All bleeding stops eventually.

Arch Surg. 2010 Aug;145(8):748

Authors: Gould JC

PMID: 20737733 [PubMed - in process]

The need for sustainability in contemporary global health efforts: missions vs mission.

Arch Surg. 2010 Aug;145(8):752-3

Authors: Farmer DL

PMID: 20737734 [PubMed - in process]

Bile leaks and sepsis: drain now, fix later.

Arch Surg. 2010 Aug;145(8):763

Authors: Krige JE, Bornman PC, Kahn D

PMID: 20737735 [PubMed - in process]

Mom is not permitted to be ill.

Arch Surg. 2010 Aug;145(8):780

Authors: Joehl RJ

PMID: 20737736 [PubMed - in process]

Globalization of Surgery: Let’s Get Serious.

Arch Surg. 2010 Aug;145(8):715-6

Authors: McIntyre T, Zenilman ME

PMID: 20713920 [PubMed - in process]

Bilateral robotic-assisted transaxillary surgery.

Arch Surg. 2010 Aug;145(8):717-20

Authors: Landry CS, Grubbs EG, Perrier ND

HYPOTHESIS: Robotic-assisted transaxillary surgery (RATS) for the removal of thyroid glands is feasible by surgeons in the United States. DESIGN: Case report. SETTING: Academic research. Patient A 53-year-old woman. INTERVENTION: Total thyroidectomy via the transaxillary approach. Main Outcome Measure Successful completion thyroidectomy using bilateral RATS. RESULTS: Right thyroid lobectomy was performed via RATS to remove a 2.2-cm Hurthle cell neoplasm of the thyroid gland per cytologic analysis. Final pathologic analysis was consistent with minimally invasive follicular thyroid carcinoma. The patient then underwent completion thyroidectomy via left-sided RATS. There were no complications. CONCLUSIONS: Bilateral RATS to perform total thyroidectomy is a feasible option in properly selected patients. To our knowledge, this is the first reported use of this technique in the United States.

PMID: 20713921 [PubMed - in process]

Operative mortality in resource-limited settings: the experience of medecins sans frontieres in 13 countries.

Arch Surg. 2010 Aug;145(8):721-5

Authors: Chu KM, Ford N, Trelles M

OBJECTIVE: To determine operative mortality in surgical programs from resource-limited settings. Design, Setting, and PARTICIPANTS: A retrospective cohort study of 17 surgical programs in 13 developing countries by 1 humanitarian organization, Médecins Sans Frontières, was performed between January 1, 2001, and December 31, 2008. Participants included patients undergoing surgical procedures. Main Outcome Measure Operative mortality. Determinants of mortality were modeled using logistic regression. RESULTS: Between 2001 and 2008, 19 643 procedures were performed on 18 653 patients. Among these, 8329 procedures (42%) were emergent; 7933 (40%) were for obstetric-related pathology procedures and 2767 (14%) were trauma related. Operative mortality was 0.2% (31 deaths) and was associated with programs in conflict settings (adjusted odds ratio [AOR] = 4.6; P = .001), procedures performed under emergency conditions (AOR = 20.1; P = .004), abdominal surgical procedures (AOR = 3.4; P = .003), hysterectomy (AOR = 12.3; P = .001), and American Society of Anesthesiologists classifications of 3 to 5 (AOR = 20.2; P < .001). CONCLUSIONS: Surgical care can be provided safely in resource-limited settings with appropriate minimum standards and protocols. Studies on the burden of surgical disease in these populations are needed to improve service planning and delivery. Quality improvement programs are needed for the various stakeholders involved in surgical delivery in these settings.

PMID: 20713922 [PubMed - in process]

Medication utilization and annual health care costs in patients with type 2 diabetes mellitus before and after bariatric surgery.

Arch Surg. 2010 Aug;145(8):726-31

Authors: Makary MA, Clarke JM, Shore AD, Magnuson TH, Richards T, Bass EB, Dominici F, Weiner JP, Wu AW, Segal JB

OBJECTIVE: To examine the relationship of bariatric surgery with the use of diabetes medications and with total health care costs in patients with type 2 diabetes mellitus. DESIGN: We studied 2235 adults with type 2 diabetes and commercial health insurance who underwent bariatric surgery in the United States during a 4-year period from January 1, 2002, through December 31, 2005. We used administrative claims data to measure the use of diabetes medications at specified time intervals before and after surgery and total median health care costs per year. SETTING: Seven states in the Blue Cross/Blue Shield Obesity Care Collaborative. PATIENTS: Two thousand two hundred thirty-five patients with type 2 diabetes mellitus who underwent bariatric surgery. RESULTS: Surgery was associated with elimination of diabetes medication therapy in 1669 of 2235 patients (74.7%) at 6 months, 1489 of 1847 (80.6%) at 1 year, and 906 of 1072 (84.5%) at 2 years after surgery. Reduction of use was observed in all classes of diabetes medications. The median cost of the surgical procedure and hospitalization was $29 959. In the 3 years following surgery, total annual health care costs per person increased by 9.7% ($616) in year 1 but then decreased by 34.2% ($2179) in year 2 and by 70.5% ($4498) in year 3 compared with a preoperative annual cost of $6376 observed from 1 to 2 years before surgery. CONCLUSIONS: Bariatric surgery is associated with reductions in the use of medication and in overall health care costs in patients with type 2 diabetes. Health insurance should cover bariatric surgery because of its health and cost benefits.

PMID: 20713923 [PubMed - in process]

Effect of physician ownership of specialty hospitals and ambulatory surgery centers on frequency of use of outpatient orthopedic surgery.

Arch Surg. 2010 Aug;145(8):732-8

Authors: Mitchell JM

BACKGROUND: Physician-owned specialty hospitals and ambulatory surgery centers have become commonplace in many markets throughout the United States. Little is known about whether the financial incentives linked to ownership affect frequency of outpatient surgery. OBJECTIVE: To evaluate if financial incentives linked to physician ownership influence frequency of outpatient orthopedic surgical procedures. DESIGN AND SETTING: We analyzed 5 years of claims data from a large private insurer in Idaho to compare frequency by orthopedic surgeon owners and nonowners of surgical procedures that could be performed in either ambulatory surgery centers or hospital outpatient surgery departments. Main Outcome Measure Frequency of use, calculated as number of patients treated with the specific diagnoses who received the surgical procedure of interest divided by the number of patients with such diagnoses treated by each physician. RESULTS: Age- and sex-adjusted odds ratios indicate that the likelihood of having carpal tunnel repair was 54% to 129% higher for patients of surgeon owners compared with surgeon nonowners. For rotator cuff repair, the adjusted odds ratios of having surgery were 33% to 100% higher for patients treated by physician owners. The age- and sex-adjusted probability of arthroscopic surgery was 27% to 78% higher for patients of surgeon owners compared with surgeon nonowners. CONCLUSION: The consistent finding of higher use rates by physician owners across time clearly suggests that financial incentives linked to ownership of either specialty hospitals or ambulatory surgery centers influence physicians’ practice patterns.

PMID: 20713924 [PubMed - in process]

Impact of mesh use on morbidity following ventral hernia repair with a simultaneous bowel resection.

Arch Surg. 2010 Aug;145(8):739-44

Authors: Xourafas D, Lipsitz SR, Negro P, Ashley SW, Tavakkolizadeh A

OBJECTIVE: To evaluate the impact of mesh use on outcomes following ventral hernia repairs and simultaneous bowel resection. DESIGN: Retrospective review. SETTING: Teaching academic hospital. PATIENTS: We studied 177 patients who underwent a ventral hernia repair with a bowel resection between May 1, 1992, and May 30, 2007. A prosthesis was used in 51 repairs (mesh group), while 126 repairs were primary (mesh-free group). MAIN OUTCOME MEASURES: Demographic characteristics, comorbidities, mesh type, bowel resection type (colon vs small bowel), defect size, drain use, and length of hospital stay were compared between groups with Fisher exact test and multivariate analysis. RESULTS: There were no statistically significant differences between patient characteristics and relevant comorbidities. The incidence of postoperative infection (superficial or deep) was 22% in the mesh group vs 5% in the mesh-free group (P = .001). Other complications (fistula, seroma, hematoma, bowel obstruction) occurred in 24% of patients in the mesh group vs 8% of patients in the mesh-free group (P = .009). Focusing on the patients who developed an infection, prosthetic mesh use was the only significant risk factor on multivariate regression analysis, irrespective of drain use, defect size, and type of bowel resection. CONCLUSIONS: We recommend caution in using mesh when performing a ventral hernia repair with a simultaneous bowel resection because of significantly increased postoperative infectious complications. Drain use, defect size, and bowel resection type did not influence outcomes.

PMID: 20713925 [PubMed - in process]

Laparoscopic ileostomy in severe, obscure gastrointestinal hemorrhage: diagnostic laparoscopic ileostomy.

Arch Surg. 2010 Aug;145(8):745-8

Authors: Patel T, Bickenbach K, Semrad C, Alverdy J

HYPOTHESIS: Laparoscopic diverting ileostomy should help define whether a severe, obscure gastrointestinal hemorrhage is in the upper or lower gastrointestinal tract in preparation for subtotal resection without increasing risk of patient morbidity and mortality. DESIGN: Case reports. SETTING: University hospital. PATIENTS: Patient 1 is an 83-year-old woman. Patient 2 is a 75-year-old woman. Both were admitted to the hospital for massive gastrointestinal hemorrhage, which required multiple blood transfusions. Extensive workup revealed multiple diverticula in the small and large intestines without identification of any source of active bleeding in either patient. INTERVENTION: Laparoscopic exploration of the abdominal cavity was performed. The terminal ileum at the ileocecal valve was identified and, 5 cm proximal to the ileocecal valve, the small bowel was transected. The distal end staple line was secured in end-to-side fashion to the proximal end, and the proximal end was brought out as an end ileostomy. Patients were then observed for bleeding into the ostomy bag or in the rectum. Main Outcome Measure Localization of the source of bleeding as upper or lower, occurrence of surgical complications, and clinical outcome. RESULTS: No intraoperative complications occurred in either patient. Patient 1 had significant bleeding into her ileostomy bag on postoperative day 1. She was taken back to the operating room for empirical small bowel resection. She was discharged, had no further bleeding, and underwent closure of the ileostomy 2 months later. The postoperative course of patient 2 was complicated by a small parastomal abscess that resolved with percutaneous drainage and antibiotics. Patient 2 returned on postoperative day 22 with bleeding in the rectum. She was taken to the operating room for laparoscopic total colectomy with ileosigmoid anastomosis and ileostomy closure. Both patients recovered uneventfully and had no recurrent bleeding. CONCLUSIONS: Our experience with these 2 patients suggests that in cases in which the risk of blind resection appears ill-advised, laparoscopic compartmentalization of the small bowel from the colon via end ileostomy may be safely performed.

PMID: 20713926 [PubMed - in process]

Surgery in the horn of Africa: a 1-year experience of an american-sponsored surgical residency in eritrea.

Arch Surg. 2010 Aug;145(8):749-52

Authors: Khambaty FM, Ayas HM, Mezghebe HM

OBJECTIVE: To describe the 1-year experience of a unique postgraduate medical education program set in Eritrea, a recently war-torn country. DESIGN: The Partnership for Eritrea, a cooperative between The George Washington University Medical Center, Physicians for Peace, and the Eritrean Ministry of Health, formed a surgical residency program, launched January 2, 2008, in Asmara, Eritrea, to train native Eritrean surgeons. No prior residency program (to our knowledge) had existed in Eritrea. SETTING: Eritrea, a country in the Horn of Africa. PATIENTS: Five Eritrean physicians participated in the surgical residency. MAIN OUTCOME MEASURES: The number of operations performed, length of stay, antibiotic use, and intravenous fluid use. RESULTS: The number of operations increased and resource use decreased because of improved and standardized clinical management. CONCLUSIONS: The Partnership for Eritrea established a general surgical residency program that improved clinical care in a resource-poor country that previously had lacked postgraduate training. The program experience suggests a model that can be reproduced in other developing countries.

PMID: 20713927 [PubMed - in process]

Bile Duct Injuries Associated With Laparoscopic Cholecystectomy: Timing of Repair and Long-term Outcomes.

