Volume-Outcome Association in Bariatric Surgery: A Systematic Review.

Ann Surg. 2012 May 11;

Authors: Zevin B, Aggarwal R, Grantcharov TP

Abstract

OBJECTIVE:: To systematically examine the association between annual hospital and surgeon case volume and patient outcomes in bariatric surgery. BACKGROUND:: Bariatric surgery remains a technically demanding field with significant risk for morbidity and mortality. To mitigate this risk, minimum annual hospital and surgeon case volume requirements are being set and certain hospitals are being designated as “Bariatric Surgery Centers of Excellence.” The effects of these interventions on patient outcomes remain unclear. METHODS:: A comprehensive systematic review on volume-outcome association in bariatric surgery was conducted by searching MEDLINE, Cochrane Database of Systematic Reviews, and Evidence Based Medicine Reviews databases. Abstracts of identified articles were reviewed and pertinent full-text versions were retrieved. Manual search of bibliographies was performed and relevant studies were retrieved. Methodological quality assessment and data extraction were completed in a systematic fashion. Pooling of results was not feasible due to the heterogeneity of the studies. A qualitative summary of results is presented. RESULTS:: From a total of 2928 unique citations, 24 studies involving a total of 458,032 patients were selected for review. Two studies were prospective cohorts (level of evidence [LOE] 1), 3 were retrospective cohorts (LOE 3), 2 were retrospective case controls (LOE 3), and 17 were retrospective case series (LOE 4). The overall methodological quality of the reviewed studies was fair. A positive association between annual surgeon volume and patient outcomes was reported in 11 of 13 studies. A positive association between annual hospital volume and patient outcomes was reported in 14 of 17 studies. CONCLUSIONS:: There is strong evidence of improved patient outcomes in the hands of high-volume surgeons and high-volume centers. This study supports the concept of “Bariatric Surgery Center of Excellence” accreditation; however, future research into the quality of care characteristics of successful bariatric programs is recommended. Understanding the characteristics of high-volume surgeons, which lead to improved patient outcomes, also requires further investigation.

PMID: 22584692 [PubMed - as supplied by publisher]

Durability of Roux-en-Y Gastric Bypass Surgery: A Meta-Regression Study.

Ann Surg. 2012 May 11;

Authors: Attiah MA, Halpern CH, Balmuri U, Vinai P, Mehta S, Baltuch GH, Williams NN, Wadden TA, Stein SC

Abstract

OBJECTIVE:: The present meta-regression pools data from reports of long-term follow-up (>2 years) to assess durability of the efficacy associated with Roux-en-Y gastric bypass (RYGB) surgery. DATA SOURCES:: Medline and PubMed searches for articles pertaining to long-term weight loss after RYGB surgery were performed. BACKGROUND:: Various studies have consistently shown short-term (<2 years) efficacy of RYGB surgery for morbid obesity, corroborated by meta-analytic techniques. Relatively few studies have assessed efficacy over longer periods of time. This is the first meta-analysis to analyze long-term effects of RYGB surgery on weight loss. METHODS:: Twenty-two reports with a total of 4206 patient cases were included. Sixteen of the 22 studies had multiple follow-up times, ranging from 2 to 12.3 years (mean: 3.6 years). An inverse variance weighted model and meta-regression were used to generate the pooled percent mean excess weight loss (EWL) and the durability of EWL over time, respectively. RESULTS:: Meta-regression did not reveal any significant change in EWL over time. Pooled mean EWL was 66.5%, and there was no significant association between EWL and length of follow-up. CONCLUSIONS:: Pooling data from multiple studies meta-analytically revealed that weight loss after RYGB is maintained over the long-term. Further investigation would be necessary to ascertain similar durability in comorbidity reduction after RYGB surgery.

PMID: 22584693 [PubMed - as supplied by publisher]

Wound Protectors Reduce Surgical Site Infection: A Meta-Analysis of Randomized Controlled Trials.

Ann Surg. 2012 May 11;

Authors: Edwards JP, Ho AL, Tee MC, Dixon E, Ball CG

Abstract

OBJECTIVE:: A meta-analysis of randomized clinical trials (RCTs) was conducted to evaluate whether wound protectors reduce the risk of surgical site infection (SSI) after gastrointestinal and biliary tract surgery. BACKGROUND:: The effectiveness of impervious wound edge protectors for reduction of SSI remains unclear. METHODS:: A systematic review was conducted in Medline, EMBASE, and the Cochrane Library to identify RCTs that evaluate the risk of SSI after gastrointestinal and biliary surgeries with and without the use of an impervious wound protector. The pooled risk ratio was estimated with random-effect meta-analysis. Sensitivity analyses were performed to examine the impact of structural design of wound protector, publication year, study quality, inclusion of emergent surgeries, preoperative antibiotic administration, and bowel preparation on the pooled risk of SSI. RESULTS:: Of the 347 studies identified, 6 RCTs representing 1008 patients were included. The use of a wound protector was associated with a significant decrease in SSI (RR = 0.55, 95% CI 0.31-0.98, P = 0.04). There was a nonsignificant trend toward greater protective effect in studies using a dual ring protector (RR = 0.31, 95% CI 0.14-0.67, P = 0.003), rather than a single ring protector (RR = 0.83, 95% CI 0.38-1.83, P = 0.64). Publication year (P = 0.03) and blinding of outcome assessors (P = 0.04) significantly modified the effect of wound protectors on SSI. CONCLUSIONS:: Our results suggest that wound protectors reduce rates of SSI after gastrointestinal and biliary surgery.

PMID: 22584694 [PubMed - as supplied by publisher]

Anastomotic Leak Is Not Associated With Oncologic Outcome in Patients Undergoing Low Anterior Resection for Rectal Cancer.

Ann Surg. 2012 May 11;

Authors: Smith JD, Paty PB, Guillem JG, Temple LK, Weiser MR, Nash GM

Abstract

OBJECTIVE:: To examine the association between anastomotic leak and oncologic outcome after anterior resection, stratifying for defunctioning stoma. BACKGROUND:: It has been hypothesized that anastomotic leak predisposes rectal cancer patients to local recurrence. Many have a defunctioning stoma to reduce risk of clinically significant leakage. METHODS:: The records of patients undergoing low anterior resection (1991-2010) for rectal adenocarcinoma (≤15 cm from anal verge) were retrospectively analyzed using a prospectively collected colorectal database. Data (age, gender, stage, defunctioning stoma, neoadjuvant treatment, distance from anal verge, anastomotic leak) were collected. Clinical leakage was defined as anastomotic complication requiring intervention or interventional radiology within 60 days of surgery. Estimated local recurrence, overall survival, and disease-specific survival were compared using log-rank method and Cox regression analysis. RESULTS:: 1127 patients were included, with 5.6-year median follow-up. The incidence of clinical anastomotic leak was 3.5%. Sixteen of 677 with defunctioning stoma (2.2%) developed clinical leak; 24 of 450 without stoma (6.3%) developed leak (P = 0.005). There were no perioperative deaths among patients with clinical leakage. When stratified for defunctioning stoma, there was no association between clinical leak and local recurrence, disease-free survival, or overall survival. On multivariable analysis, when controlling for neoadjuvant therapy, distance of tumor from anal verge, defunctioning stoma, and pathologic stage, clinical leak was not associated with time to local recurrence, disease-free survival, or overall survival. CONCLUSIONS:: In this cohort, anastomotic leakage was not associated with risk of local recurrence. Defunctioning stoma was associated with lower incidence of clinical leakage but not with difference in oncologic outcome. Careful patient selection for defunctioning stoma helps reduce risk of clinically significant anastomotic leak.

PMID: 22584695 [PubMed - as supplied by publisher]

The Role of Surgeon Error in Withdrawal of Postoperative Life Support.

Ann Surg. 2012 May 11;

Authors: Schwarze ML, Redmann AJ, Brasel KJ, Alexander GC

Abstract

BACKGROUND:: Surgeons may be reluctant to withdraw postoperative life support after a poor outcome. METHODS:: A cross-sectional random sample was taken from a US mail survey of 2100 surgeons who routinely perform high-risk operations. We used a hypothetical vignette of a specialty-specific operation complicated by a hemiplegic stroke and respiratory failure. On postoperative day 7, the patient and family requested withdrawal of life-supporting therapy. We experimentally modified the timing and role of surgeon error to assess their influence on surgeons’ willingness to withdraw life-supporting care. RESULTS:: The adjusted response rate was 56%. Sixty-three percent of respondents would not honor the request to withdraw life-supporting treatment. Willingness to withdraw life-support was significantly lower in the setting of surgeon error (33% vs 41%, P < 0.008) and elective operations rather than in emergency cases (33% vs 41%, P = 0.01). After adjustment for specialty, years of experience, geographic region, and gender, odds of withdrawing life-supporting therapy were significantly greater in cases in which the outcome was not explicitly from error during an emergency operation as compared to iatrogenic injury in elective cases (odds ratio 1.95, 95% confidence intervals 1.26-3.01). Surgeons who did not withdraw life-support were significantly more likely to report the importance of optimism regarding prognosis (79% vs 62%, P < 0.0001) and concern that the patient could not accurately predict future quality of life (80% vs 68%, P < 0.0001). CONCLUSIONS:: Surgeons are more reluctant to withdraw postoperative life-supporting therapy for patients with complications from surgeon error in the elective setting. This may also be influenced by personal optimism and a belief that patients are unable to predict the value of future health states.

PMID: 22584696 [PubMed - as supplied by publisher]

Defining a Successful Esophagectomy.

Ann Surg. 2012 May 10;

Authors: Donohoe CL, Reynolds JV

PMID: 22580934 [PubMed - as supplied by publisher]

Prospective, Randomized Assessment of the Acquisition, Maintenance, and Loss of Laparoscopic Skills.

Ann Surg. 2012 May 10;

Authors: Gallagher AG, Jordan-Black JA, O’Sullivan GC

Abstract

BACKGROUND:: Laparoscopic skills are difficult to learn. We, therefore, assessed the factors involved in skill acquisition, maintenance, and loss in 2 prospective, randomized studies. METHODS:: In study 1, 24 laparoscopic novices were randomly assigned to a control condition who performed the laparoscopic assessment task; Massed condition who trained on virtual reality (VR) simulation during 1 day or Interval condition who had the same amount of VR training distributed over 3 consecutive days. All groups also completed a novel laparoscopic box-trainer task on 5 consecutive days. In study 2, 16 laparoscopic novices were randomly assigned to a Practice or a No-practice condition. All subjects were required to train on a VR simulation curriculum for the same duration and skill attainment level. The week after completion of training, subjects in the Practice condition were allowed 1 complete practice trial on the simulator. Both groups completed the same tasks 2 weeks after completion of the training. RESULTS:: In study 1, the Interval trained group showed the fastest rate of learning and on completion of training significantly outperformed both the Massed and Control groups (P < 0.0001). In study 2, both groups showed significant skills improvement from training trial T1 to T3 (P < 0.0001). The subjects in the Practice group maintained or improved their skills at 1 week but those in the No practice group showed significant decline of skills at 2 weeks after training completion (P < 0.0001). CONCLUSIONS:: Laparoscopic skills are optimally acquired on an Interval training schedule. They significantly decline with 2 weeks of nonuse.

PMID: 22580935 [PubMed - as supplied by publisher]

Cholangiocarcinoma or IgG4-Associated Cholangitis: How Feasible It Is to Avoid Unnecessary Surgical Interventions?

Ann Surg. 2012 May 10;

Authors: Lytras D, Kalaitzakis E, Webster GJ, Imber CJ, Amin Z, Rodriguez-Justo M, Pereira SP, Olde Damink SW, Malago’ M

Abstract

OBJECTIVE:: To evaluate the experience of a tertiary hepatopancreaticobiliary (HPB) center in the diagnostic approach and management of patients with suspicion of cholangiocarcinoma (CCa), focusing on excluding patients with IgG4-associated cholangitis (IAC) from unnecessary major surgical interventions. METHODS:: Between January 2008 and September 2010, a total number of 152 patients with suspicion of CCa underwent evaluation through a HPB multidisciplinary team meeting. Patients without tissue diagnosis were managed surgically or medically on the basis of probable presence of IAC as underlying pathology. Serology, immunostaining, and imaging were reviewed and analyzed according to the HISORt (Histology, Imaging, Serology, Other organ involvement, Response to therapy) criteria for IAC. RESULTS:: Tissue diagnosis during the diagnostic workup was achieved in 104 patients (68%), whereas the remaining 48 were classified as “highly suspicious for CCa” (n = 35) or as “probable IAC” (n = 13). Among 16 “highly suspicious for CCa” patients who underwent surgery, pathology revealed 2 patients harboring IAC (n = 1) and a benign chronic inflammatory biliary stricture (n = 1), respectively. Among the 13 patients with primarily medical management as “probable IAC,” final diagnosis was CCa (n = 3) and IAC (n = 9), while 1 patient had no proven diagnosis. The accuracy of serum IgG4 for diagnosis of IAC reached 60%. Sensitivity and specificity of immunostaining for IAC in biopsy specimens were 56% and 89%, respectively. Imaging features suggesting IAC yielded sensitivity, specificity, and accuracy of 75%, 89%, and 83%, respectively. Initial imaging was revised at the referral institute in 75% of IAC patients (P = 0.009), while an isolated stricture (P = 0.038), a biliary mass (P = 0.006), and normal pancreas on computed tomography (P = 0.01) were statistically significant parameters for distinguishing between CCa and IAC. The mean time for establishing a diagnosis of IAC was 12.4 months (range: 2.5-32 months) CONCLUSIONS:: Differential diagnosis between CCa and IAC mandates high index of suspicion and low threshold for referral in high volume institutes. The delayed establishment of diagnosis particularly for CCa needs to be balanced versus avoiding unnecessary surgery for IAC. Imaging features may be most helpful for optimal management.

PMID: 22580936 [PubMed - as supplied by publisher]

Partial Pancreaticoduodenectomy Can Provide Cure for Duodenal Gastrinoma Associated With Multiple Endocrine Neoplasia Type 1.

Ann Surg. 2012 May 10;

Authors: Lopez CL, Falconi M, Waldmann J, Boninsegna L, Fendrich V, Goretzki PK, Langer P, Kann PH, Partelli S, Bartsch DK

Abstract

OBJECTIVE:: To evaluate the outcome of pancreaticoduodenectomy (PD) versus non-PD resections for the treatment of gastrinoma in multiple endocrine neoplasia type 1. BACKGROUND:: Gastrinoma in MEN1 is considered a rarely curable disease and its management is highly controversial both for timing and extent of surgery. METHODS:: Clinical characteristics, complications and outcomes of 27 prospectively collected MEN1 patients with biochemically proven gastrinoma, who underwent surgery, were analyzed with special regard to the gastrinoma type and the initial operative procedure. RESULTS:: Twenty-two (81%) patients with gastrinoma in MEN1 had duodenal gastrinomas and 5 patients (19%) had pancreatic gastrinomas. At the time of diagnosis, 21 (77%) gastrinomas were malignant (18 duodenal, 3 pancreatic), but distant metastases were only present in 4 (15%) patients. Patients with pancreatic gastrinomas underwent either distal pancreatic resections or gastrinoma enucleation with lymphadenectomy, 2 patients also had synchronous resections of liver metastases. One of these patients was biochemically cured after a median of 136 (77-312) months. Thirteen patients with duodenal gastrinomas underwent PD resections (group 1, partial PD [n = 11], total PD [n = 2]), whereas 9 patients had no-PD resections (group 2) as initial operative procedure. Perioperative morbidity and mortality, including postoperative diabetes, differed not significantly between groups (P > 0.5). All patients of group 1 and 5 of 9 (55%) patients of group 2 had a negative secretin test at hospital discharge. However, after a median follow-up of 136 (3-276) months, 12 (92%) patients of group 1 were still normogastrinemic compared to only 3 of 9 (33%) patients of group 2 (P = 0.023). Three (33%) patients of group 2 had to undergo up to 3 reoperations for recurrent or metastatic disease compared to none of group 1. CONCLUSIONS:: Duodenal gastrinoma in MEN1 should be considered a surgically curable disease. PD seems to be the adequate approach to this disease, providing a high cure rate and acceptable morbidity compared to non-PD resections.

PMID: 22580937 [PubMed - as supplied by publisher]

Human Equilibrative Nucleoside Transporter 1 Expression Predicts Survival of Advanced Cholangiocarcinoma Patients Treated With Gemcitabine-Based Adjuvant Chemotherapy After Surgical Resection.

Ann Surg. 2012 May 10;

Authors: Kobayashi H, Murakami Y, Uemura K, Sudo T, Hashimoto Y, Kondo N, Sueda T

Abstract

OBJECTIVE:: The aim of this study was to evaluate whether intratumoral human equilibrative nucleoside transporter 1 (hENT1) expression can predict the survival of advanced cholangiocarcinoma patients treated with adjuvant gemcitabine-based chemotherapy (AGC) after surgical resection. BACKGROUND:: There have been no reports concerning a useful predictive biomarker in patients with cholangiocarcinoma treated with adjuvant gemcitabine chemotherapy. METHODS:: Intratumoral hENT1 expression was investigated immunohistochemically in 105 patients with resected advanced cholangiocarcinoma. Relationships between intratumoral hENT1 expression and clinicopathological factors were evaluated by univariate and multivariate analyses. This study was a retrospective analysis on retrospectively collected tissue and data. RESULTS:: Fifty-one patients received AGC, and 54 did not. High and low intratumoral hENT1 expression was found in 74 (70%) and 31 patients (30%), respectively. There were no significant differences in clinicopathological factors between patients with high hENT1 expression and those with low hENT1 expression. Survival patients with high hENT1 expression were significantly better than those with low hENT1 expression among patients who received AGC (P = 0.008), but not among patients who did not (P = 0.894). Moreover, a significant difference in survival between patients who received AGC and those who did not was observed among patients with high hENT1 expression (P = 0.002), but not among patients with low hENT1 expression (P = 0.525). Intratumoral hENT1 expression was only an independent predictive factor for patients treated with AGC by multivariate analysis (P = 0.027). CONCLUSIONS:: Intratumoral hENT1 expression may be a potent predictive marker for advanced cholangiocarcinoma patients treated with AGC.

PMID: 22580938 [PubMed - as supplied by publisher]

Propranolol Induces Regression of Hemangioma Cells Through HIF-1α-Mediated Inhibition of VEGF-A.

Ann Surg. 2012 May 10;

Authors: Chim H, Armijo BS, Miller E, Gliniak C, Serret MA, Gosain AK

Abstract

OBJECTIVE:: To investigate the mechanism of propranolol on regression of infantile hemangiomas. BACKGROUND:: Propranolol has been found to be effective in treatment of severe hemangiomas of infancy. However, its mechanism of action is as yet unknown. METHODS:: Cultured proliferating and involuting hemangioma endothelial cells were treated with varying concentrations of propranolol for up to 4 days. Analysis was performed using cell viability, migration, and tubulogenesis assays, as well as quantitative RT-PCR and flow cytometry. Western blots and ELISA assays were used to assess protein expression. RESULTS:: Treatment with propranolol led to a dose dependent cytotoxic effect in hemangioma endothelial cells with decreased cell viability, migration, and tubulogenesis. This cytotoxic effect was VEGF (vascular endothelial growth factor) dependent, as demonstrated by decreased VEGF, VEGF-R1, and VEGF-R2 production. Decreased signaling through the VEGF pathway resulted in downregulation of PI3/Akt and p38/MAPK activity. Decreased VEGF activity was mediated through the hypoxia inducible factor (HIF)-1α pathway but not through NF-κβ signaling. CONCLUSIONS:: Collectively, these data suggest that propranolol exerts its suppressive effects on hemangiomas through the HIF-1α-VEGF-A angiogenesis axis, with effects mediated through the PI3/Akt and p38/MAPK pathways. These findings provide a plausible mechanism of action of propranolol on regression of infantile hemangiomas.

PMID: 22580939 [PubMed - as supplied by publisher]

Patient Selection for Cytoreductive Surgery in Colorectal Peritoneal Carcinomatosis Using Serum Tumor Markers: An Observational Cohort Study.

Ann Surg. 2012 May 10;

Authors: Cashin PH, Graf W, Nygren P, Mahteme H

Abstract

OBJECTIVE:: There were 2 objectives: first, to investigate how many patients were excluded from surgery on the basis of the radiological extent of the peritoneal carcinomatosis (PC) or the clinical examination; and second, to develop a score based primarily on serum tumor markers (STMs) that could predict short cancer-specific survival (<12 months). BACKGROUND:: Patient selection and prediction of prognosis is crucial for successful treatment of colorectal PC. METHODS:: All patients with colorectal PC referred for cytoreductive surgery and intraperitoneal chemotherapy (2005-2008) at Uppsala University hospital were included. Patients were divided into 2 groups-nonsurgery and surgery. Clinicopathological and laboratory parameters were collected in the surgery group. A Corep (COloREctal-Pc) score was developed using hazard ratios from histology, hematological status, serial serum tumor markers (STMs), and STM changes over time. Sensitivity, specificity, positive predicted value (PPV), and negative predicted value (NPV) were calculated in a second validating dataset (n = 24) with a survival cutoff of less than 12 months. RESULTS:: A total of 107 patients were included in the study, 42 in the nonsurgery group and 65 in the surgery group. In the nonsurgery group, 2 patients were excluded solely on the basis of the radiological extent of PC and 7 patients on clinical examination. The Corep score ranged from 0 to 18. A score of 6 or more showed a validated sensitivity of 80%, specificity 100%, PPV 1.0, and NPV 0.93. CONCLUSIONS:: Radiological extent of PC was not a main deciding factor for treatment decisions and had less impact than the clinical examination. The Corep score identified patients with short cancer-specific survival that may not be suitable for treatment.

