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]

Ethnicity, insurance status, and hospitals serving predominantly minorities: comment on “association between hospitals caring for a disproportionately high percentage of minority patients with trauma and increased mortality due to trauma”.

Arch Surg. 2012 Jan;147(1):70

Authors: Salim A

PMID: 22250117 [PubMed - in process]

Synoptic operative reports: comment on “the computerized synoptic operative report”.

Arch Surg. 2012 Jan;147(1):74-5

Authors: Schecter WP

PMID: 22250118 [PubMed - in process]

Vagotomy, inflammation, and the injured patient: comment on “vagus nerve and postinjury inflammatory response”.

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

Authors: Jurkovich GJ

PMID: 22250119 [PubMed - in process]

The perforated duodenal diverticulum.

Arch Surg. 2012 Jan;147(1):81-8

Authors: Thorson CM, Ruiz PS, Roeder RA, Sleeman D, Casillas VJ

Abstract

OBJECTIVE: To perform a literature review of perforated duodenal diverticulum with attention to changes in management.

DATA SOURCES: We searched PubMed for relevant studies published from January 1, 1989, through August 1, 2011. In addition, we identified and reviewed 4 cases at our institution.

STUDY SELECTION: Search phrases were perforated duodenal diverticulum and duodenal diverticulitis.

DATA EXTRACTION: Patient demographics, clinical characteristics, radiologic findings, treatment, and outcomes were obtained.

RESULTS: We reviewed 39 studies producing 57 cases, which were combined with the 4 at our institution for a total of 61 patients. The addition of 2 previous series revealed a total of 162 patients in the world literature. Perforations were most commonly located in the second or third portion of the duodenum (60 of 61 cases [98%]), and the most frequent cause was diverticulitis (42 of 61 [69%]). There has been a dramatic improvement in the preoperative diagnosis of perforated diverticula. Only 13 of 101 reported cases (13%) were correctly diagnosed before 1989, and 29 of 61 (48%) in the present series were identified with radiologic examinations. Most patients in the current series (47 of 61) underwent operative treatment for their perforation, although 14 underwent successful nonoperative management. Complications were reported in 17 of 47 patients in the surgical group (36%), whereas only 1 complication was seen in patients undergoing nonoperative management. Mortality in the surgical group was 6% (3 of 47), and no deaths were reported in the nonoperative group.

CONCLUSIONS: Perforation of a duodenal diverticulum is rare, with only 162 cases reported in the world literature. Nonoperative management has emerged as a safe, practical alternative to surgery in selected patents.

PMID: 22250120 [PubMed - in process]

Experience be a jewel: comment on “the perforated duodenal diverticulum”.

Arch Surg. 2012 Jan;147(1):88

Authors: May PE

PMID: 22250121 [PubMed - in process]

Surgical management of the succinate dehydrogenase-associated familial paraganglioma syndromes.

Arch Surg. 2012 Jan;147(1):89-91

Authors: Cocieru A, Saldinger PF

Abstract

Paragangliomas are rare neuroendocrine tumors arising from the neural crest cells in the extra-adrenal location. Paragangliomas can be sporadic or associated with a range of endocrine and genetic syndromes in 25% to 30% of all cases. Specifically, succinate dehydrogenase gene mutations are involved in the development of paraganglioma syndromes type 1 through type 4. In this article, we will describe 2 cases of succinate dehydrogenase-associated familial paraganglioma syndrome and provide a review of the existing literature on the condition’s etiologic factors, diagnosis, and management.

PMID: 22250122 [PubMed - in process]

Image of the month–quiz case.

Arch Surg. 2012 Jan;147(1):93

Authors: Zoccali M, Hart J, Fichera A

PMID: 22250123 [PubMed - in process]

Image of the month–quiz case.

Arch Surg. 2012 Jan;147(1):95

Authors: Nelson EC, Thompson GR, Vidovszky TJ

PMID: 22250124 [PubMed - in process]

The Effect of HLA-DR Matching on Pediatric Kidney Transplantation.

Arch Surg. 2012 Jan;147(1):97

Authors: Grimaldi V, Napoli C

PMID: 22250125 [PubMed - in process]

Neuroendocrine liver metastasis: transplant as part of multimodality liver-directed therapy.

Arch Surg. 2012 Jan;147(1):98-9

Authors: Mayo SC, Cameron AM, Pawlik TM

PMID: 22250126 [PubMed - in process]

Predictive Factors of Splenic Injury in Colorectal Surgery: Data from the Nationwide Inpatient Sample, 2006-2008.

Arch Surg. 2011 Dec 19;

Authors: Masoomi H, Carmichael JC, Mills S, Ketana N, Dolich MO, Stamos MJ

Abstract

OBJECTIVES: To determine frequency of splenic injury and to evaluate predictive risk factors of splenic injury during colorectal surgery. DESIGN: Retrospective database analysis. SETTING: The National Inpatient Sample database. PATIENTS: Patients who underwent a colorectal resection during the period from 2006 to 2008 in the United States. MAIN OUTCOME MEASURES: Patient characteristics, patient comorbidities, type of pathology, type of resection, surgical technique used, type of admission, and teaching hospital status were evaluated for splenic injury during colorectal surgery. RESULTS: A total of 975 825 patients underwent colorectal resection during this period. Overall, the rate of splenic injury was 0.96%, of which 84.75% were treated with complete splenectomy (splenorrhaphy, 13.55%; partial splenectomy, 1.70%). The most common procedure associated with splenic injury was transverse colectomy (3.40%). Using multivariate regression analysis, we found that transverse colectomy (adjusted odds ratio [AOR], 5.30), left colectomy (AOR, 5.08), total colectomy (AOR, 2.85), open operation (AOR, 2.68), malignant tumor (AOR, 2.11), diverticulitis (AOR, 1.93), teaching hospital (AOR, 1.73), male sex (AOR 1.20), peripheral vascular disease (AOR, 1.14), and emergent admission (AOR, 1.06) were associated with a higher risk of splenic injury. There was no association between age, race, hypertension, diabetes, chronic lung disease, congestive heart failure, renal failure, liver disease, obesity, sigmoidectomy, proctectomy, ulcerative colitis, or Crohn disease and splenic injury. CONCLUSIONS: Type of resection (transverse, total, or left colectomy), type of pathology (malignancy or diverticulitis), open operation, and teaching hospital are potent independent predictors of splenic injury. Male sex, peripheral vascular disease, and emergent admission are less effective predictors. Surgeons should be aware of these risk factors and inform patients accordingly. In higher-risk circumstances, it may be appropriate to consider prophylactic vaccination.

PMID: 22184130 [PubMed - as supplied by publisher]

Are Surgeons Rising to the Challenge of Managing Morbidly Obese Patients Undergoing Hepatic Resection?: Comment on “Safety of Hepatic Resections in Obese Veterans”

Arch Surg. 2011 Dec 19;

Authors: Millis JM

PMID: 22184131 [PubMed - as supplied by publisher]

Association Between Trauma Quality Indicators and Outcomes for Injured Patients.

Arch Surg. 2011 Dec 19;

Authors: Glance LG, Dick AW, Mukamel DB, Osler TM

Abstract

OBJECTIVE: To examine the association between the American College of Surgeons Committee on Trauma (ACSCOT) quality indicators and outcomes. DESIGN: Cross-sectional study. SETTING: Data from the Pennsylvania Trauma Outcome Study. PATIENTS: We studied data from 210 942 patients admitted to 35 trauma centers in Pennsylvania between 2000 and 2009. MAIN OUTCOME MEASURES: Regression analyses were performed to examine the association between ACSCOT quality indicators and in-hospital mortality and death or major complications. RESULTS: Seven of the ACSCOT quality indicators were associated with either increased (1) in-hospital mortality or (2) death or major complications. No head computed tomography scan in patients with a Glasgow Coma Scale score less than 13 was associated with a 4-fold increase in mortality (adjusted odds ratio [AOR], 4.39; 95% confidence interval [CI], 3.18-6.07) and a nearly 3-fold increased risk of death or major complications (AOR, 2.76; 95% CI 2.05-3.72). Gunshot wounds to the abdomen managed nonoperatively were associated with a nearly 5-fold increase in mortality (AOR, 4.80; 95% CI, 2.95-7.81). Femoral fractures treated with nonfixation were also strongly associated with mortality (AOR, 4.08; 95% CI, 2.50-6.66) and death or major complications (AOR, 2.54; 95% CI, 1.96-3.31). CONCLUSION: Several current ACSCOT quality indicators have a strong association with clinical outcomes. These findings should be interpreted with caution because some measures may lack face validity for identifying poor-quality care in complex patients with multiple injuries.

PMID: 22184132 [PubMed - as supplied by publisher]

Safety of Hepatic Resections in Obese Veterans.

