Immediate laparoscopic adrenalectomy versus observation: cost evaluation for incidental adrenal lesions with atypical imaging characteristics.

Am J Surg. 2012 May 14;

Authors: Melck AL, Rosengart MR, Armstrong MJ, Stang MT, Carty SE, Yip L

Abstract

BACKGROUND: Because of controversy in the management of nonfunctional adrenal masses <6 cm with lipid-poor imaging characteristics, the study was conducted to compare the costs of observation versus immediate laparoscopic adrenalectomy. METHODS: A total of 370 patients who were evaluated for incidental adrenal masses between January 1999 and December 2007 were identified, and 32 (8.7%) patients had lesions with imaging characteristics that were inconsistent with a benign adenoma (ie, atypical appearing). Sixteen patients underwent immediate surgery and 16 had observation with serial imaging and biochemical studies. The associated total costs were subjected to intention-to-treat analysis. RESULTS: In the observation cohort, 7 patients converted and underwent adrenalectomy after a mean of 13.1 months. Initially, costs of immediate surgery exceeded those of observation ($12,015.72 vs $11,601.18, P = .10). After projecting costs of annual surveillance, a cost advantage for immediate surgery was demonstrated after 9 years (P = .02). CONCLUSIONS: In patients with <6 cm atypical-appearing adrenal lesions, the costs of surgery and of observation are initially equal. After 9 years, the costs of surveillance exceed that of initial laparoscopic adrenalectomy.

PMID: 22591697 [PubMed - as supplied by publisher]

Clinicopathologic characteristics of patients with non-B non-C hepatitis virus hepatocellular carcinoma after hepatectomy.

Am J Surg. 2012 May 14;

Authors: Kaibori M, Ishizaki M, Matsui K, Kwon AH

Abstract

BACKGROUND: A substantial population of hepatocellular carcinoma (HCC) patients is negative for markers of hepatitis B virus and hepatitis C virus (HCV) infection (non-B non-C hepatitis virus [NBC]). METHODS: Clinicopathologic data and outcomes were compared retrospectively for HCC patients with hepatitis B virus, HCV, and NBC who had undergone hepatectomy. RESULTS: The TNM stage was significantly higher, and the prevalence of cirrhosis was significantly lower, in the NBC group compared with the HCV group. Among patients with a maximum tumor diameter of 5 cm or less, the survival rates were significantly higher in the NBC group than in the HCV group. Multivariate analysis revealed that preoperative serum des-gamma-carboxy prothrombin (DCP) level was a prognostic factor for survival in NBC-HCC patients. The DCP/tumor size ratio was significantly higher in NBC-HCC patients with normal liver histology than in patients with hepatitis or cirrhosis. CONCLUSIONS: NBC-HCC patients had more advanced tumors compared with HCV-HCC patients, but significantly higher survival rates. Measurement of DCP potentially is significant for early diagnosis of NBC HCC, which may increase the chance of curative therapy without recurrence.

PMID: 22591698 [PubMed - as supplied by publisher]

The surgery clerkship: an opportunity for preclinical credentialing in urinary catheterization.

Am J Surg. 2012 May 14;

Authors: Yang RL, Reinke CE, Mittal MK, Kean CR, Diaz E, Fishman NO, Morris JB, Kelz RR

Abstract

BACKGROUND: At our hospital, medical students lost privileges to perform urinary catheterization because of concern regarding catheter-associated urinary tract infections. We hypothesized that trained medical students could perform urinary catheterization with the same proficiency as licensed practitioners. METHODS: Medical students completed a credentialing program in urinary catheterization. Prospectively, the rate of catheter-associated urinary tract infections after urinary catheterization performed by medical students was compared with the health system-wide rate of catheter-associated urinary tract infections after urinary catheterization performed by non-medical students using an incidence rate ratio (IRR). RESULTS: Over 9 months, a total of 432 and 55,401 catheter days accrued in patients who underwent urinary catheterization by medial students and non-medical students, resulting in 1 and 129 catheter-associated urinary tract infections, respectively. The incidence rate of catheter-associated urinary tract infections per 1,000 catheter days was 2.31 in the medical student-placed catheters and 2.33 in the non-MS-placed catheters (IRR = .99, P = .55). CONCLUSIONS: Preclinical credentialing in urinary catheterization resulted in the reinstatement of urinary catheterization privileges to qualified medical students. Student proficiency in urinary catheterization can match that of licensed practitioners.

PMID: 22591699 [PubMed - as supplied by publisher]

Facilitating safer surgery and anesthesia in a disaster zone.

Am J Surg. 2012 May 14;

Authors: Jawa RS, Zakrison TL, Richards AT, Young DH, Heir JS

PMID: 22591700 [PubMed - as supplied by publisher]

Mechanism, assessment, and incidence of male infertility after inguinal hernia surgery: a review of the preclinical and clinical literature.

Am J Surg. 2012 May 10;

Authors: Tekatli H, Schouten N, van Dalen T, Burgmans I, Smakman N

Abstract

BACKGROUND: The treatment of inguinal hernia has changed considerably over the past 15 years. We reviewed the preclinical and clinical literature to find out the effect of inguinal hernia surgery on male fertility because it has been suggested that hernia surgery may impair testicular function and male fertility. DATA SOURCES: A search on Embase, MEDLINE, and the Cochrane Library was performed to find related articles. CONCLUSIONS: Animal models show substantial effects of hernia repair on the structures in the spermatic cord, which is more pronounced in mesh repairs. Although the number of studies and the included numbers of patients were limited, clinical studies indicate that these potential adverse effects do not seem to have a clinical impact on male fertility in humans with inguinal hernias. Future clinical studies, preferably with bilateral patients, are necessary to investigate the clinical relevance of the effects of inguinal hernia and hernia surgery on male fertility.

PMID: 22578405 [PubMed - as supplied by publisher]

Beta-blocker exposure in the absence of significant head injuries is associated with reduced mortality in critically ill patients.

Am J Surg. 2012 May 10;

Authors: Bukur M, Lustenberger T, Cotton B, Arbabi S, Talving P, Salim A, Ley EJ, Inaba K

Abstract

BACKGROUND: The effect of β-blockade in trauma patients without significant head injuries is unknown. The purpose of this investigation was to determine the impact of β-blocker exposure on mortality in critically injured trauma patients who did not sustain significant head injuries. METHODS: Critically ill trauma patients (Injury Severity Score ≥ 25) admitted to the surgical intensive care unit from January 2000 to December 2008 without severe traumatic brain injuries (head Abbreviated Injury Score ≥ 3) were included in this retrospective review. Patients who received β-blockers within 30 days of intensive care unit admission were compared with those who did not. The primary outcome measure evaluated was in-hospital mortality. RESULTS: During the 9-year study period, 663 critically injured patients (Injury Severity Score ≥ 25) were admitted to the intensive care unit. Of these, 98 patients (14.8%) received β-blockers. Patients exposed to β-blockers had significantly lower in-hospital mortality (11.2% vs 19.3%, P = .006). Stepwise logistic regression identified β-blocker use as an independent protective factor for mortality (adjusted odds ratio, .37; P = .007) in critically injured patients. CONCLUSIONS: Beta-blocker exposure was associated with reduced mortality in critically injured patients without head injuries. Prospective validation of this finding is warranted.

PMID: 22578406 [PubMed - as supplied by publisher]

The role of sentinel lymph node biopsy in select sarcoma patients: a meta-analysis.

Am J Surg. 2012 May 10;

Authors: Wright S, Armeson K, Hill EG, Streck C, Leddy L, Cole D, Esnaola N, Camp ER

Abstract

BACKGROUND: Sentinel lymph node (SLN) biopsy is a staging technique for occult lymph node disease. SLN biopsy has been applied to select patients with sarcoma, although the clinical utility remains uncertain. METHODS: A PubMed/MEDLINE literature search was performed, and SLN biopsy outcomes were analyzed using a Bayesian meta-analytic approach to obtain point and interval estimates of rates of interest. RESULTS: Sixteen studies involving SLN biopsy in patients with sarcoma were identified. Of 114 patients reported, 14 patients had positive SLNs (crude estimate, 12%; meta-analysis estimate, 17%). The meta-analysis false-negative rate was 29% (95% credible interval, 5%-59%). Recurrence and death rates in the SLN-positive group were higher than in the SLN-negative group. CONCLUSIONS: This investigation highlights the current role of SLN biopsy in select patients with sarcoma for tumor staging. Questions regarding the high false-negative rate and management of micrometastatic lymphatic disease in patients with sarcoma still exist.

PMID: 22578407 [PubMed - as supplied by publisher]

Management of the focal nodular hyperplasia of the liver: evaluation of the surgical treatment comparing with observation only.

Am J Surg. 2012 May 10;

Authors: Perrakis A, Demir R, Müller V, Mulsow J, Aydin U, Alibek S, Hohenberger W, Yedibela S

Abstract

BACKGROUND: Long-term results of both surgery and observation for patients with focal nodular hyperplasia (FNH) in a large single-center experience do not exist. Accordingly, the aim of this study was to compare long-term outcomes in patients with FNH who underwent either elective hepatectomy or observation alone. METHODS: A retrospective single-institution analysis of 185 patients with FNH, treated from 1990 to 2009, was performed. RESULTS: Seventy-eight patients underwent elective hepatectomy and 107 patients observation alone, with a median follow-up period of 113 months. There was no perioperative mortality. Postoperative complications were recorded in 12 patients, and 92% of patients reported symptomatic reductions. Among observation patients, 9 (13%) developed additional symptoms; tumor enlargement was seen in 3 patients (4%). CONCLUSIONS: Elective liver resection for FNH is a safe procedure at high-volume centers. This single-center experience showed that 13% of observed patients had protracted symptoms. This justifies the therapeutic algorithm that elective surgery should be considered in symptomatic patients or in those with marked enlargement.

PMID: 22578408 [PubMed - as supplied by publisher]

True pancreaticoduodenal aneurysms with celiac stenosis or occlusion.

Am J Surg. 2012 May 10;

Authors: Brocker JA, Maher JL, Smith RW

Abstract

BACKGROUND: Pancreaticoduodenal artery (PDA) aneurysms are rare, representing only 2% of all visceral artery aneurysms. True PDA aneurysms associated with celiac stenosis or occlusion make up an even smaller subset of this group. No relationship between aneurysm size and the likelihood of rupture of PDA aneurysms is apparent. PDA aneurysm rupture is associated with a mortality rate upwards of 50%; therefore, accepted practice is treatment upon diagnosis. There is debate in the literature on whether the treatment of coexisting celiac axis stenosis is necessary for the prevention of recurrence. DATA SOURCES: Literature relating to PDA aneurysms associated with celiac stenosis or occlusion was identified by performing a PubMed keyword search. References from identified articles were also assessed for relevance. The current literature was then reviewed and summarized. CONCLUSIONS: Characteristics of this patient population are identified. Based on current evidence, our best practice recommendation for the treatment of coexisting celiac axis stenosis is provided.

PMID: 22578409 [PubMed - as supplied by publisher]

Overexpression of LAPTM4B-35 is associated with poor prognosis in colorectal carcinoma.

Am J Surg. 2012 May 10;

Authors: Kang Y, Yin M, Jiang W, Zhang H, Xia B, Xue Y, Huang Y

Abstract

BACKGROUND: The purpose of this study was to determine whether lysosome-associated protein transmembrane-4 beta (LAPTM4B) overexpression is associated with the prognosis in patients with colorectal cancer. METHODS: LAPTM4B expression was evaluated in colorectal cancer patients by Western blot analysis and immunohistochemistry. Univariate and multivariate analyses were performed to determine the association between LAPTM4B expression and prognosis. RESULTS: Among the 136 patients with colorectal cancer, 51 patients had low LAPTM4B expression, and 85 patients had high LAPTM4B expression. The sensitivity and specificity of LAPTM4B overexpression were 62.5% and 100%, respectively. The 5-year overall survival (OS) rates for patients with high and low LAPTM4B expression were 37.38% and 98.04%, respectively (hazard ratio = 22.774; 95% confidence interval [CI], 5.287-98.091; P < .0001). The 5-year disease-free survival rate was 21.15% for patients in the high-expression group and 91.82% for patients in the low-expression group (hazard ratio = 11.674; 95% CI, 3.562-38.263; P < .0001). CONCLUSIONS: LAPTM4B overexpression is an independent factor in colorectal cancer prognosis, and it may be an important potential biomarker.

PMID: 22578410 [PubMed - as supplied by publisher]

Transanal endoscopic microsurgery: safe for midrectal lesions in morbidly obese patients.

Am J Surg. 2012 May 10;

Authors: Kumar AS, Chhitwal N, Coralic J, Stahl TJ, Ayscue JM, Fitzgerald JF, Smith LE

Abstract

BACKGROUND: Transanal endoscopic microsurgery is a safe option for proximal rectal tumors in morbidly obese patients for whom transabdominal pelvic dissection often is fraught with morbidity. METHODS: From a database of 318 patients who underwent transanal endoscopic microsurgery, we report a retrospective case-control study of 9 patients with a body mass index range of 35 to 66 with sessile rectal lesions 6 to 15 cm from the anal verge who underwent transanal endoscopic microsurgery. Case subjects were compared with 15 controls and matched for age, tumor type, and level of tumor. The average body mass index of controls was 30 (P < .001). By using t test analysis, perioperative outcomes (surgical time, blood loss, and hospital length of stay) and postoperative complications were compared. RESULTS: Sessile tumors were located 7 to 11 cm from the anal verge with a diameter of 1 to 4 cm. Patient and tumor factors such as age, distal tumor margin from anal verge, and tumor diameter were not significantly different between case subjects and controls. Surgical blood loss, surgical time, and hospital length of stay were not significantly different between the 2 groups. One complication occurred among the cases. No complications occurred in the control group. All patients had complete surgical resections with negative margins. CONCLUSIONS: Transanal endoscopic microsurgery in morbidly obese patients is a safe, feasible, and a viable alternative to low anterior resection.

PMID: 22578411 [PubMed - as supplied by publisher]

Routine peritoneal drainage of the surgical bed after elective distal pancreatectomy: is it necessary?