Arch Surg. 2010 Aug;145(8):757-63

Authors: Sahajpal AK, Chow SC, Dixon E, Greig PD, Gallinger S, Wei AC

OBJECTIVES: To report on a large experience with laparoscopic cholecystectomy-associated bile duct injuries (LC-BDIs) and examine factors influencing outcomes. DESIGN: A retrospective medical record review. Univariate statistical analysis was used to identify risk factors for postoperative complications. SETTING: Two university-affiliated hospitals. PATIENTS: Sixty-nine patients who underwent surgical repair of LC-BDI between January 1, 1992, and December 31, 2007. MAIN OUTCOME MEASURES: Outcomes following repair of LC-BDI, relationship between timing of LC-BDI repair and outcomes, complications, and long-term results following LC-BDI repair. RESULTS: Thirteen immediate repairs (0-72 hours post-LC), 34 intermediate repairs (72 hours-6 weeks), and 22 late repairs (>6 weeks) were performed. The LC-BDIs were Strasberg type A in 1 patient (1%), D in 2 patients (3%), E1 in 22 patients (32%), E2 in 16 patients (23%), E3 in 22 patients (32%), E4 in 4 patients (6%), and E5 in 2 patients (3%). Forty-one hepaticojejunostomies (59%), 24 choledochojejunostomies (35%), 3 right hepatic hepatectomies with biliary reconstruction (4%), and 1 primary common bile duct repair (1%) were performed. The overall morbidity rate was 30% (21 patients). The mortality rate was 1% (1 patient). Twelve patients (17%) developed short-term postoperative complications. There were no factors found to be associated with early postoperative morbidity. The most common long-term complication was biliary stricture, which occurred in 10 patients (14%). Patients whose BDIs were repaired in the intermediate period were more likely to develop biliary stricture than patients with repairs performed in the immediate or late periods (P = .03). CONCLUSIONS: Our results suggest that the timing of LC-BDI repair is an important determinant of long-term outcome. Repairs in the intermediate period were significantly associated with biliary stricture. Thus, repairs should be undertaken either in the immediate (0-72 hours) or delayed (>6 weeks) periods after LC.

PMID: 20713928 [PubMed - in process]

Surgical decompression for abdominal compartment syndrome in severe acute pancreatitis.

Arch Surg. 2010 Aug;145(8):764-9

Authors: Mentula P, Hienonen P, Kemppainen E, Puolakkainen P, Leppäniemi A

HYPOTHESIS: In patients with severe acute pancreatitis and abdominal compartment syndrome, establishment of the indications and optimal time for surgical decompression may avoid exacerbation of multiple-organ dysfunction syndrome. DESIGN: Retrospective study. SETTING: Tertiary care university teaching hospital. PATIENTS: Twenty-six consecutive patients with severe acute pancreatitis and abdominal compartment syndrome treated by surgical decompression between January 1, 2002, and December 31, 2007. INTERVENTION: Surgical decompression of the abdomen. MAIN OUTCOME MEASURES: Morbidity, mortality, and organ dysfunction before and after surgical decompression. RESULTS: At the time of surgical decompression, the median sequential organ failure assessment score among patients was 12 (interquartile range, 10-15), and the median intra-abdominal pressure was 31.5 (interquartile range, 27-35) mm Hg. After surgical decompression, renal or respiratory function was improved in 14 patients (54%). The overall hospital mortality was 46%, but mortality was 18% among 17 patients in whom surgical decompression was performed within the first 4 days after disease onset. CONCLUSIONS: Patients with severe acute pancreatitis and abdominal compartment syndrome managed by surgical decompression had severe multiple-organ dysfunction syndrome and high mortality. Surgical decompression may improve renal or respiratory function. Early surgical decompression is associated with reduced mortality in patients with severe acute pancreatitis, early multiple-organ dysfunction syndrome, and abdominal compartment syndrome.

PMID: 20713929 [PubMed - in process]

Gossypiboma: tales of lost sponges and lessons learned.

Arch Surg. 2010 Aug;145(8):770-5

Authors: McIntyre LK, Jurkovich GJ, Gunn ML, Maier RV

OBJECTIVE: To review the details surrounding cases of patients found to have retained laparotomy sponges after surgical procedures and share policy changes that have led to process improvements at one academic medical center. DESIGN: Retrospective medical record review as part of a quality improvement process. SETTING: Single academic medical center. PATIENTS: Patients identified through the quality improvement process as having had retained foreign bodies after surgery. CONCLUSIONS: Sentinel events such as retained foreign bodies after surgery require intensive review to identify systems problems. This can lead to protocol changes to improve the process. After a series of incidents, protocol changes at our institution have led to no further incidents of retained foreign bodies.

PMID: 20713930 [PubMed - in process]

Impact of race and socioeconomic status on presentation and management of ventral hernias.

Arch Surg. 2010 Aug;145(8):776-80

Authors: Bowman K, Telem DA, Hernandez-Rosa J, Stein N, Williams R, Divino CM

OBJECTIVE: To assess for disparity in presentation and management of ventral hernias. DESIGN: Retrospective review. SETTING: Academic center. PATIENTS: Three hundred twenty-one patients who underwent ventral hernia repair from 2005 to 2008. MAIN OUTCOME MEASURES: Disparity in ventral hernia presentation, management, and outcome. Univariate analysis was conducted by unpaired t test and chi(2) test. RESULTS: Black individuals were more likely than white individuals to present with acute hernia complications requiring emergent surgery (11% vs 4%; P < .01). This finding persisted after controlling for socioeconomic status (SES). Assessment by SES demonstrated patients with Medicaid were more likely to present with incarcerated or strangulated hernias (39% vs 25%; P < .001) and had longer hospital stays (4.7 vs 3 days; P < .05) as compared with patients with private insurance. Patients classified as low income had increased 30-day readmission rates as compared with average- or high-income patients (32% vs 9% vs 7%, respectively; P < .01). No difference in use of minimally invasive technique, performance of primary vs mesh repair, or postoperative morbidity or mortality was demonstrated. Twelve-month follow-up demonstrated no difference in recurrence rate by race or SES. CONCLUSIONS: Our study demonstrates the existence of disparity in patient presentation with complicated ventral hernia. Despite clear disparity by race and SES, at our institution, disparate presentation did not equate to disparate treatment or postoperative complications. No difference was demonstrated by use of operative technique, perioperative outcome, or 12-month recurrence rate. This study illustrates the need for long-term measures directed at reevaluation of organizational and institutional factors that perpetuate inequality.

PMID: 20713931 [PubMed - in process]

Robotic posterior retroperitoneal adrenalectomy: operative technique.

Arch Surg. 2010 Aug;145(8):781-4

Authors: Berber E, Mitchell J, Milas M, Siperstein A

OBJECTIVE: To describe a robotic technique for posterior retroperitoneal (PR) adrenalectomy. DESIGN: Prospective study. SETTING: Academic hospital. PATIENTS: Twenty-three patients had robotic adrenalectomy within a year. Of these, 8 cases were done using a PR approach. MAIN OUTCOME MEASURES: Feasibility of the robotic approach, patient and tumor characteristics, operative time, and complications. RESULTS: There were 5 women and 3 men (mean age, 52 years). There were no conversions to laparoscopic or open surgery. Pathology included benign adrenocortical adenoma in 3 patients, aldosteronoma in 2, and pheochromocytoma, subclinical Cushing syndrome, and lymphangioma in 1 patient each. The right and left sides were each involved in 4 patients. The mean (SD) tumor size was 2.9 (1.7) cm. The procedures were done using 3 trocars and 5-mm robotic instruments. The mean (SD) operative time was 214.8 (40.8) minutes; docking time, 21.7 (16.6) minutes; and console time, 97.1 (24.2) minutes. Estimated blood loss was 24 (35) mL. All patients were discharged to home in 24 hours. There were no complications. Subjectively, the dissection was felt to be easier with the robotic technique compared with the laparoscopic approach owing to the improved dexterity of the instruments. CONCLUSIONS: To our knowledge, this is the first article describing robotic PR adrenalectomy, and we have demonstrated the technique to be feasible and safe. Owing to the limitations of a conventional laparoscopic PR approach, we believe that use of the robot is a refinement of the technique.

PMID: 20713932 [PubMed - in process]

Asian race/ethnicity as a risk factor for bile duct injury during cholecystectomy.

Arch Surg. 2010 Aug;145(8):785-7

Authors: Downing SR, Datoo G, Oyetunji TA, Fullum T, Chang DC, Ahuja N

Iatrogenic bile duct injury (BDI) is an uncommon but serious complication of cholecystectomy, with identified risk factors of acute cholecystitis, male sex, older age, and aberrant biliary anatomy. The Nationwide Inpatient Sample (1998-2006) was queried for cholecystectomy performed on hospital day 0 or 1. Bile duct injury repair procedure codes were used as a surrogate for BDI. We identified 377 424 patients who underwent cholecystectomy, with 1124 BDIs (0.3%). On multivariate logistic regression analysis, Asian race/ethnicity was a significant risk factor for BDI (odds ratio [OR], 2.26; 95% confidence interval [CI], 1.59-3.23; P < .001). This persisted for laparoscopic (OR, 2.62; 95% CI, 1.28-5.39; P = .009) and open (2.21; 1.59-3.07; P < .001) cholecystectomies. No other race/ethnicity was identified as a risk factor for BDI. We report a new finding that Asian race/ethnicity is a significant risk factor for BDI in laparoscopic and open cholecystectomies.

PMID: 20713933 [PubMed - in process]

Uninformed consent for children undergoing operations.

Arch Surg. 2010 Aug;145(8):788-90

Authors: Livingston EH

PMID: 20713934 [PubMed - in process]

Image of the month–quiz case.

Arch Surg. 2010 Aug;145(8):791

Authors: Schorn VJ, Baquerizo A, Mason RJ

PMID: 20713935 [PubMed - in process]

Image of the month–quiz case.

Arch Surg. 2010 Aug;145(8):793

Authors: Clemente G, Giordano M, De Rose AM, Nuzzo G

PMID: 20713936 [PubMed - in process]

ERCP vs Laparoscopic Common Bile Duct Exploration for Common Bile Duct Stones: Are the 2 Techniques Truly Equivalent?

Arch Surg. 2010 Aug;145(8):795

Authors: Yachimski P, Poulose BK

PMID: 20713937 [PubMed - in process]

ERCP or laparoscopic exploration for the treatment of suspected choledocholithiasis?

Arch Surg. 2010 Aug;145(8):796

Authors: Singh VK, Khashab MA, Okolo PI, Kalloo AN

PMID: 20713938 [PubMed - in process]

Is laparoscopic surgery for early gallbladder cancer less invasive or dangerous?

Arch Surg. 2010 Aug;145(8):797-8

Authors: Fujita T

PMID: 20713939 [PubMed - in process]

Laparoscopic cholecystectomy for early gallbladder carcinoma.

Arch Surg. 2010 Aug;145(8):797

Authors: Badruddoja M

PMID: 20713940 [PubMed - in process]

Association with a high number of lymph nodes and microsatellite instability in colorectal cancer.

Arch Surg. 2010 Aug;145(8):799

Authors: Søreide K, Nedrebø BS, Søreide JA, Kørner H

PMID: 20713941 [PubMed - in process]

Never say never: understanding centers for medicare and medicaid services policy on usually preventable harm.

Arch Surg. 2010 Aug;145(8):800-1

Authors: Grossbart SR

PMID: 20713942 [PubMed - in process]

Related Articles

Laparoscopic vs Open Distal Pancreatectomy: A Single-Institution Comparative Study.

Arch Surg. 2010 Jul;145(7):616-21

Authors: Vijan SS, Ahmed KA, Harmsen WS, Que FG, Reid-Lombardo KM, Nagorney DM, Donohue JH, Farnell MB, Kendrick ML

HYPOTHESIS: Laparoscopic distal pancreatectomy (LDP) provides outcome advantages compared with open distal pancreatectomy (ODP). DESIGN: Single-institutional, retrospective review from January 1, 2004, to May 1, 2009. SETTING: Tertiary referral center. PATIENTS: Patients undergoing LDP (n = 100) were matched by age, pathologic diagnosis, and pancreatic specimen length to a cohort undergoing ODP (n = 100). MAIN OUTCOME MEASURES: Perioperative outcomes and overall 30-day morbidity and mortality. Univariate and multivariate analyses were performed using logistic or linear regression as appropriate. RESULTS: Patients in the LDP group did not differ from those in the ODP group in age (mean, 59.0 vs 58.6 years; P = .85), sex (60% vs 50% female; P = .16), body mass index (calculated as weight in kilograms divided by height in meters squared) (mean, 27.4 vs 27.9; P = .44), or American Society of Anesthesiologists score of 3 or higher (58% vs 52%; P = .39). Tumor size was greater in the ODP group than in the LDP group (mean, 4.0 vs 3.3 cm; P = .02). The LDP group as compared with the ODP group demonstrated decreased blood loss (mean, 171 vs 519 mL; P < .001) and shorter duration of hospital stay (mean, 6.1 vs 8.6 days; P < .001). There were no differences between the LDP and ODP groups in operative time (mean, 214 vs 208 minutes; P = .50), pancreatic leak rate (17% vs 17%; P > .99), overall 30-day morbidity (34% vs 29%; P = .45), and 30-day mortality (3% vs 1%; P = .62). CONCLUSIONS: The laparoscopic approach to distal pancreatectomy appears to provide advantages of reduced blood loss and length of hospital stay in selected patients compared with the open approach. Overall complication rates appear similar. Patient selection bias and limits of a retrospective analysis warrant prospective validation.