Arch Surg. 2011 Dec 19;

Authors: Saunders JK, Rosman AS, Neihaus D, Gouge TH, Melis M

Abstract

OBJECTIVE: To determine the effects of body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) on outcomes after liver resection performed at Veterans Affairs medical centers. Design, Setting, and PATIENTS: We queried the Veterans Affairs Surgical Quality Improvement Program database for liver resections (2005-2008) and grouped the patients into 5 BMI categories: normal weight (BMI 18.5-24.9), overweight (BMI 25.0-29.9), obese class 1 (BMI 30.0-34.9), obese class 2 (BMI 35.0-39.9), and obese class 3 (BMI ≥40.0). Differences in risk factors and perioperative complications across groups were analyzed in univariate and multivariate analyses. RESULTS: Of 403 patients who underwent hepatectomy, 106 (26%) were normal weight, 161 (40%) were overweight, 94 (23%) were obese class 1, 31 (8%) were obese class 2, and 11 (3%) were obese class 3. Among these groups, higher BMI was associated with increased rates of hypertension (52%, 61%, 77%, 77%, and 73%, respectively; P = .002) and diabetes (18%, 27%, 36%, 39%, and 45%, respectively; P = .04) and lower incidence of smokers (53%, 35%, 30%, 16%, and 9%, respectively; P < .001). The BMI groups were similar in demographic characteristics and metrics correlating with preexisting liver disease. There were no differences across BMI groups in overall and specific morbidity or in length of stay. Compared with the other groups, obese class 3 patients received more blood transfusions (mean [SD], 4.3 [2.7] in obese class 3 patients vs 1.1 [0.2] in normal-weight patients; P = .02) and had a higher 30-day mortality (27% in obese class 3 patients vs 6% in normal-weight patients; P = .05). Multivariate analyses confirmed obese class 3 as an independent predictor of postoperative mortality. CONCLUSIONS: Obesity did not increase postoperative complications after liver resection in veterans. After adjusting for other clinical factors, extreme obesity (BMI ≥40.0) was an independent risk factor for increased mortality.

PMID: 22184133 [PubMed - as supplied by publisher]

Predictable Criteria for Selective, Rather Than Routine, Calcium Supplementation Following Thyroidectomy.

Arch Surg. 2011 Dec 19;

Authors: Landry CS, Grubbs EG, Hernandez M, Hu MI, Hansen MO, Lee JE, Perrier ND

Abstract

OBJECTIVES: To identify patients at risk for symptomatic hypocalcemia and to make recommendations for safe, selective calcium supplementation. DESIGN: Retrospective review of consecutive patients undergoing thyroidectomy. Patients were divided into 2 groups. Group 1 (the “high-risk/calcium-yes” group) included patients who were found to have (1) postoperative symptoms of hypocalcemia (ie, tingling and numbness), (2) any postoperative serum calcium level of less than 7 mg/dL, or (3) a parathyroid hormone level of less than 3 pg/mL on postoperative day 1. Group 2 (the “low-risk/calcium-no” group) included all other patients. Demographic, operative, biochemical, and pathologic data, as well as postoperative calcium supplementation data, were recorded. Trends in serum calcium level and parathyroid hormone level were analyzed during the immediate postoperative period to identify specific factors unique to group 1. PATIENTS: A total of 156 patients who underwent a thyroidectomy. SETTING: Tertiary care center. RESULTS: Of the 156 patients reviewed, 78% were female, 70% had a malignant disease, and the median age at operation was 50 years. Thirty-four patients (22%) were in group 1, and 122 patients (78%) were in group 2. Twenty-nine (19%) patients had a parathyroid hormone level of less than 3 pg/mL within 24 hours after a thyroidectomy. Patients who underwent a central neck dissection (P = .001), had malignant disease (P = .01), or had a documented removal of the parathyroid gland (with or without autotransplantation) at operation (P = .013) were most likely to be classified into group 1. Forty-two percent of patients in group 2 had either a parathyroid hormone level of less than 6 pg/mL or a serum calcium level of less than 8 mg/dL on postoperative day 1, but all patients in group 1 who were symptomatic met these parameters. CONCLUSION: Limiting supplementation to patients with a parathyroid hormone level of less than 6 pg/mL or a serum calcium level of less than 8 mg/dL on postoperative day 1 may eliminate unnecessary calcium/vitamin D intake, phlebotomy, and follow-up assessments in up to 58% of patients undergoing thyroidectomy. Validation is required in a prospective setting.

PMID: 22184134 [PubMed - as supplied by publisher]

Technical Proficiency in Hand-Assisted Laparoscopic Colon and Rectal Surgery: Determining How Many Cases Are Required to Achieve Mastery.

Arch Surg. 2011 Dec 19;

Authors: Pendlimari R, Holubar SD, Dozois EJ, Larson DW, Pemberton JH, Cima RR

Abstract

OBJECTIVE: To determine how many cases are required to achieve technical proficiency for hand-assisted laparoscopic surgery (HALS). DESIGN: Retrospective study. SETTING: Tertiary care hospital. PATIENTS: Using a prospective database, all HALS colorectal resections from 2003 to 2009 by 2 surgeons (A and B) were reviewed. Over 6 years, surgeons A and B performed 397 and 322 cases. INTERVENTIONS: Change-Point Analysis (CUSUM) was used to define the number of cases required to effect improvement in operative time. Cases before and after the change point were considered as being in the “learning period” and “skilled period.” MAIN OUTCOME MEASURES: Operative time; short-term outcomes. RESULTS: The change point occurred after 108 and 105 cases for surgeons A and B, respectively. The learning period and skilled period were similar with respect to age, sex, body mass index, prior abdominal surgery, medical comorbidities, and American Society of Anesthesiologists class. Mean overall operative time decreased from 263 to 185 minutes (P < .001). The decrease in mean operative duration for specific resections were as follows: right colectomy, 35 minutes (P = .003); left colectomy, 63 minutes (P = .006); sigmoid colectomy, 63 minutes (P < .001); anterior resection, 70 minutes (P < .001); coloanal anastomosis, 52 minutes (P = .003); subtotal colectomy, 75 minutes (P < .001); and total proctocolectomy with ileal reservoir, 80 minutes (P < .001). Intraoperative complications and conversion rate were similar, but overall morbidity, infectious complications, readmissions, and length of stay were all significantly (P < .05) lower during the skilled period. CONCLUSIONS: For HALS colorectal resection, technical proficiency occurred after approximately 105 cases, and increased surgeon experience resulted in improved short-term outcomes. These data suggest that the learning curve for HALS colorectal resection will extend beyond fellowship training for many colorectal surgeons.

PMID: 22184135 [PubMed - as supplied by publisher]

Proficiency, Competency, and Mastery: Where Are You on the Learning Curve?: Comment on “Technical Proficiency in Hand-Assisted Laparoscopic Colon and Rectal Surgery”

Arch Surg. 2011 Dec 19;

Authors: Oleynikov D

PMID: 22184136 [PubMed - as supplied by publisher]

Splenic Injury During Colon Surgery: A Matter of Technique?: Comment on “Predictive Factors of Splenic Injury in Colorectal Surgery”

Arch Surg. 2011 Dec 19;

Authors: Kastenmeier A, Ludwig KA

PMID: 22184137 [PubMed - as supplied by publisher]

Time to Turn the Page: Moving on to Write New Chapters for Trauma Care: Comment on “Association Between Trauma Quality Indicators and Outcomes for Injured Patients”

Arch Surg. 2011 Dec 19;

Authors: Mabry CD

PMID: 22184138 [PubMed - as supplied by publisher]

Archives of Surgery Board Bids Adieu to Catherine DeAngelis, MD, as Editor in Chief of JAMA.

Arch Surg. 2011 Dec;146(12):1346

Authors: Freischlag JA

PMID: 22184290 [PubMed - in process]

Comanaging an organ transplantation and melanoma.

Arch Surg. 2011 Dec;146(12):1347-8

Authors: Balch CM

PMID: 22184291 [PubMed - in process]

Innovative leadership of casualty care: comment on “eliminating preventable death on the battlefield”.

Arch Surg. 2011 Dec;146(12):1358

Authors: Wren SM

PMID: 22184292 [PubMed - in process]

Maneuvers to decrease laparoscopy-induced shoulder and upper abdominal pain: a randomized controlled study.

Arch Surg. 2011 Dec;146(12):1360-6

Authors: Tsai HW, Chen YJ, Ho CM, Hseu SS, Chao KC, Tsai SK, Wang PH

Abstract

OBJECTIVE: To evaluate the effectiveness of the pulmonary recruitment maneuver (PRM) and intraperitoneal normal saline infusion (INSI) in removing postlaparoscopic carbon dioxide from the abdominal cavity to decrease laparoscopy-induced abdominal or shoulder pain after surgery. Design, Setting, and

PATIENTS: A prospective, randomized, controlled trial was conducted at Taipei Veterans General Hospital, Taipei, Taiwan, from August 1, 2009, through June 30, 2010. One hundred fifty-eight women undergoing laparoscopic surgery for benign gynecologic lesions were randomly assigned to 3 groups: the PRM group (n = 53), the INSI group (n = 54), and the control group (n = 51).

