Laparoscopic Colorectal Surgery: A Better Look Into the Latest Trends.

Arch Surg. 2012 Apr 16;

Authors: Kang CY, Halabi WJ, Luo R, Pigazzi A, Nguyen NT, Stamos MJ

Abstract

BACKGROUND: The latest trends of laparoscopic colorectal surgery (LCRS) after the introduction of International Classification of Diseases, Ninth Revision laparoscopic procedure codes in 2008 remains unknown. This study evaluates LCRS trends before and after the application of specific codes for LCRS. DESIGN: Retrospective analysis of elective surgery for colon cancer, rectal cancer, and diverticulitis using Nationwide Inpatient Sample data from 2007 and 2009. Main Outcome Measure  Primary outcome measures included in-hospital mortality, length of stay, and total charge. RESULTS: A total of 126  921 patients in 2007 and 117  177 patients in 2009 underwent colorectal surgery. Laparoscopic colorectal surgery increased dramatically from 13.8% in 2007 to 42.6% in 2009 (P < .01). This trend was disease and procedure specific. When compared with 2007, patients who underwent LCRS in 2009 had lower conversion rates (14.8% vs 32.1%, P < .001). In 2009, LCRS had lower in-hospital mortality (0.5% vs 1.1%, P < .001) and a shorter length of hospital stay (5 vs 6 days, P < .001) compared with open surgery. In 2009, when compared with successful LCRS, conversion to open surgery was associated with a longer length of hospital stay (6 vs 5 days, P < .01), increased hospital charges, and increased mortality (0.7% vs 0.5%, P < .01). CONCLUSION: The marked increase in LCRS when comparing these 2 years is unlikely only due to the changing practice of colorectal surgery but brings into question the accuracy of data prior to 2009. Our report of Nationwide Inpatient Sample 2009 data represents the most accurate reflection of the use of LCRS in the United States. These data can serve as a benchmark for future comparative studies.

PMID: 22508667 [PubMed - as supplied by publisher]

Perioperative Risk Assessment in Robotic General Surgery: Lessons Learned From 884 Cases at a Single Institution.

Arch Surg. 2012 Apr 16;

Authors: Buchs NC, Addeo P, Bianco FM, Gorodner V, Ayloo SM, Elli EF, Oberholzer J, Benedetti E, Giulianotti PC

Abstract

OBJECTIVE: To assess factors associated with morbidity and mortality following the use of robotics in general surgery. DESIGN: Case series. SETTING: University of Illinois at Chicago. Patients and INTERVENTION: Eight hundred eighty-four consecutive patients who underwent a robotic procedure in our institution between April 2007 and July 2010. Main Outcomes Measures  Perioperative morbidity and mortality. RESULTS: During the study period, 884 patients underwent a robotic procedure. The conversion rate was 2%, the mortality rate was 0.5%, and the overall postoperative morbidity rate was 16.7%. The reoperation rate was 2.4%. Mean length of stay was 4.5 days (range, 0.2-113 days). In univariate analysis, several factors were associated with increased morbidity and included either patient-related (cardiovascular and renal comorbidities, American Society of Anesthesiologists score ≥3, body mass index [calculated as weight in kilograms divided by height in meters squared] <30, age ≥70 years, and malignant disease) or procedure-related (blood loss ≥500 mL, transfusion, multiquadrant operation, and advanced procedure) factors. In multivariate analysis, advanced procedure, multiquadrant surgery, malignant disease, body mass index of less than 30, hypertension, and transfusion were factors significantly associated with a higher risk for complications. American Society of Anesthesiologists score of 3 or greater, age 70 years or older, cardiovascular comorbidity, and blood loss of 500 mL or more were also associated with increased risk for mortality. CONCLUSIONS: Use of the robotic approach for general surgery can be achieved safely with low morbidity and mortality. Several risk factors have been identified as independent causes for higher morbidity and mortality. These can be used to identify patients at risk before and during the surgery and, in the future, to develop a scoring system for the use of robotic general surgery.

PMID: 22508668 [PubMed - as supplied by publisher]

Overcoming the Challenges of Single-Incision Cholecystectomy With Robotic Single-Site Technology.

Arch Surg. 2012 Apr 16;

Authors: Pietrabissa A, Sbrana F, Morelli L, Badessi F, Pugliese L, Vinci A, Klersy C, Spinoglio G

Abstract

OBJECTIVE: To analyze the preliminary experience with the new da Vinci single-site technology for cholecystectomy. HYPOTHESIS: Single-incision laparoscopic cholecystectomy is technically challenging and a related learning curve clearly exists. A novel approved robotic single-port platform has recently been introduced. This technology may help overcome some of the limitations of manual single-incision surgery relating to triangulation of instruments, ergonomics, and surgical exposure. DESIGN: A prospective longitudinal observational study was conducted on 100 consecutive da Vinci single-site cholecystectomies. SETTING: Five Italian centers of robotic general surgery. MAIN OUTCOME MEASURES: Primary end points were feasibility without conversion and the absence of major complications. Operative times were analyzed to define the learning curve using a mixed regression model. A questionnaire collected the opinions of the surgeons involved in using the new technique. RESULTS: Two patients underwent conversion. No major intraoperative complications occurred, but there were 12 minor incidents (7 ruptures of the gallbladder and 5 cases of minor bleeding from the gallbladder bed). Mean (SD) total operative time was 71 (19) minutes, with a mean (SD) console time of 32 (13) minutes. No significant reduction in the operative times was observed with the increasing of each surgeon’s experience. The technique was judged more complex than standard 4-port laparoscopy but easier than single-incision laparoscopy. CONCLUSIONS: Da Vinci single-site cholecystectomy is an easy and safe procedure for expert robotic surgeons. It allows the quick overcoming of the learning curve typical of single-incision laparoscopic surgery and may potentially increase the safety of this approach.

PMID: 22508669 [PubMed - as supplied by publisher]

Bariatric Surgery as a Highly Effective Intervention for Diabetes: Comments on “Obesity, Type 2 Diabetes Mellitus, and Other Comorbidities”

Arch Surg. 2012 Apr 16;

Authors: Gould JC

PMID: 22508670 [PubMed - as supplied by publisher]

Obesity, Type 2 Diabetes Mellitus, and Other Comorbidities: A Prospective Cohort Study of Laparoscopic Sleeve Gastrectomy vs Medical Treatment.

Arch Surg. 2012 Apr 16;

Authors: Leonetti F, Capoccia D, Coccia F, Casella G, Baglio G, Paradiso F, Abbatini F, Iossa A, Soricelli E, Basso N

Abstract

OBJECTIVE: To compare the effect of sleeve gastrectomy vs medical therapy on type 2 diabetes mellitus and other obesity-related comorbidities (obstructive sleep apnea syndrome, hypertension, and dyslipidemia) in prospectively enrolled and matched obese patients with type 2 diabetes. DESIGN: A prospective cohort study. Morbidly obese patients with type 2 diabetes who either underwent sleeve gastrectomy or conventional therapy were followed up and assessed for their diabetic state and other comorbidities every 3 months for 18 months. SETTING: Centre for the Surgical-Medical Treatment of Morbid Obesity, Policlinico “Umberto I,” University of Rome “Sapienza,” Italy. PATIENTS: A total of 30 morbidly obese patients with type 2 diabetes who underwent sleeve gastrectomy (group A) and a total of 30 morbidly obese patients with type 2 diabetes who underwent conventional therapy (group B). RESULTS: In group A, the preoperative mean (SD) body mass index, fasting plasma glucose level, and hemoglobin A(1c) level were 41.3 (6.0), 166.6 (68.1) mg/dL, and 7.9% (2.1%), respectively, and, at 18 months, these values were 28.3 (5.4), 96.2 (29.4) mg/dL, and 6.0% (1.5%), respectively. For 80% of patients, diabetes was resolved. With regard to other comorbidities, the prevalence of obstructive sleep apnea syndrome dropped from 50% to 10%, and patients reduced significantly their use of medication for hypertension and dyslipidemia. In group B, the preoperative mean (SD) body mass index, fasting plasma glucose level, and hemoglobin A(1c) level were 39.0 (5.5), 183.7 (63.5) mg/dL, and 8.1% (1.7%), respectively, and, at 18 months, these values were 39.8 (5.0), 150 (48) mg/dL, and 7.1% (1.3%), respectively. All patients remained diabetic and continued or increased their level of hypoglycemic therapy. With regard to other comorbidities, we observed an increase in the use of medication for hypertension and dyslipidemia, and the prevalence of obstructive sleep apnea syndrome did not change. CONCLUSIONS: This study confirms the efficacy of sleeve gastrectomy in the treatment of morbidly obese type 2 diabetic patients when compared with conventional medical treatment.

PMID: 22508671 [PubMed - as supplied by publisher]

Predictors of Lymph Node Count in Colorectal Cancer Resections: Data From US Nationwide Prospective Cohort Studies.

Arch Surg. 2012 Apr 16;

Authors: Morikawa T, Tanaka N, Kuchiba A, Nosho K, Yamauchi M, Hornick JL, Swanson RS, Chan AT, Meyerhardt JA, Huttenhower C, Schrag D, Fuchs CS, Ogino S

Abstract

OBJECTIVE: To identify factors that influence the total and negative lymph node counts in colorectal cancer resection specimens independent of pathologists and surgeons. DESIGN: We used multivariate negative binomial regression. Covariates included age, sex, body mass index, family history of colorectal carcinoma, year of diagnosis, hospital setting, tumor location, resected colorectal length (specimen length), tumor size, circumferential growth, TNM stage, lymphocytic reactions and other pathological features, and tumor molecular features (microsatellite instability, CpG island methylator phenotype, long interspersed nucleotide element 1 [LINE-1] methylation, and BRAF, KRAS, and PIK3CA mutations). SETTING: Two US nationwide prospective cohort studies. PATIENTS: Patients with rectal and colon cancer (N = 918). MAIN OUTCOME MEASURES: The negative and total node counts (continuous). RESULTS: Specimen length, tumor size, ascending colon location, T3N0M0 stage, and year of diagnosis were positively associated with the negative node count (all P ≤ .002). Mutation of KRAS might also be positively associated with the negative node count (P = .03; borderline significance considering multiple hypothesis testing). Among node-negative (stages I and II) cases, specimen length, tumor size, and ascending colon location remained significantly associated with the node count (all P ≤ .002), and PIK3CA and KRAS mutations might also be positively associated (P = .03 and P = .049, respectively, with borderline significance). CONCLUSIONS: This molecular pathological epidemiology study shows that specimen length, tumor size, tumor location, TNM stage, and year of diagnosis are operator-independent predictors of the lymph node count. These crucial variables should be examined in any future evaluation of the adequacy of lymph node harvest and nodal staging when devising individualized treatment plans for patients with colorectal cancer.

PMID: 22508672 [PubMed - as supplied by publisher]

Health policy update: making sense of accountable care organizations.

Arch Surg. 2012 Apr;147(4):305-7

Authors: Hong AS, Dimick JB

PMID: 22508776 [PubMed - in process]

“Selective rather than routine”: comment on “predictable criteria for selective, rather than routine, calcium supplementation following thyroidectomy”.

Arch Surg. 2012 Apr;147(4):344

Authors: Delbridge L

PMID: 22508777 [PubMed - in process]

Routine Leak Testing in Colorectal Surgery in the Surgical Care and Outcomes Assessment Program.

Arch Surg. 2012 Apr;147(4):345-351

Authors: Kwon S, Morris A, Billingham R, Frankhouse J, Horvath K, Johnson M, McNevin S, Simons A, Symons R, Steele S, Thirlby R, Whiteford M, Flum DR,

Abstract

OBJECTIVE: To evaluate the effect of routine anastomotic leak testing (performed to screen for leaks) vs selective testing (performed to evaluate for a suspected leak in a higher-risk or technically difficult anastomosis) on outcomes in colorectal surgery because the value of provocative testing of colorectal anastomoses as a quality improvement metric has yet to be determined. DESIGN: Observational, prospectively designed cohort study. SETTING: Data from Washington state’s Surgical Care and Outcomes Assessment Program (SCOAP). PATIENTS: Patients undergoing elective left-sided colon or rectal resections at 40 SCOAP hospitals from October 1, 2005, to December 31, 2009. INTERVENTIONS: Use of leak testing, distinguishing procedures that were performed at hospitals where leak testing was selective (<90% use) or routine (≥90% use) in a given calendar quarter. Main Outcome Measure  Adjusted odds ratio of a composite adverse event (CAE) (unplanned postoperative intervention and/or in-hospital death) at routine testing hospitals. RESULTS: Among 3449 patients (mean [SD] age, 58.8 [14.8] years; 55.0% women), the CAE rate was 5.5%. Provocative leak testing increased (from 56% in the starting quarter to 76% in quarter 16) and overall rates of CAE decreased (from 7.0% in the starting quarter to 4.6% in quarter 16; both P ≤ .01) over time. Among patients at hospitals that performed routine leak testing, we found a reduction of more than 75% in the adjusted risk of CAEs (odds ratio, 0.23; 95% CI, 0.05-0.99). CONCLUSION: Routine leak testing of left-sided colorectal anastomoses appears to be associated with a reduced rate of CAEs within the SCOAP network and meets many of the criteria of a worthwhile quality improvement metric.

PMID: 22508778 [PubMed - as supplied by publisher]

Effects of large hiatal hernias on esophageal peristalsis.

