A left circum-aortic renal vein aneurysm.

Am J Surg. 2010 Sep;200(3):e37-e38

Authors: Lin TC, Lin CM, Chang HC, Kao CC, Sun GH, Cha TL

A well-defined, slow-flowing vascular lesion was found incidentally by Doppler abdominal sonography in the left renal hilar region of a 36-year-old Taiwanese woman. Clinically, the physical examination and laboratory screening were unremarkable. A magnetic resonance angiography of the area near the renal hilum showed a saccular mass (3.5 x 3.1 x 2.5 cm) embracing the aorta by the anterior and posterior branch of the aneurysm originating from the left renal vein to the inferior vena cava. However, the patient refused further invasive intervention and has since been examined periodically by ultrasonography for 18 months without increasing size or symptoms.

PMID: 20800712 [PubMed - as supplied by publisher]

Eversion endarterectomy of the internal carotid artery combined with open endarterectomy of the common carotid artery.

Am J Surg. 2010 Sep;200(3):e44-e47

Authors: Sterpetti AV

The author presents a technique for endarterectomy and reconstruction of the carotid bifurcation in difficult cases when the plaque extends high into the internal carotid artery. The technique combines the aspects of the 2 most commonly performed procedures: carotid endarterectomy after a longitudinal arteriotomy extending from the common carotid artery into the internal carotid artery and eversion endarterectomy in which the plaque is removed from the internal carotid artery sectioned from the common carotid artery and everted. The author suggests applying this technique selectively in patients in whom the atherosclerotic plaque extends very high into the internal carotid artery. The technique offers the advantages of removing the plaque into the common carotid artery under direct vision and leaving the original dimensions and geometry of the internal carotid artery, theoretically decreasing the probability of early thrombosis and recurrent carotid disease. For routine cases, the author prefers and recommends standard carotid bifurcation endarterectomy with patch closure when the size of the arteries is reduced like in women and selected male patients.

PMID: 20800713 [PubMed - as supplied by publisher]

Post-appendectomy visits to the emergency department within the global period: a target for cost containment.

Am J Surg. 2010 Sep;200(3):357-362

Authors: Aiello FA, Gross ER, Krajewski A, Fuller R, Morgan A, Duffy A, Longo W, Kozol R, Chandawarkar R

BACKGROUND: Postoperative visits to the emergency department (ED) instead of the surgeon’s office consume enormous cost. HYPOTHESIS: Postoperative ED visits can be avoided. SETTING: Fully accredited, single-institution, 617-bed hospital affiliated with the University of Connecticut School of Medicine. PATIENTS: Retrospective analysis of 597 consecutive patients with appendectomies over a 4-year period. METHODS: Demographic and medical data, at initial presentation, surgery, and ED visit were recorded as categorical variables and statistically analyzed (Pearson chi(2) test, Fisher exact test, and linear-by-linear). Costs were calculated from the hospital’s billing department. RESULTS: Forty-six patients returned to the ED within the global period with pain (n = 22, 48%), wound-related issues (n = 6, 13%), weakness (n = 4, 9%), fever (13%), and nausea and vomiting (n = 3, 6%). Thirteen patients (28%) required readmission. Predictive factors for ED visit postoperatively were perforated appendicitis (2-fold increase over uncomplicated appendicitis) and comorbidities (cardiovascular or diabetes). The cost of investigations during ED visits was $55,000 plus physician services. CONCLUSIONS: ED visits during the postoperative global period are avoidable by identifying patients who may need additional care; improving patient education, optimizing pain control, and improving patient office access.

PMID: 20800714 [PubMed - as supplied by publisher]

The use of laparoscopic surgery in pregnancy: evaluation of safety and efficacy.

Am J Surg. 2010 Sep;200(3):363-367

Authors: Corneille MG, Gallup TM, Bening T, Wolf SE, Brougher C, Myers JG, Dent DL, Medrano G, Xenakis E, Stewart RM

BACKGROUND: Laparoscopic surgery in pregnant women has become increasingly more common since the 1990s; however, the safety of laparoscopy in this population has been widely debated, particularly in emergent and urgent situations. METHODS: A retrospective chart review of all pregnant women following a nonobstetric abdominal operation at a University hospital between 1993 and 2007. Perioperative morbidity and mortality for the mother and fetus were evaluated. RESULTS: Ninety-four subjects were identified; 53 underwent laparoscopic procedures and 41 underwent open procedures. Cholecystectomy and appendectomy were performed in both groups with salpingectomy/ovarian cystectomy only in the laparoscopic group. No maternal deaths occurred, while fetal loss occurred in 3 cases within 7 days of the operation and in 1 case 7 weeks postoperatively. This and other perinatal complications occurred in 36.7% of the laparoscopic group and 41.7% of the open group. CONCLUSION: Laparoscopic appendectomy and cholecystectomy appear to be as safe as the respective open procedures in pregnant patients; however, this population in particular remains at risk for perinatal complications regardless of the method of abdominal access.

PMID: 20800715 [PubMed - as supplied by publisher]

The clinical impact and outcomes of immunohistochemistry-only metastasis in breast cancer.

Am J Surg. 2010 Sep;200(3):368-373

Authors: Pugliese M, Stempel M, Patil S, Hsu M, Ho A, Traina T, Morrow M, Cody H, Gemignani ML

BACKGROUND: Modern surgical and pathological techniques can detect small-volume axillary metastases in breast cancer with unknown clinical significance. METHODS: A retrospective database review from 1996 through 2004 identified all patients with immunohistochemical (IHC)-only sentinel node (IHC-SN) metastases and compared them with negative controls (Neg-SN). RESULTS: When comparing the 232 IHC-SN patients with the 252 Neg-SN controls, the IHC-SN patients had larger tumors, more lobular histology, a higher grade, and more HER2/neu positivity. They also received more systemic therapy. With a median follow-up of 5 years, there were no differences in recurrence-free survival or overall survival. In 123 IHC-SN patients treated with axillary dissection (axillary lymph node dissection), 16% had positive non-SLNs. Patients with positive non-SLNs tended to have worse outcomes. CONCLUSIONS: IHC-only sentinel lymph node (SLN) metastases were associated with worse prognostic features and higher rates of systemic therapy. However, no outcomes differences were noted.

PMID: 20800716 [PubMed - as supplied by publisher]

Parenteral nutrition: a clear and present danger unabated by tight glucose control.

Am J Surg. 2010 Sep;200(3):386-390

Authors: Matsushima K, Cook A, Tyner T, Tollack L, Williams R, Lemaire S, Friese R, Frankel H

BACKGROUND: The infectious risks of parenteral nutrition (PN) in critical illness are well described, although most literature predates tight glucose control (TGC) practice. The authors hypothesized that PN-related complications are ameliorated by TGC and are equivalent to those in enteral nutrition (EN) patients. METHODS: A prospective cohort study of patients admitted to the surgical intensive care unit was conducted, comparing PN and EN patients. TGC target was 80 to 110 mg/dL. Univariate and multivariate logistic regression was used to explore the association between infectious outcomes and PN use. RESULTS: One hundred fifty-five patients were studied. Mean daily glucose values were lower for the PN group than for the EN patients (118.2 vs 125.6 mg/dL, P = .002). Nonetheless, the incidence of bloodstream infection and catheter-related bloodstream infection was significantly associated with the administration of PN. In a multivariate logistic regression model, PN was associated with a >4-fold increase in the odds of having a catheter-related bloodstream infection (odds ratio, 4.48; 95% confidence interval, 1.14-17.49; P = .03). CONCLUSIONS: Despite the successful implementation of TGC, PN is still a significant risk factor for infectious complications among surgical intensive care unit patients.

PMID: 20800717 [PubMed - as supplied by publisher]

Biomechanical analysis of polypropylene prosthetic implants for hernia repair: an experimental study.

Am J Surg. 2010 Sep;200(3):406-412

Authors: Sergent F, Desilles N, Lacoume Y, Tuech JJ, Marie JP, Bunel C

BACKGROUND: Although polypropylene (PP) is the most common biomaterial used for ventral and inguinal hernia repairs, its mechanical properties remain obscure. METHODS: Retraction, solidity, and elasticity of 3 large pore-size monofilament PP prostheses, 1 heavy-weight PP (HWPP), a second low-weight PP, and a third coated with atelocollagen were evaluated in a rabbit incisional hernia model. A small pore-size multifilament PP implant (MPP) also was tested. RESULTS: Unlike pore size, the weight of the prosthesis was not an influencing factor for retraction. Atelocollagen coating reduced retraction (P < .05). HWPP and MPP were less likely to rupture (P < .05). HWPP had comparatively better elasticity (P < .05), whereas MPP supported the greatest elastic force (P < .05). Nevertheless, the amount of shrinkage of MPP (30% of the original size) made this prosthesis unusable. CONCLUSIONS: In this study, HWPP presented the most advantageous biomechanical compromise for hernia surgery.

PMID: 20800718 [PubMed - as supplied by publisher]

Invited commentary on “Duration of deep vein thrombosis prophylaxis in the surgical patient and its relation to quality issues” by Muntz.

Am J Surg. 2010 Sep;200(3):422-3

Authors: Clements RH

PMID: 20800719 [PubMed - in process]

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Evaluation of a new ultrasonic device in thyroid surgery: comparative randomized study.