Am J Surg. 2012 May 10;

Authors: Paulus EM, Zarzaur BL, Behrman SW

Abstract

BACKGROUND: Recent literature suggests that peritoneal drainage (PD) is not helpful after elective pancreatectomy and may be detrimental. Data specific to distal pancreatectomy (DP) have not received prior evaluation. METHODS: We performed a retrospective review of patients who underwent DP. Factors examined included postoperative morbidity and the need for therapeutic intervention. RESULTS: Sixty-nine patients had DP, 30 without PD. Thirty-four patients suffered 45 complications, most were intra-abdominal in nature. Twelve, 19, and 3 patients required radiologic drainage, reoperation, or both, respectively. There was no difference between groups relative to intra-abdominal complications or the need for therapeutic intervention. Of 39 patients undergoing PD, 19 had abdominal morbidity. The drain was useful in identifying and/or treating the complication in 3 patients. CONCLUSIONS: First, PD after DP does not confer a reduction in morbidity or the need for therapeutic intervention versus patients with no drains. Second, the presence of a drain infrequently was helpful in detecting complications. Third, a multi-institutional, randomized study is recommended.

PMID: 22579230 [PubMed - as supplied by publisher]

Utility of shock index calculation in combat casualty triage protocol?

Am J Surg. 2012 May 9;

Authors: Pasquier P, Tourtier JP, Boutonnet M, Malgras B, Mérat S

PMID: 22579231 [PubMed - as supplied by publisher]

Impact of incisional hernia on health-related quality of life and body image: a prospective cohort study.

Am J Surg. 2012 May 9;

Authors: van Ramshorst GH, Eker HH, Hop WC, Jeekel J, Lange JF

Abstract

BACKGROUND: We investigated the impact of incisional hernia (IH) on quality of life and body image. METHODS: Open abdominal surgery patients were included in a prospective cohort study performed between 2007 and 2009 in an academic hospital. Main outcomes were incidence of IH after approximately 12 months and Short-Form 36 and body image questionnaire results. RESULTS: There were 374 patients who were examined after a median follow-up period of 16 months (range, 10-24 mo). Seventy-five patients had developed IH (20%); 63 (84%) were symptomatic. Adjusted for age, sex, and Charlson Comorbidity Index score, patients with IH reported significantly lower mean scores for components physical functioning (P = .033), role physical (P = .002), and physical component summary (P = .010). A trend toward significance was found for general health (P = .061). Patients with IH reported significantly lower mean cosmetic scores (P = .002), and body image and total body image scores (both P < .001). CONCLUSIONS: Patients with IH reported lower mean scores on physical components of health-related quality of life and body image.

PMID: 22579232 [PubMed - as supplied by publisher]

Palliative management for patients with subacute obstruction and stage IV unresectable rectosigmoid cancer: colostomy versus endoscopic stenting: final results of a prospective randomized trial.

Am J Surg. 2012 May 8;

Authors: Fiori E, Lamazza A, Schillaci A, Femia S, Demasi E, Decesare A, Sterpetti AV

Abstract

BACKGROUND: Survival in patients with stage IV unresectable rectosigmoid cancer is significantly reduced, and when patients are seen with symptoms of obstruction, it is advisable to perform a diverting colostomy before acute obstruction occurs. The aim of this study was to compare the results of endoscopic stent placement with diverting proximal colostomy in patients with stage IV rectosigmoid cancer and symptoms of chronic subacute obstruction. METHODS: In a prospective randomized trial, 22 patients with stage IV unresectable rectosigmoid cancer and symptoms of chronic subacute obstruction were randomized to either endoscopic placement of an expandable stent or diverting proximal colostomy. Patients were followed until death. RESULTS: There was no case of mortality or major postoperative complications. Oral feeding and bowel function were restored within 24 hours after endoscopic stent placement and within 72 hours after diverting colostomy. Hospital stays were shorter (mean, 2.6 days) in patients with endoscopic stent placement than in those with diverting stomas (mean, 8.1 days) (P < .05). Mean long-term survival was 297 days (range, 125-612 days) in patients who had stents and 280 days (range, 135-591 days) in patients with stomas (P = NS). No case of mortality during follow-up was related to the procedures. All patients with stomas found them quite unacceptable. The same feelings were present in family members. None of the patients with stents or their family members found any inconvenience about the procedure. CONCLUSIONS: Endoscopic expandable stent placement offers a valid solution in patients with stage IV unresectable cancer and symptoms of chronic subacute obstruction, with shorter hospital stays. The procedure is much better accepted, psychologically and practically, by patients and their family members.

PMID: 22575396 [PubMed - as supplied by publisher]

Safety of methylene blue dye for lymphatic mapping in patients taking selective serotonin reuptake inhibitors.

Am J Surg. 2012 May 8;

Authors: Shah-Khan MG, Lovely J, Degnim AC

Abstract

Methylene blue dye has an important role in lymphatic mapping for sentinel lymph node surgery. A recent safety announcement from the US Food and Drug Administration warned physicians about possible serious central nervous system reactions in patients on serotonergic medications who received intravenous methylene blue for the identification of parathyroid glands. This report summarizes evidence from the Food and Drug Administration’s announcement and methylene blue pharmacokinetics. The authors conclude that the use of methylene blue dye at low doses for lymphatic mapping likely carries very little risk for serotonin neurotoxicity, although breast surgeons should be aware of this potential complication in the event of mental status or neuromuscular changes in patients after lymphatic mapping.

PMID: 22575397 [PubMed - as supplied by publisher]

Disability index in a randomized controlled trial of emergency sclerotherapy versus portacaval shunt for bleeding varices in cirrhosis.

Am J Surg. 2012 May 8;

Authors: Orloff MJ, Isenberg JI, Wheeler HO, Haynes KS, Jinich-Brook H, Rapier R, Vaida F, Hye RJ, Orloff SL

Abstract

BACKGROUND: Disability has not been studied after emergency treatment of bleeding esophageal varices (BEV). We created a disability index (DI) in a randomized controlled trial comparing emergency endoscopic therapy (EST) versus emergency portacaval shunt (EPCS). METHODS: There were 211 unselected, consecutive patients with cirrhosis and acute BEV who were randomized to EST (n = 106) or EPCS (n = 105). Diagnostic work-up and treatment were performed within 8 hours. Ninety-six percent underwent more than 10 years follow-up evaluation. Disability was measured by assessing 9 factors to create a DI. RESULTS: Ten-year survival was 8% after EST versus 51% after EPCS (P < .001). EPCS had a significantly better DI. The EST and EPCS values were as follows: liver function improvement: not applicable and ++; worsening liver function, ++ and not applicable; portal-systemic encephalopathy (PSE) incidence, 36 and 15; PSE episodes, 179 and 94; packed red blood cell units, 1,005 and 320; hospital readmissions, 387 and 292; and number of readmission days, 9.6 and 4.7. All of the P values were less than .001. CONCLUSIONS: EPCS resulted in a markedly better DI than EST, a significantly higher survival rate, better control of bleeding, and a lower incidence of PSE. EPCS is an effective first-line emergency treatment of BEV.

PMID: 22575398 [PubMed - as supplied by publisher]

Secular trends in small-bowel obstruction and adhesiolysis in the United States: 1988-2007.

Am J Surg. 2012 May 8;

Authors: Scott FI, Osterman MT, Mahmoud NN, Lewis JD

Abstract

BACKGROUND: Postoperative adhesions are common after surgery and can cause small-bowel obstruction (SBO) and require adhesiolysis. The impact that laparoscopy and other surgical advances have had on rates of SBO and adhesiolysis remains controversial. This study examines trends in discharges from US hospitals for SBO and adhesiolysis from 1988 to 2007. METHODS: We performed an analysis of secular trends for SBO and adhesiolysis, using the National Hospital Discharge Survey. Spearman correlation coefficients were calculated to assess trends over time. RESULTS: Rates of SBO were stable over time (ρ = .140; P = .28). Adhesiolysis rates were stable over time (ρ = -.18; P = .17), although there were significant downward trends in patients older than age 65 (ρ = -.55; P = .01) and age 15 to 44 (ρ = -.84; P < .01). CONCLUSIONS: There has been no significant change in overall rates of SBO or adhesiolysis from 1988 to 2007. For adhesiolysis, there were decreasing trends when stratified by age. Further research is required to understand the factors associated with adhesion-related complications.

PMID: 22575399 [PubMed - as supplied by publisher]

Influence of obesity on complications and costs after intestinal surgery.

Am J Surg. 2012 May 8;

Authors: Wakefield H, Vaughan-Sarrazin M, Cullen JJ

Abstract

BACKGROUND: Obesity is a risk factor for many comorbid conditions that increase the cost of health care. We sought to examine the effect of obesity on surgical complications and cost in a group of patients undergoing intestinal surgery. METHODS: Using the Veterans Affairs Surgical Quality Improvement Program (VASQIP), which includes clinical data abstracted from medical records for Veterans Affairs (VA) surgical patients, and the VA Decision Support System, which provides the costs of individual patient encounters on the basis of relative values assigned to intermediate products, we examined surgical complications and costs of care in 4,881 patients undergoing intestinal surgery in 2006. Patients were classified into 4 groups based on body mass index (BMI): malnourished (<18), normal weight (18-30), obesity class I to II (30-40), and obesity class III (>40). Patient endpoints included the occurrence of any complication and surgical costs incurred within 30 days of surgery. Endpoints were compared across the 4 BMI categories in unadjusted analyses and risk-adjusted analyses and hospital-level variation using multivariable models. RESULTS: After controlling for patient risk factors and hospital-level variation, patients in obesity class I to II were 1.21 times more likely to have any complication and patients in obesity class III were 1.41 times more likely to have any complication when compared with normal-weight patients. Similarly, patients in obesity class I to II were 1.44 times more likely to develop a wound complication compared with normal-weight patients, and patients in class III were 1.84 times more likely to develop a wound complication and 1.55 times more likely to develop a respiratory complication compared with normal-weight patients. In contrast, costs were greatest for malnourished patients at $45,000 compared with normal-weight patients at $37,000. However, after controlling for patient risk factors and variation in costs attributable to the admitting hospital, there were no significant cost differences between the 4 BMI categories. CONCLUSIONS: Obesity leads to increased wound and respiratory complications in intestinal surgery. Nevertheless, obesity alone is not an independent risk factor for increased costs in intestinal surgery.

PMID: 22575400 [PubMed - as supplied by publisher]

A randomized, double-blind, placebo-controlled study to assess the effect of recombinant human erythropoietin on functional outcomes in anemic, critically ill, trauma subjects: the Long Term Trauma Outcomes Study.

Am J Surg. 2012 Apr;203(4):508-16

Authors: Luchette FA, Pasquale MD, Fabian TC, Langholff WK, Wolfson M

Abstract

BACKGROUND: Achieving a higher hemoglobin (Hb) level might allow the anemic, critically ill, trauma patient to have an improved outcome during rehabilitation therapy.

METHODS: Patients with major blunt trauma orthopedic injuries were administered epoetin alfa or placebo weekly both in hospital and for up to 12 weeks after discharge or until the Hb level was >12.0 g/dL, whichever occurred first. The 36-question Short Form Health Assessment questionnaire (SF-36) was used to evaluate physical function (PF) outcomes at baseline, at hospital discharge, and at several time points posthospital discharge.

RESULTS: One hundred ninety-two patients were enrolled (epoetin alfa [n = 97], placebo [n = 95]). Hb increased from baseline to hospital discharge in both groups (epoetin alfa: 1.2 g/dL vs placebo: 0.9 g/dL), and transfusion requirements were similar between groups. Both groups showed improvements in SF-36 PF; there were no significant differences in the average of all posthospital discharge scores (epoetin alfa: 27.3 vs placebo 30.9; P = 0.38). Thromboembolic events were similar between groups.

CONCLUSIONS: No differences were observed in physical function outcomes or safety in anemic, critically ill, trauma patients treated with epoetin alfa compared with placebo.

PMID: 22177550 [PubMed - indexed for MEDLINE]

A 60-year literature review of stump appendicitis: the need for a critical view.

Am J Surg. 2012 Apr;203(4):503-7

Authors: Subramanian A, Liang MK

Abstract

BACKGROUND: Stump appendicitis is an underreported and poorly defined condition. It is the development of obstruction and inflammation of the residual appendix after appendectomy. This is a review of the basic clinical, pathological, and surgical significance of stump appendicitis, and the “critical view” required for prevention.

DATA SOURCES: PubMed MEDLINE search was performed using terms “stump appendicitis” and “retained appendix” to obtain reported cases of stump appendicitis. Sixty-one cases were identified. Each case was charted based on 14 variables. Data were analyzed.

CONCLUSIONS: Stump appendicitis warrants early detection. Patients can present with abdominal pain, nausea, and vomiting. A prior history of appendectomy can delay the diagnosis. A diagnosis can be made with an abdominal ultrasound or computed tomography scan. If treated early, laparoscopic or open completion appendectomy can be performed. If diagnosis is delayed and perforation is found, extensive resection is often required. A “critical view,” as described in this article, is key for prevention.

PMID: 22153086 [PubMed - indexed for MEDLINE]

Palliative resections versus palliative bypass procedures in pancreatic cancer–a systematic review.

Am J Surg. 2012 Apr;203(4):496-502

Authors: Gillen S, Schuster T, Friess H, Kleeff J

Abstract

BACKGROUND: Although resection is the only treatment option that offers a chance for prolonged survival in pancreatic cancer, R2 resections are controversial and not a generally accepted approach.

METHODS: A systematic review and meta-analysis of studies of patients with pancreatic cancer was performed to analyze R2 resections in comparison with palliative surgical bypass procedures. Trials were identified by searching MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from 1966 to February 2011.

RESULTS: Four cohort studies were identified comparing 138 patients with R2 resections with 261 patients undergoing surgical bypass procedures. Morbidity and mortality were increased in the R2 resection group, with pooled risk ratios of 1.75 (95% confidence interval [CI], 1.35-2.26; P < .0001) and 2.98 (95% CI, 1.31-6.75; P = .009), respectively. R2 resections were associated with longer operating times (mean difference, 164 minutes; 95% CI, 127-201 minutes; P < .00001) and hospital stays (mean difference, 5 days; 95% CI, 1-9 days; P = .02). Pooled median survival times were 8.2 months for R2 resection and 6.7 months for palliative bypass procedures.

CONCLUSIONS: Planned palliative R2 resections are not justified in patients with pancreatic cancer.

PMID: 21872208 [PubMed - indexed for MEDLINE]

National incidence and outcomes of postoperative urinary retention in the Surgical Care Improvement Project.