Arch Surg. 2012 Apr;147(4):352-7

Authors: Roman S, Kahrilas PJ, Kia L, Luger D, Soper N, Pandolfino JE

Abstract

HYPOTHESIS: Anatomic changes induced by large hiatal hernia may alter esophageal pressure topography measurements made during high-resolution manometry.

DESIGN: Retrospective study.

SETTING: Single-institution tertiary hospital.

PATIENTS: Ninety patients with large (>5 cm) hiatal hernias on endoscopy were compared with a control group of 46 patients without hernia selected from the same database of 2000 consecutive clinical high-resolution manometry studies.

INTERVENTION: High-resolution manometry with at least 7 evaluable swallows for analysis. Main Outcomes Measures  Esophageal pressure topography was analyzed for lower esophageal sphincter pressure, distal contractile integral, contraction amplitude, contractile front velocity, and distal latency time. Esophageal length was measured on esophageal pressure topography from the distal border of the upper esophageal sphincter to the proximal border of the lower esophageal sphincter. Esophageal pressure topography diagnosis was based on the Chicago Classification.

RESULTS: The manometry catheter was coiled in the hernia and did not traverse the diaphragm in 44 patients (49%) with large hernia. Patients with large hernias had lower average lower esophageal sphincter pressures, a lower distal contractile integral, slower contractile front velocity, and shorter distal latency time than patients without hernia. They also exhibited a shorter mean esophageal length. However, the distribution of peristaltic abnormalities was not different in patients with and without large hernia.

CONCLUSIONS: Patients with large hernias had an alteration of esophageal pressure topography measurements and a shortened esophagus. However, the distribution of peristaltic disorders was unaffected by the presence of hernia.

PMID: 22508779 [PubMed - in process]

What do the esophagus and a jump rope have in common?: comment on “effects of large hiatal hernias on esophageal peristalsis”.

Arch Surg. 2012 Apr;147(4):357-8

Authors: Peters JH

PMID: 22508780 [PubMed - in process]

Effect of laparoscopy on the risk of small-bowel obstruction: a population-based register study.

Arch Surg. 2012 Apr;147(4):359-65

Authors: Angenete E, Jacobsson A, Gellerstedt M, Haglind E

Abstract

OBJECTIVE: To investigate the incidence and risk factors for small-bowel obstruction (SBO) after certain surgical procedures.

DESIGN: A population-based retrospective register study.

SETTING: Small-bowel obstruction causes considerable patient suffering. Risk factors for SBO have been identified, but the effect of surgical technique (open vs laparoscopic) on the incidence of SBO has not been fully elucidated.

PATIENTS: The Inpatient Register held by the Swedish National Board of Health and Welfare was used. The hospital discharge diagnoses and registered performed surgical procedures identified data for cholecystectomy, hysterectomy, salpingo-oophorectomy, bowel resection, anterior resection, abdominoperineal resection, rectopexy, appendectomy, and bariatric surgery performed from January 1, 2002, through December 31, 2004. Data on demographic characteristics, comorbidity, previous abdominal surgery, and death were collected.

MAIN OUTCOME MEASURES: Episodes of hospital stay and surgery for SBO within 5 years after the index surgery.

RESULTS: A total of 108 141 patients were included. The incidence of SBO ranged from 0.4% to 13.9%. Multivariate analysis revealed age, previous surgery, comorbidity, and surgical technique to be risk factors for SBO. Laparoscopy exceeded other risk factors in reduction of the risk of SBO for most of the surgical procedures.

CONCLUSIONS: Open surgery seems to increase the risk of SBO at least 4 times compared with laparoscopy for most of the abdominal surgical procedures studied. Other factors such as age, previous abdominal surgery, and comorbidity are also of importance.

PMID: 22508781 [PubMed - in process]

Minimal invasion and maximal benefit: comment on “effect of laparoscopy on the risk of small-bowel obstruction”.

Arch Surg. 2012 Apr;147(4):365

Authors: Funk LM, Ashley SW

PMID: 22508782 [PubMed - in process]

Prognostic significance of tumor-infiltrating lymphocytes for patients with colorectal cancer.

Arch Surg. 2012 Apr;147(4):366-72

Authors: Huh JW, Lee JH, Kim HR

Abstract

OBJECTIVE: To evaluate the prognostic significance of tumor-infiltrating lymphocytes (TILs) in patients with colorectal cancer.

DESIGN: A retrospective review of prospectively collected data.

SETTING: Tertiary care hospital.

PATIENTS: A total of 546 patients who underwent curative surgery for primary nonmetastatic colorectal cancers from May 1, 2004, through December 31, 2007.

MAIN OUTCOME MEASURES: The prognostic value of macroscopic ulceration, tumor border configuration, and TILs at the invasive margin was assessed.

RESULTS: The low TIL group was significantly correlated with a poorly differentiated status and perineural invasion. During the median 54-month follow-up period, the low TIL group had significantly lower 5-year overall survival and disease-free survival rates than the high TIL group of patients with stage III colorectal cancer (P = .005 and P = .03, respectively); however, for patients with stage I and II cancers, the survival rates did not differ between the 2 groups. The 5-year overall survival and 5-year disease-free survival rates were significantly different between the high and low TIL groups of patients with rectal cancer (P = .003 and P = .01, respectively). The multivariate analysis confirmed that the TIL grade was significantly and independently associated with a worse prognosis for overall survival but not for disease-free survival.

CONCLUSIONS: An inflammatory cell reaction at the tumor invasive border is considered a useful predictor of survival after colorectal cancer surgery, particularly for patients with stage III disease or rectal cancer.

PMID: 22508783 [PubMed - in process]

Survival prediction for patients with colorectal carcinoma incorporating tumor-infiltrating lymphocyte grade: comment on “prognostic significance of tumor-infiltrating lymphocytes for patients with colorectal cancer”.

Arch Surg. 2012 Apr;147(4):371-2

Authors: Bland KI

PMID: 22508784 [PubMed - in process]

Wound Healing and Infection in Surgery: The Clinical Impact of Smoking and Smoking Cessation: A Systematic Review and Meta-analysis.

Arch Surg. 2012 Apr;147(4):373-83

Authors: Sørensen LT

Abstract

OBJECTIVES: To clarify the evidence on smoking and postoperative healing complications across surgical specialties and to determine the impact of perioperative smoking cessation intervention.

DATA SOURCES: Cohort studies and randomized controlled trials.

STUDY SELECTION: Selected studies were identified through electronic databases (CENTRAL, MEDLINE, and EMBASE) and by hand searching.

DATA EXTRACTION: Multiple data on study characteristics were extracted. Risk of bias was assessed by means of the Newcastle-Ottawa Scale and Jadad score. Healing outcome was classified as necrosis, healing delay and dehiscence, surgical site infection, wound complications, hernia, and lack of fistula or bone healing. Mantel-Haenszel and inverse variance methods for meta-analysis (fixed- and random-effects models) were used.

DATA SYNTHESIS: Smokers and nonsmokers were compared in 140 cohort studies including 479 150 patients. The pooled adjusted odds ratios (95% CI) were 3.60 (2.62-4.93) for necrosis, 2.07 (1.53-2.81) for healing delay and dehiscence, 1.79 (1.57-2.04) for surgical site infection, 2.27 (1.82-2.84) for wound complications, 2.07 (1.23-3.47) for hernia, and 2.44 (1.66-3.58) for lack of fistula or bone healing. Former smokers and patients who never smoked were compared in 24 studies including 47 764 patients, and former smokers and current smokers were compared in 20 studies including 40 629 patients. The pooled unadjusted odds ratios were 1.30 (1.07-1.59) and 0.69 (0.56-0.85), respectively, for healing complications combined. In 4 randomized controlled trials, smoking cessation intervention reduced surgical site infections (odds ratio, 0.43 [95% CI, 0.21-0.85]), but not other healing complications (0.51 [0.22-1.19]).

CONCLUSIONS: Postoperative healing complications occur significantly more often in smokers compared with nonsmokers and in former smokers compared with those who never smoked. Perioperative smoking cessation intervention reduces surgical site infections, but not other healing complications.

PMID: 22508785 [PubMed - in process]

Kicking Society’s Tobacco Habit: Comment on “The Clinical Effect of Smoking and Smoking Cessation on Wound Healing and Infection in Surgery”.

Arch Surg. 2012 Apr;147(4):383

Authors: Winter DC

PMID: 22508786 [PubMed - in process]

In Vitro and Ex Vivo Delivery of Short Hairpin RNAs for Control of Hepatitis C Viral Transcript Expression.

Arch Surg. 2012 Apr;147(4):384-7

Authors: Lonze BE, Holzer HT, Knabel MK, Locke JE, Dicamillo GA, Karhadkar SS, Montgomery RA, Sun Z, Warren DS, Cameron AM

Abstract

Recurrent hepatitis C virus (HCV) infection is the most common cause of graft loss and patient death after transplantation for HCV cirrhosis. Transplant surgeons have access to uninfected explanted livers before transplantation and an opportunity to deliver RNA interference-based protective gene therapy to uninfected grafts. Conserved HCV sequences were used to design short interfering RNAs and test their ability to knockdown HCV transcript expression in an in vitro model, both by transfection and when delivered via an adeno-associated viral vector. In a rodent model of liver transplantation, portal venous perfusion of explanted grafts with an adeno-associated viral vector before transplantation produced detectable short hairpin RNA transcript expression after transplantation. The ability to deliver anti-HCV short hairpin RNAs to uninfected livers before transplantation and subsequent exposure to HCV offers hope for the possibility of preventing the currently inevitable subsequent infection of liver grafts with HCV.

PMID: 22508787 [PubMed - in process]

Image of the month–quiz case.

Arch Surg. 2012 Apr;147(4):389

Authors: Kondo H, Adachi K

PMID: 22508788 [PubMed - in process]

Image of the month–quiz case.

Arch Surg. 2012 Apr;147(4):391

Authors: Renz EM, Ling G, Mork KJ, Ecklund JM

PMID: 22508789 [PubMed - in process]

Positive and negative staining of hepatic segments by use of fluorescent imaging techniques during laparoscopic hepatectomy.

Arch Surg. 2012 Apr;147(4):393-4

Authors: Ishizawa T, Zuker NB, Kokudo N, Gayet B

PMID: 22508790 [PubMed - in process]

Positional Dyspnea and Tracheal Compression as Indications for Goiter Resection.

Arch Surg. 2012 Mar 19;

Authors: Stang MT, Armstrong MJ, Ogilvie JB, Yip L, McCoy KL, Faber CN, Carty SE

Abstract

Hypotheses  Goiter is a surgically reversible cause of positional dyspnea (PD). Substernal tracheal compression (TC) predicts PD relief after thyroidectomy (Tx). DESIGN: Retrospective analysis of a prospective structured management algorithm. SETTING: Endocrine surgery academic center. METHODS: Before Tx, 1081 patients were queried about PD. Those patients with substernal goiter underwent computed tomography, and their degree of TC was estimated as greatest percent reduction of transverse tracheal diameter. For 197 patients with PD, TC, or both, surgical outcomes were examined with a mean follow-up of 12.6 months. After Tx, patients who carried the diagnosis of obstructive sleep apnea were referred for repeat sleep study evaluation. RESULTS: Positional dyspnea was reported by 188 of 1081 patients, and after Tx the PD improved or resolved in 82.4%. In the 151 patients with substernal goiter, TC was present on imaging in 97.2%; the mean (range) TC was 34% (5%-90%). Patients with TC had a high likelihood of PD (93.5%). After substernal goiter resection, PD improved in stepwise association with total resected thyroid gland weight. Improvement in PD was strongly predicted by both gland weight of 100 g or more (P < .001) and by TC of 35% or more (P < .01). After Tx, 59 of 77 snorers (76.6%) reported improvement in snoring, 77.1% of patients with obstructive sleep apnea reported improved PD, and 2 of 3 retested patients with obstructive sleep apnea demonstrated objective improvement in sleep study apnea-hypopnea index. CONCLUSIONS: Resection of bulky goiter frequently improves PD, which in substernal goiter is highly associated with TC. Either PD or TC of 35% or more prompt Tx. Goiter should be considered when obstructive sleep apnea is diagnosed.

PMID: 22430090 [PubMed - as supplied by publisher]

Risk Factors for Anastomotic Leak and Mortality in Diabetic Patients Undergoing Colectomy: Analysis From a Statewide Surgical Quality Collaborative.

