Reply to the commentary: Should we, not could we? A commentary on “Pyloric valve transposition as substitute for a colostomy in humans: a preliminary report”

Am J Surg. 2012 Feb 4;

Authors: Chandra A

PMID: 22306431 [PubMed - as supplied by publisher]

Defining a new paradigm for surgical education.

Am J Surg. 2012 Feb 4;

Authors: Maa J

PMID: 22306432 [PubMed - as supplied by publisher]

False-negative fine-needle aspiration of thyroid nodules cannot be attributed to sampling error alone.

Am J Surg. 2012 Jan 25;

Authors: Yu XM, Patel PN, Chen H, Sippel RS

Abstract

BACKGROUND: The goal of this study was to determine whether sampling error was the major cause for false-negative fine needle aspiration (FNA) results for thyroid nodules. METHODS: Patients who underwent preoperative FNA between 1994 and 2008 were identified, and the results were compared with surgical pathology findings. Other related variables including nodule number and size were also recorded. RESULTS: Excluding the microcarcinomas, the false-negative rate was 4% (19/479). Sampling errors occurred in only 4 (21%) cases in which the malignant nodule was not actually biopsied. Of the other 15 cases, 8 (53%) were solitary nodules, 8 (53%) were ≥4 cm in size, and 5 (33%) had underlying thyroiditis. Because of the missed diagnosis, 9 patients (47%) had lobectomy only as the initial surgery, which then required a completion thyroidectomy. CONCLUSIONS: Sampling error is a minor cause for false-negative FNAs, suggesting that there are some inherent limitations to cytological evaluation of the thyroid.

PMID: 22284047 [PubMed - as supplied by publisher]

Team spirit.

Am J Surg. 2012 Jan 24;

Authors: Albrecht RM

PMID: 22281503 [PubMed - as supplied by publisher]

Towards optimizing perioperative colorectal care: outcomes for 1,000 consecutive laparoscopic colon procedures using enhanced recovery pathways.

Am J Surg. 2012 Jan 18;

Authors: Delaney CP, Brady K, Woconish D, Parmar SP, Champagne BJ

Abstract

BACKGROUND: Learning curves and efficiency concerns have slowed the integration of laparoscopy into colorectal practice. We evaluated our experience with laparoscopic colorectal (LC) surgery using enhanced recovery pathways (ERPs). METHODS: One thousand consecutive LC procedures performed by 2 surgeons over a 5-year period using previously published, standardized ERPs were assessed. RESULTS: The mean age was 59, and the mean body mass index was 29.5. Procedures included segmental colectomy (54%), proctectomy (19%), total colectomy (11%), ostomy (5%), and other procedures (11%). Diagnoses included malignancy (41%), diverticulitis (16%), inflammatory bowel disease (13%), and other (30%). The mean operative time was 151 minutes, and the mean blood loss was 55 mL. Conversion to an open surgery occurred in 5.8%, whereas 2.3% were performed using a hand-assist procedure. The mean hospital stay was 4.1 days (median 3), with a 6% readmission rate. Complications (20%) included mortality (0.3%), wound infection (4%), and anastomotic leak (1.4%). CONCLUSIONS: LC surgery with ERP offers excellent outcomes with efficient use of resources.

PMID: 22264739 [PubMed - as supplied by publisher]

Hürthle cell metaplasia on fine-needle aspiration biopsy is not by itself an indication for thyroid surgery.

Am J Surg. 2012 Jan 18;

Authors: Hudak K, Mazeh H, Sippel RS, Chen H

Abstract

INTRODUCTION: The aim of this study was to assess the malignancy rate in patients with Hürthle cell metaplasia (HCM) on fine-needle aspiration biopsy (FNAB). METHODS: The pathology results of patients with benign colloid (BC) and HCM on FNAB were compared using a prospective database. RESULTS: One hundred fifty-three (65%) patients had BC on FNAB, and 82 (35%) had HCM. The mean nodule size was similar in both groups (25 ± 2 mm vs 26 mm ± 2 mm, P = .83). Malignancy was identified on the final pathology report in 21 (14%) versus 13 (16%) patients in the BC and HCM groups, respectively (P = .66). Of the patients with malignancy, the tumor was determined as microcarcinoma in 76% in the BC groups versus 85% in the HCM group (P = .48) and as incidental in 71% versus 85% (P = .39). CONCLUSIONS: A result of HCM on FNAB carries a similar rate of malignancy as BC and should not be treated differently. Most of the malignancies found were incidental microcarcinomas.

PMID: 22264740 [PubMed - as supplied by publisher]

Endovascular repair of traumatic thoracic aortic tears.

Am J Surg. 2012 Jan 20;

Authors: Mansour MA, Kirk JS, Cuff RF, Banegas SL, Ambrosi GM, Liao TH, Chambers CM, Wong PY, Heiser JC

Abstract

BACKGROUND: Patients with thoracic aorta injuries (TAI) present a unique challenge. The purpose of this study was to review the outcomes of thoracic endovascular aortic repair (TEVAR) in patients with TAI. METHODS: A retrospective chart review of all patients admitted for TEVAR for trauma was performed. RESULTS: In a 5-year period, 19 patients (6 women and 13 men; average age, 42 y) were admitted to our trauma center with TAI. Mechanism of injury was a motor vehicle crash in 12 patients, motorcycle crash in 2 patients, automobile-pedestrian accident in 2 patients, 1 fall, 1 crush injury, and 1 stab wound to the back. A thoracic endograft was used in 6 patients and proximal aortic cuffs were used in 13 patients (68%). One patient (5%) died. There were no strokes, myocardial infarctions, paraplegia, or renal failure. CONCLUSIONS: TEVAR for TAI appears to be a safe option for patients with multiple injuries. TEVAR in young patients is still controversial because long-term endograft behavior is unknown.

PMID: 22265092 [PubMed - as supplied by publisher]

The outcome after stent placement or surgery as the initial treatment for obstructive primary tumor in patients with stage IVU colon cancer.

Am J Surg. 2012 Jan 19;

Authors: Lee WS, Baek JH, Kang JM, Choi S, Kwon KA

Abstract

BACKGROUND: It is still a matter of debate as to whether palliative resection of obstructive primary tumors may prolong the survival of patients with obstructive colon cancer and unresectable synchronous metastases. The main goal of this retrospective study was to compare the use of self-expanding metallic stents (SEMS) with open surgery for the palliation of patients with respect to survival, morbidity, and the time to start chemotherapy. METHODS: Between January 2000 and January 2008, 88 consecutive patients (52 who underwent surgery and 36 who underwent SEMS insertion) with obstructive colon cancer and unresectable synchronous metastases were retrospectively evaluated. RESULTS: The median hospital stay for all admissions was 7.2 days (range, 3-29 days) in the SEMS group and 12.3 days (range, 6-45 days) in the surgery group (P = .001). The incidence of stoma formation was significantly lower in the SEMS group than in the surgery group (16.7% vs 38.5%, respectively, P = .021). The median time to starting chemotherapy was significantly shorter in patients who underwent SEMS insertion compared with those who underwent surgery (8.1 vs 21.7 days, respectively, P = .001). The 1-year and 2-year survival rates were 44.2% and 21.27% in the surgery group and 16.7% and 2.8% in the SEMS group, respectively. The median survival for all patients was 15 months from the initiation of treatment (95% confidence interval, 6.0-19 months). CONCLUSIONS: Both procedures can be safely performed, but the choice of treatment should be individualized and discussed with a multidisciplinary team.

PMID: 22265203 [PubMed - as supplied by publisher]

Posterior and open anterior components separations: a comparative analysis.

Am J Surg. 2012 Jan 11;

Authors: Krpata DM, Blatnik JA, Novitsky YW, Rosen MJ

Abstract

BACKGROUND: Anterior components separation (ACS) creates large lipocutaneous flaps to release the external oblique fascia often leading to major wound complications. Posterior components separation (PCS) involves the release of the posterior rectus sheath and transversus abdominis muscles. We hypothesized that PCS provides effective fascial advancement while reducing wound morbidity during abdominal wall reconstructions. METHODS: A retrospective review of consecutive components separation performed by a single surgeon over 5 years. RESULTS: One hundred eleven patients (56 ACS/55 PCS) were analyzed. The mean defect size was 472 and 531 cm(2), respectively (P = .28). Five patients in each group required a bridging repair. Wound complications occurred in significantly more ACS than PCS patients (48.2% vs 25.5%, P = .01). The recurrence rate was also higher in the ACS group (14.3% vs 3.6%, P = .09). CONCLUSIONS: PCS provides equivalent myofascial advancement with significantly less wound morbidity when compared with ACS. Although further studies are needed, PCS has evolved as an important addition to the armamentarium of surgeons undertaking complex abdominal wall reconstructions.

PMID: 22244073 [PubMed - as supplied by publisher]

Getting back to zero with nucleated red blood cells: following trends is not necessarily a bad thing.

Am J Surg. 2012 Jan 11;

Authors: Shah R, Reddy S, Horst HM, Stassinopoulos J, Jordan J, Rubinfeld I

Abstract

BACKGROUND: The presence of nucleated red blood cells (NRBCs) has been identified as a poor prognostic indicator. We investigated the relationship of NRBC trends in patients with and without trauma. METHODS: We retrospectively reviewed surgical intensive care unit admissions over 4 years, categorizing trauma and nontrauma patients and subdividing them into 3 groups: group A, all-zero NRBC; group B, positive NRBC value returning to zero; and group C, positive NRBC value that did not return to zero. We analyzed all groups for outcomes of length of stay and mortality. RESULTS: Group A was the largest and had the shortest length of stay and least mortality. Group C had the highest mortality rate. No statistical difference was observed with mortality. CONCLUSIONS: Any positive NRBC was associated with poor outcome, and increasing NRBC was associated with increasing mortality. Trends in NRBC values showed that returning to zero was protective.

PMID: 22244074 [PubMed - as supplied by publisher]

The role of laparoscopy and laparoscopic ultrasound in the preoperative staging of patients with resectable colorectal liver metastases: a meta-analysis.

Am J Surg. 2012 Jan 12;

Authors: Hariharan D, Constantinides V, Kocher HM, Tekkis PP

Abstract

BACKGROUND: The role of staging laparoscopy (SL) with laparoscopic ultrasound (LUS) in patients with resectable colorectal liver metastases (CRLM) remains controversial. METHODS: A meta-analysis of all studies (from 1998 to the present) on the effect of SL/LUS in patients with potentially resectable CRLM with respect to alteration in surgical management was performed. RESULTS: Twelve studies satisfied the inclusion criteria. A total of 1,047 patients underwent SL/LUS. The true yield of SL/LUS for CRLM was 19% (95% confidence interval [CI], 16%-22%), with a diagnostic odds ratio of 132 (95% CI, 56-310) and an overall sensitivity of 59% (95% CI, 53%-65%). Subgroup analysis for detection of other liver and peritoneal lesions showed a sensitivity of 59% (95% CI, 49%-67%) and 75% (95% CI, 63%-85%) respectively. There was major between-study heterogeneity for all analyses, with no obvious cause revealed by meta-regression. CONCLUSIONS: The true benefit of using SL/LUS universally seems limited. It appears more useful as an adjunct in patients when peritoneal disease is suspected.

PMID: 22244586 [PubMed - as supplied by publisher]

Calcium-lowering medications in patients with primary hyperparathyroidism: intraoperative findings and postoperative hypocalcemia.

Am J Surg. 2012 Jan 13;

Authors: Schneider DF, Day GM, Jong SA

Abstract

BACKGROUND: We analyzed how calcium-lowering medications (CLMs) influenced surgical findings in patients with primary hyperparathyroidism. METHODS: A retrospective review was conducted of 281 patients undergoing surgery for primary hyperparathyroidism. Logistic regression evaluated the relationship between CLM and surgical findings. A mixed-effects model determined the influence of CLMs on these curves. RESULTS: We found that CLM (P = .018) and a higher serum calcium level (P = .018) were variables making 4-gland hyperplasia less likely. Analysis of intraoperative parathyroid hormone (IOPTH) plots revealed that CLMs altered the kinetics (P = .043). However, the 2 groups did not differ in the number of measurements necessary for a 50% decrease in IOPTH levels. Multivariate logistic regression also revealed that patients taking more than one CLM had an increased association with postoperative hypocalcemia (P = .018). CONCLUSIONS: Although CLM contributed to differences in IOPTH curves, their use does not require changing standard IOPTH protocol but should alert the surgeon to the risk of postoperative hypocalcemia.

PMID: 22245506 [PubMed - as supplied by publisher]

Laparoscopic or open liver resection? Let systematic review decide it.

Am J Surg. 2012 Jan 13;

Authors: Rao A, Rao G, Ahmed I

Abstract

BACKGROUND: Laparoscopic liver resection is increasingly being used for the excision of benign and malignant hepatic lesions. The aim of this study was to perform meta-analysis on the compiled data from available observational studies. METHODS: All the studies comparing laparoscopic versus open liver resections were searched on the available databases. Data were analyzed using Review Manager software version 5.0 (The Cochrane Collaboration, Software Update, Oxford, UK). RESULTS: There was a total of 2,466 patients: 1,161 (47.1%) in the laparoscopic group and 1,305 (52.9%) in the open group. The laparoscopic group was associated with a reduced overall complication rate (odds ratio = .35; 95% confidence interval [CI], .28-.45; P < .001; heterogeneity (HG): P = .51), fewer positive resection margins for malignant tumor resections (odds ratio = .38; CI, .20-.76; P = .006; HG: P = .52) and a decrease in the number of patients requiring blood transfusion (odds ratio = .36; CI, .23-.74; P < .001; HG: P = .30). CONCLUSIONS: Laparoscopic liver resection showed a reduced overall morbidity rate and favorable and comparable outcomes when compared with the open group. However, there is still a need for randomized controlled trials to compare laparoscopic versus open hepatic resection in benign and malignant lesions.

PMID: 22245507 [PubMed - as supplied by publisher]

Health care and socioeconomic impact of falls in the elderly.

Am J Surg. 2012 Jan 16;

Authors: Siracuse JJ, Odell DD, Gondek SP, Odom SR, Kasper EM, Hauser CJ, Moorman DW

Abstract

BACKGROUND: Elderly falls are associated with long hospital stays, major morbidity, and mortality. We sought to examine the fate of patients ≥75 years of age admitted after falls. METHODS: We reviewed all fall admissions in 2008. Causes, comorbidities, injuries, procedures, mortality, readmission, and costs were analyzed. RESULTS: Seven hundred eight patients ≥75 years old were admitted after a fall, with 89% being simple falls. Short-term mortality was 6%. Male sex, atrial fibrillation, acute myocardial infarction, congestive heart failure (CHF), intracranial hemorrhage, hospital-acquired pneumonia, trigger events, Clostridium difficile, and intubation were predictors of death (P < .05). Thirty-day readmission occurred in 14%; CHF, craniotomy, and acute renal failure were predictive. The median cost of hospitalization was $11,000 with cardiac disease, anemia, major orthopedic and neurosurgical procedures, pneumonia, and intubation as predictive. CONCLUSIONS: Simple falls in the elderly have high morbidity, mortality, and costs. Methodologies for prevention are warranted and should be studied intensively.

PMID: 22257741 [PubMed - as supplied by publisher]

Diversification and trends in biliary tree cancer among the three major ethnic groups in the state of New Mexico.

Am J Surg. 2012 Jan 9;

Authors: Nir I, Wiggins CL, Morris K, Rajput A

Abstract

BACKGROUND: New Mexico’s population is composed of 45% non-Hispanic whites, 42% Hispanics, 10% American Indians, and 3% other minorities. The purpose of this study was to compare the trends of biliary tract cancer among these groups over the past 3 decades. METHODS: The state’s tumor registry was used to ascertain the incidence of gallbladder cancer, extrahepatic bile duct cancer, and intrahepatic bile duct cancer. RESULTS: A total of 1,449 new biliary cancers were diagnosed between 1981 and 2008. The contemporary incidence of gallbladder cancer remains several times higher among American Indians than in other ethnicities: for men, 4.1%, 1.1%, and .8% for American Indians, Hispanics, and non-Hispanic whites, respectively, and for women, 8.1%, 2.1%, and 1.0%, respectively. CONCLUSIONS: Biliary malignancies are more prevalent among American Indians. Despite a decline in the incidence of gallbladder cancer among American Indians and Hispanics, it remains higher compared with the state’s non-Hispanic white population.

PMID: 22236535 [PubMed - as supplied by publisher]

Outcomes of cytoreduction with hyperthermic intraperitoneal chemotherapy: our experience at a Midwest community hospital.