Am J Surg. 2012 May 3;

Authors: Wu AK, Auerbach AD, Aaronson DS

Abstract

BACKGROUND: The national incidence of postoperative urinary retention (POUR), its risk factors, and associated outcomes are not well understood. METHODS: We identified patients undergoing one of the Surgical Care Improvement Project surgeries using the National Inpatient Sample. By using International Classification of Diseases, 9th revision, Clinical Modification codes (ICD-9-CM), we identified POUR and the outcomes urinary tract infection, noninfectious catheter-related complications, length of stay, and posthospitalization care. Multivariable analysis identified predictors of POUR and its associated outcomes. RESULTS: A total of 415,409 patients, representing 2,077,045 nationally, underwent one of the Surgical Care Improvement Project procedures with 43,030 (2.1%) developing POUR. Age, sex, type of surgery, and medical comorbidities were predictive of POUR with a .71 area under the curve. Patients with POUR had greater odds of having urinary tract infections (odds ratio [OR], 2.3; 95% confidence interval [CI], 2.2-2.5), suffering catheter-related complications (OR, 5.2; 95% CI, 3.8-7.0), and needing additional posthospitalization care (OR, 1.3; 95% CI, 1.25-1.4), and they had a greater length of stay (.24 extra days). CONCLUSIONS: Patients at risk for POUR can be identified, and they may benefit from interventions to prevent POUR.

PMID: 22560203 [PubMed - as supplied by publisher]

Statistical assessment of the clinical performance of the Masimo Radical-7.

Am J Surg. 2012 May 3;

Authors: Pologe JA, Menschik M

PMID: 22560860 [PubMed - as supplied by publisher]

Expansion of statistical analysis in noninvasive hemoglobin monitoring.

Am J Surg. 2012 May 3;

Authors: Causey MW, Miller S, Martin M

PMID: 22560861 [PubMed - as supplied by publisher]

Plasma insulin and glucose time courses after biliary pancreatic diversion in morbidly obese patients with and without diabetes.

Am J Surg. 2012 Apr 3;

Authors: Currò G, Centorrino T, Low V, Navarra G

Abstract

BACKGROUND: The exact mechanism for the dramatic effect of surgical procedures for obesity on type 2 diabetes remains unknown. METHODS: Five diabetic morbidly obese patients and 5 nondiabetic morbidly obese patients undergoing biliopancreatic diversion were compared retrospectively. A 75-g trans-gastrostomy glucose tolerance test was administered on the fifth day postoperatively and a standard 75-g oral glucose tolerance test was performed on the seventh day postoperatively, with blood sampling for measuring plasma glucose and insulin levels at 0, 30, 60, 90, 120, and 180 minutes. RESULTS: All 5 diabetic patients were shown, at the same time, still to have diabetes or an impaired glucose tolerance test when tested through the biliopancreatic limb but patients were normal when tested through the new alimentary channel. No significant difference was seen in the nondiabetic patients. CONCLUSIONS: Biliopancreatic diversion can completely normalize the glycemic cycle in type 2 diabetes patients in the week after the intervention, even before any significant weight loss has occurred. The surgical procedure itself, designed to exclude most of the stomach, duodenum, and part of the jejunum, directly affects carbohydrate homeostasis.

PMID: 22481065 [PubMed - as supplied by publisher]

The predictive value of preoperative carcinoembryonic antigen level in the prognosis of colon cancer.

Am J Surg. 2012 Apr 3;

Authors: Kirat HT, Ozturk E, Lavery IC, Kiran RP

Abstract

BACKGROUND: We evaluated factors associated with an increased preoperative carcinoembryonic antigen (CEA) level for colon cancer patients undergoing elective curative surgery and assessed whether this was associated with prognosis when accounting for other potential confounders. METHODS: Prospectively accrued data of patients with stage I, II, and III colon cancer undergoing surgery (1980-2008) were retrieved retrospectively. Patients with a preoperative CEA level greater than 5 ng/mL (group B) were compared with those with a CEA level of 5 ng/mL or less (group A). RESULTS: There were 651 patients (379 men) with a median age of 67 years (range, 21-94 y) and a median follow-up period of 5.9 years. Groups A (n = 451) and B (n = 200) had similar ages and tumor locations. Group B had larger tumors; more patients with T3 and N1/N2; and more patients with stage II/III tumors, and hence greater use of chemotherapy (P = .04). On multivariate analysis, patient age, tumor stage, and differentiation were associated with oncologic outcomes. A CEA level greater than 5 ng/mL was not associated independently with recurrence, recurrence-free survival (P = .47), or overall survival (P = .3). CONCLUSIONS: An increased preoperative CEA level is a marker for a more advanced tumor stage. For adequately staged patients, a high preoperative CEA level is not associated independently with oncologic outcomes.

PMID: 22481066 [PubMed - as supplied by publisher]

Axillary ultrasound examination is useful for selecting patients optimally suited for sentinel lymph node biopsy after primary systemic chemotherapy.

Am J Surg. 2012 Apr 4;

Authors: Shigekawa T, Sugitani I, Takeuchi H, Misumi M, Nakamiya N, Sugiyama M, Sano H, Matsuura K, Takahashi T, Fujiuchi N, Osaki A, Saeki T

Abstract

BACKGROUND: Controversy surrounds the reliability of sentinel lymph node biopsy after primary systemic chemotherapy. In this study, we assessed axillary ultrasound for selecting patients most likely to optimally benefit from biopsy. METHODS: The study included 87 patients who received primary systemic chemotherapy and underwent a sentinel lymph node biopsy followed by axillary lymph node dissection. Lymph nodes >10 mm in diameter, irregularly swollen, round, and homogeneously hypoechoic without an echo-rich center were considered axillary ultrasound positive. RESULTS: In axillary ultrasound-negative patients before and after primary systemic chemotherapy, identification, sensitivity, and false-negative rates were 81%, 100%, and 0%, respectively. However, in patients whose lymph nodes converted from positive to negative after primary systemic chemotherapy, these values were 83%, 70.8%, and 29.2%, respectively. CONCLUSIONS: Axillary ultrasound-negative patients before and after primary systemic chemotherapy were suitable for sentinel lymph node biopsy. Axillary ultrasound should be used during primary systemic chemotherapy and before surgery.

PMID: 22483167 [PubMed - as supplied by publisher]

Impact of axillary ultrasound and core needle biopsy on the utility of intraoperative frozen section analysis and treatment decision making in women with invasive breast cancer.

Am J Surg. 2012 Apr 6;

Authors: Caretta-Weyer H, Sisney GA, Beckman C, Burnside ES, Salkowsi LR, Strigel RM, Wilke LG, Neuman HB

Abstract

BACKGROUND: Our objective was to evaluate the impact of preoperative axillary ultrasound and core needle biopsy (CNB) on breast cancer treatment decision making. A secondary aim was to evaluate the impact on the utility of intraoperative sentinel lymph node (SLN) frozen section. METHODS: A review of 84 patients with clinically negative axilla who underwent axillary ultrasound was performed. Sensitivity, specificity, and positive/negative predictive value for axillary ultrasound with CNB was calculated. RESULTS: Thirty-one (37%) had suspicious nodes. Of 27 amenable to CNB, 12 (14%) were malignant, changing treatment plans. The sensitivity of ultrasound and CNB was 54% and specificity 100%; the positive and negative predictive values were 100% and 80%, respectively. In 41 patients with normal ultrasounds who underwent SLN frozen section, 10 (24%) were positive. CONCLUSIONS: Preoperative axillary ultrasound impacts treatment decision making in 14%. With a sensitivity of 54%, it is a useful adjunct to, but not replacement for, SLN biopsy. Frozen section remains of utility even after a negative axillary ultrasound.

PMID: 22483606 [PubMed - as supplied by publisher]

Commentary on “the role of the breast cancer surgeon in personalized cancer care: clinical utility of the 21-gene assay”

Am J Surg. 2012 Apr 9;

Authors: Iglehart JD, Valero MG

PMID: 22494880 [PubMed - as supplied by publisher]

Running sutures anchored with square knots are unreliable.

Am J Surg. 2012 Apr 9;

Authors: Aanning HL, Osdol AV, Allamargot C, Becker BE, Howard TC, Likness ML, Merkwan CE, Tarver DD

Abstract

BACKGROUND: A previous study showed that running polypropylene sutures anchored with square knots retain only 75% of their strength compared with half hitches. The aim of this study was to investigate whether anchor knot geometry similarly affects the tensile strength of other types of sutures used in continuous closures. METHODS: Monofilament and multifilament sutures (all 3-0) were anchored with either square knots or half hitches to 1 tensionometer post, and the running ends were secured to the other. The force required to break the running suture and the site of suture failure were recorded. RESULTS: The running sutures anchored with square knots retained only 50% to 84% of the strength of the identical sutures secured with half hitches (P < .001). CONCLUSIONS: A running suture anchored with half hitches is stronger and safer in comparison with the same suture anchored with square knots. This study provokes a fundamental reconsideration of the use of square knots to anchor running sutures.

PMID: 22494881 [PubMed - as supplied by publisher]

The role of the breast cancer surgeon in personalized cancer care: clinical utility of the 21-gene assay.

Am J Surg. 2012 Apr 18;

Authors: Laronga C, Harness JK, Dixon M, Borgen PI

Abstract

BACKGROUND: Breast cancer surgeons represent the first line of defense for many patients battling this disease. They often have the first contact to discuss treatment options with the patient after diagnosis. However, the potential impact of this consultation has evolved with the arrival of commercialized multigene prognostic and predictive tests that continue to reshape the landscape of breast cancer management, including modern surgical practice. METHOD: This review was compiled from peer-reviewed literature indexed in PubMed. CONCLUSIONS: The advent of genomic analysis has advanced the treatment and management of breast cancer toward the goal of personalized care. Therefore, the role of the surgeon now extends beyond extirpation of the tumor and includes an understanding of the biology of the disease as well as an appreciation of this new technology. Breast cancer surgeons should seize this opportunity to provide patients and colleagues with this information in an expeditious manner to optimize clinical outcomes.

PMID: 22516676 [PubMed - as supplied by publisher]

Prevention of early-onset pneumonia in surgical patients by chemoprophylaxis.

Am J Surg. 2012 Apr 24;

Authors: Diez-Sebastian J, Herruzo R, Garcia-Caballero J

Abstract

BACKGROUND: The purpose of this study was to explore the impact of surgical antimicrobial chemoprophylaxis on the prevention of early-onset postsurgical pneumonia (EOPP) using a logistic regression model that included the principal risk or confusion factors associated with incidence of early-onset postsurgical pneumonia. MATERIALS AND METHODS: The sample chosen corresponded to 13 years during which the epidemiological surveillance system was in place in the general and digestive surgery department (N = 13,024 patients) and was designed as a prospective cohort study. Risk factors associated with EOPP development were analyzed using a cohort-nested case-control study. RESULTS: Cumulative incidence of EOPP in this series of patients was .6%, accounting for 24.7% of total nosocomial pneumonias. The multivariate model showed the following risks or confusion factors for EOPP: age, emergency admission, type of surgery, duration of surgical intervention, infection on admission, and antimicrobial chemoprophylaxis (administered, odds ratio = .18; 95% confidence interval, .09-.33). CONCLUSIONS: Surgical antimicrobial chemoprophylaxis was associated as an independent factor with incidence reduction of early-onset postsurgical pneumonia, and, aside from its known effect on surgical site infection, its administration, where indicated, is useful for the prevention of early-onset postsurgical pneumonia.

PMID: 22537471 [PubMed - as supplied by publisher]

Educational feedback in the operating room: a gap between resident and faculty perceptions.

Am J Surg. 2012 Apr 24;

Authors: Jensen AR, Wright AS, Kim S, Horvath KD, Calhoun KE

Abstract

BACKGROUND: Immediate feedback regarding performance in the operating room remains a key component of resident education. The aim of this study was to assess resident and faculty perceptions regarding postoperative feedback. METHODS: Anonymous surveys were distributed to residents and faculty members. Questions addressed the timing, amount, and specificity of feedback; satisfaction; and the definition and importance of feedback. Additional questions regarded the importance and frequency of feedback in 7 specific areas of surgical competency. RESULTS: Resident satisfaction with timing, amount, and specificity of feedback was significantly lower than faculty satisfaction. Perceptions of the importance of feedback for each of the 7 specific areas did not differ. Faculty members’ perceptions on the frequency of feedback were higher than residents’ perception in all competencies of feedback (5-point scale, all P values = .001). CONCLUSIONS: There are significant differences between resident and faculty perceptions regarding postoperative feedback. Although faculty members believed they delivered appropriate amounts of timely, quality feedback, this perception was not shared by residents.

PMID: 22537472 [PubMed - as supplied by publisher]

Systematic review and meta-analysis of electrocautery versus scalpel for surgical skin incisions.

Am J Surg. 2012 Apr 24;

Authors: Aird LN, Brown CJ

Abstract

BACKGROUND: The creation of surgical skin incisions has historically been performed using a cold scalpel. The use of electrocautery for this purpose has been controversial with respect to patient safety and surgical efficacy. A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to compare skin incisions made by electrocautery and a scalpel. DATA SOURCES: A systematic electronic literature search was performed using 2 electronic databases (MEDLINE and PubMed), and the methodological quality of included publications was evaluated. Six RCTs were identified comparing electrocautery (n = 606) and a scalpel (n = 628) for skin incisions. CONCLUSIONS: No significant difference in wound infection rates or scar cosmesis was identified between the treatment groups. Electrocautery significantly reduced the incision time and postoperative wound pain. A trend toward less incisional blood loss from skin incisions made with electrocautery was noted. Electrocautery is a safe and effective method for performing surgical skin incisions.

PMID: 22537473 [PubMed - as supplied by publisher]

A randomized controlled trial of emergency treatment of bleeding esophageal varices in cirrhosis for hepatocellular carcinoma.

Am J Surg. 2012 Feb;203(2):182-90

Authors: Orloff MJ, Isenberg JI, Wheeler HO, Haynes KS, Jinich-Brook H, Rapier R, Vaida F, Hye RJ, Orloff SL

Abstract

BACKGROUND: Ninety percent of patients with hepatocellular carcinoma (HCC) have cirrhosis. Bleeding esophageal varices (BEV) is a frequent complication of cirrhosis. Detection of HCC in cirrhotic patients with BEV has not been studied.

METHODS: Two hundred eleven unselected patients with cirrhosis and BEV were randomized to endoscopic sclerotherapy (n = 106) or emergency portacaval shunt (n = 105). Diagnostic workup and treatment were initiated within 8 hours. Ninety-six percent had >10 years of follow-up. HCC screening involved serum α-fetoprotein (AFP) every 3 months, ultrasonography every 6 months, and selective computed tomography (CT).

RESULTS: HCC occurred in 15 patients, all incurable, a mean of 2.94 years after entry. They died a mean 1.33 years after discovery. Serial AFP and ultrasound examinations were unrevealing over a mean of 2.3 years. The mean model of end-stage liver disease score was 12.7 at entry and 17.4 at HCC diagnosis.

CONCLUSIONS: Long-term screening by AFP and ultrasound plus selective CT failed to detect HCC at a curable stage. The detection of HCC in cirrhotic patients with BEV remains a serious, unsolved problem. The use of CT for routine screening warrants consideration despite increased costs.

