Perioperative Risk of Laparoscopic Fundoplication: Safer than Previously Reported-Analysis of the American College of Surgeons National Surgical Quality Improvement Program 2005 to 2009.

J Am Coll Surg. 2012 May 9;

Authors: Niebisch S, Fleming FJ, Galey KM, Wilshire CL, Jones CE, Litle VR, Watson TJ, Peters JH

Abstract

BACKGROUND: Several prospective randomized controlled trials show equal effectiveness of surgical fundoplication and proton pump inhibitor therapy for the treatment of gastroesophageal reflux disease. Despite this compelling evidence of its efficacy, surgical antireflux therapy is underused, occurring in a very small proportion of patients with gastroesophageal reflux disease. An important reason for this is the perceived morbidity and mortality associated with surgical intervention. Published data report perioperative morbidity between 3% and 21% and mortality of 0.2% and 0.5%, and current data are uncommon, largely from previous decades, and almost exclusively single institutional. STUDY DESIGN: The study population included all patients in the American College of Surgeons National Surgical Quality Improvement Program database from 2005 through 2009 who underwent laparoscopic fundoplication with or without related postoperative ICD-9 codes. Comorbidities, intraoperative occurrences, and 30-day postoperative outcomes were collected and logged into statistical software for appropriate analysis. Postoperative occurrences were divided into overall and serious morbidity. RESULTS: A total of 7,531 fundoplications were identified. Thirty-five percent of patients were younger than 50 years old, 47.1% were 50 to 69 years old, and 16.8% were older than 69 years old. Overall, 30-day mortality was 0.19% and morbidity was 3.8%. Thirty-day mortality was rare in patients younger than age 70 years, occurring in 5 of 10,000 (0.05%). Mortality increased to 8 of 1,000 (0.8%) in patients older than 70 years (p < 0.0001). Complications occurred in 2.2% of patients younger than 50 years, 3.8% of those 50 to 69 years, and 7.3% of patients older than 69 years. Serious complications occurred in 8 of 1,000 (0.8%) patients younger than 50 years, 1.8% in patients 50 to 69 years, and 3.9% of those older than 69 years. CONCLUSIONS: Analysis of this large cohort demonstrates remarkably low 30-day morbidity and mortality of laparoscopic fundoplication. This is particularly true in patients younger than 70 years, who are likely undergoing fundoplication for gastroesophageal reflux disease. These data suggest that surgical therapy carries an acceptable risk profile.

PMID: 22578304 [PubMed - as supplied by publisher]

Optimizing Clinical and Economic Outcomes of Surgical Therapy for Patients with Colorectal Cancer and Synchronous Liver Metastases.

J Am Coll Surg. 2012 May 3;

Authors: Abbott DE, Cantor SB, Hu CY, Aloia TA, You YN, Nguyen S, Chang GJ

Abstract

BACKGROUND: Traditionally, for patients with colorectal cancer with resectable synchronous liver metastases, resections were performed separately. However, the safety and efficacy of simultaneous resection have been demonstrated in selected patients. The purpose of this study was to evaluate outcomes and economic implications of simultaneous and staged resections. STUDY DESIGN: We conducted a retrospective cohort study of consecutive colorectal cancer patients with resectable synchronous liver metastases treated between 1993 and 2010, constructing a decision tree comparing simultaneous and staged resections. For generalizability, the analysis was conducted from a payer perspective, using costs derived from 2010 Medicare reimbursement. Decision models incorporated the severity-refined DRG complications (complicating condition/major complicating condition) modifiers. Sensitivity analyses used alternative models of DRG reimbursement. RESULTS: There were 144 patients analyzed. Sixty (41.7%) underwent simultaneous resection and 84 (58.3%) underwent staged resection. Median overall survival did not differ between the simultaneous and the staged cohorts (66.3 vs 65.6 months, respectively), nor did the overall complication rate (38.3% vs 40.5%, respectively). Median total length of hospitalization was significantly shorter in the simultaneous cohort (8 vs 14 days; p = 0.001). In the base model, the simultaneous strategy cost less than the staged strategy ($20,983 vs $25,298 per case)-a savings of 17.1%. Sensitivity analyses examining alternative severity-refined DRG reimbursements demonstrated potential cost savings, in all but 1 extreme sensitivity analysis, ranging from 9.8% to 27.3% favoring simultaneous resection. CONCLUSIONS: The simultaneous resection strategy was oncologically equivalent and more cost efficient for patients with primary colorectal cancer presenting with resectable liver metastases. A reduction in overall length of hospital stay was an associated benefit. Future studies should explore the feasibility and clinical implications of policies to maximize the potential for simultaneous resection in this cohort of patients.

PMID: 22560316 [PubMed - as supplied by publisher]

Surgical Management of Inoperable Lymphedema: The Re-emergence of Abandoned Techniques.

J Am Coll Surg. 2012 May 3;

Authors: Doscher ME, Herman S, Garfein ES

PMID: 22560317 [PubMed - as supplied by publisher]

The First National Examination of Outcomes and Trends in Robotic Surgery in the United States.