PMID: 22580940 [PubMed - as supplied by publisher]

Reoperation Versus Clinical Recurrence Rate After Ventral Hernia Repair.

Ann Surg. 2012 May 10;

Authors: Helgstrand F, Rosenberg J, Kehlet H, Strandfelt P, Bisgaard T

Abstract

OBJECTIVE:: To compare the clinical recurrence rate with reoperation rate for recurrence after ventral hernia repair. BACKGROUND:: Reoperation is often used as an outcome measure after ventral hernia repair, but it is unknown whether reoperation rate reflects the overall clinical risk for recurrence. METHODS:: The study cohort was recruited from the Danish Ventral Hernia Database and the Danish National Patient Registry during January 1, 2007, to December 31, 2007. Inclusion criteria were primary umbilical/epigastric (umb/epi) or incisional hernia repair from a regional area of 2 million inhabitants. A prospective clinical follow-up was conducted in January 2011 using a validated questionnaire on reoperation and possible recurrence. Suspicion of recurrence was the criterion for clinical examination. A telephone interview and/or patients’ hospital files confirmed reoperation. RESULTS:: A total of 945 patients were eligible, and 902 patients responded to the questionnaire (response rate 95%) with a median postoperative follow-up of 41 months (range 0-48 months). The analysis comprised 646 patients with umb/epi and 256 patients with incisional hernia repair. Clinical examination was required in 241 patients. After umb/epi and incisional hernia repair, the cumulative risks of reoperation and overall recurrence (reoperation + clinical) were 4% and 15% (fourfold underestimation), and 8% and 37% (fivefold underestimation) (P < 0.001), respectively. CONCLUSIONS:: Reoperation rate for recurrence 41 months after primary umbilical/epigastric or incisional hernia repair underestimated overall risk of recurrence by four- to fivefolds. This study was registered in www.clinicaltrials.gov (NCT01325246).

PMID: 22580941 [PubMed - as supplied by publisher]

Progression Following Neoadjuvant Systemic Chemotherapy May Not Be a Contraindication to a Curative Approach for Colorectal Carcinomatosis.

Ann Surg. 2012 May 10;

Authors: Guillaume P, Delphine V, Eddy C, Benoit Y, Sylvie I, Noël GF, Faheez M, Olivier G

Abstract

OBJECTIVE:: The objective of this retrospective study was to evaluate the influence of neoadjuvant systemic chemotherapy on patients with colorectal carcinomatosis before a curative procedure. BACKGROUND:: Peritoneal carcinomatosis (PC) from colorectal cancer may be treated with a curative intent by cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). The role of perioperative systemic chemotherapy for this particular metastatic disease remains unclear. METHODS:: One hundred twenty patients with PC from colorectal cancer were consecutively treated by 131 procedures combining CRS with HIPEC. The response to neoadjuvant systemic chemotherapy was assessed on data from previous explorative surgery and/or radiological imaging. RESULTS:: Ninety patients (75%) were treated with neoadjuvant systemic chemotherapy in whom 32 (36%) were considered to have responded, 19 (21%) had stable disease, and 19 (21%) developed diseases progression. Response could not be evaluated in 20 patients (22%). On univariate analysis, the use of neoadjuvant systemic chemotherapy had a significant positive prognostic influence (P = 0.042). On multivariate analysis, the completeness of CRS and the use of adjuvant systemic chemotherapy were the only significant prognostic factors (P < 0.001 and P = 0.049, respectively). Response to neoadjuvant systemic chemotherapy had no significant prognostic impact with median survival of 31.4 months in patients showing disease progression. CONCLUSIONS:: In patients with PC from colorectal cancer without extraperitoneal metastases, failure of neoadjuvant systemic chemotherapy should not constitute an absolute contraindication to a curative procedure combining CRS and HIPEC.

PMID: 22580942 [PubMed - as supplied by publisher]

Factors Predictive of 30-Day Postoperative Mortality in HIV/AIDS Patients in the Era of Highly Active Antiretroviral Therapy.

Ann Surg. 2012 May 10;

Authors: Wiseman SM, Forrest JI, Chan JE, Zhang W, Yip B, Hogg RS, Lima VD, Montaner JS

Abstract

BACKGROUND:: Factors that predict HIV (human immunodeficiency virus)/AIDS patient postoperative mortality have remained poorly defined. OBJECTIVES:: The primary objective of this study was to identify factors predictive of short-term, postoperative mortality in HIV/AIDS patients. The secondary objective of this study was to develop a scoring system that would predict short-term postoperative mortality in HIV/AIDS patients. METHODS:: We retrospectively reviewed all HIV/AIDS patients who underwent surgical procedures in British Columbia, Canada, between April 1995 and March 2002. The primary outcome evaluated was 30-day postoperative mortality. Demographic, clinical, and hospitalization-related data were obtained and utilized to predict outcomes using a logistic regression model. RESULTS:: A total of 2305 procedures were carried out on 1322 patients during the study period. Admissions were classified as urgent/emergent for 1311 procedures (57%) and the overall 30-day postoperative mortality was 9.5% (126 deaths). Urgent/emergent admission, older age, prior surgery, a CD4 cell count of ≤ 50 cells/mm, a hemoglobin level ≤ 120 g/L, and a white blood cell count >11 g/L within 90 days before the surgical procedure was predictive of an increased 30-day postoperative mortality in a multivariate model. Using these variables, we formulated the HIV Surgical Mortality Score (HSMS) to obtain the median-estimated probability of postoperative death. CONCLUSIONS:: For accurate preoperative mortality risk stratification for HIV/AIDS patients, we have found that several clinical and laboratory variables must be evaluated. If appropriately validated, our proposed HSMS could be utilized to estimate the probability of short-term postoperative death among HIV/AIDS patients.

PMID: 22580943 [PubMed - as supplied by publisher]

A Randomized, Controlled, Double-Blind Crossover Study on the Effects of 2-L Infusions of 0.9% Saline and Plasma-Lyte 148 on Renal Blood Flow Velocity and Renal Cortical Tissue Perfusion in Healthy Volunteers.

Ann Surg. 2012 May 10;

Authors: Chowdhury AH, Cox EF, Francis ST, Lobo DN

Abstract

OBJECTIVE:: We compared the effects of intravenous infusions of 0.9% saline ([Cl] 154 mmol/L) and Plasma-Lyte 148 ([Cl] 98 mmol/L, Baxter Healthcare) on renal blood flow velocity and perfusion in humans using magnetic resonance imaging (MRI). BACKGROUND:: Animal experiments suggest that hyperchloremia resulting from 0.9% saline infusion may affect renal hemodynamics adversely, a phenomenon not studied in humans. METHODS:: Twelve healthy adult male subjects received 2-L intravenous infusions over 1 hour of 0.9% saline or Plasma-Lyte 148 in a randomized, double-blind manner. Crossover studies were performed 7 to 10 days apart. MRI scanning proceeded for 90 minutes after commencement of infusion to measure renal artery blood flow velocity and renal cortical perfusion. Blood was sampled and weight recorded hourly for 4 hours. RESULTS:: Sustained hyperchloremia was seen with saline but not with Plasma-Lyte 148 (P < 0.0001), and fall in strong ion difference was greater with the former (P = 0.025). Blood volume changes were identical (P = 0.867), but there was greater expansion of the extravascular fluid volume after saline (P = 0.029). There was a significant reduction in mean renal artery flow velocity (P = 0.045) and renal cortical tissue perfusion (P = 0.008) from baseline after saline, but not after Plasma-Lyte 148. There was no difference in concentrations of urinary neutrophil gelatinase-associated lipocalin after the 2 infusions (P = 0.917). CONCLUSIONS:: This is the first human study to demonstrate that intravenous infusion of 0.9% saline results in reductions in renal blood flow velocity and renal cortical tissue perfusion. This has implications for intravenous fluid therapy in perioperative and critically ill patients. NCT01087853.

PMID: 22580944 [PubMed - as supplied by publisher]

Trauma Center Quality Improvement Programs in the United States, Canada, and Australasia.

Ann Surg. 2012 May 10;

Authors: Stelfox HT, Straus SE, Nathens A, Gruen RL, Hameed SM, Kirkpatrick A

Abstract

OBJECTIVE:: To compare quality improvement (QI) programs of trauma centers in 4 high-income countries. BACKGROUND:: Injury is a leading cause of morbidity and mortality in countries around the world, but patient outcomes vary among countries with similar systems of trauma care. METHODS:: We surveyed medical directors and program managers from 330 trauma centers verified by professional trauma organizations in the United States (n = 263), Canada (n = 46), and Australasia (Australia, n = 18; New Zealand, n = 3) regarding their QI programs. Quality indicators were requested from all centers that measured quality of care. Follow-up interviews were performed with 75 centers purposively sampled across 6 baseline criteria. RESULTS:: A total of 251 centers (76% response rate) responded to the survey, with a similar distribution across countries. Trauma centers in the United States were more likely than those in Canada and Australasia to report measuring quality indicators (100% vs 94% vs 93%, P = 0.008), using report cards (53% vs 33% vs 31%, P = 0.033) and benchmarking (81% vs 61% vs 69%, P = 0.019). Centers in all 3 regions primarily used hospital process and outcome measures designed to establish whether care was safe (98% vs 97% vs 75%, P = 0.008), effective (97% vs 97% vs 92% P = 0.399), timely (88% vs 100% vs 92%, P = 0.055), and efficient (95% vs 100% vs 83%, P = 0.082). QI programs were largely local in nature, used different criteria to identify patients under QI purview, and employed diverse quality indicators and improvement strategies. Few centers evaluated the effectiveness of their QI program. CONCLUSIONS:: This study provides the first international comparison of trauma center QI programs and demonstrates broad implementation in verified trauma centers in the United States, Canada, and Australasia. Significant variation exists in how trauma centers perform QI activities. Opportunities exist for improving and standardizing QI processes.

PMID: 22580945 [PubMed - as supplied by publisher]

Identification of a Subgroup of Patients at Highest Risk for Complications After Surgical Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy.

Ann Surg. 2012 May 10;

Authors: Baratti D, Kusamura S, Mingrone E, Balestra MR, Laterza B, Deraco M

Abstract

OBJECTIVE:: To assess the influence of parietal and visceral peritonectomy procedures on moderate/severe morbidity in patients undergoing surgical cytoreducion and hyperthermic intraperitoneal chemotherapy (HIPEC) and to identify subgroups of patients at highest operative risk. BACKGROUND:: Cytoreducion with HIPEC is an effective but potentially morbid treatment option for peritoneal surface malignancies. Although complication rates have recently decreased with increasing experience, risk-factors for adverse operative outcome are still poorly understood. METHODS:: A prospective database of 426 combined procedures was reviewed. Multivariate analysis tested the correlation between major morbidity and 6 peritonectomies (greater and lesser omentectomy, pelvic, parietal anterior, left and right diaphragmatic peritonectomy), 14 visceral resections, 5 other operative factors, and 12 clinical variables. The extent of peritoneal involvement was quantified by peritoneal cancer index (PCI). RESULTS:: Mortality and major morbidity were 2.6% and 28.2%. PCI, number of visceral resections, poor performance status, and cisplatin dose more than 240 mg independently correlated to morbidity. The type and number of parietal peritonectomies and the type of visceral resections did not correlated to complications. Major morbidity rate was 65.7% in 35 (8.2%) patients with at least 2 of the following factors: PCI greater than 30, more than 5 visceral resections, poor performance status. Morbidity was 100% in 9 patients presenting all the risk factors. CONCLUSIONS:: Acceptable morbidity and low mortality may be achieved in high-volume centers. Operative outcome is mainly affected by a complex interplay of tumor, patient, and treatment-related factors. Preoperative and early intraoperative assessment of operative risk may identify a subset of patients unlikely to tolerate aggressive management.

PMID: 22580946 [PubMed - as supplied by publisher]

Prognostic Importance of the Extent of Ulceration in Patients With Clinically Localized Cutaneous Melanoma.

Ann Surg. 2012 May 4;

Authors: In ‘t Hout FE, Haydu LE, Murali R, Bonenkamp JJ, Thompson JF, Scolyer RA

Abstract

OBJECTIVE:: To determine the prognostic value of the extent of ulceration, categorized as diameter of ulceration and as percentage of invasive melanoma diameter. BACKGROUND:: Ulceration is an adverse prognostic factor for clinically localized primary cutaneous melanoma. However, the prognostic significance of the extent of ulceration remains unclear. METHODS:: Clinicopathologic and follow-up data on 4661 patients treated at a single center were analyzed. RESULTS:: Both the presence and extent of ulceration were independent predictors of survival. The 5-year melanoma-specific survival (MSS) for ulcerated and nonulcerated melanomas was 77.6% and 91.3%, respectively. The 5-year MSS for minimally/moderately ulcerated melanomas (≤70% or ≤5 mm) was 80.4% and 82.7%, respectively, compared to extensively ulcerated melanomas (>70% or >5 mm), which had a 5-year MSS of 66.4% and 59.3%. On multivariate analysis, tumor thickness and the presence/absence of mitoses were the most powerful predictors of MSS. The presence of ulceration was also an independent predictor of poorer MSS (hazard ratio [HR] = 1.55, P < 0.001). Patients with minimally/moderately ulcerated tumors (≤70% or ≤5 mm) had a significantly higher risk of death (HR = 1.53 and HR = 1.39, respectively) compared to nonulcerated melanoma, as did patients with extensively ulcerated tumors (>70%: HR = 2.20 and >5 mm: HR = 2.03). CONCLUSIONS:: Extent of ulceration (measured either as diameter or percentage of tumor width) provides more accurate prognostic information than the mere presence of ulceration. This has potential implications for melanoma patients with regard to prognosis, staging, management, and eligibility for clinical trials. We recommend that extent of ulceration be recorded in pathology reports for all ulcerated primary cutaneous melanomas.

PMID: 22566014 [PubMed - as supplied by publisher]

Wound Healing and Infection in Surgery: The Pathophysiological Impact of Smoking, Smoking Cessation, and Nicotine Replacement Therapy: A Systematic Review.

Ann Surg. 2012 May 4;

Authors: Sørensen LT

Abstract

OBJECTIVE:: The aim was to clarify how smoking and nicotine affects wound healing processes and to establish if smoking cessation and nicotine replacement therapy reverse the mechanisms involved. BACKGROUND:: Smoking is a recognized risk factor for healing complications after surgery, but the pathophysiological mechanisms remain largely unknown. METHODS:: Pathophysiological studies addressing smoking and wound healing were identified through electronic databases (PubMed, EMBASE) and by hand-search of articles’ bibliography. Of the 1460 citations identified, 325 articles were retained following title and abstract reviews. In total, 177 articles were included and systematically reviewed. RESULTS:: Smoking decreases tissue oxygenation and aerobe metabolism temporarily. The inflammatory healing response is attenuated by a reduced inflammatory cell chemotactic responsiveness, migratory function, and oxidative bactericidal mechanisms. In addition, the release of proteolytic enzymes and inhibitors is imbalanced. The proliferative response is impaired by a reduced fibroblast migration and proliferation in addition to a downregulated collagen synthesis and deposition. Smoking cessation restores tissue oxygenation and metabolism rapidly. Inflammatory cell response is reversed in part within 4 weeks, whereas the proliferative response remains impaired. Nicotine does not affect tissue microenvironment, but appears to impair inflammation and stimulate proliferation. CONCLUSIONS:: Smoking has a transient effect on the tissue microenvironment and a prolonged effect on inflammatory and reparative cell functions leading to delayed healing and complications. Smoking cessation restores the tissue microenvironment rapidly and the inflammatory cellular functions within 4 weeks, but the proliferative response remain impaired. Nicotine and nicotine replacement drugs seem to attenuate inflammation and enhance proliferation but the effect appears to be marginal.

PMID: 22566015 [PubMed - as supplied by publisher]

Simulated Procedure Rehearsal Is More Effective Than a Preoperative Generic Warm-Up for Endovascular Procedures.

Ann Surg. 2012 May 4;

Authors: Willaert WI, Aggarwal R, Daruwalla F, Van Herzeele I, Darzi AW, Vermassen FE, Cheshire NJ

Abstract

INTRODUCTION:: Patient-specific simulated rehearsal (PsR) of a carotid artery stenting procedure (CAS) enables the interventionalist to rehearse the case before performing the procedure on the actual patient by incorporating patient-specific computed tomographic data into the simulation software. This study aimed to evaluate whether PsR of a CAS procedure can enhance the operative performance versus a virtual reality (VR) generic CAS warm-up procedure or no preparation at all. METHODS:: During a 10-session cognitive/technical VR course, medical residents were trained in CAS. Thereafter, in a randomized crossover study, each participant performed a patient-specific CAS case 3 times on the simulator, preceded by 3 different tasks: a PsR, a generic case, or no preparation. Technical performances were assessed using simulator-based metrics and expert-based ratings. RESULTS:: Twenty medical residents (surgery, cardiology, radiology) were recruited. Training plateaus were observed after 10 sessions for all participants. Performances were significantly better after PsR than after a generic warm-up or no warm-up for total procedure time (16.3 ± 0.6 vs 19.7 ± 1.0 vs 20.9 ± 1.1 minutes, P = 0.001) and fluoroscopy time (9.3 ± 0.1 vs 11.2 ± 0.6 vs 11.2 ± 0.5 minutes, P = 0.022) but did not influence contrast volume or number of roadmaps used during the “real” case. PsR significantly improved the quality of performance as measured by the expert-based ratings (scores 28 vs 25 vs 25, P = 0.020). CONCLUSIONS:: Patient-specific simulated rehearsal of a CAS procedure significantly improves operative performance, compared to a generic VR warm-up or no warm-up. This technology requires further investigation with respect to improved outcomes on patients in the clinical setting.

PMID: 22566016 [PubMed - as supplied by publisher]

Medical and Financial Risks Associated With Surgery in the Elderly Obese.

Ann Surg. 2012 May 4;

Authors: Silber JH, Rosenbaum PR, Kelz RR, Reinke CE, Neuman MD, Ross RN, Even-Shoshan O, David G, Saynisch PA, Kyle FA, Bratzler DW, Fleisher LA

Abstract

OBJECTIVE:: To study the medical and financial outcomes associated with surgery in elderly obese patients and to ask if obesity itself influences outcomes above and beyond the effects from comorbidities that are known to be associated with obesity. BACKGROUND:: Obesity is a surgical risk factor not present in Medicare’s risk adjustment or payment algorithms, as BMI is not collected in administrative claims. METHODS:: A total of 2045 severely or morbidly obese patients (BMI ≥ 35 kg/m, aged between 65 and 80 years) selected from 15,914 elderly patients in 47 hospitals undergoing hip and knee surgery, colectomy, and thoracotomy were matched to 2 sets of 2045 nonobese patients (BMI = 20-30 kg/m). A “limited match” controlled for age, sex, race, procedure, and hospital. A “complete match” also controlled for 30 additional factors such as diabetes and admission clinical data from chart abstraction. RESULTS:: Mean BMI in the obese patients was 40 kg/m compared with 26 kg/m in the nonobese. In the complete match, obese patients displayed increased odds of wound infection: OR (odds ratio) = 1.64 (95% CI: 1.21, 2.21); renal dysfunction: OR = 2.05 (1.39, 3.05); urinary tract infection: OR = 1.55 (1.24, 1.94); hypotension: OR = 1.38 (1.07, 1.80); respiratory events: OR = 1.44 (1.19, 1.75); 30-day readmission: OR = 1.38 (1.08, 1.77); and a 12% longer length of stay (8%, 17%). Provider costs were 10% (7%, 12%) greater in obese than in nonobese patients, whereas Medicare payments increased only 3% (2%, 5%). Findings were similar in the limited match. CONCLUSIONS:: Obesity increases the risks and costs of surgery. Better approaches are needed to reduce these risks. Furthermore, to avoid incentives to underserve this population, Medicare should consider incorporating incremental costs of caring for obese patients into payment policy and include obesity in severity adjustment models.

PMID: 22566017 [PubMed - as supplied by publisher]

Predicting Risk for Venous Thromboembolism With Bariatric Surgery: Results From the Michigan Bariatric Surgery Collaborative.