PMID: 21679921 [PubMed - indexed for MEDLINE]

Role of interleukin-10 in the pathogenesis of necrotizing enterocolitis.

Am J Surg. 2012 Apr;203(4):428-35

Authors: Emami CN, Chokshi N, Wang J, Hunter C, Guner Y, Goth K, Wang L, Grishin A, Ford HR

Abstract

BACKGROUND: Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency in premature neonates. The pathogenesis of NEC is characterized by an intestinal epithelial injury caused by perinatal insults, leading to the activation of the mucosal innate immune system and exacerbation of the epithelial barrier damage. Cytokines play an important role in mucosal immunity. Interleukin-10 (IL-10) is an anti-inflammatory cytokine that has been shown to play a role in epithelial integrity and modulation of the mucosal immune system. We hypothesized that IL-10 may protect against the development of experimental NEC by blunting the inflammatory response in the intestine.

METHODS: Wild-type and IL-10 -/- mice underwent a NEC-inducing regimen of formula feeding in combination with hypoxia and hypothermia (FF+HH). Integrity of the gut barrier was assessed through measurement of epithelial apoptosis, tight junction disruption, and inducible nitric oxide synthase. A total of 5 μg of exogenous IL-10 was administered intraperitoneally to IL-10-/-mouse pups before the initiation of FF+HH to test dependence of gene knockout phenotype on IL-10.

RESULTS: IL-10 -/- FF+HH showed more severe morphologic and histologic changes compared with controls as evidenced by increased epithelial apoptosis, decreased junctional adhesion molecule-1 localization, and increased intestinal inducible nitric oxide synthase expression. Administration of exogenous IL-10 alleviated the mucosal injury.

CONCLUSIONS: We conclude that IL-10 plays a protective role in the pathogenesis of NEC by attenuating the degree of intestinal inflammation.

PMID: 22450025 [PubMed - in process]

Inhalation of carbon monoxide reduces skeletal muscle injury after hind limb ischemia-reperfusion injury in mice.

Am J Surg. 2012 Apr;203(4):488-95

Authors: Patel R, Albadawi H, Steudel W, Hashmi FF, Kang J, Yoo HJ, Watkins MT

Abstract

BACKGROUND: The purpose of this study was to determine if inhaled carbon monoxide (CO) can ameliorate skeletal muscle injury, modulate endogenous heme oxygenase-1 expression, and improve indexes of tissue integrity and inflammation after hind limb ischemia reperfusion.

METHODS: C57BL6 mice inhaling CO (250 ppm) or room air were subjected to 1.5 hours of ischemia followed by limb reperfusion for either 3 or 6 hours (total treatment time, 4.5 or 7.5 h). After the initial period of reperfusion, all mice breathed only room air until 24 hours after the onset of ischemia. Mice were killed at either the end of CO treatment or at 24 hours’ reperfusion. Skeletal muscle was subjected to histologic and biochemical analysis.

RESULTS: CO treatment for 7.5 hours protected skeletal muscle from histologic and structural evidence of skeletal muscle injury. Serum and tissue cytokines were reduced significantly (P < .05) in mice treated with CO for 7.5 hours. Tubulin, heme oxygenase, and adenosine triphosphate levels were higher in CO-treated mice.

CONCLUSIONS: Inhaled CO protected muscle from structural injury and energy depletion after ischemia reperfusion.

PMID: 22450026 [PubMed - in process]

Identifying best practice guidelines for debriefing in surgery: a tri-continental study.

Am J Surg. 2012 Apr;203(4):523-9

Authors: Ahmed M, Sevdalis N, Paige J, Paragi-Gururaja R, Nestel D, Arora S

Abstract

BACKGROUND: Changes in surgical training have decreased opportunities for experiential learning in the operating room (OR). With this decrease, a commensurate increase in debriefing-dependent simulation-based activities has occurred. Effective debriefing could optimize learning from both simulated and real clinical encounters.

METHODS: Thirty-three semistructured interviews with surgeons, anesthesiologists, and OR nurses from the United Kingdom, United States, and Australia identified the goals of debriefing, core components of an effective debrief, and solutions to its effective implementation. Interviews were audiotaped, transcribed, and coded using emergent theme analysis.

RESULTS: Core components of an effective debrief include having the appropriate approach, establishing a learning environment, learner engagement, managing learner reaction, reflection, analysis, diagnosis, and application to real clinical practice. Solutions to enhance practice involve promotion of a debriefing culture within the surgical community with protected time to conduct a structured debriefing.

CONCLUSIONS: A need exists to enhance surgical training through regular structured debriefing. Identifying the key components of an effective debrief is a first step toward improving practice and embedding a debriefing culture within the OR.

PMID: 22450027 [PubMed - in process]

The script concordance test as a measure of clinical reasoning: a national validation study.

Am J Surg. 2012 Apr;203(4):530-4

Authors: Nouh T, Boutros M, Gagnon R, Reid S, Leslie K, Pace D, Pitt D, Walker R, Schiller D, Maclean A, Hameed M, Fata P, Charlin B, Meterissian SH

Abstract

INTRODUCTION: The script concordance test (SCT) is an innovative tool for clinical reasoning assessment. It has previously been shown to be a reliable and valid measure of clinical reasoning among general surgical residents.

PURPOSE: To determine if the SCT maintained its validity and reliability when administered on a national level.

METHODS: The test was administered to 202 residents (51 R1, 45 R2, 45 R3, 28 R4, and 33 R5) in 9 general surgery programs across Canada.

RESULTS: The optimized version of the test had a reliability (Cronbach alpha) of .85. Scores increased progressively from R1 (64.5 ± 7.6) to R2 (69.5 ± 5.8) to R3 (69.9 ± 6.7) to R4 (72.0 ± 6.2) with a dip in the R5s (68.3 ± 8.6). The test was able to differentiate junior (R1+ R2 = 66.8 ± 7.2) from senior residents (R3 + R4 + R5 = 70.0 ± 7.3, P = .001) across all the programs.

CONCLUSIONS: The SCT maintained its reliability and validity as a measure of intraoperative clinical reasoning among general surgical residents when administered across multiple centers. We believe that the SCT can be developed to measure clinical reasoning in high-stakes national examinations.

PMID: 22450028 [PubMed - in process]

Use of absorbable hemostatic gauze with medical adhesive is effective for achieving hemostasis in presacral hemorrhage.

Am J Surg. 2012 Apr;203(4):e5-8

Authors: Zhang CH, Song XM, He YL, Han F, Wang L, Xu JB, Chen CQ, Cai SR, Zhan WH

Abstract

BACKGROUND: Management of presacral hemorrhage is always challenging. Herein we describe the use of an absorbable hemostatic gauze with α-cyanoacrylate medical adhesive to achieve hemostasis.

METHODS: In this study, we conducted total mesorectal excision for the treatment of rectal cancer in 258 patients from March 2006 to May 2009. Intraoperative presacral hemorrhage developed in 5 (2%) patients during rectal mobilization.

RESULTS: In these 5 patients, massive bleeding could not be controlled by pressure and pelvic packing with gauze. An absorbable hemostatic gauze spread with medical adhesive was compressed onto the bleeding vessel for at least 20 minutes. Hemostasis was achieved successfully and was maintained during the surgery. Patients recovered uneventfully and no postoperative events were noted.

CONCLUSIONS: The use of an absorbable hemostatic gauze with medical adhesive is a simple and effective method for achieving hemostasis when massive presacral hemorrhage occurs. However, its effectiveness needs to be confirmed in a controlled study in a properly selected patient population.

PMID: 22450029 [PubMed - in process]

Expediting return of bowel function after colorectal surgery.

Am J Surg. 2012 Mar 27;

Authors: Sindell S, Causey MW, Bradley T, Poss M, Moonka R, Thirlby R

Abstract

BACKGROUND: Postoperative ileus is the main determinant of the length of hospital stay after colorectal surgery. Our objective was to analyze modifiable factors, including polyethylene glycol administration, associated with the return of bowel function. METHODS: A retrospective review of all patients who underwent elective open partial colectomy from 2004 to 2006 at a single institution. RESULTS: The time to the first bowel movement with and without oral intake within 48 hours postoperatively was 76 hours versus 134 hours (P < .001); with and without polyethylene glycol administration it was 73 hours versus 94 hours (P = .001); and with and without frequent ambulation it was 78 hours versus 95 hours (P = .012). With postoperative nasogastric tube drainage, the time to the first bowel movement was 22 hours longer (P = .002). CONCLUSIONS: These data confirm previous findings supporting no nasogastric tube drainage, early feeding, and frequent ambulation after colorectal surgery. Additionally, our data suggest a strong association (P = .001) between the use of polyethylene glycol and the early return of bowel function.

PMID: 22459445 [PubMed - as supplied by publisher]

Laparoscopic surgical exploration is an effective strategy for locating occult primary neuroendocrine tumors.

Am J Surg. 2012 Mar 27;

Authors: Massimino KP, Han E, Pommier SJ, Pommier RF

Abstract

BACKGROUND: Many patients with neuroendocrine tumors (NETs) have metastases at diagnosis. Despite extensive metastases the primary tumors remain small and difficult to locate. METHODS: Records of patients diagnosed with metastatic abdominal NETs from 2006 to 2010 were reviewed retrospectively. Results of preoperative imaging, procedures, and surgical explorations were compared for their efficacy at finding primary tumors. RESULTS: Sixty-three patients were identified. Seventeen percent (11 of 63) of tumors were located by preoperative testing. The sensitivities of preoperative colonoscopy (23% [n = 26]), computed tomography scan (6.7% [n = 60]), and somatostatin receptor scintigraphy (2.0% [n = 52]) were low. No tumors were found by magnetic resonance imaging (n = 9), upper endoscopy (n = 24), capsule endoscopy (n = 2), or bronchoscopy (n = 4). Surgical exploration was the most sensitive (79% [n = 63]) method of tumor detection. Seventy-two percent of surgical localizations were laparoscopic. CONCLUSIONS: Surgical exploration was superior to all other modalities for locating primary NETs. Laparoscopy had a high probability of finding occult primary neuroendocrine tumors.

PMID: 22459446 [PubMed - as supplied by publisher]

Outcomes associated with type of intervention and timing in complex pediatric empyema.

Am J Surg. 2012 Mar 27;

Authors: Goldin AB, Parimi C, Lariviere C, Garrison MM, Larison CL, Sawin RS

Abstract

BACKGROUND: The presence of effusion/empyema in pediatric pneumonia can increase treatment complexity by possibly requiring pleural drainage. Currently, no data support the superiority of any drainage modalities in children. METHODS: We performed a retrospective cohort study using the Pediatric Health Information System database from 2003 to 2008. RESULTS: A total of 14,936 children were hospitalized with effusion/empyema. Fifty-two percent of children were treated with antibiotics alone. Compared with patients receiving a chest tube, patients receiving antibiotics alone, thoracotomy, and video-assisted thoracoscopic surgery had a shorter length of stay, lower mortality rates, and fewer re-interventions. Delaying drainage by 1 to 3 days was associated with a lower mortality rate, and a delay of more than 7 days was associated with a higher mortality rate. CONCLUSIONS: Half of all children with effusion/empyema are treated with antibiotics alone with low morbidity and mortality. Initial video-assisted thoracoscopic surgery or thoracotomy had improved outcomes compared with other interventions. Intervention should not be delayed beyond 7 days.

PMID: 22459447 [PubMed - as supplied by publisher]

Complications nearly double the cost of care after pancreaticoduodenectomy.

Am J Surg. 2012 Mar 29;

Authors: Enestvedt CK, Diggs BS, Cassera MA, Hammill C, Hansen PD, Wolf RF

Abstract

BACKGROUND: Despite considerable data focused on the morbidity of pancreaticoduodenectomy (PD), the financial impact of complications has been infrequently analyzed. This study evaluates the impact of the most common complications associated with PD on the cost of care. Additionally, we identified cost centers that were significantly affected by complications. METHODS: A retrospective analysis of a prospective database in a network of community-based teaching hospitals was performed. All patients (n = 145) who underwent PD were included for years 2005 to 2009. Of these, 144 had complete in-hospital cost data. Complications were assessed and classified into major and minor categories according to Dindo et al. Forty-nine cost centers were analyzed for their association with the cost of complications. Univariate and multivariate linear regression analyses were performed. Significance was reported for P < .05. RESULTS: The median cost for PD was $30,937. Patients with major complications had significantly higher median cost compared with those without ($56,224 vs $29,038; P < .001). Independent predictors of increased cost included reoperation; sepsis; pancreatic fistula; bile leak; delayed gastric emptying; and pulmonary, renal, and thromboembolic complications. Cost center analysis showed significant added charges for patients with major complications for blood bank ($1,018), clinical laboratory ($3,731), a computed tomography scan ($4,742), diagnostic imaging ($697), intensive care unit ($4,986), pharmacy ($33,850) and respiratory therapy ($1,090) (P < .05, all). CONCLUSIONS: This study identified the major complications of PD, which are significantly associated with a higher cost. Substantial cost center increases were associated with major complications, particularly in pharmacy ($33,850). Measures aimed at limiting complications through centralization of care or care pathways may reduce the overall cost of care for patients after pancreatic resection.

PMID: 22464011 [PubMed - as supplied by publisher]

An analysis of fine needle aspiration versus core needle biopsy in clinically palpable breast lesions: a report on the predictive values and a cost comparison.

Am J Surg. 2012 Mar 29;

Authors: Nagar S, Iacco A, Riggs T, Kestenberg W, Keidan R

Abstract

BACKGROUND: Although fine-needle aspiration (FNA) is an established tool in the biopsy of breast masses, there has been a trend toward using core-needle biopsy (CNB). The aim of this study was to determine whether FNA has comparable predictive value with CNB and whether FNA is more cost effective. METHODS: A retrospective review was conducted on 162 patients who underwent either FNA or CNB of palpable breast lesions and had histologic confirmation with surgical biopsy in calendar year 2005. RESULTS: There were no false-positives or false-negatives in either group. The sensitivity, specificity, and positive predictive value for FNA were 89%, 98%, and 94%, respectively. CNB had sensitivity, specificity, and positive predictive value of 100%, 90%, and 93%, respectively. The cost to perform FNA was $166.34, compared with $477.92 for CNB. CONCLUSIONS: FNA and CNB had comparable predictive value, with FNA being more cost effective.

PMID: 22464444 [PubMed - as supplied by publisher]

Positron emission tomography in hepatobiliary and pancreatic malignancies: a review.