Arch Surg. 2012 Mar 19;

Authors: Ziegler MA, Catto JA, Riggs TW, Gates ER, Grodsky MB, Wasvary HJ

Abstract

OBJECTIVES: To determine the risk factors in diabetic patients that are associated with increased postcolectomy mortality and anastomotic leak. DESIGN: A prospectively acquired statewide database of patients who underwent colectomy was reviewed. Primary risk factors were diabetes mellitus, hyperglycemia (glucose level ≥140 mg/dL), steroid use, and emergency surgery. Categorical analysis, univariate logistic regression, and multivariate regression were used to evaluate the effects of these risk factors on outcomes. SETTING: Participating hospitals within the Michigan Surgical Quality Collaborative. PATIENTS: Database review of patients from hospitals within the Michigan Surgical Quality Collaborative. MAIN OUTCOME MEASURES: Anastomotic leak and 30-day mortality rate. RESULTS: Of 5123 patients, 153 (3.0%) had leaks and 153 (3.0%) died. Preoperative hyperglycemia occurred in 15.6% of patients, only 54% of whom were known to have diabetes. Multivariate analysis showed that the risk of leak for patients with and without diabetes increased only by preoperative steroid use (P < .05). Mortality among diabetic patients was associated with emergency surgery (P < .01) and anastomotic leak (P < .05); it was not associated with hyperglycemia. Mortality among nondiabetic patients was associated with hyperglycemia (P < .005). The presence of an anastomotic leak was associated with increased mortality among diabetic patients (26.3% vs 4.5%; P < .001) compared with nondiabetic patients (6.0% vs 2.5%; P < .05). CONCLUSIONS: The presence of diabetes did not have an effect on the presence of an anastomotic leak, but diabetic patients who had a leak had more than a 4-fold higher mortality compared with nondiabetic patients. Preoperative steroid use led to increased rates of anastomotic leak in diabetic patients. Mortality was associated with hyperglycemia for nondiabetic patients only. Improved screening may identify high-risk patients who would benefit from perioperative intervention.

PMID: 22430091 [PubMed - as supplied by publisher]

Influence of Rescrubbing Before Laparotomy Closure on Abdominal Wound Infection After Colorectal Cancer Surgery: Results of a Multicenter Randomized Clinical Trial.

Arch Surg. 2012 Mar 19;

Authors: Ortiz H, Armendariz P, Kreisler E, Garcia-Granero E, Espin-Basany E, Roig JV, Martín A, Parajo A, Valero G, Martínez M, Biondo S

Abstract

OBJECTIVE: To test the hypothesis that strict asepsis in closing wounds following laparotomy reduces the risk for surgical wound infection in elective colorectal cancer surgery. DESIGN: Multicenter randomized clinical trial conducted from June 1, 2009, through June 1, 2010. Settings  Colorectal surgery units of 9 Spanish hospitals. PATIENTS: A total of 969 patients who underwent elective colorectal cancer surgery were eligible for randomization. In closing the laparotomy wound, the patients were randomized to 2 groups: conventional (n = 516) and new operation (n = 453). In the conventional group, a new set of instruments was used, surgical staff changed their gloves, and the surgical drapes surrounding the laparotomy were covered by a new set of drapes. The new operation group involved removing all drapes, the surgical staff scrubbed again, and a new set of drapes and instruments was used. MAIN OUTCOME MEASURES: Incisional (superficial and deep) surgical site infection 30 days after the operation and risk factors for postoperative wound infections. RESULTS: A total of 146 incisional surgical site infections (15.1%) were diagnosed. Of these, 96 (9.9%) were superficial and 50 (5.1%) were deep infections. On an intent-to-treat basis, significant differences were found between both groups (66 [12.8%] in the conventional group vs 80 [17.7%] in the new operation group [P = .04]). CONCLUSION: This study does not support the use of rescrubbing to reduce the incidence of incisional surgical site infection. Trial Registration  isrctn.org Identifier: ISRCTN19463413.

PMID: 22430092 [PubMed - as supplied by publisher]

Comparative Analysis of Diaphragmatic Hernia Repair Outcomes Using the Nationwide Inpatient Sample Database.

Arch Surg. 2012 Mar 19;

Authors: Paul S, Nasar A, Port JL, Lee PC, Stiles BC, Nguyen AB, Altorki NK, Sedrakyan A

Abstract

OBJECTIVE: To determine the comparative effectiveness of various approaches to diaphragmatic hernia (DH) repair, including open abdominal, laparoscopic abdominal, and thoracotomy. Design, Setting, and PATIENTS: Using the Nationwide Inpatient Sample from 1999 to 2008, a comprehensive cohort of 38 764 patients (mean [SD] age, 60.8 [19.5] years) hospitalized with a primary diagnosis of DH who underwent repair was identified. Main Outcomes Measures  Morbidity and mortality of patients who underwent DH repair. RESULTS: Open approaches were the most common, performed in 91% of patients (open abdominal, n = 28 824 [74.4%]; thoracotomy, n = 6573 [17.0%]). Hospital mortality was 1.1% or less for each of the approaches. However, patients who underwent a laparoscopic DH repair had a shorter length of stay (mean [SD], 4.5 [0.10] days) and fewer discharges to skilled nursing facilities than those who underwent open abdominal or thoracotomy repair approaches. Patients who underwent a DH repair through a thoracotomy approach had the longest length of stay (mean [SD], 7.8 [0.11] days) and a higher need for postoperative mechanical ventilation than those undergoing open or laparoscopic abdominal approaches (5.6% vs 3.2% vs 2.3%, respectively; P < .001). In addition, the thoracotomy approach was found to be an independent predictor for the development of a pulmonary embolism. CONCLUSIONS: This large national study demonstrates that most DH repairs are performed through open abdominal and thoracic approaches. Laparoscopic approaches are associated with decreased length of stay and more routine discharges than open abdominal and thoracotomy approaches.

PMID: 22430093 [PubMed - as supplied by publisher]

Comparison of Hospital Performance in Trauma vs Emergency and Elective General Surgery: Implications for Acute Care Surgery Quality Improvement.

Arch Surg. 2012 Mar 19;

Authors: Ingraham AM, Haas B, Cohen ME, Ko CY, Nathens AB

Abstract

Hypotheses  As emergency general surgery (EMGS) and trauma care are increasingly being provided by the same personnel with overlapping resources, we postulated that the quality of care provided to EMGS and trauma patients would be similar. We also evaluated the relationship between trauma and elective general surgery (ELGS) care, believing that performance would be similar across these services as it reflects institutional culture. DESIGN: Retrospective cohort study comparing hospital performance in trauma and EMGS care and in trauma and ELGS care. Regression models for mortality and serious morbidity were constructed for trauma, EMGS, and ELGS hospitals contributing to both the National Trauma Data Bank (2007) and American College of Surgeons National Surgical Quality Improvement Program (2005-2008). SETTING: Forty-six hospitals. MAIN OUTCOME MEASURES: Correlations of observed to expected ratios were examined. Outlier status (hospitals with CIs of observed to expected ratios excluding 1.0) was compared using weighted κ. RESULTS: There was no significant relationship between trauma and EMGS mortality (r = -0.01, P = .94; κ = -0.10, P = .61) or between trauma and ELGS mortality (r = 0.23, P = .12; κ = 0.07, P = .62). There was no significant relationship between trauma and EMGS morbidity (r = 0.21, P = .17; κ = 0.04, P = .63) or between trauma and ELGS morbidity (r = 0.16, P = .30; κ = 0.11, P = .37). No hospitals were consistently low or high outliers across all 3 groups. CONCLUSIONS: Trauma performance improvement programs are well established compared with those for EMGS. Although EMGS patients use similar structures and processes as trauma patients, there is a lack of correlation between the quality of care provided to trauma and EMGS patients; EMGS should be incorporated into trauma performance improvement programs.

PMID: 22430094 [PubMed - as supplied by publisher]

“A Culture of Safety” or “The Pursuit of Excellence”?: Comment on “Comparison of Hospital Performance in Trauma vs Emergency and Elective General Surgery”

Arch Surg. 2012 Mar 19;

Authors: Hemmila MR

PMID: 22430095 [PubMed - as supplied by publisher]

The Best Method to Repair Diaphragmatic Hernias: Only the First Chapter of the Story: Comment on “Comparative Analysis of Diaphragmatic Hernia Repair Outcomes Using the Nationwide Inpatient Sample Database”

Arch Surg. 2012 Mar 19;

Authors: Deveney K

PMID: 22430096 [PubMed - as supplied by publisher]

Risky Business?: Collaborative Databases and Quality Improvement: Comment on “Risk Factors for Anastomotic Leak and Mortality in Diabetic Patients Undergoing Colectomy”

Arch Surg. 2012 Mar 19;

Authors: Matthews JB

PMID: 22430097 [PubMed - as supplied by publisher]

“Doctor, My Thyroid Is Choking Me”: Common Sense and Scientific Inquiry: Comment on “Positional Dyspneaand Tracheal Compression as Indications for Goiter Resection”

Arch Surg. 2012 Mar 19;

Authors: Schneider D, Chen H

PMID: 22430098 [PubMed - as supplied by publisher]

Perception and orientation in minimally invasive surgery.

Arch Surg. 2012 Mar;147(3):210-1

Authors: Sodergren M, Yang GZ, Darzi LA

PMID: 22430900 [PubMed - in process]

Is there a role for peer support in times of emotional stress?: is it enough?: comment on “physicians’ needs in coping with emotional stressors”.

Arch Surg. 2012 Mar;147(3):218

Authors: Tarpley JL, Tarpley JV

PMID: 22430901 [PubMed - in process]

Laparoscopic colectomy: should it be the standard of care?: comment on “reduced risk of medical morbidity and mortality in patients selected for laparoscopic colorectal resection in England”.

Arch Surg. 2012 Mar;147(3):227

Authors: Efron J

PMID: 22430902 [PubMed - in process]

Is my patient wet or dry? Should my patient be wet or dry?: a first step in answering these queries: comment on “effect of the volume of fluids administered on intraoperative oliguria in laparoscopic bariatric surgery”.

Arch Surg. 2012 Mar;147(3):234-5

Authors: Thirlby RC

PMID: 22430903 [PubMed - in process]

Emergent repair of acute thoracic aortic catastrophes: a comparative analysis.

Arch Surg. 2012 Mar;147(3):243-9

Authors: Naughton PA, Park MS, Morasch MD, Rodriguez HE, Garcia-Toca M, Wang CE, Eskandari MK

Abstract

OBJECTIVE: To provide a contemporary institutional comparative analysis of expedient correction of acute catastrophes of the descending thoracic aorta (ACDTA) by traditional direct thoracic aortic repair (DTAR) or thoracic endovascular aortic repair (TEVAR).

DESIGN: Single-center retrospective review (April 2001-January 2010).

SETTING: Academic medical center.

PATIENTS: One hundred patients with ACDTA treated with either TEVAR (n = 76) or DTAR (n = 24). Indications for repair included ruptured degenerative aneurysm (n = 41), traumatic transection (n = 27), complicated acute type B dissection (n = 20), penetrating ulcer (n = 4), intramural hematoma (n = 3), penetrating injury (n = 3), and embolizing lesion (n = 2).

MAIN OUTCOME MEASURES: Demographics and 30-day and late outcomes were analyzed using multivariate analysis over a mean follow-up of 33.8 months.

RESULTS: Among the 100 patients, mean (SD) age was 58.5 (17.3) years (range, 18-87 years). Demographics and comorbid conditions were similar between the 2 groups, except more patients in the DTAR group had prior aortic surgery (P = .02) and were older (P = .01). Overall 30-day mortality was significantly better among the TEVAR group (8% vs 29%; P = .007). Incidence of postoperative myocardial infarction, acute renal failure, stroke, and paraplegia/paresis was similar between the 2 treatment groups (TEVAR, 5%, 12%, 8%, and 8% vs DTAR, 13%, 13%, 9%, and 13%, respectively). Major respiratory complications were lower in the TEVAR group (16% vs 48%; P < .05). Mean length of hospital stay was also shorter after TEVAR (13.5 vs 16.3 days; P = .30). Independent predictors of patient mortality included age (P = .004) and DTAR (P = .001).

CONCLUSION: Patients presenting with ACDTA are best treated with TEVAR whenever feasible.

PMID: 22430904 [PubMed - in process]

Thoracic aortic endovascular aneurysm repair for acute thoracic aortic catastrophes: the need for subgroup analysis: comment on “emergent repair of acute thoracic aortic catastrophes”.

Arch Surg. 2012 Mar;147(3):249-50

Authors: Abularrage CJ

PMID: 22430905 [PubMed - in process]

Erythropoiesis-stimulating agent administration and survival after severe traumatic brain injury: a prospective study.

Arch Surg. 2012 Mar;147(3):251-5

Authors: Talving P, Lustenberger T, Inaba K, Lam L, Mohseni S, Chan L, Demetriades D

Abstract

OBJECTIVE: To validate previous findings of the effects of erythropoiesis-stimulating agent (ESA) administration following severe traumatic brain injury.

DESIGN: Prospective observational study of all patients with severe traumatic brain injury admitted to the surgical intensive care unit (SICU) at our institution from January 1, 2009, to December 31, 2010 (head Abbreviated Injury Scale score ≥3). Propensity scores were calculated to match patients who received ESA within 30 days after admission to patients who did not receive ESA.

PATIENTS: A total of 566 patients with severe traumatic brain injury were admitted to the SICU. After matching in a 1:1 ratio, 75 matched pairs were analyzed.

MAIN OUTCOME MEASURES: Δ Glasgow Coma Scale score (difference between admission and SICU discharge), in-hospital morbidity, and mortality.

RESULTS: Patients who received ESA and control subjects who did not receive ESA had similar age, mechanisms of injury, vital signs on admission, Abbreviated Injury Scale scores, Injury Severity Scores, and specific intracranial injuries. Patients who received ESA experienced significantly longer lengths of stay in the SICU (mean [SD], 16.1 [1.3] days vs 8.6 [0.8] days; P < .001) and comparable SICU-free days. There was no statistically significant difference in the incidence of major in-hospital complications including deep venous thrombosis and pulmonary embolism when comparing the 2 study cohorts. The Δ Glasgow Coma Scale mean [standard error of the mean] score was 3.0 [0.4] and 2.4 [0.5] in patients who received ESA and those who did not, respectively (P = .33). However, in-hospital mortality was significantly lower for patients who received ESA compared with those who did not (9.3% vs 25.3%; odds ratio, 0.25; 95% CI, 0.08-0.75; P = .012).