Ann Surg. 2012 May 4;

Authors: Finks JF, English WJ, Carlin AM, Krause KR, Share DA, Banerjee M, Birkmeyer JD, Birkmeyer NJ,

Abstract

OBJECTIVE:: We sought to identify risk factors for venous thromboembolism (VTE) among patients undergoing bariatric surgery in Michigan. BACKGROUND:: VTE remains a major source of morbidity and mortality after bariatric surgery. It is unclear which factors should be used to identify patients at high risk for VTE. METHODS:: The Michigan Bariatric Surgery Collaborative maintains a prospective clinical registry of bariatric surgery patients. For this study, we identified all patients undergoing primary bariatric surgery between June 2006 and April 2011 and determined rates of VTE. Potential risk factors for VTE were analyzed using a hierarchical logistic regression model, accounting for clustering of patients within hospitals. Significant risk factors were used to develop a risk calculator for development of VTE after bariatric surgery. RESULTS:: Among 27,818 patients who underwent bariatric surgery during the study period, 93 patients (0.33%) experienced a VTE complication, including 51 patents with pulmonary embolism. There were 8 associated deaths. Significant risk factors included previous history of VTE (OR 4.15, CI 2.42-7.08); male gender (OR 2.08, CI 1.36-3.19); operative time more than 3 hours (OR 1.86, CI 1.07-3.24); BMI category (per 10 units) (OR 1.37, CI 1.06-1.75); age category (per 10 years) (OR 1.25, CI 1.03-1.51); and procedure type (reference adjustable gastric band): duodenal switch (OR 9.45, CI 2.50-35.97); open gastric bypass (OR 6.48, CI 2.17-19.41); laparoscopic gastric bypass (OR 3.97, CI 1.77-8.91); and sleeve gastrectomy (OR 3.50, CI 1.30-9.34). Nearly 97% of patients had a predicted VTE risk less than 1%. CONCLUSIONS:: In this population-based study, overall VTE rates were low among patients undergoing bariatric surgery. The use of an empirically based risk calculator will allow for the development of a risk-stratified approach to VTE prophylaxis.

PMID: 22566018 [PubMed - as supplied by publisher]

Questions About the Evidence Regarding the Benefits of Enteral Nutrition Enriched With Eicosapentaenoic Acid in Esophageal Cancer Surgery.

Ann Surg. 2012 May 4;

Authors: Franch-Arcas G, González-Sánchez C, Gómez-Alonso A

PMID: 22566019 [PubMed - as supplied by publisher]

Metronidazole Therapy to Prevent Clostridium Difficile Infection.

Ann Surg. 2012 May 4;

Authors: Drekonja DM

PMID: 22566020 [PubMed - as supplied by publisher]

Response to Letter.

Ann Surg. 2012 May 4;

Authors: Ryan AM, Healy LA, Reynolds JV

PMID: 22566021 [PubMed - as supplied by publisher]

Response to Letter.

Ann Surg. 2012 May 4;

Authors: Metzger R, Swenson BR, Sawyer RG, Sawyer RG

PMID: 22566022 [PubMed - as supplied by publisher]

Gallbladder Cancer Involving the Extrahepatic Bile Duct.

Ann Surg. 2012 May 4;

Authors: Miura F, Sano K, Amano H, Watanabe T, Takada T, Matsubara H

PMID: 22566023 [PubMed - as supplied by publisher]

Reply to Letter: Gallbladder Cancer Involving the Extrahepatic Bile Duct.

Ann Surg. 2012 May 4;

Authors: Nishio H, Nagino M

PMID: 22566024 [PubMed - as supplied by publisher]

Electrochemotherapy for Non-Melanoma Head and Neck Cancers: Clinical Outcomes in 25 Patients.

Ann Surg. 2012 Apr 27;

Authors: Gargiulo M, Papa A, Capasso P, Moio M, Cubicciotti E, Parascandolo S

Abstract

OBJECTIVE:: To evaluate and confirm the efficacy and safety of electrochemotherapy (ECT) using bleomicyn in a large series of non-melanoma head and neck cancers. BACKGROUND:: ECT combines chemotherapy and electroporation to increase drug uptake into cancer cells. ECT has proven to be effective in the treatment of tumor nodules of cutaneous and subcutaneous localization. Up to now, this therapy has been mainly used as a local control of melanoma skin metastasis. Few studies have focused on its role in the treatment of head and neck cutaneous and subcutaneous cancers. METHODS:: Twenty-five patients underwent ECT for the treatment of non-melanoma head and neck cancers. All tumors were classified by histological type (confirmed by biopsy), size, and TNM Classification of Malignant Tumors (TNM). Treatments were performed using a bolus of bleomicyn and a pulse generator under local or general anesthesia after the ESOPE (European Standard Operating Procedures of Electrochemotherapy) standard operating procedures. RESULTS:: An objective response was achieved in 100% of treated patients (n = 25) at 6 weeks after the initial treatment. The complete response rate according to the WHO criteria was 72% (n = 18); the partial response rate was 28% (n = 7). None of the lesions that achieved a complete response relapsed after a median follow-up period of 18 months. Partial responders showed stable disease for the duration of the follow-up. CONCLUSIONS:: In accordance with the clinical results shown, we encourage further investigation to establish ECT’s use as first line treatment especially in basocellular carcinomas of the head and neck area and for squamocellular carcinomas of the lip with no detectable cervical lymphoadenopathy.

PMID: 22549747 [PubMed - as supplied by publisher]

Negative Pressure Wound Therapy for At-Risk Surgical Closures in Patients With Multiple Comorbidities: A Prospective Randomized Controlled Study.

Ann Surg. 2012 Apr 27;

Authors: Masden D, Goldstein J, Endara M, Xu K, Steinberg J, Attinger C

Abstract

PURPOSE:: The purpose of this study is to evaluate the effect of Negative Pressure Wound Therapy (NPWT) on closed surgical incisions. We performed a prospective randomized controlled clinical trial comparing NPWT to standard dry dressings on surgical incisions. METHODS:: Patients presenting to a high-volume wound center were randomized to receive either a V.A.C. (KCI, San Antonio, TX) or a standard dry dressing over their incision at the conclusion of surgery. These were primarily high-risk patients with multiple comorbidities. The 2 groups were compared, and all incisions were evaluated for infection and dehiscence postoperatively. RESULTS:: Eighty-one patients were included for analysis. Thirty-seven received dry dressings, and 44 received NPWT. Seventy-four of these underwent lower extremity wound closure. Average follow-up was 113 days. There were no differences in demographic, preoperative, and operative variables between groups; 6.8% of the NPWT group and 13.5% of the dry dressing group developed wound infection, but this was not statistically significant (P = 0.46). There was no difference in time to develop infection between the groups. There was no statistical difference in dehiscence between NPWT and dry dressing group (36.4% vs 29.7%; P = 0.54) or mean time to dehiscence between the 2 groups (P = 0.45). Overall, 35% of the dry dressing group and 40% of the NPWT group had a wound infection, dehiscence, or both. Of these, 9 in the NPWT group (21%) and 8 in the dry dressing group (22%) required reoperation. CONCLUSIONS:: There is a significant rate of postoperative infection and dehiscence in patients with multiple comorbidities. There was no difference in the incidence of infection or dehiscence between the NPWT and dry dressing group. This study is registered with ClinicalTrials.gov. The unique registration number is NCT01366105.

PMID: 22549748 [PubMed - as supplied by publisher]

A Meta-Analysis of the Effect of Combinations of Immune Modulating Nutrients on Outcome in Patients Undergoing Major Open Gastrointestinal Surgery.

Ann Surg. 2012 Apr 27;

Authors: Marimuthu K, Varadhan KK, Ljunqvist O, Lobo DN

Abstract

BACKGROUND:: Immune modulating nutrition (IMN) has been shown to reduce complications after major surgery, but strong evidence to recommend its routine use is still lacking. OBJECTIVE:: The aim of this meta-analysis was to evaluate the impact of IMN combinations on postoperative infectious and noninfectious complications, length of hospital stay, and mortality in patients undergoing major open gastrointestinal surgery. METHODS:: Randomized controlled trials published between January 1980 and February 2011 comparing isocaloric and isonitrogenous enteral IMN combinations with standard diet in patients undergoing major open gastrointestinal surgery were included. The quality of evidence and strength of recommendation for each postoperative outcome were assessed using the GRADE approach and the outcome measures were analyzed with RevMan 5.1 software (Cochrane Collaboration, Copenhagen, Denmark). RESULTS:: Twenty-six randomized controlled trials enrolling 2496 patients (1252 IMN and 1244 control) were included. The meta-analysis suggests strong evidence in support of decrease in the incidence of postoperative infectious [risk ratio (RR) (95% confidence interval [CI]): 0.64 (0.55, 0.74)] and length of hospital stay [mean difference (95% CI): -1.88 (-2.91, -0.84 days)] in those receiving IMN. Even though significant benefit was observed for noninfectious complications [RR (95% CI): 0.82 (0.71, 0.95)], the quality of evidence was low. There was no statistically significant benefit on mortality [RR (95% CI): 0.83 (0.49, 1.41)]. CONCLUSIONS:: IMN is beneficial in reducing postoperative infectious and noninfectious complications and shortening hospital stay in patients undergoing major open gastrointestinal surgery.

PMID: 22549749 [PubMed - as supplied by publisher]

Multivisceral Transplantation for Diffuse Portomesenteric Thrombosis.

Ann Surg. 2012 Apr 27;

Authors: Vianna RM, Mangus RS, Kubal C, Fridell JA, Beduschi T, Tector AJ

Abstract

OBJECTIVE:: To evaluate the clinical outcomes of multivisceral transplantation (MVT) in the setting of diffuse thrombosis of the portomesenteric venous system. BACKGROUND:: Liver transplantation (LT) in the face of cirrhosis and diffuse portomesenteric thrombosis (PMT) is controversial and contraindicated in many transplant centers. LT using alternative techniques such as portocaval hemitransposition fails to eliminate complications of portal hypertension. MVT replaces the liver and the thrombosed portomesenteric system. METHODS:: A database of intestinal transplant patients was maintained with prospective analysis of outcomes. The diagnosis of diffuse PMT was established with dual-phase abdominal computed tomography or magnetic resonance imaging with venous reconstruction. RESULTS:: Twenty-five patients with grade IV PMT received 25 MVT. Eleven patients underwent simultaneous cadaveric kidney transplantation. Biopsy-proven acute cellular rejection was noted in 5 recipients, which was treated successfully. With a median follow-up of 2.8 years, patient and graft survival were 80%, 72%, and 72% at 1, 3, and 5 years, respectively. To date, all survivors have good graft function without any signs of residual/recurrent features of portal hypertension. CONCLUSIONS:: MVT can be considered as an option for the treatment of patients with diffuse PMT. MVT is the only procedure that completely reverses portal hypertension and addresses the primary disease while achieving superior survival results in comparison to the alternative options.

PMID: 22549750 [PubMed - as supplied by publisher]

Risk of Colonic Neoplasia After Proctectomy for Rectal Cancer in Hereditary Nonpolyposis Colorectal Cancer.

Ann Surg. 2012 Apr 27;

Authors: Kalady MF, Lipman J, McGannon E, Church JM

Abstract

OBJECTIVE:: To define the neoplastic risk in the remaining colon after proctectomy for rectal cancer in patients with hereditary nonpolyposis colorectal cancer (HNPCC). BACKGROUND:: The extent of surgery for rectal cancer in HNPCC is controversial. In determining which operation to perform, surgeons and patients must consider cancer risk in the remaining colon as well as functional consequences of removing the entire colorectum. The natural history of colon neoplasia in this situation is understudied and is not well-defined. METHODS:: A single-institution hereditary colorectal cancer database was queried for patients meeting Amsterdam criteria and with rectal cancer. Patient demographics, surgical management, and follow-up were recorded. RESULTS:: Fifty HNPCC patients with a primary diagnosis of rectal cancer treated by proctectcomy were included. Detailed follow-up colonoscopy data were available for 33 patients. Forty-eight high-risk adenomas developed in 13 patients (39.4%). Five patients (15.2%) developed metachronous adenocarcinoma at a median of 6 years (range 3.5-16) after proctectomy, including 3 at advanced stage. One of these patients developed a high-risk adenoma before cancer. Mean interval between the last normal colonoscopy and cancer discovery was 42 months (range 23.8-62.1) with one developing within 2 years. Thus, 17 of 33 patients (51.5%) developed high-risk adenoma or cancer after proctectomy. CONCLUSIONS:: Surgeons and patients need to be aware of substantial risk for metachronous neoplasia after proctectomy. Selection of operation should be individualized, but total proctocolectomy and ileoanal pouch should be strongly considered. If patients undergo proctectomy alone, close surveillance is mandatory.

PMID: 22549751 [PubMed - as supplied by publisher]

Results of a Japanese Nationwide Multi-Institutional Study on Lateral Pelvic Lymph Node Metastasis in Low Rectal Cancer: Is It Regional or Distant Disease?

Ann Surg. 2012 Apr 27;

Authors: Akiyoshi T, Watanabe T, Miyata S, Kotake K, Muto T, Sugihara K

Abstract

OBJECTIVE:: To evaluate whether lateral pelvic lymph nodes (LNs) in low rectal cancer are metastatic disease or part of regional LNs that are amenable to curative resection. BACKGROUND:: It is highly controversial whether lateral pelvic LNs should be considered as regional or distant disease, although the American Joint Committee on Cancer (AJCC) defines internal iliac LNs as regional LNs of rectal cancer. METHODS:: Data of patients with stage I to III low rectal cancer who underwent curative resection from 1978 to 1998 were extracted from the multi-institutional registry of large bowel cancer in Japan. Patients with only mesorectal LN metastasis were classified as the mesorectal-LN group. Patients with lateral pelvic LN metastasis localized to or extending beyond the internal iliac area were classified as the internal lateral pelvic lymph nodes (LPLN) group and external-LPLN group, respectively. Overall survival (OS) and cancer-specific survival (CSS) were compared between the groups. RESULTS:: Lateral pelvic LN dissection was performed in 5789 (50%) of 11,567 patients. Overall, 3905 (34%), 411 (3.6%), and 244 (2.1%) patients were classified as the mesorectal-LN, internal-LPLN, and external-LPLN groups, respectively. When the mesorectal LN group was subdivided as defined by the AJCC, both 5-year OS and CSS were not significantly different between the N2a and internal-LPLN groups (OS: 45% vs 45%, P = 0.9585; CSS: 51% vs 49%, P = 0.5742), and the N2b and external-LPLN groups (OS: 32% vs 29%, P = 0.3342; CSS: 37% vs 34%, P = 0.4347). OS and CSS were significantly better in the external-LPLN group than in stage IV patients who underwent curative resection (OS: 29% vs 24%, P = 0.0240; CSS: 34% vs 27%, P = 0.0117). CONCLUSIONS:: Lateral pelvic LNs can be considered as regional LNs in low rectal cancer, although metastasis extending beyond the internal iliac area is associated with poorer survival.

PMID: 22549752 [PubMed - as supplied by publisher]

Does a Well-Done Analysis of Poor-Quality Data Constitute Evidence of Benefit?

Ann Surg. 2012 Apr 27;

Authors: Barie PS

PMID: 22549753 [PubMed - as supplied by publisher]

Hospital Variation in 30-Day Mortality After Colorectal Cancer Surgery in Denmark: The Contribution of Hospital Volume and Patient Characteristics.

Ann Surg. 2012 Apr 27;

Authors: Burns EM, Faiz OD

PMID: 22546986 [PubMed - as supplied by publisher]

Evaluating the Feasibility of Extended Partial Mastectomy and Immediate Reduction Mammoplasty Reconstruction as an Alternative to Mastectomy.

Ann Surg. 2012 Mar 30;

Authors: Chang EI, Peled AW, Foster RD, Lin C, Zeidler KR, Ewing CA, Alvarado M, Hwang ES, Esserman LJ

Abstract

OBJECTIVES:: To assess the efficacy of using concurrent partial mastectomy and reduction mammoplasty for resection of a wide range of tumor sizes and compare oncologic outcomes and postoperative complications on the basis of tumor size. BACKGROUND:: Although tumor size greater than 4 cm has been considered an indication for undergoing a mastectomy, this dictum may not apply in women with breast hypertrophy, where the ratio of tumor size to breast size may still permit breast conservation. We wished to evaluate whether an approach combining partial mastectomy with reduction mammoplasty could provide a safe oncologic procedure with immediate breast reconstruction that could technically be applied even for large (>4 cm) lesions. METHODS:: A retrospective review of all patients undergoing partial mastectomy and concurrent reduction mammoplasty performed at our institution from 2000 to 2009. Clinical characteristics at presentation, pathologic data, and follow-up data were collected and analyzed. RESULTS:: Eighty-five consecutive simultaneous partial mastectomy/reduction mammoplasty procedures were performed in 79 patients. Average tumor size was 2.8 cm for ductal carcinoma in situ (0.05-17.0 cm), 2.4 cm for invasive ductal carcinoma (IDC) (0.2-8.9 cm), 3.5 cm for lobular carcinoma (1.6-8.0 cm), and 5.7 cm for phyllodes tumors (3.7-7.6 cm). Twenty-five of 85 tumors (29.4%) were larger than 4 cm. Distribution for stage 0, I, II, III, and IV disease was 15, 12, 35, 19, and 2 tumors respectively, with an additional 2 phyllodes tumors. Median follow-up was 39 months (10-130 months). Seventy-five patients (94.9%) achieved successful breast conservation, whereas 4 patients (5.1%) went on to completion mastectomy. Thirteen patients (16.4%) required 1 reexcision to achieve clear margins, and 2 (2.5%) required multiple reexcisions. Two patients had a local recurrence during the follow-up period, one of whom underwent reexcision and the other underwent mastectomy. The overall complication rate was 14.1%, which included 4 major complications (4.7%) requiring an unplanned return to the operating room and need for hospital readmission, and 8 minor wound-related complications (9.4%). Neither recurrence nor complication rates were increased in patients with tumors greater than 4 cm when compared with tumors less than or equal to 4 cm. CONCLUSIONS:: A partial mastectomy with concurrent reduction mammoplasty technique is a viable option for breast conservation even for larger tumors, combining a safe oncologic procedure with excellent cosmesis. A combined effort between breast surgeons and reconstructive surgeons has a high probability of success with low recurrence rates. In carefully selected patients, this approach may be preferable to mastecomy and breast reconstruction, particularly when postmastectomy radiation therapy is anticipated.

PMID: 22470069 [PubMed - as supplied by publisher]

Dangerous Dogs, Like Other Exotic Pets (ie, Leopards), Need to Be Regulated!

Ann Surg. 2012 Mar 30;

Authors:

PMID: 22470072 [PubMed - as supplied by publisher]

Primary Hyperparathyroidism in MEN1 Patients: Preferred Surgical Procedure and Relation With Genotype–a Cohort Study With Long-Term Follow-Up.

Ann Surg. 2012 Mar 30;

Authors: Pieterman CR, van Hulsteijn LT, den Heijer M, van der Luijt RB, Bonenkamp JJ, Hermus AR, Borel Rinkes IH, Vriens MR, Valk GD,

Abstract

OBJECTIVE:: To identify the optimal surgical strategy for multiple endocrine neoplasia type 1 (MEN1)-related primary hyperparathyroidism (pHPT). To describe the course of postoperative hypoparathyroidism and to assess whether genotype is associated with persistent/recurrent pHPT. BACKGROUND:: Surgery is the preferred treatment in MEN1-related pHPT, but the surgical procedure of choice is still uncertain. METHODS:: This retrospective cohort study was performed at the Departments of Endocrinology of the University Medical Centers of Utrecht and Nijmegen, the Netherlands. Patients were selected from the Dutch MEN1 database, including all patients 16 years or older treated for MEN1 from 1990 to 2009. Data were collected by medical record review. RESULTS:: Seventy-three patients underwent parathyroid surgery. Persistent/recurrent pHPT occurred in 53% after less than 3 parathyroids resected (<SPTX), 17% after subtotal resection (SPTX), and 19% after total resection with autotransplantation (TPTX). Persistent (≥6 months) postoperative hypoparathyroidism occurred in 24% after <SPTX, 39% after SPTX, and 66% after TPTX. Median duration of hypoparathyroidism was 1.5 years, in 65% successful cessation of vitamin D/calcium was possible, even after more than 10 years. After <SPTX, patients with nonsense or frameshift mutations in exons 2, 9, and 10 had a significantly lower risk of persistent/recurrent pHPT than patients with other mutations. After SPTX/TPTX persistence/recurrence did not differ with genotype. After SPTX/TPTX persistence/recurrence was more frequent (P = 0.07) in patients without bilateral transcervical thymectomy (TCT). CONCLUSIONS:: SPTX with bilateral TCT is the procedure of choice for MEN1-related pHPT. Genotype seems to affect the chance of recurrence. Postoperative hypoparathyroidism lasting 6 months or more should not be considered permanent in MEN1.

PMID: 22470073 [PubMed - as supplied by publisher]

Should Laparoscopic Colorectal Surgery Still be Considered Unsafe?

Ann Surg. 2012 Mar 30;

Authors: Arezzo A, Famiglietti F, Morino M, Passera R

PMID: 22470081 [PubMed - as supplied by publisher]

Risk of Gastric Pouch Enlargement With Adjustable Gastric Banding in Premenopausal Women: Sex Hormones May Play a Role?

Ann Surg. 2012 Apr 11;

Authors: Dixon JB, Cobourn CS

Abstract

OBJECTIVE:: To examine the influence of age and gender on the development of proximal gastric pouch distension (PPD) after laparoscopic adjustable gastric banding (LAGB) surgery. BACKGROUND:: PPD is the most common reason for revision with adjustable gastric banding surgery. Maintaining the anatomical integrity of bariatric surgery is a key to long-term success. It is therefore important to understand risk factors for complications. METHODS:: We extracted details of 3000 consecutive individuals who underwent primary LAGB procedures at a single center between February 2005 and May 2011. Contemporaneous details of all complications were recorded in a database. The characteristics of those that subsequently required revision surgery for PPD were assessed and compared with those that did not. RESULTS:: There were 132 cases for PPD requiring surgical intervention before September 2011. Incident PPD occurred in 5.1% and 1.3% of women and men, respectively. The mean age of those with PPD was 39.9 ± 9.25 compared with 43.9 ± 11.0 for those without it. The age and gender effects were independent, and the age effect was restricted to women. The adjusted odds ratios were 0.971 (95% CI [confidence interval], 0.954-0.986, P < 0.001) for age and 0.26 (95% CI, 0.12-0.56, P = 0.001) for male gender and younger women were more likely to have asymmetrical distension. CONCLUSIONS:: Younger women are at higher risk of PPD after LAGB surgery than men and women older than 50 years. Sex hormones may play a role in predisposing to gastric stretch after surgery. These findings may apply more broadly to the gastric “restrictive” component of other bariatric procedures.