Am J Surg. 2012 Mar 29;

Authors: Lan BY, Kwee SA, Wong LL

Abstract

BACKGROUND: The prognosis for hepatobiliary and pancreatic malignancies is dismal. Surgery remains the primary curative option, but unresectable disease is often discovered during operative exploration. Positron emission tomography (PET) provides unique biological information different from current imaging modalities. The role of PET in detecting hepatobiliary and pancreatic malignancies has not yet been established. The purpose of this article was to review the literature on the use of PET in hepatobiliary and pancreatic malignancies. DATA SOURCES: We performed an extensive search on PubMed using PET and hepatocellular, pancreatic, gallbladder, and cholangiocarcinoma as keywords, excluding articles not written in English or on nonhuman subjects, case reports, and series with <5 patients. CONCLUSIONS: Although PET has shown usefulness in the diagnosis of certain cancers, current literature cautions against the use of PET for determining malignant potential of primary liver and pancreatic lesions. Literature on PET more strongly supports clinical roles for restaging of hepatobiliary and pancreatic malignancies, and for identifying metastatic disease.

PMID: 22464445 [PubMed - as supplied by publisher]

The age of transfused blood predicts hematocrit response among critically ill surgical patients.

Am J Surg. 2012 Mar 31;

Authors: Pieracci FM, Moore EE, Chin T, Townsend N, Gonzalez E, Burlew CC, Barnett CC

Abstract

BACKGROUND: In vitro data suggest that erythrocytes undergo storage time-dependent degradation, eventuating in hemolysis. We hypothesize that transfusion of old blood, as compared with newer blood, results in a smaller increment in hematocrit. METHODS: We performed an analysis of packed red blood cell transfusions administered in the surgical intensive care unit. Age of blood was analyzed as continuous, dichotomized at 14 days (old vs new), and grouped by weeks old. RESULTS: A total of 136 U of packed red blood cells were given to 52 patients; 110 (80.9%) were 14 days old or more. A linear, inverse correlation was observed between the age of blood and the increment in hematocrit (r(2) = -.18, P = .04). The increment in hematocrit was greater after transfusion of new as compared with old blood (5.6% vs 3.5%, respectively; P = .005). A linear relationship also was observed between the age of transfused blood in weeks and the increment in hematocrit (P = .02). CONCLUSIONS: There is an inverse relationship between the age of blood and the increment in hematocrit. The age of blood should be considered before transfusion of surgical patients with intensive care unit anemia.

PMID: 22465434 [PubMed - as supplied by publisher]

Femoral vessel blood flow dynamics after totally extraperitoneal versus Stoppa procedure in bilateral inguinal hernias: the need for evidence-based surgery.

Am J Surg. 2012 Mar 31;

Authors: Mangano A, Rausei S, Dionigi G

PMID: 22465435 [PubMed - as supplied by publisher]

The combat experience of military surgical assets in Iraq and Afghanistan: a historical review.

Am J Surg. 2012 Mar 20;

Authors: Schoenfeld AJ

Abstract

BACKGROUND: The Forward Surgical Team and Combat Support Hospital have been used extensively only during the past decade in Iraq and Afghanistan. The scope of their operational experience and historical development remain to be described. METHODS: The literature was searched to obtain publications regarding the historical development of Forward Surgical Teams and Combat Support Hospitals, as well as their surgical experiences in Iraq and Afghanistan. Relevant publications were reviewed in full and their results summarized. RESULTS: The doctrine behind the use of modern military surgical assets was not well developed at the start of the Iraq and Afghanistan conflicts. The Forward Surgical Team and Combat Support Hospital were used in practice only over the past decade. Because of the nature of these conflicts, both types of modern military surgical assets have not been used as intended and such units have operated in various roles, including combat support elements and civilian medical treatment facilities. CONCLUSIONS: As more research comes to light, a better appreciation for the future of American military medicine and surgery will develop.

PMID: 22440274 [PubMed - as supplied by publisher]

The benefits of laparoscopic appendectomies in obese patients.

Am J Surg. 2012 Mar 23;

Authors: Tan-Tam C, Yorke E, Wasdell M, Barcan C, Konkin D, Blair P

Abstract

BACKGROUND: Systematic reviews and randomized controlled trials comparing laparoscopic appendectomy (LA) with open appendectomy (OA) show a reduction in wound infections associated with LA but a 3-fold increase in intra-abdominal abscess with LA. Surgical time and operation costs are higher with LA. The advantage of LA over OA is small. Although these patients have not been specifically analyzed in the report, the systematic review recommends the routine use of LA in young women and obese people. The purpose of this study is to determine if obese patients benefit in a shorter length of stay (LOS) by having LA versus OA surgery compared with their nonobese counterparts. METHODS: A retrospective chart review of 315 adult patients who have undergone appendectomies at Royal Columbian and Burnaby Hospitals between April 1, 2010 and March 31, 2011. Appendectomies performed in pregnant women combined with other surgeries and those converted to OA were excluded. Outcomes and the postoperative stay for obese and nonobese patients were assessed. RESULTS: The LOS is shorter with LAs than with OAs (2.06 vs 4.13 days, P < .05). The LOS, in obese patients, is much shorter with LAs than with OAs (1.69 vs 6.82 days, P < .05). The variability in LOS is much higher in obese patients as compared with nonobese patients (standard deviation = 8.57 vs 2.67). The body mass index and the type of surgery contribute to a significant difference in LOS. CONCLUSIONS: Obese patients who undergo LA have a decreased LOS as compared with obese patients who undergo OA for appendicitis. This is the first study showing specifically that LA benefits obese patients and the health care system.

PMID: 22444711 [PubMed - as supplied by publisher]

Bioprosthetic mesh use for the problematic thoracoabdominal wall: outcomes in relation to contamination and infection.

Am J Surg. 2012 Mar 23;

Authors: Ouellet JF, Ball CG, Kortbeek JB, Mack LA, Kirkpatrick AW

Abstract

BACKGROUND: Limited controlled data exist regarding the role of bioprosthetic meshes for hernia repair. Often the only option available in contaminated cases, their high cost calls for an evaluation of their utility and indications for use. METHODS: A retrospective review of cases in which human acellular dermal matrix (HADM) was used to reconstruct a thoracoabdominal wall defect at the Foothills Medical Centre of Calgary was conducted. Attention was placed to identify the need for surgical reintervention postoperatively. RESULTS: Over 2 years, 13 patients required the use of HADM for reconstruction of their thoracoabdominal wall; 69.2% of the cases were contaminated or infected. Three patients (23.1%) presented postoperative infectious complications; only 1 required reoperation. No patients required removal of their prosthesis. Two patients presented recurrences (median follow-up = 126 days). CONCLUSIONS: The use of HADM for complex thoracoabdominal wall defects in contaminated or infected settings is a reliable option available for surgeons.

PMID: 22444712 [PubMed - as supplied by publisher]

Recurrence and virulence of colonic diverticulitis in immunocompromised patients.

Am J Surg. 2012 Mar 23;

Authors: Biondo S, Borao JL, Kreisler E, Golda T, Millan M, Frago R, Fraccalvieri D, Guardiola J, Jaurrieta E

Abstract

BACKGROUND: To evaluate the probability of recurrence and the virulence of colonic diverticulitis correlated with immunocompromised status. METHODS: Nine hundred thirty-one patients admitted in a single tertiary referral university hospital over a 14-year period were included. Patients were divided into 2 groups: group 1, 166 immunosuppressed patients, and group 2, 765 nonimmunosuppressed patients. The variables studied were sex, age, American Society of Anesthesiologist status, reasons of immunosuppression (eg, chronic use of corticosteroids, transplant recipients, and diseases affecting the immune system), severity of the diverticulitis episode, recurrence, emergency and elective surgery, and morbidity and mortality rates. RESULTS: Two hundred thirteen patients underwent an emergency operation during the first hospitalization and 26 patients in further episodes. One hundred thirty-six patients developed 1 or more recurrent episodes of diverticulitis. The overall recurrence rate was similar in both groups. Patients in group 1 with a severe first episode presented significantly higher rates of recurrence and severity without needing more emergency surgery. Mortality after emergency surgery was 33.3% in group 1 and 15.9% in group 2 (P = .004). CONCLUSIONS: After successful medical treatment of acute diverticulitis, patients with immunosuppression need not be advised to have an elective sigmoidectomy.

PMID: 22444713 [PubMed - as supplied by publisher]

Use and outcomes of emergent laparoscopic resection for acute diverticulitis.

Am J Surg. 2012 Mar 21;

Authors: Rea JD, Herzig DO, Diggs BS, Cone MM, Lu KC

Abstract

BACKGROUND: The use and outcomes of laparoscopic sigmoid resection during emergency admissions for diverticulitis are unknown. METHODS: The Nationwide Inpatient Sample was queried for colorectal resections performed for diverticulitis during emergent hospital admissions (2003-2007). Univariate and multivariate analyses including patient, hospital, and outcome variables were performed. RESULTS: A national estimate of 67,645 resections (4% laparoscopic) was evaluated. The rate of conversion to open operation was 55%. Ostomies were created in 66% of patients, 67% open and 41% laparoscopic. Laparoscopy was not a predictor of mortality (odds ratio [OR] =.70; confidence interval [CI], .32-1.53). Laparoscopy predicted routine discharge (OR = 1.31; CI, 1.06-1.63) and a decreased length of stay (absolute days = -.78; CI, -1.19 to -.37). There was no difference in the cost of hospitalization between the 2 groups (P = .45). CONCLUSIONS: In acute diverticulitis, urgent laparoscopic resection decreases the length of stay. However, it is associated with a high conversion rate, no cost savings, and no difference in mortality.

PMID: 22444830 [PubMed - as supplied by publisher]

Comparison of the prognostic value of tumour and patient related factors in patients undergoing potentially curative resection of gastric cancer.

Am J Surg. 2012 Mar 21;

Authors: Dutta S, Crumley AB, Fullarton GM, Horgan PG, McMillan DC

Abstract

BACKGROUND: There is increasing evidence that the patient-related systemic inflammatory response is a powerful prognostic factor. The aim of the present study was to compare the prognostic value of selected markers of the systemic inflammatory response in patients undergoing resection of gastric cancer. METHODS: One hundred twenty patients undergoing resection of gastric cancer, had measurements of various systemic inflammatory markers in addition to tumor-related factors. From these, the modified Glasgow Prognostic Score (mGPS), neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, and metastatic lymph node ratio were calculated. RESULTS: On multivariate analysis, only the ratio of positive to total lymph nodes (hazard ratio, 2.29%; 95% confidence interval, 1.57%-3.33%; P < .001) and the mGPS (hazard ratio, 2.23%; 95% confidence interval, 1.40%-3.54%; P = .001) were independently associated with cancer-specific survival in patients with gastric cancer. An increase in the mGPS was associated with a higher neutrophil/lymphocyte ratio (P < .05) and poorer survival (P < .001). CONCLUSIONS: The present study indicates that the mGPS, an acute-phase, protein-based prognostic score, is a superior predictor of cancer survival compared with the cellular components of the systemic inflammatory response in patients undergoing resection of gastric cancer.

PMID: 22444831 [PubMed - as supplied by publisher]

Impact of American College of Surgeons Oncology Group Z0011 and National Surgical Adjuvant Breast and Bowel Project B-32 trial results on surgeon practice in the Pacific Northwest.

Am J Surg. 2012 Mar 23;

Authors: Massimino KP, Hessman CJ, Ellis MC, Naik AM, Vetto JT

Abstract

BACKGROUND: Recent clinical trials have suggested no survival benefit for completion axillary node dissection (CALND) after sentinel lymph node biopsy (American College of Surgeons Oncology Group Z0011) and no clinically meaningful benefit for the routine use of immunohistochemistry (National Surgical Adjuvant Breast and Bowel Project B-32) in clinically node-negative breast cancer. METHODS: A 12-question electronic survey was distributed to members of 3 Pacific Northwest surgical societies. Surgeons were queried regarding the impact of the trial results on their surgical management of breast cancer. RESULTS: The 181 respondents reported performing fewer CALNDs (63%), fewer intraoperative frozen sections (21%), and no immunohistochemistry (12%) because of trial data. However, 28% of surgeons continued to perform CALND in patients with 1 to 2 positive sentinel lymph nodes undergoing lumpectomy and postoperative radiation. CONCLUSIONS: Recent trial data have impacted the performance of CALNDs and the pathological evaluation of sentinel lymph nodes among Pacific Northwest surgeons. Our results suggest a need for regional surgical societies to disseminate practice-changing trial data to members.

PMID: 22445745 [PubMed - as supplied by publisher]

Results of routine shunting and patch closure during carotid endarterectomy.

Am J Surg. 2012 Mar 15;

Authors: Kret MR, Young B, Moneta GL, Liem TK, Mitchell EL, Azarbal AF, Landry GJ

Abstract

BACKGROUND: The role of shunting and patching during carotid endarterectomy remains controversial. METHODS: This is a retrospective case series evaluating consecutive patients undergoing carotid endarterectomy with routine shunting and patching. The primary endpoints were perioperative stroke, arterial injury, and lesion recurrence by duplex. RESULTS: Of the 220 operations performed, 43% were for symptomatic disease. Successful shunt placement occurred in 98%, with no shunt-related injuries. There was 1 minor perioperative stroke and no major strokes. At a mean follow-up of 24 months (median = 12 months), there was 1 restenosis potentially related to shunt placement. The incidence of asymptomatic >50% stenosis in the patched segment was 8%. CONCLUSIONS: A combined policy of routine shunting and patching simplifies intraoperative decision making with results that rival or exceed those of trials in which their use was not standardized. Shunts need not be avoided because of concern of arterial injury.

PMID: 22425447 [PubMed - as supplied by publisher]

Thrombelastography-identified coagulopathy is associated with increased morbidity and mortality after traumatic brain injury.

Am J Surg. 2012 Mar 15;

Authors: Kunio NR, Differding JA, Watson KM, Stucke RS, Schreiber MA

Abstract

BACKGROUND: The purpose of this study was to determine the relationship between coagulopathy and outcome after traumatic brain injury. METHODS: Patients admitted with a traumatic brain injury were enrolled prospectively and admission blood samples were obtained for kaolin-activated thrombelastogram and standard coagulation assays. Demographic and clinical data were obtained for analysis. RESULTS: Sixty-nine patients were included in the analysis. A total of 8.7% of subjects showed hypocoagulability based on a prolonged time to clot formation (R time, > 9 min). The mortality rate was significantly higher in subjects with a prolonged R time at admission (50.0% vs 11.7%). Patients with a prolonged R time also had significantly fewer intensive care unit-free days (8 vs 27 d), hospital-free days (5 vs 24 d), and increased incidence of neurosurgical intervention (83.3% vs 34.9%). CONCLUSIONS: Hypocoagulability as shown by thrombelastography after traumatic brain injury is associated with worse outcomes and an increased incidence of neurosurgical intervention.