CONCLUSIONS: Erythropoiesis-stimulating agent administration demonstrates a significant survival advantage without an increase in morbidity in patients with severe traumatic brain injury.

PMID: 22430906 [PubMed - in process]

Randomized Clinical Trial of Total Extraperitoneal Inguinal Hernioplasty vs Lichtenstein Repair: A Long-term Follow-up Study.

Arch Surg. 2012 Mar;147(3):256-60

Authors: Eker HH, Langeveld HR, Klitsie PJ, Van’t Riet M, Stassen LP, Weidema WF, Steyerberg EW, Lange JF, Bonjer HJ, Jeekel J

Abstract

HYPOTHESIS: Mesh repair is generally preferred for surgical correction of inguinal hernia, although the merits of endoscopic techniques over open surgery are still debated. Herein, minimally invasive total extraperitoneal inguinal hernioplasty (TEP) was compared with Lichtenstein repair to determine if one is associated with less postoperative pain, hypoesthesia, and hernia recurrence.

DESIGN: Prospective multicenter randomized clinical trial.

SETTING: Academic research.

PATIENTS: Six hundred sixty patients were randomized to TEP or Lichtenstein repair.

MAIN OUTCOME MEASURES: The primary outcome was postoperative pain. Secondary end points were hernia recurrence, operative complications, operating time, length of hospital stay, time to complete recovery, quality of life, chronic pain, and operative costs.

RESULTS: At 5 years after surgery, TEP was associated with less chronic pain (P = .004). Impairment of inguinal sensibility was less frequently seen after TEP vs Lichtenstein repair (1% vs 22%, P < .001). Operative complications were more frequent after TEP vs Lichtenstein repair (6% vs 2%, P < .001), while no difference was noted in length of hospital stay. After TEP, patients had faster time to return to daily activities (P < .002) and less absence from work (P = .001). Although operative costs were higher for TEP, total costs were comparable for the 2 procedures, as were overall hernia recurrences at 5 years after surgery. However, among experienced surgeons, significantly lower hernia recurrence rates were seen after TEP (P < .001).

CONCLUSIONS: In the short term, TEP was associated with more operative complications, longer operating time, and higher operative costs; however, total costs were comparable for the 2 procedures. Chronic pain and impairment of inguinal sensibility were more frequent after Lichtenstein repair. Although overall hernia recurrence rates were comparable for both procedures, hernia recurrence rates among experienced surgeons were significantly lower after TEP. Patient satisfaction was also significantly higher after TEP. Therefore, TEP should be recommended in experienced hands. Trial Registration  clinicaltrials.gov Identifier: NCT00788554.

PMID: 22430907 [PubMed - in process]

Surgical Management of Insulinomas: Short- and Long-term Outcomes After Enucleations and Pancreatic Resections.

Arch Surg. 2012 Mar;147(3):261-6

Authors: Crippa S, Zerbi A, Boninsegna L, Capitanio V, Partelli S, Balzano G, Pederzoli P, Di Carlo V, Falconi M

Abstract

OBJECTIVE: To analyze the characteristics and outcomes following enucleation and pancreatic resections of insulinomas.

DESIGN: Retrospective cohort study; prospective database. Settings  Academic, tertiary, and referral centers.

PATIENTS: Consecutive patients with insulinomas (symptoms of hyperinsulinism and positive fasting glucose test) who underwent surgical treatment between January 1990 and December 2009.

MAIN OUTCOME MEASURES: Operative morbidity, tumor recurrence, and survival after treatment.

RESULTS: A total of 198 patients (58.5% women; median age, 48 years) were identified. There were 175 (88%) neuroendocrine tumors grade G1 and 23 (12%) neuroendocrine tumors grade G2. Malignant insulinomas defined by lymph node/liver metastases were found in 7 patients (3.5%). Multiple insulinomas were found in 8% of patients, and 5.5% of patients had multiple endocrine neoplasia type 1. Surgical procedures included 106 enucleations (54%) and 92 pancreatic resections (46%). Mortality was nil. Rate of clinically significant pancreatic fistula was 18%. Enucleations had a higher reoperation rate compared with pancreatic resections (8.5% vs 1%; P = .02). Multiple endocrine neoplasia type 1 was significantly associated with younger age at onset (P < .005) and higher rates of malignancies and multiple lesions. Median follow-up was 65 months. Six patients (3%; 5 patients had neuroendocrine tumors grade G2) developed tumor recurrence. Four patients (2%) died of disease. New exocrine (1.5%) and endocrine (4%) insufficiencies were associated only with pancreatic resections.

CONCLUSIONS: Outcomes following surgical resection of insulinomas are satisfactory, with no mortality and good functional results. Recurrence is uncommon (3%), and it is more likely associated with neuroendocrine tumors grade G2. Insulinomas in multiple endocrine neoplasia type 1 are at higher risk for being malignant and multifocal, requiring pancreatic resections.

PMID: 22430908 [PubMed - in process]

Incidence of iatrogenic ureteral injury after laparoscopic colectomy.

Arch Surg. 2012 Mar;147(3):267-71

Authors: Palaniappa NC, Telem DA, Ranasinghe NE, Divino CM

Abstract

OBJECTIVE: To compare the incidence of iatrogenic ureteral injury between laparoscopic and open colectomies at a single institution.

DESIGN: From June 1, 2005, through July 31, 2010, patients were identified from a prospectively maintained database and hospital records were retrospectively reviewed.

SETTING: Mount Sinai Medical Center.

PATIENTS: Fourteen patients who underwent colectomy complicated by a ureteral injury.

MAIN OUTCOME MEASURES: A significant increase in ureteral injuries occurred after laparoscopic vs open procedures (0.66% vs 0.15%, P = .007).

RESULTS: A total of 5729 colectomies were performed during the study period. Fourteen ureteral injuries occurred, resulting in a 0.244% incidence of iatrogenic ureteral injury. Patient demographics demonstrated that 9 injuries (64%) occurred in females and 7 patients (50%) had undergone prior abdominal operations. Operative indications were inflammatory bowel disease (n = 7), diverticulitis (n = 2), and malignant neoplasm (n = 4). Thirteen operations (87%) in this study were elective colectomies, and 7 patients (50%) underwent laparoscopic procedures, with 2 open conversions. Of the 5729 colectomies, 4669 were open and 1060 laparoscopic. Regarding ureteral injuries, no difference was observed in intraoperative identification of ureteral injury in patients who underwent preoperative ureteral stent placement (n = 4) vs those who did not (50% [2 of 4] vs 50% [5 of 10]).

CONCLUSIONS: A significant increase was found in the incidence of iatrogenic ureteral injuries with laparoscopy compared with open colectomies. Preoperative stent placement did not ensure intraoperative identification of injury. Female sex and increased operative blood loss appear to predispose patients to injury.

PMID: 22430909 [PubMed - in process]

Ureteral injury during laparoscopic colectomy: the need for more information: comment on “incidence of iatrogenic ureteral injury after laparoscopic colectomy”.

Arch Surg. 2012 Mar;147(3):271

Authors: Wick EC, Hechenbleikner E

PMID: 22430910 [PubMed - in process]

Robotic vs Laparoscopic Posterior Retroperitoneal Adrenalectomy.

Arch Surg. 2012 Mar;147(3):272-5

Authors: Agcaoglu O, Aliyev S, Karabulut K, Siperstein A, Berber E

Abstract

OBJECTIVE: To compare robotic vs laparoscopic posterior retroperitoneal adrenalectomy with regard to perioperative outcomes.

DESIGN: Prospectively study.

SETTING: Tertiary academic center.

PATIENTS: Thirty-one patients who underwent robotic posterior retroperitoneal adrenalectomy and 31 consecutive patients who underwent laparoscopic posterior retroperitoneal adrenalectomy from a prospective institutional review board-approved database.

MAIN OUTCOME MEASURES: Demographic and clinical parameters, operative time, presence of complications, length of hospital stay, and pain score on postoperative days 1 and 14.

RESULTS: The mean (SEM) tumor sizes for the robotic and laparoscopic groups were similar (3.1 [0.2] and 3.0 [0.2] cm, respectively; P = .48). For all patients, the mean (SEM) skin-to-skin operative times were similar in both groups (163.2 [10.1] and 165.7 [9.5] minutes, respectively; P = .43). When the last 21 patients who underwent robotic posterior retroperitoneal adrenalectomy were compared with the 31 patients from the laparoscopic series, it was seen that the mean (SEM) operative time was shorter for the robotic group than for the laparoscopic group (139.1 [10.9] vs 166.9 [8.2] minutes; P = .046). The mean (SEM) estimated blood losses and hospital stays were similar between groups. The mean (SEM) pain score on postoperative day 1 was lower in the robotic group than in the laparoscopic group (2.5 [0.3] vs 4.2 [0.4]; P = .008); however, the mean (SEM) pain scores for the groups were similar on postoperative day 14 (P = .53). There were no deaths or cases of morbidity in either group.

CONCLUSIONS: Our study shows that, beyond the learning curve for experienced laparoscopic surgeons, robotic posterior retroperitoneal adrenalectomy shortens the skin-to-skin operative time compared with the laparoscopic approach. Our results also suggest that the immediate postoperative pain may be less severe for patients who undergo robotic posterior retroperitoneal adrenalectomy.

PMID: 22430911 [PubMed - in process]

Robotic Posterior Retroperitoneal Adrenalectomy: For What Benefit and at What Cost?: Comment on “Robotic vs Laparoscopic Posterior Retroperitoneal Adrenalectomy”.

Arch Surg. 2012 Mar;147(3):275-6

Authors: Kebebew E

PMID: 22430912 [PubMed - in process]

Management of asymptomatic inguinal hernia: a systematic review of the evidence.

Arch Surg. 2012 Mar;147(3):277-81

Authors: Mizrahi H, Parker MC

Abstract

OBJECTIVE: To establish a literature-based surgical approach to asymptomatic inguinal hernia (IH).

DATA SOURCES: PubMed, the Cochrane Library database, Embase, national guidelines (including the National Library of Guidelines Specialist Library), National Institute for Health and Clinical Excellence guidelines, and the National Research Register were searched for prospective randomized trials comparing surgical treatment of patients with asymptomatic IH with conservative treatment.

STUDY SELECTION: The literature search retrieved 216 article headlines, and these articles were analyzed. Of those studies, a total of 41 articles were found to be relevant and 2 large well-conducted randomized controlled studies that published their results in several articles were reviewed.

DATA EXTRACTION: The pain and discomfort, general health status, complications, and life-threatening events of patients with asymptomatic IH managed by surgery or watchful waiting were determined.

DATA SYNTHESIS: No significant difference in pain scores and general health status were found when comparing the patients who were followed up with the patients who had surgery. A significant crossover ratio ranging between 23% and 72% from watchful waiting to surgery was found. In patients with watchful waiting, the rates of IH strangulation were 0.27% after 2 years of follow-up and 0.55% after 4 years of follow-up. In patients who underwent elective surgery, the range of operative complications was 0% to 22.3% and the recurrence rate was 2.1%.

CONCLUSION: Both treatment options for asymptomatic IH are safe, but most patients will develop symptoms (mainly pain) over time and will require operation.

PMID: 22430913 [PubMed - in process]

Disclosure of “nonharmful” medical errors and other events: duty to disclose.

Arch Surg. 2012 Mar;147(3):282-6

Authors: Chamberlain CJ, Koniaris LG, Wu AW, Pawlik TM

Abstract

An estimated 98 000 patients die in the United States each year because of medical errors. One million or more total medical errors are estimated to occur annually, which is far greater than the actual number of reported “harmful” mistakes. Although it is generally agreed that harmful errors must be disclosed to patients, when the error is deemed to have not resulted in a harmful event, physicians are less inclined to disclose it. Little has been written about the handling of near misses or “nonharmful” errors, and the issues related to disclosure of such events have rarely been discussed in medicine, although they are routinely addressed within the aviation industry. Herein, we elucidate the arguments for reporting nonharmful medical errors to patients and to reporting systems. A definition of what constitutes harm is explored, as well as the ethical issues underpinning disclosure of nonharmful errors. In addition, systematic institutional implications of reporting nonharmful errors are highlighted. Full disclosure of nonharmful errors is advocated, and recommendations on how to discuss errors with patients are provided. An argument that full error disclosure may improve future patient care is also outlined.

PMID: 22430914 [PubMed - in process]

Routine nasogastric decompression is unnecessary after pancreatic resections.

Arch Surg. 2012 Mar;147(3):287-9

Authors: Roland CL, Mansour JC, Schwarz RE

Abstract

Data regarding the use of nasogastric tubes (NGTs) in patients who are undergoing pancreatic resections are limited. We analyzed outcomes after 231 consecutive pancreatectomy procedures in an academic surgical oncology practice. We routinely placed NGTs intraoperatively throughout the first part of the study interval; orogastric tubes (OGTs) were removed intraoperatively before endotracheal extubation whenever possible in the second part of the study (n = 75 [32%]). The median postoperative NGT duration was 1 day (OGT group, 0 days; NGT group, 2 days [P < .001]). Reinsertion of the NGT was necessary in 43 patients (19%) and did not differ between patients after routine NGT or OGT use (19% vs 19%). Nasogastric tubes were reinserted after 74% of major complications compared with 29% of minor complications (P < .001). Our experience demonstrates that the use of NGTs can be safely avoided in patients who are undergoing pancreatectomies.