Am J Surg. 2012 Jan 5;

Authors: Goslin B, Sevak S, Siripong A, Onesti J, Wright GP, Melnik M, Chung M

Abstract

BACKGROUND: Most cytoreduction with hyperthermic intraperitoneal chemotherapy procedures are performed at academic tertiary referral centers with numerous surgical oncology faculty. The objective of this study was to review the postoperative morbidity and mortality data of our institution, a large community hospital. METHODS: This was a retrospective cohort study of patients who underwent cytoreduction with hyperthermic intraperitoneal chemotherapy at a single institution. Two surgical oncologists performed all the procedures between May 2005 and June 2011. RESULTS: We retrospectively analyzed 57 patients. The most common pathology being treated was pseudomyxoma peritonei (34 of 57; 59.6%), followed by colorectal cancer (9 of 57; 15.8%). Other types of cancer included peritoneal mesothelioma and gastric adenocarcinoma. The average surgery time was 6.9 hours. Approximately 51% of patients suffered grade 3 or 4 morbidity and there were no perioperative mortalities. CONCLUSIONS: Cytoreduction with hyperthermic intraperitoneal chemotherapy can be performed at our institution with comparable outcomes as academic referral centers.

PMID: 22226143 [PubMed - as supplied by publisher]

Acute prognosis of critically ill patients with secondary peritonitis: the impact of the number of surgical revisions, and of the duration of surgical therapy.

Am J Surg. 2012 Jan 5;

Authors: Rüttinger D, Kuppinger D, Hölzwimmer M, Zander S, Vilsmaier M, Küchenhoff H, Jauch KW, Hartl WH

Abstract

BACKGROUND: Duration of surgical therapy and the number of surgical revisions performed to control the focus may be important prognostic variables. Association of such time-dependent therapies with survival, however, has not yet been studied. METHODS: We analyzed survival times of adult patients (n = 283) who were suffering from secondary peritonitis and associated organ failure. Cox-type additive hazard regression models were used to analyze associations of surgical variables with survival time. RESULTS: Seventy-two patients (25.4%) survived the period of excess mortality after intensive care unit admission. A total of 79.5% of the 283 patients required one or more surgical revisions. Besides the underlying disease and disease severity at intensive care unit admission, there was a nonlinear smoothed association between a poorer outcome and the duration of surgical therapy, and the number of surgical revisions. For the latter, hazard ratios increased sharply between 1 and 5 revisions, and remained largely constant later on. CONCLUSIONS: In critically ill patients with peritonitis, a long therapy and the necessity for a high number of reoperations is related inversely to acute survival.

PMID: 22226144 [PubMed - as supplied by publisher]

Healthcare disparities in Asians and Pacific Islanders with hepatocellular cancer.

Am J Surg. 2012 Jan 6;

Authors: Wong LL, Hernandez B, Kwee S, Albright CL, Okimoto G, Tsai N

Abstract

BACKGROUND: Hawaii has the highest incidence of hepatocellular cancer (HCC) in the United States and the largest proportion of Asians and Pacific Islanders. HCC studies generally combine these groups into 1 ethnicity, and we sought to examine differences between Asian and Pacific Islander subpopulations. METHODS: Demographic, clinical, and treatment data for 617 patients with HCC (420 Asians, 114 whites, and 83 Pacific Islanders) were reviewed. Main outcome measures included HCC screening and liver transplantation. RESULTS: Asian and Pacific Islander subgroups had significantly more immigrants, and age was different between groups. Compared with whites, Pacific Islanders and Filipinos had less HCC screening and liver transplantation procedures, fewer met Milan criteria, and a smaller proportion of those with Milan criteria actually underwent transplantation. CONCLUSIONS: There were significant differences in risk factors, clinical presentation, treatment, and access to care among Asian, Pacific Islander, and white patients with HCC. Future HCC studies may benefit from differentiating subgroups within Asian and Pacific Islander populations to better focus these efforts.

PMID: 22227170 [PubMed - as supplied by publisher]

Expression of vascular endothelial growth factor-C in gastric carcinoma and the effect of its antisense gene transfection on the proliferation of human gastric cancer cell line SGC-7901.

Am J Surg. 2012 Jan 6;

Authors: Zhu P, Zhang J, Chen Q, Wang J, Wang Y

Abstract

PURPOSE: The aim of this study was to investigate the relationship between the expression of vascular endothelial growth factor-C (VEGF-C) in gastric carcinoma and tumor lymphangiogenesis and to determine the effect of antisense-VEGF-C gene transfection on proliferation. METHODS: Adjacent cancer tissues were collected from 72 gastric carcinoma cases and compared with 10 nongastric carcinoma tissues to detect the expression of VEGF-C and its messenger RNA (mRNA) and calculate the density of neonatal lymphatic microvessels. The in vitro-cultured gastric cancer cell line SGC-7901 was transfected with recombinant plasmid pCI-neo-anti VEGF-C. The expression in the transfected cells and the proliferation were determined. RESULTS: The positive rate of VEGF-C mRNA in the lymph node metastasis tissues was 85.7% compared with negative controls (20%, P < .05). The density of lymphatic vessels in the metastasis group was 6.65 ± 1.57 compared with the negative group (3.75 ± 1.47, P < .05). Protein and mRNA of VEGF-C were reduced in transfected cells. Proliferation was inhibited as well. CONCLUSIONS: VEGF-C can increase the invasiveness of gastric cancer and promote lymphangiogenesis in adjacent tissues. Transfection with antisense VEGF-C can reduce the expression of VEGF-C and inhibit the proliferation. VEGF-C can inhibit the tumor growth and reduce its metastasis and recurrence.

PMID: 22227171 [PubMed - as supplied by publisher]

Trends in the utilization of inguinal hernia repair techniques: a population-based study.

Am J Surg. 2012 Jan 3;

Authors: Zendejas B, Ramirez T, Jones T, Kuchena A, Martinez J, Ali SM, Lohse CM, Farley DR

Abstract

BACKGROUND: The use of inguinal hernia repair techniques in the community setting is poorly understood. METHODS: A retrospective review of all inguinal hernia repairs performed on adult residents of Olmsted County, MN, from 1989 to 2008 was performed through the Rochester Epidemiology Project. RESULTS: A total of 4,433 inguinal hernia repairs among 3,489 individuals were reviewed. Non-mesh-based repairs predominated in the late 1980s (94% in 1989), declined throughout the 1990s (40% in 1996), and are rarely used nowadays (4% in 2008). Open mesh-based repairs comprised 21% in 1990, peaked in 2001 with 72%, and declined to 55% in 2008. The adoption of laparoscopic repairs began in 1992 (6%) and has increased steadily to 41% in 2008 (P < .001). CONCLUSIONS: Although non-mesh-based repairs, once the predominant method, have been supplanted by open mesh-based techniques, nowadays the use of laparoscopic inguinal hernia repair techniques has increased substantially to nearly equal that of open mesh-based techniques.

PMID: 22221993 [PubMed - as supplied by publisher]

Continued rationale of why hospital mortality is not an appropriate measure of trauma outcomes.

Am J Surg. 2012 Jan 3;

Authors: Kelly KB, Koeppel ML, Como JJ, Carter JW, McCoy AM, Claridge JA

Abstract

BACKGROUND: We hypothesized that standardized withdrawal of care (WOC) practices and an aggressive long-term acute care facility (LTAC) discharge protocol could change hospital mortality and national ranking among trauma centers. STUDY DESIGN: Patients who died while admitted to the trauma service at a level 1 trauma center were classified as either an “LTAC candidate” or “not a LTAC candidate” at 4 time points before death. RESULTS: A total of 216 patients died, and 48% had WOC. Hospital mortality was 3.3%. More than 26% of these qualified as LTAC candidates. The aggressive LTAC discharge protocol reduced hospital mortality by .9%. This was sufficient to move a trauma center into a lower quartile on the National Trauma DataBank benchmark report for 2009. CONLUSIONS: It is possible to reduce hospital mortality and improve quality ranking with standardized WOC and LTAC discharge protocols. This highlights the importance of measuring outcomes beyond discharge.

PMID: 22221994 [PubMed - as supplied by publisher]

Using manual dexterity to predict the quality of the final product in the small bowel anastomosis after a period of training.

Am J Surg. 2012 Jan 3;

Authors: Masud D, Undre S, Darzi A

Abstract

OBJECTIVE: The use of aptitude tests in the selection of surgeons has gained recent attention. Few have described its relevance in predicting the acquisition of surgical techniques. We aim to show whether assessing manual dexterity can predict the quality of the final product after a period of training. METHODS: Thirty-six medical students had their manual dexterity assessed completed bench model small bowel anastomosis in 8 consecutive sessions. The fine details (accuracy (number of sutures that traversed full thickness) and number of sutures placed) and gross details (bowel apposition) of quality of final product was objectively assessed. RESULTS: Manual dexterity correlated with grade only in the initial sessions (Pearson correlation coefficient, r = -.578, P < .01). There was no significant correlation with the fine details with any session. CONCLUSIONS: There was a correlation with manual dexterity and outcome measures in the initial sessions of training with grade only. This relationship was eliminated by the end of training sessions. This suggests that the outcome of procedures after a period of training cannot be predicted by measuring manual dexterity skills.

PMID: 22221995 [PubMed - as supplied by publisher]

The role of transcervical thymectomy in patients With hyperparathyroidism.

Am J Surg. 2012 Jan 3;

Authors: Welch K, McHenry CR

Abstract

BACKGROUND: The most common location for supernumerary or ectopic parathyroid glands is the thymus. METHODS: A review of patients who underwent parathyroidectomy for hyperparathyroidism from 1990 to 2010 was completed to determine indications for thymectomy, the yield of parathyroid tissue, and outcome of therapy. RESULTS: Seventy of 379 patients with hyperparathyroidism underwent parathyroidectomy and transcervical thymectomy. Intrathymic parathyroid tissue was present in 23 (33%) patients, including supernumerary glands in 8 patients (11%). Indications for thymectomy were renal hyperparathyroidism in 35 patients (50%) and primary hyperparathyroidism with a missing inferior gland in 20 patients (29%), an ectopic adenoma in 9 patients (13%), hyperplasia in 5 patients (7%), and carcinoma in 1 patient (1%). Cure rates were similar (96% and 98%; P = not significant) and only transient hypocalcemia was higher (51% vs 24%, P < .05) after parathyroidectomy with thymectomy versus parathyroidectomy alone. CONCLUSIONS: Transcervical thymectomy results in a high yield of parathyroid tissue and is essential for cure of selected patients with hyperparathyroidism.

PMID: 22221996 [PubMed - as supplied by publisher]

Long-term symptom relief and patient satisfaction after Heller myotomy and Toupet fundoplication for achalasia.

Am J Surg. 2012 Jan 3;

Authors: Popoff AM, Myers JA, Zelhart M, Maroulis B, Mesleh M, Millikan K, Luu MB

Abstract

BACKGROUND: The goal of this study was to review the results, symptom relief, and patient satisfaction after laparoscopic Heller myotomy and Toupet fundoplication. METHODS: A cohort of patients who underwent laparoscopic esophagomyotomy and a Toupet fundoplication was identified. A retrospective chart review was conducted and patients then were interviewed by telephone using a modified 5-point Likert scale. RESULTS: Long-term follow-up data were obtained for 51 patients with a mean of 5.9 years. Thirty-two (63%) patients reported infrequent or no dysphagia. Chest pain, heartburn, or regurgitation were reported in 6 of 51 (12%) patients, 14 of 51 (27%) patients, and 11 of 51 (22%) patients, respectively. Two patients (3.9%) had pneumatic dilation and 1 patient underwent completion esophagectomy (1.9%). Thirty-three (33 of 51; 65%) patients were on acid-suppression therapy. Forty-one (80%) patients reported their overall satisfaction with the procedure was either excellent or good, and 46 of 51 (90%) patients stated they would undergo surgery again. CONCLUSIONS: Our data show acceptable long-term results.

PMID: 22221997 [PubMed - as supplied by publisher]

The additional value of intraoperative parathyroid hormone assessment is marginal in patients with nonfamilial primary hyperparathyroidism: A prospective cohort study.

Am J Surg. 2011 Dec 20;

Authors: Twigt BA, van Dalen T, Vollebregt AM, Kortlandt W, Vriens MR, Borel Rinkes IH

Abstract

BACKGROUND: The success of minimally invasive parathyroidectomy is attributed to evolving preoperative imaging techniques and intraoperative parathyroid hormone (IOPTH) measurement. The additional value of IOPTH measurement in patients undergoing surgery for primary hyperparathyroidism (pHPT) was evaluated. METHODS: Between 1999 and 2010 there were 119 patients who underwent surgery for pHPT at our institutions. In all patients, preoperative imaging was performed and IOPTH samples were collected prospectively but the results were not disclosed during surgery. RESULTS: Postoperative calcium level normalized in 114 patients (96%). The 5 surgical failures represented the maximum yield of IOPTH sampling. Three of these patients would have been identified intraoperatively by an inadequate IOPTH decrease, whereas IOPTH decreased inaccurately in the other 2 patients. In addition, in 1 of these 3 patients no abnormal gland was found during minimally invasive parathyroidectomy and subsequent conventional neck exploration. Therefore, only 2 reoperations would have been prevented (1.7%). CONCLUSIONS: IOPTH would have changed the outcome in 2 patients, increasing the biochemical cure rate from 96% to 98%. We believe that although it can be helpful in certain cases, it may not be necessary routinely in patients treated for pHPT.

PMID: 22192616 [PubMed - as supplied by publisher]

Effects of vitamin D deficiency in critically ill surgical patients.

Am J Surg. 2011 Dec 27;

Authors: Flynn L, Zimmerman LH, McNorton K, Dolman M, Tyburski J, Baylor A, Wilson R, Dolman H

Abstract

BACKGROUND: The incidence of vitamin D deficiency in critically ill patients is reported to be up to 50%, with a 3-fold increase in predicted mortality, but limited data exist concerning vitamin D deficiency in critically ill surgical patients. METHODS: Sixty-six adult surgical intensive care unit patients who had 25-hydroxyvitamin D serum levels evaluated from January 2010 to February 2011 were prospectively identified. Patients were divided into groups according to vitamin D level (<20 vs ≥20 ng/mL). RESULTS: Of the 66 patients evaluated, 49 (74%) had vitamin D levels < 20 ng/mL, and 17 (26%) had vitamin D levels ≥ 20 ng/mL. Patients with vitamin D levels < 20 versus ≥ 20 ng/mL had longer lengths of hospital stay. Lengths of intensive care unit stay were clinically longer, although not significant. Infection rates tended to be higher (P = .09), and a higher incidence of sepsis was seen in the patients with vitamin D levels < 20 ng/mL. CONCLUSIONS: Vitamin D levels < 20 ng/mL have a significant impact on length of stay, organ dysfunction, and infection rates. More data are needed on the value of supplementation to improve these outcomes.

PMID: 22206852 [PubMed - as supplied by publisher]

Surgery via natural orifices in human beings: yesterday, today, tomorrow.

Am J Surg. 2011 Dec 27;

Authors: Moris DN, Bramis KJ, Mantonakis EI, Papalampros EL, Petrou AS, Papalampros AE

Abstract

BACKGROUND: We performed an evaluation of models, techniques, and applicability to the clinical setting of natural orifice surgery (mainly natural orifice transluminal endoscopic surgery [NOTES]) primarily in general surgery procedures. NOTES has attracted much attention recently for its potential to establish a completely alternative approach to the traditional surgical procedures performed entirely through a natural orifice. Beyond the potentially scar-free surgery and abolishment of dermal incision-related complications, the safety and efficacy of this new surgical technology must be evaluated. METHODS: Studies were identified by searching MEDLINE, EMBASE, Cochrane Library, and Entrez PubMed from 2007 to February 2011. Most of the references were identified from 2009 to 2010. There were limitations as far as the population that was evaluated (only human beings, no cadavers or animals) was concerned, but there were no limitations concerning the level of evidence of the studies that were evaluated. RESULTS: The studies that were deemed applicable for our review were published mainly from 2007 to 2010 (see Methods section). All the evaluated studies were conducted only in human beings. We studied the most common referred in the literature orifices such as vaginal, oral, gastric, esophageal, anal, or urethral. The optimal access route and method could not be established because of the different nature of each procedure. We mainly studied procedures in the field of general surgery such as cholecystectomy, intestinal cancers, renal cancers, appendectomy, mediastinoscopy, and peritoneoscopy. All procedures were feasible and most of them had an uneventful postoperative course. A number of technical problems were encountered, especially as far as pure NOTES procedures are concerned, which makes the need of developing new endoscopic instruments, to facilitate each approach, undeniable. CONCLUSIONS: NOTES is still in the early stages of development and more robust technologies will be needed to achieve reliable closure and overcome technical challenges. Well-designed studies in human beings need to be conducted to determine the safety and efficacy of NOTES in a clinical setting. Among these NOTES approaches, the transvaginal route seems less complicated because it virtually eliminates concerns for leakage and fistulas. The transvaginal approach further favors upper-abdominal surgeries because it provides better maneuverability to upper-abdominal organs (eg, liver, gallbladder, spleen, abdominal esophagus, and stomach). The stomach is considered one of the most promising targets because this large organ, once adequately mobilized, can be transected easily with a stapler. The majority of the approaches seem to be feasible even with the equipment used nowadays, but to achieve better results and wider applications to human beings, the need to develop new endoscopic instruments to facilitate each approach is necessary.