PMID: 22498891 [PubMed - as supplied by publisher]

Bile Exposure Inhibits Expression of Squamous Differentiation Genes in Human Esophageal Epithelial Cells.

Ann Surg. 2012 Apr 11;

Authors: Reveiller M, Ghatak S, Toia L, Kalatskaya I, Stein L, Dʼsouza M, Zhou Z, Bandla S, Gooding WE, Godfrey TE, Peters JH

Abstract

OBJECTIVE:: This study aimed to identify pathways and cellular processes that are modulated by exposure of normal esophageal cells to bile and acid. BACKGROUND:: Barrett’s esophagus most likely develops as a response of esophageal stem cells to the abnormal reflux environment. Although insights into the underlying molecular mechanisms are slowly emerging, much of the metaplastic process remains unknown. METHODS:: We performed a global analysis of gene expression in normal squamous esophageal cells in response to bile or acid exposure. Differentially expressed genes were classified into major biological functions using pathway analysis and interaction network software. Array data were verified by quantitative PCR and western blot both in vitro and in human esophageal biopsies. RESULTS:: Bile modulated expression of 202 genes, and acid modulated expression of 103 genes. Genes involved in squamous differentiation formed the largest functional group (n = 45) all of which were downregulated by bile exposure. This included genes such as involucrin (IVL), keratinocyte differentiation-associated protein (KRTDAP), grainyhead-like 1 (GRHL1), and desmoglein1 (DSG1) the downregulation of which was confirmed by quantitative PCR and western blot. Bile also caused expression changes in genes involved in cell adhesion, DNA repair, oxidative stress, cell cycle, Wnt signaling, and lipid metabolism. Analysis of human esophageal biopsies demonstrated greatly reduced expression of IVL, KRTDAP, DSG1, and GRHL1 in metaplastic compared to squamous epithelia. CONCLUSIONS:: We report for the first time that bile inhibits the squamous differentiation program of esophageal epithelial cells. This, coordinated with induction of genes driving intestinal differentiation, may be required for the development of Barrett’s esophagus.

PMID: 22498892 [PubMed - as supplied by publisher]

The Importance of Blood Loss During Colon Cancer Surgery for Long-Term Survival: An Epidemiological Study Based on a Population Based Register.

Ann Surg. 2012 Apr 11;

Authors: Mörner ME, Gunnarsson U, Jestin P, Svanfeldt M

Abstract

OBJECTIVE:: This study tested the hypothesis that the amount of blood loss during surgery for colonic cancer influences long-term survival. BACKGROUND:: The perioperative blood loss during surgery for colorectal cancer relates to the risk for complications and early mortality. METHODS:: All patients who underwent surgery for colon cancer between 1997 and 2003 in the health-care region of Uppsala/Örebro were prospectively registered at the regional oncological center. Data on patients who underwent radical surgery for stages I to III disease were analyzed. Patients who died within 6 months after surgery were excluded. Hazard ratios were calculated with uni- and multivariate Cox proportional hazard regression. Because of covariation, blood loss, blood transfusion, and complications were tested in separate multivariate analyses. RESULTS:: Blood loss of 250 mL or more during surgery, male gender, occurrence of complications, age more than 75 years, and stage III disease were risk factors for overall mortality in the uni- and multivariate analyses. Perioperative blood transfusion was shown to be a risk factor in the univariate analysis only. CONCLUSIONS:: The results support the hypothesis that degree of blood loss during surgery for colon cancer is a factor that influences long-term survival.

PMID: 22498893 [PubMed - as supplied by publisher]

Options and Limitations in Applying the Fistula Classification by the International Study Group for Pancreatic Fistula.

Ann Surg. 2012 Apr 12;

Authors: Gebauer F, Kloth K, Tachezy M, Vashist YK, Cataldegirmen G, Izbicki JR, Bockhorn M

Abstract

BACKGROUND:: Because of its retrospective character, the classification system of the International Study Group of Pancreatic Fistula (ISGPF) lacks prognostic capacity regarding fistula-related complications. This study aimed to evaluate the options and limitations of the ISGPF classification system and to identify risk factors with respect to clinical decision making. METHODS:: Between 1992 and 2009, 1966 patients underwent surgery of the pancreas. All patient data were entered into a prospective clinical data management system. RESULTS:: After surgery, 276 patients (14%) developed postoperative pancreatic fistula (POPF). ISGPF type A fistula was seen in 69 patients (25%), type B in 110 (39.9%), and type C in 97 (34.1%). Solely due to their death, 16 patients had to be classified as type C fistula, even though they suffered only type A or B. Compared to genuine C fistulas, we were not able to detect any significant predictors, which may allow to distinguish the development in their further clinical course. The level of drainage amylase is of no use, whereas univariate analysis identified underlying disease, type of operation, and high levels of serum amylase or bilirubin on the day of onset of POPF to be prognostic parameters for reoperation. Multivariate analysis found elevated serum C-reactive protein to be an independent factor for increased in-hospital mortality. CONCLUSIONS:: The ISGPF classification system has its limitations in clinical decision making, because it does not adequately describe a large subgroup of patients. To improve clinical decision making about management of patients, it is crucial that the ISGPF classification system is merged with newer clinical data.

PMID: 22504279 [PubMed - as supplied by publisher]

A Systematic Proactive Risk Assessment of Hazards in Surgical Wards: A Quantitative Study.

Ann Surg. 2012 Apr 12;

Authors: Anderson O, Brodie A, Vincent CA, Hanna GB

Abstract

OBJECTIVE:: To identify and prioritize hazards in surgical wards and recommend interventions. BACKGROUND:: Retrospective and prospective studies report the frequency and severity of surgical adverse events, but not in sufficient detail to allow interventions to be recommended in surgical wards. METHODS:: Seventy hours of observations were used to record all activities occurring in surgical wards, and from these activities health care processes were derived. Fifty-nine patients and staff quantified the hazard associated with each health care process through a risk assessment survey. Modified health care failure mode and effects analysis was applied to the most hazardous of these processes to quantify the hazard of their associated failures. Cause analysis was applied to the most hazardous failures within analyzed processes. Interventions addressing the prioritized failures were recommended. RESULTS:: Surgical ward observations identified 81 activities. The risk assessment survey was used to quantify the hazard associated with 10 health care processes derived from these activities. The 5 most hazardous processes were prioritized for modified health care failure mode and effects analysis including hand hygiene, isolation of infection, vital signs, medication delivery, and hand off. Of 190 failures within these processes, 50 (26%) were considered hazardous and did not have effective control measures in place. The causes of these failures allowed interventions to be recommended. CONCLUSIONS:: Proactive risk assessments were used to systematically identify and prioritize hazards in surgical wards and allowed interventions to be recommended. These are practical tools that can determine where patient safety efforts should be targeted in clinical health care environments.

PMID: 22504280 [PubMed - as supplied by publisher]

Laparoscopic Sleeve Gastrectomy in 108 Obese Children and Adolescents Aged 5 to 21 Years.

Ann Surg. 2012 Apr 16;

Authors: Alqahtani AR, Antonisamy B, Alamri H, Elahmedi M, Zimmerman VA

Abstract

OBJECTIVE:: To report experience with laparoscopic sleeve gastrectomy (LSG) in 108 severely obese children and adolescents. BACKGROUND:: Obesity during childhood and adolescence can be accompanied by serious long-term adverse health and longevity outcomes. With increased use of bariatric surgery to treat obesity in these patients, diverse guidelines have been published, most of which exclude children aged younger than 14 years. Few reports describe LSG in children and adolescents, delaying determining its safety and effectiveness and developing guidance regarding its use. METHODS:: A retrospective review of LSG performed from March 2008 through February 2011 by a single surgeon at King Saud University Hospitals, Riyadh, Saudi Arabia, included 108 patients aged 5 through 21 years. RESULTS:: Patients attending follow-up visits at 3 (n = 88), 6 (n = 76), 12 (n = 41), and 24 (n = 8) months postoperatively experienced median excess weight loss (EWL) of 28.9%, 48.1%, 61.3%, and 62.3%, respectively. At 6 and 12 months follow-up, 42.1% (n = 32) and 73.2% (n = 30) of patients achieved at least 50% EWL, whereas 7.9% (n = 6) and 4.9% (n = 2) had 25% or less EWL, respectively. There were no serious postoperative complications and no adverse sequelae developed during the current follow-up. Available comorbidity data indicate resolution of dyslipidemia, 21 of 30 (70.0%); hypertension, 27 of 36 (75.0%); prehypertension, 15 of 18 (83.3%); symptoms of obstructive sleep apnea, 20 of 22 (90.9%); diabetes, 15 of 16 (93.8%); and prediabetes, 11 of 11 (100.0%). CONCLUSIONS:: LSG resulted in successful short-term weight loss in more than 90% of pediatric patients and 70% or more comorbidity resolution during up to 24 months of follow-up. Long-term data are necessary to evaluate persistence of weight loss and maturation to adulthood.

PMID: 22504281 [PubMed - as supplied by publisher]

Transanal Employment of Single Access Ports Is Feasible for Rectal Surgery.

Ann Surg. 2012 Apr 12;

Authors: Barendse RM, Doornebosch PG, Bemelman WA, Fockens P, Dekker E, de Graaf EJ

Abstract

OBJECTIVE:: To evaluate the feasibility of transanal single port surgery in 15 consecutive patients. BACKGROUND:: The current method of choice for local resection of rectal tumors is transanal endoscopic microsurgery (TEM), a complex and expensive technique. Single access surgery is easy, relatively cheap, and more broadly applied in laparoscopy. Evidence regarding transanal use of single access ports is scarce. METHODS:: Consecutive patients with a rectal lesion otherwise eligible for TEM were operated using the Single Site Laparoscopic Access System (SSL) and standard laparoscopic instrumentation. Patient, lesion and procedure characteristics, hospitalization length, and peroperative and postoperative complications were recorded. RESULTS:: Fifteen patients were planned for single port transanal surgery. In 2 patients (13.3%), intrarectal retractor expansion failed, and conversion to conventional TEM was necessary. The remaining 13 patients were successfully operated. Rectal lesions (mean diameter 36 mm, standard deviation ±25 mm, mean distance from the dentate line 6 cm [±4.5]) included adenoma in 7 patients, T1 adenocarcinoma in 1, T2 adenocarcinoma in 3, carcinoid in 1, and fibrosis only in 1 (after prior polypectomy). All patients were operated in lithotomy position. Resections were en bloc, full thickness, and had complete margins. Resection specimens measured 65 (±35) × 52 (±24) mm. Twelve rectal defects were sutured. One peroperative pneumoscrotum occurred. Mean operating time was 57 (±39) minutes. One patient presented with postoperative hemorrhage, treated conservatively (postoperative morbidity rate 7.7%). Mean hospitalization lasted 2.5 days (±2.7). CONCLUSIONS:: Transanal single port surgery via the SSL is feasible and safe and may become a promising alternative to TEM.

PMID: 22504282 [PubMed - as supplied by publisher]

Laparoscopic Distal Pancreatectomy Is Associated With Significantly Less Overall Morbidity Compared to the Open Technique: A Systematic Review and Meta-Analysis.

Ann Surg. 2012 Apr 16;

Authors: Venkat R, Edil BH, Schulick RD, Lidor AO, Makary MA, Wolfgang CL

Abstract

OBJECTIVE:: To compare laparoscopic distal pancreatectomy (LDP) versus open distal pancreatectomy (ODP) by using meta-analytical techniques. BACKGROUND:: LDP is increasingly performed as an alternative approach for distal pancreatectomy in selected patients. Multiple studies have tried to assess the safety and efficacy of LDP compared with ODP. METHODS:: A systematic review of the literature was performed to identify studies comparing LDP and ODP. Intraoperative outcomes, postoperative recovery, oncologic safety, and postoperative complications were evaluated. Meta-analysis was performed using a random-effects model. RESULTS:: Eighteen studies matched the selection criteria, including 1814 patients (43% laparoscopic, 57% open). LDP had lower blood loss by 355 mL (P < 0.001) and hospital length of stay by 4.0 days (P < 0.001). Overall complications were significantly lower in the laparoscopic group (33.9% vs 44.2%; odds ratio [OR] = 0.73, 95% confidence interval [CI] 0.57-0.95), as was surgical site infection (2.9% vs 8.1%; OR = 0.45, 95% CI 0.24-0.82). There was no difference in operative time, margin positivity, incidence of postoperative pancreatic fistula, and mortality. CONCLUSIONS:: LDP has lower blood loss and reduced length of hospital stay. There was a lower risk of overall postoperative complications and wound infection, without a substantial increase in the operative time. Although a thorough evaluation of oncological outcomes was not possible, the rate of margin positivity was comparable to the open technique. The improved complication profile of LDP, taken together with the lack of compromise of margin status, suggests that this technique is a reasonable approach in selected cancer patients.

PMID: 22511003 [PubMed - as supplied by publisher]

The Core Competencies of James Marion Sims, MD.

Ann Surg. 2012 Apr 17;

Authors: Straughn JM, Gandy RE, Rodning CB

Abstract

: The concept of core competencies in graduate medical education was introduced by the Accreditation Council for Graduate Medical Education of the American Medical Association to semiquantitatively assess the professional performance of students, residents, practitioners, and faculty. Many aspects of the career of J. Marion Sims, MD, are exemplary of those core competencies: MEDICAL KNOWLEDGE:: Author of the first American textbook related to gynecology. MEDICAL CARE:: Innovator of the Sims’ Vaginal Speculum, Sims’ Position, Sims’ Test, and vesico-/rectovaginal fistulorrhaphy; advocated abdominal exploration for penetrating wounds; performed the first cholecystostomy. PROFESSIONALISM:: Served as President of the New York Academy of Medicine, the American Medical Association, and the American Gynecologic Society. INTERPERSONAL RELATIONSHIPS/COMMUNICATION:: Cared for the indigent, hearthless, indentured, disenfranchised; served as consulting surgeon to the Empress Eugénie (France), the Duchess of Hamilton (Scotland), the Empress of Austria, and other royalty of the aristocratic Houses of Europe; accorded the National Order of the Legion of Honor. PRACTICE-BASED LEARNING:: Introduction of silver wire sutures; adoption of the principles of asepsis/antisepsis; adoption of the principles of general anesthesia. SYSTEMS-BASED PRACTICE:: Established the Woman’s Hospital, New York City, New York, the predecessor of the Memorial Sloan-Kettering Center for the Treatment of Cancer and Allied Diseases; organized the Anglo-American Ambulance Corps under the patronage of Napoleon III. What led him to a life of clinical and humanitarian service? First, he was determined to succeed. His formal medical/surgical education was perhaps the best available to North Americans during that era. Second, he was courageous in experimentation and innovation, applying new developments in operative technique, asepsis/antisepsis, and general anesthesia. Third, his curiosity was not burdened by rigid adherence to old doctrines or antiquated theories. Fourth, he broadened his professional experience and knowledge by travels to renowned intellectual centers in Western Europe. Fifth, he was perceived as cautiously optimistic and judiciously positive as he interacted with patients, students, and colleagues. Courage, confidence, creativity, compassion, charisma, character, and controversy marked his career. His legacy is illustrative and exemplary of the core competencies fostered contemporaneously in graduate medical educational programs.

PMID: 22514000 [PubMed - as supplied by publisher]

Weight Loss and Metabolic Improvement in Morbidly Obese Subjects Implanted for 1 Year With an Endoscopic Duodenal-Jejunal Bypass Liner.

Ann Surg. 2012 Apr 24;

Authors: Escalona A, Pimentel F, Sharp A, Becerra P, Slako M, Turiel D, Muñoz R, Bambs C, Guzmán S, Ibáñez L, Gersin K

Abstract

OBJECTIVE:: To evaluate safety, weight loss, and cardiometabolic changes in obese subjects implanted with the duodenal-jejunal bypass liner (DJBL) for 1 year. BACKGROUND:: The DJBL is an endoscopic implant that mimics the duodenal-jejunal bypass component of the Roux-en-Y gastric bypass. Previous reports have shown significant weight loss and improvement in type 2 diabetes for up to 6 months. METHODS:: Morbidly obese subjects were enrolled in a single arm, open label, prospective trial and implanted with the DJBL. Primary endpoints included safety and weight change from baseline to week 52. Secondary endpoints included changes in waist circumference, blood pressure, lipids, glycemic control, and metabolic syndrome. RESULTS:: The DJBL was implanted endoscopically in 39 of 42 subjects (age: 36 ± 10 years; 80% female; weight: 109 ± 18 kg; BMI: 43.7 ± 5.9 kg/m); 24 completed 52 weeks of follow-up. Three subjects could not be implanted due to short duodenal bulb. Implantation time was 24 ± 2 minutes. There were no procedure-related complications and there were 15 early endoscopic removals. In the 52-week completer population, total body weight change from baseline was -22.1 ± 2.1 kg (P < 0.0001) corresponding to 19.9 ± 1.8% of total body weight and 47.0 ± 4.4% excess of weight loss. There were also significant improvements in waist circumference, blood pressure, total and low-density lipoprotein cholesterol, triglycerides, and fasting glucose. CONCLUSIONS:: The DJBL is safe when implanted for 1 year, and results in significant weight loss and improvements in cardiometabolic risk factors. These results suggest that this device may be suitable for the treatment of morbid obesity and its related comorbidities. This study was registered at www.clinicaltrials.gov (NCT00985491).

PMID: 22534421 [PubMed - as supplied by publisher]

Mesh Reinforcement of Pancreatic Transection Decreases Incidence of Pancreatic Occlusion Failure for Left Pancreatectomy: A Single-Blinded, Randomized Controlled Trial.

Ann Surg. 2012 Apr 24;

Authors: Hamilton NA, Porembka MR, Johnston FM, Gao F, Strasberg SM, Linehan DC, Hawkins WG

Abstract

INTRODUCTION:: Pancreatic leak or fistula is the most frequent complication after left pancreatectomy. We performed a single-blinded, parallel-group, randomized controlled trial comparing stapled left pancreatectomy with stapled left pancreatectomy using mesh reinforcement of the staple line with either Seamguard or Peristrips Dry. METHODS:: All patients undergoing left pancreatectomy at a large tertiary hospital were eligible for participation. Patients were randomized to either mesh reinforcement or no-mesh reinforcement intraoperatively after being determined a candidate for resection. Patients were blinded to the result of their randomization for 6 weeks. Primary outcome measure was clinically significant leak as defined by the ISGPF (International Study Group on Pancreatic Fistula) pancreatic leak grading system. RESULTS:: One hundred patients were randomized to either mesh (54) or no-mesh (46) reinforcement of their pancreatic transection. There was 1 death in each group. ISGPF grade B and C leaks were seen in 1.9% (1/53) of patients undergoing resection with mesh reinforcement and 20% (11/45) of patients without mesh reinforcement (P = .0007). CONCLUSIONS:: Mesh reinforcement of pancreatic transection line significantly reduces the incidence of significant pancreatic fistula in patients undergoing left pancreatectomy. TRIAL REGISTRATION:: Clinicaltrials.gov: NCT01359410.

PMID: 22534422 [PubMed - as supplied by publisher]

An Important Next Step in the Evolution of Our Understanding of the Value and Importance of Trauma Systems.

Ann Surg. 2012 Apr 24;

Authors: Meredith JW

PMID: 22534423 [PubMed - as supplied by publisher]

Surgical stress response and postoperative immune function after laparoscopy or open surgery with fast track or standard perioperative care: a randomized trial.

Ann Surg. 2012 Feb;255(2):216-21

Authors: Veenhof AA, Vlug MS, van der Pas MH, Sietses C, van der Peet DL, de Lange-de Klerk ES, Bonjer HJ, Bemelman WA, Cuesta MA

Abstract

OBJECTIVE: To evaluate the effect of laparoscopic or open colectomy with fast track or standard perioperative care on patient’s immune status and stress response after surgery.

METHODS: Patients with nonmetastasized colon cancer were randomized to laparoscopic or open colectomy with fast track or standard care. Blood samples were taken preoperatively (baseline), and 1, 2, 24, and 72 hours after surgery. Systemic HLA-DR expression, C-reactive protein, interleukin-6, growth hormone, prolactin, and cortisol were analyzed.

RESULTS: Nineteen patients were randomized for laparoscopy and fast track care (LFT), 23 for laparoscopy and standard care (LS), 17 for open surgery and fast track care (OFT), and 20 for open surgery and standard care (OS). Patient characteristics were comparable. Mean HLA-DR was 74.8 in the LFT group, 67.1 in the LS group, 52.8 in the OFT group, and 40.7 in the OS group. Repeated-measures 2-way analysis of variance (ANOVA) showed this can be attributed to type of surgery and not aftercare (P = 0.002). Interleukin-6 levels were highest in the OS group. Repeated-measures 2-way ANOVA showed this can be attributed to type of surgery and not aftercare (P = 0.001). C-reactive protein levels were highest in the OS group. Following repeated-measures 2-way ANOVA, this can be attributed to type of surgery and not aftercare (P = 0.022). Growth hormone was lowest in the LFT group. Following repeated-measures 2-way ANOVA, this can be attributed to type of aftercare and not to type of surgery (P = 0.033). No differences between the groups were seen regarding prolactin or cortisol. No differences in (infectious) complication rates were observed between the groups.