INTERVENTIONS: Postoperative maneuvers included PRM and INSI.

MAIN OUTCOME MEASURES: Evaluation of pain, including abdominal pain and shoulder pain, was performed at 12, 24, and 48 hours postoperatively.

RESULTS: The frequency of postoperative shoulder pain at 24 and 48 hours was significantly decreased in the INSI group compared with that of either the PRM or control group (40.7% and 24.1% in the INSI group vs 66.0% and 50.9% in the PRM group [P = .009 and .004, respectively] or vs 72.5% and 54.9% in the control group [both P < .001]). Both methods significantly reduced the frequency of upper abdominal pain compared with the control condition (73.6% in the PRM group at 24 hours [P = .03] or 72.2% at 24 hours [P .02] and 44.4% at 48 hours [P = .01] in the INSI group vs 90.2% at 24 hours and 68.6% at 48 hours in the control group).

CONCLUSIONS: Both PRM and INSI could effectively reduce pain after laparoscopic surgery, but INSI might be better for both upper abdominal and shoulder pain. Trial Registration  clinicaltrials.gov Identifier: NCT01135836.

PMID: 22184293 [PubMed - in process]

The 0.9% solution?: comment on “maneuvers to decrease laparoscopy-induced shoulder and upper abdominal pain”.

Arch Surg. 2011 Dec;146(12):1366-7

Authors: Rattner DW

PMID: 22184294 [PubMed - in process]

Association between implementation of a medical team training program and surgical morbidity.

Arch Surg. 2011 Dec;146(12):1368-73

Authors: Young-Xu Y, Neily J, Mills PD, Carney BT, West P, Berger DH, Mazzia LM, Paull DE, Bagian JP

Abstract

OBJECTIVE: To determine whether there is an association between the Veterans Health Administration Medical Team Training (MTT) program and surgical morbidity. Design, Setting, and

PARTICIPANTS: A retrospective health services study was conducted with a contemporaneous control group. Outcome data were obtained from the Veterans Health Administration Surgical Quality Improvement Program. The analysis included aggregated measures representing 119 383 sampled procedures from 74 Veterans Health Administration facilities that provide care to veterans.

MAIN OUTCOME MEASURES: The primary outcome measure was the rate of change in annual surgical morbidity rate 1 year after facilities enrolled in the MTT program as compared with 1 year before and compared with the non-MTT program sites.

RESULTS: Facilities in the MTT program (n = 42) had a significant decrease of 17% in observed annual surgical morbidity rate (rate ratio, 0.83; 95% CI, 0.79-0.88; P = .01). Facilities not trained (n = 32) had an insignificant decrease of 6% in observed morbidity (rate ratio, 0.94; 95% CI, 0.86-1.05; P = .11). After adjusting for surgical risk, we found a decrease of 15% in morbidity rate for facilities in the MTT program and a decrease of 10% for those not yet in the program. The risk-adjusted annual surgical morbidity rate declined in both groups, and the decline was 20% steeper in the MTT program group (P = .001) after propensity-score matching. The steeper decline in annual surgical morbidity rates was also observed in specific morbidity outcomes, such as surgical infection.

CONCLUSION: The Veterans Health Administration MTT program is associated with decreased surgical morbidity.

PMID: 22184295 [PubMed - in process]

Surgical care is a team sport: comment on “association between implementation of a medical team training program and surgical morbidity”.

Arch Surg. 2011 Dec;146(12):1374

Authors: Fried GM

PMID: 22184296 [PubMed - in process]

Splenic vein-inferior mesenteric vein anastomosis to lessen left-sided portal hypertension after pancreaticoduodenectomy with concomitant vascular resection.

Arch Surg. 2011 Dec;146(12):1375-81

Authors: Ferreira N, Oussoultzoglou E, Fuchshuber P, Ntourakis D, Narita M, Rather M, Rosso E, Addeo P, Pessaux P, Jaeck D, Bachellier P

Abstract

HYPOTHESIS: A splenic vein (SV)-inferior mesenteric vein (IMV) anastomosis reduces congestion of the stomach and spleen after pancreaticoduodenectomy with resection of the SV-mesenteric vein confluence but carries a risk of left-sided venous hypertension.

DESIGN: Comparative retrospective study.

SETTING: Department of Digestive Surgery and Transplantation, University of Strasbourg, Strasbourg, France.

PATIENTS: From January 1, 2002, to February 28, 2010, 39 patients underwent pancreaticoduodenectomy with resection of the SV-mesenteric vein confluence for pancreatic adenocarcinoma. All patients had a terminoterminal portal vein-superior mesenteric vein anastomosis. The SV blood flow into the portal vein was preserved in 11 patients by reimplantation of the SV into the portal vein. Sixteen patients underwent surgical reconstruction of the SV-IMV confluence by anastomosis (group 1), and in 12 patients the natural SV-IMV confluence was preserved (group 2).

MAIN OUTCOME MEASURES: Preoperative and postoperative spleen volume and platelet count.

RESULTS: Demographic characteristics, preoperative tumor staging, pathological outcome, and postoperative complications were comparable in both groups. There was no difference in platelet count between groups 1 and 2 preoperatively (mean [SD], 293.13 [125.37] vs 241.09 [49.12] × 10(3)/μL [to convert to ×10(9)/L, multiply by 1.0], respectively; P = .21) or postoperatively (mean [SD], 231.75 [156.39] vs 164.31 [76.46] × 10(3)/μL, respectively; P = .32). Likewise, no difference was found in the spleen volume preoperatively (mean [SD], 258.96 [179.23] vs 237.31 [122.46] mL, respectively; P = .76) and on postoperative day 15 (mean [SD], 279.08 [158.10] vs 299.12 [153.11] mL, respectively; P = .78).

CONCLUSION: Early assessment shows that SV-IMV anastomosis is as feasible and as safe as the preservation of a natural SV-IMV confluence in patients undergoing pancreaticoduodenectomy with vascular resection for pancreatic head adenocarcinoma.

PMID: 22184297 [PubMed - in process]

Safety and effectiveness of splenic vein to inferior mesenteric vein anastomosis during pancreaticoduodenectomy: comment on “splenic vein-inferior mesenteric vein anastomosis to lessen left-sided portal hypertension after pancreaticoduodenectomy with concomitant vascular resection”.

Arch Surg. 2011 Dec;146(12):1381-2

Authors: Arnaoutakis D, Eckhauser F

PMID: 22184298 [PubMed - in process]

Spectrum of thoracic outlet syndrome presentation in adolescents.

Arch Surg. 2011 Dec;146(12):1383-7

Authors: Chang K, Graf E, Davis K, Demos J, Roethle T, Freischlag JA

Abstract

OBJECTIVE: To study the outcomes of children with thoracic outlet syndrome (TOS) treated surgically with transaxillary first-rib resection and scalenectomy (FRRS).

DESIGN: A retrospective database review.

SETTING: The Johns Hopkins Medical Institutions.

PATIENTS: Patients 18 years or younger who had undergone FRRS.

INTERVENTIONS: All patients underwent FRRS. Patients with venous TOS underwent venography 2 weeks postoperatively. Main Outcomes Measures  For patients with venous TOS, good outcomes included patent subclavian veins. For patients with neurogenic and arterial TOS, good outcomes included relief of pain and discomfort.

RESULTS: Thirty-five adolescents, including 14 male and 21 female patients, presented with TOS. Of these, 18 had venous symptoms, 9 had neurogenic symptoms, and 8 had arterial symptoms. Seventeen of the 18 patients with venous TOS had thrombosis. At postoperative venography, 13 patients required dilation of a stenotic vein, 2 had patent veins, and 2 had chronically occluded veins. All 18 patients had patent veins, but 1 had persistent ipsilateral neurogenic symptoms. Physical therapy before FRRS had failed in all 9 patients with neurogenic TOS. Five of the 8 patients with arterial TOS presented with abnormal ribs. Two had episodes of embolization, and 1 had an occluded radial artery. None had an axillosubclavian aneurysm. All 8 patients underwent FRRS; 3 also required removal of the fused cervical rib. All 35 patients had a favorable follow-up period.

CONCLUSIONS: Adolescents present more frequently with venous and arterial TOS than do adults. However, in nearly all adolescent patients, treatment with FRRS leads to a rapid return to full activity.

PMID: 22184299 [PubMed - in process]

Thoracic outlet syndrome in adolescents is real: comment on “spectrum of thoracic outlet syndrome presentation in adolescents”.

Arch Surg. 2011 Dec;146(12):1388

Authors: Illig KA

PMID: 22184300 [PubMed - in process]

Service or education: in the eye of the beholder.