Am J Surg. 2010 Jun;199(6):736-40

Authors: Miccoli P, Materazzi G, Miccoli M, Frustaci G, Fosso A, Berti P

BACKGROUND: Conventional techniques for hemostasis during thyroidectomy rely on knot tying, clips, and electrocoagulation. Recently, the Harmonic FOCUS Shear (Ethicon Endo-Surgery, Inc, Cincinnati, OH) was developed for thyroidectomy. METHODS: Between December 2007 and March 2008, 62 consecutive patients (45 women, 17 men; mean age 50.9 years) undergoing thyroidectomy were randomized into 2 groups: group A, where the FOCUS was used, and group B, where electrocoagulation and clamp-and-tie technique were used. RESULTS: The 2 groups were similar in terms of age, sex ratio, indication for surgery, and thyroid volume. Operative time was significantly shorter in group A. Significantly fewer clips and ties were used, and postoperative pain and suction balloon amount were also significantly lower in the FOCUS group. The only postoperative complication was a patient with transient hypocalcemia in group B. CONCLUSIONS: FOCUS is a reliable and safe tool for thyroidectomy. Its utilization is associated with a shorter operative time, less blood loss, and less postoperative pain.

PMID: 20609718 [PubMed - indexed for MEDLINE]

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Femoral vessel blood flow dynamics following totally extraperitoneal vs Stoppa procedure in bilateral inguinal hernias.

Am J Surg. 2010 Jun;199(6):741-5

Authors: Ozmen M, Zulfikaroglu B, Ozalp N, Moran M, Soydinc P, Ziraman I

BACKGROUND: Both totally extraperitoneal (TEP) and open preperitoneal (Stoppa) procedures involve the placement of prosthetic material preperitoneally. Because the prosthetic material overlies the femoral artery and vein, the aim of this study was to assess its effect on the velocities and diameters of the artery and vein using color Doppler ultrasonography in both approaches. METHODS: Sixty-four patients with bilateral groin hernias were prospectively randomized to undergo either TEP (n = 32) or Stoppa (n = 32) repair. All patients underwent color Doppler ultrasound 6 months after the procedures, and the median follow-up period was 18 months. RESULTS: Neither mean diameter nor mean flow velocity was changed by the insertion of the mesh preperitoneally. The only change was observed in peak systolic femoral arterial blood velocity, which was significantly decreased in the Stoppa group. Also, no patient in this study developed clinically significant deep venous thrombosis during 6 months of follow-up. CONCLUSIONS: The insertion of a prosthetic mesh during TEP and Stoppa procedures does not influence the mean peak flow velocities and cross-sectional areas of the vessels in the inguinal region and can be used safely for open and laparoscopic preperitoneal approaches.

PMID: 20609719 [PubMed - indexed for MEDLINE]

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Structured operative reporting: a randomized trial using dictation templates to improve operative reporting.

Am J Surg. 2010 Jun;199(6):846-50

Authors: Gillman LM, Vergis A, Park J, Minor S, Taylor M

BACKGROUND: Few studies have addressed the quality of dictated operative reports (ORs). This study documents changes in resident dictation after the introduction of a standardized OR template. METHODS: Twenty residents dictated an OR based on a surgical procedure video. Residents were randomized to receive an OR template or no intervention. Residents dictated another report 3 months later. Outcomes measures were dictation quality using a previously validated tool and resident comfort with dictation. RESULTS: There was no overall difference in quality in the intervention group as measured by the Structured Assessment Form (SAF) (28.6 vs 30.0, P = .36) and Global Quality Ratings Scale (GQRS) (21.7 vs 21.8, P = .96). However, junior resident subgroup analysis revealed an improvement in the intervention group on both the SAF (23.2 vs 28.3, P = .02) and GQRS (17.1 vs 20.4, P = .02). Subjective comfort level improved in the intervention group (P = .02). CONCLUSIONS: The operative dictation template can significantly improve resident comfort level with dictation and has the potential to improve the quality of junior resident dictations.

PMID: 20609727 [PubMed - indexed for MEDLINE]

Ileoileal intussusception due to ileal ectopic pancreas with abundant fat tissue mimicking lipoma.

Am J Surg. 2010 Aug;200(2):e25-e27

Authors: Chuang MT, Tsai KB, Ma CJ, Hsieh TJ

A 26-year-old woman presented with symptoms of bowel obstruction. An emergent computed tomography (CT) scan was performed which showed ileoileal intussusceptions due to a fatty nodule. Exploratory laparotomy and removal of the involved small bowel was performed. The pathology showed the leading point of the intussusception to be ectopic pancreas with abundant fatty infiltration.

PMID: 20678617 [PubMed - as supplied by publisher]

Racial disparities in motorcycle-related mortality: an analysis of the National Trauma Data Bank.

Am J Surg. 2010 Aug;200(2):191-196

Authors: Crompton JG, Pollack KM, Oyetunji T, Chang DC, Efron DT, Haut ER, Cornwell EE, Haider AH

BACKGROUND: Studies have shown racial disparities in outcomes after motor vehicle crashes; however, it is currently unknown if race impacts the likelihood of mortality after a motorcycle crash (MCC). The primary objective of this study was to determine if race is associated with MCC mortality. METHODS: We performed a retrospective cross-sectional analysis of MCCs included in the National Trauma Data Bank between 2002 and 2006. Multiple logistic regression was used to adjust for age, sex, insurance status, year, helmet use, and injury severity characteristics. RESULTS: Black patients had a 1.58 (95% confidence interval, 1.28-1.97) increased odds of mortality after a MCC, but were more likely to use a helmet (1.30; 95% confidence interval, 1.19-1.43) compared with their white counterparts (n = 62,840). CONCLUSIONS: Black motorcyclists appear more likely to die after a MCC compared with whites. Although the reasons for this disparity are unclear, these data suggest that resources beyond encouraging helmet use are necessary to reduce fatalities among black motorcyclists.

PMID: 20678618 [PubMed - as supplied by publisher]

Surgical treatment in Paget’s disease of the breast.

Am J Surg. 2010 Aug;200(2):241-246

Authors: Siponen E, Hukkinen K, Heikkilä P, Joensuu H, Leidenius M

BACKGROUND: The aim of this study was to evaluate the outcomes of surgical treatment of Paget’s disease of the breast, with special emphasis on magnetic resonance imaging (MRI) and sentinel node biopsy (SNB). METHODS: The study included 58 consecutive patients with Paget’s disease treated from 1995 to 2006. RESULTS: Twenty-five patients had ductal carcinoma in situ, and 31 had invasive carcinoma. MRI was performed in 14 patients, with positive findings in 7 patients, 5 of whom had negative findings on conventional imaging. The overall mastectomy rate was 76%. Eighteen patients underwent SNB, and 26 patients underwent full or partial axillary clearance. Fourteen patients had no axillary surgery. One patient had local recurrence after breast conservation, and another had axillary recurrence after negative results on SNB. Six patients had distant metastases. Four patients died of breast cancer. CONCLUSIONS: Paget’s disease is frequently associated with peripheral or multicentric cancer. MRI may be helpful when considering breast conservation or omitting axillary nodal staging.

PMID: 20678619 [PubMed - as supplied by publisher]

Indications and results for transduodenal sphincteroplasty in the era of endoscopic sphincterotomy.

Am J Surg. 2010 Aug;200(2):247-251

Authors: Miccini M, Bonapasta SA, Gregori M, Bononi M, Fornasari V, Tocchi A

BACKGROUND: Transduodenal sphincterotomy (TS) has fallen into disuse since endoscopists developed techniques to treat sphincter problems nonsurgically. However, some patients experience recurrent sphincter strictures after endoscopic sphincterotomy (ES), with the ampulla endoscopically inaccessible, and pancreas divisum (PD); these patients are referred to a surgeon because they are unsuitable for ES. METHODS: The medical records of patients who underwent TS at the First Department of Surgery of the Medical School, University of Rome “La Sapienza,” between January 1997 and December 2005 were reviewed. A total of 82 patients, including 47 women and 35 men with a mean age of 47 years (range, 26-67 y), underwent TS in our unit in the aforementioned period. Previous unsuccessful endoscopic retrograde cholangiography and ES were the indications for TS in 44 patients, and previous gastric surgery with duodenal bypass was the indication for TS in 21 patients. Five patients underwent TS because of a PD and 10 because of the intraoperative findings of daughter hydatid cysts in the common bile duct and of a wide communication between the cyst cavity and the intrahepatic biliary tree. Two patients were referred to our institution after a surgical papillotomy performed elsewhere. Symptoms included abdominal pain in 100% of patients, nausea and/or vomiting in 78% of patients, and referred back pain in 56% of patients. Acute pancreatitis was present in the history of 26 patients, including 23 with previous ES. All patients underwent TS. Sphincteroplasty of the accessory papilla was performed in all patients with PD. Cornerstones of a successful TS are depicted. RESULTS: Asymptomatic hyperamylasemia was observed in 37 patients, and cholangitis and pancreatitis, which was resolved with conservative management, occurred in 2 patients. One patient developed an intra-abdominal abscess that was treated with image-guided percutaneous drainage. No perioperative deaths occurred in this series. The mean length of follow-up evaluation was 84.4 months (range, 16-115 mo). Good results were achieved in 53 patients (73.6%), fair results in 17 patients (23.6%), and poor results in 2 patients (2.7%). Both patients with poor results required reoperation because of recurrent pancreatitis and pancreatic pseudocyst. CONCLUSIONS: TS still represents, although undoubtedly with updated indications compared with the past, a surgical procedure that must be up to date, ensuring absolutely satisfactory results.