CONCLUSIONS: This randomized trial showed that immune function of HLA-DR in patients undergoing laparoscopic surgery with fast track care remains highest. This can be attributed to type of surgery and not aftercare. These results may indicate a reason for the accelerated recovery of patients treated laparoscopically within a fast track program as described in the LAparoscopy and/or FAst track multimodal management versus standard care (LAFA-Trial) (www.trialregister.nl, protocol NTR222).

PMID: 22241289 [PubMed - indexed for MEDLINE]

Effectiveness of Sentinel Lymph Node Intraoperative Examination in 753 Women With Breast Cancer: Are We Overtreating Patients?

Ann Surg. 2012 Mar 11;

Authors: Mario T, Isacco M, Donatella S, Monica F, Simone Z, Giampaolo U, Margherita S, Giancarlo R

Abstract

OBJECTIVE:: The goal of our study was to evaluate the sensitivity and specificity of sentinel lymph node biopsy (SLNB) frozen section (FS) examinations to detect metastatic lymph nodes and also its potential role in avoiding unnecessary demolitive axillary surgery. BACKGROUND:: SLNB is the standard of care in surgical oncology of the breast. Intraoperative evaluation of the SLN seems to achieve sufficient sensitivity for macrometastasis (Ma), leading to axillary lymph node dissection (ALND) only when strictly necessary. Is it equally as clear when to perform ALND if micrometastasis (Mi) or isolated tumor cells (ITCs) are detected? METHODS:: All consecutive patients from January 2005 to September 2010 operated on for breast cancer were prospectively enrolled. All patients underwent an FS SLNB. The sensitivity and specificity of SLN FSs in detecting Ma, Mi, and ITCs was calculated. All patients with Ma or Mi at FS underwent ALND. For all patients who underwent ALND, the number of metastatic non-SLNs was recorded and correlated to the size of the SLN metastasis. RESULTS:: A total of 753 patients were enrolled. FS examination had an overall 54% sensitivity and 100% specificity in detecting metastatic disease (Ma/Mi/ITCs). The sensitivity rises to 89% if only Mas were considered and to 64% if Mas and Mis were counted together. All patients with Mas or Mis detected at FS had a completion ALND during the same procedure (156/222). All patients with Mas detected at final pathology (16 false negatives, 2.6%) and 50 women with Mis or ITCs (119 false negatives, 20%) underwent a delayed ALND. When Mis or ITCs were detected in the SLN, only 8 of 73 (10.9%) and none of 4 (0%) patients, respectively, had at least 1 metastatic non-SLN after ALND. Two patients (2/460, 0.43%) who had negative SLNs showed local axillary recurrence. After a mean follow-up of 32 months, none of the 71 patients with Mis or ITCs who did not undergo a second operation showed local recurrence. CONCLUSIONS:: SLNB FS is highly effective in detecting the subgroup of patients who may benefit from completion ALND during the same surgical procedure. The role of Mi/ITCs in the SLN(s) is still unclear, but our data lean toward a less aggressive surgical approach.

PMID: 22415419 [PubMed - as supplied by publisher]

Relapse-Free Survival in Patients With Nonmetastatic, Surgically Resected Pancreatic Neuroendocrine Tumors: An Analysis of the AJCC and ENETS Staging Classifications.

Ann Surg. 2012 Mar 11;

Authors: Strosberg JR, Cheema A, Weber JM, Ghayouri M, Han G, Hodul PJ, Kvols LK

Abstract

BACKGROUND:: The risk of metastatic spread among patients with early-stage pancreatic neuroendocrine tumors has not been well established. The authors sought to evaluate whether the new TNM staging systems proposed by the American Joint Committee on Cancer (AJCC) and European Neuroendocrine Tumor Society (ENETS) are prognostic for relapse-free survival (RFS) after surgical resection. METHODS:: Patients with surgically resected localized or locally advanced pancreatic NETs treated at the H. Lee Moffitt Cancer Center between 1999 and 2010 were assigned a stage (I-III) based on the AJCC and ENETS classifications. RFS and overall survival were measured using Kaplan-Meier methodology, with log-rank testing for evaluation of the 2 tumor staging systems. Multivariate analysis was performed controlling for tumor grade, location, surgery type, functional hormonal status, and incidental diagnosis. RESULTS:: The authors identified 123 patients with nonmetastatic, surgically resected pancreatic NETs. When using the AJCC classification, 5-year RFS rates for stages I through III were 78%, 53%, and 33%, respectively (P < 0.01). Using the ENETS classification, 5-year RFS rates for stages I to III were 100%, 70%, and 53% (P < 0.18). When excluding patients who were referred after their metastatic recurrence, the 5-year RFS rates for stages I to III were 90%, 73%, and 66% according to the AJCC classification, and 100%, 84%, and 75% according to the ENETS classification. Recurrence rates peaked at approximately 2 years after surgery. CONCLUSIONS:: The AJCC and ENETS TNM classifications for pancreatic NETs are prognostic for recurrence-free survival and can be adopted in clinical practice.

PMID: 22415420 [PubMed - as supplied by publisher]

Long-Term Follow-Up of Malignancy Biomarkers in Patients With Barrett’s Esophagus Undergoing Medical or Surgical Treatment.

Ann Surg. 2012 Mar 11;

Authors: Martinez de Haro LF, Ortiz A, Parrilla P, Munitiz V, Martinez CM, Revilla B, de Angulo DR, Bermejo J, Yélamos J, Molina J

Abstract

OBJECTIVE:: This study aims to compare some validated biomarkers of malignancy (Ki-67, p53, and apoptosis) between 2 groups of patients with Barrett’s esophagus (BE) undergoing randomly medical or surgical treatment. BACKGROUND:: The treatment of choice to prevent the malignant progression of BE remains controversial. Translational studies using biomarkers associated with the metaplasia-tumor pathway could be useful to provide some information in this regard. METHODS:: The study group consisted of 45 patients: 20 under medical treatment with 40 mg/day of proton pump inhibitors (PPIs) and 25 after Nissen fundoplication (NFP). After a median follow-up of 8 years (range, 5-10 years), the values of Ki-67, p53, and apoptosis were analyzed in all patients before treatment (n = 45) and then 1 year (n = 45), 3 years (n = 45), 5 years (n = 45), and 10 years (n = 25) afterwards in both groups of treatment. These values were also analyzed in 2 subgroups of patients with successful medical and surgical treatment. RESULTS:: Both Ki-67 and p53 remained stable after NFP, whereas they increased progressively in patients under PPIs with statistically significant differences between the 2 groups. Conversely, the apoptotic index increased progressively after NFP and decreased in the patients under PPIs with significant differences at 3, 5, and 10 years of follow-up. On comparing the subgroups of successful treatment the same differences were found. CONCLUSIONS:: Barrett’s epithelium remains more stable after a long-term follow-up in patients with BE treated surgically than in those under PPIs even in the absence of abnormal rates of acid reflux.

PMID: 22415421 [PubMed - as supplied by publisher]

Evaluation Study of Different Strategies for Detecting Surgical Site Infections Using the Hospital Information System at Lyon University Hospital, France.

Ann Surg. 2012 Mar 11;

Authors: Gerbier-Colomban S, Bourjault M, Cêtre JC, Baulieux J, Metzger MH

Abstract

OBJECTIVE:: To evaluate different strategies for detecting surgical site infections (SSIs) using different sources (notification by the surgeon, bacteriological results, antibiotic prescription, and discharge diagnosis codes). BACKGROUND:: Surveillance plays a role in reducing the risks of SSIs but the performance of case reports by surgeons is insufficient. Indirect methods of SSI detection are an alternative to increase the quality of surveillance. METHODS:: A retrospective cohort study of 446 patients operated consecutively during the first half of 2007 was set up in a 56-bed general surgery unit in Lyon University Hospital, France. Patients were followed up 30 days after intervention. Different methods of detection were established by combining different data sources. The sensitivity and specificity of these methods were calculated by using, as reference method, the manual review of the medical records. RESULTS:: The sensitivity and specificity of SSI detection were, respectively, 18.4% (95% confidence interval [CI]: 7.9-31.6) and 100% for surgeon notification; 63.2% (95% CI: 47.3-78.9) and 95.1% (95% CI: 92.9-97.1) for detection based on positive cultures; 68.4% (95% CI: 52.6-81.6) and 87.5% (95% CI: 84.3-90.7) using antibiotic prescription; 26.3% (95% CI: 13.2-42.1) and 99.5% (95% CI: 98.8-100) using discharge diagnosis codes. By combining the latter 3 sources, the sensitivity increased at 86.8% (95% CI: 76.3-97.4) and the specificity was lowered at 85.5% (95% CI: 82.1-89.0). CONCLUSIONS:: SSI detection based on the combination of data extracted automatically from the hospital information system performed well. This strategy has been implemented gradually in Lyon University Hospital.

PMID: 22415422 [PubMed - as supplied by publisher]

Reporting of Short-Term Clinical Outcomes After Esophagectomy: A Systematic Review.

Ann Surg. 2012 Mar 5;

Authors: Blencowe NS, Strong S, McNair AG, Brookes ST, Crosby T, Griffin SM, Blazeby JM

Abstract

OBJECTIVE:: This review summarizes reporting of complications of esophageal cancer surgery. BACKGROUND:: Accurate assessment of morbidity and mortality after surgery for cancer is essential to compare centers, allow data synthesis, and inform clinical decision-making. A lack of defined standards may distort clinically relevant treatment effects. METHODS:: Systematic literature searches identified articles published between 2005 and 2009 reporting morbidity and mortality after esophagectomy for cancer. Data were analyzed for frequency of complication reporting and to check whether outcomes were defined and classified for severity and whether a validated system for grading complications was used. Information about reporting outcomes adjusting for baseline risk factors was collated, and a descriptive summary of the results of included outcomes was undertaken. RESULTS:: Of 3458 abstracts, 224 full papers were reviewed and 122 were included (17 randomized trials and 105 observational studies), reporting outcomes of 57,299 esophagectomies. No single complication was reported in all papers, and 60 (60.6%) did not define any of the measured complications. Anastomotic leak was the most commonly reported morbidity, assessed in 80 (80.1%) articles, defined in 28 (28.3%), but 22 different descriptions were used. Five papers (5.1%) categorized morbidity with a validated grading system. One hundred fifteen papers reported postoperative mortality rates, 25 defining the term using 10 different definitions. In-hospital mortality was the most commonly used term for postoperative death, with 6 different interpretations of this phrase. Eighteen papers adjusted outcomes for baseline risk factors and 60 presented baseline measures of comorbidity. CONCLUSIONS:: Outcome reporting after esophageal cancer surgery is heterogeneous and inconsistent, and it lacks methodological rigor. A consensus approach to reporting clinical outcomes should be considered, and at the minimum it is recommended that a “core outcome set” is defined and used in all studies reporting outcomes of esophageal cancer surgery. This will allow meaningful cross study comparisons and analyses to evaluate surgery.

PMID: 22395090 [PubMed - as supplied by publisher]

An Integrated Proteomics and Metabolomics Approach for Defining Oncofetal Biomarkers in the Colorectal Cancer.

Ann Surg. 2012 Mar 5;

Authors: Ma Y, Zhang P, Wang F, Liu W, Yang J, Qin H

Abstract

OBJECTIVE:: The present study was designed to search for potential diagnostic biomarkers in the serum of colorectal cancer (CRC). BACKGROUND:: CRC is the third most common cancer worldwide, and its prognosis is poor at early stages. A panel of novel biomarkers is urgently needed for early diagnosis of CRC. METHODS:: An integrated proteomics and metabolomics approach was performed to define oncofetal biomarkers in CRC by protein and metabolite profiling of serum samples from CRC patients, healthy control adults, and fetus. The differentially expressed proteins were identified by a 2-D DIGE (2-Dimensional Difference Gel Electrophoresis) coupled with a Finnigan LTQ-based proteomics approach. Meanwhile, the serum metabolome was analyzed using gas chromatography-mass spectrometry integrated with a commercial mass spectral library for peak identification. RESULTS:: Of the 28 identified proteins and the 34 analyzed metabolites, only 5 protein spots and 6 metabolites were significantly increased or decreased in both CRC and fetal serum groups compared with the healthy adult group. Data from supervised predictive models allowed a separation of 93.5% of CRC patients from the healthy controls using the 6 metabolites. Finally, correlation analysis was applied to establish quantitative linkages between the 5 individual metabolite 3-hydroxybutyric acid, L-valine, L-threonine, 1-deoxyglucose, and glycine and the 5 individual proteins MACF1, APOH, A2M, IGL@, and VDB. Furthermore, 10 potential oncofetal biomarkers were characterized and their potential for CRC diagnosis was validated. CONCLUSION:: The integrated approach we developed will promote the translation of biomarkers with clinical value into routine clinical practice.

PMID: 22395091 [PubMed - as supplied by publisher]

Randomized, Controlled, Blinded Trial of Tisseel/Tissucol for Mesh Fixation in Patients Undergoing Lichtenstein Technique for Primary Inguinal Hernia Repair: Results of the TIMELI Trial.

Ann Surg. 2012 Mar 5;

Authors: Campanelli G, Pascual MH, Hoeferlin A, Rosenberg J, Champault G, Kingsnorth A, Miserez M

Abstract

OBJECTIVE:: Test the hypothesis that fibrin sealant mesh fixation can reduce the incidence of postoperative pain/numbness/groin discomfort by up to 50% compared with sutures for repair of inguinal hernias using the Lichtenstein technique. BACKGROUND:: Inguinal hernia repair is the most common procedure in general surgery, thus improvements in surgical techniques, which reduce the burden of undesirable postoperative outcomes, are of clinical importance. METHODS:: A randomized, controlled, patient- and evaluator-blinded study (Tissucol/Tisseel for MEsh fixation in LIchtenstein hernia repair [TIMELI]; trial NCT00306839) was conducted among patients eligible for Lichtenstein repair of uncomplicated unilateral primary inguinal small-medium sized hernia. Patients were subject to mesh fixation with either fibrin sealant or sutures. Main outcome measures were visual analogue scale (VAS) assessments for “pain,” “numbness,” and “groin discomfort” on a scale of 0 = best and 100 = worst outcome. The primary endpoint was a composite that evaluated the prevalence of chronic disabling complications (VAS score >30 for pain/numbness/groin discomfort) at 12 months after surgery. RESULTS:: In total, 319 patients were randomized between January 2006 and April 2007 (159 fibrin sealant, 160 sutures). At 12 months, the prevalence of 1 or more disabling complication was significantly lower in the fibrin sealant group than in the sutures group (8.1% vs 14.8%; P = 0.0344). Less pain was reported in the fibrin sealant group than in the sutures group at 1 and 6 months (P = 0.0132; P = 0.0052), as reflected by a lower proportion of patients using analgesics in the fibrin group over the study duration (65.2% vs 79.7%; P = 0.0009). Only 3 of 316 patients (0.9%) experienced recurrence. The incidences of wound-healing complications and other adverse events were comparable between groups. CONCLUSIONS:: Fibrin sealant for mesh fixation in Lichtenstein repair of small-medium sized inguinal hernias is well tolerated and reduces the rate of pain/numbness/groin discomfort by 45% relative to sutures without increasing hernia recurrence (NCT00306839).

PMID: 22395092 [PubMed - as supplied by publisher]

Multicenter Study for Optimal Categorization of Extramural Tumor Deposits for Colorectal Cancer Staging.

Ann Surg. 2012 Mar 5;

Authors: Ueno H, Mochizuki H, Shirouzu K, Kusumi T, Yamada K, Ikegami M, Kawachi H, Kameoka S, Ohkura Y, Masaki T, Kushima R, Takahashi K, Ajioka Y, Hase K, Ochiai A, Wada R, Iwaya K, Nakamura T, Sugihara K,

Abstract

OBJECTIVE:: This study aimed to determine the optimal categorization of extramural tumor deposits lacking residual lymph node (LN) structure (EX) in colorectal cancer staging. BACKGROUND:: The TNM classification system categorizes EX on the basis of their contour characteristics (the contour rule). METHODS:: We conducted a multicenter, retrospective, pathological review of 1716 patients with stage I to III curatively resected colorectal cancer who were treated at 11 institutions (1994-1998). In addition, 2242 patients from 9 institutions (1999-2003) were enrolled as a second cohort for validating results. EX were classified as isolated foci confined to vascular or perineural spaces (ie, lymphatic, venous, or perineural invasion) or as tumor nodules (ND). N- and T-staging systems employing different categories for staging were compared in terms of their prognostic power. In addition, the diagnoses of extramural, discontinuously spreading lesions made by 11 observers from different institutions were assessed for interobserver agreement. RESULTS:: EX were observed in 18.2% of patients in the first cohort. The method of categorization of EX in tumor staging has a stronger impact on N than T staging. The N-staging system in which all ND types were classified as N factor (the ND rule) could more effectively stratify the survival outcome than the contour rule (Akaike information criterion, 3040.8 vs 3059.5; the Harrell C-index, 0.7255 vs 0.7103). EX were observed in 16.9% of patients in the second cohort. Statistically, the ND rule was more informative than the contour rule for N staging. The Fleiss kappa coefficient for distinguishing LN metastases from EX (0.74) was lower than expected for complete agreement, and it decreased further to 0.51 when calculated for the judgment of ND with smooth contours. CONCLUSIONS:: Classifying all ND types as N factors irrespective of contours can simplify the tumor staging system by enhancing diagnostic objectivity, resulting in improved prognostic accuracy.

PMID: 22395093 [PubMed - as supplied by publisher]

Evaluation of Clinical Outcomes With Alvimopan in Clinical Practice: A National Matched-Cohort Study in Patients Undergoing Bowel Resection.

Ann Surg. 2012 Mar 1;

Authors: Delaney CP, Craver C, Gibbons MM, Rachfal AW, Vandepol CJ, Cook SF, Poston SA, Calloway M, Techner L

Abstract

OBJECTIVE:: To evaluate in-hospital clinical outcomes after open and laparoscopic bowel resection (BR) with or without alvimopan treatment. BACKGROUND:: Delayed return of gastrointestinal function after BR may be associated with greater postoperative morbidity and increased hospital length of stay (LOS). In clinical trials, alvimopan-a peripherally acting μ-opioid receptor antagonist-accelerated gastrointestinal recovery after open BR. METHODS:: A retrospective matched-cohort study (NCT01150760) was conducted using a national inpatient database. Each alvimopan patient was exact matched (surgical procedure, surgeon specialty) and propensity score matched (baseline characteristics) to a nonalvimopan BR patient. Outcomes included gastrointestinal and other morbidity (cardiovascular, pulmonary, infection, cerebrovascular, thromboembolic); mortality; readmission rate; and intensive care unit (ICU) stay (intent-to-treat [ITT] population). Postoperative LOS and estimated cost were also compared (modified ITT population). RESULTS:: Each cohort included 3525 ITT patients with similar baseline characteristics. Gastrointestinal (29.8% vs 35.7%) and other morbidity (cardiovascular [19.4% vs 24.0%], pulmonary [7.3% vs 10.5%], infectious [9.6% vs 11.8%], thromboembolic [1.2% vs 2.1%]), mortality (0.4% vs 1.0%), and mean ICU stay (0.3 vs 0.6 days) were lower in the alvimopan group (P ≤ 0.003 for each). Postoperative LOS and estimated direct cost were lower for all alvimopan patients and after laparoscopic and open BR (LOS: -1.1, -0.8, and -1.8 days respectively; cost: -$2345, -$1382, and -$3218, respectively; P ≤ 0.0008 for each). CONCLUSIONS:: On average, alvimopan-treated patients had a lower incidence of mortality and most incidents of morbidities. Length of stay, ICU use, and estimated cost were also lower with comparable readmissions. These results in patients outside the clinical trial setting include laparoscopic colectomy and demonstrate a potential association between acceleration of gastrointestinal recovery and improved early postoperative outcomes.

PMID: 22388106 [PubMed - as supplied by publisher]

Avoiding Burnout: The Personal Health Habits and Wellness Practices of US Surgeons.

Ann Surg. 2012 Mar 1;

Authors: Shanafelt TD, Oreskovich MR, Dyrbye LN, Satele DV, Hanks JB, Sloan JA, Balch CM

Abstract

OBJECTIVE:: To evaluate the health habits, routine medical care practices, and personal wellness strategies of American surgeons and explore associations with burnout and quality of life (QOL). BACKGROUND:: Burnout and low mental QOL are common among US surgeons and seem to adversely affect quality of care, job satisfaction, career longevity, and risk of suicide. The self-care strategies and personal wellness promotion practices used by surgeons to deal with the stress of practice are not well explored. METHODS:: Members of the American College of Surgeons were sent an anonymous, cross-sectional survey in October 2010. The survey included self-assessment of health habits, routine medical care practices, and personal wellness strategies and standardized assessments of burnout and QOL. RESULTS:: Of 7197 participating surgeons, 3911 (55.0%) participated in aerobic exercise and 2611 (36.3%) in muscle strengthening activities, in a pattern consistent with the Centers for Disease Control and Prevention recommendations. The overall and physical QOL scores were superior for surgeons’ following the Centers for Disease Control and Prevention recommendations (all P < 0.0001). A total of 3311 (46.2%) participating surgeons had seen their primary care provider in the last 12 months. Surgeons who had seen their primary care provider in the last 12 months were more likely to be up to date with all age-appropriate health care screening and had superior overall and physical QOL scores (all P < 0.0001). Ratings of the importance of 16 personal wellness promotion strategies differed for surgeons without burnout (all P < 0.0001). On multivariate analysis, surgeons placing greater emphasis on finding meaning in work, focusing on what is important in life, maintaining a positive outlook, and embracing a philosophy that stresses work/life balance were less likely to be burned out (all P < 0.0001). Although many factors associated with lower risk of burnout were also associated with achieving a high overall QOL, notable differences were observed, indicating surgeons’ need to employ a broader repertoire of wellness promotion practices if they desire to move beyond neutral and achieve high well-being. CONCLUSIONS:: This study identifies specific measures surgeons can take to decrease burnout and improve their personal and professional QOL.