PMID: 22206853 [PubMed - as supplied by publisher]

Control charts to identify adverse outcomes in elective colon resection.

Am J Surg. 2011 Dec 27;

Authors: Fry DE, Pine M, Jones BL, Meimban RJ

Abstract

BACKGROUND: Control charts have been proposed for the measurement of quality in surgical care. METHODS: For each of 181 study hospitals in the 2005 National Inpatient Sample of the Healthcare Cost and Utilization Project database, an average moving range control chart for risk-adjusted postoperative length of stay (RApoLOS) was created for patients discharged alive after elective colectomy. RApoLOS outliers using upper control limits of 2.0σ, 2.5σ, and 3.0σ were correlated to coded complications (CCs). Hospital costs were correlated to RApoLOS outliers and CCs. RESULTS: Of 13,118 live discharges, 902 (6.9%) were outliers using a 3.0σ upper control limit, 1,350 (10.3%) were 2.5σ outliers, and 2,053 (15.7%) were 2.0σ outliers. CCs were identified in 92.7% of 3.0σ outliers, in 81.3% of 2.5σ outliers, and 70.6% of 2.0σ outliers. Increased costs were associated with RApoLOS outliers and poorly with CCs. CONCLUSIONS: Average moving range control charts for RApoLOS outliers are valid tools for measurement of surgical quality and costs.

PMID: 22206854 [PubMed - as supplied by publisher]

Receptor changes in metachronous breast tumors-our experience of 10 years.

Am J Surg. 2011 Dec 27;

Authors: Bhullar JS, Unawane A, Subhas G, Poonawala H, Dubay L, Ferguson L, Goriel Y, Jacobs MJ, Kolachalam RB, Silapaswan S, Mittal VK

Abstract

INTRODUCTION: Patients with primary breast cancer (PBC) are at 2 to 6 times higher risk for developing synchronous and metachronous breast cancer (MBC). The pathology and behavior of MBC still remains unclear. METHODS: We reviewed the charts of 108 women with MBC at our hospital over the past 10 years. Profile patterns of the estrogen receptor (ER), the progesterone receptor (PR), and Her2/neu receptors were explored. RESULTS: Of 33 patients with ER(+)/PR(+) in the primary tumor, 23 (70%) retained the status in MBC. Forty-five (92%) of 49 patients with ER(-)/PR(-) in the primary tumor remained the same in MBC. Most Her2(-) tumors (22/31, 71%) remained negative, but 50% (8/16) of Her2(+) tumors became negative. CONCLUSIONS: Most MBC retained the ER/PR expression patterns irrespective of the treatment for the primary tumor, thus suggesting a common origin. Because MBCs tend to be triple negative and thus more aggressive, early detection and close surveillance techniques must be devised.

PMID: 22206855 [PubMed - as supplied by publisher]

Laparoendoscopic single-site gastric bands versus standard multiport gastric bands: a comparison of technical learning curve measured by surgical time.

Am J Surg. 2011 Dec 27;

Authors: Gawart M, Dupitron S, Lutfi R

Abstract

BACKGROUND: We aimed to evaluate our learning curve comparing surgical time of laparoendoscopic single-site (LESS) banding with multiport laparoscopy. METHODS: We performed a retrospective analysis of prospectively collected data comparing our first 48 LESS bands with our first 50 multiport laparoscopic bands at our institution. We then compared the first 24 LESS bands with the last 24 bands. RESULTS: The average body mass index for the LESS group was significantly lower than for the laparoscopic group (43.19 vs 48.3; P < .0001). The surgical time was much faster toward the second half of our experience performing the LESS procedure (85.34 vs 68.8; P = .0055). LESS banding took significantly longer than our early traditional laparoscopic adjustable gastric banding (76.85 vs 64.4; P = .0015). CONCLUSIONS: We conclude that in experienced hands, single-incision banding is feasible and safe to perform. Long-term data are needed to prove that LESS banding is as good a surgery as traditional laparoscopic surgery.

PMID: 22206856 [PubMed - as supplied by publisher]

What I’ve learned.

Am J Surg. 2011 Dec;202(6):623-31

Authors: Nelson EW

PMID: 22137131 [PubMed - in process]

The care of the patient: character, science, and service.

Am J Surg. 2011 Dec;202(6):632-40

Authors: Stewart RM

Abstract

Surgery as a profession rests on an age-old foundation based on 3 fundamental pillars: the collective character of our surgeons, their commitment to a practice based on science, and their pledge of service to humanity. The past 2 centuries bear witness to the success of surgical science. Significant improvement in the remaining 2 pillars is less evident. Our profession would be transformed in a positive way if we strengthened our commitment to improving our character while consciously building the character of our young, if we made the scientific method a way of life, and if we truly dedicated ourselves to the service of others.

PMID: 22137132 [PubMed - in process]

Innovation in surgery: from imagination to implementation.

Am J Surg. 2011 Dec;202(6):641-5

Authors: Chagpar AB

Abstract

Surgeons, perhaps more than any other specialists, recognize the concept of furthering the current state of the art by making conscious changes, whether by tweaking how a surgical procedure is done to push the envelope of minimally invasive techniques, finding novel means of advancing surgical education in the face of work-hour restrictions, or advancing quality initiatives in an era of health care reform. Indeed, innovation seems to be the imperative to moving the field forward, for surgeons recognize that without continual process improvement, we stagnate in the status quo. This article pays tribute to Dr Edgar J. Poth by describing innovation in surgery as an iterative cycle beginning with an imaginative idea that is subjected to a series of “plan, do, check, act” quality cycles and ultimately is implemented as a new initiative, only to yield further creative ideas for improvement.

PMID: 22137133 [PubMed - in process]

Prognostic implications of anatomic location of primary cutaneous melanoma of 1 mm or thicker.

Am J Surg. 2011 Dec;202(6):659-65

Authors: Callender GG, Egger ME, Burton AL, Scoggins CR, Ross MI, Stromberg AJ, Hagendoorn L, Robert Martin CG, McMasters KM

Abstract

BACKGROUND: Breslow thickness, ulceration, and sentinel lymph node (SLN) status are well established as the most important prognostic factors for patients with cutaneous melanoma. Anatomic location of the primary tumor is generally considered to play a minor role in determining prognosis compared with these other factors. This analysis was performed to better define the influence of anatomic location of the primary melanoma on prognosis.

METHODS: In this post hoc analysis of a prospective randomized trial that included patients ages 18 to 70 years with melanomas 1 mm or greater in Breslow thickness, all patients underwent SLN biopsy and completion lymphadenectomy if tumor-positive SLN were found. Kaplan-Meier survival analysis and univariate and multivariate analyses were performed to evaluate factors predictive of disease-free survival (DFS), local and in-transit recurrence-free survival (LITRFS), and overall survival (OS).

RESULTS: A total of 2,500 patients were included in this analysis with a median follow-up period of 68 months. Anatomic locations included head, neck, trunk, upper extremity, and lower extremity. Age, Breslow thickness, and percentage of patients with a positive SLN were significantly different by anatomic location on univariate analysis, as were positive SLN status, presence of regression, sex, and histologic subtype (P < .0001). On multivariate analysis, anatomic location was an independent predictor of SLN status (P < .0001), DFS (P = .045), LITRFS (P = .023), and OS (P < .0001). By Kaplan-Meier analysis, anatomic location was associated significantly with DFS, LITRFS, and OS.

CONCLUSIONS: Anatomic location of the primary melanoma is an important independent predictor of SLN status and prognosis. Patients with primary melanomas of the head/neck and trunk have a worse prognosis than primary melanomas of other anatomic locations.

PMID: 22137134 [PubMed - in process]

Incidence of blunt cerebrovascular injury in low-risk cervical spine fractures.

Am J Surg. 2011 Dec;202(6):684-9

Authors: Kopelman TR, Leeds S, Berardoni NE, O’Neill PJ, Hedayati P, Vail SJ, Pieri PG, Feiz-Erfan I, Pressman MA

Abstract

BACKGROUND: It has been suggested that specific cervical spine fractures (CSfx) (location at upper cervical spine [CS], subluxation, or involvement of the transverse foramen) are predictive of blunt cerebrovascular injury (BCVI). We sought to determine the incidence of BCVI with CSfx in the absence of high-risk injury patterns.

METHODS: We performed a retrospective study in patients with CSfx who underwent evaluation for BCVI. The presence of recognized CS risk factors for BCVI and other risk factors (Glasgow coma score ≤ 8, skull-based fracture, complex facial fractures, soft-tissue neck injury) were reviewed. Patients were divided into 2 groups based on the presence/absence of risk factors.

RESULTS: A total of 260 patients had CSfx. When screened for high-risk pattern of injury for BCVI, 168 patients were identified and 13 had a BCVI (8%). The remaining 92 patients had isolated low CSfx (C4-C7) without other risk factors for BCVI. In this group, 2 patients were diagnosed with BCVI (2%). Failure to screen all patients with CSfx would have missed 2 of 15 BCVIs (13%).

CONCLUSIONS: We propose that all CS fracture patterns warrant screening for BCVI.

PMID: 22137135 [PubMed - in process]

Mopeds: the legal loophole for repeat driving while intoxicated offenders.

Am J Surg. 2011 Dec;202(6):697-700

Authors: Brintzenhoff RA, Christmas AB, Braxton VG, Janulis KE, Huynh TT, Sing RF

Abstract

BACKGROUND: Mopeds have less stringent licensing laws than automobiles. Moped operators in motorized vehicle collisions (MVCs) exhibit significantly higher rates of driving while intoxicated (DWI) and higher blood alcohol levels than automobile or motorcycle operators. This study evaluates the public safety issue of DWI recidivism among moped operators.

METHODS: Moped operators evaluated after MVCs were identified from 2007 to 2009. Demographics, hospital data, and Department of Motor Vehicles records were reviewed.

RESULTS: Sixty-five moped operators were evaluated. Thirty-two (49%) had a positive blood alcohol level, 29 (45%) had a previous DWI, and 21 (72%) of those were repeat offenders. Twenty-five (38%) had a revoked license at the time of injury. Of these, 19 (76%) incurred multiple revocations. Twenty-two (34%) showed prior charges of driving with a revoked license (DWRL), with 15 (68%) incurring multiple DWRL charges.

CONCLUSIONS: Moped operators are often intoxicated at the time of injury and represent a public safety hazard. The majority are recidivists with multiple alcohol-related traffic charges. Current laws allow repeat offenders the sustained opportunity to operate motorized vehicles. Re-evaluation of current moped laws is needed to keep habitual offenders off the road.

PMID: 22137136 [PubMed - in process]

Implementation of an acute care surgery service at an academic trauma center.

Am J Surg. 2011 Dec;202(6):779-86

Authors: Ciesla DJ, Cha JY, Smith JS, Llerena LE, Smith DJ

Abstract

BACKGROUND: The establishment of acute care surgery is rapidly becoming a solution to meet emergency surgical needs. Challenges include competition for emergency surgery opportunities and the ability to economically sustain a practice.

METHODS: Clinical activity was measured by reviewing the institutional and practice plan databases. Work relative value units and practice plan collection rates defined clinical activity and revenue.

RESULTS: Operative procedures and intensive care unit activity accounted for 52% and 36% of activity, respectively. Although procedures on the digestive tract accounted for half of the operative activity, significant activity was observed in nearly all other systems. Overall clinical productivity remained constant but did demonstrate a 25% increase in operative work relative value units. Current billing activity supports 4.0 clinical full-time equivalents, but estimated collections would cover <73% of physician direct costs.

CONCLUSIONS: The authors describe the implementation of an acute care surgery service that combines trauma, emergency general surgery, and surgical critical care in an established academic surgery department. Developing a sustainable economic model must include income sources other than patient service revenue.

PMID: 22137137 [PubMed - in process]

Esophageal salvage with removable covered self-expanding metal stents in the setting of intrathoracic esophageal leakage.

Am J Surg. 2011 Dec;202(6):796-801

Authors: David EA, Kim MP, Blackmon SH

Abstract

BACKGROUND: Intrathoracic contamination from esophageal perforation, staple line dehiscence, or trauma can be a preterminal event. In our institution, covered self-expanding metal stents have been used aggressively in the management of esophageal leak, but their use remains controversial. The primary objective of this study was to evaluate the efficacy of esophageal salvage using stents to assist in the management of intrathoracic esophageal leakage.

METHODS: Over 38 months, 63 patients with esophageal or gastric leaks were evaluated for stenting as primary treatment and identified using a prospective database.

RESULTS: Fifty-six patients were managed with endoscopic stenting as primary therapy and 30 of those patients required a thoracic intervention after stenting. Seven of these patients required esophageal diversion after stent failure. Thirty-day mortality was 10% in the patients with intrathoracic contamination.

CONCLUSIONS: We suggest that the use of covered self-expanding metal stents in patients with intrathoracic leak after esophageal perforation is safe and offers esophageal salvage in 77% regardless of time of presentation.

PMID: 22137138 [PubMed - in process]

Nonsurgical management of blunt splenic injury: is it cost effective?

Am J Surg. 2011 Dec;202(6):810-6

Authors: Bruce PJ, Helmer SD, Harrison PB, Sirico T, Haan JM

Abstract

BACKGROUND: This study analyzed outcomes and cost of splenic embolization compared with surgery for the management of blunt splenic injury.

METHODS: We performed a retrospective chart review of all patients admitted with isolated, blunt splenic injury. An intent-to-treat analysis was initially conducted. Outcomes and cost/charges were compared in patients treated with embolization and surgical treatment.

RESULTS: Of 236 patients admitted with isolated, blunt splenic injury, 190 patients were ultimately managed by observation, 31 by splenic embolization, and 15 by surgical management. Comparing outcomes and cost data for splenic embolization versus surgical management, there was no significant difference in intensive care unit use, hospital stay, complications, or re-admission. Surgical management patients required more blood transfusions and incurred higher procedure charges. Conversely, splenic embolization patients underwent more radiologic evaluations and charges. Total procedure-related charges were higher for surgical management when compared with splenic embolization ($28,709 vs $19,062; P = .016), but total hospital cost and total hospital charges were not significantly different.

CONCLUSIONS: Nonsurgical treatment of blunt splenic injury is safe and cost effective. Angioembolization was statistically similar to surgical therapy regarding cost.

PMID: 22137139 [PubMed - in process]

Autotransfusion of hemothorax blood in trauma patients: is it the same as fresh whole blood?

Am J Surg. 2011 Dec;202(6):817-22

Authors: Salhanick M, Corneille M, Higgins R, Olson J, Michalek J, Harrison C, Stewart R, Dent D

Abstract

BACKGROUND: Autotransfusable shed blood has been poorly characterized in trauma and may have similarities to whole blood with additional benefits.

METHODS: This was a prospective descriptive study of adult patients from whom ≥50 mL of blood was drained within the first 4 hours after chest tube placement. Pleural and venous blood samples were analyzed for coagulation, hematology, and electrolytes.

RESULTS: Twenty-two subjects were enrolled in 9 months. The following measured coagulation factors of hemothorax were significantly depleted compared with venous blood: international normalized ratio (>9 in contrast to 1.1, P < .001), activated partial thromboplastin time (>180 in contrast to 28.5 seconds, P < .001), and fibrinogen (<50 in contrast to 288 mg/dL, P < .001). The mean hematocrit (26.4 in contrast to 33.9), (P = .003), hemoglobin (9.3 in contrast to 11.8 g/dL, P = .004), and platelet count (53 in contrast to 174 K/μL, P < .001) of hemothorax were significantly lower than venous blood. A hemothorax volume of 726 mL was calculated to be equivalent to 1 U of red blood cells.

CONCLUSIONS: Hemothorax blood contains significantly decreased coagulation factors and has lower hemoglobin when compared with venous blood.

PMID: 22137140 [PubMed - in process]

Gender influences outcomes in trauma patients with elevated systolic blood pressure.

Am J Surg. 2011 Dec;202(6):823-8

Authors: Clond MA, Mirocha J, Singer MB, Bukur M, Salim A, Marguiles DR, Ley EJ

Abstract

BACKGROUND: This analysis explored the association between gender and systolic blood pressure (SBP) in trauma patients and then established how gender influenced outcomes in those with elevated SBP.