PMID: 20678620 [PubMed - as supplied by publisher]

Laparoscopic versus open mesh repair for recurrent inguinal hernia: a meta-analysis of outcomes.

Am J Surg. 2010 Aug;200(2):291-297

Authors: Dedemadi G, Sgourakis G, Radtke A, Dounavis A, Gockel I, Fouzas I, Karaliotas C, Anagnostou E

BACKGROUND: The objective of this study was to examine the outcomes of comparisons between laparoscopic and open mesh repairs in the setting of recurrent inguinal hernia. METHODS: The electronic databases MEDLINE, Embase, Pubmed, and the Cochrane Library were used to search for articles from 1990 to 2008. The present meta-analysis pooled the effects of outcomes of a total of 1,542 patients enrolled into 5 randomized controlled trials and 7 comparative studies, using classic and modern meta-analytic methods. RESULTS: Significantly fewer cases of hematoma/seroma formation were observed in the laparoscopic group in comparison with the Lichtenstein group (odds ratio, .38; .15-.96; P = .04). A matter of great importance is the higher relative risk of overall recurrence in the transabdominal preperitoneal group compared with the totally extraperitoneal group (relative risk, 3.25; 1.32-7.9; P = .01). CONCLUSIONS: Laparoscopic versus open mesh repair for recurrent inguinal hernia was equivalent in most of the analyzed outcomes.

PMID: 20678621 [PubMed - as supplied by publisher]

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Panel discussion for symposium on safety and quality improvement in specialty surgery in smaller hospitals.

Am J Surg. 2010 Jul;200(1):e1-e14

Authors: McCafferty M, Shively E, Cronen P

PMID: 20637327 [PubMed - in process]

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Papillary carcinoma arising in subhyoid ectopic thyroid gland with no orthotopic thyroid tissue.

Am J Surg. 2010 Jul;200(1):e17-e18

Authors: Sevinç AI, Unek T, Canda AE, Guray M, Kocdor MA, Saydam S, Harmancıoglu O

Ectopic thyroid gland with no orthotopic thyroid tissue is extremely rare. The authors present a case of a follicular variant of papillary carcinoma developed from an ectopic thyroid gland with no orthotopic thyroid tissue.

PMID: 20637328 [PubMed - as supplied by publisher]

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Bile leak test by indocyanine green fluorescence images after hepatectomy.

Am J Surg. 2010 Jul;200(1):e19-e23

Authors: Sakaguchi T, Suzuki A, Unno N, Morita Y, Oishi K, Fukumoto K, Inaba K, Suzuki M, Tanaka H, Sagara D, Suzuki S, Nakamura S, Konno H

Bile leak remains a serious complication after hepatectomy. The conventional leak test by intrabiliary injection of normal saline solution is not sensitive. The authors present a new bile leak test using indocyanine green (ICG) fluorescence. After hepatic transection, ICG solution (.05 mg/mL) was intrabiliarily injected through a transcystic tube under distal common bile duct clamping, and fluorescent images were visualized using an infrared camera system. The ICG leak test was performed in 27 patients undergoing hepatectomy without biliary reconstruction. Bile leaks were intraoperatively found in 8 patients and fixed, resulting in no postoperative leaks. There was no adverse reaction to ICG. In contrast, postoperative bile leaks occurred in 2 of 32 patients who received the conventional leak test with normal saline solution between April 2007 and March 2008. The new bile leak test by ICG fluorography is useful to prevent postoperative bile leak.

PMID: 20637329 [PubMed - as supplied by publisher]

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Consensus statement on the adoption of the COPE guidelines.

Am J Surg. 2010 Jul;200(1):1

Authors:

PMID: 20637330 [PubMed - in process]

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Incisional hernia repair by fascial component separation: results in 128 cases and evolution of technique.

Am J Surg. 2010 Jul;200(1):2-8

Authors: Clarke JM

BACKGROUND: Most ventral incisional hernias are repaired using 1 of 2 principal techniques: (1) prosthetic repair (open or laparoscopic) and (2) primary reconstruction by fascial component separation. Primary midline restoration provides physiological advantages, and avoidance of mesh may reduce complications. This report describes 128 cases of incisional hernia repair by fascial release. Evolution of the technique produced modifications and fewer complications. METHODS: Fascial component separation was performed either by “classic” technique (broad skin flaps) in group 1 and by “perforator preservation” (fascial release through separate inferolateral incisions) in group 2. RESULTS: Mortality was .75% (1/128). Major complications occurred in 7 patients (5.5%). Total recurrence rate is 16% (21/128) with major recurrences in 9.3% (12/128). Both groups were statistically equivalent in demographics, comorbidities, and recurrences. Group 1 had significantly higher rates of skin necrosis (P < .001) and chronic pain (P = .003). CONCLUSIONS: Fascial component separation can provide satisfactory results in uncomplicated incisional hernias, but skin necrosis is prohibitive without perforator preservation.

PMID: 20637331 [PubMed - as supplied by publisher]

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Randomized comparison of Limberg flap versus modified primary closure for the treatment of pilonidal disease.

Am J Surg. 2010 Jul;200(1):9-14

Authors: Muzi MG, Milito G, Cadeddu F, Nigro C, Andreoli F, Amabile D, Farinon AM

BACKGROUND: The best surgical technique for sacrococcygeal pilonidal disease is still controversial. The aim of this randomized prospective trial was to compare both the results of Limberg flap procedure and primary closure. METHODS: A total of 260 patients with sacrococcygeal pilonidal disease were assigned randomly to undergo Limberg flap procedure or tension-free primary closure. RESULTS: Success of surgery was achieved in 84.62% of Limberg flap patients versus 77.69% of primary closure (P = .0793). Surgical time for primary closure was shorter. Wound infection was more frequent in the primary closure group (P = .0254), which experienced less postoperative pain (P < .0001). No significant difference was found in time off from work (P = .672) and wound dehiscence. Recurrence was observed in 3.84% versus 0% in the primary closure versus Limberg flap group (P = .153). CONCLUSIONS: Our results do not show a clear benefit for surgical management by Limberg flap or primary closure. Limberg flap showed less convalescence and wound infection; our technique of tension-free primary closure was a day case procedure, less painful, and shorter than Limberg flap.

PMID: 20637332 [PubMed - as supplied by publisher]

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Long-term results after surgical treatment of nonparasitic hepatic cysts.

Am J Surg. 2010 Jul;200(1):23-31

Authors: Loehe F, Globke B, Marnoto R, Bruns CJ, Graeb C, Winter H, Jauch KW, Angele MK

BACKGROUND: Studies evaluating surgical success in patients with benign liver cysts focus on cyst recurrence. The aim of this study was to evaluate the efficacy of surgical treatment with regard to clinical complaints. MATERIALS AND METHODS: Between 1995 and 2007, 99 patients (M:F 1:7.25) with symptomatic, benign, nonparasitic liver cysts (77 simple liver cysts [SLCs], 22 polycystic liver disease [PCLD]) underwent surgical treatment (77% laparoscopic surgery, 23% open surgery). Perioperative parameters (including morbidity) were evaluated. Moreover, a questionnaire was completed by 65 patients monitoring subjective complaints focusing on abdominal pain, vegetative symptoms, and dyspnea pre- and postoperatively (mean follow-up 76 months). RESULTS: Severe complications occurred in 7 patients. Abdominal pain, vegetative symptoms, and dyspnea were significantly improved in SLC patients. In PCLD patients abdominal pain and dyspnea were significantly decreased, whereas vegetative symptoms were unaffected by surgery. The symptom recurrence rate for SLC patients was significantly lower compared with PCLD patients (41% vs 66.6%). CONCLUSION: Indications for surgical treatment of PCLD should be well considered and limited to a selected group of patients.

PMID: 20637333 [PubMed - as supplied by publisher]

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Trends, outcomes, and predictors of open and conversion to open cholecystectomy in Veterans Health Administration hospitals.

Am J Surg. 2010 Jul;200(1):32-40

Authors: Kaafarani HM, Smith TS, Neumayer L, Berger DH, Depalma RG, Itani KM

BACKGROUND: Laparoscopic cholecystectomy (LC) accounts for more than 85% of cholecystectomies. Factors prompting open cholecystectomy (OC) or conversion from LC to OC (CONV) are not completely understood. METHODS: Prospectively collected data from the National Surgical Quality Improvement Program (NSQIP) were combined with administrative data to identify patients undergoing cholecystectomy from October 2005 to October 2008. Three cohorts were defined: LC, OC, and CONV. Using logistic hierarchical modeling, we identified predictors of the choice of OC and the decision to CONV. RESULTS: A total of 11,669 patients underwent cholecystectomy at 117 VA hospitals, including 9,530 LC (81.7%). While the rate of conversion from LC to OC remained stable over the study period (9.0% overall), the percentage of OC decreased from 11.5% in 2006 to 10.1% in 2007 and 8.9% in 2008 (P = .0002). Compared with LC, the OC cohort had more comorbidities (35 of 41 preoperative characteristics, all P <.05), a higher 30-day morbidity rate (18.7% vs 4.8%. P <.0001), and a higher 30-day mortality rate (2.4% vs .4%, P <.0001). American Society of Anesthesiologist (ASA) class, patient comorbidities (eg, ascites, bleeding disorders, pneumonia) and functional status predicted a choice of OC. Age, preoperative albumin, previous abdominal surgery and emergency status predicted OC and CONV (all P <.05). A higher hospital conversion rate was independently predictive of OC (odds ratio [1% rate increase]: 1.05 [1.02-1.07]; P = .0004). CONCLUSION: In the last 3 years, there has been a trend towards performing fewer OCs in VA hospitals. More patient comorbidities and higher hospital-level conversion rates are predictive of the choice to perform or convert to OC.