PMID: 22388107 [PubMed - as supplied by publisher]

Reliability Adjustment for Reporting Hospital Outcomes With Surgery.

Ann Surg. 2012 Mar 1;

Authors: Dimick JB, Ghaferi AA, Osborne NH, Ko CY, Hall BL

Abstract

BACKGROUND:: Reliability adjustment, a novel technique for quantifying and removing statistical “noise” from quality rankings, is becoming more widely used outside surgery. We sought to evaluate its impact on hospital outcomes assessed with the American College of Surgeons’ National Surgical Quality Improvement Program (ACS-NSQIP). METHODS:: We used prospective, clinical data from the ACS-NSQIP to identify all patients undergoing colon resection in 2007 (n = 181 hospitals, n = 18,455 patients). We first used standard NSQIP techniques to generate risk-adjusted mortality and morbidity rates for each hospital. Using hierarchical logistic regression models, we then adjusted these for reliability using empirical Bayes techniques. To evaluate the impact of reliability adjustment, we first estimated the extent to which hospital-level variation was reduced. We then compared hospital mortality and morbidity rankings and outlier status before and after reliability adjustment. RESULTS:: Reliability adjustment greatly diminished apparent variation in hospital outcomes. For risk-adjusted mortality, there was a 6-fold difference before (1.4%-7.8%) and less than a 2-fold difference (3.2% to 5.7%) after reliability adjustment. For risk-adjusted morbidity, there was a 2-fold difference (18.0%-38.2%) before and a 1.5-fold difference (20.8%-34.8%) after reliability adjustment. Reliability adjustment had a large impact on hospital mortality and morbidity rankings. For example, with rankings based on mortality, 44% (16 hospitals) of the “best” hospitals (top 20%) were reclassified after reliability adjustment. Similarly, 22% (8 hospitals) of the “worst” hospitals (bottom 20%) were reclassified after reliability adjustment. CONCLUSIONS:: Reliability adjustment reduces variation due to statistical noise and results in more accurate estimates of risk-adjusted hospital outcomes. Given the risk of misclassifying hospitals and surgeons using standard approaches, this technique should be considered when reporting surgical outcomes.

PMID: 22388108 [PubMed - as supplied by publisher]

The Effects of Intraoperative Hypothermia on Surgical Site Infection: An Analysis of 524 Trauma Laparotomies.

Ann Surg. 2012 Mar 1;

Authors: Seamon MJ, Wobb J, Gaughan JP, Kulp H, Kamel I, Dempsey DT

Abstract

OBJECTIVES:: Our primary study objective was to determine whether intraoperative hypothermia predisposes patients to postoperative surgical site infections (SSI) after trauma laparotomy. BACKGROUND:: Although intraoperative normothermia is an important quality performance measure for patients undergoing colorectal surgery, the effects of intraoperative hypothermia on SSI remain unstudied in trauma. METHODS:: A review of all patients (July 2003-June 2008) who survived 4 days or more after urgent trauma laparotomy at a level I trauma center revealed 524 patients. Patient characteristics, along with preoperative and intraoperative care focusing on SSI risk factors, including the depth and duration of intraoperative hypothermia, were evaluated. The primary outcome measure was the diagnosis of SSI within 30 days of surgery. Cut-point analysis of the entire range of lowest intraoperative temperature measurements established the temperature nadir that best predicted SSI development. Single and multiple variable logistic regression determined SSI predictors. RESULTS:: The mean intraoperative temperature nadir of the study population (n = 524) was 35.2°C ± 1.1°C and 30.5% had at least 1 temperature measurement less than 35°C. Patients who developed SSI (36.1%) had a lower mean intraoperative temperature nadir (P = 0.009) and had a greater number of intraoperative temperature measurements <35°C (P < 0.001) than those who did not. Cut-point analysis revealed an intraoperative temperature of 35°C as the nadir temperature most predictive of SSI development. Multivariate analysis determined that a single intraoperative temperature measurement less than 35°C independently increased the site infection risk 221% per degree below 35°C (OR: 2.21; 95% CI: 1.24-3.92, P = 0.007). CONCLUSIONS:: Just as intraoperative hypothermia is an SSI risk factor in patients undergoing elective colorectal procedures, intraoperative hypothermia less than 35°C adversely affects SSI rates after trauma laparotomy. Our results suggest that intraoperative normothermia should be strictly maintained in patients undergoing operative trauma procedures.

PMID: 22388109 [PubMed - as supplied by publisher]

No risk of surgical site infections from residual bacteria after disinfection with povidone-iodine-alcohol in 1014 cases: a prospective observational study.

Ann Surg. 2012 Mar;255(3):565-9

Authors: Tschudin-Sutter S, Frei R, Egli-Gany D, Eckstein F, Valderrabano V, Dangel M, Battegay M, Widmer AF

Abstract

OBJECTIVE: : We studied the impact of residual bacteria at the incision site after disinfection with polyvinylpyrrolidone (PVP or povidone)-iodine-alcohol and the correlation with postoperative surgical site infections (SSIs).

BACKGROUND: : Chlorhexidine-based preparations are significantly more effective for catheter insertion care than povidone-iodine solutions to prevent catheter-associated infections, suggesting that the use of PVP-iodine should be reevaluated for disinfection of the surgical site. In the majority of European hospitals PVP-iodine-alcohol is still standard of care to prepare the preoperative site.

METHODS: : We consecutively and prospectively enrolled 1005 patients from representative surgical disciplines. Skin cultures to determine skin microbial counts were taken after disinfection with PVP-iodine-alcohol, immediately before incision. Disinfection of the surgical site was performed using standardized procedure under supervision. Criteria for SSI were based on guidelines issued by the Centers for Disease Control including appropriate follow-up of 30 days and 1 year.

RESULTS: : A total of 1014 skin cultures from surgical sites were analyzed from 1005 patients, of which 36 (3.6%) revealed significant colonization of the preoperative site, and 41 SSIs were detected, accounting for an SSI rate of 4.04%; residual bacteria before incision were completely unrelated to the incidence of SSI, even after adjustment for multiple potentially confounding variables.

CONCLUSIONS: : A low rate of SSIs of 4.04% was achieved when using PVP-iodine-alcohol for disinfection of the preoperative site. Remaining bacteria after standardized 3-step disinfection did not at all correlate with the development of an SSI. Our data provide clear evidence that PVP-iodine-alcohol is effective for preparation of the preoperative site.

PMID: 22330031 [PubMed - in process]

Regenerative Medicine as Applied to General Surgery.

Ann Surg. 2012 Feb 23;

Authors: Orlando G, Wood KJ, De Coppi P, Baptista PM, Binder KW, Bitar KN, Breuer C, Burnett L, Christ G, Farney A, Figliuzzi M, Holmes JH, Koch K, Macchiarini P, Mirmalek Sani SH, Opara E, Remuzzi A, Rogers J, Saul JM, Seliktar D, Shapira-Schweitzer K, Smith T, Solomon D, Van Dyke M, Yoo JJ, Zhang Y, Atala A, Stratta RJ, Soker S

Abstract

The present review illustrates the state of the art of regenerative medicine (RM) as applied to surgical diseases and demonstrates that this field has the potential to address some of the unmet needs in surgery. RM is a multidisciplinary field whose purpose is to regenerate in vivo or ex vivo human cells, tissues, or organs to restore or establish normal function through exploitation of the potential to regenerate, which is intrinsic to human cells, tissues, and organs. RM uses cells and/or specially designed biomaterials to reach its goals and RM-based therapies are already in use in several clinical trials in most fields of surgery. The main challenges for investigators are threefold: Creation of an appropriate microenvironment ex vivo that is able to sustain cell physiology and function in order to generate the desired cells or body parts; identification and appropriate manipulation of cells that have the potential to generate parenchymal, stromal and vascular components on demand, both in vivo and ex vivo; and production of smart materials that are able to drive cell fate.

PMID: 22330032 [PubMed - as supplied by publisher]

Chest surgical disorders in ancient egypt: evidence of advanced knowledge.

Ann Surg. 2012 Mar;255(3):605-8

Authors: Jungraithmayr W, Weder W

Abstract

The ancient Egyptians laid the foundation for the development of the earliest recorded systems of medical treatment. Many specialties such as gynecology, neurosurgery, ophthalmology, and chest disorders were subject to diagnosis, which were followed by an appropriate treatment. Here, we elucidate the remarkable level of their knowledge and understanding of anatomy and physiology in the field of chest medicine. Furthermore, we look at how ancient Egyptian physicians came to a diagnosis and treatment based on the thoracic cases in the Edwin Smith papyrus.

PMID: 22330033 [PubMed - in process]

Laparoscopic versus open distal gastrectomy for gastric cancer: a meta-analysis of randomized controlled trials and high-quality nonrandomized studies.

Ann Surg. 2012 Mar;255(3):446-56

Authors: Viñuela EF, Gonen M, Brennan MF, Coit DG, Strong VE

Abstract

OBJECTIVE: : To perform a meta-analysis of high-quality published trials, randomized and observational, comparing laparoscopic distal gastrectomy (LDG) and open distal gastrectomy (ODG) for gastric cancer.

BACKGROUND: : Controversy persists about the clinical utility of minimally invasive techniques for the treatment of gastric cancer. Prospective data is limited to a few small randomized trails.

METHODS: : Studies published from January 1992 to March 2010 that compare LDG and ODG were identified. No restrictions in pathologic stage were applied. All randomized controlled trials (RCTs) were included. Selection of high-quality, nonrandomized comparative studies (NRCTs) was based on a validated tool (Methodological Index for Nonrandomized Studies). Mortality, complications, harvested lymph nodes, operative time, blood loss, and hospital stay were compared using weighted mean differences (WMDs) and odds ratios (ORs).

RESULTS: : Twenty-five studies were included in the analyses, 6 RCTs and 19 NRCTs, compromising 3055 patients (1658 LDG, 1397 ODG). LDG was associated with longer operative times (WMD 48.3 minutes; P < 0.001) and lower overall complications (OR 0.59; P < 0.001), medical complications (OR 0.49; P = 0.002), minor surgical complications (OR 0.62; P = 0.001), estimated blood loss (WMD -118.9 mL; P < 0.001), and hospital stay (WMD -3.6 days; P < 0.001). Mortality and major complications were similar. Patients in the ODG group had a significantly higher number of lymph nodes harvested (WMD 3.9 nodes; P < 0.001), although the estimated proportion of patients with less than 15 retrieved nodes was similar (OR 1.26, P = 0.09).

CONCLUSIONS: : LDG can be performed safely with a shorter hospital stay and fewer complications than open surgery. The long-term significance of a difference of less than 5 nodes in the number of harvested lymph nodes remains unclear. Lymph node staging appears to be unaffected. These results need to be validated in Western patients with advanced gastric cancer.

PMID: 22330034 [PubMed - in process]

Defining the impact of resident participation on outcomes after appendectomy.

Ann Surg. 2012 Mar;255(3):577-82

Authors: Scarborough JE, Bennett KM, Pappas TN

Abstract

OBJECTIVE: : To determine whether resident participation impacts complication rates after appendectomy.

BACKGROUND: : The effect of resident participation on postoperative outcomes has not been well defined.

METHODS: : Data from the National Surgical Quality Improvement Program Participant User File from 2005 through 2009 were used to assess the association between resident participation during appendectomy and postoperative complication rates. Multivariate logistic regression analysis was used to adjust for patient comorbidity, surgical approach, and severity of appendiceal disease. Similar analyses were performed to determine whether outcomes after appendectomy are influenced by the postgraduate training level of the participating surgical resident.

RESULTS: : A total of 54,467 appendectomy procedures were included in our analysis. Resident participation was an independent risk factor for major complications [adjusted odds ratio 1.27 (95% CI 1.14-1.42), P < 0.0001] after appendectomy. Increasing seniority of the participating resident was associated with longer operative time and higher postoperative complications rates.

CONCLUSIONS: : Resident participation represents an independent risk factor for postoperative complications after appendectomy.

PMID: 22330035 [PubMed - in process]

High body mass index and smoking predict morbidity in breast cancer surgery: a multivariate analysis of 26,988 patients from the national surgical quality improvement program database.

Ann Surg. 2012 Mar;255(3):551-5

Authors: de Blacam C, Ogunleye AA, Momoh AO, Colakoglu S, Tobias AM, Sharma R, Houlihan MJ, Lee BT

Abstract

OBJECTIVE: : The purpose of this study was to examine the incidence of complications of breast cancer surgery in a multi-institutional, prospective, validated database and to identify preoperative risk factors that predispose to these complications.

BACKGROUND: : There is an increased emphasis on clinical outcomes to improve the quality of surgical care. Although mastectomy and breast conserving surgery have low risk for complications, few US studies have examined the incidence of these complications in large, multicenter patient populations. The broad scale of the National Surgical Quality Improvement Program (NSQIP) data set facilitates multivariate analysis of patient characteristics that predispose to development of postoperative complications in breast cancer surgery.

METHODS: : A prospective, multi-institutional study of patients undergoing mastectomy and breast conserving surgery was performed from the National Surgical Quality Improvement Program from 2005 to 2007. Study subjects were selected as a random sample of patients at more than 200 participating community and academic medical centers. Thirty-day morbidity was prospectively collected and the incidence of postoperative complications was determined, with particular emphasis on superficial and deep surgical site infections. Multivariate logistic regression was performed to identify independent risk factors for postoperative wound infections in each.

RESULTS: : A total of 26,988 patients were identified who underwent mastectomy (N = 10,471) and breast conserving surgery (N = 16,517). As expected, the overall 30-day morbidity rate for all procedures was low (5.6%), with significantly higher morbidity for mastectomies (4.0%) than breast conserving surgery (1.6%, P < 0.001). The most common complications in all procedures were superficial surgical site infections and deep surgical site infections. Independent risk factors for development of any wound infection in patients undergoing mastectomy were a high body mass index, smoking, and diabetes (ORs = 1.8, 1.6, 1.8). In patients who had a lumpectomy, a high body mass index, smoking, and a history of surgery within 90 days prior to this procedure (ORs = 1.7, 1.9, 2.0) were independent risk factors.

CONCLUSIONS: : Although complication rates in breast cancer surgery are low, wound infections remain the most common complication. A high body mass index and current tobacco use were the only independent risk factors for development of a postoperative wound infection across all procedures. This study highlights the benefit of a multi-institutional database in assessing risk factors for adverse outcomes in breast cancer surgery.

PMID: 22330036 [PubMed - in process]

Inferior allograft outcomes in adolescent recipients of renal transplants from ideal deceased donors.

Ann Surg. 2012 Mar;255(3):556-64

Authors: Levine MH, Reese PP, Wood A, Baluarte JH, Huverserian A, Naji A, Abt PL

Abstract

OBJECTIVE: : To measure the impact of the Share-35 policy on the allocation of ideal deceased donor kidneys and to examine the impact of age on outcomes after kidney transplantation using ideal donor kidneys.

BACKGROUND: : In the United States, through Share-35, transplant candidates aged 18 years or younger receive priority for the highest-quality deceased donor kidneys. Adolescent (15-18 years) kidney transplant recipients (KTRs), however, may be more susceptible to allograft loss due to elevated rates of acute rejection and a possible increased risk of primary renal disease recurrence.

METHODS: : We used registry data to perform a retrospective cohort study of 39,136 KTRs from January 1, 1994, to December 31, 2008. Ideal donors were defined as 2 to 34 years old with creatinine <1.5 mg/dL and absence of hypertension, diabetes, and hepatitis C.

RESULTS: : After Share-35, the percentage of ideal donor kidneys allocated to pediatric recipients increased from 7% to 16%. In multivariable Cox regression, compared with adolescent KTRs, all age strata except recipients older than 70 years had a lower risk of allograft failure (P < 0.01 for each comparison); results were similar after excluding KTRs with diseases at high risk of recurrence. Adolescent recipients had higher mortality rates than KTRs younger than 14 years, similar mortality compared with that of KTRs older than 18 and younger than 40 years, and lower mortality than KTRs older than 40 years.

CONCLUSIONS: : The allocation of “ideal donors” to adolescent recipients may not maximize graft utility. Reevaluation of pediatric allocation priority may offer opportunities to optimize ideal renal allograft survival.

PMID: 22330037 [PubMed - in process]

Right Portal Vein Ligation Combined With In Situ Splitting Induces Rapid Left Lateral Liver Lobe Hypertrophy Enabling 2-Staged Extended Right Hepatic Resection in Small-for-Size Settings.

Ann Surg. 2012 Mar;255(3):405-14

Authors: Schnitzbauer AA, Lang SA, Goessmann H, Nadalin S, Baumgart J, Farkas SA, Fichtner-Feigl S, Lorf T, Goralcyk A, Hörbelt R, Kroemer A, Loss M, Rümmele P, Scherer MN, Padberg W, Königsrainer A, Lang H, Obed A, Schlitt HJ

Abstract

OBJECTIVE: : To evaluate a new 2-step technique for obtaining adequate but short-term parenchymal hypertrophy in oncologic patients requiring extended right hepatic resection with limited functional reserve.

BACKGROUND: : Patients presenting with primary or metastatic liver tumors often face the dilemma that the remaining liver tissue may not be sufficient. Preoperative portal vein embolization has thus far been established as the standard procedure for achieving resectability.

METHODS: : Two-staged hepatectomy was performed in patients who preoperatively appeared to be marginally resectable but had a tumor-free left lateral lobe. Marginal respectability was defined as a left lateral lobe to body weight ratio of less than 0.5. In the first step, surgical exploration, right portal vein ligation (PVL), and in situ splitting (ISS) of the liver parenchyma along the falciform ligament were performed. Computed tomographic volumetry was performed before ISS and before completion surgery.

RESULTS: : The study included 25 patients with primary liver tumors (hepatocellular carcinoma: n = 3, intrahepatic cholangiocarcinoma: n = 2, extrahepatic cholangiocarcinoma: n = 2, malignant epithelioid hemangioendothelioma: n = 1, gallbladder cancer: n = 1 or metastatic disease [colorectal liver metastasis]: n = 14, ovarian cancer: n = 1, gastric cancer: n = 1). Preoperative CT volumetry of the left lateral lobe showed 310 mL in median (range = 197-444 mL). After a median waiting period of 9 days (range = 5-28 days), the volume of the left lateral lobe had increased to 536 mL (range = 273-881 mL), representing a median volume increase of 74% (range = 21%-192%) (P < 0.001). The median left lateral liver lobe to body weight ratio was increased from 0.38% (range = 0.25%-0.49%) to 0.61% (range = 0.35-0.95). Ten of 25 patients (40%) required biliary reconstruction with hepaticojejunostomy. Rapid perioperative recovery was reflected by normalization of International normalized ratio (INR) (80% of patients), creatinine (84% of patients), nearly normal bilirubin (56% of patients), and albumin (64% of patients) values by day 14 after completion surgery. Perioperative morbidity was classified according to the Dindo-Clavien classification of surgical complications: grade I (12 events), grade II (13 events), grade III (14 events, III a: 6 events, III b: 8 events), grade IV (8 events, IV a: 3 events, IV b: 5 events), and grade V (3 events). Sixteen patients (68%) experienced perioperative complications. Follow-up was 180 days in median (range: 60-776 days) with an estimated overall survival of 86% at 6 months after resection.

CONCLUSIONS: : Two-step hepatic resection performing surgical exploration, PVL, and ISS results in a marked and rapid hypertrophy of functional liver tissue and enables curative resection of marginally resectable liver tumors or metastases in patients that might otherwise be regarded as palliative.

PMID: 22330038 [PubMed - in process]

Playing Play-Doh to Prevent Postoperative Liver Failure: The “ALPPS” approach.

Ann Surg. 2012 Mar;255(3):415-7

Authors: de Santibañes E, Clavien PA

PMID: 22330039 [PubMed - in process]

Comparison of a Lymph Node Ratio-Based Staging System With the 7th AJCC System for Gastric Cancer: Analysis of 18,043 Patients From the SEER Database.

Ann Surg. 2012 Mar;255(3):478-85

Authors: Wang J, Dang P, Raut CP, Pandalai PK, Maduekwe UN, Rattner DW, Lauwers GY, Yoon SS

Abstract

OBJECTIVES: : The American Joint Committee on Cancer (AJCC) staging system for gastric cancer bases N status on absolute number of metastatic nodes, regardless of the number of examined nodes. We examined a modified staging system utilizing node ratio (Nr), the ratio of metastatic to examined nodes.