METHODS: Demographics and outcomes were compared using the Los Angeles County Trauma System Database and multivariable modeling determined predictors for SBP, pneumonia, and mortality.

RESULTS: Age and male sex were significant predictors for increased SBP, whereas the Injury Severity Score (ISS) ≥16 was a significant predictor for decreased SBP. In both male and female TBI patients, SBP ≥160 mmHg was associated with increased pneumonia (Adjusted odds ratio [AOR] = 1.74, P = .002 and AOR = 2.37, P = .046, respectively), whereas SBP ≥160 mmHg was a predictor for mortality only among male TBI patients (AOR = 1.48, P = .03). In non-TBI patients, SBP ≥160 mmHg was not a predictor for pneumonia or mortality in either sex.

CONCLUSIONS: In this retrospective review of trauma registry data, men presented with higher SBP. In patients with TBI, regardless of gender, increased SBP was associated with increased pneumonia, and in men with TBI increased SBP was associated with increased mortality. The cause and relevance of these epidemiological findings require further investigation.

PMID: 22137141 [PubMed - in process]

Robotic telepresence: a helpful adjunct that is viewed favorably by critically ill surgical patients.

Am J Surg. 2011 Dec;202(6):843-7

Authors: Sucher JF, Todd SR, Jones SL, Throckmorton T, Turner KL, Moore FA

Abstract

BACKGROUND: The purpose of this study was to assess how surgical intensive care unit (SICU) patients and their families would perceive robotic telepresence. We hypothesized that they would view such technology positively.

METHODS: This research was an Institutional Review Board-approved prospective observational study. Our robotic telepresence program augmented the SICU multidisciplinary team rounding process. We anonymously surveyed patients and their families on their perceptions. Those who interacted at least once with the robot served as our participant base.

RESULTS: Twenty-four patients and 26 family members completed the survey. Ninety-two percent of respondents were comfortable with the robot, and 84% believed communication was “easy.” Ninety percent did not perceive the robot as “annoying” and 92% did not believe that “the doctor cared less about them” because of the robot. Ninety-two percent of respondents supported the continued use of the robot.

CONCLUSIONS: Robotic telepresence was viewed positively by patients and their families in the SICU. Furthermore, they believed the robot was beneficial to their care and indicated their support for its continued use.

PMID: 22137142 [PubMed - in process]

War stories: a qualitative analysis of narrative teaching strategies in the operating room.

Am J Surg. 2011 Nov 14;

Authors: Hu YY, Peyre SE, Arriaga AF, Roth EM, Corso KA, Greenberg CC

Abstract

BACKGROUND: “War stories” are commonplace in surgical education, yet little is known about their purpose, construct, or use in the education of trainees. METHODS: Ten complex operations were videotaped and audiotaped. Narrative stories were analyzed using grounded theory to identify emergent themes in both the types of stories being told and the teaching objectives they illustrated. RESULTS: Twenty-four stories were identified in 9 of the 10 cases (mean, 2.4/case). They were brief (mean, 58 seconds), illustrative of multiple teaching points (mean, 1.5/story), and appeared throughout the operations. Anchored in personal experience, these stories taught both clinical (eg, operative technique, decision making, error identification) and programmatic (eg, resource management, professionalism) topics. CONCLUSIONS: Narrative stories are used frequently and intuitively by physicians to emphasize a variety of intraoperative teaching points. They socialize trainees in the culture of surgery and may represent an underrecognized approach to teaching the core competencies. More understanding is needed to maximize their potential.

PMID: 22088266 [PubMed - as supplied by publisher]

SBAR M&M: a feasible, reliable, and valid tool to assess the quality of, surgical morbidity and mortality conference presentations.

Am J Surg. 2011 Nov 14;

Authors: Mitchell EL, Lee DY, Arora S, Kwong KL, Liem TK, Landry GL, Moneta GL, Sevdalis N

Abstract

BACKGROUND: The Surgical Morbidity and Mortality (M&M) conference is considered the golden hour of surgical education. However, evaluation methods for ensuring that quality M&M presentations efficiently contribute to resident education have not been clearly defined. To provide surgical trainees with the skills required to present a quality M&M presentation it is essential to have a robust tool to measure presentation skill and guide formative feedback. METHODS: A prospective observational study was conducted to develop an assessment tool for M&M conference. Literature review and expert consensus provided content for tool development. The tool, created using the situation, background, assessment, and recommendation format, was refined successively based on assessor feedback and assessed for reliability (internal consistency, interassessor reliability) and construct validity. RESULTS: Three successive iterations of the tool were developed. Internal consistency and interassessor reliability improved from the first to third versions. A trend also was shown for increasing construct validity with the third iteration of the tool. CONCLUSIONS: A psychometrically robust assessment tool based on the situation, background, assessment, and recommendation format was developed and validated to identify and improve the overall quality and educational value of the surgical M&M conference.

PMID: 22088267 [PubMed - as supplied by publisher]

Comparing three pedagogical approaches to psychomotor skills acquisition.

Am J Surg. 2011 Nov 14;

Authors: Willis RE, Richa J, Oppeltz R, Nguyen P, Wagner K, Van Sickle KR, Dent DL

Abstract

BACKGROUND: We compared traditional pedagogical approaches such as time- and repetition-based methods with proficiency-based training. METHODS: Laparoscopic novices were assigned randomly to 1 of 3 training conditions. In experiment 1, participants in the time condition practiced for 60 minutes, participants in the repetition condition performed 5 practice trials, and participants in the proficiency condition trained until reaching a predetermined proficiency goal. In experiment 2, practice time and number of trials were equated across conditions. RESULTS: In experiment 1, participants in the proficiency-based training conditions outperformed participants in the other 2 conditions (P < .014); however, these participants trained longer (P < .001) and performed more repetitions (P < .001). In experiment 2, despite training for similar amounts of time and number of repetitions, participants in the proficiency condition outperformed their counterparts (P < .038). In both experiments, the standard deviations for the proficiency condition were smaller than the other conditions. CONCLUSIONS: Proficiency-based training results in trainees who perform uniformly and at a higher level than traditional training methodologies.

PMID: 22088268 [PubMed - as supplied by publisher]

Engaging medical students in the feedback process.

Am J Surg. 2011 Nov 8;

Authors: Rogers DA, Boehler ML, Schwind CJ, Meier AH, Wall JC, Brenner MJ

Abstract

BACKGROUND: There are potential advantages to engaging medical students in the feedback process, but efforts to do so have yielded mixed results. The purpose of this study was to evaluate a student-focused feedback instructional session in an experimental setting. METHODS: Medical students were assigned randomly to either the intervention or control groups and then assigned randomly to receive either feedback or compliments. Tests of knowledge, skills, and attitudes were given before and after the intervention. RESULTS: There was a significant gain of knowledge and skill in the group that received instruction. Satisfaction was higher after compliments in the control group but higher after feedback in the instructional group. There was no change in the subject’s willingness to seek feedback. CONCLUSIONS: A student-focused component should be carefully included as part of an overall effort to improve feedback in surgical education. The role of medical student attitudes about feedback requires further investigation.

PMID: 22075119 [PubMed - as supplied by publisher]

A novel multimodal platform for assessing surgical technical skills.

Am J Surg. 2011 Nov 8;

Authors: Sonnadara R, Rittenhouse N, Khan A, Mihailidis A, Drozdzal G, Safir O, Leung SO

Abstract

BACKGROUND: Established methods for assessing surgical performance face limitations. Global rating scales and procedure-specific checklists are resource intensive and rely on expert opinions. Alternatives that use technology to track hand movements, such as magnetic and optical tracking systems, are generally expensive and ill suited to the surgical environment. METHODS: The authors present a new platform that integrates a novel, low-cost optical tracking system, magnetic tracking technology and a videographic recording system to quantify surgical performance synchronously across all modalities. The validity of this platform was tested by examining its ability to differentiate between the performance of expert and novice participants on a basic surgical task. RESULTS: Each modality was able to differentiate between expert and novice participants, and metrics were well correlated across modalities. CONCLUSIONS: The authors have developed a platform for assessing surgical performance. It can operate in the absence of expert raters and has the potential to provide immediate feedback to trainees.

PMID: 22075120 [PubMed - as supplied by publisher]

How do supervising surgeons evaluate guidance provided in the operating room?

Am J Surg. 2011 Nov 9;

Authors: Chen XP, Williams RG, Sanfey HA, Dunnington GL

Abstract

BACKGROUND: This study explored the amount of guidance provided to residents in the operating room (OR) and the relationship of OR guidance with postgraduate year (PGY) and operative performance rating (OPR). METHODS: We used OPR instruments to collect data from supervising surgeons after each performance. External expert raters blindly rated the amount of guidance for 5 videotaped performances. RESULTS: Three hundred sixty-eight performances were analyzed for 5 procedures performed by 26 residents with 16 supervising surgeons over 6 months. Guidance ratings varied with procedure, individual supervising surgeons varied in the amount of guidance reported, the amount of guidance decreased as residents’ PGY level increased, and the correlation between guidance rating and overall performance was .62. In comparison cases, most supervising surgeons underestimated the amount of guidance provided. CONCLUSIONS: Controlling for the amount of supervising surgeon guidance has important implications for training and evaluation as we strive to prepare residents to practice independently.

PMID: 22079031 [PubMed - as supplied by publisher]

Assessment of the learning curve for pancreaticoduodenectomy.

Am J Surg. 2011 Nov 9;

Authors: Fisher WE, Hodges SE, Wu MF, Hilsenbeck SG, Brunicardi FC

Abstract

BACKGROUND: Experience with the Whipple procedure has been associated with improved outcomes, but the learning curve for this complex procedure is not well defined. METHODS: Outcomes with 162 consecutive Whipple procedures during the 1st 11.5 years of practice was documented in a prospective database. A period of low (≤11/y) and high (≥23/y) case volume was compared using the Wilcoxon rank-sum test and Fisher exact test. RESULTS: With low case volume, blood loss was higher (800 vs 400 mL, P = .001), more patients were transfused (44% vs 18%, P = .027), there were more complications (58% vs 46%, P = .0337), and a longer length of stay (10 vs 7 days, P = .006). There was only 1 mortality (.7%). CONCLUSIONS: Frequent repetition of the Whipple procedure is associated with an improvement in quantifiable quality benchmarks, and improvement continues with extensive experience. However, with proper training and the right environment, this procedure can be performed during the learning curve with acceptable outcomes.

PMID: 22079032 [PubMed - as supplied by publisher]

A preliminary review of a pilot curriculum to teach open surgical skills during general surgery residency with initial feedback.

Am J Surg. 2011 Nov 9;

Authors: Are C, Lomneth C, Stoddard H, Azarow K, Thompson JS

Abstract

INTRODUCTION: The aim of this study is to provide a preliminary review of a pilot curriculum to teach open surgical skills during general surgery residency and obtain initial feedback. DATA SOURCE: The general surgery residency program introduced an open surgical skills training curriculum in 2009. The skills sessions are undertaken under the guidance of the faculty. An annual survey was distributed to the residents and faculty to obtain their feedback. CONCLUSIONS: A total of 50 sessions were conducted over the last 2 years. Ninety-five percent of the residents perceived this educational activity to be above average to exceptional with nearly 70% rating it as exceptional. Sixty-three percent of the faculty perceived it as above average to exceptional, with nearly 40% rating it as exceptional. The open surgical skills training curriculum was rated as the most educational activity in the program by residents and faculty alike.

PMID: 22079033 [PubMed - as supplied by publisher]

Sleep deprivation increases cognitive workload during simulated surgical tasks.

Am J Surg. 2011 Nov 9;

Authors: Tomasko JM, Pauli EM, Kunselman AR, Haluck RS

Abstract

BACKGROUND: There have been conflicting reports of the effects of modest sleep deprivation on surgical skills. The aim of this study was to assess the effects of a 24-hour call shift on technical and cognitive function, as well as the ability to learning a new skill. METHODS: Thirty-one students trained to expert proficiency on a virtual reality part-task trainer. They then were randomized to either a control or sleep-deprived group. On the second testing day they were given a novel task. Fatigue was assessed using the Epworth Sleepiness Scale. The National Aeronautics and Space Administration-Task Load Index was used to assess cognitive capabilities. RESULTS: There was no difference between the control and sleep-deprived groups for performance or learning of surgical tasks. Subjectively, the Epworth Sleepiness Scale showed an increase in sleepiness. The National Aeronautics and Space Administration-Task Load Index showed an increase in total subjective mental workload for the sleep-deprived group. CONCLUSIONS: Sleep-deprived subjects were able to complete the tasks despite the increased workload, and were able to learn a new task proficiently, despite an increase in sleepiness.

PMID: 22079034 [PubMed - as supplied by publisher]

Kindlin-2: a novel adhesion protein related to tumor invasion, lymph node metastasis, and patient outcome in gastric cancer.

Am J Surg. 2011 Nov 4;

Authors: Shen Z, Ye Y, Dong L, Vainionpää S, Mustonen H, Puolakkainen P, Wang S

Abstract

BACKGROUND: Kindlin-2 has been confirmed as an essential element of bidirectional integrin signaling. In recent years, the relationship between Kindlin-2 expression and cancers has been a focus of interest. However, the relationship between Kindlin-2 expression in gastric cancer and tumor invasion, metastasis, and the outcome of patients have not been studied. METHODS: Kindlin-2 expression at protein and RNA levels were detected by Western blot and real-time polymerase chain reaction in 40 pairs of gastric cancer samples. In addition, the correlations between Kindlin-2 expression and clinicopathologic factors as well as the prognosis of the patients were analyzed. Multivariate Cox regression was used to study the effect of Kindlin-2 expression on overall and progression-free survival. RESULTS: We found that Kindlin-2 was up-regulated both at RNA (P = .027) and protein levels (P = .014) in gastric cancer tissues. Tumor samples with high Kindlin-2 expression (Kindlin-2/β-actin:tumor tissue/paraneoplastic tissue, ≥2) was observed in 55% of the patients. Moreover, Kindlin-2 expression had a significant positive correlation with tumor stromal invasion (P = .014), lymph node metastasis (P = .007), and TNM stage (P = .014). Patients with high Kindlin-2 expression had significantly poorer overall survival (P = .012) and progression-free survival (P = .012). High Kindlin-2 expression was an independent risk factor of progression-free survival (hazard ratio, 5.2; 95% confidence interval, 1.1-3.3; P = .032). CONCLUSIONS: Kindlin-2 may play an important role in the development of gastric cancer and it is a potential factor that could be used to evaluate the outcome of gastric cancer. Kindlin-2 may shed new light on evaluating the prognosis and targeted therapy of gastric cancer.

PMID: 22056622 [PubMed - as supplied by publisher]

The effect of junior residents on surgical quality: a study of surgical outcomes in breast surgery.

Am J Surg. 2011 Oct 27;

Authors: Aguilar B, Sheikh F, Pockaj B, Wasif N, Gray R

Abstract

BACKGROUND: Patients are often concerned about the participation of junior trainees in their operative treatment. Breast-conserving therapy (BCT) for nonpalpable breast lesions requires the use of localization devices and carries a significant risk for positive margins of excision. It was therefore hypothesized that the participation of junior residents in BCT operations for nonpalpable breast lesions could result in an increased rate of positive margins of excision. METHODS: Retrospective analysis of a prospective database of all patients with nonpalpable tumors who underwent BCT from August 1999 to August 2009 was performed. Patient and tumor characteristics and factors involved in resection were analyzed. A ≥2-mm margin of normal breast tissue beyond tumor was considered an adequate margin. Chi-square analysis and Student’s t test were performed to determine relationships between independent variables and margin status. RESULTS: Of 308 BCT procedures for nonpalpable tumors, 241 (78%) were performed by attending surgeons and junior residents (group 1) and 67 (22%) by attending surgeons without resident assistance (group 2). The operations for group 1 took significantly longer than the operations for group 2 (mean, 130 vs 116 min, P = .006). Intraoperative reexcision of margins was performed for 37% of group 1 patients and 31% of group 2 patients (P = .249), and reoperation for inadequate margins was performed in 11% of group 1 patients and 13% of group 2 patients (P = .361). CONCLUSIONS: Junior resident participation in BCT procedures was not associated with higher rates of inadequate margins of excision. Patients can be reassured that junior resident involvement in their BCT operations is safe and effective.

PMID: 22036204 [PubMed - as supplied by publisher]

Current surgical approach to Paget’s disease.