PMID: 20637334 [PubMed - in process]

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Serum thyroglobulin is a poor diagnostic biomarker of malignancy in follicular and Hurthle-cell neoplasms of the thyroid.

Am J Surg. 2010 Jul;200(1):41-46

Authors: Suh I, Vriens MR, Guerrero MA, Griffin A, Shen WT, Duh QY, Clark OH, Kebebew E

BACKGROUND: Serum thyroglobulin (Tg) is the most accurate biomarker for thyroid cancer recurrence. However, some clinicians measure preoperative Tg as a diagnostic cancer marker despite lack of supporting evidence. We examined whether Tg accurately predicts malignancy in follicular or Hürthle-cell neoplasms. METHODS: We reviewed 366 patients who underwent thyroidectomies for follicular/Hürthle-cell neoplasms. We compared Tg in malignant versus benign tumors by univariate and receiver-operator characteristic analyses. We also examined several Tg-derived indices that normalized Tg to known confounding factors including nodule size, thyroid function, and type of Tg assay. RESULTS: Thirty-nine patients met inclusion criteria for analysis. There were no differences between malignant (n = 16) and benign (n = 23) lesions in Tg or any of the normalized indexes. Receiver-operator characteristic analysis revealed an area under the curve of .59. Lesions with Tg levels greater than 500 mug/L had a positive predictive value of .75. CONCLUSIONS: Tg has poor accuracy for predicting malignancy in follicular or Hürthle-cell thyroid neoplasms.

PMID: 20637335 [PubMed - as supplied by publisher]

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A correlation between polyomavirus JC virus quantification and genotypes in renal transplantation.

Am J Surg. 2010 Jul;200(1):53-58

Authors: Yin WY, Lu MC, Lee MC, Liu SC, Lin TY, Lai NS

OBJECTIVE: To determine whether the John Cunningham virus (JCV) viral load and the multigenotypes in viruria are correlated with transplant patients. METHODS: The urine of 60 renal transplant patients and 60 healthy controls were screened. We used quantitative real-time polymerase chain reaction and capillary electrophoresis to assess viral load and genotype respectively. RESULTS: The incidence of viruria and viral load were higher in transplant patients with P = .0092 and P = .0094, respectively. The incidence of different genotype in transplant patients versus controls was 8.3% versus 13.3% for single genotype, 26.7% versus 5% for 2 genotypes, and 5% versus 0% for multigenotypes (P = .0004). The incidence of more than 2 genotypes was high in people with a high viral load and closely related with the transplant patients (P = .007). CONCLUSIONS: Not only viral load but also genotypes are important as a screening parameter to understand the immune milieu of the patients to prevent subsequent complications like polyomavirus nephropathy, infection, and malignancy.

PMID: 20637336 [PubMed - as supplied by publisher]

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Outpatient surgery performed in an ambulatory surgery center versus a hospital: comparison of perioperative time intervals.

Am J Surg. 2010 Jul;200(1):64-67

Authors: Trentman TL, Mueller JT, Gray RJ, Pockaj BA, Simula DV

BACKGROUND: In 2005, the authors’ ambulatory surgery center (ASC) was closed, and the breast operations performed there were integrated into the hospital. This change allowed a comparison of perioperative time intervals for patients undergoing these procedures at an outpatient facility versus a hospital. METHODS: The records of 92 patients who underwent breast operations at the ASC between January 2004 and December 2005 were compared with those of 92 patients who underwent outpatient breast operations at the hospital starting January 2006. Anesthetic techniques, recovery room events, and perioperative time intervals were analyzed. RESULTS: Age and recovery room times were similar. Complications were negligible at both facilities. The preoperative, operating room entry to incision, and total facility time intervals significantly increased when breast cases were moved back to the hospital setting. CONCLUSIONS: These data demonstrate significantly shorter perioperative time intervals at the ASC. Incorporating time-saving practices from the outpatient setting could contribute to greater hospital productivity.

PMID: 20637337 [PubMed - as supplied by publisher]

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Influence of stapler size used at ileal pouch-anal anastomosis on anastomotic leak, stricture, long-term functional outcomes, and quality of life.

Am J Surg. 2010 Jul;200(1):68-72

Authors: Kirat HT, Kiran RP, Lian L, Remzi FH, Fazio VW

BACKGROUND: The aim of this study was to evaluate whether stapler size used at ileal pouch-anal anastomosis (IPAA) influences outcomes. METHODS: Data of patients undergoing stapled IPAA (1983-2007) were obtained. Differences between groups A (stapler size 28-29 mm) and B (31-33 mm) for pre- and perioperative factors, stricture, leak, quality of life (QOL), and function were compared. Associations between stapler size and stricture or leak were assessed with a multivariable Cox model. RESULTS: Groups A (n = 1,221) and B (n = 899) had comparable age, diagnosis, body mass index (BMI), and albumin level. Group B had more males (P < .001) but fewer patients with ileostomy (P < .001). There was no significant difference in rates of leak (4.5% vs 6.2%, P = .08) or stricture (1.9% vs 2.7%, P = .1) for groups A and B. On multivariate analysis, female gender was associated with stricture, while greater BMI and male gender were associated with leak. Group A had greater urgency at 1 year and nighttime pad use at 15 years. The other determinants of function and QOL were similar. CONCLUSIONS: There was no significant association between the size of stapler used at IPAA and long-term complications.

PMID: 20637338 [PubMed - as supplied by publisher]

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Introduction: safety and quality improvement in specialty surgery in smaller hospitals.

Am J Surg. 2010 Jul;200(1):81

Authors: Polk HC

PMID: 20637339 [PubMed - in process]

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A situational overview of surgical quality and safety in 2010.

Am J Surg. 2010 Jul;200(1):82-89

Authors: Polk HC, Tyson MB, Galandiuk S

BACKGROUND: Surgical safety and quality initiatives have now moved to the front of the agenda for contemporary surgery. METHODS: Sixty-two surgical specialists began to study quality and cost control in 1998, and those efforts grew into a Centers for Medicare and Medicaid Services-funded pilot study of the Surgical Care Improvement Project in 2004. Subsequent symposia and studies evolved. RESULTS: A greater awareness of the issues and methods for meaningful improvement of surgical safety in nearly 25,000 specialty surgeries have been described in numerous peer-reviewed publications. CONCLUSIONS: Surgeon-initiated efforts have led to marked improvements in multiple specialties and in many small and large hospitals and academic training centers.

PMID: 20637340 [PubMed - as supplied by publisher]

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A closer look at surgical quality measures across different surgical specialties.

Am J Surg. 2010 Jul;200(1):90-96

Authors: Watkins JM, Qadan M, Battista C, Polk HC

BACKGROUND: Most studies of surgical quality improvement have been performed in large and/or teaching hospitals; the efficacy of safety and quality efforts in smaller hospitals have not been reported. METHODS: Four smaller hospitals joined a collaborative to study process measures through an expanded surgical time-out and some outcomes. The data were collected in real time. RESULTS: Well-performing hospitals (all 4) improved further but variably. Gynecologic and orthopedic surgeons performed more consistently in most measures than did general surgeons. CONCLUSIONS: These small hospitals readily accepted a time-out-based real-time data collection and with their surgical staff improved in most parameters.

PMID: 20637341 [PubMed - as supplied by publisher]

Related Articles

Standards of surgery beyond metropolitan centers: a fresh look at perioperative quality measures in small-town America.

Am J Surg. 2010 Jul;200(1):97-104

Authors: Cronen P, Qadan M, Hicks NZ, Polk HC

BACKGROUND: Surgical quality measures have room for improvement in both large- and small-town hospitals. METHODS: We sought concurrence of surgical specialists (general, orthopedic, gynecologic) to study accepted quality and safety parameters using a surgical time-out-based platform. RESULTS: Surgeons and hospitalists participated promptly and actively and recorded enhanced performance measures compared with prior work and within the period of study. Practice patterns varied, and interchange among participating hospitals was helpful. CONCLUSIONS: Smaller institutions are more nimble than larger ones and developed interchangeable ideas for improvement. Surgical process measures improved such that all 4 hospitals are concerned about and committed to maintaining the gains.

PMID: 20637342 [PubMed - as supplied by publisher]

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Virtual partnerships: aligning hospital and surgeon incentives.