PMID: 22425448 [PubMed - as supplied by publisher]

Loss of expression of the cancer stem cell marker aldehyde dehydrogenase 1 correlates with advanced-stage colorectal cancer.

Am J Surg. 2012 Mar 9;

Authors: Hessman CJ, Bubbers EJ, Billingsley KG, Herzig DO, Wong MH

Abstract

BACKGROUND: Colorectal cancer (CRC) progression is mediated by cancer stem cells (CSCs). We sought to determine if the expression of the CSC marker aldehyde dehydrogenase 1 (ALDH1) in CRC tumors varies by American Joint Committee on Cancer stage or correlates to clinical outcomes. METHODS: Primary and metastatic CRC samples from 96 patients were immunostained with antibodies to ALDH1 and imaged to evaluate marker expression. The percentage of ALDH1(+) cells was correlated to clinical outcomes. RESULTS: ALDH1 was overexpressed in CRC tumors compared with nonneoplastic tissue. Marker expression was highest in nonmetastatic tumors. The loss of expression was associated with advanced stage and metastatic disease. No significant correlation was found between ALDH1 expression and metastasis, recurrence, or survival. CONCLUSIONS: ALDH1 was highly expressed in nonmetastatic CRC, but expression was lost with advancing stage. ALDH1 could be an effective therapeutic target in early CRC but not late-stage disease. No correlation was found between ALDH1 and disease prognosis.

PMID: 22405917 [PubMed - as supplied by publisher]

The duodenal switch for morbid obesity: modification of cardiovascular risk markers compared with standard bariatric surgeries.

Am J Surg. 2012 Mar 8;

Authors: Nelson D, Porta R, Blair K, Carter P, Martin M

Abstract

BACKGROUND: Obesity is associated with cardiovascular risk factors such as lipid levels and increased levels of C-reactive peptide (CRP). We hypothesized that duodenal switch (DS) would show equivalent or superior risk reduction compared with standard bariatric surgeries. METHODS: Patients underwent DS, sleeve gastrectomy (SG), or gastric bypass (GB) over a 2-year period. Body mass index (BMI), lipid panel, and CRP were measured preoperatively and then 3, 6, and 12 months postoperatively. RESULTS: A total of 130 patients were identified; 42 underwent DS, 40 underwent SG, and 48 underwent GB. All groups had similar sex and comorbidity profiles, but the mean preoperative BMI was greatest in the DS group (mean = 52). At all intervals weight loss was greater in the DS group (P < .01), with a final BMI of 31 for the DS group, 31 for the SG group, and 28 for the GB group. Cholesterol and low-density lipoprotein showed significantly greater improvement at all time points with DS compared with SG and GB (P < .01). Baseline CRP levels among DS patients were double that of SG and GB, but rapidly declined to equivalent levels by 3 months and normalized in 79%. CONCLUSIONS: The DS procedure resulted in a superior reduction in cardiovascular and proinflammatory risk markers compared with GB and SG.

PMID: 22405918 [PubMed - as supplied by publisher]

A modified laparoscopic sleeve gastrectomy for the treatment of diabetes mellitus type 2 and metabolic syndrome in obesity.

Am J Surg. 2012 Mar 10;

Authors: Pirolla EH, Jureidini R, Barbosa ML, Ishikawa LC, Camargo PR

Abstract

BACKGROUND: Ghrelin is a gastrointestinal peptide hormone (a 28-amino acid peptide) produced primarily by X/A cells in the oxyntic glands of the stomach fundus and cells lining the duodenum cavern. It suppresses insulin secretion and action and commands a significant role in regulating food intake. The aim of the present study was to show that modified laparoscopic sleeve gastrectomy (MLSG), in which a significant part of the gastric fundus and body of the stomach is removed up to 1 inch from the pylorus vein, may contribute to decreasing circulating ghrelin levels. METHODS: A study population consisting of 150 individuals was monitored after undergoing a MLSG, with individuals chosen based on a documented history of diabetes mellitus type 2 and metabolic syndrome, clinical results determining a body mass index (BMI) of 35 to 60 kg/m(2), peptide C level greater than 1, negative anti-glutamic acid decarboxylase, negative anti-insulin, and confirmed stability of drug/insulin treatment and glycosylated hemoglobin greater than 6.5% for at least 24 and 3 months, respectively, before enrollment. RESULTS: Twenty-four months after surgery, 150 patients (86.6%) presented with normal glycemic levels between 77 and 99 mg/dL. All patients improved average serum insulin levels by 9 mU/L and average glycosylated hemoglobin levels by 5.1% (normal range, 4%-6%). All patients tested negative for Helicobacter pylori and stopped using insulin, with 3 patients prescribed twice-daily use of an oral hypoglycemiant. In 14% of cases, patients experienced partial hair loss with low serum zinc levels and were prescribed oral zinc reposition and topical hair stimulants. The average weight loss recorded was 44.6% for patients with a BMI less than 45 kg/m(2) and 58% for patients with a BMI greater than 50 kg/m(2). CONCLUSIONS: The MLSG is a safe procedure with a low morbidity rate (2.7%) (4 cases of fistula and 2 of bleeding) and no surgical mortality in this study. This surgery can promote control of diabetes mellitus type 2 and aid the treatment of exogenous overweight and morbidly obese individuals. The results of this study show that only through resection of the ghrelin-producing gastric area can most obesity cases and diabetes type II conditions be reverted to nonobese and controlled diabetes.

PMID: 22409993 [PubMed - as supplied by publisher]

Temporal trends in the treatment of severe traumatic hemorrhage.

Am J Surg. 2012 Mar 12;

Authors: Heidary B, Bell N, Ngai JT, Simons RK, Chipperfield K, Hameed SM

Abstract

BACKGROUND: This study examined the evolution of damage control resuscitation (DCR) and outcomes in severe traumatic hemorrhage (STH) at a large Canadian trauma center. METHODS: This was a retrospective cohort study of trauma patients admitted to a level 1 trauma center between 2005 and 2010, who received 10 or more units of packed red blood cells within 24 hours of admission. Demographic and clinical findings were compared between survivors and nonsurvivors. RESULTS: Forty-five patients were included. Twenty-five percent of patients were coagulopathic at admission. Early crystalloid use declined over the study period. The mean 24-hour fresh-frozen plasma:platelets:packed red blood cells ratio was 1:1:2. Hemorrhage-related mortality was 69%. No pedestrians survived STH. A total of 1,032 blood product units were used in the first day for nonsurvivors. CONCLUSIONS: Principles of DCR crept into clinical practice even before the implementation of a formal STH protocol. DCR appeared to reduce the intensive care unit length of stay but not mortality. STH is associated with heavy use of blood bank resources and high mortality rates. Futility of resuscitative efforts may be predictable by mechanism and early physiological markers.

PMID: 22417848 [PubMed - as supplied by publisher]

Correlating Haller Index and cardiopulmonary disease in pectus excavatum.

Am J Surg. 2012 Mar 12;

Authors: Swanson JW, Avansino JR, Phillips GS, Yung D, Whitlock KB, Redding GJ, Sawin RS

Abstract

BACKGROUND: The Haller Index (HI) has become standard for determining the severity of pectus excavatum. We compared patterns of cardiopulmonary dysfunction and their relationship with HI in patients with pectus excavatum. METHODS: We performed cardiopulmonary exercise testing and chest computed tomography scans on 90 patients with pectus excavatum deformities at a regional pediatric hospital. RESULTS: The median HI was 4.9 in patients with combined dysfunction, 4.4 in patients with isolated pulmonary dysfunction, 3.6 in patients with isolated cardiac dysfunction, and 3.4 in patients with normal function. HI varied significantly by disease group (P < .009). HI was significantly lower in patients with normal forced vital capacity than with abnormal forced vital capacity (P = .001). However, HI was similar in patients with normal and abnormal oxygen pulse (P = .24) or peak oxygen consumption (P = .37). CONCLUSIONS: Fifty-nine percent of patients had cardiac and/or pulmonary limitation. A HI greater than 3.6 is associated with pulmonary dysfunction, but not cardiac dysfunction.

PMID: 22417849 [PubMed - as supplied by publisher]

Practice referral patterns and outcomes in patients with primary retroperitoneal sarcoma in British Columbia.

Am J Surg. 2012 Mar 12;

Authors: Merchant S, Cheifetz R, Knowling M, Khurshed F, McGahan C

Abstract

BACKGROUND: We examined practice referral patterns for primary retroperitoneal sarcoma (PRS) in British Columbia (BC) and associations between the timing of referral to tertiary care and patient outcomes. METHODS: Using ICD-10 coding, the Cancer Agency Information System was used to identify patients with PRS from 2000 to 2009 who had been referred to tertiary care and had undergone a surgical resection. RESULTS: Eighty-two patients were included. Those referred before surgery were significantly more likely to receive a complete resection (P = .0002) and adjuvant radiation (P = .0000) compared with patients referred after surgery. Referral before surgery was associated with a significantly increased overall (P = .0619) and recurrence-free (P = .0400) survival; however, in the multivariate model this was not significant. CONCLUSIONS: Referral before surgery is associated with higher rates of complete resection and the use of adjuvant radiation; furthermore, it is associated with prolonged survival in the univariate but not in the multivariate model.

PMID: 22417850 [PubMed - as supplied by publisher]

Acute care surgery: the impact of an acute care surgery service on assessment, flow, and disposition in the emergency department.

Am J Surg. 2012 Mar 6;

Authors: Ball CG, Maclean AR, Dixon E, Quan ML, Nicholson L, Kirkpatrick AW, Sutherland FR

Abstract

BACKGROUND: Acute care surgery (ACS) services are becoming increasingly popular. METHODS: Assessment, flow, and disposition of adult ACS patients (acute, nontrauma surgical conditions) through the emergency department (ED) in a large health care system (Calgary) were prospectively analyzed. RESULTS: Among 447 ACS ED consultations over 3 centers (70% admitted to ACS), the median wait time from the consultation request to ACS arrival was 36 minutes, and from ACS arrival to the admission request it was 91 minutes. The total ACS-dependent time was 127 minutes compared with 261 minutes for initial ED activities and 104 minutes for transfer to a hospital ward (P < .05). Forty percent of patients underwent computed tomography (CT) imaging (76% before consultation). The time to ACS consultation was 305 minutes when a CT scan was performed first. CONCLUSIONS: An ACS service results in rapid ED assessment of surgical emergencies. Patient waiting is dominated by the time before requesting ACS consultation and/or waiting for transfer to the ward.

PMID: 22402265 [PubMed - as supplied by publisher]

Beta-catenin expression is prognostic of improved non-small cell lung cancer survival.

Am J Surg. 2012 Mar 6;

Authors: Chiu CG, Chan SK, Fang ZA, Masoudi H, Wood-Baker R, Jones SJ, Gilks B, Laskin J, Wiseman SM

Abstract

INTRODUCTION: The objectives of this study were to determine the frequency and prognostic significance of beta-catenin expression in a cohort of non-small cell lung cancer (NSCLC) patients. METHODS: Tissue microarrays were constructed using clinically annotated formalin-fixed paraffin-embedded tumor samples from individuals diagnosed with NSCLC who underwent surgical resection with curative intent and had beta-catenin expression status determined by immunohistochemistry. RESULTS: Negative beta-catenin expression was seen in 28% (103/370) of NSCLC cases and was prognostic of a reduced overall patient survival (P = .008) and also was significantly correlated with the presence of lymphatic invasion (P = .015). In multivariate analysis, the loss of beta-catenin expression retained independent prognostic significance and showed an adjusted hazard ratio of 3.18 (confidence interval, 1.46-6.91, P = .004) for reduced patient survival when adjusting for the presence of lymphatic invasion, tumor grade, nodal status, and tumor stage. CONCLUSIONS: Beta-catenin represents an important prognostic marker in individuals diagnosed with surgically resectable NSCLC.

PMID: 22402266 [PubMed - as supplied by publisher]

Changing the surgical education paradigm for the 21st century.

Am J Surg. 2012 Mar;203(3):282-6

Authors: Neumayer L

PMID: 22364899 [PubMed - in process]

Biplanar flap reconstruction for pressure ulcers: experience in patients with immobility from chronic spinal cord injuries.

Am J Surg. 2012 Mar;203(3):303-7

Authors: Mehta A, Baker TA, Shoup M, Brownson K, Amde S, Doren E, Shah S, Kuo P, Angelats J

Abstract

BACKGROUND: Surgical therapy for advanced-stage pressure ulcers recalcitrant to healing is a widely accepted practice. The present study examined the incidence of wound recurrence after reconstruction with fasciocutaneous versus combined (biplanar) muscle and fasciocutaneous flaps.

METHODS: A retrospective review identified 90 nonambulatory patients with spinal cord injury who underwent reconstruction for persistent decubitus ulcers from 2002 to 2008. Electronic medical records were surveyed for patient comorbidities and postoperative complications. Statistical methods included the Fisher exact test and the Mann-Whitney U test with a 2-sided P value of less than .05.

RESULTS: Among 90 patients reviewed, 33% (n = 30) received fasciocutaneous flaps and 66% (n = 60) underwent biplanar reconstruction. Comorbidities were the same between cohorts with the exception of a greater prevalence of diabetes in the biplanar group (27% vs 50%; P < .05). The incidence of recurrence for biplanar flaps (25%) was significantly lower than for fasciocutaneous reconstruction (53%; P < .01).

CONCLUSIONS: Biplanar flap reconstruction should be considered for chronically immobilized patients at high risk for recurrent decubitus ulceration.

PMID: 22364900 [PubMed - in process]

Outcomes using a bioprosthetic mesh at the time of permanent stoma creation in preventing a parastomal hernia: a value analysis.

Am J Surg. 2012 Mar;203(3):323-6

Authors: Figel NA, Rostas JW, Ellis CN

Abstract

PURPOSE/METHODS: A retrospective review of the medical records of all patients who had a prosthetic placed at the time of stoma creation for the prevention of a parastomal hernia was performed. The purpose of this study was to evaluate the safety, efficacy, and cost-effectiveness of bioprosthetics.

RESULTS: A bioprosthetic was used in 16 patients to prevent the occurrence of a parastomal hernia. The median follow-up was 38 months. There were no mesh-related complications, and no parastomal hernias occurred. On value analysis, to be cost-effective, the percentage of patients who would have subsequently needed surgical repair of a parastomal hernia would have to be in excess of 39% or the bioprosthetic would have to cost less than $2,267 to $4,312.