Am J Surg. 2011 Oct 27;

Authors: Dominici LS, Lester S, Liao GS, Guo L, Specht M, Smith BL, Golshan M

Abstract

BACKGROUND: Paget’s disease constitutes between 1% and 3% of all breast malignancies, which makes defining standard surgical therapy difficult. We sought to identify preoperative factors that would select patients for successful breast conservation. METHODS: Fifty-one patients with Paget’s disease underwent surgical therapy between October 1998 and January 2010. Clinical presentation of Paget’s disease, preoperative imaging, pathologic tumor characteristics, as well as surgical, radiation, and adjuvant therapies were reviewed. RESULTS: Thirty-seven percent underwent breast conservation whereas 63% underwent mastectomy. Twelve patients presented with a palpable mass, and all were treated with mastectomy. Twenty-two patients underwent a mammogram, identifying extensive abnormality requiring mastectomy. Magnetic resonance imaging added to surgical planning in 52% of patients who participated in the study. None of our patients had a local/regional recurrence at 29 months of follow-up evaluation. CONCLUSIONS: Paget’s disease of the breast can be treated with breast conservation in a properly selected subset of patients. Successful breast conservation was achieved in patients without a palpable finding, a benign mammogram, and a normal magnetic resonance imaging scan.

PMID: 22036205 [PubMed - as supplied by publisher]

Use of computed tomography in the initial evaluation of anterior abdominal stab wounds.

Am J Surg. 2011 Oct 27;

Authors: Berardoni NE, Kopelman TR, O’Neill PJ, August DL, Vail SJ, Pieri PG, Pressman MA

Abstract

BACKGROUND: The purpose of this study was to assess the ability of computed tomography (CT) to facilitate initial management decisions in patients with anterior abdominal stab wounds. METHODS: A retrospective review was conducted of patients with anterior abdominal stab wounds who underwent CT over 4.5 years. Any abnormality suspicious for intra-abdominal injury was considered a positive finding on CT. RESULTS: Ninety-eight patients met the study’s inclusion criteria. Positive findings on CT were noted in 30 patients (31%), leading to operative intervention in 67%. Injuries were confirmed in 95% of cases, but only 70% were therapeutic. Ten patients had nonoperative management despite positive findings on CT, including 5 patients with solid organ injuries. One patient underwent operative intervention for clinical deterioration, with negative findings. No computed tomographic evidence of injury was noted in the remaining 68 patients (69%), but 1 patient was noted to have a splenic injury while undergoing operative evaluation of the diaphragm. All remaining patients were treated nonoperatively with success. CONCLUSIONS: In patients with anterior abdominal stab wounds, CT should be considered to facilitate initial management decisions, as it has the ability to delineate abnormalities suspicious for injury.

PMID: 22036206 [PubMed - as supplied by publisher]

Trauma center designation and the decreasing incidence of post-traumatic acute respiratory distress syndrome: A potential guidepost for quality improvement.

Am J Surg. 2011 Oct 27;

Authors: Plurad DS, Bricker S, Talving P, Lam L, Demetriades D

Abstract

BACKGROUND: The incidence of post-traumatic acute respiratory distress syndrome (ARDS) is decreasing. We hypothesized that disparities exist in the overall incidence and incidence of ARDS over time across different types of trauma centers. METHODS: The National Trauma Databank version 7.0 was queried for patients admitted to designated trauma centers (I-III) and ventilated at least 48 hours. Level I university admissions (group 1) were compared with level I community and level II/III center admissions (group 2). RESULTS: There were 43,664 patients with an incidence of ARDS of 5.2% (2,260) overall, 4.1% (1,062/25,937) in group 1, and 6.8% (1,198/17,727) in group 2 (P < .001). The incidence decreased significantly in group 1 in contrast to group 2 yearly. The incidence in level I community centers was marked (608/5,180 [11.7%]) and increased significantly over time. On logistic regression, admission to a level I university center (.646 [.590-.707],<.001) was independently associated with ARDS. CONCLUSIONS: Admission to a level I center may not necessarily confer similar results reflecting potential variation in management between centers that presumably provide similar service. These investigations may have significance to quality improvement.

PMID: 22036207 [PubMed - as supplied by publisher]

Impact of histology on survival in retroperitoneal sarcoma.

Am J Surg. 2011 Oct 24;

Authors: Brown RE, St Hill CR, Greene QJ, Farmer RW, Reuter NP, Callendar GG, Martin RC, McMasters KM, Scoggins CR

Abstract

BACKGROUND: The current American Joint Committee on Cancer AJCC staging system applies to all soft-tissue sarcomas and does not allow for consideration of many features unique to retroperitoneal sarcomas (RPSs). The aim of this study was to analyze factors predictive of recurrence and survival for patients with resected RPSs. METHODS: This was a retrospective analysis of consecutive patients with primary RPS who underwent resection. A 3-tiered histological classification was examined: atypical lipomatous tumors (ALTs), non-ALT liposarcomas (LPSs), and other. Univariate and multivariate analyses were used to identify factors associated with differences in disease-free survival (DFS) and overall survival (OS) among groups. RESULTS: Sixty RPS patients were analyzed: 16 patients (27%) had ALTs, 7 patients (12%) had LPSs, and 37 patients (62%) had other histologies. A comparison of the 3 groups showed a significant difference in OS among groups (P < .017). High-grade tumors favored shorter DFS (P = .06) but were not associated with decreased OS when compared with low-grade tumors (P = .86). CONCLUSIONS: These findings support an alternative staging system for RPS, inclusive of histology, which may prove useful in operative planning and prognostication.

PMID: 22030405 [PubMed - as supplied by publisher]

Blunt chest trauma: the role of chest x-ray, chest/abdomen computed tomography scan and physical examination.

Am J Surg. 2011 Oct 24;

Authors: Paydar S, Johari HG

PMID: 22030406 [PubMed - as supplied by publisher]

Surgeons provide definitive care to patients with gallstone pancreatitis.

Am J Surg. 2011 Oct 17;

Authors: Judkins SE, Moore EE, Witt JE, Barnett CC, Biffl WL, Burlew CC, Johnson JL

Abstract

BACKGROUND: The optimal management of patients with gallstone pancreatitis (GP) remains a matter of debate. There are wide variations in the use of diagnostic testing and same-stay cholecystectomy. We hypothesize that a general surgery service (SURG) will deliver more efficient, definitive care for patients with GP. METHODS: A retrospective cohort study of consecutive GP patients in an urban hospital from 2006 to 2009. Differences between groups were assessed by the two-tailed Student t test for continuous variables and the Fisher exact test for ordinal data. RESULTS: One hundred twenty-four patients with GP were admitted, 79 to medicine (MED) and 45 to surgery (SURG). In the MED group, 21 patients (27%) underwent same-stay cholecystectomy, and 7 patients (9%) returned with recurrent biliary pancreatitis. In the SURG group, 44 patients had definitive surgery, and none returned with recurrent disease (P < .01 and .09, respectively). The SURG group had fewer laboratory tests, antibiotics, and consultations. CONCLUSIONS: For patients with GP, admission to surgery results in definitive treatment with same-stay cholecystectomy. This is a more efficient approach with fewer readmissions for the same disease process.

PMID: 22014646 [PubMed - as supplied by publisher]

Do the CMS proposed breast cancer quality measures actually predict improved outcomes?

Am J Surg. 2011 Oct 17;

Authors: Dooley W, Squires R, Bong J, Parker J

Abstract

BACKGROUND: In 2007, professional collaborations developed a unified set of quality standards for breast cancer care. METHODS: This was an Institutional Review Board-approved, retrospective review of all breast cancer patients treated initially at University of Oklahoma Medical Center from 2000 to 2008. All tumor registry data were reviewed to test compliance with the Center for Medicare and Medicaid Services (CMS) (Medicare) quality standards. RESULTS: Overall and disease-free survival was better for patients meeting the radiation for breast conservation standard (P < .02). Whether estrogen receptor positive (ER+) or estrogen receptor negative, there were similar statistically significant benefits of combination chemotherapy in overall and disease-free survival rates for all patients with tumors greater than 1 cm in size (P < .05). Hormonal therapy was associated with an overall survival benefit (P < .005) but only a trend toward improvement in disease-free survival (P = .076). CONCLUSIONS: We believe the current CMS standards are a reasonable first step at monitoring breast cancer quality of care. Our data suggest that these may be improved by including combination chemotherapy in ER+ disease when data show a net survival benefit over hormonal therapy alone.

PMID: 22014647 [PubMed - as supplied by publisher]

Availability of acute care surgeons improves outcomes in patients requiring emergent colon surgery.

Am J Surg. 2011 Oct 17;

Authors: Moore LJ, Turner KL, Jones SL, Fahy BN, Moore FA

Abstract

BACKGROUND: The need for emergent colon surgery is a common cause of severe sepsis/septic shock and mortality among surgical patients. We wanted to benchmark our outcomes against those of the National Surgical Quality Improvement Program (NSQIP). We hypothesized that having acute care surgeons to provide comprehensive perioperative care and rapid source control surgery would improve outcome. METHODS: We queried the 2005 to 2007 NSQIP dataset and our prospective database for patients with severe sepsis/septic shock requiring emergency colon surgery. Demographics, Acute Physiology and Chronic Health Evaluation II score, sepsis source, and hospital mortality data were obtained for all patients. RESULTS: Both cohorts were similar with regard to age and sex. The overall mortality rate for patients in our dataset was 28.3% compared with 40.1% in the NSQIP dataset (P = .06). The average Acute Physiology and Chronic Health Evaluation II score for our patients was 31 ± 8.2 with a predicted mortality rate of 73% (P < .0001 when compared with actual mortality rate of 28.3%). CONCLUSIONS: Patients with severe sepsis/septic shock requiring emergent colon surgery have a high mortality rate. Delivery of comprehensive emergency surgical care by acute care surgeons appears to improve survival.

PMID: 22014648 [PubMed - as supplied by publisher]

Portomesenteric venous thrombosis: a community hospital experience with 103 consecutive patients.

Am J Surg. 2011 Oct 17;

Authors: Abraham MN, Mathiason MA, Kallies KJ, Cogbill TH, Shapiro SB

Abstract

BACKGROUND: Portomesenteric venous thrombosis (PMVT) is uncommon but associated with ischemic bowel and mortality. OBJECTIVE: The purpose of this study was to determine the occurrence of PMVT in a community setting and evaluate current diagnosis, treatment, and outcomes. METHODS: Medical records of consecutive patients admitted to a community-based hospital diagnosed with PMVT were reviewed. Patients were divided into 2 groups: those diagnosed from 1997 to 2003 and those diagnosed from 2004 to 2009. RESULTS: One hundred three patients were included. The proportion of chronic PMVT diagnoses increased in the recent group (14% in contrast to 44%, P = .001). Treatment was more common in acute in contrast to chronic PMVTs (70% in contrast to 48%, P = .035). The median length of stay decreased over time (6 in contrast to 3 days, P = .004). Three patients underwent surgical intervention. Overall, 30-day mortality was 17% and did not change over time. CONCLUSIONS: Diagnosis and treatment have changed with increased differentiation between acute and chronic PMVT; outcomes were similar. Surgical intervention was rarely necessary. Mortality is attributed to patient comorbidity rather than PMVT.

PMID: 22014649 [PubMed - as supplied by publisher]

Short-term safety and symptomatic outcomes of transoral incisionless fundoplication with or without hiatal hernia repair in patients with chronic gastroesophageal reflux disease.

Am J Surg. 2011 Oct 18;

Authors: Ihde GM, Besancon K, Deljkich E

Abstract

BACKGROUND: A retrospective community-based study evaluated the safety and symptomatic outcomes of the transoral incisionless fundoplication (TIF) procedure with or without hiatal hernia repair (HHR) in patients with chronic gastroesophageal reflux disease (GERD). MATERIALS AND METHODS: Forty-eight patients underwent TIF using EsophyX (EndoGastric Solutions, Redmond, WA) in 3 community hospitals. Patients who presented with a hiatal hernia 3 cm or more in the greatest transverse diameter underwent laparoscopic HHR before TIF. RESULTS: Forty-two patients completed follow-up assessment at a median of 6 (range 1-11) months. Laparoscopic HHR was performed in 18 (43%) patients before TIF. There were no long-term postoperative complications. GERD-health related quality of life scores indicated heartburn elimination in 63% of patients. The need for daily proton pump inhibitor (PPI) therapy was eliminated in 76% of patients. Atypical symptom relief measured by the median reflux symptom index score reduction was significant (5 [0-47] vs 22 [2-42] on PPIs, P < .001). CONCLUSIONS: Our results support the safety and symptomatic improvement of TIF with or without laparoscopic HHR. The patients’ symptoms were significantly improved, and PPI use was significantly reduced.

PMID: 22014853 [PubMed - as supplied by publisher]

A comparison of postoperative outcomes utilizing a continuous preperitoneal infusion versus epidural for midline laparotomy.

Am J Surg. 2011 Oct 20;

Authors: Gross ME, Nelson ET, Mone MC, Hansen HJ, Sklow B, Glasgow RE, Scaife CL

Abstract

BACKGROUND: Postoperative pain management with a continuous preperitoneal infusion (CPI) for locoregional anesthesia has been shown to have improved postoperative outcomes. This is the first direct comparison of CPI versus epidural infusion (EPI), both in conjunction with systemic analgesia. METHODS: A retrospective review was performed of midline laparotomy cases, comparing the use of CPI with systemic patient-controlled analgesia to EPI with systemic patient-controlled analgesia for postoperative outcomes. RESULTS: A total of 240 cases from 2007 to 2009 were reviewed. There were 41.3% using CPI and 58.7% with EPI. There were no differences with respect to age, body mass index, or American Society of Anesthesiologists score between CPI and EPI cases. In a multivariate model, total hospital stay was 2 days shorter for the CPI group (P < .001), and the total admission cost was less for CPI (by $6,164; P < .001). CONCLUSIONS: The use of CPI results in decreased length of hospital stay, decreased number of days with a Foley catheter, and lower hospital costs, compared with EPI use. These findings show that the routine use of CPI for pain management after laparotomy is a safe alternative to EPI.

PMID: 22018440 [PubMed - as supplied by publisher]

Do topical anesthetics reduce periareolar injectional pain before sentinel lymph node biopsy?

Am J Surg. 2011 Oct 19;

Authors: O’Connor JM, Helmer SD, Osland JS, Cusick TE, Tenofsky PL

Abstract

BACKGROUND: Topical anesthetics have been used in various procedures. The purpose of this study was to evaluate efficacy of lidocaine/prilocaine cream in decreasing the pain of injection for sentinel lymph node biopsy. METHODS: A prospective, randomized, placebo-controlled study was conducted on female breast cancer patients undergoing periareolar injection for sentinel lymph node isolation. Subjects applied lidocaine/prilocaine cream or a placebo cream before injection and completed a survey postoperatively. RESULTS: Twenty treatment and 19 control patients were studied. There was a trend for control subjects to indicate that the injection was “painful” or “extremely painful” more often than treatment subjects (52.6% vs 25.0%, respectively, P = .074). The treatment group was more likely to recommend the cream to other cancer patients (70.0% vs 42.1%), with a trend toward significance (P = .076). CONCLUSIONS: This study showed no statistically significant reduction in pain scores in subjects receiving the topical anesthetic. Further studies targeting patients with low pain tolerance may prove more effective.

PMID: 22018765 [PubMed - as supplied by publisher]

National trends in minimally invasive and open operative experience of graduating general surgery residents: implications for surgical skills curricula development?

Am J Surg. 2011 Oct 19;

Authors: Carson JS, Smith L, Are M, Edney J, Azarow K, Mercer DW, Thompson JS, Are C

Abstract

BACKGROUND: The aim of this study was to analyze national trends in minimally invasive and open cases of all graduating residents in general surgery. METHODS: A retrospective analysis was performed on data obtained from Accreditation Council for Graduate Medical Education logs (1999-2008) of graduating residents from all US general surgery residency programs. Data were analyzed using Mantel-Haenszel χ(2) tests and the Bonferroni adjustment to detect trends in the number of minimally invasive and open cases. RESULTS: Minimally invasive procedures accounted for an increasing proportion of cases performed (3.7% to 11.1%, P < .0001), with a proportional decrease in open cases. An increase in minimally invasive procedures with a proportional decrease in open procedures was noted in subcategories such as alimentary tract, abdominal, vascular, thoracic, and pediatric surgery (P < .0001). CONCLUSIONS: The results of this study demonstrate that general surgery residents in the United States are performing a greater number of minimally invasive and fewer open procedures for common surgical conditions.

PMID: 22018766 [PubMed - as supplied by publisher]

Surgical intern survival skills curriculum as an intern: does it help?