PMID: 20644122 [PubMed - in process]

Related Articles

Prognostic information from sentinel lymph node biopsy in patients with thick melanoma.

Arch Surg. 2010 Jul;145(7):622-7

Authors: Scoggins CR, Bowen AL, Martin RC, Edwards MJ, Reintgen DS, Ross MI, Urist MM, Stromberg AJ, Hagendoorn L, McMasters KM

HYPOTHESIS: Sentinel lymph node (SLN) biopsy provides valuable prognostic information for patients with thick (T4) melanoma. DESIGN: Post hoc analysis of data from a prospective, randomized trial. SETTING: Academic and private hospitals. PATIENTS: Data of 240 patients with melanoma thicker than 4 mm were analyzed. Patients with tumor-positive SLNs underwent completion lymphadenectomy. Disease-free and overall survival were evaluated by Kaplan-Meier analysis. Univariate and multivariate analyses were performed to evaluate factors predictive of tumor-positive SLNs and disease-free and overall survival. RESULTS: Median thickness of melanoma was 5.6 mm, and patients were followed up for a median of 50 months. The SLNs were tumor positive in 100 patients (41.7%); 18% of these had additional positive nodes on completion lymphadenectomy. Extremity tumor location (risk ratio, 1.66; 95% confidence interval, 1.24-2.24; P = .001), Clark level (1.95; 1.33-2.87; P = .02), and lymphovascular invasion (1.57; 1.13-2.17; P = .01) were associated with a greater risk of tumor-positive SLNs. The patients with tumor-negative SLNs had significantly better median disease-free survival (46.5 vs 31.0 months; P = .04) and overall survival (55.5 vs 43.0 months; P = .004) compared with patients with tumor-positive SLNs. On multivariate analysis, male sex (risk ratio, 1.59; 95% confidence interval, 1.05-2.50; P = .02), increasing Breslow thickness (1.58; 1.10- 2.30; P = .03), ulceration (1.73; 1.18-2.59; P = .02), and tumor-positive SLNs (1.68; 1.17-2.43; P = .009) were associated with worse overall survival. CONCLUSION: The SLN biopsy provides useful prognostic information for patients with T4 melanoma.

PMID: 20644123 [PubMed - in process]

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Operative failure in the era of focused parathyroidectomy: a contemporary series of 845 patients.

Arch Surg. 2010 Jul;145(7):628-33

Authors: Lew JI, Rivera M, Irvin GL, Solorzano CC

HYPOTHESIS: Focused parathyroidectomy guided by intraoperative parathyroid hormone monitoring (IPM) may lead to higher failure rates because of missed multiglandular disease. DESIGN: Retrospective review of prospectively collected data. SETTING: Tertiary referral center. PATIENTS: From September 8, 1993, through January 30, 2009, a total of 845 consecutive patients with sporadic primary hyperparathyroidism underwent focused parathyroidectomy guided by IPM at a single institution. MAIN OUTCOME MEASURES: Parathyroid hormone dynamics and perioperative data were analyzed for factors affecting outcome. Operative failure was defined as hypercalcemia with elevated parathyroid hormone levels within 6 months after parathyroidectomy. Detailed intraoperative data from the failed operations were also reviewed. RESULTS: Of 723 patients followed up for at least 6 months, 702 (97.1%) had successful parathyroidectomy, and 21 (2.9%) had failed parathyroidectomy. The major cause of operative failure was the surgeon’s inability to find the abnormal parathyroid gland (16 of 21 patients [76.2%]). In the remaining patients, IPM results were false-positive in 5 of 21 patients (23.8%) or 0.7% overall. Among the cohort, IPM correctly identified missed multiglandular disease in 33 of 38 patients (86.8%). Patients having operative failure were more likely to have a history of thyroidectomy or parathyroidectomy and were less likely to have correct findings on technetium Tc 99m sestamibi or ultrasonographic localizing studies compared with patients having operative success. CONCLUSION: Inability of the surgeon to find the abnormal parathyroid gland-not missed multiglandular disease-is the main cause of operative failure in focused parathyroidectomy guided by IPM.

PMID: 20644124 [PubMed - in process]

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Effect of hospital volume, surgeon experience, and surgeon volume on patient outcomes after pancreaticoduodenectomy: a single-institution experience.

Arch Surg. 2010 Jul;145(7):634-40

Authors: Schmidt CM, Turrini O, Parikh P, House MG, Zyromski NJ, Nakeeb A, Howard TJ, Pitt HA, Lillemoe KD

OBJECTIVE: To determine the importance of hospital volume, surgeon experience, and surgeon volume in performing pancreaticoduodenectomy (PD). Design, Setting, and PATIENTS: From 1980 through 2007, 1003 patients underwent PD by 19 surgeons at a university hospital. MAIN OUTCOME MEASURES: Patient morbidity and mortality, quality of resection, and learning curve were examined according to hospital volume (period 1: 1980-2003 vs period 2: 2004-2007), surgeon experience (total number of PDs), and surgeon volume (number of PDs per year). RESULTS: Perioperative morbidity and mortality for all 1003 PDs were 41% and 3%, respectively. Differences existed between period 1 and period 2 in percentage of PDs performed in elderly patients (7% vs 17%), mortality (4% vs 2%), estimated blood loss (1817 mL vs 780 mL), length of stay (18 days vs 12 days), and proportion of International Study Group on Pancreatic Fistula grade C pancreatic fistulae (29% vs 12%). Surgeons with less experience (<50 PDs) performed PD with higher morbidity (53% vs 39%), pancreatic fistula rate (20% vs 10%), estimated blood loss (1918 mL vs 1101 mL), and operative time (458 minutes vs 335 minutes) compared with surgeons with more experience (>/=50 PDs). Experienced surgeons had comparable outcomes irrespective of annual volume. Mortality, margins, and number of lymph nodes resected were not affected by surgeon experience or surgeon volume. Learning curves projected that less experienced surgeons would achieve morbidity and mortality rates equivalent to those of experienced surgeons when they reached 20 and 60 PDs, respectively. CONCLUSIONS: Improvement in PD outcomes, including mortality, occurred with increased PD volume at a pancreatic center. Surgeon experience remained an important determinant of overall morbidity. Experienced surgeons, however, had comparable outcomes irrespective of annual volume.

PMID: 20644125 [PubMed - in process]

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Surgical case listing accuracy: failure analysis at a high-volume academic medical center.

Arch Surg. 2010 Jul;145(7):641-6

Authors: Cima RR, Hale C, Kollengode A, Rogers JC, Cassivi SD, Deschamps C

HYPOTHESIS: Describe the incidence, type, and detection method of surgical listing errors and implement a system to reduce errors. DESIGN: All errors/discrepancies between the surgical listing and the performed procedure reported to an institutional event line during 2008 were analyzed. SETTING: Academic tertiary medical center. MAIN OUTCOME MEASURES: Error characteristics and detection mode were documented. An error causal tree analysis was developed and used to modify the standard listing process to reduce errors. RESULTS: During 2008, 759 listing errors were reported of 55 197 surgical procedures for an error rate of 1.38%. No wrong-site surgeries occurred. The errors were missing laterality (501; 66%), incorrect side (108; 14%), incorrect listing besides laterality (86; 11%), and other (64; 9%). Identification/correction of the listing error occurred in the following areas: nursing review the evening prior to surgery (517; 68%), preoperative admission unit (132; 17%), operating room (98; 12%), recovery room (6; 0.8%), and other (6; 0.8%). Using a causal tree analysis, error-proofing strategies applied in an electronic standardized case listing system significantly reduced the error rate from 1.50% to 0.54% (P < .05) and 2.06% to 0.49% (P < .05) in gynecologic and colorectal surgery, respectively. CONCLUSIONS: Surgical listings errors occur with a low constant rate across specialties. The majorities of errors were related to laterality and were detected prior to surgery. An electronic listing system using standardized case descriptions with required laterality significantly reduced the error frequency.

PMID: 20644126 [PubMed - in process]

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Surgical warranties to improve quality and efficiency in elective colon surgery.

Arch Surg. 2010 Jul;145(7):647-52

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

BACKGROUND: Uncomplicated surgical care has highly variable costs. High costs of complications have led payers to deny additional payments even for predictable complications. HYPOTHESIS: A payment warranty indexed to effective and efficient hospitals can promote quality and economic stewardship in surgical care. DESIGN: Analysis of hospital costs for elective colon surgery in the Healthcare Cost and Utilization Project’s National Inpatient Sample from 2002 through 2005. SETTING: A 20% sample of acute care hospitals in the United States. Patients and METHODS: Data for elective colon resections were used to create predictive models for adverse outcomes (AOs) and costs. Total hospital costs were determined using cost-to-charge ratios. Costs of AOs were computed as total costs minus predicted costs of uncomplicated care. Surgical warranties were computed as the probability of AOs times per-case predicted costs of AOs. Final predictive models were calibrated using data only from effective and efficient hospitals. RESULTS: We studied 51 602 cases from 632 hospitals. There were 4048 (7.8%) AOs with 505 deaths (1.0%); 19 hospitals had excessive AOs and 95 hospitals had excessive costs. For 518 effective and efficient hospitals, total per-case costs for routine care were $9843 with an average warranty of $1294 and a $276 stop-loss allocation. This cost model would reduce national expenditures for colon surgery by 6%. CONCLUSIONS: Complications and costs of care can be indexed to quality performing hospitals. Warranties for surgical care can reward effective and efficient care and preclude the need for additional payments for complications.

PMID: 20644127 [PubMed - in process]

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Short- and Long-term Outcomes After Steatotic Liver Transplantation.

Arch Surg. 2010 Jul;145(7):653-60

Authors: Doyle MB, Vachharajani N, Wellen JR, Anderson CD, Lowell JA, Shenoy S, Brunt EM, Chapman WC

OBJECTIVE: To determine if the use of steatotic grafts adversely affects outcomes in liver transplantation. DESIGN: A retrospective review of a prospectively maintained database. SETTING: A single center. PATIENTS: Four hundred ninety adults who underwent liver transplantation from January 1, 2002, to December 31, 2008, at a single center. Graft biopsies were available in 310 (63.3%) cases. Grafts were classified based on amount of macrovesicular steatosis: 5% or less (n = 222), more than 5% to less than 35% (n = 66), and 35% or more (n = 22). MAIN OUTCOME MEASURES: Recipient demographics, Model for End-Stage Liver Disease (MELD) score, patient/graft survival, complications, transfusion rates, and liver function test results. RESULTS: One-, 3-, and 5-year patient and graft survivals, respectively, were similar (90.38%, 84.7%, and 74.4%, respectively, P = .3; and 88.7%, 82.5%, and 73.3%, respectively, P = .15). Median follow-up was 25 months. Recipient age, sex, body mass index, laboratory MELD score, and ischemia times were similar among all groups. Packed red blood cell (3 vs 8 U, P < .001), fresh frozen plasma (2 vs 4 U, P = .007), and cryoprecipitate transfusion rates were significantly increased in grafts with 35% or more steatosis. Intensive care unit (5 vs 11 days, P = .02) and hospital (11 vs 21 days, P < .001) stay was also increased in those with grafts with 35% or more steatosis compared with those with 5% or less steatosis. The grafts with 35% or more steatosis had higher transaminase peaks and longer times for bilirubin to normalize (P < .001). CONCLUSIONS: Use of carefully selected steatotic grafts was not associated with higher rates of primary nonfunction or poorer outcomes. However, the use of steatotic grafts is associated with increased resource use in the perioperative period.

PMID: 20644128 [PubMed - in process]

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The effect of steatosis on echogenicity of colorectal liver metastases on intraoperative ultrasonography.