CONCLUSIONS: These data show the safety and efficacy of using a bioprosthetic at the time of permanent stoma creation in preventing a parastomal hernia and defines the parameters for this approach to be cost-effective.

PMID: 22364901 [PubMed - in process]

Does resident involvement effect surgical times and complication rates during laparoscopic appendectomy for uncomplicated appendicitis? An analysis of 16,849 cases from the ACS-NSQIP.

Am J Surg. 2012 Mar;203(3):347-52

Authors: Advani V, Ahad S, Gonczy C, Markwell S, Hassan I

Abstract

BACKGROUND: Controversy exists regarding whether resident involvement during surgery impacts patient outcomes. We compared surgical times and perioperative complications of patients undergoing laparoscopic appendectomy with and without residents.

METHODS: Patients undergoing laparoscopic appendectomy for uncomplicated acute appendicitis during 2005 to 2008 were identified from the American College of Surgeons National Surgical Quality Improvement Program database.

RESULTS: During the study period, 16,849 patients underwent laparoscopic appendectomy for uncomplicated appendicitis (residents participated in 68% of procedures). There were no statistical and/or clinically meaningful differences between median age, sex, body mass index, American Society of Anesthesiology score, and morbidity probability between the 2 groups, suggesting that case mix was not a significant confounder. Patients undergoing laparoscopic appendectomy with residents compared with patients undergoing laparoscopic appendectomy without residents had a higher incidence of serious and overall morbidity and longer surgical times. However, surgical times and complications were similar between residents in postgraduate years 1 to 5.

CONCLUSIONS: Regardless of the postgraduate year level, resident involvement resulted in a clinically appreciable increase in surgical times and a statistically significant increase in certain complications.

PMID: 22364902 [PubMed - in process]

Does a history of wound infection predict postoperative surgical site infection after ventral hernia repair?

Am J Surg. 2012 Mar;203(3):370-4

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

Abstract

BACKGROUND: Stratification of risks of postoperative wound/mesh infection after hernia repair remains a challenge. We aimed to determine the role of a previous wound infection on surgical site infection in patients undergoing open ventral hernia repair.

METHODS: All patients undergoing open ventral hernia repair in a clean setting were evaluated from a prospectively maintained database. The primary end point was the development of a postoperative surgical site infection.

RESULTS: A total of 146 patients were included in the analysis, and 22 patients had a history of previous wound infection. The rate of surgical site infection did not differ between those with or without a history of wound infection (14% vs 9%; P = .444). Patients with a history of chronic obstructive pulmonary disease or smoking were at an increased risk of developing a surgical site infection.

CONCLUSIONS: For patients undergoing open ventral hernia repair, a history of previous wound infection is not predictive of postoperative surgical site infection.

PMID: 22364903 [PubMed - in process]

Outcomes of ileocolic resection and right hemicolectomies for Crohn’s patients in comparison with non-Crohn’s patients and the impact of perioperative immunosuppressive therapy with biologics and steroids on inpatient complications.

Am J Surg. 2012 Mar;203(3):375-8

Authors: Mascarenhas C, Nunoo R, Asgeirsson T, Rivera R, Kim D, Hoedema R, Dujovny N, Luchtefeld M, Davis AT, Figg R

Abstract

BACKGROUND: The purpose of this study was to compare medication use and complication rates between Crohn’s disease (CD) and non-CD patients undergoing ileocolic resections and right hemicolectomies.

METHODS: A review of patients who underwent ileocolic resections and right hemicolectomies from January 1, 2003, through December 31, 2010, was performed. Data collected included demographics and clinical information, biologics use (eg, infliximab, adalimumab), other medication use (eg, steroids), complications, and mortality.

RESULTS: There were 791 records reviewed, with 93 CD patients. There was no significant difference in major or minor complications, anastomotic leaks, operating room time, or postoperative ileus occurrence between the CD and non-CD groups (P > .05). Use of biologics and steroids were significantly higher among the CD patients. Mortality, age, and American Society of Anesthesiologists score were significantly higher in the non-CD group.

CONCLUSIONS: Ileocolic resections and right hemicolectomies in CD patients are not associated with an increase in complication rates even when the patients use steroids and biologics in the preoperative period.

PMID: 22364904 [PubMed - in process]

Developing an experimental model for surgical drainage investigations: an initial report.

Am J Surg. 2012 Mar;203(3):388-91

Authors: Swartz AL, Azuh O, Obeid LV, Munaco AJ, Toursavadkohi S, Adams J, Dulchavsky M, Dobie L, Berardo DJ, Horst M, Patton JH, Falvo AJ, Rubinfeld I

Abstract

BACKGROUND: We sought to pilot and initiate validation of a surgical drainage model.

METHODS: We designed a laboratory model to compare Jackson-Pratt surgical drains using 3 soups to emulate body fluids of serous, purulent, and necrotic debris. Each drain was trialed with each of the 3 fluids. Time and completeness of drainage were recorded. A survey of surgical residents and faculty was performed for convenience sampling.

RESULTS: Under serous conditions, the round Jackson-Pratt drained the cavity quicker, but left a larger residual volume of fluid. Under purulent conditions, the round Jackson-Pratt was slower and drained less fluid. With debris fluid, the round Jackson-Pratt was quicker with less residual fluid whereas the flat type clogged each time. Survey results showed adequate concordance with surgeons in agreement on soup choice.

CONCLUSIONS: The Jackson-Pratt drains perform differently depending on the drainage situation. The surgical community requires improved drain data to drive practice patterns.

PMID: 22364905 [PubMed - in process]

Does gender predict performance of novices undergoing Fundamentals of Laparoscopic Surgery (FLS) training?

Am J Surg. 2012 Mar;203(3):397-400

Authors: White MT, Welch K

Abstract

BACKGROUND: This study was performed to assess the hypothesis that performance levels for Fundamentals of Laparoscopic Surgery (FLS) tasks were not dependent on trainee gender.

METHODS: Initial and final task completion times for 4 FLS tasks performed by 132 novices (4th-year medical students and 1st-year residents) were collated by task type and compared by gender.

RESULTS: All novices improved significantly with training (P > .001) on all tasks. Initial performance by men was better than by women but only reached significance for peg transfer and intracorporeal knot tying (P > .05). With training, women’s performance became equivalent to that of men but showed a comparable or greater response to training.

CONCLUSIONS: The gender-related differences noted in initial FLS task performance disappeared after training. Gender displayed no effect on FLS training outcomes. The use of initial FLS task performance levels, seemingly objective selection criteria, would introduce gender bias into the ranking process.

PMID: 22364906 [PubMed - in process]

Tale of two sites: capillary versus arterial blood glucose testing in the operating room.

Am J Surg. 2012 Feb 24;

Authors: Akinbami F, Segal S, Schnipper JL, Stopfkuchen-Evans M, Mills J, Rogers SO

Abstract

INTRODUCTION: Pre- and intraoperative glycemic control has been identified as a putative target to improve outcomes of surgical patients. Glycemic control requires frequent monitoring of blood glucose levels with appropriate adjustments. However, monitoring standards have been called into question, especially in cases in which capillary samples are used. Point-of-care testing (POCT) using capillary samples and glucometers has been noted to give relatively accurate results for critically ill patients. However, the package inserts of most glucometers warn that they should not be used for patients in shock. This has led clinicians to doubt their accuracy in the operating room. The accuracy of capillary samples when tested in patients undergoing surgical procedures has not been proven. This study aims to determine the accuracy of intraoperative blood glucose values using capillary samples relative to arterial samples. METHODS: A prospective study was conducted by collecting paired capillary and arterial samples of patients undergoing major operations at a tertiary medical center from August 2009 to May 2011. Subjects were a convenience sample of patients who had arterial lines and needed glucose testing while undergoing the procedure. Precision Xceed Pro (Abbott) handheld glucometers were used to obtain the blood glucose values. Our primary outcome of interest was the degree of correlation between capillary and arterial blood glucose values or the degree to which arterial glucose levels can be predicted by capillary glucose samples. We used linear regression and the Student t tests for statistical analyses. RESULTS: Seventy-two-paired samples were collected. Of the cases, 54% were major abdominal operations, whereas 24% were vascular operations. The mean values ± standard deviation for glucose levels were 146 ± 35 mg/dL (capillary) and 147 ± 36 mg/dL (arterial). The mean time ± standard deviation between the collection of both samples was 3.5 ± 1.3 minutes. The regression coefficient showed a strong positive correlation of .91 between capillary glucose values and arterial values (P < .001) although correlation was less stringent at the hyperglycemic range of values. The R(2) statistic was 84%. Differences in values between capillary and arterial samples would not have altered the diagnosis of hypo- and hyperglycemia using typical thresholds. CONCLUSIONS: Capillary samples collected intraoperatively are strongly correlated with arterial samples. Glucose monitoring in the operating room can be safely performed by collecting capillary samples for POCT. However, clinicians should still be cautious when interpreting glucose levels that are high, either by repeating the blood glucose test or by having samples sent to the laboratory.

PMID: 22365099 [PubMed - as supplied by publisher]

Self-reporting of height and weight: valid and reliable identification of malnutrition in preoperative patients.

Am J Surg. 2012 Feb 22;

Authors: Haverkort EB, de Haan RJ, Binnekade JM, Schueren MA

Abstract

BACKGROUND: Preoperative screening for malnutrition has become mandatory in The Netherlands. A sensitive method to diagnose malnutrition would save time and improve effectiveness. METHODS: A prospective cross-sectional study of 488 adult elective preoperative outpatients was performed. The accuracy of self-reported height and weight was compared with measured data and 3 commonly used malnutrition screening tools. Interobserver agreement was calculated by the intraclass correlation coefficient, studied in Bland and Altman plots, and analyzed by using Cohen’s κ statistic. Accuracy was expressed in sensitivity, specificity, and false-negative rates. RESULTS: Differences between self-reported and measured data were significant, but clinically irrelevant, because only 1 patient was falsely identified as well nourished. Intraclass correlation coefficient for height, weight, and body mass index was high (.97-.99). Bland-Altman plots showed that the mean ± standard deviation differences and 95% limits of agreement between both methods were as follows: height, .0096 m (±.0262, -.0417 to +.0609 m); weight, -1.28 kg (±2.29, -5.76 to +3.20 kg); body mass index, -.72 kg/m(2) (±1.11, -2.92 to +1.46 kg/m(2)). The κ coefficient was .84 (95% confidence interval, .75-.94). Sensitivity was .97 and specificity was .98. Sensitivity and false-negative rates of self-reported data were better overall compared with the screening tools. CONCLUSIONS: Self-reported data provide highly sensitive information to diagnose malnutrition in preoperative outpatients.

PMID: 22365153 [PubMed - as supplied by publisher]

Beyond consent–improving understanding in surgical patients.

Am J Surg. 2012 Jan;203(1):112-20

Authors: Mulsow JJ, Feeley TM, Tierney S

Abstract

BACKGROUND: Little is known of the actual understanding that underlies patient choices with regard to their surgical treatment. This review explores current knowledge of patient understanding and techniques that may be used to improve this understanding.

METHODS: MEDLINE and PubMed were searched using the terms “patient understanding,” “patient comprehension,” “consent,” “video,” “multimedia,” “patient information leaflet,” “internet,” “test-feedback,” “extended discussion,” “shared decision making,” and “decision aid.” All retrieved peer-reviewed studies were included in the review.

RESULTS: Understanding in surgical patients is poor. There is little evidence to support the use of information leaflets, although multimedia appears to be effective in improving patient understanding. The internet is not used effectively as an aid to consent by health care providers. Patients with lower educational levels may gain most from additional interventions. Improving patient understanding does not impact on their satisfaction with the treatment they have received but may reduce periprocedural anxiety.

CONCLUSIONS: There is a need for greater awareness of patients’ information needs, and novel approaches that may enhance decision making through improved understanding are required.

PMID: 21641573 [PubMed - indexed for MEDLINE]

Effective home laparoscopic simulation training: a preliminary evaluation of an improved training paradigm.

Am J Surg. 2012 Jan;203(1):1-7

Authors: Korndorffer JR, Bellows CF, Tekian A, Harris IB, Downing SM

Abstract

BACKGROUND: Laparoscopic simulation training has proven to be effective in developing skills but requires expensive equipment, is a challenge to integrate into a work-hour restricted surgical residency, and may use nonoptimal practice schedules. The purpose of this study was to evaluate the efficacy of laparoscopic skills training at home using inexpensive trainer boxes.

METHODS: Residents (n = 20, postgraduate years 1-5) enrolled in an institutional review board-approved laparoscopic skills training protocol. An instructional video was reviewed, and baseline testing was performed using the fundamentals of laparoscopic surgery (FLS) peg transfer and suturing tasks. Participants were randomized to home training with inexpensive, self-contained trainer boxes or to simulation center training using standard video trainers. Discretionary, goal-directed training of at least 1 hour per week was encouraged. A posttest and retention test were performed. Intragroup and intergroup comparisons as well as the relationship between the suture score and the total training sessions, the time in training, and attempts were studied.

RESULTS: Intragroup comparisons showed significant improvement from baseline to the posttest and the retention test. No differences were shown between the groups. The home-trained group practiced more, and the number of sessions correlated with suture retention score (r(2) = .54, P < .039).

CONCLUSIONS: Home training results in laparoscopic skill acquisition and retention. Training is performed in a more distributed manner and trends toward improved skill retention.

PMID: 22172481 [PubMed - indexed for MEDLINE]

Construction of an evidence-based, graduated training curriculum for D-box, a webcam-based laparoscopic basic skills trainer box.

Am J Surg. 2012 Feb 14;

Authors: Debes AJ, Aggarwal R, Balasundaram I, Jacobsen MB

Abstract

BACKGROUND: Surgical training programs are now including simulators as training tools for teaching laparoscopic surgery. The aim of this study was to develop a standardized, graduated, and evidence-based curriculum for the newly developed D-box (D-box Medical, Lier, Norway) for training basic laparoscopic skills. METHODS: Eighteen interns with no laparoscopic experience completed a training program on the D-box consisting of 8 sessions of 5 tasks with assessment on a sixth task. Performance was measured by the use of 3-dimensional electromagnetic tracking of hand movements, path length, and time taken. Ten experienced surgeons (>100 laparoscopic surgeries, median 250) were recruited for establishing benchmark criteria. RESULTS: Significant learning curves were obtained for all construct valid parameters for tasks 4 (P < .005) and 5 (P < .005) and reached plateau levels between the fifth and sixth session. Within the 8 sessions of this study, between 50% and 89% of the interns reached benchmark criteria on tasks 4 and 5. CONCLUSIONS: Benchmark criteria and an evidence-based curriculum have been developed for the D-box. The curriculum is aimed at training and assessing surgical novices in basic laparoscopic skills.