Arch Surg. 2011 Dec;146(12):1389-95

Authors: Sanfey H, Cofer J, Hiatt JR, Hyser M, Jakey C, Markwell S, Mellinger J, Sidwell R, Smink D, Wise S, Wohltman C, Dunnington G

Abstract

OBJECTIVES: To elicit and compare surgical resident and program director (PD) perspectives on service and education in surgical training and the conditions that influence these opinions.

DESIGN: Cross-sectional, multi-institutional national study conducted through an online survey.

SETTING: General surgical residency programs in the United States.

PARTICIPANTS: General surgical residents and PDs.

MAIN OUTCOME MEASURES: Resident and PD perspectives on the circumstances, conditions, and context in which activities are perceived as service vs education.

RESULTS: Respondents scored 24 resident activities on 5-point Likert scales and commented on conditions that influenced these scores. From 17 residency programs, 105 of 218 PDs (48.4%) responded, and 407 of 645 residents (63.1%) responded. Compared with residents, PDs rated 21 of 24 activities (87.5%) as more educational than service (P ≤ .05). In more than half these activities, notable minorities (≥25%) of residents stated that these activities were service and educational, depending on factors that included the particular attending physician, case complexity, and experience with the activity. Postgraduate year seniority correlated with service and educational perceptions in 12 activities (P < .05). Attending physician teaching and learning environment correlated positively (P < .05) with perception as educational in 8 and 5 activities, respectively.

CONCLUSIONS: This study demonstrated significant differences in service and education definitions for PDs and residents. The implication that these activities are mutually exclusive may devalue residents’ perceptions of the importance of patient care as an essential component of surgical competency. In an era of diminished work hours and continuity of care, educators must teach residents to appreciate the educational value in providing care for all patients and develop a sense of patient ownership in both faculty and residents.

PMID: 22184301 [PubMed - in process]

Asking (and Answering) the Wrong Questions?: Comment on “Service or Education”.

Arch Surg. 2011 Dec;146(12):1395-6

Authors: Cochran A

PMID: 22184302 [PubMed - in process]

Impact of localization studies and clinical scenario in patients with hyperparathyroidism being evaluated for reoperative neck surgery.

Arch Surg. 2011 Dec;146(12):1397-403

Authors: Shin JJ, Milas M, Mitchell J, Berber E, Ross L, Siperstein A

Abstract

BACKGROUND: Previous studies have focused on the success of localization studies (LSs) in patients undergoing reoperative parathyroid surgery; however, patients who did not undergo reexploration surgery have been excluded from analysis. In addition, the concept of whether clinical scenario (CS) suggests single- vs multiple-gland disease in reoperative strategy is often underemphasized.

OBJECTIVE: To evaluate how LSs and CS direct operative strategy in patients being considered for reexploration.

DESIGN: Retrospective review of a prospective database.

SETTING: Tertiary referral center.

PATIENTS: Two hundred three patients with hyperparathyroidism who underwent previous neck surgery. The CS stratified patients as candidates for single- or multiple-site exploration (or unknown). Main Outcome Measure  Ability of CS and LSs to direct successful reexploration.

RESULTS: Of 203 patients, 27 were not explored owing to nonlocalizing studies. Of the remaining 176 patients, LSs accurately guided reexploration in 85%. However, when including the 27 nonexplored patients, the success of LSs decreased to 73%. The cure rate in reoperated patients was 96% but was reduced to 83% when including nonexplored patients. Of the reoperated patients, 83% had single-site disease and 17% had multiple-site disease. The positive predictive value of LSs in predicting single- or multiple-site disease was 92% and 73%, respectively. However, when stratified by CS, the positive predictive value increased to 95% for single-site disease and to 100% for multiple-site disease.

CONCLUSIONS: Failure to cure patients was 4 times more likely to be due to nonlocalizing studies than to a failed reexploration. Stratification by CS was useful in the interpretation of LSs and in determining the most accurate reoperative approach.

PMID: 22184303 [PubMed - in process]

The bayes theorem wins: comment on “impact of localization studies and clinical scenario in patients with hyperparathyroidism being evaluated for reoperative neck surgery”.

Arch Surg. 2011 Dec;146(12):1403

Authors: Duh QY

PMID: 22184304 [PubMed - in process]

Antibiotic Prophylaxis Before Surgery vs After Cord Clamping in Elective Cesarean Delivery: A Double-blind, Prospective, Randomized, Placebo-Controlled Trial.

Arch Surg. 2011 Dec;146(12):1404-9

Authors: Witt A, Döner M, Petricevic L, Berger A, Germann P, Heinze G, Tempfer C

Abstract

CONTEXT: Perioperative antibiotic prophylaxis during elective cesarean delivery at term to reduce postoperative maternal infectious morbidity is generally used but may not be effective on the basis of the available data. Also, the optimal timing of prophylactic antibiotic administration is unclear.

OBJECTIVE: To compare the effectiveness of cefazolin administered before skin incision vs cefazolin administered after umbilical cord clamping vs placebo in a 3-arm randomized trial. The primary objective of the study was to compare postoperative infectious morbidity, defined as wound infection, endometritis, or urinary tract infection (primary end point), in women with cefazolin vs placebo. The comparison between the 2 arms administering cefazolin before skin incision vs after umbilical cord clamping was a secondary end point.

DESIGN: Double-blind, prospective, randomized, placebo-controlled trial.

SETTING: The Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria.

PATIENTS: We recruited 1112 women undergoing elective cesarean delivery at term from March 1, 2004, through January 31, 2010.

INTERVENTIONS: In group 1, cefazolin (2 g) was administered 20 to 30 minutes before skin incision. In group 2, cefazolin (2 g) was administered immediately after clamping of the cord. In group 3, placebo was administered before skin incision.

RESULTS: The primary outcome was observed in 18 of 370 women in group 1 (4.9%) and in 14 of 371 women in group 2 (3.8%), whereas it was noted in 45 of 371 women in group 3 (12.1%) (P < .001 for group 1 plus group 2 vs group 3). The number needed to treat to avoid 1 primary outcome was 13 (95% CI, 9 to 24). Between groups 1 and 2, there was no statistically significant difference regarding postoperative infectious morbidity (P = .60).

CONCLUSION: We were able to demonstrate the usefulness in elective cesarean delivery of prophylactic cefazolin vs placebo in reducing postoperative maternal infectious morbidity. Trial Registration  clinicaltrials.gov Identifier: NCT01248078.

PMID: 22184305 [PubMed - in process]

History and Comparative Effectiveness Research: Comment on “Antibiotic Prophylaxis Before Surgery vs After Cord Clamping in Elective Cesarean Delivery”.

Arch Surg. 2011 Dec;146(12):1409-10

Authors: Malangoni MA

PMID: 22184306 [PubMed - in process]

Error in Data in: Halo Effect for Bariatric Surgery: Collateral Weight Loss in Patients’ Family Members.

Arch Surg. 2011 Dec;146(12):1410

Authors:

PMID: 22184307 [PubMed - in process]

Appropriateness criteria to assess variations in surgical procedure use in the United States.

Arch Surg. 2011 Dec;146(12):1433-40

Authors: Lawson EH, Gibbons MM, Ingraham AM, Shekelle PG, Ko CY

Abstract

OBJECTIVES: To systematically describe appropriateness criteria (AC) developed in the United States for surgical procedures and to summarize how these criteria have been applied to identify overuse and underuse of procedures in US populations.

DATA SOURCES: MEDLINE literature search performed in February 2010 and May 2011.

STUDY SELECTION: Studies were included if they addressed the appropriateness of a surgical procedure using the RAND-UCLA Appropriateness Method. Non-US studies were excluded.

DATA EXTRACTION: Information was abstracted on study design, surgical procedure, and reported rates of appropriate use, overuse, and underuse. Identified AC were cross-referenced with lists of common procedures from the Nationwide Inpatient Sample and the State Ambulatory Surgery databases.

DATA SYNTHESIS: A total of 1601 titles were identified; 39 met the inclusion criteria. Of these, 17 developed AC and 27 applied AC to US populations. Appropriateness criteria have been developed for 16 surgical procedures. Underuse has only been studied for coronary artery bypass graft surgery, and rates range from 24% to 57%. Overuse has been more broadly studied, with rates ranging from 9% to 53% for carotid endarterectomy, 0% to 14% for coronary artery bypass graft, 11% to 24% for upper gastrointestinal tract endoscopy, and 16% to 70% for hysterectomy. Appropriateness criteria exist for 10 of the 25 most common inpatient procedures and 6 of the 15 top ambulatory procedures in the United States. Most studies are more than 5 years old.

CONCLUSIONS: Most existing AC are outdated, and AC have never been developed for most common surgical procedures. A broad and coordinated effort to develop and maintain AC would be required to implement this tool to address variation in the use of surgical procedures.

PMID: 22184308 [PubMed - in process]

Raising the thinker: new concept for dissecting the cystic pedicle during laparoscopic cholecystectomy.