PMID: 22430915 [PubMed - in process]

Image of the month–quiz case.

Arch Surg. 2012 Mar;147(3):291

Authors: Martins PN, Varma MC, Elias N, Markmann JF

PMID: 22430916 [PubMed - in process]

Image of the month–quiz case.

Arch Surg. 2012 Mar;147(3):293

Authors: Adachi K, Yokoro S

PMID: 22430917 [PubMed - in process]

Vagus nerve and postinjury inflammatory response.

Arch Surg. 2012 Jan;147(1):76-80

Authors: Peterson CY, Krzyzaniak M, Coimbra R, Chang DC

Abstract

OBJECTIVE: To determine whether injured patients who received a vagotomy would have worse outcomes after injury.

DESIGN: Retrospective analysis of the Nationwide Inpatient Sample (NIS) database over 10 years.

PATIENTS: Patients admitted for trauma (primary International Classification of Diseases, Ninth Revision [ICD-9 ] diagnosis codes 800-959) who had a vagotomy (ICD-9 procedure codes 44.00, 44.01, and 44.03) were included. A second cohort of injured patients without vagotomy was extracted and matched 3 to 1 on the following criteria: age, race, sex, concurrent splenectomy, survival risk ratio, payer status, comorbidities, and calendar year.

MAIN OUTCOME MEASURES: The primary outcome measured was in-hospital mortality. Secondary outcomes included septicemia, systemic inflammatory response syndrome, acute respiratory distress syndrome, ulcer disease, length of stay, and total charges.

RESULTS: A total of 56 and 115 patients were included in the vagotomy and control groups, respectively, and were similar in demographic characteristics, comorbidities, and injury severity. We found that the vagotomy group had elevated mortality (27.27% vs 9.57% for controls; P = .003). Patients who received vagotomy also had more septicemia (26.79% vs 3.48%; P < .001) and ulcer disease (71.43% vs 2.61%; P < .001) but not systemic inflammatory response syndrome or acute respiratory distress syndrome. Patients who received vagotomy also had an increased length of hospital stay (36.4 vs 9.6 mean days; P < .001) and total cost ($211 899.90 vs $59 321.64; P < .001).

CONCLUSIONS: Vagotomy after traumatic injury is associated with an increase in ulcer disease, septicemia, and mortality. This may reflect a loss of control over the systemic response to injury and warrants further study.

PMID: 22355817 [PubMed - in process]

Variation in Lymph Node Examination After Esophagectomy for Cancer in the United States.

Arch Surg. 2012 Feb 20;

Authors: Merkow RP, Bilimoria KY, Chow WB, Merkow JS, Weyant MJ, Ko CY, Bentrem DJ

Abstract

OBJECTIVES: To evaluate the quality of lymph node examination after esophagectomy for cancer in the United States based on current treatment guidelines (≥15 nodes) and to assess the association of patient, tumor, and hospital factors with the adequacy of lymph node examination. DESIGN: Retrospective observational study from 1998 to 2007. SETTING: National cancer database. PATIENTS: Patients with stage I through III esophageal cancer undergoing esophagectomy and not treated with neoadjuvant chemoradiotherapy. Main Outcome Measure  Rate of adequate lymph node examination (≥15 nodes). RESULTS: A total of 13 995 patients were identified from 639 hospitals. Overall, 4014 patients (28.7%) had at least 15 lymph nodes examined, which increased from 23.5% to 34.4% during the study period. At the hospital level, only 45 centers (7.0%) examined a median of at least 15 lymph nodes. In the most recent period (2005-2007), at least 15 nodes were examined in 38.9% of patients at academic centers vs 28.0% at community hospitals and in 44.1% at high-volume centers vs 29.3% at low-volume centers. On multivariable analysis, hospital type, surgical volume status, and geographic location remained significant predictors of having at least 15 lymph nodes examined. CONCLUSIONS: Fewer than one-third of patients and fewer than 1 in 10 hospitals met the benchmark of examining at least 15 lymph nodes. Hospitals should perform internal process improvement activities to improve guideline adherence.

PMID: 22351873 [PubMed - as supplied by publisher]

Clinical Calculator of Conditional Survival Estimates for Resected and Unresected Survivors of Pancreatic Cancer.

Arch Surg. 2012 Feb 20;

Authors: Katz MH, Hu CY, Fleming JB, Pisters PW, Lee JE, Chang GJ

Abstract

OBJECTIVE: To calculate conditional survival estimates for patients with pancreatic adenocarcinoma. DESIGN: We constructed separate multivariate survival models adjusted for 7 clinicopathologic factors for patients who did and did not undergo radical surgical resection. PARTICIPANTS: Patients with pancreatic adenocarcinoma diagnosed between 1988 and 2005 included in the Surveillance Epidemiology End Results cancer registry. Main Outcome Measure  Internet browser-based calculator to compute personalized survival estimates. RESULTS: Conditional survival probabilities increased over time for all patients with pancreatic cancer regardless of patient characteristics, disease stage, or treatment. For patients with resected stage I, II, or III disease, 3-year conditional cancer-specific survival increased from 38% to 70%, 19% to 54%, and 8% to 39%, respectively, over the 3 years following diagnosis. The relative improvement in survival over time was larger for patients with advanced disease. A customizable, Internet browser-based clinical calculator was implemented that may be used to compute in real time personalized conditional survival estimates based on an individual’s unique clinicopathologic profile. CONCLUSIONS: Conditional survival estimates provide a more accurate-and typically more optimistic-assessment of prognosis for patients with pancreatic cancer than traditional survival estimates that apply only at the initial diagnosis.

PMID: 22351874 [PubMed - as supplied by publisher]

Surgical Outcomes Beyond the Individual: Comment on “The Association of Community Health Indicators With Outcomes for Kidney Transplant Recipients in the United States”

Arch Surg. 2012 Feb 20;

Authors: Slakey DP

PMID: 22351875 [PubMed - as supplied by publisher]

The Association of Community Health Indicators With Outcomes for Kidney Transplant Recipients in the United States.

Arch Surg. 2012 Feb 20;

Authors: Schold JD, Buccini LD, Kattan MW, Goldfarb DA, Flechner SM, Srinivas TR, Poggio ED, Fatica R, Kayler LK, Sehgal AR

Abstract

OBJECTIVE: To evaluate the association of community health indicators with outcomes for kidney transplant recipients. DESIGN: Retrospective observational cohort study using multivariable Cox proportional hazards models. SETTING: Transplant recipients in the United States from the Scientific Registry of Transplant Recipients merged with health indicators compiled from several national databases and the Centers for Disease Control and Prevention, including the National Center for Health Statistics, the Behavioral Risk Factor Surveillance System, and the National Center for Chronic Disease Prevention and Health Promotion. PATIENTS: A total of 100 164 living and deceased donor adult (aged ≥18 years) kidney transplant recipients who underwent a transplant between January 1, 2004, and December 31, 2010. MAIN OUTCOME MEASURES: Risk-adjusted time to posttransplant mortality and graft loss. RESULTS: Multiple health indicators from recipients’ residence were independently associated with outcomes, including low birth weight, preventable hospitalizations, inactivity rate, and smoking and obesity prevalence. Recipients in the highest-risk counties were more likely to be African American (adjusted odds ratio, 1.59, 95% CI, 1.51-1.68), to be younger (aged 18-39 years; 1.46; 1.32-1.60), to have lower educational attainment (<high school; 1.84; 1.62-2.08), and to have public insurance (1.46; 1.38-1.54). Proportions of recipients from higher-risk counties varied dramatically by center and region. There was an independent graded effect between health indicators and posttransplant mortality, including notable hazard associated with the highest-risk counties (adjusted hazard ratio, 1.26; 95% CI, 1.13-1.40). CONCLUSIONS: In a national cohort of patients undergoing complex medical procedures, health indicators from patients’ communities are strong independent predictors of all-cause mortality. Findings highlight the importance of community conditions for risk stratification of patients and development of individualized treatment protocols. Findings also demonstrate that standard risk adjustment does not capture important factors that may affect unbiased performance evaluations of transplant centers.

PMID: 22351876 [PubMed - as supplied by publisher]

Pregnancy Among Women Surgeons: Trends Over Time.

Arch Surg. 2012 Feb 20;

Authors: Turner PL, Lumpkins K, Gabre J, Lin MJ, Liu X, Terrin M

Abstract

BACKGROUND: Women compose half of all medical students but are underrepresented in the field of general surgery. Concerns about childbirth and pregnancy during training and practice are factors that may dissuade women from electing a career in surgery. OBJECTIVE: To assess experiences related to childbirth and pregnancy among women general surgeons. DESIGN: Survey questionnaire. SETTING: Self-administered survey sent individually to women surgeons in training and practice. PARTICIPANTS: Women members of the Association for Women Surgeons or the American College of Surgeons who graduated from medical school and practice general surgery or a general surgery subspecialty. MAIN OUTCOME MEASURES: Descriptive data on the timing of pregnancy and perception of stigma attending childbirth and pregnancy as experienced by women surgeons, according to date of medical school graduation (0-9 years since graduation, 10-19 years, 20-29 years, and ≥ 30 years). The survey response rate was 49.6%. Trends over time were evaluated using comparisons of proportions and the Cochrane-Armitage trend tests across age cohorts. RESULTS: The perception of stigma associated with pregnancy during training remained large but decreased from 76% in the most remote cohort to 67% in the most recent graduation cohort (P < .001). External influences, even women resident colleagues, were perceived as evincing negative instead of encouraging attitudes toward childbearing during residency, though less so than men, both resident colleagues and faculty. Frequency of pregnancy and pregnancies earlier in training increased over the time cohorts. CONCLUSIONS: The number of women general surgeons becoming pregnant during training has increased in recent years; however, substantial negative bias persists. Although the overall magnitude of perceived negative attitudes is greater among male peers than female peers and among faculty than peers, even women residents hold negative views of pregnancy among their colleagues during training. More than half of all women surgeons delay childbearing until they are in independent practice, post-training. Surgical residents and faculty of both sexes exerted negative influences with regard to consideration of childbearing. There was also a trend toward increased childbearing in more recent graduates.

PMID: 22351877 [PubMed - as supplied by publisher]

Fate of the Pancreatic Remnant After Resection for an Intraductal Papillary Mucinous Neoplasm: A Longitudinal Level II Cohort Study.

Arch Surg. 2012 Feb 20;

Authors: Moriya T, Traverso LW

Abstract

OBJECTIVE: To determine the occurrence of new disease in the pancreatic remnant after resection for intraductal papillary mucinous neoplasms. DESIGN: A longitudinal level II cohort study. SETTING: Virginia Mason Medical Center, Seattle, Washington. PATIENTS: The primary cohort was a “resection cohort” of 203 patients who underwent partial pancreatic resection for an intraductal papillary mucinous neoplasm. MAIN OUTCOME MEASURES: The occurrence rate of lesions in the pancreatic remnant after resection for an intraductal papillary mucinous neoplasm, determined by use of an annual computed tomographic scan of the pancreas. RESULTS: New lesions were observed in the remnant of 17 of the 203 patients (8%) after a median follow-up of 40 months and a median interval of 38 months from the initial resection. Only 1 of these 17 patients with new lesions had a surgical margin that was positive for an adenoma at the time of resection. Comparing the 17 patients with new lesions with the 186 patients without new lesions, we found no difference in age, sex, procedure type, location in ductal system, original histology, or original margin status. In the new lesion group, no treatment was used for 12 patients who had side-branch disease detected by imaging (6% of all patients). Surgical treatment was used for 5 patients (2% of all patients): 2 with adenomas, 1 with a carcinoma in situ, and 2 with an invasive ductal carcinoma (1 with liver metastases). CONCLUSIONS: We found that, following a partial pancreatic resection for an intraductal papillary mucinous neoplasm and a 40-month follow-up with an annual computed tomographic scan of the pancreas, 17 of 203 patients (8%) developed a new intraductal papillary mucinous neoplastic lesion in the pancreatic remnant. As follow-up time increases, we suspect that new lesions will constantly appear regardless of whether the surgical margin was negative at initial resection.

PMID: 22351878 [PubMed - as supplied by publisher]

The Double Jeopardy of Blunt Thoracoabdominal Trauma.