Arch Surg. 2010 Jul;145(7):661-7

Authors: van Vledder MG, Torbenson MS, Pawlik TM, Boctor EM, Hamper UM, Olino K, Choti MA

OBJECTIVE: To investigate the association of relative tumor echogenicity and hepatic steatosis in patients undergoing resection of colorectal liver metastases (CRLM). DESIGN: Prospective study. SETTING: The Johns Hopkins Hospital. PATIENTS: A total of 126 patients undergoing liver surgery for CRLM from January 1, 1998, through December 31, 2008, in whom 191 lesions had complete intraoperative ultrasonography images for review and adequate linked pathological data available. MAIN OUTCOME MEASURES: The intraoperative ultrasonography images were reviewed and scored for echogenicity (hypoechoic, isoechoic, or hyperechoic). In addition, a histopathologic review of the nontumorous liver tissue was performed, and the extent of steatosis was scored and correlated with tumor echogenicity. RESULTS: Of the patients undergoing surgery, 49 (38.8%) were found to have mild to severe steatosis. Of the 191 total CRLM visualized by intraoperative ultrasonography, 91 (47.6%) were found to be hypoechoic, 65 (34.0%) were isoechoic, and 35 (18.3%) were hyperechoic. In patients with steatosis, lesions were significantly more likely to be hypoechoic when compared with patients without steatosis (odds ratio, 4.17; 95% confidence interval, 1.87-8.47; P = .001). Echogenicity was independent of the cause of steatosis or response to chemotherapy. CONCLUSIONS: The echogenicity of CRLM was significantly affected by the presence of liver steatosis, with decreased echogenicity and increased conspicuity of lesions despite overall poorer image quality. These findings might reinforce the usefulness of intraoperative ultrasonography in identifying additional CRLM in patients undergoing surgical therapy, even in those with fatty liver tissue.

PMID: 20644129 [PubMed - in process]

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Motivations to pursue fellowships are gender neutral.

Arch Surg. 2010 Jul;145(7):671-8

Authors: Borman KR, Biester TW, Rhodes RS

OBJECTIVE: To determine the importance of factors in decision making by general surgery chief residents to pursue fellowships and to relate factor importance to gender and residency characteristics. DESIGN: Prospective, voluntary, national survey conducted April through May, 2008, in which finishing chief residents rated the importance of 12 factors in their decision making to pursue fellowships. SETTING: General surgery chief residents who applied for admission to the American Board of Surgery Qualifying Examination process. PARTICIPANTS: All 1034 first-time applicants. MAIN OUTCOME MEASURES: chi(2) tests and 1-way analyses of variance were used to correlate gender and residency type, size, and location with summed values and scaled mean scores for ratings of the importance of 12 potential factors in fellowship decision making. RESULTS: The fellowship rate was 77% and correlated with residency size and location. Women were dispersed asymmetrically across residencies overall but future female fellows were distributed similarly to male ones. Survey item response rates for future fellows were 96% to 98%. Clinical mastery and specialty activities were valued most highly by more than 90% of men and women. Men placed more value on income potential and spousal influence. Lifestyle factors reached only midrange importance for both genders. Program size had more significant relationships to decision-making factors than did gender. CONCLUSIONS: The ability to master an area of clinical practice and the clinical activities of a specialty are the most important factors for chief residents in fellowship decision making, regardless of gender. Lifestyle factors are of midrange importance. Program size is as influential as is gender.

PMID: 20644130 [PubMed - in process]

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Endovascular repair of blunt traumatic thoracic aortic injuries: seven-year single-center experience.

Arch Surg. 2010 Jul;145(7):679-83

Authors: Garcia-Toca M, Naughton PA, Matsumura JS, Morasch MD, Kibbe MR, Rodriguez HE, Pearce WH, Eskandari MK

HYPOTHESIS: Thoracic endovascular aortic repair (TEVAR) for acute blunt thoracic aortic injury has good early and mid-term results. DESIGN: Single-center retrospective 7-year review from January 2001 to December 2008. SETTING: Urban tertiary care hospital. PATIENTS: Twenty-four consecutive patients with acute blunt thoracic aortic injury treated with TEVAR. MAIN OUTCOME MEASURES: Procedure-related mortality, stroke, or paraplegia; injury severity score; and complications. RESULTS: Among the 24 treated patients (mean age, 41 years; range, 20-71 years), the mean injury severity score was 43 (range, 25-66). Thoracic endovascular aortic repair was successful in treating the aortic injury in all patients and there were no instances of procedure-related death, stroke, or paraplegia. Access to the aorta was obtained through an open femoral/iliac approach (n = 7) or an entirely percutaneous groin approach (n = 17). Systemic heparin was not used in 84% of cases. Two access complications (8%) occurred, requiring an iliofemoral bypass in one patient and a thrombectomy in another. One patient required secondary intervention for device collapse, which was treated successfully with repeat endografting. There have been no delayed device failures or complications among the entire cohort at mid-term follow-up. CONCLUSION: Thoracic endovascular aortic repair, via a percutaneous groin approach and without systemic anticoagulation, for blunt thoracic aortic injury can be performed safely with low periprocedural mortality and morbidity.

PMID: 20644131 [PubMed - in process]

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Contributing factors for the willingness to donate organs in the Hispanic american population.

Arch Surg. 2010 Jul;145(7):684-9

Authors: Salim A, Schulman D, Ley EJ, Berry C, Navarro S, Chan LS

OBJECTIVE: To identify factors that contribute to intent to donate organs in Hispanic American individuals. DESIGN: Cross-sectional telephone surveys. SETTING: Four southern California neighborhoods with a high percentage of Hispanic American individuals. PATIENTS: Respondents 18 years or older were drawn randomly from lists of Hispanic surnames. MAIN OUTCOME MEASURES: Telephone surveys were conducted that measured demographic and socioeconomic factors, cultural factors, awareness and knowledge, and perception and belief regarding organ donation, as well as the intent to become an organ donor. Logistic regression was performed to identify independent contributing factors to intent to register for organ donation. RESULTS: Five hundred twenty-four telephone surveys were conducted over a 3-week period. Seventy-three percent of those surveyed were between the ages of 18 and 44 years and the sample was equally divided between men and women. The following independent risk factors contributed to intent to register: low acculturation (adjusted odds ratio [AOR], 0.39; 95% confidence interval [CI], 0.24-0.62; P < .001), religion (AOR, 0.33; 95% CI, 0.17-0.60; P < .001), perception that the wealthy are more likely to receive organs (AOR, 0.41; 95% CI, 0.25-0.65; P = .001), belief that donation disfigures the body and impacts the funeral (AOR, 0.45; 95% CI, 0.22-0.89; P = .02), and family influence (AOR, 2.02; 95% CI, 1.28-3.22; P = .004). CONCLUSIONS: Among Hispanic American individuals, low acculturation, religion, belief, and family influence affect the intent to register for organ donation. To improve organ donation, these risk factors should be considered using specific, effective educational programs.

PMID: 20644132 [PubMed - in process]

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Autologous blood transfusion during emergency trauma operations.

Arch Surg. 2010 Jul;145(7):690-4

Authors: Brown CV, Foulkrod KH, Sadler HT, Richards EK, Biggan DP, Czysz C, Manuel T

HYPOTHESIS: Intraoperative cell salvage (CS) of shed blood during emergency surgical procedures provides an effective and cost-efficient resuscitation alternative to allogeneic blood transfusion, which is associated with increased morbidity and mortality in trauma patients. DESIGN: Retrospective matched cohort study. SETTING: Level I trauma center. PATIENTS: All adult trauma patients who underwent an emergency operation and received CS as part of their intraoperative resuscitation. The CS group was matched to a no-CS group for age, sex, Injury Severity Score, mechanism of injury, and operation performed. MAIN OUTCOME MEASURES: Amount and cost of allogeneic transfusion of packed red blood cells and plasma. RESULTS: The 47 patients in the CS group were similar to the 47 in the no-CS group for all matched variables. Patients in the CS group received an average of 819 mL of autologous CS blood. The CS group received fewer intraoperative (2 vs 4 U; P = .002) and total (4 vs 8 U; P < .001) units of allogeneic packed red blood cells. The CS group also received fewer total units of plasma (3 vs 5 U; P = .03). The cost of blood product transfusion (including the total cost of CS) was less in the CS group ($1616 vs $2584 per patient; P = .004). CONCLUSION: Intraoperative CS provides an effective and cost-efficient resuscitation strategy as an alternative to allogeneic blood transfusion in trauma patients undergoing emergency operative procedures.

PMID: 20644133 [PubMed - in process]

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Sepsis in general surgery: the 2005-2007 national surgical quality improvement program perspective.

Arch Surg. 2010 Jul;145(7):695-700

Authors: Moore LJ, Moore FA, Todd SR, Jones SL, Turner KL, Bass BL

OBJECTIVE: To document the incidence, mortality rate, and risk factors for sepsis and septic shock compared with pulmonary embolism and myocardial infarction in the general-surgery population. DESIGN: Retrospective review. SETTING: American College of Surgeons National Surgical Quality Improvement Program institutions. PATIENTS: General-surgery patients in the 2005-2007 National Surgical Quality Improvement Program data set. MAIN OUTCOME MEASURES: Incidence, mortality rate, and risk factors for sepsis and septic shock. RESULTS: Of 363 897 general-surgery patients, sepsis occurred in 8350 (2.3%), septic shock in 5977 (1.6%), pulmonary embolism in 1078 (0.3%), and myocardial infarction in 615 (0.2%). Thirty-day mortality rates for each of the groups were as follows: 5.4% for sepsis, 33.7% for septic shock, 9.1% for pulmonary embolism, and 32.0% for myocardial infarction. The septic-shock group had a greater percentage of patients older than 60 years (no sepsis, 40.2%; sepsis, 51.7%; and septic shock, 70.3%; P < .001). The need for emergency surgery resulted in more cases of sepsis (4.5%) and septic shock (4.9%) than did elective surgery (sepsis, 2.0%; septic shock, 1.2%) (P < .001). The presence of any comorbidity increased the risk of sepsis and septic shock 6-fold (odds ratio, 5.8; 95% confidence interval, 5.5-6.2) and increased the 30-day mortality rate 22-fold (odds ratio, 21.8; 95% confidence interval, 17.6-26.9). CONCLUSIONS: The incidences of sepsis and septic shock exceed those of pulmonary embolism and myocardial infarction. The risk factors for mortality include age older than 60 years, the need for emergency surgery, and the presence of any comorbidity. This study emphasizes the need for early recognition of patients at risk via aggressive screening and the rapid implementation of evidence-based guidelines.

PMID: 20644134 [PubMed - in process]

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“Live kidney donors live longer” and would you like to buy part of a bridge in brooklyn?

Arch Surg. 2010 Jul;145(7):701-2

Authors: Andreoni KA

PMID: 20644135 [PubMed - in process]

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Image of the month–quiz case.

Arch Surg. 2010 Jul;145(7):703

Authors: Nguyen TK, Edil BH

PMID: 20644136 [PubMed - in process]

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Image of the month–quiz case.

Arch Surg. 2010 Jul;145(7):705

Authors: Hong JJ, Schrump DS, Hughes MS

PMID: 20644137 [PubMed - in process]

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A novel method for reproducibly measuring the effects of interventions to improve emotional climate, indices of team skills and communication, and threat to patient outcome in a high-volume thoracic surgery center.

Arch Surg. 2010 May;145(5):489-95

Authors: Nurok M, Lipsitz S, Satwicz P, Kelly A, Frankel A

OBJECTIVE: To create and test a reproducible method for measuring emotional climate, surgical team skills, and threats to patient outcome by conducting an observational study to assess the impact of a surgical team skills and communication improvement intervention on these measurements. DESIGN: Observational study. SETTING: Operating rooms in a high-volume thoracic surgery center from September 5, 2007, through June 30, 2008. PARTICIPANTS: Thoracic surgery operating room teams. INTERVENTIONS: Two 90-minute team skills training sessions focused on findings from a standardized safety culture survey administered to all participants and highlighting positive and problematic aspects of team skills, communication, and leadership. The sessions created an interactive forum to educate team members on the importance of communication and to role-play optimal interactive and communication strategies. MAIN OUTCOME MEASURES: Calculated indices of emotional climate, team skills, and threat to patient outcome. RESULTS: The calculated communication and team skills score improved from the preintervention to postintervention periods, but the improvement extinguished during the 3 months after the intervention (P < .001). The calculated threat-to-outcome score improved following the team training intervention and remained statistically improved 3 months later (P < .001). CONCLUSIONS: Using a new method for measuring emotional climate, teamwork, and threats to patient outcome, we were able to determine that a teamwork training intervention can improve a calculated score of team skills and communication and decrease a calculated score of threats to patient outcome. However, the effect is only durable for threats to patient outcome.