Arch Surg. 2011 Dec;146(12):1441-4

Authors: Neychev V, Saldinger PF

Abstract

Imprecise dissection due to poor visualization of anatomic structures is among the major causes of biliary injuries during laparoscopic cholecystectomy. Developing new illustrational and rendering techniques represents an important part in decreasing visual deception and subsequent bile duct injuries. We use the model of one of the most well-known pieces of art, Rodin’s The Thinker, to visualize the gallbladder and cystic pedicle structures. This minimizes visual deception before dissection, especially in cases with obscured structures. Our method, raising The Thinker, is based on the remarkable similarity between the sculpture and the topographic anatomy of the gallbladder. The method can be used not only for better orientation and visualization during laparoscopic cholecystectomy but also as a tool to complement the teaching of laparoscopic biliary anatomy to surgical residents and medical students.

PMID: 22184309 [PubMed - in process]

Image of the month–quiz case.

Arch Surg. 2011 Dec;146(12):1445

Authors: Bradbury R, Lambrianides AL, O’Loughlin B, Manawwar S

PMID: 22184310 [PubMed - in process]

Image of the month–quiz case.

Arch Surg. 2011 Dec;146(12):1447

Authors: Brooke BS, Choti MA

PMID: 22184311 [PubMed - in process]

Image of the month–quiz case.

Arch Surg. 2011 Dec;146(12):1449

Authors: Molaro R, Morpurgo E

PMID: 22184312 [PubMed - in process]

Mortality associated with nonelective hospital admission.

Arch Surg. 2011 Dec;146(12):1451

Authors: Marco J, Barba R, Zapatero A

PMID: 22184313 [PubMed - in process]

Antegrade access: choose the right operator and the right patient.

Arch Surg. 2011 Dec;146(12):1451-2

Authors: Biondi-Zoccai G, Sangiorgi G, Modena MG

PMID: 22184314 [PubMed - in process]

Deficits in surgical technical performance: prolonged effects of alcohol.

Arch Surg. 2011 Dec;146(12):1452

Authors: O’Sullivan GC, Kearney PP, Lönn L, McGlade K

PMID: 22184315 [PubMed - in process]

Surgeon sleep deprivation and outcomes in cardiac surgery: common sense, machismo, and statistics.

Arch Surg. 2011 Dec;146(12):1453-4

Authors: Santini F, Onorati F, Faggian G, Mazzucco A

PMID: 22184316 [PubMed - in process]

Analytical concerns regarding complications of elective liver resections in a center with low mortality.

Arch Surg. 2011 Dec;146(12):1455

Authors: Tamhane A, McGwin G

PMID: 22184317 [PubMed - in process]

Effect of the Volume of Fluids Administered on Intraoperative Oliguria in Laparoscopic Bariatric Surgery: A Randomized Controlled Trial.

Arch Surg. 2011 Nov 21;

Authors: Matot I, Paskaleva R, Eid L, Cohen K, Khalaileh A, Elazary R, Keidar A

Abstract

OBJECTIVE: To determine whether intraoperative fluid management affects urine output in patients undergoing laparoscopic bariatric operations. DESIGN: Randomized controlled trial. SETTING: Academic tertiary referral center. PATIENTS: Morbidly obese patients scheduled to undergo laparoscopic bariatric procedures. INTERVENTIONS: Patients were randomly assigned to receive intraoperatively high (10 mL/kg/h, n = 55) or low (4 mL/kg/h, n = 52) amounts of Ringer lactate solution. MAIN OUTCOME MEASURES: The primary end point was urine output. Secondary end points were postoperative creatinine serum concentration and complication rate. RESULTS: Significantly more fluids were administered intraoperatively to patients in the high-volume group compared with the low-volume group (P < .001). Regardless of the amount of fluids administered intraoperatively, low urine outputs (median [range], 100 [15-1050] mL in the high-volume group vs 107 [25-500] mL in the low-volume group; P = .34) were documented and were not significantly different. The mean creatinine serum concentration was within normal range at all times and was not significantly different between the groups (P = .68). The number of patients with complications was nonsignificantly lower in the low-volume group compared with the high-volume group (7 vs 10 patients, respectively; P = .60). CONCLUSIONS: In patients undergoing laparoscopic bariatric surgery, intraoperative urine output is low regardless of the use of relatively high-volume fluid therapy. The results suggest that we should reconsider the common practice to administer intraoperative fluids in response to low urine output. Further studies are required to evaluate these data in other surgical patient populations. Trial Registration  clinicaltrials.gov Identifier: NCT00753402.

PMID: 22106246 [PubMed - as supplied by publisher]

Physicians’ Needs in Coping With Emotional Stressors: The Case for Peer Support.

Arch Surg. 2011 Nov 21;

Authors: Hu YY, Fix ML, Hevelone ND, Lipsitz SR, Greenberg CC, Weissman JS, Shapiro J

Abstract

OBJECTIVE: To design an evidence-based intervention to address physician distress, based on the attitudes toward support among physicians at our hospital. Design, Setting, and PARTICIPANTS: A 56-item survey was administered to a convenience sample (n = 108) of resident and attending physicians at surgery, emergency medicine, and anesthesiology departmental conferences at a large tertiary care academic hospital. MAIN OUTCOME MEASURES: Likelihood of seeking support, perceived barriers, awareness of available services, sources of support, and experience with stress. RESULTS: Among the resident and attending physicians, 79% experienced either a serious adverse patient event and/or a traumatic personal event within the preceding year. Willingness to seek support was reported for legal situations (72%), involvement in medical errors (67%), adverse patient events (63%), substance abuse (67%), physical illness (62%), mental illness (50%), and interpersonal conflict at work (50%). Barriers included lack of time (89%), uncertainty or difficulty with access (69%), concerns about lack of confidentiality (68%), negative impact on career (68%), and stigma (62%). Physician colleagues were the most popular potential sources of support (88%), outnumbering traditional mechanisms such as the employee assistance program (29%) and mental health professionals (48%). Based on these results, a one-on-one peer physician support program was incorporated into support services at our hospital. CONCLUSIONS: Despite the prevalence of stressful experiences and the desire for support among physicians, established services are underused. As colleagues are the most acceptable sources of support, we advocate peer support as the most effective way to address this sensitive but important issue.

PMID: 22106247 [PubMed - as supplied by publisher]

Reduced Risk of Medical Morbidity and Mortality in Patients Selected for Laparoscopic Colorectal Resection in England: A Population-Based Study.

Arch Surg. 2011 Nov 21;

Authors: Mamidanna R, Burns EM, Bottle A, Aylin P, Stonell C, Hanna GB, Faiz O

Abstract

OBJECTIVES: To quantify the occurrence of significant medical complications following elective colorectal resection and investigate potential differences in medical morbidity following open and minimal access colorectal surgery. DESIGN: Retrospective analysis of Hospital Episode Statistics, which is a prospectively maintained national database. SETTING: All patients undergoing colorectal resection in National Health Service trusts in England. PATIENTS: Adult patients undergoing elective or planned surgery between April 2001 and March 2008. INTERVENTION: Colorectal resection for benign and malignant diagnoses. MAIN OUTCOME MEASURES: Mortality and morbidity at 30 days and 1 year following elective colorectal resection. RESULTS: One hundred thirty-eight thousand seven hundred thirty-five elective colorectal resections were identified between the study dates. Thirty-day in-hospital mortality was 3.4% and 1.7% following conventional and laparoscopic surgery, respectively (P < .001). Overall, the 30-day postoperative medical morbidity rate was 14.6%. Use of the minimal access approach demonstrated a significant reduction in total morbidity risk at 30 days (odds ratio, 0.79; P < .001) and 365 days (odds ratio, 0.81; P < .001) following case-mix adjustment. Multiple regression analyses demonstrated that cardiorespiratory complications and venous thromboembolism occurred less frequently during the index admission and up to 1 year following minimal access surgery when compared with the conventional approach (P < .049). CONCLUSIONS: In this population-based study, patients selected for laparoscopic colorectal resection were associated with lower risk of mortality as well as reduced cardiorespiratory and venous thromboembolic risk than those undergoing open surgery.

PMID: 22106248 [PubMed - as supplied by publisher]

The Relationship Between Body Mass Index and 30-Day Mortality Risk, by Principal Surgical Procedure.