Am J Surg. 2010 Jul;200(1):105-110

Authors: Fry DE, Pine M, Pine G

BACKGROUND: Payment schemes exist for health care in the United States that are perverse and, in many cases, antithetical to the goals of all concerned. A fundamental reorganization will be required if care is to be broadened and sensible economies achieved. METHODS: For some time, we have experimented intellectually with reorganization of the specialist/hospital axis in contemporary medical care, seeking a more functional relationship among the parties (ie, doctors, nurses, hospitals, and their patients). RESULTS: A virtual partnership between surgical specialists and the hospital provides many of the favored factors for productive and mutually respected care for patients with a feasible method for limiting costs. CONCLUSIONS: A virtual partnership, as exemplified for 3 major surgeries, could create a relationship that benefits the patient, the surgical specialist, the hospital, and the ethical payer.

PMID: 20637343 [PubMed - as supplied by publisher]

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Bacterial translocation and infected pancreatic necrosis in acute necrotizing pancreatitis derives from small bowel rather than from colon.

Am J Surg. 2010 Jul;200(1):111-117

Authors: Fritz S, Hackert T, Hartwig W, Rossmanith F, Strobel O, Schneider L, Will-Schweiger K, Kommerell M, Büchler MW, Werner J

BACKGROUND: The clinical course of acute necrotizing pancreatitis (ANP) is determined by the superinfection of pancreatic necrosis. To date, the pathophysiology of the underlying bacterial translocation is poorly understood. The present study investigated the bacterial source of translocation. METHODS: A terminal loop ileostomy was applied in rats. Selective digestive decontamination (SDD) of either the small bowel or the colon was performed. After 3 days of SDD, severe ANP was induced. At 24 hours, bacterial translocation was assessed by cultures of bowel mucosa, mesenteric lymph nodes, and pancreas using a scoring system (0-4). RESULTS: Without SDD, pancreatic infection was present in all cases with an average score of 2.67. Colon SDD reduced pancreatic superinfection to 1.67 (not significant). SDD of the small bowel significantly reduced superinfection to 1.0 (P < .005). CONCLUSIONS: Bacterial translocation from the colon is less frequent than translocation from the small bowel. Thus, the small bowel seems to be the major source of enteral bacteria in infected pancreatic necrosis.

PMID: 20637344 [PubMed - as supplied by publisher]

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Preventing intraperitoneal adhesions with atorvastatin and sodium hyaluronate/carboxymethylcellulose: a comparative study in rats.

Am J Surg. 2010 Jul;200(1):118-123

Authors: Lalountas MA, Ballas KD, Skouras C, Asteriou C, Kontoulis T, Pissas D, Triantafyllou A, Sakantamis AK

OBJECTIVES: The aim of this study was to compare the effectiveness of atorvastatin with the sodium hyaluronate/carboxymethylcellulose (HA/CMC, Seprafilm; Genzyme; Genzyme Biosurgery Corporation, Cambridge, MA) in preventing postoperative intraperitoneal adhesion formation in rats. METHODS: Sixty Wistar rats underwent a laparotomy, and adhesions A were induced by cecal abrasion. The animals were divided into 4 groups: group 1, control A; group 2, (A + atorvastatin); group 3, (A + HA/CMC), and group 4, (A + atorvastatin + HA/CMC). The atorvastatin (groups 2 and 4) and HA/CMC (groups 3 and 4) were administered intraperitoneally before the abdominal wall was closed. After 14 days, adhesions were classified by 2 independent surgeons. RESULTS: The adhesion scores (mean +/- standard deviation) for groups 1, 2, 3, and 4 were 2.93 +/- .59, 1.85 +/- 1.07, 1.80 +/- .86, and 1.93 +/- .70, respectively. The differences in adhesion scores among all 3 preventive groups (groups 2, 3, and 4) were statistically significant when compared with the control group (P = .005, P = .002, and P = .009, respectively). CONCLUSIONS: These data suggest that atorvastatin, administered intraperitoneally, is as effective as HA/CMC without an expectable additive effect in preventing postoperative adhesions in rats.

PMID: 20637345 [PubMed - as supplied by publisher]

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Surgical implications of B-Raf(V600E) mutation in fine-needle aspiration of thyroid nodules.

Am J Surg. 2010 Jul;200(1):136-143

Authors: Mekel M, Nucera C, Hodin RA, Parangi S

BACKGROUND: Management of patients with thyroid nodules is based on establishing an accurate diagnosis; however, differentiating benign from malignant lesions preoperatively is not always possible using current cytological techniques. Novel molecular testing on cytological material could lead to clearer treatment algorithms. B-Raf(V600E) mutation is the most common genetic alteration in thyroid cancer, specifically found in papillary thyroid cancer (PTC), and usually reported to be associated with aggressive disease. DATA SOURCE: A literature search using PubMed identified all the pertinent literature on the identification and utilization of the B-Raf(V600E) mutation in thyroid cancer. CONCLUSIONS: The utility of using B-Raf mutation testing for nodules with indeterminate cytology is limited since many of those nodules (benign and malignant) do not harbor B-Raf mutations. However, when the pathologist sees cytological features suspicious for PTC, B-Raf(V600E) mutation analysis may enhance the assessment of preoperative risks for PTC, directing a more aggressive initial surgical management when appropriate.

PMID: 20637346 [PubMed - as supplied by publisher]

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Elective laparoscopic sigmoid resection for diverticular disease has fewer complications than conventional surgery: a meta-analysis.

Am J Surg. 2010 Jul;200(1):144-161

Authors: Siddiqui MR, Sajid MS, Qureshi S, Cheek E, Baig MK

BACKGROUND: We performed a meta-analysis of published literature comparing the complications after open and laparoscopic elective sigmoidectomy for diverticular disease. METHODS: Electronic databases were searched from January 1991 to March 2009. A systematic review was performed to obtain a summative outcome. RESULTS: Nineteen comparative studies involving 2,383 patients were analyzed. There were 1,014 patients in the laparoscopic group and 1,369 patients in the open group. There was no significant heterogeneity among any of the complications analyzed. Patients in the laparoscopic sigmoid resection group had fewer wound infections (fixed effects model: risk ratio [RR], .54; 95% confidence interval [CI], .36-.80; z, -3.05; P < .01; random effects model: RR, .59; 95% CI, .39-.89; z, -2.54; P < .05), blood transfusions (fixed effects model: RR, .25; 95% CI, .10-.60; z, -3.10; P < .01; random effects model: RR, .28; 95% CI, .11-.68; z, -2.81; P < .01), and ileus rates (fixed effects model: RR, .37; 95% CI, .20-.66; z, -3.34; P = .001; random effects model: RR, .37; 95% CI, .20-.68; z, -3.21; P = .001) compared with open sigmoid resections. No difference was seen for medical complications, need for rehospitalization, and reoperation. CONCLUSIONS: Laparoscopic sigmoid resection is safe and has fewer postoperative surgical complications. This approach should be considered for elective cases, however, more randomized controlled trials are required to strengthen the evidence.

PMID: 20637347 [PubMed - as supplied by publisher]

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The use of a lightly preserved cadaver and full thickness pig skin to teach technical skills on the surgery clerkship-a response to the economic pressures facing academic medicine today.

Am J Surg. 2010 Jul;200(1):162-166

Authors: Dimaggio PJ, Waer AL, Desmarais TJ, Sozanski J, Timmerman H, Lopez JA, Poskus DM, Tatum J, Adamas-Rappaport WJ

BACKGROUND: In response to declining instruction in technical skills, the authors instituted a novel method to teach basic procedural skills to medical students beginning the surgery clerkship. METHODS: Sixty-three medical students participated in a skills training laboratory. The first part of the laboratory taught basic suturing skills, and the second involved a cadaver with pig skin grafted to different anatomic locations. Clinical scenarios were simulated, and students performed essential procedural skills. RESULTS: Students learned most of their suturing skills in the laboratory skills sessions, compared with the emergency room or the operating room (P = .01). Students reported that the laboratory allowed them greater opportunity to participate in the emergency room and operating room. Students also felt that the suture laboratory contributed greatly to their skills in wound closure. Finally, 90% of students had never received instruction on suturing, and only 12% had performed any procedural skills before beginning the surgery rotation. CONCLUSIONS: The laboratory described is an effective way of insuring that necessary technical skills are imparted during the surgery rotation.

PMID: 20637348 [PubMed - as supplied by publisher]

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Educational value of the operating room experience during a core surgical clerkship.

Am J Surg. 2010 Jul;200(1):167-172

Authors: Irani JL, Greenberg JA, Blanco MA, Greenberg CC, Ashley S, Lipsitz SR, Hafler JP, Breen E

BACKGROUND: The amount and content of medical student teaching in the operating room and its alignment with clerkship goals was unknown. METHODS: A qualitative research design using field observations, followed by qualitative and quantitative data coding and analysis. RESULTS: A mean of 9.8% of the total case time (range 1.6%-20.2%) was spent teaching clerkship goals. Teaching strategies based on basic principles of learning were used during a mean of 66% of the total case time (range 30%-99%). The most common teaching strategy was active student participation (28%) followed by command (14%) and lecture (13%). Educational experience in the OR was rated 4.0 (out of 5) by faculty and 3.3 by students. No correlation existed between student satisfaction and time actively participating in the operation or time spent teaching to clerkship goals (P = .66, P = .95, respectively). CONCLUSION: Teaching in the OR is more focused on technical aspects of the operation than the goals of a core surgery clerkship.