PMID: 22340961 [PubMed - as supplied by publisher]

Effects of duodenal-jejunal exclusion on beta cell function and hormonal regulation in Goto-Kakizaki rats.

Am J Surg. 2012 Feb 15;

Authors: de Luis D, Domingo M, Romero A, Sagrado MG, Pacheco D, Primo D, Conde R

Abstract

BACKGROUND: The aim of our work was to investigate the hormones that control glycemic status and in vitro β-cell function in diabetes mellitus after a duodenal-jejunal exclusion in Goto-Kakizaki rats (Taconic, Denmark). METHODS: Twenty-three rats (age, 12-14 wk) were randomized as follows: group 1 (n = 14), no intervention (control); or group 2 (n = 9), duodenal-jejunal exclusion. RESULTS: In group 2, levels of glucagon and leptin were lower than in group 1 at 1 week and at 8 weeks. Glucagon-like peptide 1 levels had a significant increase at 8 weeks from basal value in group 2 and this value was higher than in group 1. The insulin secretion at 60 minutes in group 2 was higher than in group 1 (group 1, 12.9 ± 12.0 μg/L vs group 2, 41.9 ± 36.3 μg/L; P < .05). Messenger RNA (mRNA) expression of insulin at 2 months was higher in the rat pancreas of the experimental group than in the control group (group 1, .99 ± .48 mRNA amount vs group 2, 1.66 ± .33 mRNA amount; P < .05). CONCLUSIONS: Gastrojejunal bypass in this model improves glucose ratios, with a significant increase of glucagon-like peptide 1 and decrease of homeostasis model assessment, glucagon, and leptin levels after surgery. This type of surgery improves mRNA insulin expression in pancreatic islets and insulin secretion as well.

PMID: 22341521 [PubMed - as supplied by publisher]

A comparison of ambulatory perioperative times in hospitals and freestanding centers.

Am J Surg. 2012 Feb 15;

Authors: Hair B, Hussey P, Wynn B

Abstract

BACKGROUND: The volume of surgical procedures performed in ambulatory surgical centers has increased rapidly. METHODS: Ambulatory surgical visits of Medicare beneficiaries were compared for hospital-based and freestanding ambulatory surgical centers (ASCs). The main outcomes were time in surgery, time in operating room, time in postoperative care, and total perioperative time. RESULTS: The mean total perioperative time for all procedures examined was 39% shorter in freestanding ASCs then in hospital-based ASCs (83 vs 135 min; P < .01); surgery time was 37% shorter (19 vs 30 min; P < .01), operating room time was 37% shorter (34 vs 54 min; P < .01), and postoperative time was 35% shorter (48 vs 74 min; P < .01). CONCLUSIONS: Perioperative times were significantly shorter in freestanding ASCs than in hospital-based ASCs. It is unclear how much of the difference was the result of efficiency versus patient selection.

PMID: 22341522 [PubMed - as supplied by publisher]

Is double-gloving really protective? A comparison between the glove perforation rate among perioperative nurses with single and double gloves during surgery.

Am J Surg. 2012 Feb 16;

Authors: Guo YP, Wong PM, Li Y, Or PP

Abstract

BACKGROUND: Surgical teams rely on surgical gloves as a barrier to protect themselves against blood-borne pathogenic infections during surgery. Double-gloving is adopted by surgeons to tackle the problem of glove perforation. Nevertheless, double-gloving is not practiced commonly by operating room nurses and there are only limited studies about double-gloving that targets only perioperative nurses. The aim of this research was to assess the effectiveness of double-gloving in protecting perioperative nurses by comparing the frequency of glove perforation between single-gloving and double-gloving groups. METHODS: A prospective and randomized study was performed. Nurses were assigned randomly to single-gloved and double-gloved groups for comparison of the glove perforation rate. Water-leakage and air-inflation tests were used to detect glove perforation. RESULTS: Glove perforations was detected in 10 of 112 sets of single-gloves (8.9%) and 12 of 106 sets of outer gloves in the double-gloved group (11.3%). There was no inner double-glove perforation (0%). Glove perforations were found in 6 and 4 of the 112 sets of single-gloves for the first assistants (5.36%) and the scrub nurses (3.57%), and 5 and 7 of 106 sets of outer gloves in the double-gloved group for the first assistants (4.72%) and the scrub nurses (6.60%), respectively. The average occurrence of perforation was 69.8 minutes (range, 20-110 min) after the beginning of surgery. The sites of perforation were localized mostly on the left middle finger (42%) and the left ring finger (33.3%). CONCLUSIONS: Based on the findings of the study, double-gloving is indeed effective in protecting operating room nurses against blood-borne pathogen exposure. It should be introduced as a routine practice.

PMID: 22342011 [PubMed - as supplied by publisher]

Disparity in the management of Graves’ disease observed at an urban county hospital; a decade-long experience.

Am J Surg. 2012 Feb 6;

Authors: Jin J, Sandoval V, Lawless ME, Sehgal AR, McHenry CR

Abstract

BACKGROUND: The objective of this study was to determine whether health care disparities exist in management of Graves’ disease. METHODS: Patients treated for Graves’ disease from 1999 to 2009 were divided into medical and surgical treatment groups. A comparative analysis of age, sex, race, health insurance, and income was completed. Address and/or zip code were geocoded and median income was determined from census data. RESULTS: A total of 634 patients were treated for Graves’ disease; 535 (84%) medically and 99 (16%) surgically. Mean age (40 ± 15 vs 43 ± 11 y), percentage of women (84% vs 91%), and racial distribution were similar in the 2 groups (P > .05). In the surgical group, median income was lower ($31,530 vs $34,404; P = .07) and 52% of patients were uninsured compared with 30% of patients treated medically (P < .0001). CONCLUSIONS: A disproportionate number of uninsured patients underwent thyroidectomy for Graves’ disease. Social and economic factors may have a role in determining definitive therapy for Graves’ disease.

PMID: 22317948 [PubMed - as supplied by publisher]

Author’s reply.

Am J Surg. 2012 Feb 6;

Authors: Goldsmith HS

PMID: 22317949 [PubMed - as supplied by publisher]

A resident perspective on increasing duty-hour limitations.

Am J Surg. 2012 Feb 7;

Authors: Cannon RM, Egger ME, Bozeman MC

PMID: 22321853 [PubMed - as supplied by publisher]

Re: “Colon preparation and surgical site infection”

Am J Surg. 2012 Feb 7;

Authors: Dellinger EP

PMID: 22321854 [PubMed - as supplied by publisher]

Worsening severity of vitamin D deficiency is associated with increased length of stay, surgical intensive care unit cost, and mortality rate in surgical intensive care unit patients.

Am J Surg. 2012 Feb 9;

Authors: Matthews LR, Ahmed Y, Wilson KL, Griggs DD, Danner OK

Abstract

BACKGROUND: >Vitamin D deficiency is the most common nutritional deficiency in the United States. It is seldom measured or recognized, and rarely is treated, particularly in critically ill patients. The purpose of this study was to investigate the prevalence and impact of vitamin D deficiency in surgical intensive care unit patients. We hypothesized that severe vitamin D deficiency increases the length of stay, mortality rate, and cost in critically ill patients admitted to surgical intensive care units. METHODS: We performed a prospective observational study of vitamin D status on 258 consecutive patients admitted to the Surgical Intensive Care Unit at Grady Memorial Hospital between August 2009 and January 2010. Vitamin D levels (25 [OH]2 vitamin-D3) were measured by high-pressure liquid chromatography and tandem mass spectrometry. Vitamin D deficiency was defined as follows: severe deficiency was categorized as less than 13 ng/mL; moderate deficiency was categorized as 14 to 26 ng/mL; mild deficiency was categorized as 27 to 39 ng/mL; and normal levels were categorized as greater than 40 ng/mL. RESULTS: Of the 258 patients evaluated, 70.2% (181) were men, and 29.8% (77) were women; 57.6% (148) were African American and 32.4% (109) were Caucasian. A total of 138 (53.5%) patients had severe vitamin D deficiency, 96 (37.2%) had moderate deficiency, 18 (7.0%) had mild deficiency, and 3 (1.2%) of the patients had normal vitamin D levels. The mean length of stay in the Surgical Intensive Care Unit for the severe vitamin D-deficient group was 13.33 ± 19.5 days versus 7.29 ± 15.3 days and 5.17 ± 6.5 days for the moderate and mild vitamin D-deficient groups, respectively, which was clinically significant (P = .002). The mean treatment cost during the patient stay in the surgical intensive care unit was $51,413.33 ± $75,123.00 for the severe vitamin D-deficient group, $28,123.65 ± $59,752.00 for the moderate group, and $20,414.11 ± $25,714.30 for the mild vitamin D-deficient group, which also was clinically significant (P = .027). More importantly, the mortality rate for the severe vitamin D-deficient group was 17 (12.3%) versus 11 (11.5%) in the moderate group (P = .125). Because no deaths occurred in the mildly or normal vitamin D-deficient groups, we compared the mortality rate between severe/moderate and mild/normal vitamin D groups (P = .047). CONCLUSIONS: In univariate analysis, severe and moderate vitamin D deficiency was related inversely to the length of stay in the surgical intensive care unit (r = .194; P = .001), related inversely to surgical intensive care unit treatment cost (r = .194; P = .001) and mortality (r = .125; P = .023), compared with the mild vitamin D-deficient group, after adjusting for age, sex, race, and comorbidities (myocardial infarctions, acute renal failure, and pneumonia); the length of stay, surgical intensive care unit cost, and mortality remained significantly associated with vitamin D deficiency.

PMID: 22325335 [PubMed - as supplied by publisher]

Utilization of a cognitive task analysis for laparoscopic appendectomy to identify differentiated intraoperative teaching objectives.

Am J Surg. 2012 Feb 9;

Authors: Smink DS, Peyre SE, Soybel DI, Tavakkolizadeh A, Vernon AH, Anastakis DJ

Abstract

BACKGROUND: Experts become automated when performing surgery, making it difficult to teach complex procedures to trainees. Cognitive task analysis (CTA) enables experts to articulate operative steps and cognitive decisions in complex procedures such as laparoscopic appendectomy, which can then be used to identify central teaching points. METHODS: Three local surgeon experts in laparoscopic appendectomy were interviewed using critical decision method-based CTA methodology. Interview transcripts were analyzed, and a cognitive demands table (CDT) was created for each expert. The individual CDTs were reviewed by each expert for completeness and then combined into a master CDT. Percentage agreement on operative steps and decision points was calculated for each expert. The experts then participated in a consensus meeting to review the master CDT. Each surgeon expert was asked to identify in the master CDT the most important teaching objectives for junior-level and senior-level residents. The experts’ responses for junior-level and senior-level residents were compared using a χ(2) test. RESULTS: The surgeon experts identified 24 operative steps and 27 decision points. Eighteen of the 24 operative steps (75%) were identified by all 3 surgeon experts. The percentage of operative steps identified was high for each surgeon expert (96% for surgeon 1, 79% for surgeon 2, and 83% for surgeon 3). Of the 27 decision points, only 5 (19%) were identified by all 3 surgeon experts. The percentage of decision points identified varied by surgeon expert (78% for surgeon 1, 59% for surgeon 2, and 48% for surgeon 3). When asked to identify key teaching points, the surgeon experts were more likely to identify operative steps for junior residents (9 operative steps and 6 decision points) and decision points for senior residents (4 operative steps and 13 decision points) (P < .01). CONCLUSIONS: CTA can deconstruct the essential operative steps and decision points associated with performing a laparoscopic appendectomy. These results provide a framework to identify key teaching principles to guide intraoperative instruction. These learning objectives could be used to guide resident level-appropriate teaching of an essential general surgery procedure.

PMID: 22325336 [PubMed - as supplied by publisher]

Content and face validity of a comprehensive robotic skills training program for general surgery, urology, and gynecology.

Am J Surg. 2012 Feb 8;

Authors: Dulan G, Rege RV, Hogg DC, Gilberg-Fisher KK, Tesfay ST, Scott DJ

Abstract

BACKGROUND: The authors previously developed a comprehensive, proficiency-based robotic training curriculum that aimed to address 23 unique skills identified via task deconstruction of robotic operations. The purpose of this study was to determine the content and face validity of this curriculum. METHODS: Expert robotic surgeons (n = 12) rated each deconstructed skill regarding relevance to robotic operations, were oriented to the curricular components, performed 3 to 5 repetitions on the 9 exercises, and rated each exercise. RESULTS: In terms of content validity, experts rated all 23 deconstructed skills as highly relevant (4.5 on a 5-point scale). Ratings for the 9 inanimate exercises indicated moderate to thorough measurement of designated skills. For face validity, experts indicated that each exercise effectively measured relevant skills (100% agreement) and was highly effective for training and assessment (4.5 on a 5-point scale). CONCLUSIONS: These data indicate that the 23 deconstructed skills accurately represent the appropriate content for robotic skills training and strongly support content and face validity for this curriculum.

PMID: 22326049 [PubMed - as supplied by publisher]

Does increased experience with laparoscopic cholecystectomy yield more complex bile duct injuries?

Am J Surg. 2012 Feb 8;

Authors: Chuang KI, Corley D, Postlethwaite DA, Merchant M, Harris HW

Abstract

BACKGROUND: Two decades since the advent of laparoscopic cholecystectomy, the rate of bile duct injuries still remains higher than in the open cholecystectomy era. METHODS: The rate and complexity of bile duct injuries was evaluated in 83,449 patients who underwent laparoscopic cholecystectomy between 1995 and 2008 in the Kaiser Permanente Northern California system. Fifty-six surgeons who performed a laparoscopic cholecystectomy in the past were surveyed to determine factors that predispose to bile duct injuries. RESULTS: The overall incidence of bile duct injuries was .10%; 59.5% of the 84 injuries were cystic duct leaks. Incidence varied slightly from .10% (1995-1998) to .08% (1999-2003) and .12% (2004-2008). There was a trend toward more proximal injuries (injury <2 cm from the bifurcation: 14.3% to 44.4% to 50.0% of major injuries). The misinterpretation of anatomy was cited by 92.9% of surgeons as the primary cause of bile duct injuries; 70.9% cited a lack of experience as a contributing factor. CONCLUSIONS: Laparoscopic cholecystectomy has an overall low risk of bile duct injuries; the rate remains constant, but injury complexity may have increased over time.

PMID: 22326050 [PubMed - as supplied by publisher]

Commentary on: feasibility study of two-stage hepatectomy for bilobar liver metastases.

Am J Surg. 2012 Feb 10;

Authors: Vauthey JN, Abbott DE

PMID: 22326822 [PubMed - as supplied by publisher]

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]