Am J Surg. 2011 Oct 22;

Authors: Todd SR, Fahy BN, Paukert J, Johnson ML, Bass BL

Abstract

BACKGROUND: The transition from medical student to surgical intern is fraught with anxiety. We implemented a surgical intern survival skills curriculum to alleviate this through a series of lectures and interactive sessions. The purpose of this pilot study was to evaluate its effectiveness. METHODS: This was a prospective observational pilot study of our surgical intern survival skills curriculum, the components of which included professionalism, medical documentation, pharmacy highlights, radiographic interpretations, nutrition, and mock clinical pages. The participants completed pre-course and post-course surveys to assess their confidence levels in the elements addressed using a 5-point Likert scale (1 = unsatisfactory, 5 = excellent). A P value of less than .05 was considered significant. RESULTS: In 2009, 8 interns participated in the surgical intern survival skills curriculum. Fifty percent were female and their mean age was 27.5 ± 1.5 years. Of 33 elements assessed, interns rated themselves as more confident in 27 upon completion of the course. CONCLUSIONS: The implementation of a surgical intern survival skills curriculum significantly improved the confidence levels of general surgery interns and seemed to ease the transition from medical student to surgical intern.

PMID: 22019283 [PubMed - as supplied by publisher]

Legal perspective: surgeons and imaging-are self-reads a mistake?

Am J Surg. 2011 Oct 12;

Authors: Mezrich JL

PMID: 22000113 [PubMed - as supplied by publisher]

Acute cholecystitis in high surgical risk patients: percutaneous cholecystostomy or emergency cholecystectomy?

Am J Surg. 2011 Oct 12;

Authors: Rodríguez-Sanjuán JC, Arruabarrena A, Sánchez-Moreno L, González-Sánchez F, Herrera LA, Gómez-Fleitas M

Abstract

BACKGROUND: Percutaneous cholecystostomy (PC) is an alternative treatment in acute cholecystitis (AC) in high-risk or elderly patients although its advantage over emergency cholecystectomy has not yet been established. STUDY DESIGN: AC prospective database analysis in high-risk patients treated by PC (group 1, 29 patients) or emergency cholecystectomy (group 2, 32 patients). Surgical risk was estimated by physiological POSSUM, Charlson, Apache II, and American Society of Anesthesiologists (ASA) scores. RESULTS: The groups showed homogeneity concerning age and surgical risk. PC allowed AC resolution in 19 patients (70.4%), but 8 (29.6%) needed emergency cholecystectomy. Morbidity and mortality rates were 31% and 17.2%, respectively. Mortality was significantly associated with ASA IV (P = .01). In group 2, the morbidity rate was 28.1% without mortality. There was no statistical difference in morbidity (P = .6) although mortality was significantly higher in group 1 (P = .02). CONCLUSIONS: PC seems of little benefit and ought to be left for those very old patients with surgical contraindication.

PMID: 22000114 [PubMed - as supplied by publisher]

The effect of a dedicated endocrine surgery program on general surgery training: a single institutional experience.

Am J Surg. 2011 Oct 12;

Authors: Wiseman JE, Ituarte PH, Ro K, Pasternak JD, Quach CA, Tillou AK, Hines OJ, Hiatt JR, Yeh MW

Abstract

BACKGROUND: The endocrine surgery program was established at the University of California, Los Angeles, in 2006 to enhance the educational experience of surgical residents in this area. The impact of this program on subjective and objective measures of resident education was prospectively tracked. METHODS: Resident case logs, American Board of Surgery In-Training Examination scores, self-assessment surveys, and annual rotation evaluations from July 2005 to June 2009 were reviewed. RESULTS: The mean number of endocrine cases reported by graduates doubled during the study period (from 18 to 36, P < .001). Self-assessment scores increased for thyroid (from 4.53 to 5.76, P = .04) and parathyroid (from 4.46 to 5.90, P = .03) disorders. The mean rating for the endocrine rotation (from 3.23 to 3.95, P = .005) improved, with specific increases in the quantity (from 3.05 to 3.74, P = .02) and quality (from 3.25 to 3.95, P = .002) of operative experience. Since 2006, trainees have coauthored 17 peer-reviewed reports and 3 textbook chapters on endocrine topics. CONCLUSIONS: The establishment of a dedicated endocrine surgery program has a measurable impact on resident education within this core content area.

PMID: 22000115 [PubMed - as supplied by publisher]

Organ donation after traumatic cardiopulmonary arrest.

Am J Surg. 2011 Oct 12;

Authors: Raoof M, Joseph BA, Friese RS, Kulvatunyou N, O’Keeffe T, Tang A, Wynne J, Latifi R, Rhee P

Abstract

BACKGROUND: The gap between demand of transplantable organs and their supply continues to widen. Trauma patients constitute a significant proportion of organ donors. The incidence of organ donation after traumatic cardiopulmonary arrest (TCPA), however, is not clear. The goals of this study were to determine the success rate of organ donation in patients undergoing cardiopulmonary resuscitation (CPR) after trauma and to determine if there are variables that may predict successful organ donation. METHODS: All trauma patients who sustained TCPA from April 2007 to March 2010 were reviewed. We identified all patients who required CPR in the field or the trauma center. Patients were classified as donors if the heart, lung, kidney, small bowel, pancreas, or liver was harvested. Primary outcome was organ donation after CPR. RESULTS: A total of 252 patients required CPR for TCPA in the field or in the trauma center. There were 39 (15.5%) survivors and 213 (84.5%) fatalities. Only 19 of 213 (8.9%) patients who died after TCPA became organ donors. A total of 26 organs were harvested including 15 kidneys, 6 livers, 4 hearts, and 1 pancreas. Of those who failed to donate organs, 64.7% had a cardiac arrest after the donor network had been contacted but before their arrival. CONCLUSIONS: Survival rate after TCPA is low but organ donation is an important secondary outcome. Patients with predominant head injuries, without thoracic and minimal extremity injuries, should be identified as having a higher chance of going on to organ donation. The greatest barrier to organ donation in TCPA patients is cardiac arrest before donor network arrival.

PMID: 22000116 [PubMed - as supplied by publisher]

The impact of biopsy technique on upstaging, residual disease, and outcome in cutaneous melanoma.

Am J Surg. 2011 Oct 12;

Authors: Egnatios GL, Dueck AC, Macdonald JB, Laman SD, Warschaw KE, Dicaudo DJ, Nemeth SA, Sekulic A, Gray RJ, Wasif N, Pockaj BA

Abstract

BACKGROUND: After skin biopsy of malignant melanoma, the findings in the subsequent wide local excision (WLE) sometimes result in upgrading of the T-category. Herein, we examine the influence of biopsy technique on residual disease in melanoma WLE specimens and on upstaging. METHODS: We performed a retrospective review of data from malignant melanoma patients who underwent sentinel lymph node biopsy between 1997 and 2010. RESULTS: A total of 609 patients were biopsied by shave (51%), punch (19%), and excision (30%). Residual disease was seen in 240 patients (39%) at WLE, of whom 60% had undergone shave biopsy. Fifty-nine patients had a T-category upgrade after WLE (10% of all patients); 64% were sampled by shave. Seven percent of patients with a T-category upgrade had negative margins initially. Positive biopsy margin and greater thickness predicted T-category upgrade. CONCLUSIONS: Partial biopsy for melanoma resulted in more residual disease at WLE and a higher rate of T-category upgrade. Moreover, the presence of negative margins at biopsy did not ensure lack of residual disease.

PMID: 22000117 [PubMed - as supplied by publisher]

What is the likelihood of requiring contralateral inguinal hernia repair after unilateral repair?

Am J Surg. 2011 Oct 13;

Authors: Clark JJ, Limm W, Wong LL

Abstract

BACKGROUND: Factors that predispose patients to the development of inguinal hernias will persist after repair. This study aimed to determine the incidence of future contralateral hernia repair. METHODS: We performed a retrospective review of a non-Medicare claims database (1999-2009) to identify patients billed for 2 asynchronous initial inguinal hernia repairs. RESULTS: In this database, 7,050 patients were followed up for a mean of 3.6 years, 272 patients required a contralateral hernia repair. The mean time between hernia repairs was 2.9 years and the same surgeon repaired both hernias in 67.6%. Fifteen patients had incarcerated contralateral hernias (5.5%). Patients who required contralateral repairs were older (62.2 vs 59.6 y; P = .014) and had prostate disease (odds ratio, 1.45; P = .0001). The risk of needing a contralateral inguinal hernia repair at 5 and 10 years of follow-up evaluation was 2.5% and 3.8%, respectively. CONCLUSIONS: Despite a reported 8% to 22% incidence of clinically unsuspected contralateral inguinal hernia, the likelihood of undergoing contralateral repair within 10 years is low at 3.8%.

PMID: 22000721 [PubMed - as supplied by publisher]

Follow-up study after resection of intraductal papillary mucinous neoplasm of the pancreas; special references to the multifocal lesions and development of ductal carcinoma in the remnant pancreas.

Am J Surg. 2011 Oct 12;

Authors: Ohtsuka T, Kono H, Tanabe R, Nagayoshi Y, Mori Y, Sadakari Y, Takahata S, Oda Y, Aishima S, Igarashi H, Ito T, Ishigami K, Nakamura M, Mizumoto K, Tanaka M

Abstract

BACKGROUND: Frequency and characteristics of metachronous occurrence of multifocal intraductal papillary mucinous neoplasms (IPMNs) or distinct pancreatic ductal adenocarcinomas (PDACs) in the remnant pancreas during follow-up evaluation after pancreatectomy for IPMNs have not been well known. The aim of this study was to investigate the outcomes after resection of IPMNs, especially focusing on the metachronous occurrence of multifocal IPMNs and distinct PDACs. METHODS: Medical records of 172 patients who underwent resection of IPMNs were reviewed retrospectively, and the data regarding the occurrence of metachronous IPMNs or PDACs in the remnant pancreas during a mean postoperative follow-up period of 64 months were collected. RESULTS: The incidence including synchronous and metachronous multifocal occurrence of IPMNs was 20% (34 of 172), and that of distinct PDACs was 9.9% (17 of 172). Ten metachronous IPMNs developed in the remnant pancreas after a mean time of 23 postoperative months (range, 12-84 mo), and 2 with main duct IPMNs (both were carcinoma in situ) required remnant pancreatectomy. Six distinct PDACs developed in the remnant pancreas after a mean time of 84 postoperative months (range, 12-150 mo). Four of them were found to have a tumor with a size of less than 2 cm, whereas the remaining 2 PDACs were found to be unresectable more than 10 years after resection of IPMNs. CONCLUSIONS: Intense long-term follow-up evaluation is necessary for the early detection of metachronous occurrence of distinct PDACs as well as malignant IPMNs after resection of IPMNs.

PMID: 21996346 [PubMed - as supplied by publisher]

Increasing minority patient participation in cancer clinical trials using oncology nurse navigation.

Am J Surg. 2011 Oct 12;

Authors: Holmes DR, Major J, Lyonga DE, Alleyne RS, Clayton SM

Abstract

BACKGROUND: Residential distance from an academic or cancer center is a significant barrier to minority patient participation in cancer research. Most cancer clinical trials (CTs) are only accessible at academic and cancer centers, yet most cancer patients receive treatment in their home communities where access to CTs may be limited. Oncology nurse navigation is an innovative approach for increasing minority CT participation by facilitating access to cancer CTs in communities where minority patients live. The purpose of this study was to evaluate the impact of oncology nurse navigation on community-based recruitment of black patients to breast cancer CTs at a major cancer center. METHODS: We merged the roles of a traditional oncology research nurse and a professional patient navigator to create a novel health care provider role, the oncology nurse navigator. The primary duties of the oncology nurse navigator were to engage black cancer patients in the offices of their community physicians and to collaborate with community physicians to increase black patient participation in cancer research. The oncology nurse navigator played a key role in all phases of the CT participation process (e.g., screening for eligibility and completion of informed consent and clinical research forms) and guided each patient around barriers in the health care system. The accrual of eligible patients to breast cancer CTs was used to assess the impact of oncology nurse navigation on community-based recruitment of blacks to cancer CTs. RESULTS: Between January 2007 and December 2008, a total of 132 black breast cancer patients were screened by a single oncology nurse navigator for eligibility to University of Southern California-sponsored breast cancer CTs. Fifty-nine patients were eligible for CTs, and each was invited to participate in 1 or more CTs for which they were eligible. Fifty-one of 59 eligible black patients (86% of eligible patients) were enrolled to 1 or more research protocols. The estimated cost per enrolled patient was $5,677, nearly half the expected per patient cost of treating patients on CT at an academic or cancer center. CONCLUSIONS: Oncology nurse navigation is an effective outreach strategy for increasing black patient participation in cancer research and may be achieved at nearly half the cost of traditional methods of enrolling patients in CTs at cancer centers.

PMID: 21996347 [PubMed - as supplied by publisher]

Postoperative long-term evaluation of interposition reconstruction compared with Roux-en-Y after total gastrectomy in gastric cancer: prospective randomized controlled trial.

Am J Surg. 2011 Sep;202(3):247-53

Authors: Ishigami S, Natsugoe S, Hokita S, Aoki T, Kashiwagi H, Hirakawa K, Sawada T, Yamamura Y, Itoh S, Hirata K, Ohta K, Mafune K, Nakane Y, Kanda T, Furukawa H, Sasaki I, Kubota T, Kitajima M, Aikou T

Abstract

BACKGROUND: The postoperative clinical superiority of the interposition of jejunum reconstruction (INT) to Roux-en-Y reconstruction (RY) after total gastrectomy has not been clarified. Postoperative quality of life (QOL) was evaluated between the 2 methods by a multi-institutional prospective randomized trial.

METHODS: A total of 103 patients with gastric cancer were prospectively randomly divided into groups for RY (n = 51) or INT reconstruction (n = 52) after total gastrectomy. They were stratified by sex, age, institute, histology, and degree of lymph node dissection. Postoperatively, body mass index (BMI) and nutritional conditions were measured serially, and QOL and postoperative squalor scores were evaluated at 3, 12, and 60 months and compared between the 2 groups.

RESULTS: After removing patients who did not complete the follow-up survey or censured cases, 24 patients in the RY group and 18 patients in the INT group were clinically available and their postoperative status was assessed. QOL scores were increased and complication scores were improved in the postoperative periods (P < .01). Postoperative BMI significantly deteriorated compared with preoperative BMI in each group. The postoperative QOL and complication scores at 60 months after surgery were significantly better than those at 3 months after surgery in each group (P < .01). However, there was no significant difference of QOL scores and postoperative complication scores between the 2 reconstruction groups. The nutritional condition in the INT group was nearly the same as that in the RY group.

CONCLUSIONS: Although our patient sample was small and patients who did not complete the follow-up survey were present, we could not identify any clinical difference between INT and RY after total gastrectomy 60 months after surgery. The safer and simpler RY method may be a more suitable reconstruction method than INT after total gastrectomy.

PMID: 21871978 [PubMed - indexed for MEDLINE]

Postoperative long-term evaluation of interposition reconstruction compared with Roux-en-Y after total gastrectomy in gastric cancer: prospective randomized controlled trial.

Am J Surg. 2011 Sep;202(3):247-53

Authors: Ishigami S, Natsugoe S, Hokita S, Aoki T, Kashiwagi H, Hirakawa K, Sawada T, Yamamura Y, Itoh S, Hirata K, Ohta K, Mafune K, Nakane Y, Kanda T, Furukawa H, Sasaki I, Kubota T, Kitajima M, Aikou T

Abstract

BACKGROUND: The postoperative clinical superiority of the interposition of jejunum reconstruction (INT) to Roux-en-Y reconstruction (RY) after total gastrectomy has not been clarified. Postoperative quality of life (QOL) was evaluated between the 2 methods by a multi-institutional prospective randomized trial.

METHODS: A total of 103 patients with gastric cancer were prospectively randomly divided into groups for RY (n = 51) or INT reconstruction (n = 52) after total gastrectomy. They were stratified by sex, age, institute, histology, and degree of lymph node dissection. Postoperatively, body mass index (BMI) and nutritional conditions were measured serially, and QOL and postoperative squalor scores were evaluated at 3, 12, and 60 months and compared between the 2 groups.

RESULTS: After removing patients who did not complete the follow-up survey or censured cases, 24 patients in the RY group and 18 patients in the INT group were clinically available and their postoperative status was assessed. QOL scores were increased and complication scores were improved in the postoperative periods (P < .01). Postoperative BMI significantly deteriorated compared with preoperative BMI in each group. The postoperative QOL and complication scores at 60 months after surgery were significantly better than those at 3 months after surgery in each group (P < .01). However, there was no significant difference of QOL scores and postoperative complication scores between the 2 reconstruction groups. The nutritional condition in the INT group was nearly the same as that in the RY group.

CONCLUSIONS: Although our patient sample was small and patients who did not complete the follow-up survey were present, we could not identify any clinical difference between INT and RY after total gastrectomy 60 months after surgery. The safer and simpler RY method may be a more suitable reconstruction method than INT after total gastrectomy.