Arch Surg. 2011 Nov 21;

Authors: Turrentine FE, Hanks JB, Schirmer BD, Stukenborg GJ

Abstract

OBJECTIVE: To examine the relationship between body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) and 30-day mortality risk among patients in the participant use data file database of the American College of Surgeons National Surgical Quality Improvement Program. Obesity is a prevalent chronic disease in the United States, and general and vascular surgeons are caring for an increasing population of obese patients. DESIGN: Multivariable logistic regression analysis was used to assess the statistical significance of the relationship between BMI and mortality, with adjustments for patient-level differences in overall mortality risk and principal operating procedures. Odds ratios with 95% CIs were calculated to measure the relative difference in mortality by BMI quintile, with reference to the middle quintile of the BMI. The overall significance of the BMI and of the other covariates was measured using the Wald χ(2) test statistic. A separate multivariable logistic regression model was developed to assess the significance of the interaction between BMI and primary procedure. SETTING: A total of 183 sites. PATIENTS: Patients with major surgical procedures reported in the participant use data file database of the American College of Surgeons National Surgical Quality Improvement Program. RESULTS: The data included 189 533 cases of general and vascular surgical procedures reported in 2005 and 2006 for patients with known overall probabilities of death. Among these, 3245 patients died within 30 days of their surgery (1.7%). Patients with a BMI of less than 23.1 demonstrated a significant increased risk of death, with 40% higher odds compared with patients in the middle range for BMI (26.3 to <29.7). Important differences in the association between BMI and mortality risk occur by type of primary procedure. CONCLUSIONS: Body mass index is a significant predictor of mortality within 30 days of surgery, even after adjusting for the contribution to mortality risk made by type of surgery and for a specific patient’s overall expected risk of death.

PMID: 22106249 [PubMed - as supplied by publisher]

Maria petrocini ferretti, the first female surgeon in florence, Italy.

Arch Surg. 2011 Nov;146(11):1231-2

Authors: Lippi D, Vannucci L

PMID: 22106314 [PubMed - in process]

Bariatric Surgery in High-Risk Patients: Is it Time to Reconsider?

Arch Surg. 2011 Nov;146(11):1233-4

Authors: Lidor AO

PMID: 22106315 [PubMed - in process]

Cardiothoracic surgeon management of postoperative cardiac critical care.

Arch Surg. 2011 Nov;146(11):1253-60

Authors: Whitman GJ, Haddad M, Hirose H, Allen JG, Lusardi M, Murphy MA

Abstract

OBJECTIVE: To determine whether postoperative cardiac care by cardiothoracic surgeons in a semiclosed intensive care unit model could be distinguished from that given by intensivists who are not board certified in cardiothoracic surgery.

DESIGN: From January 2007 to February 2009, we retrospectively examined data on patients after cardiac operations from 2 consecutive periods during which full-time management of intensive care was changed from noncardiothoracic intensivists (period 1, 168 patients) to cardiothoracic surgeons (period 2, 272 patients).

MAIN OUTCOME MEASURES: Variables measured included Society of Thoracic Surgeons observed and expected mortality, central venous line infections, ventilator-acquired pneumonia, red blood cell exposure, adherence to blood glucose level target at 6 am on the first and second postoperative days, length of stay, and intensive care unit pharmacy costs. Results were compared using a 2-sample t test or 2-tailed Fisher exact test.

RESULTS: In similar populations, as witnessed by equivalent Society of Thoracic Surgeons operative risk, cardiothoracic surgeons providing postoperative critical care led to a mean (SD) decrease in hospital length of stay from 13.4 (0.9) to 11.2 (0.4) days (P = .01) and decreased drug costs from $4300 (1000) to $1800  (200) (P < .001). These improvements occurred without losing benefits in other quality measures.

CONCLUSIONS: By virtue of their cardiac-specific operative and nonoperative training, cardiothoracic surgeons may be uniquely qualified to provide postoperative cardiac critical care. In a semiclosed unit where care of the patient is codirected, the improvements noted may have been facilitated by the commonalities between surgeons and intensivists associated with similar training and experiences.

PMID: 22106316 [PubMed - in process]

Outcomes of renal transplants from centers for disease control and prevention high-risk donors with prospective recipient viral testing: a single-center experience.

Arch Surg. 2011 Nov;146(11):1261-6

Authors: Lonze BE, Dagher NN, Liu M, Kucirka LM, Simpkins CE, Locke JE, Desai NM, Cameron AM, Montgomery RA, Segev DL, Singer AL

Abstract

HYPOTHESIS: The use of kidneys from deceased donors considered at increased infectious risk represents a strategy to increase the donor pool.

DESIGN: Single-institution longitudinal observational study.

SETTING: Tertiary care center.

PATIENTS: Fifty patients who gave special informed consent to receive Centers for Disease Control and Prevention high-risk (CDCHR) donor kidneys were followed up by serial testing for viral transmission after transplantation. Nucleic acid testing for human immunodeficiency virus, hepatitis B virus, and hepatitis C virus was performed on all high-risk donors before transplantation. Outcomes of CDCHR kidney recipients were compared with outcomes of non-high-risk (non-HR) kidney recipients.

MAIN OUTCOME MEASURES: New viral transmission, graft function, and waiting list time.

RESULTS: No recipient seroconversion was detected during a median follow-up period of 11.3 months. Compared with non-HR donors, CDCHR donors were younger (mean [SD] age, 35 [11] vs 43 [18] years, P = .01), fewer were expanded criteria donors (2.0% vs 24.8%, P < .001), and fewer had a terminal creatinine level exceeding 2.5 mg/dL (4.0% vs 8.8%, P = .002). The median creatinine levels at 1 year after transplantation were 1.4 (interquartile range, 1.2-1.7) mg/dL for CDCHR recipients and 1.4 (interquartile range, 1.1-1.9) mg/dL for non-HR recipients (P = .4). Willingness to accept a CDCHR kidney significantly shortened the median waiting list time (274 vs 736 days, P < .001).

CONCLUSIONS: We show safe use of CDCHR donor kidneys and good 1-year graft function. With continued use of these organs and careful follow-up care, we will be better able to gauge donor risk and match it to recipient need to expand the donor pool and optimize patient benefit.

PMID: 22106317 [PubMed - in process]

Effect of Paget’s Disease on Survival in Breast Cancer: An Exploratory Study.

Arch Surg. 2011 Nov;146(11):1267-70

Authors: Ortiz-Pagan S, Cunto-Amesty G, Narayan S, Crawford S, Derrick C, Larkin A, Khan A, Quinlan R, Layeequr Rahman R

Abstract

OBJECTIVE: To explore whether Paget’s disease (PD) has an effect on outcome in patients with breast cancer.

DESIGN: Retrospective analysis of comprehensive pathology database, medical records, and slides of samples showing pathologic features.

SETTING: UMass Memorial Health Care.

PATIENTS: All patients with breast cancer and PD with records in a prospectively maintained database between January 1, 1990, and December 31, 2008, were identified. Each participant was matched (criteria: age within 5 years, year of treatment, and stage of breast cancer) with 2 controls (1:2 ratio).

MAIN OUTCOME MEASURES: Overall and disease-free survival were analyzed using Kaplan-Meier statistics and Cox proportional hazards modeling, accounting for matching in the latter analyses by using robust standard error estimates.

RESULTS: Mean (SD) follow-up was 47 (33) months. Treatment involved mastectomy in 29 (91%) PD vs 16 (25%) non-PD patients (P < .001), radiotherapy in 14 (44%) PD vs 53 (83%) non-PD patients (P < .001), and hormonal therapy in 14 (44%) PD vs 33 (52%) non-PD patients (P = .004). Biological markers were not significantly different except for ERBB2 (formerly HER2 or HER2/neu) overexpression in 14 (44%) PD vs 16 (25%) non-PD patients (P = .008). The PD group had an overall 5-year survival of 81.2% vs 93.8% of the non-PD group (Kaplan-Meier log-rank, P = .03). The unadjusted hazard ratio for the PD vs non-PD group was 5.31 (95% CI, 1.74-16.27; P = .003). The corresponding hazard ratio after adjusting for local and systemic treatment was 2.26 (95% CI, 0.46-11.06; P = .32).

CONCLUSIONS: These exploratory data show that PD may have a negative effect on breast cancer survival. This finding needs to be substantiated in larger data sets.

PMID: 22106318 [PubMed - in process]

Differential association of race with treatment and outcomes in medicare patients undergoing diverticulitis surgery.

Arch Surg. 2011 Nov;146(11):1272-6

Authors: Schneider EB, Haider A, Sheer AJ, Hambridge HL, Chang DC, Segal JB, Wu AW, Lidor AO

Abstract

BACKGROUND: Observed racial disparities in diverticulitis surgery have been attributed to differences in health insurance status and medical comorbidity.

OBJECTIVE: To examine disparities in procedure type (elective vs urgent/emergency) and mortality in patients with surgically treated diverticulitis insured by Medicare, accounting for comorbidities.

DESIGN: Retrospective analysis of Medicare Provider Analysis and Review inpatient data.

PATIENTS: All blacks and whites 65 years and older undergoing surgical treatment for primary diverticulitis with complete admission and outcome data were eligible.

MAIN OUTCOME MEASURES: In-hospital mortality was examined across procedure categories (elective vs urgent/emergency). Multivariable regression controlled for age, sex, and medical comorbidity (Charlson Comorbidity Index).

