon to manage complex choledocholithiasis at the time of laparoscopic cholecystectomy. The authors describe their experience with six patients with cholelithiasis and complex common bile duct stone disease who underwent successful laparoscopic cholecystectomy and antegrade sphincterotomies.Patients with complex choledocholithiasis have represented a technical challenge to the minimally invasive surgeon. Recently, a laparoscopic technique of antegrade biliary sphincterotomy has been reported by DePaulo in Brazil. This technique has been successful at clearing the common bile duct at the time of laparoscopic cholecystectomy.Laparoscopic antegrade sphincterotomy was performed in six patients with multiple common bile duct stones. A standard endoscopic sphincterotome was introduced antegrade via the cystic duct or common bile duct and guided through the ampulla. A side-viewing duodenoscope was used to confirm proper positioning of the sphincterotome. Then a blended current was applied until the sphincterotomy was complete.There was no mortality or morbidity associated with laparoscopic antegrade sphincterotomy. The mean additional operative time to complete laparoscopic antegrade sphincterotomy was 19 minutes. Three of the six patients were noted to have transient, asymptomatic elevation in serum amylase levels immediately after surgery (average 252 international units/L; normal < 115), which normalized within 72 hours. The mean postoperative hospital stay was 2.9 days. At a mean follow-up of 5 months (range 1 to 10 months), five patients remain asymptomatic. One individual with acquired immune deficiency syndrome had persistent symptoms, and a diagnosis of cytomegalovirus pancreatitis was eventually made.Laparoscopic antegrade sphincterotomy appears to be a safe and effective technique for the management of complex biliary tract disease.

    View details for Web of Science ID A1995QF80800004

    View details for PubMedID 7857142

  • PRELIMINARY-RESULTS OF A PROSPECTIVE RANDOMIZED TRIAL OF LAPAROSCOPIC ONLAY VERSUS CONVENTIONAL INGUINAL HERNIORRHAPHY Vogt, D. M., Curet, M. J., Pitcher, D. E., Martin, D. T., Zucker, K. A. EXCERPTA MEDICA INC-ELSEVIER SCIENCE INC. 1995: 84-90

    Abstract

    To compare laparoscopic onlay hernia repair with conventional surgery, 61 patients were randomized to either open or laparoscopic surgery.Traditional repairs were done according to the surgeons' preference. Laparoscopic repairs utilized a modified onlay technique with a meshed prototype prosthesis.Mean operative time was 62.5 minutes for the laparoscopic group and 80.9 minutes for the open group. Each group had five complications. There were two conversions from laparoscopic to open surgery. Individuals undergoing laparoscopic surgery reported a mean intake of 5 doses of an oral narcotic analgesic versus 16 doses in the open group. Return to normal activity (nonstrenuous) was 7.5 days in the laparoscopic group and 18.5 days in the open group. After a mean follow-up of 8 months (range 1 to 14), there have been two recurrences in the open group and one in the laparoscopic group.Laparoscopic onlay inguinal herniorrhaphy is a viable alternative for those who prefer a minimally invasive treatment for this disease.

    View details for Web of Science ID A1995QA17600012

    View details for PubMedID 7818003

  • SUCCESSFUL MANAGEMENT OF SEVERE GASTROESOPHAGEAL REFLUX DISEASE WITH LAPAROSCOPIC NISSEN FUNDOPLICATION Pitcher, D. E., Curet, M. J., Martin, D. T., Castillo, R. R., GERSTENBERGER, P. D., Vogt, D., Zucker, K. A. CAHNERS PUBL CO. 1994: 547-554

    Abstract

    Nissen fundoplication has been shown to be superior to medical treatment in the management of severe or complicated gastroesophageal reflux disease (GERD). Rapid advances in minimally invasive surgical technique and recognition of the advantages of reduced incision-related morbidity have fostered application of laparoscopic techniques to antireflux surgery. A prospective evaluation of 70 patients undergoing laparoscopic Nissen fundoplication for severe GERD was undertaken.Rigid selection criteria for laparoscopic Nissen fundoplication included severe or refractory disease with documentation of abnormal esophageal acid exposure by 24-hour pH probe monitoring, documentation of a mechanically defective lower esophageal sphincter by esophageal manometry, and absence of severe esophageal and/or gastric motility disorders.Sixty-eight of 70 patients were completed laparoscopically with an intraoperative morbidity rate of 9%. Major postoperative complications occurred in 3 patients (4%) and included deep venous thrombosis (n = 1), delayed gastric leak (n = 1), and trocar site hernia (n = 1). The average hospital stay was 3.0 days, and the average time to return to normal activity was 7.0 days. All patients experienced relief of symptoms of reflux with mean follow-up of 7.7 months. Transient, mild dysphagia was experienced by 37% of patients, and persistent, severe dysphagia by 7%. The mean increase in lower esophageal sphincter pressure was 16.2 mm Hg. The total and intra-abdominal sphincter lengths increased an average of 1.5 and 1.4 cm, respectively.These preliminary data suggest that laparoscopic Nissen fundoplication can be performed by experienced laparoscopic surgeons with excellent symptomatic and physiologic results and a morbidity rate comparable to conventional open antireflux procedures. Rigid patient selection criteria will help identify the patients most likely to benefit from reconstruction of a mechanically defective lower esophageal sphincter. Adherence to established operative principles for Nissen fundoplication will reduce the incidence of significant postfundoplication symptoms.

    View details for Web of Science ID A1994PU97500008

    View details for PubMedID 7977994

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