Arch Surg. 2012 Feb 20;

Authors: Berg RJ, Okoye O, Teixeira PG, Inaba K, Demetriades D

Abstract

OBJECTIVES: To examine the specific injuries, need for operative intervention, and clinical outcomes of patients with blunt thoracoabdominal trauma. DESIGN: Trauma registry and medical record review. SETTING: Level I trauma center in Los Angeles, California. PATIENTS: All patients with thoracoabdominal injuries from January 1996 to December 2010. MAIN OUTCOME MEASURES: Injuries, incidence and type of operative intervention, clinical outcomes, and risk factors for mortality. RESULTS: Blunt thoracoabdominal injury occurred in 1661 patients. Overall, 474 (28.5%) required laparotomy, 31 (1.9%) required thoracotomy (excluding resuscitative thoracotomy), and 1146 (69.0%) required no thoracic or abdominal operation. Overall incidence of intra-abdominal solid organ injury was 59.7% and hollow viscus injury, 6.0%. Blunt cardiac trauma occurred in 6.3%; major thoracic vessel injury, in 4.6%; and diaphragmatic trauma, in 6.0%. The majority of solid organ injuries were managed nonoperatively (liver, 83.9%; spleen, 68.3%; and kidney, 91.2%). Excluding patients with severe head trauma, mortality ranged from 4.5% with nonoperative management to 18.1% and 66.7% in those requiring laparotomy and dual cavitary exploration, respectively. Age 55 years or older, Injury Severity Score of 25 or more, Glasgow Coma Scale score of 8 or less, initial hypotension, massive transfusion, and liver, cardiac, or abdominal vascular trauma were all independent risk factors for mortality. CONCLUSIONS: Most patients with blunt thoracoabdominal trauma are managed nonoperatively. The need for nonresuscitative thoracotomy or combined thoracoabdominal operation is rare. The abdomen contains the overwhelming majority of injuries requiring operative intervention and should be the initial cavity of exploration in the patient requiring emergent surgery without directive radiologic data.

PMID: 22351879 [PubMed - as supplied by publisher]

The JAMA Connection.

Arch Surg. 2012 Feb;147(2):106

Authors: Freischlag JA

PMID: 22351901 [PubMed - in process]

The JAMA Connection: The View From JAMA.

Arch Surg. 2012 Feb;147(2):107-8

Authors: Livingston EH

PMID: 22351902 [PubMed - in process]

Minimum response rates for survey research.

Arch Surg. 2012 Feb;147(2):110

Authors: Livingston EH, Wislar JS

PMID: 22351903 [PubMed - in process]

Increased risk of death in young african american dialysis patients.

Arch Surg. 2012 Feb;147(2):111-2

Authors: Norman SP

PMID: 22351904 [PubMed - in process]

Antifibrinolytics in Trauma Patients: Does It MATTER?: Comment on “Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study”.

Arch Surg. 2012 Feb;147(2):119

Authors: Inaba K

PMID: 22351905 [PubMed - in process]

Use of national surgical quality improvement program outcomes data to change guidelines: a sound idea?: comment on “increased risk of postoperative deep vein thrombosis and pulmonary embolism in patients with inflammatory bowel disease”.

Arch Surg. 2012 Feb;147(2):124

Authors: White LE, Hassoun HT

PMID: 22351906 [PubMed - in process]

How should we risk-adjust hospital outcome comparisons?: comment on “predicting in-hospital mortality in patients undergoing complex gastrointestinal surgery”.

Arch Surg. 2012 Feb;147(2):135-6

Authors: Dimick JB

PMID: 22351907 [PubMed - in process]

Efficacy of the Omental Roll-up Technique in Pancreaticojejunostomy as a Strategy to Prevent Pancreatic Fistula After Pancreaticoduodenectomy.

Arch Surg. 2012 Feb;147(2):145-50

Authors: Choi SB, Lee JS, Kim WB, Song TJ, Suh SO, Choi SY

Abstract

BACKGROUND: Most morbidity and mortality are caused by a pancreatic fistula after pancreaticoduodenectomy (PD), and its prevention is the major concern. We applied the omental roll-up technique around pancreaticojejunostomy and investigated the effectiveness of this technique to prevent a pancreatic fistula.

DESIGN: Retrospective study.

SETTING: Tertiary hepatobiliary and pancreas surgery clinic, Korea University Guro Hospital, Seoul.

PATIENTS: Between March 1, 2009, and March 31, 2011, 68 patients underwent PD. The patients were divided into 2 groups according to the surgical application of the omental roll-up technique around the PJ site: group 1 (those who did not undergo the omental roll-up technique) compared with group 2 (those who did undergo the omental roll-up technique). Main Outcome Measure  The occurrence of a pancreatic fistula.

RESULTS: No differences were noted in the clinical characteristics, including patients’ demographics and operation-related factors, between the 2 groups. A pancreatic fistula occurred in 23 of 39 patients in group 1 (59%) and in 6 of 29 patients in group 2 (20.7%). Group 2 had a significantly lower incidence of pancreatic fistula (P = .002), and these fistulas were classified as being grade A using the International Study Group on Pancreatic Fistula Definition showing a transient high amylase level in the drainage fluid without significantly affecting the patient’s recovery. Drain removal was performed earlier in group 2 (P < .001). Mean postoperative hospital stay was 23.4 days in group 1 compared with 15.9 days in group 2 (P = .009). Overall mortality was 1.5%; however, no deaths were related to a pancreatic fistula.

CONCLUSIONS: The omental roll-up technique for the PJ site definitely reduced the occurrence of a pancreatic fistula. Therefore, the omental roll-up technique is a simple and effective strategy to prevent a pancreatic fistula.

PMID: 22351908 [PubMed - in process]

Omental Roll-up Technique Decreases Pancreatic Fistula-or Does It?: Comment on “Efficacy of Omental Roll-up Technique in Pancreaticojejunostomy as a Strategy to Prevent Pancreatic Fistula After Pancreaticoduodenoectomy”.

Arch Surg. 2012 Feb;147(2):150-1

Authors: Lillemoe KD

PMID: 22351909 [PubMed - in process]

Complication-associated mortality following trauma: a population-based observational study.

Arch Surg. 2012 Feb;147(2):152-8

Authors: Osler T, Glance LG, Hosmer DW

Abstract

CONTEXT: Complications are common in the care of trauma patients and contribute to morbidity, mortality, and cost. However, no comprehensive list of surgical complications is widely accepted.

OBJECTIVES: To create an empirical list of complications based on the International Classification of Diseases, Ninth Revision (ICD-9) lexicon and estimate the contribution of these complications to mortality.

DESIGN: Retrospective database analysis.

SETTING: Office of Statewide Health Planning and Development data set.

PATIENTS: The Office of Statewide Health Planning and Development provided information on 409 393 patients admitted to 1 of 159 California hospitals between 2004 and 2008. We defined a complication to be any ICD-9- coded condition that accrued after hospital admission and significantly increased mortality.

MAIN OUTCOME MEASURES: Odds of mortality for individual complications and number of excess deaths due to individual complications based on attributable risk fractions.

RESULTS: Eighty-two different ICD-9 codes contributed significantly to mortality as complications. Odds ratios ranged from 1.02 (hyperosmolarity) to 46.1 (ventricular fibrillation). There were a total of 175 299 complications (range, 0-14; average 0.4/patient). Twenty-four percent of patients had at least 1 complication. Mortality increased with the number of complications; each additional complication increased mortality by 8%. Absent any complications, there would have been 7292 fewer deaths, a 64% reduction in overall mortality.

CONCLUSIONS: Most complication-related mortality is due to 25 individual complications. Eliminating all complications might prevent two-thirds of deaths, but because many complications are not preventable, this figure is the upper bound on possible mortality reduction. Hospitals vary in their proportions of deaths due to complications, and thus, efforts to prevent complications might improve survival at some hospitals.

PMID: 22351910 [PubMed - in process]

Intertransversalis fascia approach in urologic laparoscopic operations.

Arch Surg. 2012 Feb;147(2):159-67

Authors: Li G, Qian Y, Bai H, Song Z, Hong B, Jia J, Shi B, Zhang X

Abstract

OBJECTIVES: To study the clinical anatomy of the transversalis fascia (TF) and to explore the intertransversalis fascia approach in urologic laparoscopic operations (ULOs).

DESIGN: Prospective study.

SETTING: Two academic hospitals. Other

PARTICIPANTS: Data from 1217 urologic laparoscopic or open operations and 10 laparoscopic hernia repairs were analyzed between January 1, 2009, and April 30, 2011. Findings from 3 fresh autopsies were also included.

MAIN OUTCOME MEASURES: The anatomy of the TF was studied and the intertransversalis fascia approach was explored in ULOs; furthermore, they were proved in the open operations and fresh autopsies. Photographs were taken from the intertransversalis fascia approach in ULOs, micrographs were obtained to examine the microscopic structure of the TF, and the color atlas of TF anatomy (cross and sagittal sections) was drawn.

RESULTS: The TF is a general plane of connective tissue lying between the inner surface of the transversus abdominis and the extraperitoneal fat. It can be divided into 2 layers (superficial and deep), with an amorphous fibroareolar space between them. The intertransversalis fascia approach in ULOs is the approach between the 2 layers of the TF.

CONCLUSIONS: The intertransversalis fascia approach is described for the first time, to our knowledge. Surgeons can obtain a clean, clear, and bloodless operating space in ULOs using the intertransversalis fascia approach.

PMID: 22351911 [PubMed - in process]

Alternative routes to the summit require experienced climbers: comment on “intertransversalis fascia approach in urologic laparoscopic operations”.

Arch Surg. 2012 Feb;147(2):167

Authors: Unwala DJ

PMID: 22351912 [PubMed - in process]

Prevalence of alcohol use disorders among american surgeons.

Arch Surg. 2012 Feb;147(2):168-74

Authors: Oreskovich MR, Kaups KL, Balch CM, Hanks JB, Satele D, Sloan J, Meredith C, Buhl A, Dyrbye LN, Shanafelt TD

Abstract

OBJECTIVES: To determine the point prevalence of alcohol abuse and dependence among practicing surgeons.

DESIGN: Cross-sectional study with data gathered through a 2010 survey.

SETTING: The United States of America.

PARTICIPANTS: Members of the American College of Surgeons.

MAIN OUTCOME MEASURES: Alcohol abuse and dependence.

RESULTS: Of 25 073 surgeons sampled, 7197 (28.7%) completed the survey. Of these, 1112 (15.4%) had a score on the Alcohol Use Disorders Identification Test, version C, consistent with alcohol abuse or dependence. The point prevalence for alcohol abuse or dependence for male surgeons was 13.9% and for female surgeons was 25.6%. Surgeons reporting a major medical error in the previous 3 months were more likely to have alcohol abuse or dependence (odds ratio, 1.45; P < .001). Surgeons who were burned out (odds ratio, 1.25; P = .01) and depressed (odds ratio, 1.48; P < .001) were more likely to have alcohol abuse or dependence. The emotional exhaustion and depersonalization domains of burnout were strongly associated with alcohol abuse or dependence. Male sex, having children, and working for the Department of Veterans Affairs were associated with a lower likelihood of alcohol abuse or dependence.

CONCLUSIONS: Alcohol abuse and dependence is a significant problem in US surgeons. Organizational approaches for the early identification of problematic alcohol consumption followed by intervention and treatment where indicated should be strongly supported.

PMID: 22351913 [PubMed - in process]

Surgeon, heal thyself: comment on “prevalence of alcohol use disorders among american surgeons”.

Arch Surg. 2012 Feb;147(2):174

Authors: Fromson JA

PMID: 22351914 [PubMed - in process]

Change in mechanical bowel obstruction demographic and etiological patterns during the past century: observations from one health care institution.

Arch Surg. 2012 Feb;147(2):175-80

Authors: Drofdf W, Budzynski P

Abstract

OBJECTIVE: To compare epidemiological analysis concerning sex, age, location of blockage, and frequency of occurrence of etiological factors in 2 groups of patients treated for mechanical bowel obstruction 100 years apart.

DESIGN: Epidemiological analysis of patients undergoing an operation for small-bowel obstruction (SBO) or large-bowel obstruction (LBO) from 1868 to 1898 (group 1) and from 2000 to 2003 (group 2).

SETTING: Second Clinic of Surgery of the Jagiellonian University Medical College.

PATIENTS: One hundred ninety-three patients in group 1 and 207 in group 2. Main Outcome Measure  Change in demographic and etiological patterns of mechanical bowel obstruction during the past 100 years.

RESULTS: In both groups, the prevalence of bowel obstruction was similar in particular segments of the intestine (approximately 75% for SBO and 25% for LBO). The primary cause of SBO in group 2 remained incarcerated abdominal hernia (30.8% for group 1 compared with 55.0%). The second most common cause of SBO was intraperitoneal adhesions (29.4% compared with 34.4%). Isolated small-bowel volvulus as the cause of bowel obstruction decreased significantly (P ≤ .05) (16.8% compared with 2.7%). Significant changes were also observed in the etiology of LBO. A century ago, the most common cause was volvulus of the sigmoid colon or of the cecum (72.0%); in the later group, obstruction was caused by cancer in 80.4% of cases.

CONCLUSIONS: During the past 100 years, no changes were observed concerning the location of bowel obstruction or the patients’ sex. Etiological factors in SBO and LBO changed significantly. The age of surgical patients also increased significantly.

PMID: 22351915 [PubMed - in process]

Mechanical bowel obstruction: a tale of 2 eras ; comment on “change in mechanical bowel obstruction demographic and etiological patterns during the past century”.

Arch Surg. 2012 Feb;147(2):180

Authors: Kozol R

PMID: 22351916 [PubMed - in process]

Effect of Perioperative Statins on Death, Myocardial Infarction, Atrial Fibrillation, and Length of Stay: A Systematic Review and Meta-analysis.

Arch Surg. 2012 Feb;147(2):181-9

Authors: Chopra V, Wesorick DH, Sussman JB, Greene T, Rogers M, Froehlich JB, Eagle KA, Saint S

Abstract

OBJECTIVE: To assess the influence of perioperative statin treatment on the risk of death, myocardial infarction, atrial fibrillation, and hospital and intensive care unit length of stay in statin-naive patients undergoing cardiac or noncardiac surgery.