PMID: 20637349 [PubMed - as supplied by publisher]

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Morphea of the breast-an uncommon cause of breast erythema.

Am J Surg. 2010 Jul;200(1):173-176

Authors: Clark CJ, Wechter D

BACKGROUND: Breast-associated morphea (BAM) can mimic benign and malignant inflammatory breast disorders. The aim of the current study was to document our experience with this rare sclerosing dermatologic disorder. METHOD: We conducted a retrospective study at a single institution of all patients who had pathological diagnosis of morphea between January 1995 and October 2007. RESULTS: We identified 15 patients with pathological evidence of morphea involving the breast. Two thirds of these patients were initially misdiagnosed with inflammatory breast cancer or breast infections. While 2 patients had previous exposure to external beam radiation, the remaining patients had no identifiable predisposing risk factors. BAM resulted in limited morbidity and did not result in significant disfiguration. Treatment included topical steroids, topical calcineurin inhibitor, and surgical excision. CONCLUSIONS: Our experience with BAM emphasizes the benefit of early tissue biopsy in patients with unexplained breast erythema to confirm a clinical diagnosis and thus guide subsequent therapeutic interventions.

PMID: 20637350 [PubMed - as supplied by publisher]

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Retrieval of immature oocytes from unstimulated ovaries followed by in vitro maturation and vitrification: A novel strategy of fertility preservation for breast cancer patients.

Am J Surg. 2010 Jul;200(1):177-183

Authors: Huang JY, Chian RC, Gilbert L, Fleiszer D, Holzer H, Dermitas E, Elizur SE, Gidoni Y, Levin D, Son WY, Tan SL

BACKGROUND: We report a novel fertility preservation strategy that may be useful for young breast cancer patients who present with time constraints or concerns about the effect of ovarian stimulation. METHODS: The protocol involves retrieval of immature oocyte from unstimulated ovaries followed by in vitro maturation (IVM), and vitrification of oocytes or embryos. RESULTS: Thirty-eight patients (age 24-45 years) underwent vitrification of oocytes (n = 18) or embryos (n = 20). The mean ages were 33.1 +/- 5.0 years and 34.7 +/- 4.8 years, respectively. The mean days required to complete the egg collection was 13 days. The median numbers of vitrified oocytes and embryos per retrieval were 7 (range 1-22) and 4 (range 1-13), respectively. CONCLUSIONS: The strategy of immature oocyte retrieval without ovarian stimulation followed by IVM and oocyte or embryo vitrification, which does not increase the serum estradiol level and delay cancer treatment, represents an attractive option of fertility preservation for many breast cancer patients.

PMID: 20637351 [PubMed - as supplied by publisher]

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Optimal trocar placement for ergonomic intracorporeal sewing and knotting in laparoscopic hiatal surgery.

Am J Surg. 2010 Jul 15;

Authors: Fingerhut A, Hanna GB, Veyrie N, Ferzli G, Millat B, Alexakis N, Leandros E

BACKGROUND: Trocar placement presently is mostly empiric. Our goal was to define simple distances from bony landmarks to locate the optimal ergonomic placement of manipulation trocars for access to the lower esophagus and hiatal orifice, for suture placement, and knotting of the gastric fundus and crura. Hypothesizing that the ideal ergonomic principles of a manipulation angle of 60 degrees , an elevation angle (alpha(e)) of 30 degrees to 60 degrees , and an intracorporeal/extracorporeal length ratio (I/E) of working instruments close to 1:1 are interrelated by simple trigonometric functions, the variations of each of these parameters were calculated in a dependent manner for 2 standard lengths of needle holders: 48.5 cm and 58.5 cm. RESULTS: Trocar placement can be calculated easily according to simple formulas dependent on the alpha(e), the distance from the sternoxiphoid junction to the median of the intertrocar span (d) and the vertical distance from the stenoxiphoid junction to the average distance between the apex of the hiatal orifice and the anterior aspect of the esophagus (XH’): when the alpha(e) is 30 degrees : d is XH’ radical2 and when alpha(e) is 45 degrees , d is XH’/ radical2. Likewise, when alpha(e) is 30 degrees the intertrocar span (LR) is 2XH’, half on either side of the optical axis (d), and when alpha(e) is 45 degrees , LR is XH’ radical2, XH’/ radical2 on either side of the optical axis. The most ergonomic solution is to work with an alpha(e) of 40 degrees to 45 degrees by placing the 2 working (manipulation) trocars, between 10 and 14 cm caudad from the sternoxiphoid junction, between 10 and 12 cm on either side of the longitudinal axis corresponding to the optic-target axis. The shorter needle holder works best in this configuration because the I/E ratio will be between .8 and 1. If, however, the surgeon wants to work with an alpha(e) closer to 30 degrees , then the longer needle holder should be used, and the trocars should be placed between 20 and 21 cm from the sternoxiphoid junction, 14.5 to 15 cm on either side of the optical axis. The I/E ratio will vary between 1 and 1.1. When a 1/1 I/E ratio was prioritized, the alpha(e) would be 40 degrees and 32 degrees , for the shorter and longer instruments, respectively. The deeper crural closure requires increasing the alpha(e) by 2 degrees and 3 degrees , respectively. Hyperlordosis, as obtained by placing a cushion under the patient’s back, shortens the distances, allowing placement of the trocars closer to the sternoxiphoid junction. CONCLUSIONS: Based on ergonomic principles (manipulation angle, 60 degrees ; alpha(e), 40 degrees -45 degrees ; and an I/E ratio of working instruments, close to 1:1), simple trigonometric considerations allow easy calculation of the ideal placement of trocars corresponding to working instruments in hiatal surgery necessary for ergonomic dissection, suturing, and intracorporeal knotting. Ideal trocar placement is dependent only on the vertical depth of the target organ.

PMID: 20638045 [PubMed - as supplied by publisher]

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Collagen in the transversalis fascia of patients with inguinal hernia.

Am J Surg. 2010 Jul 12;

Authors: Pascual G, Bellón JM

PMID: 20630494 [PubMed - as supplied by publisher]

Perioperative synbiotic treatment to prevent infectious complications in patients after elective living donor liver transplantation. A prospective randomized study.

Am J Surg. 2010 Jul 7;

Authors: Eguchi S, Takatsuki M, Hidaka M, Soyama A, Ichikawa T, Kanematsu T

BACKGROUND: Although the effect of synbiotic therapy using prebiotics and probiotics has been reported in hepatobiliary surgery, there are no reports of the effect on elective living-donor liver transplantation (LDLT). METHODS: Fifty adult patients undergoing LDLT between September 2005 and June 2009 were randomized into a group receiving 2 days of preoperative and 2 weeks of postoperative synbiotic therapy (Bifidobacterium breve, Lactobacillus casei, and galactooligosaccharides [the BLO group]) and a group without synbiotic therapy (the control group). Postoperative infectious complications were recorded as well as fecal microflora before and after LDLT in each group. RESULTS: Only 1 systemic infection occurred in the BLO group (4%), whereas the control group showed 6 infectious complications (24%), with 3 cases of sepsis and 3 urinary tract infections with Enterococcus spp (P = .033 vs BLO group). No other type of complication showed any difference between the groups. CONCLUSIONS: Infectious complications after elective LDLT significantly decreased with the perioperative administration of synbiotic therapy.

PMID: 20619394 [PubMed - as supplied by publisher]

Determinants of outcome in elderly patients with positive sentinel lymph nodes.

Am J Surg. 2010 Jul 7;

Authors: Karam AK, Hsu M, Patil S, Stempel M, Traina TA, Ho AY, Cody HS, Morrow M, Gemignani ML

BACKGROUND: Older women are less likely to receive standard of care treatment for breast cancer. METHODS: We examined variables that affected the outcome of elderly patients >/=70 years old among 1,470 patients with invasive cancer with positive sentinel lymph nodes (SLNs). RESULTS: Elderly patients were less likely to undergo mastectomy, completion axillary node dissection (ALND), adjuvant chemotherapy, and radiotherapy (RT) following breast-conserving therapy (BCT) compared with patients <70 years old. The 5-year risk of disease progression and cumulative incidence of breast cancer-specific deaths were not significantly different for both groups. On multivariate analysis, hormone receptor-negative status, number of metastatic lymph nodes, high nuclear grade, and tumor size were the factors independently associated with increased risk of disease progression. CONCLUSIONS: Tumor factors were the primary determinants of breast cancer outcomes in our cohort. Elderly patients are less likely to receive aggressive surgical interventions and adjuvant therapy because of perceived life expectancy.

PMID: 20619395 [PubMed - as supplied by publisher]

Development of a simple model for predicting need for surgery in patients who initially undergo conservative management for adhesive small bowel obstruction.