PMID: 20479349 [PubMed - indexed for MEDLINE]

Parenteral nutrition: future directions.

Arch Surg. 2010 Jun;145(6):538-9

Authors: Matheson PJ

PMID: 20575188 [PubMed - in process]

Better is the enemy of good.

Arch Surg. 2010 Jun;145(6):557

Authors: Baigrie RJ

PMID: 20575189 [PubMed - in process]

The baby with the bathwater.

Arch Surg. 2010 Jun;145(6):577

Authors: Buyske J

PMID: 20575190 [PubMed - in process]

Finding the problems before fixing them: the culture of perioperative safety.

Arch Surg. 2010 Jun;145(6):589

Authors: Bold RJ

PMID: 20575191 [PubMed - in process]

Finding the problems before fixing them: the culture of perioperative safety.

Arch Surg. 2010 Jun;145(6):589

Authors: Bold RJ

PMID: 20575191 [PubMed - in process]

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Comparison of laparoscopic and open repair with mesh for the treatment of ventral incisional hernia: a randomized trial.

Arch Surg. 2010 Apr;145(4):322-8; discussion 328

Authors: Itani KM, Hur K, Kim LT, Anthony T, Berger DH, Reda D, Neumayer L,

BACKGROUND: Laparoscopic repair of ventral incisional hernias has not been proved to be safer than open mesh repair. DESIGN: Prospective randomized trial conducted between February 1, 2004, to January 31, 2007. SETTING: Four Veterans Affairs medical centers. PARTICIPANTS: One hundred sixty-two patients with ventral incisional hernias. INTERVENTIONS: Standardized laparoscopic or open repair. MAIN OUTCOME MEASURES: Overall complication rates at 8 weeks and the odds of complications, adjusted for study site, body mass index, and hernia type. RESULTS: Of the 162 randomized patients, 146 underwent surgery (73 open and 73 laparoscopic repairs). Complications were less common in the laparoscopic group (23 patients [31.5%]) compared with the open repair group (35 patients [47.9%]; adjusted odds ratio [AOR], 0.45; 95% confidence interval [CI], 0.22-0.91; P = .03). Surgical site infection through 8 weeks was less common in the laparoscopic group (5.6% vs 23.3%; AOR, 0.2; 95% CI, 0.1-0.6). The mean worst pain score in the laparoscopic group was 15.2 mm lower on a visual analog scale at 52 weeks (95% CI, 1.0-29.3; P = .04). Time to resume work activities was shorter for the laparoscopic group than for the open repair group (median, 23.0 days vs 28.5 days), with an adjusted hazard ratio of 0.54 (95% CI, 0.28-1.04; P = .06). Overall recurrence at 2 years was 12.5% in the laparoscopic group and 8.2% in the open repair group (AOR, 1.6; 95% CI, 0.5-4.7; adjusted P = .44). CONCLUSIONS: Laparoscopic repair was associated with fewer, albeit more severe, complications and improved some patient-centered outcomes. Trial Registration clinicaltrials.gov Identifier: NCT00240188.

PMID: 20404280 [PubMed - indexed for MEDLINE]

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A randomized controlled trial to assess the effect of audiotaped consultations on the quality of informed consent in cardiac surgery.

Arch Surg. 2010 Apr;145(4):383-8

Authors: Mishra PK, Mathias H, Millar K, Nagrajan K, Murday A

OBJECTIVE: To evaluate the effect of audiotaping outpatient consultations on informed consent for cardiac surgery. DESIGN: Randomized controlled trial. SETTING: Tertiary health care center in Scotland. PARTICIPANTS: Eighty-four patients who had first-time coronary artery surgery conducted by 1 surgeon from February 10, 2005, through March 15, 2006, whose consultations before surgery were audiotaped. INTERVENTION: Randomization to 3 trial arms. The control group (n = 29) received no tape. The generic group (n = 25) received a tape about coronary artery surgery, which we scripted to include information covering the domains described by the General Medical Council. The consultation group (n = 30) received a tape of their consultation interview. On admission to the hospital, patients were interviewed with the Knowledge Questionnaire, the Multidimensional Health Locus of Control, and the Hospital Anxiety and Depression Scale. MAIN OUTCOME MEASURES: The effect of audiotaping in improving the informed consent process for cardiac surgery. RESULTS: The mean knowledge score of patients in the consultation group was much higher than that of the control individuals (P < .001). Patients in the consultation group reported a significantly greater sense of control with regard to their own health (P < .001) and being less anxious and depressed overall. CONCLUSION: Providing an audiotaped recording of the consultation before cardiac surgery appears to improve patients’ knowledge and perceptions of control of their health status and to reduce anxiety and depression. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN20081026.

PMID: 20404290 [PubMed - indexed for MEDLINE]

A bath a day.

Arch Surg. 2010 Mar;145(3):246

Authors: Towfigh S

PMID: 20329344 [PubMed - in process]

Further refinement of the optimal treatment following radical gastric resection for gastric adenocarcinoma.

Arch Surg. 2010 Mar;145(3):239

Authors: Ferri L, Mulder DS

PMID: 20329345 [PubMed - in process]

What do we gain and lose from database studies?

Arch Surg. 2010 Mar;145(3):253-4

Authors: Shamji MF

PMID: 20329346 [PubMed - in process]

The future of CACs in wound healing.

Arch Surg. 2010 Mar;145(3):266

Authors: Maggi J, Brem H

PMID: 20329349 [PubMed - in process]

Foregut surgery by the letter: is J better than inverted T or V?

Arch Surg. 2010 Mar;145(3):285

Authors: Farnell MB

PMID: 20329351 [PubMed - in process]

What makes a “good” quality indicator?

Arch Surg. 2010 Mar;145(3):295

Authors: Dimick JB

PMID: 20329352 [PubMed - in process]

Solution to the medical malpractice crisis: don’t hold your breath.

Arch Surg. 2010 Mar;145(3):300-1

Authors: Mabry CD

PMID: 20329353 [PubMed - in process]

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Influence of histamine receptor antagonists on the outcome of perforated appendicitis: analysis from a prospective trial.

Arch Surg. 2010 Feb;145(2):143-6

Authors: St Peter SD, Sharp SW, Ostlie DJ

HYPOTHESIS: Diphenhydramine blocks the H(1) receptor to treat pruritus or to induce sleep, while ranitidine blocks the H(2) receptor to suppress gastric acid. They are often given to ill patients, such as those with perforated appendicitis. However, these receptors are integral to the inflammatory response, and to our knowledge, the impact of H(1) or H(2) blockade on outcome in the setting of perforated appendicitis has never been evaluated. DESIGN: Prospective randomized trial. SETTING: Referral center. PATIENTS: Children undergoing an operation for perforated appendicitis from April 2005 to November 2006. MAIN OUTCOME MEASURES: We conducted multivariate analysis with Pearson correlation on data from a prospective randomized trial comparing antibiotic regimen after appendectomy for perforated appendicitis and outcome. Medications with a significant correlation to abscess development were investigated by comparing those receiving the medication with those who did not using the t test for continuous variables and chi(2) test for discrete variables. Significance was defined as P < or = .05. RESULTS: Significant correlations were found between the use of ranitidine (P = .05) or diphenhydramine (P = .03) and the development of an abscess. Direct comparison found no differences in patient or operative variables in those given either medication compared with those receiving no doses. Abscess rate in those receiving neither medication (n = 41) was 10%. Those given only ranitidine (n = 24) or diphenhydramine (n = 17) had doubled abscess rates of 17% and 18%, respectively. Those given both medications (n = 16) had a quadrupled abscess rate of 44% (P = .03). CONCLUSIONS: Ranitidine or diphenhydramine given to patients with perforated appendicitis may increase the risk of postoperative abscess. Therefore, these medications should not be used empirically in this population.

PMID: 20157081 [PubMed - indexed for MEDLINE]

Pain Following Breast Cancer Surgery: A Quality-of-Life Issue.

Arch Surg. 2010 Mar;145(3):224-5

Authors: Shockney LD

PMID: 20231621 [PubMed - in process]

Antineoplastic effects of decitabine, an inhibitor of DNA promoter methylation, in adrenocortical carcinoma cells.

Arch Surg. 2010 Mar;145(3):226-32

Authors: Suh I, Weng J, Fernandez-Ranvier G, Shen WT, Duh QY, Clark OH, Kebebew E

Hypotheses Decitabine recovers expression of silenced genes on chromosome 11q13 and has antineoplastic effects in adrenocortical carcinoma (ACC) cells. DESIGN: NCI-H295R cells were treated with decitabine (0.1-1.0muM) over 5 days. Cells were evaluated at 24-hour intervals for the effects of decitabine on ACC cell proliferation, cortisol secretion, and cell invasion. Expression was quantified for 6 genes on 11q13 (DDB1, MRPL48, NDUFS8, PRDX5, SERPING1, and TM7SF2) that were previously shown to be underexpressed in ACC. SETTING: Academic research. Study Specimen Human ACC cell line. MAIN OUTCOME MEASURES: Adrenocortical carcinoma cell proliferation, cortisol secretion, and cell invasion were measured using immunometric assays. Quantitative reverse transcription-polymerase chain reaction was used to measure gene expression relative to GAPDH. RESULTS: Decitabine inhibited ACC cell proliferation by 39% to 47% at 5 days after treatment compared with control specimens (P < .001). The inhibitory effect was cytostatic, time dependent, and dose dependent. Decitabine decreased cortisol secretion by 56% to 58% at 5 days after treatment (P = .02) and inhibited cell invasion by 64% at 24 hours after treatment (P = .03). Of 6 downregulated genes on 11q13, decitabine recovered expression of NDUFS8 (OMIM 602141) (P < .001) and PRDX5 (OMIM 606583) (P = .006). CONCLUSIONS: Decitabine exhibits antitumoral properties in ACC cells at clinically achievable doses and may be an effective adjuvant therapy in patients with advanced disease. Decitabine recovers expression of silenced genes on 11q13, which suggests a possible role of epigenetic gene silencing in adrenocortical carcinogenesis.

PMID: 20231622 [PubMed - in process]

Adjuvant Chemoradiotherapy in Patients With Stage III or IV Radically Resected Gastric Cancer: A Pilot Study.

Arch Surg. 2010 Mar;145(3):233-8

Authors: Orditura M, De Vita F, Muto P, Vitiello F, Murino P, Lieto E, Vecchione L, Romano A, Martinelli E, Renda A, Ferraraccio F, Del Genio A, Ciardiello F, Galizia G

BACKGROUND: Adjuvant chemoradiotherapy does not represent the standard of care in patients with resected high-risk gastric cancer; however, results from phase 2 and randomized trials suggest improvement in overall survival. We assessed the feasibility and toxic effects of chemoradiotherapy as adjuvant treatment in locally advanced gastric cancer. DESIGN: Pilot study. SETTING: University hospital. PATIENTS: Twenty-nine patients with T4N+ or any TN23 gastric cancer previously treated with potentially curative surgery were enrolled. All of the patients received combined adjuvant chemotherapy with FOLFOX-4 (ie, a combination of folinic acid [leucovorin], fluorouracil, and oxaliplatin [Eloxatin]) for 8 cycles and concomitant radiotherapy (45 Gy in 25 daily fractions over 5 weeks). Radiotherapy was begun after the first 2 cycles of FOLFOX-4, which was reduced by 25% during the period of concomitant radiotherapy. MAIN OUTCOME MEASURES: Treatment toxic effects according to the National Cancer Institute-Common Toxicity Criteria classification, overall and disease-free survival rates, and identification of prognostic indicators. RESULTS: All of the patients completed treatment. Severe hematologic and gastrointestinal toxic effects occurred in 10% and 33%, respectively. No acute hepatic or renal toxic effects were observed; 1 patient experienced severe neurotoxicity. Disease-free and overall survival rates at 1, 2, and 3 years were 79%, 35%, and 35% and 85%, 62.6%, and 50.1%, respectively, and were shown to be substantially better than those observed in untreated patients. Long-term outcome was related to TNM stage, basal serum tumor marker level, and, particularly, lymph node ratio. CONCLUSION: A multimodal approach with FOLFOX-4 and radiotherapy is feasible and effective for the treatment of patients with resected high-risk gastric cancer.