DATA SOURCES: MEDLINE via PubMed, EMBASE, Biosis, and the Cochrane Central Register of Controlled Trials via Ovid. Additional studies were identified through hand searches of bibliographies, trial Web sites, and clinical experts. Randomized controlled trials reporting the effect of perioperative statins in statin-naive patients undergoing cardiac and noncardiac surgery were included.

STUDY SELECTION: Two investigators independently selected eligible studies from original research published in any language studying the effects of statin use on perioperative outcomes of interest.

DATA EXTRACTION: Two investigators performed independent article abstraction and quality assessment.

DATA SYNTHESIS: Fifteen randomized controlled studies involving 2292 patients met the eligibility criteria. Random-effects meta-analyses of unadjusted and adjusted data were performed according to the method described by DerSimonian and Laird. Perioperative statin treatment decreased the risk of atrial fibrillation in patients undergoing cardiac surgery (relative risk [RR], 0.56; 95% CI, 0.45 to 0.69; number needed to treat [NNT], 6). In cardiac and noncardiac surgery, perioperative statin treatment reduced the risk of myocardial infarction (RR, 0.53; 95% CI, 0.38 to 0.74; NNT, 23) but not the risk of death (RR, 0.62; 95% CI, 0.34 to 1.14). Statin treatment reduced mean length of hospital stay (standardized mean difference, -0.32; 95% CI, -0.53 to -0.11) but had no effect on length of intensive care unit stay (standardized mean difference, -0.08; 95% CI, -0.25 to 0.10).

CONCLUSIONS: Perioperative statin treatment in statin-naive patients reduces atrial fibrillation, myocardial infarction, and duration of hospital stay. Wider use of statins to improve cardiac outcomes in patients undergoing high-risk procedures seems warranted.

PMID: 22351917 [PubMed - in process]

Statins for everyone: are we there yet?: comment on “effect of perioperative statins on death, myocardial infarction, atrial fibrillation, and length of stay”.

Arch Surg. 2012 Feb;147(2):189

Authors: Spain DA

PMID: 22351918 [PubMed - in process]

Frailty and delayed graft function in kidney transplant recipients.

Arch Surg. 2012 Feb;147(2):190-3

Authors: Garonzik-Wang JM, Govindan P, Grinnan JW, Liu M, Ali HM, Chakraborty A, Jain V, Ros RL, James NT, Kucirka LM, Hall EC, Berger JC, Montgomery RA, Desai NM, Dagher NN, Sonnenday CJ, Englesbe MJ, Makary MA, Walston JD, Segev DL

Abstract

The ability to predict outcomes following a kidney transplant is limited by the complex physiologic decline of kidney failure, a latent factor that is difficult to capture using conventional comorbidity assessment. The frailty phenotype is a recently described inflammatory state of increased vulnerability to stressors resulting from decreased physiologic reserve and dysregulation of multiple physiologic systems. We hypothesized that frailty would be associated with delayed graft function, based on putative associations between inflammatory cytokines and graft dysfunction. We prospectively measured frailty in 183 kidney transplant recipients between December 2008 and April 2010. Independent associations between frailty and delayed graft function were analyzed using modified Poisson regression. Preoperative frailty was independently associated with a 1.94-fold increased risk for delayed graft function (95% CI, 1.13-3.36; P = .02). The assessment of frailty may provide further insights into the pathophysiology of allograft dysfunction and may improve our ability to preoperatively risk-stratify kidney transplant recipients.

PMID: 22351919 [PubMed - in process]

Image of the month–quiz case.

Arch Surg. 2012 Feb;147(2):195

Authors: McKee TI

PMID: 22351920 [PubMed - in process]

Image of the month–quiz case.

Arch Surg. 2012 Feb;147(2):197

Authors: Hasbahceci M, Erol C, Seker M

PMID: 22351921 [PubMed - in process]

Venous thromboembolism in colorectal surgery: how much does laparoscopy impart an advantage?

Arch Surg. 2012 Feb;147(2):199

Authors: Trinh QD, Sun M, Sammon J, Karakiewicz PI

PMID: 22351922 [PubMed - in process]

Surveillance bias and postoperative complication rates.

Arch Surg. 2012 Feb;147(2):199-200

Authors: Rosenberg JJ, Haut ER

PMID: 22351923 [PubMed - in process]

β-Blocker Continuation After Noncardiac Surgery: A Report From the Surgical Care and Outcomes Assessment Program.

Arch Surg. 2012 Jan 16;

Authors: Kwon S, Thompson R, Florence M, Maier R, McIntyre L, Rogers T, Farrohki E, Whiteford M, Flum DR,

Abstract

BACKGROUND: Despite limited evidence of effect, β-blocker continuation has become a national quality improvement metric. OBJECTIVE: To determine the effect of β-blocker continuation on outcomes in patients undergoing elective noncardiac surgery. Design, Setting, and PATIENTS: The Surgical Care and Outcomes Assessment Program is a Washington quality improvement benchmarking initiative based on clinical data from more than 55 hospitals. Linking Surgical Care and Outcomes Assessment Program data to Washington’s hospital admission and vital status registries, we studied patients undergoing elective colorectal and bariatric surgical procedures at 38 hospitals between January 1, 2008, and December 31, 2009. MAIN OUTCOME MEASURES: Mortality, cardiac events, and the combined adverse event of cardiac events and/or mortality. RESULTS: Of 8431 patients, 23.5% were taking β-blockers prior to surgery (mean [SD] age, 61.9 [13.7] years; 63.0% were women). Treatment with β-blockers was continued on the day of surgery and during the postoperative period in 66.0% of patients. Continuation of β-blockers both on the day of surgery and postoperatively improved from 57.2% in the first quarter of 2008 to 71.3% in the fourth quarter of 2009 (P value <.001). After adjusting for risk characteristics, failure to continue β-blocker treatment was associated with a nearly 2-fold risk of 90-day combined adverse event (odds ratio, 1.97; 95% CI, 1.19-3.26). The odds were even greater among patients with higher cardiac risk (odds ratio, 5.91; 95% CI, 1.40-25.00). The odds of combined adverse events continued to be elevated 1 year postoperatively (odds ratio, 1.66; 95% CI, 1.08-2.55). CONCLUSIONS: β-Blocker continuation on the day of and after surgery was associated with fewer cardiac events and lower 90-day mortality. A focus on β-blocker continuation is a worthwhile quality improvement target and should improve patient outcomes.

PMID: 22249847 [PubMed - as supplied by publisher]

Impact of Payer Status on Treatment Options for Acute Cholecystitis: Comment on “Payer Status and Treatment Paradigm for Acute Cholecystitis”

Arch Surg. 2012 Jan 16;

Authors: Rosenthal RJ

PMID: 22249848 [PubMed - as supplied by publisher]

Can We Safely State That Laparoscopic Roux-En-Y Gastric Bypass Is a Better Weight Loss Procedure Than Adjustable Band Gastroplasty?: Comment on “Roux-en-Y Gastric Bypass vs Gastric Banding for Morbid Obesity”

Arch Surg. 2012 Jan 16;

Authors: Himpens J

PMID: 22249849 [PubMed - as supplied by publisher]

Roux-en-Y Gastric Bypass vs Gastric Banding for Morbid Obesity: A Case-Matched Study of 442 Patients.

Arch Surg. 2012 Jan 16;

Authors: Romy S, Donadini A, Giusti V, Suter M

Abstract

HYPOTHESIS: Gastric banding (GB) and Roux-en-Y gastric bypass (RYGBP) are used in the treatment of morbidly obese patients. We hypothesized that RYGBP provides superior results. DESIGN: Matched-pair study in patients with a body mass index (BMI) less than 50. SETTING: University hospital and regional community hospital with a common bariatric surgeon. PATIENTS: Four hundred forty-two patients were matched according to sex, age, and BMI. INTERVENTIONS: Laparoscopic GB or RYGBP. MAIN OUTCOME MEASURES: Operative morbidity, weight loss, residual BMI, quality of life, food tolerance, lipid profile, and long-term morbidity. RESULTS: Follow-up was 92.3% at the end of the study period (6 years postoperatively). Early morbidity was higher after RYGBP than after GB (17.2% vs 5.4%; P < .001), but major morbidity was similar. Weight loss was quicker, maximal weight loss was greater, and weight loss remained significantly better after RYGBP until the sixth postoperative year. At 6 years, there were more failures (BMI > 35 or reversal of the procedure/conversion) after GB (48.3% vs 12.3%; P < .001). There were more long-term complications (41.6% vs 19%; P < .001) and more reoperations (26.7% vs 12.7%; P < .001) after GB. Comorbidities improved more after RYGBP. CONCLUSIONS: Roux-en-Y gastric bypass is associated with better weight loss, resulting in a better correction of some comorbidities than GB, at the price of a higher early complication rate. This difference, however, is largely compensated by the much higher long-term complication and reoperation rates seen after GB.

PMID: 22249850 [PubMed - as supplied by publisher]

Payer Status and Treatment Paradigm for Acute Cholecystitis.

Arch Surg. 2012 Jan 16;

Authors: Greenstein AJ, Moskowitz A, Gelijns AC, Egorova NN

Abstract

HYPOTHESIS: Medicaid recipients who present to the emergency department with acute cholecystitis (AC) would have reduced access to cholecystectomy compared with a similar population of private insurance carriers. DESIGN: The Nationwide Inpatient Sample (NIS) database from 1998 to 2008. PARTICIPANTS: Emergent hospitalizations (843 179) with AC as a primary diagnosis. INTERVENTIONS: Insurance type was analyzed against cholecystectomy in propensity score-matched cohorts. MAIN OUTCOME MEASURES: Surgical intervention and surgical outcomes. RESULTS: Approximately 200 000 patients were in each matched cohort. The median age of the matched patients was 43.9 years, 76% were women, and the mean Charlson Comorbidity Index was 0.5. While 89% of the private insurance cohort underwent cholecystectomy during their hospitalization, only 83% of the Medicaid population received equivalent care (P < .001). The Medicaid cohort also had reduced rates of laparoscopic surgery (78% vs 69%; P < .001) and an increased conversion rate from laparoscopic to open surgery (3.9% vs 3.0%; P < .001). While disparities in the rates of laparoscopic surgery between the 2 groups sequentially narrowed during the 10-year period, overall disparities in surgical treatment remained constant over time. CONCLUSIONS: Medicaid payer status confers inferior access to surgical treatment for AC. While this finding may be due in part to patients’ health beliefs and physician preferences, the magnitude of difference suggests that health systems factors may provide a significant contribution toward clinical decision making in this entity.

PMID: 22249851 [PubMed - as supplied by publisher]

Long-term and Perioperative Corticosteroids in Anastomotic Leakage: A Prospective Study of 259 Left-Sided Colorectal Anastomoses.

Arch Surg. 2012 Jan 16;

Authors: Slieker JC, Komen NA, Mannaerts GH, Karsten TM, Willemsen P, Murawska M, Jeekel J, Lange JF

Abstract

OBJECTIVE: To determine the risk factors for symptomatic anastomotic leakage (AL) after colorectal resection. DESIGN: Review of records of patients who participated in the Analysis of Predictive Parameters for Evident Anastomotic Leakage study. SETTING: Eight health centers. PATIENTS: Two hundred fifty-nine patients who underwent left-sided colorectal anastomoses. INTERVENTION: Corticosteroids taken as long-term medication for underlying disease or perioperatively for the prevention of postoperative pulmonary complications. MAIN OUTCOME MEASURES: Prospective evaluations for risk factors for symptomatic AL. RESULTS: In 23% of patients, a defunctioning stoma was constructed. The incidence of AL was 7.3%. The clinical course of patients with AL showed that in 21% of leaks, the drain indicated leakage; in the remaining patients, computed tomography or laparotomy resulted equally often in the detection of AL. In 50% of patients with AL, a Hartmann operation was needed. The incidence of AL was significantly higher in patients with pulmonary comorbidity (22.6% leakage), patients taking corticosteroids as long-term medication (50% leakage), and patients taking corticosteroids perioperatively (19% leakage). Perioperative corticosteroids were prescribed in 8% of patients for the prevention of postoperative pulmonary complications. CONCLUSIONS: We found a significantly increased incidence of AL in patients treated with long-term corticosteroids and perioperative corticosteroids for pulmonary comorbidity. Therefore, we recommend that in this patient category, anastomoses should be protected by a diverting stoma or a Hartmann procedure should be considered to avoid AL. Trial Registration  trialregister.nl Identifier: NTR1258.

PMID: 22249852 [PubMed - as supplied by publisher]

Twice the CME!

Arch Surg. 2012 Jan;147(1):7

Authors: Freischlag JA

PMID: 22250102 [PubMed - in process]

Theme issues for 2012 and 2013: informatics and geriatrics.

Arch Surg. 2012 Jan;147(1):8

Authors: Freischlag JA

PMID: 22250103 [PubMed - in process]

Geriatric surgery: past, present, and future.

Arch Surg. 2012 Jan;147(1):10

Authors: Zenilman M

PMID: 22250104 [PubMed - in process]

Little effect of insurance status or socioeconomic condition on disparities in minority appendicitis perforation rates.

Arch Surg. 2012 Jan;147(1):11-7

Authors: Livingston EH, Fairlie RW

Abstract

OBJECTIVE: To estimate how much of the gap in appendicitis perforation rates between minority and white children is explained by differences in socioeconomic and insurance factors.

DESIGN: Observational analysis of hospital discharge information.