PMID: 21871978 [PubMed - indexed for MEDLINE]

Prospective randomized comparative study of single incision laparoscopic cholecystectomy versus conventional four-port laparoscopic cholecystectomy.

Am J Surg. 2011 Sep;202(3):254-8

Authors: Lai EC, Yang GP, Tang CN, Yih PC, Chan OC, Li MK

Abstract

BACKGROUND: This study aimed to compare the outcomes of single-incision laparoscopic cholecystectomy (SILC) versus conventional 4-port laparoscopic cholecystectomy (LC).

METHODS: From November 2009 to August 2010, 51 patients with symptomatic gallstone or gallbladder polyps were randomized to SILC (n = 24) or 4-port LC (n = 27).

RESULTS: Mean surgical time (43.5 vs 46.5 min), median blood loss (1 vs 1 mL) and mean hospital stay (1.5 vs 1.8 d) were similar for both the SILC and 4-port LC group. There were no open conversions and no major complications. The mean total wound length of the SILC group was significantly shorter (1.76 vs 2.25 cm). The median visual analogue pain score at 6 hours after surgery was similar (4.5 vs 4.0) but the SILC group had a significantly worse pain score on day 7 (1 vs 0). There was no difference in time to resume usual activity (mean, 5.6 vs 5.0 d). The median cosmetic score of SILC was significantly higher than at 3 months after surgery (7 vs 6).

CONCLUSIONS: SILC was feasible and safe for properly selected patients in experienced hands.

PMID: 21871979 [PubMed - indexed for MEDLINE]

Prospective randomized comparative study of single incision laparoscopic cholecystectomy versus conventional four-port laparoscopic cholecystectomy.

Am J Surg. 2011 Sep;202(3):254-8

Authors: Lai EC, Yang GP, Tang CN, Yih PC, Chan OC, Li MK

Abstract

BACKGROUND: This study aimed to compare the outcomes of single-incision laparoscopic cholecystectomy (SILC) versus conventional 4-port laparoscopic cholecystectomy (LC).

METHODS: From November 2009 to August 2010, 51 patients with symptomatic gallstone or gallbladder polyps were randomized to SILC (n = 24) or 4-port LC (n = 27).

RESULTS: Mean surgical time (43.5 vs 46.5 min), median blood loss (1 vs 1 mL) and mean hospital stay (1.5 vs 1.8 d) were similar for both the SILC and 4-port LC group. There were no open conversions and no major complications. The mean total wound length of the SILC group was significantly shorter (1.76 vs 2.25 cm). The median visual analogue pain score at 6 hours after surgery was similar (4.5 vs 4.0) but the SILC group had a significantly worse pain score on day 7 (1 vs 0). There was no difference in time to resume usual activity (mean, 5.6 vs 5.0 d). The median cosmetic score of SILC was significantly higher than at 3 months after surgery (7 vs 6).

CONCLUSIONS: SILC was feasible and safe for properly selected patients in experienced hands.

PMID: 21871979 [PubMed - indexed for MEDLINE]

Evaluation of morbidity and mortality after anastomotic leakage following elective colorectal surgery in patients treated with or without mechanical bowel preparation.

Am J Surg. 2011 Sep;202(3):321-4

Authors: van’t Sant HP, Weidema WF, Hop WC, Lange JF, Contant CM

Abstract

BACKGROUND: A previous multicenter randomized trial demonstrated that mechanical bowel preparation (MBP) does not guard against anastomotic leakage in elective colorectal surgery. The aim of this complementary study was to evaluate the effects of MBP on morbidity and mortality after anastomotic leakage in elective colorectal surgery.

METHODS: A subgroup analysis was performed of a randomized trial comparing the incidence of anastomotic leakage and septic complications with and without MBP in patients undergoing elective colorectal surgery.

RESULTS: Elective colorectal surgery was performed in 1,433 patients with primary anastomoses, of whom 63 patients developed anastomotic leakage. Twenty-eight patients (44%) received MBP and 35 patients (56%) did not. Mortality rate, initial need for surgical reintervention, and extent of bowel contamination did not differ between groups (29% vs 40%; P = .497, P = .667, and P = .998, respectively).

CONCLUSIONS: No benefit of MBP was found regarding morbidity and mortality after anastomotic leakage in elective colorectal surgery.

PMID: 21871987 [PubMed - indexed for MEDLINE]

Evaluation of morbidity and mortality after anastomotic leakage following elective colorectal surgery in patients treated with or without mechanical bowel preparation.

Am J Surg. 2011 Sep;202(3):321-4

Authors: van’t Sant HP, Weidema WF, Hop WC, Lange JF, Contant CM

Abstract

BACKGROUND: A previous multicenter randomized trial demonstrated that mechanical bowel preparation (MBP) does not guard against anastomotic leakage in elective colorectal surgery. The aim of this complementary study was to evaluate the effects of MBP on morbidity and mortality after anastomotic leakage in elective colorectal surgery.

METHODS: A subgroup analysis was performed of a randomized trial comparing the incidence of anastomotic leakage and septic complications with and without MBP in patients undergoing elective colorectal surgery.

RESULTS: Elective colorectal surgery was performed in 1,433 patients with primary anastomoses, of whom 63 patients developed anastomotic leakage. Twenty-eight patients (44%) received MBP and 35 patients (56%) did not. Mortality rate, initial need for surgical reintervention, and extent of bowel contamination did not differ between groups (29% vs 40%; P = .497, P = .667, and P = .998, respectively).

CONCLUSIONS: No benefit of MBP was found regarding morbidity and mortality after anastomotic leakage in elective colorectal surgery.

PMID: 21871987 [PubMed - indexed for MEDLINE]

Experience of laparoscopic paraesophageal hernia repair at a single institution.

Am J Surg. 2011 Oct 11;

Authors: Li J, Rosenthal RJ, Roy M, Szomstein S, Sesto M

Abstract

BACKGROUND: Paraesophageal hernia patients are often elderly with complicating medical comorbidities, making surgical management complex in formulating a management strategy. METHODS: Between January 2005 and July 2009, 93 patients underwent surgical treatment of paraesophageal hernia, including 8 recurrent cases after multiple repairs. Open transabdominal surgeries were performed in 14 (15%) patients, and combined thoracotomy was performed in 1 (1%). Laparoscopic surgeries were performed in 78 (84%) patients with 4 (5%) conversions. Artificial prosthetics were used in 27 (29%) patients. Fundoplication was performed in 82 (88%) patients. Gastropexy or feeding tube gastrostomy was performed in 10 (11%) patients. RESULTS: The average length of the surgery was 125 minutes (range, 51-304 min). The mean blood loss was 100 mL. The average length of stay was 4 days (range, 1-14 d). There were 2 mortalities (2%) and 4 re-operations, with a recurrence rate of 2%. CONCLUSIONS: Laparoscopic paraesophageal hernia repair can be performed safely with acceptable results when following a standard approach.

PMID: 21992807 [PubMed - as supplied by publisher]

Comparison of laparoscopic versus open appendectomy for acute nonperforated and perforated appendicitis in the obese population.

Am J Surg. 2011 Oct 11;

Authors: Masoomi H, Nguyen NT, Dolich MO, Wikholm L, Naderi N, Mills S, Stamos MJ

Abstract

BACKGROUND: Use of laparoscopic appendectomy (LA) has been increasing in obese patients. We evaluated the outcomes of LA compared with open appendectomy (OA) in obese patients. METHODS: By using the Nationwide Inpatient Sample database, clinical data of obese patients who underwent LA and OA for suspected acute appendicitis (perforated or nonperforated) from 2006 to 2008 were examined. RESULTS: A total of 42,426 obese patients underwent an appendectomy during this period. In acute nonperforated cases, LA had a lower overall complication rate (7.17% vs 11.72%; P < .01), mortality rate (.09% vs .23%; P < .01), mean hospital charges ($25,193 vs $26,380; P = .04), and shorter mean length of stay (2.0 vs 3.1 d; P < .01) compared with OA. Similarly, in perforated cases, LA was associated with a lower overall complication rate (22.34% vs 34.65%; P < .01), mortality rate (.0% vs .50%; P < .01), mean hospital charges ($36,843 vs $43,901; P < .01), and a shorter mean length of stay (4.4 vs 6.5 d; P < .01) compared with OA. CONCLUSIONS: LA can be performed safely with superior outcomes compared with OA in obese patients and should be considered the procedure of choice for perforated and nonperforated appendicitis in these patients.

PMID: 21992808 [PubMed - as supplied by publisher]

Comment on open intraperitoneal versus retromuscular mesh repair for umbilical hernias less than 3 cm in diameter.

Am J Surg. 2011 Oct 10;

Authors: Voeller G

PMID: 21992809 [PubMed - as supplied by publisher]

Overutilization of regional burn centers for pediatric patients-a healthcare system problem that should be corrected.

Am J Surg. 2011 Oct 10;

Authors: Vercruysse GA, Ingram WL, Feliciano DV

Abstract

BACKGROUND: Minor burns represent .96% to 1.5% of emergency department visits, yet burn center referral is common. Analysis of the Grady Memorial Hospital Burn Center examined the feasibility and savings if pediatric burns were managed locally with as-needed consultation. METHODS: Prospective data on 219 consecutive admissions to Grady Memorial Hospital Burn Center between December 2008 and September 2010 were reviewed. National and international cohorts were compared. RESULTS: Sixty-six percent of patients were male, the mean age was 6.1 years, and 92% were insured. The most common mechanism of burning was liquid scalding (40%). Seventy percent had burns over <10% of the total body surface area, and 73% of all pediatric admissions healed without surgery. Thirty-six percent were discharged within 24 hours of admission. Forty-five percent of patients transferred from other facilities were discharged within 24 hours. Fifteen percent were transported by helicopter; of those, 37% were discharged within 24 hours. Helicopter transport cost $12,500 and averaged 45 miles. CONCLUSIONS: Pediatric burns require assessment, debridement, and dressing changes. Grafting is rarely necessary. Patients are transferred because of a lack of training, and patients suffer economic burden and treatment delay. Savings could be realized were patients treated locally with select burn center referral.

PMID: 21992810 [PubMed - as supplied by publisher]

Swallowing dysfunction after prolonged intubation: analysis of risk factors in trauma patients.

Am J Surg. 2011 Oct 6;

Authors: Bordon A, Bokhari R, Sperry J, Testa D, Feinstein A, Ghaemmaghami V

Abstract

BACKGROUND: The clinical significance of post-extubation swallowing dysfunction (PSD) is profound, resulting in both increased morbidity and mortality. Specific risk factors have not been described in an injured patient cohort. The purpose of this pilot study was to elucidate independent factors that predict PSD in this population. METHODS: A retrospective cohort analysis was performed on 150 consecutive trauma patients intubated for more than 48 hours. Assessment of swallowing function after extubation was performed by a simple bedside speech pathology evaluation. Patients then were divided into 2 groups: those with and those without PSD. Backwards stepwise logistic regression analysis then was used to determine independent predictors of PSD after controlling for important injury characteristics and patient demographics. RESULTS: The incidence of PSD in our study cohort was 41%. Patients with PSD, although older than non-PSD patients (48 vs 37.5 y; P = .001), were similar with respect to admission Glasgow coma score (GCS) and injury severity score. Regression analysis revealed that age older than 55 years (odds ratio, 2.60; P = .037; 95% confidence interval, 1.1-6.4) and ventilator days (odds ratio, 1.14; P = .001; 95% confidence interval, 1.1-1.2) were significant independent risk factors for PSD. Interpretation of these odds ratios revealed that those patients older than age 55 had more than a 2.5-fold greater risk of PSD. The risk increased by 14% for every day a patient required intubation. There was no significant association between PSD and injury severity score, GCS, presence of medical comorbidities, or development of nosocomial pneumonia. CONCLUSIONS: PSD is a common occurrence in trauma patients. Age older than 55 years and ventilator days are independent risk factors for PSD. Injury severity, altered GCS upon arrival, comorbidities, and nosocomial pneumonia were not independent risk factors for PSD in our cohort. These results suggest that older patients with extended intensive care unit stays and ventilator requirements may benefit from early swallowing evaluation.

PMID: 21982681 [PubMed - as supplied by publisher]

Swallowing dysfunction after prolonged intubation: analysis of risk factors in trauma patients.

Am J Surg. 2011 Oct 6;

Authors: Bordon A, Bokhari R, Sperry J, Testa D, Feinstein A, Ghaemmaghami V

Abstract

BACKGROUND: The clinical significance of post-extubation swallowing dysfunction (PSD) is profound, resulting in both increased morbidity and mortality. Specific risk factors have not been described in an injured patient cohort. The purpose of this pilot study was to elucidate independent factors that predict PSD in this population. METHODS: A retrospective cohort analysis was performed on 150 consecutive trauma patients intubated for more than 48 hours. Assessment of swallowing function after extubation was performed by a simple bedside speech pathology evaluation. Patients then were divided into 2 groups: those with and those without PSD. Backwards stepwise logistic regression analysis then was used to determine independent predictors of PSD after controlling for important injury characteristics and patient demographics. RESULTS: The incidence of PSD in our study cohort was 41%. Patients with PSD, although older than non-PSD patients (48 vs 37.5 y; P = .001), were similar with respect to admission Glasgow coma score (GCS) and injury severity score. Regression analysis revealed that age older than 55 years (odds ratio, 2.60; P = .037; 95% confidence interval, 1.1-6.4) and ventilator days (odds ratio, 1.14; P = .001; 95% confidence interval, 1.1-1.2) were significant independent risk factors for PSD. Interpretation of these odds ratios revealed that those patients older than age 55 had more than a 2.5-fold greater risk of PSD. The risk increased by 14% for every day a patient required intubation. There was no significant association between PSD and injury severity score, GCS, presence of medical comorbidities, or development of nosocomial pneumonia. CONCLUSIONS: PSD is a common occurrence in trauma patients. Age older than 55 years and ventilator days are independent risk factors for PSD. Injury severity, altered GCS upon arrival, comorbidities, and nosocomial pneumonia were not independent risk factors for PSD in our cohort. These results suggest that older patients with extended intensive care unit stays and ventilator requirements may benefit from early swallowing evaluation.

PMID: 21982681 [PubMed - as supplied by publisher]

Clinical outcomes of manual bowel decompression (milking) in the mechanical small bowel obstruction: a prospective randomized clinical trial.

Am J Surg. 2011 Oct 7;

Authors: Ezer A, Torer N, Colakoglu T, Colakoglu S, Parlakgumus A, Yildirim S, Moray G

Abstract

BACKGROUND: The aim of this prospective randomized study was to investigate the effects of manual bowel decompression in patients who were operated on for mechanical small bowel obstruction. METHODS: Between March 2008 and February 2010, 40 consecutive patients with mechanical small bowel obstruction were randomized into 2 clinically comparable groups. The intestinal content of the dilated small bowel was caressed to the stomach (by milking) and aspirated via a nasogastric tube in the milking group (group M, n = 20) and left uncaressed in the control Group (group C, n = 20). Patients’ characteristics and general operative outcomes were compared and analyzed. RESULTS: The resumption of a regular diet and postoperative hospital stay (P = .68) were not significantly different in groups M and group C. Similarly, there were no differences between the 2 groups regarding respiratory complications (P = .34), bacterial translocation (P = 1), or wound infection (P = 1). CONCLUSIONS: The findings suggest that routine milking is unnecessary in mechanical small bowel obstruction.

PMID: 21982997 [PubMed - as supplied by publisher]

Clinical outcomes of manual bowel decompression (milking) in the mechanical small bowel obstruction: a prospective randomized clinical trial.

Am J Surg. 2011 Oct 7;

Authors: Ezer A, Torer N, Colakoglu T, Colakoglu S, Parlakgumus A, Yildirim S, Moray G

Abstract

BACKGROUND: The aim of this prospective randomized study was to investigate the effects of manual bowel decompression in patients who were operated on for mechanical small bowel obstruction. METHODS: Between March 2008 and February 2010, 40 consecutive patients with mechanical small bowel obstruction were randomized into 2 clinically comparable groups. The intestinal content of the dilated small bowel was caressed to the stomach (by milking) and aspirated via a nasogastric tube in the milking group (group M, n = 20) and left uncaressed in the control Group (group C, n = 20). Patients’ characteristics and general operative outcomes were compared and analyzed. RESULTS: The resumption of a regular diet and postoperative hospital stay (P = .68) were not significantly different in groups M and group C. Similarly, there were no differences between the 2 groups regarding respiratory complications (P = .34), bacterial translocation (P = 1), or wound infection (P = 1). CONCLUSIONS: The findings suggest that routine milking is unnecessary in mechanical small bowel obstruction.

PMID: 21982997 [PubMed - as supplied by publisher]

Subcutaneous delivery of nanoconjugated doxorubicin and cisplatin for locally advanced breast cancer demonstrates improved efficacy and decreased toxicity at lower doses than standard systemic combination therapy in vivo.