PMID: 20231623 [PubMed - in process]

Effect of chlorhexidine whole-body bathing on hospital-acquired infections among trauma patients.

Arch Surg. 2010 Mar;145(3):240-6

Authors: Evans HL, Dellit TH, Chan J, Nathens AB, Maier RV, Cuschieri J

OBJECTIVE: To demonstrate whether daily bathing with cloths impregnated with 2% chlorhexidine gluconate will decrease colonization of resistant bacteria and reduce the rates of health care-associated infections in critically injured patients. DESIGN: Retrospective analysis of data collected 6 months before and after institution of a chlorhexidine bathing protocol. SETTING: A 12-bed intensive care unit in a level I trauma center. PATIENTS: Two hundred eighty-six severely injured patients underwent daily chlorhexidine bathing during the 6-month intervention; 253 patients were bathed without chlorhexidine prior to the intervention. INTERVENTIONS: Daily chlorhexidine bathing. Main Outcomes Measures Rates of ventilator-associated pneumonia (VAP), bloodstream infection, and colonization with resistant organisms (methicillin-resistant Staphylococcus aureus [MRSA] or Acinetobacter species). RESULTS: Baseline patient and injury characteristics were similar between cohorts. Patients receiving chlorhexidine baths were significantly less likely to acquire a catheter-related bloodstream infection than comparators (2.1 vs 8.4 infections per 1000 catheter-days, P = .01). The incidence of VAP was not affected by chlorhexidine baths (16.9 vs 21.6 infections per 1000 ventilator-days in those with vs those without chlorhexidine baths, respectively, P = .30). However, patients who received chlorhexidine baths were less likely to develop MRSA VAP (1.6 vs 5.7 infections per 1000 ventilator-days, P = .03). The rate of colonization with MRSA (23.3 vs 69.3 per 1000 patient-days, P < .001) and Acinetobacter (1.0 vs 4.6 per 1000 patient-days, P = .36) was significantly lower in the chlorhexidine group than in the comparison group. CONCLUSIONS: Daily bathing of trauma patients with cloths impregnated with 2% chlorhexidine gluconate is associated with a decreased rate of colonization by MRSA and Acinetobacter and lower rates of catheter-related bloodstream infection and MRSA VAP.

PMID: 20231624 [PubMed - in process]

Disparities in Access to Neuro-oncologic Care in the United States.

Arch Surg. 2010 Mar;145(3):247-53

Authors: Mukherjee D, Zaidi HA, Kosztowski T, Chaichana KL, Brem H, Chang DC, Quiñones-Hinojosa A

HYPOTHESIS: Race/ethnicity and social status influence admission to high-volume hospitals among patients who undergo craniotomy for tumor biopsy or resection. DESIGN: Retrospective analysis of the Nationwide Inpatient Sample (1988-2005), with additional factors from the Area Resource File. SETTING: A 20% representative sample of all hospitals in 37 US states. PATIENTS: A total of 76 436 patients 18 years or older who were admitted and underwent craniotomy for tumor biopsy or resection. MAIN OUTCOME MEASURES: Odds ratios (ORs) for the association of age, sex, race/ethnicity, insurance status, Charlson Comorbidity Index, and county-level characteristics with admission to high-volume hospitals (>50 craniotomies per year) or low-volume hospitals. RESULTS: A total of 25 481 patients (33.3%) were admitted to high-volume hospitals. Overall access to high-volume hospitals improved over time. However, racial/ethnic disparities in access to high-volume hospitals dramatically worsened for Hispanics (OR, 0.49) and African Americans (OR, 0.62) in recent years. Factors associated with better access to high-volume hospitals included years since 1988 (OR, 1.11), greater countywide neurosurgeon density (OR, 1.66), and higher countywide median household income (OR, 1.71). Factors associated with worse access to high-volume hospitals included older age (OR, 0.34 per year increase), increased countywide poverty rate (OR, 0.57), Hispanic race/ethnicity (OR, 0.68), and higher Charlson Comorbidity Index (OR, 0.96 per point increase). CONCLUSIONS: African Americans and Hispanics have disproportionately worse access to high-quality neuro-oncologic care over time compared with whites. Higher countywide median household income and decreased countywide poverty rate were associated with better access to high-volume hospitals, implicating socioeconomic factors in predicting admission to high-quality centers.

PMID: 20231625 [PubMed - in process]

Association of increasing burn severity in mice with delayed mobilization of circulating angiogenic cells.

Arch Surg. 2010 Mar;145(3):259-66

Authors: Zhang X, Wei X, Liu L, Marti GP, Ghanamah MS, Arshad MJ, Strom L, Spence R, Jeng J, Milner S, Harmon JW, Semenza GL

OBJECTIVE: To perform a systematic exploration of the phenomenon of mobilization of circulating angiogenic cells (CACs) in an animal model. This phenomenon has been observed in patients with cutaneous burn wounds and may be an important mechanism for vasculogenesis in burn wound healing. DESIGN: We used a murine model, in which burn depth can be varied precisely, and a validated culture method for quantifying circulating CACs. SETTING: Michael D. Hendrix Burn Research Center, Baltimore, Maryland. PARTICIPANTS: Male 129S1/SvImJ mice, aged 8 weeks, and 31 patients aged 19-59 years with burn injury on 1% to 64% of the body surface area and evidence of hemodynamic stability. MAIN OUTCOME MEASURES: Burn wound histological features, including immunohistochemistry for blood vessels with CD31 and alpha-smooth muscle actin antibodies, blood flow measured with laser Doppler perfusion imaging, and mobilization of CACs into circulating blood measured with a validated culture technique. RESULTS: Increasing burn depth resulted in a progressive delay in the time to mobilization of circulating CACs and reduced mobilization of CACs. This delay and reduction in CAC mobilization was associated with reduced perfusion and vascularization of the burn wound tissue. Analysis of CACs in the peripheral blood of the human patients, using a similar culture assay, confirmed results previously obtained by flow cytometry, that CAC levels peak early after the burn wound. CONCLUSION: If CAC mobilization and wound perfusion are important determinants of clinical outcome, then strategies designed to augment angiogenic responses may improve outcome in patients with severe burn wounds. Trial Registration clinicaltrials.gov Identifier: NCT00796627.

PMID: 20231626 [PubMed - in process]

Robotics may overcome technical limitations of single-trocar surgery: an experimental prospective study of nissen fundoplication.

Arch Surg. 2010 Mar;145(3):267-71

Authors: Allemann P, Leroy J, Asakuma M, Al Abeidi F, Dallemagne B, Marescaux J

OBJECTIVE: To compare laparoscopic and robotic-assisted single-trocar access (STA) Nissen fundoplication in a porcine model. The STA procedure is an emerging concept in minimally invasive surgery that presents technical difficulties and challenges compared with traditional laparoscopy. Using multiple instruments inserted through a single trocar generates internal and external conflicts. Achieving triangulation requires the instruments and surgeon’s hands to cross over at the point of entry. Robotic-assisted surgery may overcome these difficulties owing to its capability of dissociating the hands of the surgeon from the instruments. DESIGN: Prospective study consisting of 18 randomly performed porcine STA Nissen fundoplications with and without robotic assistance. SETTING: A research institute. PARTICIPANTS: Three surgeons with different experience. MAIN OUTCOME MEASURES: Operative time, intraoperative complications, and the number of conflicts between the instruments and/or hands of the surgeons. RESULTS: All of the procedures were successfully completed. Mean operative time (45.6 +/- 11.2 vs 65.4 +/- 10.7 minutes; P = .03) and number of conflicts (1.0 +/- 0.9 vs 3.8 +/- 1.2; P < .001) were significantly reduced in the robotic series. CONCLUSIONS: Use of the robotic platform allows the surgeon to select which hand will move which instrument. Inverting the control allows crossing of the instruments without any consequences to the surgeon. Moreover, this system offers instruments with multiple degrees of freedom. These factors could explain the clear improvement demonstrated in this study. As a result, robotics may play an essential part in the diffusion of STA surgery.

PMID: 20231627 [PubMed - in process]

Central neck lymph node dissection for papillary thyroid cancer: comparison of complication and recurrence rates in 295 initial dissections and reoperations.

Arch Surg. 2010 Mar;145(3):272-5

Authors: Shen WT, Ogawa L, Ruan D, Suh I, Kebebew E, Duh QY, Clark OH

BACKGROUND: The American Thyroid Association recently changed its management guidelines for papillary thyroid cancer (PTC) to include routine central neck lymph node dissection (CLND) during thyroidectomy. We currently perform CLND during thyroidectomy only if enlarged central nodes are detected by palpation or ultrasonography; we perform CLND in the reoperative setting for recurrence in previously normal-appearing or incompletely resected nodes. Critics of this approach argue that reoperative CLND has higher complication and recurrence rates than initial CLND. We sought to test this argument, using it as our hypothesis. DESIGN: Retrospective review. SETTING: University hospital. PATIENTS: All patients undergoing CLND for PTC between January 1, 1998, and December 31, 2007. INTERVENTIONS: Thyroidectomy and CLND. MAIN OUTCOME MEASURES: Complications (neck hematoma, recurrent laryngeal nerve injury, and hypoparathyroidism) and recurrence of PTC. RESULTS: Altogether, 295 CLNDs were performed: 189 were initial operations and 106 were reoperations. The rate of transient hypocalcemia (41.8% vs 23.6%) was significantly higher in patients undergoing initial CLND compared with those undergoing reoperative CLND. Rates of neck hematoma (1.1% vs 0.9%), transient hoarseness (4.8% vs 4.7%), permanent hoarseness (2.6% vs 1.9%), and permanent hypoparathyroidism (0.5% vs 0.9%) were not different between initial and reoperative CLND. In addition, recurrence rates in the central (11.6% vs 14.1%) and lateral (21.7% vs 17.0%) compartments were not different between the 2 groups. CONCLUSIONS: Reoperative CLND for PTC has a lower rate of temporary hypocalcemia, the same rate of other complications, and the same rate of recurrence compared with initial CLND. Choosing to observe nonenlarged central neck lymph nodes for PTC does not result in increased complications or recurrence if reoperation is required.

PMID: 20231628 [PubMed - in process]

Identification of unknown primary tumors in patients with neuroendocrine liver metastases.

Arch Surg. 2010 Mar;145(3):276-80

Authors: Wang SC, Parekh JR, Zuraek MB, Venook AP, Bergsland EK, Warren RS, Nakakura EK

BACKGROUND: For patients with neuroendocrine tumor (NET) liver metastases, resection of the primary tumor may prevent local complications (obstruction, ischemia, and bleeding) and improve survival. Despite preoperative evaluation, the primary tumor location may remain unknown. DESIGN: Retrospective cohort analysis of pathology database from January 1, 1993, to August 15, 2008. SETTING: Academic medical center. PATIENTS: One hundred twenty-three patients with NET liver metastases. MAIN OUTCOME MEASURES: Successful identification and resection of the primary tumor. RESULTS: Fifteen patients underwent surgical exploration. The primary tumor was located in 13 patients (86.7%) in the small intestine and resected in 12 patients. Primary tumors in the small intestine found during surgical exploration were significantly smaller than those identified preoperatively (1.38 vs 1.91 cm, P = .03) and were often multifocal (54.2% [n = 15]). Computed tomography (34.6% [n = 78]) and somatostatin receptor scintigraphy (26.2% [n = 42]) were not sensitive in locating a primary NET in the gastrointestinal tract. Colonoscopy was sensitive in detecting colonic NETs (86.7% [n = 15]). CONCLUSION: For patients with NET liver metastases and unknown primary tumor, surgical exploration effectively identifies and resects occult primary tumors that are often located in the small intestine. Primary tumors are usually small and multifocal, so careful palpation of the small intestine is essential. Before patients are considered for surgery, a multidisciplinary team assessment and evaluation consisting of computed tomography, somatostatin receptor scintigraphy, and upper and lower endoscopy should be done.

PMID: 20231629 [PubMed - in process]

Modified makuuchi incision for foregut procedures.

Arch Surg. 2010 Mar;145(3):281-4

Authors: Chang SB, Palavecino M, Wray CJ, Kishi Y, Pisters PW, Vauthey JN

The Makuuchi or J incision completely exposes the liver and right-sided retroperitoneal organs. The modified Makuuchi incision also achieves a superb en face view of critical structures, including the hepatocaval junction and the esophageal hiatus, but does not divide the intercostal muscles, thus reducing muscle atrophy and postoperative pain. This incision also offers significant advantages over other incisions commonly used in foregut surgery. We describe herein the use of the modified Makuuchi incision for foregut procedures, with particular emphasis on strategic retractor placement.