RESULTS: A total of 49 937 whites and 2283 blacks met the study criteria. Blacks were slightly younger (74.7 vs 75.5 years, P < .001) and more likely to be female (75.2% vs 69.8%, P < .001). Blacks carried greater comorbidity than did whites (mean Charlson Comorbidity Index score: 0.98 vs 0.87, P < .001); 67.8% of blacks vs 54.7% of whites (P < .001) were urgent/emergency. After adjustment, blacks demonstrated 26% greater risk of urgent/emergency admission (relative risk, 1.26; 95% CI, 1.22-1.30). Black race was also associated with a 28% greater risk of mortality (relative risk, 1.28; 95% CI, 1.10-1.51).

CONCLUSIONS: Blacks underwent urgent/emergency surgery more often than did whites. Blacks demonstrated significantly increased mortality risk after controlling for age, sex, and comorbidities. These findings suggest that observed racial disparities encompass more than just insurance status and medical comorbidity. Mechanisms leading to worse outcomes for blacks must be elucidated.

PMID: 22106319 [PubMed - in process]

Predicting the risk of perioperative mortality in patients undergoing pancreaticoduodenectomy: a novel scoring system.

Arch Surg. 2011 Nov;146(11):1277-84

Authors: Venkat R, Puhan MA, Schulick RD, Cameron JL, Eckhauser FE, Choti MA, Makary MA, Pawlik TM, Ahuja N, Edil BH, Wolfgang CL

Abstract

OBJECTIVE: To develop and validate a risk score to predict the 30- and 90-day mortality after a pancreaticoduodenectomy or total pancreatectomy on the basis of preoperative risk factors in a high-volume program.

DESIGN: Data from a prospectively maintained institutional database were collected. In a random subset of 70% of patients (training cohort), multivariate logistic regression was used to develop a simple integer score, which was then validated in the remaining 30% of patients (validation cohort). Discrimination and calibration of the score were evaluated using area under the receiver operating characteristic curve and Hosmer-Lemeshow test, respectively.

SETTING: Tertiary referral center.

PATIENTS: The study comprised 1976 patients in a prospectively maintained institutional database who underwent pancreaticoduodenectomy or total pancreatectomy between 1998 and 2009.

MAIN OUTCOME MEASURES: The 30- and 90-day mortality.

RESULTS: In the training cohort, age, male sex, preoperative serum albumin level, tumor size, total pancreatectomy, and a high Charlson index predicted 90-day mortality (area under the curve, 0.78; 95% CI, 0.71-0.85), whereas all these factors except Charlson index also predicted 30-day mortality (0.79; 0.68-0.89). On validation, the predicted and observed risks were not significantly different for 30-day (1.4% vs 1.0%; P = .62) and 90-day (3.8% vs 3.4%; P = .87) mortality. Both scores maintained good discrimination (for 30-day mortality, area under the curve, 0.74; 95% CI, 0.54-0.95; and for 90-day mortality, 0.73; 0.62-0.84).

CONCLUSIONS: The risk scores accurately predicted 30- and 90-day mortality after pancreatectomy. They may help identify and counsel high-risk patients, support and calculate net benefits of therapeutic decisions, and control for selection bias in observational studies as propensity scores.

PMID: 22106320 [PubMed - in process]

Prognosis for the recovery of surgeons from chemical dependency: a 5-year outcome study.

Arch Surg. 2011 Nov;146(11):1286-91

Authors: Buhl A, Oreskovich MR, Meredith CW, Campbell MD, Dupont RL

Abstract

HYPOTHESIS: Rates of relapse, monitoring contract completion, and return to medical practice may differ between surgeons and nonsurgeons being monitored for diagnosed substance use disorders.

DESIGN: Retrospective 5-year longitudinal cohort study.

SETTING: A sample of 16 state physician health programs in the United States.

PARTICIPANTS: Nine hundred four physicians who underwent treatment for a substance use disorder and were consecutively admitted to 1 of 16 state physician health programs between September 1, 1995, and September 1, 2001. The study analyzed a subset of data comparing 144 surgeons with 636 nonsurgeons.

MAIN OUTCOME MEASURES: Rates of continued drug and alcohol misuse (relapse), monitoring contract completion, and return to medical practice at 5 years.

RESULTS: Surgeons were significantly more likely than nonsurgeons to enroll in a physician health program because of alcohol-related problems (odds ratio, 1.9; 95% CI, 1.3-2.7; P = .001) and were less likely to enroll because of opioid use (odds ratio, 0.5; 95% CI, 0.3-0.8, P = .002). Surgeons were neither more nor less likely than nonsurgeons to have a positive drug test result, complete or fail to complete the monitoring contract, or extend the monitoring period beyond the original 5 years specified in their agreements. Fewer surgeons than nonsurgeons were licensed and practicing medicine at the conclusion of the monitoring period, although this difference was not statistically significant.

CONCLUSIONS: Surgeons in this study had positive outcomes similar to those of nonsurgeons. However, further research is necessary to conclude whether surgeons are less likely than their nonsurgeon peers to successfully return to medical practice following chemical dependency treatment.

PMID: 22106321 [PubMed - in process]

Transfusion criteria for fresh frozen plasma in liver resection: a 3 + 3 cohort expansion study.

Arch Surg. 2011 Nov;146(11):1293-9

Authors: Yamazaki S, Takayama T, Kimura Y, Moriguchi M, Higaki T, Nakayama H, Fujii M, Makuuchi M

Abstract

OBJECTIVE: To establish transfusion criteria for use of fresh frozen plasma (FFP) in liver resection.

BACKGROUND: Fresh frozen plasma has been transfused in liver resection without adequate supporting evidence, leading to unnecessary use.

DESIGN: Prospective study using a phase 1 dose-escalation, 3 + 3 cohort expansion design, modified for FFP transfusion. We designated a serum albumin level of 3.0 g/dL (step 1) as the starting limit for no transfusion and reduced the level in 0.2-g/dL steps. Advancement to the next step was permitted when the albumin level equaled the target value for the previous step in 3 patients. If the albumin value on postoperative day 2 fell below the target value, 100 mL of albumin, 25%, was transfused on that day and on postoperative day 3. The study continued until high-grade postoperative complications occurred without transfusion. If 1 of 3 patients developed Clavien-Dindo grade II or higher complications, 3 more patients (3 + 3 cohort) were added to the same step.

SETTING: Hepatobiliary pancreatic surgery center of a university hospital.

PATIENTS: Patients with hepatocellular carcinoma who had had Child-Pugh class A liver function and an intraoperative blood loss of less than 1000 mL.

INTERVENTION: Transfusion or no transfusion of FFP. Main Outcome Measure  Reduction of transfusion rate in liver resection.

RESULTS: Of the 213 consecutive patients with liver cancer enrolled, 172 patients (80.8%) fulfilled the inclusion criteria. Step progression proceeded until step 5 (albumin level, 2.2 g/dL) without high-grade complications, but step 2 (albumin level, 2.8 g/dL) required 63 patients to complete because 1 patient developed grade II complications (massive ascites). Step progression was broken off at step 5 in the 172nd patient because the postoperative day 2 albumin value did not fall below the step 4 level (2.4 g/dL), defined as the goal limit. The overall operative morbidity rate was 27.9%; the mortality rate was 0%. The FFP transfusion rate was significantly reduced from 48.6% in a previous series involving 222 patients (unpublished historical data from our institution) to 0.6% (1 of 172 patients) in the present study (P < .001). The postoperative hospital stay in the present study was significantly shorter than that in our previous series (13 vs 16 days; P = .01). Total medical costs were significantly reduced from a median of $21 061 (range, 10 032-59 410) to $17 267 (11 823-35 785; P = .04).

CONCLUSION: In liver resection, FFP transfusion is not necessary in patients with serum albumin levels higher than 2.4 g/dL on postoperative day 2.

PMID: 22106322 [PubMed - in process]

Preoperative very low-calorie diet and operative outcome after laparoscopic gastric bypass: a randomized multicenter study.

Arch Surg. 2011 Nov;146(11):1300-5

Authors: Van Nieuwenhove Y, Dambrauskas Z, Campillo-Soto A, van Dielen F, Wiezer R, Janssen I, Kramer M, Thorell A

Abstract

HYPOTHESIS: A 14-day very low-calorie diet (VLCD) regimen before a laparoscopic gastric bypass procedure will improve perioperative and postoperative outcomes.

DESIGN: Multicenter, randomized, single-blind study.

SETTING: Five high-volume bariatric centers in Sweden, the Netherlands, Lithuania, Spain, and Belgium.

PATIENTS: Two hundred ninety-eight morbidly obese patients undergoing laparoscopic gastric bypass from March 1, 2009, through December 5, 2010.

INTERVENTION: Patients were randomly allocated to a 2-week preoperative VLCD regimen or no preoperative dietary restriction (control group).

MAIN OUTCOME MEASURES: Operating time, surgeon’s perceived difficulty of the operation, liver lacerations, intraoperative bleeding and complications, 30-day weight loss, and morbidity.