Am J Surg. 2010 Jun 28;

Authors: Komatsu I, Tokuda Y, Shimada G, Jacobs JL, Onodera H

BACKGROUND: Among patients with adhesive small bowel obstruction (ASBO) initially managed with a conservative strategy, predicting risk of operation is difficult. METHODS: We investigated ASBO patients at 2 different periods to derive and validate a clinical prediction model for risk of operation. RESULTS: One hundred fifty-four patients were enrolled into the derivation cohort and 96 into the validation cohort. Based on the derived scoring, including age >/=65 years, presence of ascites, and gastrointestinal drainage volume >500 mL on day 3, each patient was classified into 1 of 4 risk classes from low risk to high risk. When applied to the validation cohort, the positive predictive value (PPV) for operation in the high-risk class was 72%, while the negative predictive value (NPV) in the low-risk class was 100% with high sensitivity (100%) and specificity (96%). CONCLUSIONS: The prediction model performs well for risk stratification of need for surgical intervention following conservative strategy among ASBO patients.

PMID: 20591400 [PubMed - as supplied by publisher]

Biological scaffolds in reparative surgery for abdominal wall hernias.

Am J Surg. 2010 Jun 28;

Authors: López-Cano M, Armengol-Carrasco M

PMID: 20591401 [PubMed - as supplied by publisher]

Commentary for an evidence-based medicine review of lymphadenectomy extent for gastric cancer.

Am J Surg. 2010 Jun 28;

Authors: Yang SH, Zhang YC

PMID: 20591402 [PubMed - as supplied by publisher]

Re: A historic perspective on the contributions of surgeons to the understanding of acute pancreatitis.

Am J Surg. 2010 Jun 28;

Authors: Mier J

PMID: 20591403 [PubMed - as supplied by publisher]

Re: how to avoid unnecessary laparotomies in iatrogenic bile duct injuries?

Am J Surg. 2010 Jun 28;

Authors: Nuzzo G, Giuliante F, Ardito F, Vellone M, Giovannini I

PMID: 20591404 [PubMed - as supplied by publisher]

Requirement and postoperative outcomes of abdominal panniculectomy alone or in combination with other procedures in a bariatric surgery unit.

Am J Surg. 2010 Jun 28;

Authors: Ortega J, Navarro V, Cassinello N, Lledó S

BACKGROUND: A high percentage of patients present with redundant skin folds after bariatric surgery. This study aims to quantify the need for panniculectomy after open bariatric surgery and to analyze the postoperative outcomes. METHODS: A retrospective cohort study was performed. The patients were divided into 2 groups: group DLP, patients who underwent an abdominal panniculectomy alone and group DLP+, those who underwent panniculectomy in association with another surgical procedure. RESULTS: Four hundred forty-six patients underwent open bariatric surgery and 130 patients (29%) subsequently required an abdominal dermolipectomy. Seventy-six percent presented also incisional hernia and 8% presented cholelithiasis. Forty-six percent of patients presented postoperative complications: wound seroma/infection (21%), wound dehiscence due to skin necrosis (13%), and hemorrhage/hematoma (10%) were the most frequent. There were no major complications or mortality. DLP+ was not associated with an increase in complications. CONCLUSIONS: After open bariatric surgery, an abdominal panniculectomy is often required. This procedure has a high postoperative morbidity in these patients, although complications are usually mild. There is not an increase in the rate of complications when panniculectomy is associated with other procedures.

PMID: 20591405 [PubMed - as supplied by publisher]

The omentum is a site of stromal cell-derived factor 1alpha production and reservoir for CXC chemokine receptor 4-positive cell recruitment.

Am J Surg. 2010 Jun 28;

Authors: Saqib NU, McGuire PG, Howdieshell TR

BACKGROUND: The mechanism of the omental response to injury remains poorly defined. This study investigates the omental reaction to a foreign body, examining the role of a chemokine ligand/receptor pair known to play a crucial role in angiogenesis and wound healing. METHODS: A ventral hernia, surgically created in the abdominal wall of 6 swine, was repaired with silicone sheeting to activate the omentum. Omental thickness was determined by ultrasonography. Serial stromal cell-derived factor 1alpha (SDF-1alpha) concentrations were measured in blood, wound, and peritoneal fluids by enzyme-linked immunosorbent assay. RESULTS: During the 14-day study period, serial ultrasonography showed a 20-fold increase in omental thickness, and enzyme-linked immunosorbent assay revealed a 4-fold increase in SDF-1alpha concentration in local wound fluid. Omental vessel count and vascular surface area were 8- to 10-fold higher in reactive omentum. Immunohistochemistry showed nearly complete replacement of control omental fat with CXC chemokine receptor 4 (CXCR4)-positive cells by day 14. CONCLUSIONS: Activated omentum, important in the SDF-1alpha/CXCR4 axis, may serve as an intraperitoneal reservoir for recruitment of circulating bone marrow-derived cells vital to healing.

PMID: 20591406 [PubMed - as supplied by publisher]

A vanishing species.

Am J Surg. 2010 Jun 28;

Authors: Morgenstern L

PMID: 20591407 [PubMed - as supplied by publisher]

Patient attitudes to surgeons’ attire in an outpatient clinic setting: substance over style.

Am J Surg. 2010 Jun 28;

Authors: Edwards RD, Saladyga AT, Schriver JP, Davis KG

BACKGROUND: It is believed that patients prefer that surgeons convey a professional appearance with traditional business attire and white laboratory coat. We performed a prospective study to assess patient opinions regarding traditional attire versus the wearing surgical scrubs in the outpatient setting. METHODS: During a 5-month period, surgeons alternated wearing traditional clothing and surgical scrubs. Adult patients were given a questionnaire assessing their preferences regarding surgeons’ clothing. RESULTS: Six hundred twelve patients returned the questionnaire. The majority felt that scrubs were appropriate attire for physicians. Half of the patients felt that wearing white laboratory coats is necessary. A minority felt that their surgeon’s dress affects their opinion regarding the care they received. There was no difference between responses regardless of the attire actually worn. CONCLUSIONS: Surgeon’s clothing choice does not significantly influence patient’s opinion of the care they receive. Patients do not have strong preferences for white coats or more traditional surgical attire.

PMID: 20591408 [PubMed - as supplied by publisher]

Visfatin and gallstone disease.

Am J Surg. 2010 Jun 24;

Authors: Dogru T, Kara M, Ercin CN, Meral C, Erdem G

PMID: 20579969 [PubMed - as supplied by publisher]

Preoperative platelet-lymphocyte ratio in resected pancreatic ductal carcinoma: is it meaningful?

Am J Surg. 2010 Jun 24;

Authors: Domínguez I, Castillo CF

PMID: 20579970 [PubMed - as supplied by publisher]

Outcome of oncoplastic breast surgery in 90 prospective patients.

Am J Surg. 2010 Jun 21;

Authors: Meretoja TJ, Svarvar C, Jahkola TA

BACKGROUND: Oncoplastic breast surgery refers to a wide range of techniques with a parallel goal of safely removing all malignant breast tissue while achieving the best possible esthetic outcome. We report the results of our oncoplastic breast operations from 2005 to 2007. METHODS: Ninety selected breast cancer patients were treated with a variety of oncoplastic operations. The patients were prospectively monitored. Radiotherapy and systemic adjuvant treatment were given according to national guidelines. RESULTS: Fifteen patients had an immediate surgical complication, of which 8 required a reoperation. Eleven patients had an inadequate surgical margin and required a completion mastectomy. During a median follow-up of 26 months no local or regional recurrences were noticed. Three patients developed distant metastases. CONCLUSIONS: Oncoplastic breast surgery offers tools for breast conservation in patients otherwise destined for mastectomy or poor esthetic outcome. Despite the high proportion of patients in this series with large-volume ductal carcinoma in situ (DCIS) or extensive intraductal component, the use of oncoplastic techniques achieved negative margins with acceptable cosmetic results in the majority (84%) of patients.

PMID: 20573334 [PubMed - as supplied by publisher]

Compliance with guidelines to prevent surgical site infections: As simple as 1-2-3?

Am J Surg. 2010 Jun 21;

Authors: Meeks DW, Lally KP, Carrick MM, Lew DF, Thomas EJ, Doyle PD, Kao LS

BACKGROUND: The purpose of this study was to assess predictive factors and compliance with surgical site infection (SSI) prevention guidelines at 2 county hospitals. DESIGN: Chart review and analysis of laparotomy patients undergoing colorectal, hysterectomy, or abdominal vascular procedures over two 6-month periods 1 year apart and evaluation of safety climate using the Safety Attitudes Questionnaire (SAQ). RESULTS: Overall compliance with all antibiotic prophylaxis guidelines was 62% (n = 442). Gynecologic surgery was an independent predictor of compliance with antibiotic prophylaxis guidelines in elective cases, and nonemergency status was an independent predictor when all cases were considered. Postoperative normothermia was predicted by hospital, procedure length, initial intraoperative temperature, and service. The SAQ had a 91% response rate. Contrary to expected, safety domain scores and agreement with statements on collaboration and teamwork were not predictive of compliance. CONCLUSION: Interventions to improve poor compliance with infection prevention guidelines must be multifaceted, hospital- and service-specific, and resilient during emergencies. Good safety and teamwork climate are not sufficient.

PMID: 20573335 [PubMed - as supplied by publisher]

Operative performance in laparoscopic cholecystectomy using the Procedural-Based Assessment tool.