SETTING: The Healthcare Cost and Utilization Project database.

PARTICIPANTS: Appendicitis perforation rates determined from the Healthcare Cost and Utilization Project database of hospital discharges from 2001 to 2008.

MAIN OUTCOME MEASURES: The proportion of the gap between perforation rates explained by various patient- and hospital-level variables.

RESULTS: There were no disparities observed in adult appendicitis perforation rates. The perforation rate for white children was 26.7%; black children, 35.5%; and Latino children, 36.5%. Gap analysis showed that only 12.0% of the difference in perforation rates between black and white children was explained by insurance status and only 12.7% of the difference between Latino and white children was explained. Income level only accounted for 7.2% of the gap for black children and 6.1% for Latino children. Age explained one-third of the gap for Latino children and one-third was not accounted for by measurable variables. Two-thirds of the difference between appendicitis perforation rates between black and white children was not explained by measurable factors.

CONCLUSIONS: A very small amount of the gap between minority and white children’s appendicitis rates is explained by the proxy factors for health insurance and poverty status that might relate to health care access. Appendicitis perforation rates are not an appropriate indicator of health care access.

PMID: 22250105 [PubMed - in process]

Combined CD133/CD44 Expression as a Prognostic Indicator of Disease-Free Survival in Patients With Colorectal Cancer.

Arch Surg. 2012 Jan;147(1):18-24

Authors: Galizia G, Gemei M, Del Vecchio L, Zamboli A, Di Noto R, Mirabelli P, Salvatore F, Castellano P, Orditura M, De Vita F, Pinto M, Pignatelli C, Lieto E

Abstract

HYPOTHESIS: Because of some inconsistencies in the traditional model of human colorectal carcinogenesis, the cancer stem cell (CSC) model was recently proposed, in which tumor results from neoplastic transformation of stem cells, which become CSCs. Identification of CSCs by expression of surface antigens remains a critical issue because no biomarker has been shown to be completely reliable. CD133 and CD44 are commonly used as CSC markers, and correlation of their expression with colorectal cancer (CRC) clinicopathological features and outcomes may be useful.

DESIGN: Pilot study.

SETTING: University hospital.

PATIENTS: Thirty-six consecutive patients with CRC. CD133 and CD44 expression (alone or combined) was determined in nontumor cells and in tumor cells by flow cytometry, which identified viable cells only.

MAIN OUTCOME MEASURES: Correlation of CD133 and CD44 expression with each other, with other prognostic indicators, and with disease-free survival.

RESULTS: CD133 and CD44 expression was significantly higher in tumor cells than in nontumor cells, and expression of one did not necessarily correlate with expression of the other. CD133 or CD44 expression alone was variable, while combined CD133/CD44 expression identified a small subset of cells positive for CRC. CD133 or CD44 overexpression was not associated with CRC recurrence; only high frequencies of CD133(+)/CD44(+) cells were a strong indicator of worse disease-free survival and an independent risk factor for CRC recurrence.

CONCLUSION: Evaluation of combined CD133/CD44 expression could be useful to identify putative colorectal CSCs and tumors with a poor prognosis.

PMID: 22250106 [PubMed - in process]

Colorectal Cancer Stem Cells–Hype or Real?: Comment on “Combined CD133+/CD44+ Expression as a Prognostic Indicator of Disease-Free Survival in Patients With Colorectal Cancer”.

Arch Surg. 2012 Jan;147(1):24-5

Authors: Ahuja N

PMID: 22250107 [PubMed - in process]

Improvement in Perioperative and Long-term Outcome After Surgical Treatment of Hilar Cholangiocarcinoma: Results of an Italian Multicenter Analysis of 440 Patients.

Arch Surg. 2012 Jan;147(1):26-34

Authors: Nuzzo G, Giuliante F, Ardito F, Giovannini I, Aldrighetti L, Belli G, Bresadola F, Calise F, Dalla Valle R, D’Amico DF, Gennari L, Giulini SM, Guglielmi A, Jovine E, Pellicci R, Pernthaler H, Pinna AD, Puleo S, Torzilli G, Capussotti L,

Abstract

OBJECTIVE: To evaluate improvements in operative and long-term results following surgery for hilar cholangiocarcinoma. DESIGN: Retrospective multicenter study including 17 Italian hepatobiliary surgery units. PATIENTS: A total of 440 patients who underwent resection for hilar cholangiocarcinoma from January 1, 1992, through December 31, 2007. MAIN OUTCOME MEASURES: Postoperative mortality, morbidity, overall survival, and disease-free survival. RESULTS: Postoperative mortality and morbidity after liver resection were 10.1% and 47.6%, respectively. At multivariate logistic regression, extent of resection (right or right extended hepatectomy) and intraoperative blood transfusion were independent predictors of postoperative mortality (P = .03 and P = .006, respectively); in patients with jaundice, mortality was also higher without preoperative biliary drainage than with biliary drainage (14.3% vs 10.7%). During the study period, there was an increasingly aggressive approach, with more frequent caudate lobectomies, vascular resections, and resections for advanced tumors (T stage of 3 or greater and tumors with poor differentiation). Despite the aggressive approach, the blood transfusion rate decreased from 81.0% to 53.2%, and mortality slightly decreased from 13.6% to 10.8%. Median overall survival significantly increased from 16 to 30 months (P = .05). At multivariate analysis, R1 resection, lymph node metastases, and T stage of 3 or greater independently predicted overall and disease-free survival. CONCLUSIONS: Surgery for hilar cholangiocarcinoma has improved with decreased operative risk despite a more aggressive surgical policy. Long-term survival after liver resection has also increased, despite the inclusion of cases with more advanced hilar cholangiocarcinoma. Preoperative biliary drainage was a safe strategy before right or right extended hepatectomy in patients with jaundice. Pathologic factors independently predicted overall and disease-free survival at multivariate analysis.

PMID: 22250108 [PubMed - as supplied by publisher]

Stenting and the rate of pancreatic fistula following pancreaticoduodenectomy.

Arch Surg. 2012 Jan;147(1):35-40

Authors: Moriya T, Clark CJ, Kirihara Y, Kendrick ML, Reid Lombardo KM, Que FG, Farnell MB

Abstract

OBJECTIVE: To evaluate the efficacy of transanastomotic pancreatic duct internal stenting in the reduction of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy.

DESIGN: Retrospective study.

SETTING: Mayo Clinic.

PATIENTS: Between January 1, 1999, and September 30, 2010, 553 patients underwent pancreaticoduodenectomy by a single surgeon.

MAIN OUTCOME MEASURES: Rates of POPF, morbidity, and mortality between stent and no-stent groups.

RESULTS: The clinically relevant POPF (International Study Group on Pancreatic Fistula definition grade B or C) rates in the stent and no-stent groups were similar (9.6% [43 of 449 patients] and 12.5% [13 of 104 patients], respectively; P = .38). Postoperative outcomes and morbidity were also similar between the 2 groups. Mortality was 0.7% (3 of 449 patients) for the stent group and 1.0% (1 of 104 patients) for the no-stent group. Four patients (0.9%) required endoscopic retrieval of the anastomotic stent. In subset analysis, the clinically relevant POPF rates in patients with a small pancreatic duct (≤3 mm; n = 167) were similar in the stent and no-stent groups (17.7% [23 of 130 patients] and 24.3% [9 of 37 patients], respectively; P = .38). In patients with a soft pancreatic gland (n = 64), rates of clinically relevant pancreatic fistulae were also similar in the stent and no-stent groups (31.7% [13 of 41 patients] and 17.4% [4 of 23 patients], respectively; P = .20).

CONCLUSIONS: Internal transanastomotic pancreatic duct stenting does not decrease the frequency or severity of POPF. The effect of stenting on long-term anastomotic patency warrants further investigation.

PMID: 22250109 [PubMed - in process]

The right way to do a whipple procedure: comment on “stenting and the rate of pancreatic fistula following pancreaticoduodenectomy”.

Arch Surg. 2012 Jan;147(1):41

Authors: Linehan DC

PMID: 22250110 [PubMed - in process]

Oncological Efficiency Analysis of Laparoscopic Liver Resection for Primary and Metastatic Cancer: A Single-Center UK Experience.

Arch Surg. 2012 Jan;147(1):42-8

Authors: Abu Hilal M, Di Fabio F, Abu Salameh M, Pearce NW

Abstract

OBJECTIVE: To assess the oncological efficiency of laparoscopic minor and major hepatectomy for primary and metastatic liver malignant neoplasms.

DESIGN: Retrospective single-center study.

SETTING: Tertiary university hospital.

PATIENTS: One hundred twenty-eight patients undergoing 133 laparoscopic liver resections for malignant diseases.

MAIN OUTCOME MEASURES: Perioperative results and midterm overall and disease-free survival.

RESULTS: Surgical indications were colorectal carcinoma liver metastasis (n = 83), hepatocellular carcinoma (n = 18), neuroendocrine tumor metastasis (n = 17), non-colorectal carcinoma liver metastasis (n = 11), lymphoma (n = 2), and intrahepatic cholangiocarcinoma (n = 2). Two patients had 2-stage laparoscopic resections for bilobar colorectal carcinoma liver metastasis. Three patients had repeated liver resection for recurrent colorectal carcinoma liver metastasis. Forty-two major hepatectomies (32%) were performed. The median operative time was 210 minutes (range, 30-480 minutes). The median postoperative length of stay was 4 days (range, 1-15 days). Seven patients required conversion to formal open surgery and 4 patients required conversion to a laparoscopic-assisted procedure. Sixteen patients (13%) developed significant postoperative complications. One patient (0.8%) died in the hospital. In the 17 patients with neuroendocrine tumor metastasis, 6 (35%) had microscopic positive resection margins. Most of these patients underwent debulking and cytoreductive surgery. A microscopic negative resection margin was obtained in the remaining 112 of 116 resections (97%). We recorded 2-year overall survivals of 80%, 77%, and 91% in the groups with colorectal carcinoma liver metastasis, hepatocellular carcinoma, and neuroendocrine tumor metastasis, respectively.

CONCLUSIONS: Our data support the safety and oncological efficiency of laparoscopic resection for liver malignant neoplasms. Adequate patient selection and extensive experience in hepatic and laparoscopic surgery are essential prerequisites to optimize outcomes.

PMID: 22250111 [PubMed - in process]

Laparoscopic vs Open Liver Resection: Comment on “Oncological Efficiency Analysis of Laparoscopic Liver Resection for Primary and Metastatic Cancer”.

Arch Surg. 2012 Jan;147(1):48

Authors: Krige J, Kahn D

PMID: 22250112 [PubMed - in process]

Surgical outcomes and transfusion of minimal amounts of blood in the operating room.

Arch Surg. 2012 Jan;147(1):49-55

Authors: Ferraris VA, Davenport DL, Saha SP, Austin PC, Zwischenberger JB

Abstract

OBJECTIVE: To examine outcomes in patients who receive small amounts of intraoperative blood transfusion.

DESIGN: Longitudinal, uncontrolled observational study evaluating results of intraoperative transfusion in patients entered into the American College of Surgeons National Surgical Quality Improvement Program database. We made propensity-matched comparisons between patients who received and did not receive intraoperative transfusion to minimize confounding when estimating the effect of intraoperative transfusion on postoperative outcomes.

SETTING: We queried the American College of Surgeons National Surgical Quality Improvement Program database for patients undergoing operations between January 1, 2005, and December 31, 2009.

PATIENTS: A large sample of surgical patients from 173 hospitals throughout the United States.

MAIN OUTCOME MEASURES: Operative mortality and serious perioperative morbidity (≥1 of 20 complications).

RESULTS: After exclusions, 941 496 operations were analyzed in patients from 173 hospitals. Most patients (893 205 patients [94.9%]) did not receive intraoperative transfusions. Patients who received intraoperative infusion of 1 unit of packed red blood cells (15 186 patients [1.6%]) had higher unadjusted rates of mortality and more serious morbidity. These rates further increased with intraoperative transfusion of more than 1 unit of packed red blood cells in a dose-dependent manner. After propensity matching to adjust for multiple preoperative risks, transfusion of a single unit of packed red blood cells increased the multivariate risk of mortality, wound problems, pulmonary complications, postoperative renal dysfunction, systemic sepsis, composite morbidity, and postoperative length of stay compared with propensity-matched patients who did not receive intraoperative transfusion.

CONCLUSIONS: There is a dose-dependent adverse effect of intraoperative blood transfusion. It is likely that a small, possibly discretionary amount of intraoperative transfusion leads to increased mortality, morbidity, and resource use, suggesting that caution should be used with intraoperative transfusions for mildly hypovolemic or anemic patients.

PMID: 22250113 [PubMed - in process]

Minimal transfusions: comment on “surgical outcomes and transfusion of minimal amounts of blood in the operating room”.

Arch Surg. 2012 Jan;147(1):55-6

Authors: Holcomb JB

PMID: 22250114 [PubMed - in process]

Error in letter in : magnetic resonance imaging monsters and surgical vampires.

Arch Surg. 2012 Jan;147(1):56

Authors:

PMID: 22250115 [PubMed - in process]

Informed consent, trainees, and the cost of full disclosure: comment on “training surgeons and the informed consent process: routine disclosure of trainee participation and its effect on patient willingness and consent rates”.

Arch Surg. 2012 Jan;147(1):62

Authors: Salim A

PMID: 22250116 [PubMed - in process]