RESULTS: Mean (SD) preoperative weight change was -4.9 (3.6) kg in the VLCD group vs -0.4 (3.2) kg in the control group (P < .001). Although the surgeon’s perceived difficulty of the procedure was lower in the VLCD group (median [interquartile range], 26 [15-42] vs 35 [18-50] mm on a visual analog scale; P = .04), no differences were found regarding mean (SD) operating time (81 [21] vs 80 [23] min; P = .53), estimated blood loss (P = .62), or intraoperative complications (P = .88). At the 30-day follow-up, the number of complications was greater in the control compared with the VLCD group (18 vs 8; P = .04).

CONCLUSIONS: Although weight reduction with a 14-day VLCD regimen before laparoscopic gastric bypass performed in high-volume centers seems to reduce the perceived difficulty of the procedure, only minor effects on operating time, intraoperative complications, and short-term weight loss could be expected. However, the finding of reduced postoperative complication rates suggests that such a regimen should be recommended before bariatric surgery.

PMID: 22106323 [PubMed - in process]

Career phase of board-certified general surgeons: workload composition and outcomes.

Arch Surg. 2011 Nov;146(11):1307-13

Authors: Studnicki J, Fisher JW, Tsulukidze MM, Taylor YJ, Salandy S, Laditka JN

Abstract

OBJECTIVE: To examine surgeon career phase and its association with surgical workload composition and outcomes of surgery.

DESIGN: Cross-sectional study.

SETTING: The study used data from calendar years 2004 through 2006 from 4 Florida general surgeon (GS) cohorts determined by years since board certification.

PARTICIPANTS: American Board of Surgery-certified GSs regardless of subspecialty (n = 1187) performing 460 881 operations on adults 18 years or older.

MAIN OUTCOME MEASURES: Workload composition based on the Clinical Classification System, complications identified by patient safety indicators, and in-hospital mortality. Poisson regression with robust error variance estimated adjusted rate ratios (RRs) for complications and mortality.

RESULTS: Compared with late-career surgeons, the rate of complications from cardiovascular procedures was higher for surgeons in the early-career phase (RR, 1.23; 95% CI, 1.06-1.44) and the late middle-career phase (1.18; 1.02-1.37). The mortality rate for cardiovascular procedures also was higher for early-career surgeons (RR, 1.23; 95% CI, 1.04-1.46). For digestive procedures, early-career surgeons had lower complication rates than late-career surgeons (RR, 0.86; 95% CI, 0.75-0.99).

CONCLUSION: Late-career GSs perform both better and worse compared with early-career GSs, relative to their workload composition and proportional surgical volume. Factors such as training and case complexity may contribute to these career-phase differences.

PMID: 22106324 [PubMed - in process]

Safety of Laparoscopic vs Open Bariatric Surgery: A Systematic Review and Meta-analysis.

Arch Surg. 2011 Nov;146(11):1314-22

Authors: Reoch J, Mottillo S, Shimony A, Filion KB, Christou NV, Joseph L, Poirier P, Eisenberg MJ

Abstract

OBJECTIVE: To perform a systematic review and meta-analysis evaluating the risk of reoperation, wound infection, incisional hernia, anastomotic leak, and all-cause mortality associated with laparoscopic vs open bariatric surgery at a minimum of 12 months’ follow-up.

DATA SOURCES: We systematically searched the Cochrane Library, EMBASE, and MEDLINE databases through June 1, 2010, for randomized controlled trials comparing laparoscopic with open bariatric surgery.

STUDY SELECTION: We included all randomized controlled trials that reported weight loss outcomes and complications at a minimum of 12 months’ follow-up and had a minimum of 50 patients. We identified 6 randomized controlled trials, which randomized 510 patients.

DATA EXTRACTION: Data were extracted by 2 reviewers on study design, baseline characteristics, and surgical procedure. The outcome data extracted included change in weight and body mass index and the incidence of reoperation, wound infection, incisional hernia, anastomotic leak, and all-cause mortality.

DATA SYNTHESIS: We used random-effects models, which accounted for within-study and between-study variability, to estimate pooled risk ratios (95% CIs). Compared with open surgery, laparoscopic surgery was associated with lower risk of wound infection (relative risk [RR], 0.21; 95% CI, 0.07-0.65) and incisional hernia (RR, 0.11; 95% CI, 0.03-0.35). The risk of reoperation (RR, 1.06; 95% CI, 0.70-1.61), anastomotic leak (RR, 0.64; 95% CI, 0.14-2.95), and all-cause mortality (RR, 0.86; 95% CI, 0.22-3.28) may be similar for laparoscopic and open bariatric surgery.

CONCLUSION: Laparoscopic surgery may be a safer treatment than open surgery for patients requiring bariatric surgery.

PMID: 22106325 [PubMed - in process]

Hyaluronate-iodine complex: a new adjunct for the management of complex sternal wounds after a cardiac operation.

Arch Surg. 2011 Nov;146(11):1323-5

Authors: Brenes RA, Sobotka L, Ajemian MS, Manak J, Vyroubal P, Slemrova M, Adamkova V, Zajic J, Dudrick SJ

Abstract

A wound-healing agent developed in the European Union is based on the combination of organic hyaluronan with inorganic iodine. The aim of this pilot study was to assess the efficacy and safety of hyaluronate-iodine in the treatment of sternal wounds. Eight patients with sternal wound dehiscence were entered into the study. After debridement, wounds were dressed with gauze soaked in hyaluronate-iodine. In one patient with an epipleural abscess, hyaluronate-iodine was instilled directly into the abscess cavity daily. Complete healing was achieved in 7 patients, and 1 patient underwent a reconstructive operation for wound closure. The mean (SD) length of treatment was 136 (114.2) days. No adverse effects or complications were apparent in this group. Hyaluronate-iodine is safe and effective in healing sternal wound dehiscence. Randomized controlled trials are needed for further validation.

PMID: 22106326 [PubMed - in process]

Image of the month–quiz case.

Arch Surg. 2011 Nov;146(11):1327

Authors: Amin AL, Wang TS

PMID: 22106327 [PubMed - in process]

Image of the month–quiz case.

Arch Surg. 2011 Nov;146(11):1329

Authors: Grisham A, Javan R

PMID: 22106328 [PubMed - in process]

Image of the month–quiz case.

Arch Surg. 2011 Nov;146(11):1331

Authors: Huddleston SJ, Wei Lum Y, Black JH, Meneshian A

PMID: 22106329 [PubMed - in process]

Magnetic resonance imaging monsters and surgical vampires.

Arch Surg. 2011 Nov;146(11):1333

Authors: Schaefer GR, Matus HL, Goetz C, Arora VM

PMID: 22106330 [PubMed - in process]

Major abdominal surgery with continued dual antiplatelet therapy.

Arch Surg. 2011 Nov;146(11):1334-5

Authors: Quante M, Benckert C, Thelen A, Kaisers U, Jonas S

PMID: 22106331 [PubMed - in process]

Emerging trends in endoscopic retrograde cholangiopancreatography and common bile duct exploration.

Arch Surg. 2011 Nov;146(11):1336

Authors: Maa J

PMID: 22106332 [PubMed - in process]

The elusive search for predictors of healing following transmetatarsal amputation.

Arch Surg. 2011 Sep;146(9):1009-10

Authors: DeRubertis BG

PMID: 22029062 [PubMed - in process]

Still looking for the ideal procedure for complex anal fistula treatment.

Arch Surg. 2011 Sep;146(9):1016

Authors: Chiu YS

PMID: 22029063 [PubMed - in process]

Liver transplantation with donation after cardiac death: a treacherous field!

Arch Surg. 2011 Sep;146(9):1023

Authors: Esquivel CO

PMID: 22029064 [PubMed - in process]

Surgery for achalasia: is this as good as it gets?

Arch Surg. 2011 Sep;146(9):1028

Authors: Pellegrini CA

PMID: 22029065 [PubMed - in process]

When more is too much: axillary node dissection in the sentinel node era.

Arch Surg. 2011 Sep;146(9):1033-4

Authors: Wong JH

PMID: 22029066 [PubMed - in process]

Sentinel lymph node nomograms: predicting the future.

Arch Surg. 2011 Sep;146(9):1040

Authors: Lum SS

PMID: 22029067 [PubMed - in process]

Hole in the heart: is an echocardiogram really indicated 1 month later?

Arch Surg. 2011 Sep;146(9):1066-7

Authors: Schreiber MA

PMID: 22029070 [PubMed - in process]

There’s more than 1 way to split a liver and skin a cat.

Arch Surg. 2011 Sep;146(9):1059-60

Authors: Rana A, Hong JC

PMID: 22029068 [PubMed - in process]

Preventing unintended consequences of quality measurement.

Arch Surg. 2011 Sep;146(9):1072-3

Authors: Lawson EH, Ko CY

PMID: 22029071 [PubMed - in process]