PMID: 20231630 [PubMed - in process]

Quality indicators for evaluating trauma care: a scoping review.

Arch Surg. 2010 Mar;145(3):286-95

Authors: Stelfox HT, Bobranska-Artiuch B, Nathens A, Straus SE

OBJECTIVES: To systematically review the literature on quality indicators (QIs) for evaluating trauma care, identify QIs, map their definitions, and examine the evidence base in support of the QIs. DATA SOURCES: We searched MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Reviews of Effects, and Cochrane Central Register of Controlled Trials from the earliest available date through January 14, 2009. To increase the sensitivity of the search, we also searched the grey literature and select journals by hand, reviewed reference lists to identify additional studies, and contacted experts in the field. Study Selection and DATA EXTRACTION: We selected all articles that identified or proposed 1 or more QIs to evaluate the quality of care delivered to patients with major traumatic injuries. Minimum inclusion criteria were a description of 1 or more QIs designed to evaluate patients with major traumatic injuries (defined as multisystem injuries resulting in hospitalization or death) and focused on prehospital care, hospital care, posthospital care, or secondary injury prevention. DATA SYNTHESIS: The literature search identified 6869 citations. Review of abstracts led to the retrieval of 538 full-text articles for assessment, of which 192 articles were selected for review. Of these, 128 (66.7%) articles were original research, predominantly trauma database case series (57 [29.7%]) and cohort studies (55 [28.6%]), whereas 37 (19.3%) were narrative reviews and 8 (4.2%) were guidelines. A total of 1572 QIs in trauma care were identified and classified into 8 categories: non-American College of Surgeons Committee on Trauma (ACS-COT) audit filters (42.0%), ACS-COT audit filters (19.1%), patient safety indicators (13.2%), trauma center/system criteria (10.2%), indicators measuring or benchmarking outcomes of care (7.4%), peer review (5.5%), general audit measures (1.8%), and guideline availability or adherence (0.8%). Measures of prehospital and hospital processes (60.4%) and outcomes (22.8%) were the most common QIs identified. Posthospital and secondary injury prevention QIs accounted for less than 5% of QIs. CONCLUSIONS: Many QIs for evaluating the quality of trauma care have been proposed, but the evidence to support these indicators is not strong. Practical recommendations to select QIs to measure the quality of trauma care will require systematic reviews of identified candidate indicators and empirical studies to fill the knowledge gaps for postacute QIs.

PMID: 20231631 [PubMed - in process]

Solving the medical malpractice crisis: use a clear and convincing evidence standard.

Arch Surg. 2010 Mar;145(3):296-300

Authors: Engel E, Livingston EH

The medical malpractice crisis has smoldered for many years with few new ideas regarding how to improve matters. Physicians promote limits on plaintiff noneconomic damages, but this has been ferociously resisted by the legal community. They argue that limiting remuneration to patients harmed by negligent practices is fundamentally wrong. We hypothesize that malpractice litigation is out of control because of an excessively lax evidence standard. Raising the evidence standard from the current “more likely than not” to “clear and convincing” would sharply reduce medical malpractice judgments against physicians. Clear and convincing is an evidence standard currently in use by courts for certain cases, and its adoption for malpractice litigation would not limit compensation for injuries resulting from negligent practices and should be well received by the legal community.

PMID: 20231632 [PubMed - in process]

Adrenal and pancreatic presentation of subdiaphragmatic retroperitoneal bronchogenic cysts.

Arch Surg. 2010 Mar;145(3):302-4

Authors: El Youssef R, Fleseriu M, Sheppard BC

Bronchogenic cysts are aberrations of normal development throughout the embryonic foregut; abdominal or retroperitoneal presentations are rare. They will often present a diagnostic dilemma because their appearance can mimic other, more common diagnoses. The initial work-up, differential diagnosis, management, and follow-up may present clinical challenges. We present 1 case of an adrenal lesion and 1 case of a pancreatic lesion that were revealed to be retroperitoneal bronchogenic cysts after surgical extirpation.

PMID: 20231633 [PubMed - in process]

Image of the month–quiz case.

Arch Surg. 2010 Mar;145(3):305

Authors: Maxey D, Wick EC, Gearhart S

PMID: 20231634 [PubMed - in process]

Image of the month–quiz case.

Arch Surg. 2010 Mar;145(3):307

Authors: Perkins RS, Reddy J, Lal R

PMID: 20231635 [PubMed - in process]

Planned laparoscopic approach for early-stage gallbladder cancer: the glass is one-third full.

Arch Surg. 2010 Feb;145(2):133

Authors: Matthews JB

PMID: 20183936 [PubMed - in process]

Potential perils of seemingly harmless drugs.

Arch Surg. 2010 Feb;145(2):147

Authors: Heller SF, Sarr MG

PMID: 20183937 [PubMed - in process]

Broadening never events: is it a plausible road to improved patient safety?

Arch Surg. 2010 Feb;145(2):151-2

Authors: MacLeod JB

PMID: 20183938 [PubMed - in process]

Surgical care delivery and world health.

Arch Surg. 2010 Feb;145(2):160

Authors: Khalil I

PMID: 20183940 [PubMed - in process]

More than size matters.

Arch Surg. 2010 Feb;145(2):186

Authors: Chen F, Zingmond D, Ko C

PMID: 20183941 [PubMed - in process]

Validity in educational research: critically important but frequently misunderstood.

Arch Surg. 2010 Feb;145(2):201

Authors: Wright AS

PMID: 20183942 [PubMed - in process]

Health care reform and comparative effectiveness: implications for surgeons.

Arch Surg. 2010 Feb;145(2):120-2

Authors: Urbach DR, Morris AM

PMID: 20157076 [PubMed - in process]

Open letter to young surgeons interested in humanitarian surgery.

Arch Surg. 2010 Feb;145(2):123-4

Authors: Chu K

PMID: 20157077 [PubMed - in process]

Preventing outbreaks: making our medication delivery system safer.

Arch Surg. 2010 Feb;145(2):125-6

Authors: Lipsett PA

PMID: 20157078 [PubMed - in process]

Laparoscopic approach for suspected early-stage gallbladder carcinoma.

Arch Surg. 2010 Feb;145(2):128-33

Authors: Cho JY, Han HS, Yoon YS, Ahn KS, Kim YH, Lee KH

OBJECTIVE: To determine the feasibility of the laparoscopic approach for treating suspected early-stage gallbladder carcinoma. Design, Setting, and PATIENTS: Prospective study from a university hospital. From May 10, 2004, to October 9, 2007, the laparoscopic approach was considered for treating 36 patients with suspected gallbladder carcinoma at T2 or less without liver invasion based on the preoperative computed tomographic scan. To further exclude liver invasion, preoperative endoscopic ultrasonography (US) and laparoscopic US were additionally performed. Frozen biopsy was performed after completing the cholecystectomy. If carcinoma was found, laparoscopic lymphadenectomy was performed. MAIN OUTCOME MEASURES: Feasibility and operative outcome. RESULTS: Three patients who had liver invasion on endoscopic US underwent open surgery. An additional 3 patients who had liver invasion noted on laparoscopic US had their surgical procedure converted to laparotomy. Finally, 30 patients underwent a laparoscopic procedure. With combined computed tomography, endoscopic US, and laparoscopic US, the negative predictive value for excluding hepatic invasion reached 100%. For the 12 patients who had benign lesions noted on their frozen biopsies, their laparoscopic surgical procedure was completed. The remaining 18 patients who had gallbladder carcinoma underwent additional laparoscopic lymphadenectomy. During laparoscopic lymphadenectomy 1 conversion occurred owing to bleeding, the median operative time was 190 minutes, and the median blood loss was 50 mL. The complication rate was 16.7% and the median postoperative hospital stay was 4 days. After a median follow-up of 27 months, all 18 patients who underwent laparoscopic lymphadenectomy survived without any evidence of recurrence or metastasis. CONCLUSION: Laparoscopic treatment is feasible and safe in selected patients with early-stage gallbladder carcinoma.

PMID: 20157079 [PubMed - in process]

Predictors of occult nodal metastasis in patients with thin melanoma.

Arch Surg. 2010 Feb;145(2):137-42

Authors: Faries MB, Wanek LA, Elashoff D, Wright BE, Morton DL

HYPOTHESIS: Thin primary lesions are largely responsible for the rapid increase in melanoma incidence, making identification of appropriate candidates for nodal staging in this group critically important. We hypothesized that common clinical variables may accurately estimate the risk of nodal metastasis after wide excision and determine the need for sentinel node biopsy. DESIGN: Review of prospectively acquired data in a large melanoma database. SETTING: A tertiary referral center. PATIENTS: A total of 2211 patients with thin melanoma treated by wide local excision alone were identified in the database between January 1, 1971, and December 31, 2005. Of those, 1732 met entry criteria. MAIN OUTCOME MEASURES: We examined the rate of regional nodal recurrence and the impact of clinical and demographic variables by univariate and multivariate analyses. RESULTS: The overall nodal recurrence rate was 2.9%; median time to recurrence was 38.3 months. Univariate analysis of 1732 patients identified male sex (P < .001), increased Breslow thickness (P < .001), and increased Clark level (P < .001) as significant for nodal recurrence. Multivariate analysis identified male sex (hazard ratio, 3.5; 95% confidence interval, 1.8-7.0; P < .001), younger age (0.45; 0.24-0.86; P = .001), and increased Breslow thickness (2.5; 1.6-3.7; categorical P < .001) as significant for nodal recurrence. The Clark level was no longer significant (P = .63). Breslow thickness, age, and sex were used to develop a scoring system and nomogram for the risk of nodal involvement. Predictions ranged from 0.1% in the lowest-risk group to 17.4% in the highest-risk group. CONCLUSIONS: Many patients with thin melanoma will have nodal recurrence after wide excision alone. Three simple clinical variables may be used to estimate recurrence risk and select patients for sentinel node biopsy.

PMID: 20157080 [PubMed - in process]

Patient characteristics and the occurrence of never events.

Arch Surg. 2010 Feb;145(2):148-51

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

OBJECTIVE: To determine whether the occurrence of “never events” after major surgical procedures is affected by patient and disease characteristics and by the type of operation performed. DESIGN: Epidemiological analysis. INTERVENTIONS: Derivation and assessment of predictive equations for postoperative infectious events and decubitus ulcers using Healthcare Cost and Utilization Project Nationwide Inpatient Sample administrative claims data for patients hospitalized between 2002 and 2005. MAIN OUTCOME MEASURES: C statistics for each predictive equation with and without hospital dummy variables. RESULTS: Predictive equations for 6 of 8 complications had C statistics greater than 0.65 without hospital variables, while 2 had C statistics of less than 0.55. All equations had C statistics greater than 0.75 when hospital dummy variables were included. CONCLUSIONS: Patient characteristics and type of operative procedure are important predictors of complications of surgical care evaluated in this study, undermining the rationale for their current classification as “never events.” Variations in risk-adjusted complication rates among hospitals support the influence of quality of care on their occurrence. Development and use of warranties to cover costs associated with caring for the unavoidable components of potentially avoidable complications is proposed as a means of rewarding high-quality providers without creating unrealistic expectations or perverse financial incentives.

PMID: 20157082 [PubMed - in process]

Addressing the millennium development goals from a surgical perspective: essential surgery and anesthesia in 8 low- and middle-income countries.