Am J Surg. 2010 Jun 21;

Authors: Sarker SK, Maciocco M, Zaman A, Kumar I

AIMS: The Intercollegiate Surgical Curriculum Project (ISCP) has devised assessment tools for index operations to assess trainee technical skills. In this study we used the Procedural-Based Assessment (PBA) tool to evaluate operations performed by trainees. METHODS: Live and simulated laparoscopic cholecystectomies were performed by trainees. Two experienced surgeons assessed each operation blindly and independently. RESULTS: Eighty-four live (supervised) and 112 simulated (unsupervised) operations were performed by 28 trainees. Mean inter-rater reliability was kappa = .86 and .84 for live and simulated operations, respectively. Construct validity using Mann-Whitney for generic technical skills was significant for live and simulated operations, P </= .05. Assessing specific technical skills showed construct validity for simulated unsupervised operations only, Mann-Whitney P < .05, but not for supervised live operations, Mann-Whitney P > .05. CONCLUSIONS: The PBA showed good inter-rater reliability. Assessing generic technical skills, PBA showed construct validity for both types of operations and for specific technical skills in the unsupervised simulated operations. We conclude that the PBA seems to be a reliable and valid assessment tool for generic technical skills in unsupervised simulated and live supervised laparoscopic cholecystectomies.

PMID: 20573336 [PubMed - as supplied by publisher]

A five year Canadian laparoscopic adjustable gastric band experience.

Am J Surg. 2010 May;199(5):690-4

Authors: Swanson TW, Tang BQ, Rusnak CH, Schaeffer DF, Amson BJ

BACKGROUND: The aim of this study was to review 5 years of laparoscopic adjustable gastric band (LAGB) procedures in which low-pressure bands were used. METHODS: All LAGB cases at the authors’ center were retrospectively analyzed. A survey of these patients was conducted in 2008 and 2009. RESULTS: Of 90 LAGB patients, 86 were surveyed. Follow-up averaged 17.5 months. Weight loss averaged 24.8 +/- 19.4 kg. Weight loss averaged 2.7 kg/mo and did not significantly drop over the last 10.7 months (2.7 vs 1.5 kg/mo, P = .16). Excess body weight loss was 27.5%, 39.1%, and 67.2% in the first, second, and following years, respectively. Patients averaged 4.14 adjustments of their bands and vomited 2.13 times per week. The mortality rate was 0%. No band slippages or band erosion occurred. Resolution or improvement occurred in most obesity-related illness. Gastroesophageal reflux disease symptoms worsened in 25% of patients. CONCLUSIONS: These results replicate world LAGB literature. Low complication rates result either from the authors’ band or their techniques.

PMID: 20466118 [PubMed - in process]

The effects of hormone replacement therapy on postmenopausal breast cancer biology and survival.

Am J Surg. 2010 May;199(5):723

Authors: Keskek M, Ozalp N, Tez M

PMID: 20466120 [PubMed - in process]

The value of recertification.

Am J Surg. 2010 May;199(5):724

Authors: Brisson P

PMID: 20466121 [PubMed - in process]

Changes in acid-base balance during electrolytic ablation in an ex vivo perfused liver model.

Am J Surg. 2010 May 5;

Authors: Gravante G, Ong SL, Metcalfe MS, Sorge R, Fox AJ, Lloyd DM, Maddern GJ, Dennison AR

BACKGROUND: Electrolytic ablation (EA) destroys tissues through extreme pH changes in the local microenvironment. An ex vivo perfused liver model was used to assess the systemic effects of EA on the acid-base balance without the influence of compensatory organs (lungs and kidneys). METHODS: Eleven pigs were perfused extracorporeally at 39 degrees C with autologous blood; 4 also underwent EA after 1 hour of reperfusion. Arterial blood samples were obtained hourly. RESULTS: pH and CO(2) levels did not change throughout the experiments. A significant increase of HCO(3)-, anion gap, base excess, and lactate was present after the third hour. No differences were observed between EA experiments and controls. CONCLUSIONS: EA does not alter the acid-base balance even when the confounding influence of compensatory organs is removed. Such findings should be considered when planning ablations in patients with renal failure or respiratory diseases in which EA could avoid undesirable metabolic changes.

PMID: 20451173 [PubMed - as supplied by publisher]

Transfer of training in the development of intracorporeal suturing skill in medical student novices: a prospective randomized trial.

Am J Surg. 2010 May 5;

Authors: Muresan C, Lee TH, Seagull J, Park AE

BACKGROUND: To help optimize the use of limited resources in trainee education, we developed a prospective randomized trial to determine the most effective means of teaching laparoscopic suturing to novices. METHODS: Forty-one medical students received rudimentary instruction in intracorporeal suturing, then were pretested on a pig enterotomy model. They then were posttested after completion of 1 of 4 training arms: laparoscopic suturing, laparoscopic drills, open suturing, and virtual reality (VR) drills. Tests were scored for speed, accuracy, knot quality, and mental workload (National Aeronautics and Space Administration [NASA] Task Load Index). RESULTS: Paired t tests were used. Task time was improved in all groups except the VR group. Knot quality improved only in the open or laparoscopic suturing groups. Mental workload improved only for those practicing on a physical laparoscopic trainer. CONCLUSIONS: For novice trainees, the efficacy of VR training is questionable. In contrast, the other training methods had benefits in terms of time, quality, and perceived workload.

PMID: 20451174 [PubMed - as supplied by publisher]

Nuclear factor kappa B-dependent gene transcription in cholecystokinin- and tumor necrosis factor-alpha-stimulated isolated acinar cells is regulated by p38 mitogen-activated protein kinase.

Am J Surg. 2010 Apr 20;

Authors: Williard DE, Twait E, Yuan Z, Carter AB, Samuel I

BACKGROUND: Mitogen-activated protein (MAP) kinases and nuclear factor kappa B (NF-kappaB) are implicated in early stages of acute pancreatitis pathogenesis. We investigated the relationship between the p38 MAP kinase and NF-kappaB in isolated acinar cells. METHODS: Isolated rodent acinar cells were stimulated with agonists after infection with an adenovector containing a luciferase promoter driven only by NF-kappaB and an adenovector containing the dominant negative (DN) form of p38 (empty vector in controls). RESULTS: Initial immunoblots confirmed that the agonist stimulated p38 activation in acinar cells was substantially attenuated by DN p38 overexpression. Stimulation of native cholecystokinin (CCK)-A receptors or tumor necrosis factor-alpha (TNF-alpha) receptors promoted a significant increase in NF-kappaB-dependent gene transcription in cells infected with the empty vector, while overexpression of DN p38 significantly abrogated NF-kappaB-dependent luciferase activity. CONCLUSIONS: These findings support our hypothesis that p38 is involved in the activation of proinflammatory nuclear transcription factors such as NF-kappaB in pancreatic exocrine cells.

PMID: 20413104 [PubMed - as supplied by publisher]

Nuclear factor kappa B-dependent gene transcription in cholecystokinin- and tumor necrosis factor-alpha-stimulated isolated acinar cells is regulated by p38 mitogen-activated protein kinase.

Am J Surg. 2010 Apr 20;

Authors: Williard DE, Twait E, Yuan Z, Carter AB, Samuel I

BACKGROUND: Mitogen-activated protein (MAP) kinases and nuclear factor kappa B (NF-kappaB) are implicated in early stages of acute pancreatitis pathogenesis. We investigated the relationship between the p38 MAP kinase and NF-kappaB in isolated acinar cells. METHODS: Isolated rodent acinar cells were stimulated with agonists after infection with an adenovector containing a luciferase promoter driven only by NF-kappaB and an adenovector containing the dominant negative (DN) form of p38 (empty vector in controls). RESULTS: Initial immunoblots confirmed that the agonist stimulated p38 activation in acinar cells was substantially attenuated by DN p38 overexpression. Stimulation of native cholecystokinin (CCK)-A receptors or tumor necrosis factor-alpha (TNF-alpha) receptors promoted a significant increase in NF-kappaB-dependent gene transcription in cells infected with the empty vector, while overexpression of DN p38 significantly abrogated NF-kappaB-dependent luciferase activity. CONCLUSIONS: These findings support our hypothesis that p38 is involved in the activation of proinflammatory nuclear transcription factors such as NF-kappaB in pancreatic exocrine cells.

PMID: 20413104 [PubMed - as supplied by publisher]

Related Articles

To operate or not to operate? A multi-method analysis of decision-making in emergency surgery.

Am J Surg. 2010 Apr 12;

Authors: Szatmary P, Arora S, Sevdalis N

BACKGROUND: The ability to decide when to operate and when not to operate is a key surgical skill. The aim of this study was to investigate factors affecting that decision. METHODS: In phase 1, semistructured interviews were used to investigate how expert surgeons decide when to operate. In phase 2, clinical case vignettes were constructed, and 22 general surgeons at various stages of their training indicated whether they would operate and their confidence in patient outcomes. RESULTS: Interviews answers centered on the theme of “patient outcome,” which was defined similarly by all surgeons. In phase 2, surgeons chose to operate when they perceived the outcome with an operation to be better than the outcome without. Surgeons with <5 years of experience were less certain about what outcomes might be. These surgeons opted to perform significantly more operations (40 +/- 4%) than surgeons with >/=5 years of experience (18 +/- 2%). CONCLUSIONS: A subjective, balanced assessment of the likelihood of patient outcome is crucial in deciding whether to operate. Novices face higher degrees of uncertainty, explaining differences in decisions taken.

PMID: 20392432 [PubMed - as supplied by publisher]