METHODS: : A total of 18,043 gastric cancer patients who underwent gastrectomy were identified from the US Surveillance, Epidemiology, and End Results (SEER) database. A training set was divided into 5 Nr groups, and a TNrM staging system was constructed. Median survival and overall survival, based on 7th edition AJCC and TNrM staging systems, were compared, and the analysis was repeated in a validation set.

RESULTS: : Median examined nodes were 10 to 11. For the training set, overall survival for all 5 AJCC N categories was significantly different when subgrouped into 15 or fewer versus more than 15 examined nodes, but overall survival was similar regardless of the number of examined nodes in 4 of 5 Nr categories. Seven AJCC stages had statistically different overall survival between subgroups, whereas only 1 TNrM stage had statistically different overall survival between subgroups. When misclassification was defined as any subgroup in which median survival fell outside the 95% confidence interval of the group’s overall median survival, AJCC staging misclassified 57% of patients and TNrM staging misclassified only 12%. Similar results were found in the validation set.

CONCLUSIONS: : The AJCC system classifies SEER gastric cancer patients into stages in which subgroups often have wide variations in survival. For patients undergoing limited lymph node analysis, the proposed TNrM system may predict survival more accurately.

PMID: 22330040 [PubMed - in process]

Multivariate analysis of risk factors for pulmonary complications after hepatic resection.

Ann Surg. 2012 Mar;255(3):540-50

Authors: Nobili C, Marzano E, Oussoultzoglou E, Rosso E, Addeo P, Bachellier P, Jaeck D, Pessaux P

Abstract

OBJECTIVE: : To generate the first evaluation of risk factors for postoperative pulmonary complications (PPCs) after hepatectomy.

BACKGROUND: : Postoperative pulmonary complications (PPCs) after surgery are associated with significant morbidity and have been shown to increase the length of hospital stays. Several studies have been conducted to identify the risk factors for PPCs after abdominal surgery.

METHODS: : Between January 2006 and December 2009, 555 patients underwent elective hepatectomy. We prospectively collected and retrospectively analyzed demographic data, pathological variables, associated pathological conditions, and preoperative, intraoperative, and postoperative variables. The dependent variables studied were the occurrence of PPCs, pleural effusion, pneumonia, and pulmonary embolism.

RESULTS: : Multivariate analysis identified 5 independent risk factors for global PPCs: prolonged surgery [odds ratio (OR) = 1], presence of a nasogastric tube (OR = 1.6), intraoperative blood transfusion (OR = 1.7), diabetes mellitus (OR = 2.7), and a transverse subcostal bilateral muscle cutting incision (OR = 3.4). There were 4 independent risk factors for pleural effusion: prolonged surgery (OR = 1), surgery on the right lobe of the liver (OR = 1.6), neoadjuvant chemotherapy (OR = 2), and a transverse subcostal bilateral muscle cutting incision (OR = 2.5). There were 3 independent risk factors for pneumonia: intraoperative blood transfusion (OR = 1.9), diabetes mellitus (OR = 2.2), and atrial fibrillation (OR = 3). For pulmonary embolism, history of previous thromboembolic events was identified as the only risk factor (OR = 8.8).

CONCLUSIONS: : The correction of modifiable risk factors among the identified factors could reduce the incidence of PPCs and, as a consequence, improve patient outcomes and reduce the length of hospital stays.

PMID: 22330041 [PubMed - in process]

Appendectomy by Residents Is Safe and Not Associated With a Higher Incidence of Complications: A Retrospective Cohort Study.

Ann Surg. 2012 Feb 24;

Authors: Graat LJ, Bosma E, Roukema JA, Heisterkamp J

Abstract

OBJECTIVE:: The purpose of this retrospective cohort study was to investigate whether current practice where residents perform appendectomies affects quality of care. Therefore, we investigated whether there was a difference in incidence of complications and mortality in appendectomies performed by surgeons (S), supervised residents (SR), or unsupervised residents (UR). BACKGROUND:: Appendicitis is among the most frequent conditions requiring urgent surgery. Admittance and surgery are often managed by residents. Recent studies have shown that laparoscopic appendectomy can be safely performed by residents. It is not known whether these results are applicable on appendectomies in general. METHODS:: All patients undergoing appendectomy in our hospital between January 1, 2000, and December 31, 2009, were included in the analysis. Patients undergoing appendectomy by surgeons, supervised residents, and unsupervised residents were compared. Primary endpoints were complications and mortality. RESULTS:: During the study period, 1538 patients were operated. The risk of complications (S: 20% vs SR: 17% vs UR: 16%; P = 0.209, S vs SR; P = 0.149, S vs UR; and P = 0.872, SR vs UR) and mortality (S: 0.3% vs SR: 0.2% vs UR: 0.4%, P = 1.000 for all comparisons) were similar in all groups. In the multivariate model, the odds ratio for complications in the group operated by supervised residents was 0.84 (95% CI: 0.58-1.22, P = 0.357) versus 0.81 (95% CI: 0.55-1.18, P = 0.265) in the unsupervised residents’ group. CONCLUSIONS:: Current practice where residents perform appendectomies either unsupervised or supervised by an experienced surgeon should not be discouraged. We found that it is safe and does not lead to more complications or negatively affect quality of care.

PMID: 22367440 [PubMed - as supplied by publisher]

Surgery in Castleman’s Disease: A Systematic Review of 404 Published Cases.

Ann Surg. 2012 Feb 24;

Authors: Talat N, Belgaumkar AP, Schulte KM

Abstract

OBJECTIVES:: We undertook a systematic review of 404 published cases of Castleman’s disease to identify the role of the surgeon beyond assistance in tissue-based diagnosis. BACKGROUND:: Castleman’s disease is a rare primary disease of the lymph node caused by infection with herpesviridae. Little is known about the role of surgery in this condition. DATA SOURCES:: Medline, Embase, Cochrane Database of Systematic Reviews, ISI Thompson Web of Knowledge, and hand search of articles’ bibliography. STUDY SELECTION:: Of the 1791 citations identified through the initial electronic search and screened for possible inclusion, 488 articles were retained after title and abstract reviews. Of these, 239 were accepted for this review. DATA EXTRACTION:: A complete dataset containing age, gender, centricity (unicentric vs multicentric), histopathologic type (hyaline vascular [HV] vs plasma cell [PC]), anatomical location of the only focus in unicentric Castleman’s disease (UCD) or the dominant focus in multicentric Castleman’s disease (MCD), nature of the surgical approach (resective vs diagnostic), and outcome (disease-free survival [DFS] vs death due to disease) was extracted. RESULTS:: A resective or debulking surgical approach was described in 77.0% of all patients, but was far more common in unicentric (262/278; 94.2%) than multicentric (49/126; 38.9%) disease (χ 146.8; P < 0.0001). Unicentric disease had a significantly higher overall survival (95.3% vs 61.1%; χ 55.7; P < 0.0001), 3 year DFS (89.7% vs 55.6%; χ 27.8; P < 0.0001), and 5 year DFS (81.2% vs 34.4%; χ 28.6; P < 0.0001) than multicentric disease. Failure to treat unicentric disease by resective surgery resulted in a significant mortality (17.6% vs 3.8% χ; P < 0.05). In multicentric disease, outcomes are comparable between debulking surgery alone, immunochemotherapy alone, or a combination of both (28.0% vs 28.9% vs 50.0%; P = nonsignificant). CONCLUSIONS:: Surgery is the gold standard for treatment of unicentric Castelman’s disease. The role of debulking surgery in human immunodeficiency virus (-) MCD needs to be evaluated in prospective studies.

PMID: 22367441 [PubMed - as supplied by publisher]

Association Between Hospital Intraoperative Blood Transfusion Practices for Surgical Blood Loss and Hospital Surgical Mortality Rates.

Ann Surg. 2012 Feb 24;

Authors: Wu WC, Trivedi A, Friedmann PD, Henderson WG, Smith TS, Poses RM, Uttley G, Vezeridis M, Eaton CB, Mor V

Abstract

OBJECTIVE:: Blood loss during surgery is an important operative complication in patients undergoing major noncardiac surgery and may increase postoperative morbidity and mortality. Variations in the delivery of operative blood transfusions to treat blood loss depend not only on the patient and surgery characteristics but also on the hospital transfusion practices, and may explain differences in the hospitals’ postoperative outcomes. We determine the relationship between hospital-level rates of intraoperative blood transfusion and 30-day mortality among older patients with significant intraoperative blood loss. METHODS:: Among 46,608 operative patients aged 65 years or older whose estimated blood loss was 500 mL or greater in 122 Veterans Affairs (VA) hospitals during years 1997 to 2004, we examined the relationship between hospital-level transfusion rates and adjusted 30-day postoperative mortality rates using linear regression modeling. RESULTS:: Hospital-level rates of intraoperative blood transfusion for older surgical patients with significant blood loss varied from 10% to 92%. Hospitals in the highest tertile for the rate of intraoperative transfusion had the highest number of patients with 500 mL or more surgical blood loss and lowest risk-adjusted 30-day surgical mortality. For every 10% increase in the rate of intraoperative blood transfusion, there was a 0.7% (95% CI: 0.3%-1.1%) decrease in the hospital’s adjusted 30-day postoperative mortality for these high-risk patients. CONCLUSIONS:: Large variation exists in hospitals’ intraoperative blood transfusion practices for older patients with significant surgical blood loss. Hospitals with higher transfusion rates for patients with significant surgical blood loss have lower adjusted 30-day mortality for these patients. Hospital intraoperative blood transfusion practices may be a promising surgical quality indicator.

PMID: 22367442 [PubMed - as supplied by publisher]

Cost-effectiveness of Adding FDG-PET or CT to the Diagnostic Work-up of Patients With Stage III Melanoma.

Ann Surg. 2012 Feb 24;

Authors: Bastiaannet E, Uyl-de Groot CA, Brouwers AH, van der Jagt EJ, Hoekstra OS, Oyen W, Verzijlbergen F, van Ooijen B, Thompson JF, Hoekstra HJ

Abstract

OBJECTIVE:: The aim of this prospective study was to assess predictive value of fludeoxyglucose-positron emission tomography (FDG-PET) and computed tomography (CT) and to analyze their cost-effectiveness in several diagnosis-treatment combinations. BACKGROUND:: The incidence of melanoma continues to rise. A proportion will present or recur with lymph node metastases (American Joint Committee on Cancer/Union for International Cancer Control stage III). To detect distant metastases, CT and/or FDG-PET are available. However, few studies have assessed their value and costs in stage III. METHODS:: All consecutive patients with melanoma with palpable, proven lymph node metastases (2003-2008) referred for examination with FDG-PET and CT were prospectively included. Sensitivity, specificity, and accuracy, and positive predictive value (PPV) and negative predictive value (NPV) were calculated. In economic evaluation, the costs of diagnostic work-up with and without FDG-PET and CT were compared. RESULTS:: Overall, 253 patients with melanoma were included. FDG-PET showed a higher sensitivity than CT: 86.1% compared with 78.2%. Specificity was higher for CT (93.7%) compared with FDG-PET (93.1%). Overall, FDG-PET showed a higher PPV and NPV. Cost-consequence analysis showed that adding CT (True-Positive upstaging in 61 patients) to diagnostic work-up decreased cost by 5.5%, adding FDG-PET (True-Positive upstaging in 68 patients) increased cost by 7.2%, and adding both (True-Positive upstaging in 78 patients) increased cost by 15.1%. CONCLUSIONS:: In this study, FDG-PET had higher sensitivity and predictive value, whereas CT had a higher specificity. Adding one of these diagnostic tools improved the staging of stage III patients with less than 10% cost increase. A proposal for stage-specific use of imaging modalities for clinicians caring for patients with melanoma is presented.

PMID: 22367443 [PubMed - as supplied by publisher]

Clinical Significance of Left Trisectionectomy for Perihilar Cholangiocarcinoma: An Appraisal and Comparison With Left Hepatectomy.

Ann Surg. 2012 Feb 24;

Authors: Natsume S, Ebata T, Yokoyama Y, Igami T, Sugawara G, Shimoyama Y, Nagino M

Abstract

OBJECTIVE:: To review our experiences with left-sided hepatectomy for perihilar cholangiocarcinoma, to compare left hepatectomy with left trisectionectomy, and to evaluate the clinical significance of left trisectionectomy from the viewpoint of surgical oncology. BACKGROUND:: Only 4 large case series have been reported on left trisectionectomy, with only a few patients diagnosed with perihilar cholangiocarcinoma. Therefore, the oncologic advantage of left trisectionectomy compared with left hepatectomy for perihilar cholangiocarcinoma is still unclear. METHODS:: This study involved 201 patients who underwent left-sided hepatectomy for perihilar cholangiocarcinoma (86 trisectionectomies and 115 hepatectomies). Surgical outcome and survival were compared between the 2 types of hepatectomy. The length of the resected right posterior bile duct was also measured. RESULTS:: Patients who underwent trisectionectomy had more advanced tumors, thus requiring combined vascular and/or other organ resection. Operative time and blood loss were significantly greater in trisectionectomy than in hepatectomy; therefore, overall morbidity was significantly higher in the former (59.3% vs 33.0%, P < 0.001). Mortality was similar (1.2% vs 0.9%) in both techniques. The length of the resected supraportal right posterior bile duct was significantly longer in trisectionectomy than in hepatectomy (20.7 ± 6.4 vs 13.6 ± 5.2 mm, P < 0.001). However, there was no difference in length of the infraportal type right posterior bile duct. The percentage of negative radial and distal common bile duct margins was similar, but the percentage of negative right posterior bile duct margins was significantly higher in trisectionectomy than in hepatectomy (97.7% vs 89.6%, P = 0.027). Overall, R0 resection was achieved in 84.9% of patients with trisectionectomy and in 70.4% of patients with hepatectomy (P = 0.019). Survival rates were similar between patients with trisectionectomy and those with hepatectomy (36.8% vs 34.0% at 5-year), despite the fact that the former had more advanced disease. CONCLUSIONS:: Left trisectionectomy for perihilar cholangiocarcinoma, although technically demanding, can be performed with similar mortality rates as left hepatectomy. From an oncologic viewpoint, this operation can increase the number of negative proximal ductal margins, leading to a high proportion of R0 resection, and, in turn, to improved survival rates of patients with advanced left-sided perihilar cholangiocarcinoma.

PMID: 22367444 [PubMed - as supplied by publisher]

Open Versus Laparoscopic Resection of Primary Tumor for Incurable Stage IV Colorectal Cancer: A Large Multicenter Consecutive Patients Cohort Study.

Ann Surg. 2012 Feb 24;

Authors: Hida K, Hasegawa S, Kinjo Y, Yoshimura K, Inomata M, Ito M, Fukunaga Y, Kanazawa A, Idani H, Sakai Y, Watanabe ,

Abstract

OBJECTIVE:: To investigate the hypothesis that laparoscopic primary tumor resection is safe and effective when compared with the open approach for colorectal cancer patients with incurable metastases. BACKGROUND:: There are only a few reports with small numbers of patients on laparoscopic tumor resection for stage IV colorectal cancer. METHODS:: Data from consecutive patients who underwent palliative primary tumor resection for stage IV colorectal cancer between January 2006 and December 2007 were collected retrospectively from 41 institutions. Short- and long-term outcomes were compared between patients who underwent laparoscopic or open resection. RESULTS:: A total of 904 patients (laparoscopic group: 226, open group: 678) with a median age of 64 years (range: 22-95) were included in the analysis. Conversion was required in 28 patients (12.4%) and the most common reasons for conversion (23/28: 82%) were bulky or invasive tumors. There was no 30-day postoperative mortality in either group. The complication rate (NCI-CTCAE grade 2-4) after laparoscopic surgery (17%) was significantly lower than that after open surgery (24%) (P = 0.02), and the difference was greater (4% vs 12%; P < 0.001) when we limited the analysis to severe (≥grade 3) complications. The median length of postoperative hospital stay in the laparoscopic group was significantly shorter than that in the open group (14 vs 17 days; P = 0.002). In univariate analysis, overall survival for the laparoscopic group was significantly better than that for open surgery (median survival time: 25.9 vs 22.3 months, P = 0.04), although no difference was apparent in multivariate analysis. CONCLUSIONS:: Compared with open surgery, laparoscopic primary tumor resection has advantages in the short term and no disadvantages in the long term. It is a reasonable treatment option for certain stage IV colorectal cancer patients with incurable disease.

PMID: 22367445 [PubMed - as supplied by publisher]

Observational Teamwork Assessment for Surgery: Feasibility of Clinical and NonClinical Assessor Calibration With Short-Term Training.

Ann Surg. 2012 Feb 24;

Authors: Russ S, Hull L, Rout S, Vincent C, Darzi A, Sevdalis N

Abstract

OBJECTIVES:: To assess the feasibility of training clinical and nonclinical novice assessors to rate teamwork behavior in the operating room with short-term structured training using the observational teamwork assessment for surgery (OTAS) tool. BACKGROUND:: Effective teamwork is fundamental to the delivery of optimal patient care in the operating room (OR). OTAS provides a comprehensive and robust measure of teamwork in surgery. To date, assessors with a background in psychology/human factors have been shown to be able to use OTAS reliably after training. However, the feasibility of observer training over a short timescale and accessibility to the wider clinical community (ie, OTAS use by clinicians) are yet to be empirically demonstrated. METHODS:: Ten general surgery cases were observed and assessed using OTAS in real-time by an expert in rating OTAS behaviors (100+ cases rated) and 4 novices: 2 psychologists and 2 surgeons. Assessors were blinded to each other’s scores during observations. After each observation, scores were compared and discussed between expert and novice assessors in a debriefing session. RESULTS:: All novices were reliable with the expert to a acceptable degree at rating all OTAS behaviors by the end of training (intraclass correlation coefficients ≥0.68). For 3 of the 5 behaviors (communication, cooperation, and leadership), calibration improved most rapidly across the first 7 observed cases. For monitoring/situational awareness, calibration improved steadily across the 10 observed cases. For coordination, no significant improvement in calibration over time was observed because of high interrater reliability from the outset (ie, a ceiling effect). There was no significant difference between surgeons and psychologists in their calibration with the expert. CONCLUSIONS:: It is feasible to train both clinicians and nonclinicians to use OTAS to assess teamwork behaviors in ORs over a short structured training period. OTAS is an accessible tool that can be used robustly (ie, reliably) by assessors from both clinical and nonclinical backgrounds.

PMID: 22367446 [PubMed - as supplied by publisher]

A Proposal for Enhancing the General Surgical Workforce and Access to Surgical Care.

Ann Surg. 2012 Feb 24;

Authors: Polk HC, Bland KI, Ellison EC, Grosfeld J, Trunkey DD, Stain SC, Townsend CM

Abstract

OBJECTIVE(S):: The goals of this focused meeting were to verify and clarify the causes and extent of the general surgery (GS) workforce shortfalls. We also sought to define workable solutions within the existing framework of medical accreditation and certification. BACKGROUND:: Numerous peer-reviewed and lay reports describe a current and worsening availability of GS services, affecting rural areas as well as large cities, academia, and the military. METHOD:: Primary recommendations were broadly agreed upon by attendee surgeons who were selected from numerous different professional scenarios and included 2 nonmedical observers. RESULTS:: Recommendations: (1) enhance the number of GS trainees and the breadth of training, (2) incorporate more flexibility and breadth in residency, (3) minimally invasive surgery should largely return to GS, (4) broader use of community hospitals in these efforts, (5) publicize loan forgiveness and improved visa status for international medical graduates going into GS, and (6) select candidates with a bias toward a general surgical career. CONCLUSION:: These methods are promising approaches to this serious deficiency but will require regular reporting and publicity for the recording of actual increases in GS output.

PMID: 22367447 [PubMed - as supplied by publisher]

Circulating Intestinal Fatty Acid-Binding Protein as an Early Marker of Intestinal Necrosis After Aortic Surgery: A Prospective Observational Cohort Study.

Ann Surg. 2012 Feb 24;

Authors: Vermeulen Windsant IC, Hellenthal FA, Derikx JP, Prins MH, Buurman WA, Jacobs MJ, Schurink GW

Abstract

OBJECTIVE:: This study evaluated the usefulness of plasma intestinal fatty-acid binding protein (IFABP) levels in the early identification of intestinal necrosis (IN) in patients undergoing different types of aortic surgery. BACKGROUND:: Intestinal compromise greatly contributes to postoperative adverse outcome. IN is the most detrimental form of intestinal compromise and is notoriously difficult to diagnose. IFABP is a small protein exclusively expressed by mature enterocytes and a promising marker of intestinal damage. METHODS:: Plasma IFABP concentrations were measured in blood samples taken perioperatively from 55 patients undergoing open thoracic or thoracoabdominal aneurysm repair [OR-TAA(A)], 25 patients undergoing conventional open abdominal aneurysm repair (OR-abdominal aortic aneurysm [AAA]), and 16 patients undergoing endovascular aneurysm repair (EVAR). Data were compared with perioperative changes in arterial pH and serum lactate levels. RESULTS:: IFABP levels increased in all patients undergoing OR-TAA(A) and OR-AAA reaching peak levels shortly after surgery; 281 ± 33 to 2,298 ± 490 pg/mL (P < 0.001) and 187 ± 31 to 641 ± 176 pg/mL (P < 0.05) respectively. IFABP levels were significantly higher in patients undergoing OR-TAA(A) (P < 0.001). IFABP levels in EVAR patients remained at baseline concentrations throughout the study. Four patients [2 OR-AAA, 2 OR-TAA(A)] developed fatal postoperative intestinal ischemia on day 2 or 3. High levels of plasma IFABP at the end of surgery had 100% sensitivity and 98.1% specificity for the identification of patients developing IN. In OR-AAA patients, arterial pH and lactate levels were of additional discriminating value. Complete discrimination between patients with and without IN using plasma IFABP could be made on the first postoperative day. CONCLUSIONS:: Analysis of plasma IFABP levels is of additional value to other current plasma markers in the diagnosis of IN, and it enables early identification of patients with IN after aortic surgery days before clinical diagnosis.