Am J Surg. 2011 Oct 7;

Authors: Cohen SM, Mukerji R, Cai S, Damjanov I, Forrest ML, Cohen MS

Abstract

BACKGROUND: Combination cytotoxic agents in breast cancer carry dose-limiting toxicities. The aim of this study was to test the hypothesis that nanocarrier-conjugated doxorubicin and cisplatin would have improved tumor efficacy with decreased systemic toxicity over standard drugs, even at lower doses. METHODS: Female Nu/Nu mice were injected in the breast with human MDA-MB-468LN cells and treated with either standard or nanocarrier-conjugated combination therapy (doxorubicin plus cisplatin) at 50% or 75% maximum tolerated dose (MTD) and monitored for efficacy and toxicity over 12 weeks. RESULTS: Efficacy results for mice treated with hyaluronan-conjugated doxorubicin and cisplatin at 50% MTD were as follows: 5 complete responses, 2 partial responses, and 1 case of stable disease. For hyaluronan-conjugated doxorubicin and cisplatin at 75% MTD, efficacy results were as follows: 7 complete responses, 1 partial response. All complete responses were confirmed histologically. In comparison, mice given standard doxorubicin and cisplatin at 50% MTD demonstrated progressive disease in 6, stable disease in 1, and partial response in 1. For standard doxorubicin and cisplatin at 75% MTD, there were 5 cases of progressive disease and 3 of stable disease (P < .0001 on multivariate analysis of variance). At 75% MTD, standard drug-treated mice had significant weight loss compared to nanocarrier drug-treated mice (P < .001). CONCLUSIONS: Subcutaneous nanocarrier delivery of doxorubicin and cisplatin demonstrated significantly improved efficacy with decreased toxicity compared with standard agent combination therapy at all doses tested, achieving complete pathologic tumor response.

PMID: 21982998 [PubMed - as supplied by publisher]

Subcutaneous delivery of nanoconjugated doxorubicin and cisplatin for locally advanced breast cancer demonstrates improved efficacy and decreased toxicity at lower doses than standard systemic combination therapy in vivo.

Am J Surg. 2011 Oct 7;

Authors: Cohen SM, Mukerji R, Cai S, Damjanov I, Forrest ML, Cohen MS

Abstract

BACKGROUND: Combination cytotoxic agents in breast cancer carry dose-limiting toxicities. The aim of this study was to test the hypothesis that nanocarrier-conjugated doxorubicin and cisplatin would have improved tumor efficacy with decreased systemic toxicity over standard drugs, even at lower doses. METHODS: Female Nu/Nu mice were injected in the breast with human MDA-MB-468LN cells and treated with either standard or nanocarrier-conjugated combination therapy (doxorubicin plus cisplatin) at 50% or 75% maximum tolerated dose (MTD) and monitored for efficacy and toxicity over 12 weeks. RESULTS: Efficacy results for mice treated with hyaluronan-conjugated doxorubicin and cisplatin at 50% MTD were as follows: 5 complete responses, 2 partial responses, and 1 case of stable disease. For hyaluronan-conjugated doxorubicin and cisplatin at 75% MTD, efficacy results were as follows: 7 complete responses, 1 partial response. All complete responses were confirmed histologically. In comparison, mice given standard doxorubicin and cisplatin at 50% MTD demonstrated progressive disease in 6, stable disease in 1, and partial response in 1. For standard doxorubicin and cisplatin at 75% MTD, there were 5 cases of progressive disease and 3 of stable disease (P < .0001 on multivariate analysis of variance). At 75% MTD, standard drug-treated mice had significant weight loss compared to nanocarrier drug-treated mice (P < .001). CONCLUSIONS: Subcutaneous nanocarrier delivery of doxorubicin and cisplatin demonstrated significantly improved efficacy with decreased toxicity compared with standard agent combination therapy at all doses tested, achieving complete pathologic tumor response.

PMID: 21982998 [PubMed - as supplied by publisher]

Resident fatigue in 2010: Where is the beef?

Am J Surg. 2011 Oct 7;

Authors: Hegar MV, Truitt MS, Mangram AJ, Dunn EL

Abstract

BACKGROUND: The Accreditation Council for Graduate Medical Education Common Program Requirements for all residency programs (effective July 1, 2011) will limit postgraduate year-1 duty hour length to 16 hours of call. Previous studies have shown some decrement in post-call task performance. We designed a study to evaluate if these decrements still exist in 2010 and to determine specifically when they occur. METHODS: Fourteen residents were tested on 4 simulator tasks during 5 separate call periods. These tasks were completed serially at 4 different time (T) intervals (T0, T12, T18, and T24) over a 24-hour period. Task performance was measured at each of these intervals. The residents completed a post-call survey. RESULTS: Over the 24-hour call there was a trend toward decreased time for the completion of tasks with preservation of accuracy and efficiency. The performance of some residents actually improved and there was minimal correlation between perceived fatigue and performance. CONCLUSIONS: These data show no decrease in junior or senior resident task performance over a 24-hour call period, and do not support the 2011 Accreditation Council for Graduate Medical Education maximum duty hour length of 16 hours.

PMID: 21982999 [PubMed - as supplied by publisher]

Resident fatigue in 2010: Where is the beef?

Am J Surg. 2011 Oct 7;

Authors: Hegar MV, Truitt MS, Mangram AJ, Dunn EL

Abstract

BACKGROUND: The Accreditation Council for Graduate Medical Education Common Program Requirements for all residency programs (effective July 1, 2011) will limit postgraduate year-1 duty hour length to 16 hours of call. Previous studies have shown some decrement in post-call task performance. We designed a study to evaluate if these decrements still exist in 2010 and to determine specifically when they occur. METHODS: Fourteen residents were tested on 4 simulator tasks during 5 separate call periods. These tasks were completed serially at 4 different time (T) intervals (T0, T12, T18, and T24) over a 24-hour period. Task performance was measured at each of these intervals. The residents completed a post-call survey. RESULTS: Over the 24-hour call there was a trend toward decreased time for the completion of tasks with preservation of accuracy and efficiency. The performance of some residents actually improved and there was minimal correlation between perceived fatigue and performance. CONCLUSIONS: These data show no decrease in junior or senior resident task performance over a 24-hour call period, and do not support the 2011 Accreditation Council for Graduate Medical Education maximum duty hour length of 16 hours.

PMID: 21982999 [PubMed - as supplied by publisher]

The professionalism curriculum as a cultural change agent in surgical residency education.

Am J Surg. 2011 Oct 7;

Authors: Hochberg MS, Berman RS, Kalet AL, Zabar SR, Gillespie C, Pachter HL,

Abstract

BACKGROUND: Teaching professionalism effectively to fully engaged residents is a significant challenge. A key question is whether the integration of professionalism into residency education leads to a change in resident culture. METHODS: The goal of this study was to assess whether professionalism has taken root in the surgical resident culture 3 years after implementing our professionalism curriculum. Evidence was derived from 3 studies: (1) annual self-assessments of the residents’ perceived professionalism abilities to perform 20 defined tasks representing core Accrediting Council on Graduate Medical Education professionalism domains, (2) objective metrics of their demonstrated professionalism skills as rated by standardized patients annually using the objective structure clinical examination tool, and (3) a national survey of the Surgical Professionalism and Interpersonal Communications Education Study Group. RESULTS: Study 1: aggregate perceived professionalism among surgical residents shows a statistically significant positive trend over time (P = .016). Improvements were seen in all 6 domains: accountability, ethics, altruism, excellence, patient sensitivity, and respect. Study 2: the cohort of residents followed up over 3 years showed a marked improvement in their professionalism skills as rated by standardized patients using the objective structure clinical examination tool. Study 3: 41 members of the national Surgical Professionalism and Interpersonal Communications Education Study Group rated their residents’ skills in admitting mistakes, delivering bad news, communication, interdisciplinary respect, cultural competence, and handling stress. Twenty-nine of the 41 responses rated their residents as “slightly better” or “much better” compared with 5 years ago (P = .001). Thirty-four of the 41 programs characterized their department’s leadership view toward professionalism as “much better” compared with 5 years ago. CONCLUSIONS: All 3 assessment methods suggest that residents feel increasingly prepared to effectively deal with the professionalism challenges they face. Although professionalism seminars may have seemed like an oddity several years ago, residents today recognize their importance and value their professionalism skills. As importantly, department chairpersons report that formal professionalism education for residents is viewed more favorably compared with 5 years ago.

PMID: 21983000 [PubMed - as supplied by publisher]

The professionalism curriculum as a cultural change agent in surgical residency education.

Am J Surg. 2011 Oct 7;

Authors: Hochberg MS, Berman RS, Kalet AL, Zabar SR, Gillespie C, Pachter HL,

Abstract

BACKGROUND: Teaching professionalism effectively to fully engaged residents is a significant challenge. A key question is whether the integration of professionalism into residency education leads to a change in resident culture. METHODS: The goal of this study was to assess whether professionalism has taken root in the surgical resident culture 3 years after implementing our professionalism curriculum. Evidence was derived from 3 studies: (1) annual self-assessments of the residents’ perceived professionalism abilities to perform 20 defined tasks representing core Accrediting Council on Graduate Medical Education professionalism domains, (2) objective metrics of their demonstrated professionalism skills as rated by standardized patients annually using the objective structure clinical examination tool, and (3) a national survey of the Surgical Professionalism and Interpersonal Communications Education Study Group. RESULTS: Study 1: aggregate perceived professionalism among surgical residents shows a statistically significant positive trend over time (P = .016). Improvements were seen in all 6 domains: accountability, ethics, altruism, excellence, patient sensitivity, and respect. Study 2: the cohort of residents followed up over 3 years showed a marked improvement in their professionalism skills as rated by standardized patients using the objective structure clinical examination tool. Study 3: 41 members of the national Surgical Professionalism and Interpersonal Communications Education Study Group rated their residents’ skills in admitting mistakes, delivering bad news, communication, interdisciplinary respect, cultural competence, and handling stress. Twenty-nine of the 41 responses rated their residents as “slightly better” or “much better” compared with 5 years ago (P = .001). Thirty-four of the 41 programs characterized their department’s leadership view toward professionalism as “much better” compared with 5 years ago. CONCLUSIONS: All 3 assessment methods suggest that residents feel increasingly prepared to effectively deal with the professionalism challenges they face. Although professionalism seminars may have seemed like an oddity several years ago, residents today recognize their importance and value their professionalism skills. As importantly, department chairpersons report that formal professionalism education for residents is viewed more favorably compared with 5 years ago.

PMID: 21983000 [PubMed - as supplied by publisher]

Comparison of perioperative outcomes in patients undergoing laparoscopic versus open abdominoperineal resection.

Am J Surg. 2011 Oct 7;

Authors: Simorov A, Reynoso JF, Dolghi O, Thompson JS, Oleynikov D

Abstract

BACKGROUND: The aim of this study was to retrospectively compare the outcomes of laparoscopic abdominoperineal resection (APR) and open APR. METHODS: A multicenter, retrospective analysis was performed. The University HealthSystem Consortium database was accessed and searched for International Classification of Diseases, Ninth Revision, codes between October 2008 and January 2010. Discharge data were collected on patients undergoing laparoscopic APR and open APR. RESULTS: Six hundred sixty-seven patients underwent laparoscopic APR, and 2,443 underwent open APR. When lower risk patient groups with minor or moderate severity of illness were compared, laparoscopic APR showed lower morbidity, reduced length of stay, reduced cost, and reduced incidence of intensive care unit admission. Comparative analysis showed no significant difference in mortality rate or 30-day readmission. When higher risk patients were compared, there were significantly reduced costs and reduced incidence of intensive care unit cases in the laparoscopic group. CONCLUSIONS: Patients undergoing laparoscopic APR had overall superior perioperative outcomes compared with those undergoing open APR. Laparoscopic APR demonstrates excellent perioperative outcomes in appropriately selected patients.

PMID: 21983001 [PubMed - as supplied by publisher]

Comparison of perioperative outcomes in patients undergoing laparoscopic versus open abdominoperineal resection.

Am J Surg. 2011 Oct 7;

Authors: Simorov A, Reynoso JF, Dolghi O, Thompson JS, Oleynikov D

Abstract

BACKGROUND: The aim of this study was to retrospectively compare the outcomes of laparoscopic abdominoperineal resection (APR) and open APR. METHODS: A multicenter, retrospective analysis was performed. The University HealthSystem Consortium database was accessed and searched for International Classification of Diseases, Ninth Revision, codes between October 2008 and January 2010. Discharge data were collected on patients undergoing laparoscopic APR and open APR. RESULTS: Six hundred sixty-seven patients underwent laparoscopic APR, and 2,443 underwent open APR. When lower risk patient groups with minor or moderate severity of illness were compared, laparoscopic APR showed lower morbidity, reduced length of stay, reduced cost, and reduced incidence of intensive care unit admission. Comparative analysis showed no significant difference in mortality rate or 30-day readmission. When higher risk patients were compared, there were significantly reduced costs and reduced incidence of intensive care unit cases in the laparoscopic group. CONCLUSIONS: Patients undergoing laparoscopic APR had overall superior perioperative outcomes compared with those undergoing open APR. Laparoscopic APR demonstrates excellent perioperative outcomes in appropriately selected patients.

PMID: 21983001 [PubMed - as supplied by publisher]

High resolution intra-operative two-dimensional specimen mammography and its impact on second operation for re-excision of positive margins at final pathology after breast conservation surgery.

Am J Surg. 2011 Oct;202(4):387-94

Authors: Bathla L, Harris A, Davey M, Sharma P, Silva E

Abstract

BACKGROUND: In the United States, about 50% to 66% of women undergoing breast conservation surgery for cancer undergo subsequent mastectomy for positive margins on initial lumpectomy. This is despite the fact that screening mammography has resulted in a decrease in the size of newly diagnosed breast cancer to <2 cm.

METHODS: A retrospective review of 128 patients who underwent breast conservation surgery for early breast cancer was performed using intraoperative 2-dimensional Faxitron high-resolution specimen mammography without specimen compression as the only margin assessment technique. Of these, 29 patients had histories of lumpectomy with positive margins.

RESULTS: A total of 131 procedures were performed. Margins were histologically clear at initial breast conservation surgery in 84.3% of patients who underwent primary lumpectomy. Subsequent reexcision for positive margins was required in 14.7% of patients. Two-dimensional Faxitron mammographically guided intraoperative reexcision cleared the margins in 95.8% of patients (23 of 24) who would have otherwise required subsequent reexcision.

CONCLUSIONS: Intraoperative 2-dimensional Faxitron high-resolution specimen mammography can decrease rates of margin positivity and has the potential to diminish the number of subsequent undesired mastectomies for positive margins.

PMID: 21943945 [PubMed - in process]

Hypotension is 100 mm Hg on the battlefield.

Am J Surg. 2011 Oct;202(4):404-8

Authors: Eastridge BJ, Salinas J, Wade CE, Blackbourne LH

Abstract

BACKGROUND: Historically, emergency physicians and trauma surgeons have referred to a systolic blood pressure (SBP) of 90 mm Hg as hypotension. Recent evidence from the civilian trauma literature suggests that 110 mm Hg may be more appropriate based on associated acidosis and outcome measures. In this analysis, we sought to determine the relationship between SBP, hypoperfusion, and mortality in the combat casualty.

METHODS: A total of 7,180 US military combat casualties from the Joint Theater Trauma Registry from 2002 to 2009 were analyzed with respect to admission SBP, base deficit, and mortality. Base deficit, as a measure of hypoperfusion, and mortality were plotted against 10-mm Hg increments in admission SBP.

RESULTS: By plotting SBP, baseline mortality was less than 2% down to a level of 101 to 110 mm Hg, at which point the slope of the curve increased dramatically to a mortality rate of 45.1% in casualties with an SBP of 60 mm Hg or less but more than 0 mm Hg. A presenting SBP of 0 mm Hg was associated with 100% mortality. The data also established a similar effect for base deficit with a sharp increase in the rate of acidosis, which became manifest at an SBP in the range of 90 to 100 mm Hg.

CONCLUSIONS: This analysis shows that an SBP of 100 mm Hg or less may be a better and more clinically relevant definition of hypotension and impending hypoperfusion in the combat casualty. One utility of this analysis may be the more expeditious identification of battlefield casualties in need of life-saving interventions such as the need for blood or surgical intervention.

PMID: 21943946 [PubMed - in process]

Should we, not could we? A commentary on “Pyloric valve transposition as substitute for a colostomy in humans: a preliminary report”.

Am J Surg. 2011 Oct;202(4):417-8

Authors: Fleshman JW

PMID: 21943947 [PubMed - in process]