Arch Surg. 2010 Feb;145(2):154-9

Authors: Kushner AL, Cherian MN, Noel L, Spiegel DA, Groth S, Etienne C

HYPOTHESIS: Surgical and anesthetic care is increasingly recognized as a neglected but cost-effective component of primary health care in low- and middle-income countries (LMICs). Strengthening delivery can help achieve Millennium Development Goals 4, 5, and 6. Large gaps in access to essential surgical care in LMICs result in considerable morbidity and mortality. The goal of this study was to provide a baseline overview of essential surgical and anesthetic capacity at district-level health facilities in multiple LMICs. DESIGN: Survey. SETTING: District-level health facilities in multiple LMICs MAIN OUTCOME MEASURES: A standardized World Health Organization tool was used at selected district-level hospitals to assess infrastructure, supplies, and procedures relating to essential surgical and anesthetic capacity. The analysis included facilities from countries that assessed more than 5 health facilities. All data were aggregated and blinded to avoid intercountry comparisons. RESULTS: Data from 132 facilities were analyzed from 8 countries: Democratic Socialist Republic of Sri Lanka (n = 32), Mongolia (n = 31), United Republic of Tanzania (n = 25), Islamic State of Afghanistan (n = 13), Republic of Sierra Leone (n = 11), Republic of Liberia (n = 9), Republic of The Gambia (n = 6), and Democratic Republic of São Tomé and Príncipe (n = 5). Universally, facilities demonstrated shortfalls in basic infrastructure (water, electricity, oxygen) and functioning anesthesia machines. Although 73% of facilities reported performing incision and drainage of abscesses, only 48% were capable of undertaking an appendectomy. In line with Millennium Development Goals 4, 5, and 6, only 32% of facilities performed congenital hernia repairs, 44% of facilities performed cesarean sections, and few facilities always had goggles and aprons to protect surgical health care workers from human immunodeficiency virus. CONCLUSION: Enormous shortfalls in infrastructure, supplies, and procedures undertaken are common at district-level health facilities in LMICs.

PMID: 20157083 [PubMed - in process]

Underuse of axillary dissection for the management of sentinel node micrometastases in breast cancer.

Arch Surg. 2010 Feb;145(2):161-6

Authors: Wasif N, Maggard MA, Ko CY, Giuliano AE

BACKGROUND: Current American Society of Clinical Oncology guidelines for management of sentinel node micrometastases (SNMM) in breast cancer recommend axillary lymph node dissection (ALND) for all patients. OBJECTIVE: To assess nationwide use of ALND for SNMM. DESIGN: Population-based retrospective observational study. SETTING: The National Cancer Institute’s Surveillance, Epidemiology, and End Results database (1998-2005). PATIENTS: Five thousand three hundred fifty-three patients with SNMM. Main Outcome Measure Use of ALND after identification of SNMM. RESULTS: The prevalence of SNMM increased from 2.5% in 1998 to 17.7% in 2005. Of 5353 patients with SNMM, 2160 (40.4%) had no further nodal surgery and 3193 (59.6%) underwent ALND. In the latter group, histopathologic examination of nonsentinel nodes upstaged 18.6% of cases to N1, 2.2% to N2, and 0.1% to N3 disease. Multivariate analysis using logistic regression showed that age younger than 66 years (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.56-2.04), high tumor grade (OR, 1.22; 95% CI, 1.07- 1.40), and tumor size larger than 2 cm (OR, 1.16; 95% CI, 1.01-1.32) were predictive of ALND. Predictors of upstaging were infiltrating lobular histology (OR, 1.23; 95% CI, 1.00-1.51), T2 stage (OR, 1.38; 95% CI, 1.14-1.67), T3 stage (OR, 3.66; 95% CI, 1.70-7.90), and number of nodes examined (OR, 1.04; 95% CI, 1.03-1.05). CONCLUSIONS: Only 60% of patients with SNMM from breast cancer are treated according to American Society of Clinical Oncology guidelines. Nodal staging based only on sentinel node biopsy may underestimate the extent of nodal disease in 20.9% of cases. Surgical management of SNMM should be standardized.

PMID: 20157084 [PubMed - in process]

Pancreatoduodenectomy for ductal adenocarcinoma: implications of positive margin on survival.

Arch Surg. 2010 Feb;145(2):167-72

Authors: Fatima J, Schnelldorfer T, Barton J, Wood CM, Wiste HJ, Smyrk TC, Zhang L, Sarr MG, Nagorney DM, Farnell MB

OBJECTIVE: To assess the effect of R0 resection margin status and R0 en bloc resection in pancreatoduodenectomy outcomes. DESIGN: Retrospective medical record review. SETTING: Mayo Clinic, Rochester, Minnesota. PATIENTS: Patients who underwent pancreatoduodenectomy for pancreatic adenocarcinoma at our institution between January 1, 1981, and December 31, 2007, were identified and their medical records were reviewed. Main Outcome Measure Median survival times. RESULTS: A total of 617 patients underwent pancreatoduodenectomy. Median survival times after R0 en bloc resection (n = 411), R0 non-en bloc resection (n = 57), R1 resection (n = 127), and R2 resection (n = 22) were 19, 18, 15, and 10 months, respectively (P < .001). A positive resection margin was associated with death (P = .01). No difference in survival time was found between patients undergoing R0 en bloc and R0 resections after reexcision of an initial positive margin (hazard ratio, 1.19; 95% confidence interval, 0.87-1.64; P = .28). CONCLUSIONS: R0 resection remains an important prognostic factor. Achieving R0 status by initial en bloc resection or reexcision results in similar long-term survival.

PMID: 20157085 [PubMed - in process]

Revisional bariatric surgery: 13-year experience from a tertiary institution.

Arch Surg. 2010 Feb;145(2):173-7

Authors: Spyropoulos C, Kehagias I, Panagiotopoulos S, Mead N, Kalfarentzos F

OBJECTIVE: To evaluate the safety and effectiveness of revisional bariatric surgery at a tertiary institution. Revisional bariatric operations for unsuccessful weight loss or intolerable complications following the primary intervention are increasing. DESIGN: Case series from a prospective database. SETTING: Tertiary bariatric referral center. PATIENTS: From 1995 to 2008, 56 patients who had been formerly operated on for clinically severe obesity underwent a revisional procedure at our institution. Their mean (SD) age and body mass index were 39.6 (9.6) years and 46.9 (16.4), respectively. They were divided into 3 groups according to the indications for reoperation: (1) unsatisfactory weight loss (n = 39), (2) severe nutritional complications (n = 15), and (3) intolerable adverse effects (n = 2). MAIN OUTCOME MEASURES: Effectiveness of the procedures according to the indication of revision and overall morbidity and mortality rates. RESULTS: Mean (SD) follow-up was 102 (8) months. There was no mortality but there was an early morbidity rate of 33.9% due to postoperative complications, including 2 cases of acute renal failure (3.6%), 5 anastomotic leaks (13.1%), 8 cases of pneumonia (14.3%), and 1 case each of wound infection, incisional dehiscence, bile leak, and small-bowel obstruction (1.8%). Late complications included stenosis of the gastrojejunal anastomosis in 2 patients (3.6%), hypoalbuminemia in 2 patients (3.6%), and incisional herniation in 9 patients (16.1%). Late morbidity was 23.2%. CONCLUSION: Although revisional bariatric surgery is associated with higher risk of perioperative complications compared with the primary procedures, it appears to be safe and effective when performed in experienced centers.

PMID: 20157086 [PubMed - in process]

Racial and ethnic differences in the use of high-volume hospitals and surgeons.

Arch Surg. 2010 Feb;145(2):179-86

Authors: Epstein AJ, Gray BH, Schlesinger M

OBJECTIVE: To examine racial/ethnic differences in the use of high-volume hospitals and surgeons for 10 surgical procedures with documented associations between volume and mortality. DESIGN: Cross-sectional regression analysis. SETTING: New York City area hospital discharge data, 2001-2004. PATIENTS: Adults from 4 racial/ethnic categories (white, black, Asian, and Hispanic) who underwent surgery for cancer (breast, colorectal, gastric, lung, or pancreatic resection), cardiovascular disease (coronary artery bypass graft, coronary angioplasty, abdominal aortic aneurysm repair, or carotid endarterectomy), or orthopedic conditions (total hip replacement). Main Outcome Measure Treatment by a high-volume surgeon at a high-volume hospital. RESULTS: There were 133 821 patients who underwent 1 of the 10 procedures. For 9 of the 10 procedures, black patients were significantly (P < .05) less likely (after adjustment for sociodemographic characteristics, insurance type, proximity to high-volume providers, and comorbidities) to be operated on by a high-volume surgeon at a high-volume hospital and more likely to be operated on by a low-volume surgeon at a low-volume hospital. Asian and Hispanic patients, respectively, were significantly less likely to use high-volume surgeons at high-volume hospitals for 5 and 4 of the 10 procedures and more likely to use low-volume surgeons at low-volume hospitals for 3 and 5 of the 10 procedures. CONCLUSIONS: Minority patients in New York City are doubly disadvantaged in their surgical care; they are substantially less likely to use both high-volume hospitals and surgeons for procedures with an established volume-mortality association. Better information is needed about which providers minority patients have access to and how they select them.

PMID: 20157087 [PubMed - in process]

Translational research in surgical disease.

Arch Surg. 2010 Feb;145(2):187-96

Authors: Stojadinovic A, Ahuja N, Nazarian SM, Segev DL, Jacobs L, Wang Y, Eberhardt J, Zeiger MA

OBJECTIVE: To review cutting-edge, novel, implemented and potential translational research and to provide a glimpse into rich, innovative, and brilliant approaches to everyday surgical problems. DATA SOURCES: Scientific literature and unpublished results. STUDY SELECTION: Articles reviewed were chosen based on innovation and application to surgical diseases. DATA EXTRACTION: Each section was written by a surgeon familiar with cutting-edge and novel research in their field of expertise and interest. DATA SYNTHESIS: Articles that met criteria were summarized in the manuscript. CONCLUSIONS: Multiple avenues have been used for the discovery of improved means of diagnosis, treatment, and overall management of patients with surgical diseases. These avenues have incorporated the use of genomics, electrical impedence, statistical and mathematical modeling, and immunology.

PMID: 20157088 [PubMed - in process]

A unified approach to validation, reliability, and education study design for surgical technical skills training.

Arch Surg. 2010 Feb;145(2):197-201

Authors: Sweet RM, Hananel D, Lawrenz F

OBJECTIVE: To present modern educational psychology theory and apply these concepts to validity and reliability of surgical skills training and assessment. DESIGN: In a series of cross-disciplinary meetings, we applied a unified approach of behavioral science principles and theory to medical technical skills education given the recent advances in the theories in the field of behavioral psychology and statistics. CONCLUSIONS: While validation of the individual simulation tools is important, it is only one piece of a multimodal curriculum that in and of itself deserves examination and study. We propose concurrent validation throughout the design of simulation-based curriculum rather than once it is complete. We embrace the concept that validity and curriculum development are interdependent, ongoing processes that are never truly complete. Individual predictive, construct, content, and face validity aspects should not be considered separately but as interdependent and complementary toward an end application. Such an approach could help guide our acceptance and appropriate application of these exciting new training and assessment tools for technical skills training in medicine.

PMID: 20157089 [PubMed - in process]

Hemorrhagic cholecystitis.

Arch Surg. 2010 Feb;145(2):202-4

Authors: Parekh J, Corvera CU

Hemorrhagic cholecystitis is a rare cause of abdominal pain that can present in the setting of trauma, malignancy, and bleeding diathesis, such as renal failure, cirrhosis, and anticoagulation. Its symptoms are easily confused with acute calculous cholecystitis and might include hemobilia or hematemesis as blood drains from the gallbladder into the gastrointestinal tract. Imaging of hemorrhagic cholecystitis can be misleading unless the possibility of this diagnosis is considered. In this report, we present 2 cases of hemorrhagic cholecystitis along with relevant imaging and a review of the literature on this rare subject.

PMID: 20157090 [PubMed - in process]

Image of the month–quiz case.

Arch Surg. 2010 Feb;145(2):205

Authors: Raman SR, Parithivel VS, Niazi M

PMID: 20157091 [PubMed - in process]

Image of the month–quiz case.

Arch Surg. 2010 Feb;145(2):207

Authors: Markelov A, Kohli H

PMID: 20157092 [PubMed - in process]

Blunt needles for patients’ and surgeons’ safety.

Arch Surg. 2010 Feb;145(2):210-1

Authors: Mingoli A, Brachini G, Sgarzini G, Binda B, Sapienza P, Modini C

PMID: 20157093 [PubMed - in process]

Women in surgery.

Arch Surg. 2010 Feb;145(2):210

Authors: Agarwal BB

PMID: 20157094 [PubMed - in process]

Routine postoperative gastrografin studies are not necessary after laparoscopic gastric banding.

Arch Surg. 2010 Feb;145(2):211-2

Authors: Edelman DA, Laker S, Weiner M, Webber JD

PMID: 20157095 [PubMed - in process]

Advances in the relationship between lymph node status and prognosis: Comment on “Association Between a High Number of Isolated Lymph Nodes in T1 to T4 N0M0 Colorectal Cancer and the Microsatellite Instability”.

Arch Surg. 2010 Jan;145(1):17-8

Authors: Berho M, Wexner SD

PMID: 20088097 [PubMed - in process]