PMID: 22367448 [PubMed - as supplied by publisher]

The Health and Well-Being of American Surgery.

Ann Surg. 2012 Feb 24;

Authors: Kuerer HM, Holleman WL

PMID: 22367449 [PubMed - as supplied by publisher]

Overcoming Obstacles To Resident-Patient Continuity of Care.

Ann Surg. 2012 Feb 3;

Authors: Turner JP, Rodriguez HE, Daskin MS, Mehrotra S, Speicher P, Darosa DA

Abstract

OBJECTIVE:: Because continuity of care (CC) is a necessary component of resident education, this analysis was done to understand what keeps CC between residents and patients low and how it can be most effectively improved. BACKGROUND:: Many authors lament low CC between residents and patients, especially in the era of duty hour regulations. Some have tried lengthening rotations, some have tried increasing clinic attendance, and some have argued for various training models. Little detailed analysis has been done to identify root causes of low CC or ways to improve it. METHODS:: Two months of charts were reviewed to estimate baseline CC on a vascular surgery rotation. Probability theory and engineering simulations were used to determine whether CC can be enhanced by (a) lengthening rotations, (b) altering observed logistical patterns, (c) using a “resident return” model where residents are able to see patients postoperatively even if moved to a different rotation, or (d) employing an apprenticeship model. RESULTS:: Baseline analysis showed residents had 0% CC given 131 opportunities to do so. Probability analysis and the simulation outcomes suggest that rotation length plays a minor role in achieving CC. Logistical changes showed some improvement in CC, but not as much as using an apprenticeship rotation model. CONCLUSIONS:: The limitations placed on CC by rotation duration are real, but lengthening the rotation does not meaningfully resolve the gap between acceptable CC levels and actual levels. Although CC can be enhanced with longer rotations if coupled with the use of the resident return model, the greater barrier to CC is the logistical patterns such as where residents spend time, how cases are assigned, and the lack of an alert system to inform residents about returning postoperative patients. The apprenticeship model enables residents to achieve CC closer to that of the faculty.

PMID: 22311130 [PubMed - as supplied by publisher]

“Inherent Limitations” in Donors: Control Matched Study of Consequences Following a Right Hepatectomy for the Living Donation and Benign Liver Lesions.

Ann Surg. 2012 Feb 3;

Authors: Belghiti J, Liddo G, Raut V, Zappa M, Dokmak S, Vilgrain V, Durand F, Dondéro F

Abstract

OBJECTIVE:: The aim of this study was to identify “inherent limitations” in healthy donors who are responsible for donor morbidity after right hepatectomy (RH) for adult-to-adult living donor liver transplantation (ALDLT). BACKGROUND:: Right hepatectomy for ALDLT remains a challenging procedure without significant improvement in morbidity over time. This suggests some “inherent limitations” in healthy individuals, which are beyond the recent improvements in the donor evaluation and selection process and refinements in surgical technique during the learning curve. METHODS:: To identify response of RH in ALDLT, we prospectively studied 32 patients requiring an RH for benign liver lesions (BL), matched with 32 living donors (LD) operated by same team. All patients underwent liver volume evaluation by computed tomographic (CT) volumetry preoperatively and 1 week after RH, postoperative complications graded with Clavien’s system. RESULTS:: The comparison (LD vs BL) showed that remnant liver volume (RLV) on preoperative CT volumetry was higher in the BL group (450 ± 150 vs 646 ± 200 mL, P < 0.001) representing 31% ± 7% in LD group versus 36% ± 7% of the total liver volume in BL group (P = 0.03). On postoperative day 7, the RLV was similar in the 2 groups (866 ± 162 vs 941 ± 153 mL) resulting from a significantly higher regeneration rate in the LD group (89% vs 55%, P = 0.009). Overall complications rate was lower in the BL group (46% vs 21%, P = 0.035). CONCLUSIONS:: Right hepatectomy in LDLT induces a more severe deprivation of liver volume than in BL, which induce an accelerated regeneration. Accelerated regeneration could represent “inherent limitation” in healthy donors that makes them more vulnerable for postoperative complications.

PMID: 22311131 [PubMed - as supplied by publisher]

Letter to the Editor.

Ann Surg. 2012 Feb 3;

Authors: Haut ER, Kalish BT, Cotton BA, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE, Chang DC

PMID: 22311132 [PubMed - as supplied by publisher]

Differentiation of Biologic Scaffold Materials Through Physicomechanical, Thermal, and Enzymatic Degradation Techniques.

Ann Surg. 2012 Feb 4;

Authors: Deeken CR, Eliason BJ, Pichert MD, Grant SA, Frisella MM, Matthews BD

Abstract

OBJECTIVE:: The objective of this study was to characterize the physicomechanical, thermal, and degradation properties of several types of biologic scaffold materials to differentiate between the various materials. BACKGROUND:: As more biologic scaffold materials arrive on the market, it is critical that surgeons understand the properties of each material and are provided with resources to determine the suitability of these products for specific applications such as hernia repair. METHODS:: Twelve biologic scaffold materials were evaluated, including crosslinked and non-crosslinked; those of bovine, human, and porcine origin; and derivatives of pericardium, dermis, and small intestine submucosa. Physicomechanical, thermal, and degradation properties were evaluated through biomechanical testing, modulated differential scanning calorimetry, and collagenase digestion assays, respectively. Biomechanical testing included suture retention, tear strength, uniaxial tensile, and ball burst techniques. RESULTS:: All scaffolds exhibited suture retention strengths greater than 20 N, but only half of the scaffolds exhibited tear resistance greater than 20 N, indicating that some scaffolds may not provide adequate resistance to tearing. A wide range of burst strengths were observed ranging from 66.2 ± 10.8 N/cm for Permacol to 1,028.0 ± 199.1 N/cm for X-Thick AlloDerm, and all scaffolds except SurgiMend, Strattice, and CollaMend exhibited strains in the physiological range of 10% to 30% (at a stress of 16 N/cm). Thermal analysis revealed differences between crosslinked and non-crosslinked materials with crosslinked bovine pericardium and porcine dermis materials exhibiting a higher melting temperature than their non-crosslinked counterparts. Similarly, the collagenase digestion assay revealed that crosslinked bovine pericardium materials resisted enzymatic degradation significantly longer than non-crosslinked bovine pericardium. CONCLUSIONS:: Although differences were observed because of cross-linking, some crosslinked and non-crosslinked materials exhibited very similar properties. Variables other than cross-linking, such as decellularization/sterilization treatments or species/tissue type also contribute to the properties of the scaffolds.

PMID: 22314328 [PubMed - as supplied by publisher]

Predictive Factors for the Benefit of Perioperative FOLFOX for Resectable Liver Metastasis in Colorectal Cancer Patients (EORTC Intergroup Trial 40983).

Ann Surg. 2012 Feb 4;

Authors: Sorbye H, Mauer M, Gruenberger T, Glimelius B, Poston GJ, Schlag PM, Rougier P, Bechstein WO, Primrose JN, Walpole ET, Finch-Jones M, Jaeck D, Mirza D, Parks RW, Collette L, Cutsem EV, Scheithauer W, Lutz MP, Nordlinger B

Abstract

OBJECTIVE:: In EORTC study 40983, perioperative FOLFOX increased progression-free survival (PFS) compared with surgery alone for patients with initially 1 to 4 resectable liver metastases from colorectal cancer (CRC). We conducted an exploratory retrospective analysis to identify baseline factors possibly predictive for a benefit of perioperative FOLFOX on PFS. METHODS:: The analysis was based on 237 events from 342 eligible patients. Cox proportional hazards regression models with a significance level of 0.1 were used to build up univariate and multivariate models. RESULTS:: After adjustment for identified prognostic factors, moderately (5.1-30 ng/mL) and highly (>30 ng/mL) elevated carcinoembryonic antigen (CEA) serum levels were both predictive for the benefit of perioperative chemotherapy (interaction P = 0.07; hazard ratio [HR] = 0.58 and HR = 0.52 for treatment benefit). For patients with moderately or highly elevated CEA (>5 ng/mL), the 3-year PFS was 35% with perioperative chemotherapy compared to 20% with surgery alone. Performance status (PS) 0 and BMI lower than 30 were also predictive for the benefit of perioperative chemotherapy (interaction P = 0.04 and P = 0.02). However, the number of patients with PS 1 and BMI 30 or higher were limited. The benefit of perioperative therapy was not influenced by the number of metastatic lesions (1 vs 2-4, interaction HR = 0.98). CONCLUSIONS:: Perioperative FOLFOX seems to benefit in particular patients with resectable liver metastases from CRC when CEA is elevated and when PS is unaffected, regardless of the number of metastatic lesions.ClinicalTrials.gov number NCT00006479.

PMID: 22314329 [PubMed - as supplied by publisher]

Letter to the Editor.

Ann Surg. 2012 Feb 4;

Authors: Rivkind AI, Ganor O, Glassberg E

PMID: 22314330 [PubMed - as supplied by publisher]

Asian Americans in Leadership Positions in Academic Surgery.

Ann Surg. 2012 Feb 7;

Authors: Nakayama DK

Abstract

OBJECTIVE:: To examine Asian American (Chinese, Japanese, Korean, Indian subcontinent, Southeast Asian, Philippine and South Pacific Islands, and Middle East) representation in national organizations and editorial boards important in US academic surgery. BACKGROUND:: Asian Americans are overrepresented in academic departments of surgery relative to their demographic proportion of US population. Not examined is their involvement in leadership positions in the field. STUDY DESIGN:: Current rosters were surveyed for surgeons with Asian American surnames with federally supported research, members of leading surgical specialty organizations, residency review committees for surgical specialties, surgical boards of the American Board of Medical Specialties, and editorial boards of leading surgical journals. RESULTS:: Asian Americans are principal investigators in 18.9% of National Institutes of Health-supported grants in departments of surgery, and 7.7% of Society of University Surgeons and 3.2% of American Surgical Association memberships. Asian American representation on governing boards of professional organizations is only 2.3%, and none on the Boards of Regents of the American College of Surgeons, the various American Board of Medical Specialties surgical boards and councils, the residency review committees for surgery, and governing councils of 7 of 10 professional organizations. Of 302 US surgeons on the editorial boards of 5 leading surgical journals, 6 were Asian Americans (2.0%). CONCLUSIONS:: Asian American academic surgeons are absent from the governing boards of surgical organizations and peer-reviewed surgical journals, a situation that mentorship and the development of effective social networks though an Asian American surgeons’ association may correct.

PMID: 22317962 [PubMed - as supplied by publisher]

Publications, Public Policy, and Scientific Opportunity: A Few Personal Thoughts.

Ann Surg. 2012 Feb 7;

Authors: Niederhuber JE

PMID: 22317963 [PubMed - as supplied by publisher]

Mortality of Intra-Abdominal Desmoid Tumors in Patients With Familial Adenomatous Polyposis: A Single Center Review of 154 Patients.

Ann Surg. 2012 Feb 8;

Authors: Quintini C, Ward G, Shatnawei A, Xhaja X, Hashimoto K, Steiger E, Hammel J, Diago Uso T, Burke CA, Church JM

Abstract

INTRODUCTION:: Intra-abdominal desmoid tumors are one of the leading causes of death in patients with familial adenomatous polyposis. Their behavior is unpredictable and their biology is poorly understood, accounting for the lack of a standardized medical and surgical approach. The aim of this study was to evaluate the mortality rate of patients with intra-abdominal desmoid tumors and to identify prognostic factors for the evolution of the disease. MATERIALS AND METHODS:: A total of 154 patients with intra-abdominal desmoid tumors were included in the study. Each tumor was staged and each patient was categorized according to the stage of their most advanced tumor. Mortality was analyzed and the univariate risk factors associated with survival were included in a multivariable Cox regression model. A scoring system was derived from the multivariate analysis to refine outcomes within stages. RESULTS:: Five-year survival of patients with stage I, II, III, and IV intra-abdominal desmoid tumor were 95%, 100%, 89%, and 76% respectively (P < 0.001). Severe pain/narcotic dependency, tumor size larger than 10 cm, and need for total parenteral nutrition were shown to further define survival within stages. Five-year survival rate of stage IV patient with all of the above-mentioned risk factors was only 53%. CONCLUSIONS:: Our study confirmed the validity of the staging system to predict mortality in patients with intra-abdominal desmoid tumors and identified additional risk factors able to better define the risk of death within each stage. Risk stratification is crucial in directing patients with advanced disease and poor prognosis to the most appropriate medical and surgical options.

PMID: 22323009 [PubMed - as supplied by publisher]

Significant Contribution of the Portal Vein to Blood Flow Through the Common Bile Duct.

Ann Surg. 2012 Feb 8;

Authors: Slieker JC, Farid WR, van Eijck CH, Lange JF, van Bommel J, Metselaar HJ, de Jonge J, Kazemier G

Abstract

OBJECTIVE:: The aim of this study was to determine the contribution of the hepatic artery, gastroduodenal artery, and portal vein to the microvascular blood flow in the common bile duct (CBD). BACKGROUND:: Biliary complications are a common cause of graft loss after liver transplantation. The occurrence is, partly, attributed to hepatic artery thrombosis, which is considered to be the sole provider of blood flow to the bile ducts. However, the contribution of the portal vein and the gastroduodenal artery to the bile ducts is unknown. METHODS:: Microvascular blood flow in the CBD was determined in 15 patients who underwent a pancreaticoduodenectomy with a combination of laser Doppler flowmetry and reflectance spectrophotometry. Microvascular blood flow was measured at baseline, during clamping the portal vein, during clamping the hepatic artery, and during clamping both. After transection of the CBD, these 4 measurements were repeated. RESULTS:: Compared with baseline measurements, the microvascular blood flow through the CBD decreased to 62% after clamping the portal vein, 51% after clamping the hepatic artery, and 31% after clamping both. After the CBD was transected, these 3 measurements were 60%, 31%, and 20%, respectively. CONCLUSIONS:: Historically, the hepatic artery has been considered mainly responsible for biliary blood flow. We show that after transection of the CBD, mimicking the situation after liver transplantation, the contribution of the portal vein to the microvascular blood flow through the CBD is 40%. This study emphasizes the importance of the portal vein, and disturbances in portal venous blood flow could contribute to the formation of biliary complications after liver transplantation.

PMID: 22323010 [PubMed - as supplied by publisher]

Thoracoscopic Pleurodesis for Primary Spontaneous Pneumothorax With High Recurrence Risk: A Prospective Randomized Trial.

Ann Surg. 2012 Feb 8;

Authors: Chen JS, Hsu HH, Huang PM, Kuo SW, Lin MW, Chang CC, Lee JM

Abstract

OBJECTIVE:: To compare the efficacy and safety between apical pleurectomy and pleural abrasion with minocycline in primary spontaneous pneumothorax (PSP) with high recurrence risk. BACKGROUND:: The optimal thoracoscopic pleurodesis procedure for PSP with high recurrence risk remains controversial. METHODS:: Between January 2006 and May 2009, a total of 369 patients with spontaneous pneumothorax were treated by video-assisted thoracoscopic surgery. After stapled bullectomy, 160 patients with no identifiable bleb or multiple blebs (≥3) were randomly chosen to undergo apical pleurectomy (pleurectomy group, 80 patients) or pleural abrasion with minocycline (abrasion/minocycline group, 80 patients). RESULTS:: Patients in the pleurectomy group had a longer operation duration (mean, 81.4 minutes vs 55.8 minutes, P < 0.001), a greater amount of operation bleeding (mean, 29.4 mL vs 13.2 mL, P = 0.025), and a greater amount of postoperative chest drainage (mean, 287.4 mL vs 195.8 mL, P = 0.040). Patients in the abrasion/minocycline group had a higher intensity of chest pain and required more frequent meperidine injections. Hemothorax occurred in 3 pleurectomy patients (3.8%). The short-term results showed that the 2 groups had comparable durations of postoperative chest drainage, durations of postoperative hospital stay, and complication rates. After a mean follow-up of 26.1 months, recurrent ipsilateral pneumothorax occurred in 3 patients (3.8%) in the pleurectomy group and 3 patients (3.8%) in the abrasion/minocycline group. Postoperative long-term residual chest pain and pulmonary function were comparable in both groups. CONCLUSIONS:: Pleural abrasion with minocycline pleurodesis is as effective as apical pleurectomy and either technique is appropriate for treating PSP patients with high recurrence risk. This trial was registered at http://www.clinicaltrials.gov (ID: NCT00270751).

PMID: 22323011 [PubMed - as supplied by publisher]

Long-term results of a randomized, observation-controlled, phase III trial of adjuvant interferon Alfa-2b in hepatocellular carcinoma after curative resection.

Ann Surg. 2012 Jan;255(1):8-17

Authors: Chen LT, Chen MF, Li LA, Lee PH, Jeng LB, Lin DY, Wu CC, Mok KT, Chen CL, Lee WC, Chau GY, Chen YS, Lui WY, Hsiao CF, Whang-Peng J, Chen PJ,

Abstract

OBJECTIVE: To investigate the clinical efficacy of adjuvant interferon alfa-2b (IFNα-2b) therapy on recurrence-free survival (RFS) of patients with postoperative viral hepatitis-related hepatocellular carcinoma (HCC).

BACKGROUND: Despite most individual trials have failed to meet their primary endpoint, recent pooled-data meta-analyses suggest that adjuvant IFN therapy may significantly reduce the incidence of recurrence in curatively ablated HCC.

METHODS: Patients with curative resection of viral hepatitis-related HCC were eligible, and were stratified by underlying viral etiology and randomly allocated to receive either 53 weeks of adjuvant IFNα-2b treatment or observation alone. The primary endpoint of this study was RFS.

RESULTS: A total of 268 patients were enrolled with 133 in the IFNα-2b arm and 135 in the control arm. Eighty percent of them were hepatitis B surface antigen seropositive. At a median follow-up of 63.8 months, 154 (57.5%) patients had tumor recurrence and 84 (31.3%) were deceased. The cumulative 5-year recurrence-free and overall survival rates of intent-to-treat cohort were 44.2% and 73.9%, respectively. The median RFS in the IFNα-2b and control arms were 42.2 (95% confidence interval [CI], 28.1-87.1) and 48.6 (95% CI, 25.5 to infinity) months, respectively (P = 0.828, log-rank test). Adjuvant IFNα-2b treatment was associated with a significantly higher incidence of leucopenia and thrombocytopenia. Thirty-four (24.8%) of treated patients required dose reduction, and 5 (3.8%) of these patients subsequently withdrew from therapy because of excessive toxicity. Adjuvant IFNα-2b only temporarily suppressed viral replication during treatment period.

CONCLUSIONS: In this study, adjuvant IFNα-2b did not reduce the postoperative recurrence of viral hepatitis-related HCC. More potent antiviral therapy deserves to be explored for this patient population. This study is registered at ClinicalTrials.gov and carries the identifier NCT00149565.

PMID: 22104564 [PubMed - indexed for MEDLINE]

Regional recurrence in breast cancer patients with sentinel node micrometastases and isolated tumor cells.

Ann Surg. 2012 Jan;255(1):116-21

Authors: Pepels MJ, de Boer M, Bult P, van Dijck JA, van Deurzen CH, Menke-Pluymers MB, van Diest PJ, Borm GF, Tjan-Heijnen VC

Abstract

OBJECTIVE: The impact of axillary treatment in daily practice on 5-year regional recurrence rate in breast cancer patients with isolated tumor cells or micrometastases in the sentinel node (SLN).

BACKGROUND: Axillary dissection is recommended in patients with tumor-positive SLNs. But, in recent studies, regional recurrence rates seemed low if dissection was omitted.

METHODS: We identified all patients in The Netherlands with invasive breast cancer who had an SLN biopsy before 2006, favorable primary tumor characteristics, and node-negative disease, isolated tumor cells or micrometastases as final nodal status. The primary endpoint was regional recurrence rate. To investigate differences in recurrence rates between patients with and without axillary treatment, a proportional hazard regression was carried out correcting for potential confounders.

RESULTS: In total, 857 patients with node-negative disease, 795 patients with isolated tumor cells, and 1028 patients with micrometastases in the SLN were included. Without axillary treatment, the 5-year regional recurrence rates were 2.3%, 2.0%, and 5.6%, respectively. Compared with patients who underwent axillary treatment, the adjusted hazard ratio for regional recurrence in patients who underwent an SLN procedure only was 1.08 (95% CI, 0.23-4.98) for node-negative disease, 2.39 (95% CI, 0.67-8.48) for isolated tumor cells, and 4.39 (95% CI, 1.46-13.24) for micrometastases. Doubling of tumor size, grade 3 and negative hormone receptor status were also significantly associated with recurrence.

CONCLUSIONS: Not performing axillary treatment in patients with SLN micrometastases is associated with an increased 5-year regional recurrence rate. Axillary treatment is recommended in patients with SLN micrometastases and unfavorable tumor characteristics.

PMID: 22183034 [PubMed - indexed for MEDLINE]