J Am Coll Surg. 2012 May 3;

Authors: Anderson JE, Chang DC, Parsons JK, Talamini MA

Abstract

BACKGROUND: There are few population-based data describing outcomes of robotic-assisted surgery. We compared outcomes of robotic-assisted, laparoscopic, and open surgery in a nationally representative population database. STUDY DESIGN: A retrospective analysis of the Nationwide Inpatient Sample database from October 2008 to December 2009 was performed. We identified the most common robotic procedures by ICD-9 procedure codes and grouped them into categories by procedure type. Multivariate analyses examined mortality, length of stay (LOS), and total hospital charges, adjusting for age, race, sex, Charlson comorbidity index, and teaching hospital status. RESULTS: A total of 368,239 patients were identified. On adjusted analysis, compared with open, robotic-assisted laparoscopic surgery was associated with decreased odds of mortality (odds ratio = 0.1; 95% CI, 0.0-0.2; p < 0.001), decreased mean LOS (-2.4 days; 95% CI, -2.5 to 2.3; p < 0.001), and increased mean total charges in all procedures (range $3,852 to $15,329) except coronary artery bypass grafting (-$17,318; 95% CI, -34,492 to -143; p = 0.048) and valvuloplasty (not statistically significant). Compared with laparoscopic, robotic-assisted laparoscopic surgery was associated with decreased odds of mortality (odds ratio = 0.1; 95% CI, 0.0-0.6; p = 0.008), decreased LOS overall (-0.6 days; 95% CI, -0.7 to -0.5; p < 0.001), but increased LOS in prostatectomy and other kidney/bladder procedures (0.3 days; 95% CI, 0.1-0.4; p = 0.006; 0.8 days; 95% CI, 0.0-1.6; p = 0.049), and increased total charges ($1,309; 95% CI, 519-2,099; p = 0.001). CONCLUSIONS: Data suggest that, compared with open surgery, robotic-assisted surgery results in decreased LOS and diminished likelihood of death. However, these benefits are not as apparent when comparing robotic-assisted laparoscopic with nonrobotic laparoscopic procedures.

PMID: 22560318 [PubMed - as supplied by publisher]

Rib Fracture Fixation for Flail Chest: What Is the Benefit?

J Am Coll Surg. 2012 May 3;

Authors: Bhatnagar A, Mayberry J, Nirula R

Abstract

BACKGROUND: Recently, rib fracture fixation for flail chest has been used increasingly at both academic and nonacademic trauma centers. Although a few small non-US studies have demonstrated a clinical benefit, it is unclear whether this benefit outweighs the added expense and potential perioperative complications related to the procedure. We therefore sought to determine if open reduction and internal fixation of ribs for flail chest (ORIF-FC) represents a cost-effective means for managing these patients. STUDY DESIGN: A Markov transition state analysis was performed modeling the outcomes of the standard of care or ORIF-FC for flail chest. The incidences of ventilator-associated pneumonia, tracheostomy, sepsis, prolonged ventilation, deep vein thrombosis, pulmonary embolism, wound infection, and postoperative hemorrhage were obtained based on literature review. Medicare 2010 reimbursement costs were used for diagnoses and procedures. A quality of life improvement factor ranging from 0 to 15% improvement was used to estimate the improvement in pain and functional outcomes related to ORIF-FC. The most cost-effective treatment was then determined, ranging the incidences of ventilator-associated pneumonia and quality of life improvement factor. RESULTS: Cost effectiveness was $15,269 for ORIF-FC compared with $16,810 for standard of care. Even when the quality of life improvement factor was set to 0%, ORIF-FC remained the most cost-effective strategy. Similarly, ORIF-FC remained the most cost-effective strategy by $8,400 when the incidence of ventilator-associated pneumonia after ORIF was as high as 22%. CONCLUSIONS: Despite the additional cost of surgery, rib fracture fixation dominates the standard of care and should be considered in the management of appropriate flail chest patients.

PMID: 22560319 [PubMed - as supplied by publisher]

Open Repair of Blunt Thoracic Aortic Injury Remains Relevant in the Endovascular Era.

J Am Coll Surg. 2012 Apr 26;

Authors: Cannon RM, Trivedi JR, Pagni S, Dwivedi A, Bland JN, Slaughter MS, Ross CB, Richardson JD, Williams ML

Abstract

BACKGROUND: Thoracic endovascular aneurysm repair (TEVAR) has been a major advance in the treatment of blunt thoracic aortic injury (BTAI), although many patients still undergo open repair. This study was undertaken to evaluate outcomes with open repair and TEVAR for BTAI. STUDY DESIGN: A retrospective review of all patients with BTAI at a single Level I trauma center from 2001 through 2009 was performed. Patients were grouped according to treatment modality, ie, open repair, TEVAR, or medical management. Direct comparison using standard statistical methods was made between patients undergoing open repair and TEVAR since late 2006 when TEVAR began at our institution using standard statistical methods. Outcomes variables included mortality, paraplegia, length of stay, ICU stay, and ventilator requirements. RESULTS: There were 69 patients in the study, with 36 (52.2%) undergoing open repair, 10 receiving TEVAR (14.5%), 10 patients managed medically (14.5%), and 13 (18.8%) who died during triage. Overall mortality in the pre-TEVAR era was 29.6%. Since the introduction of TEVAR, there have been 8 open repairs. Patients undergoing open repair were significantly younger (32 vs. 58 years; p = 0.002) and had smaller aortic diameter (18 mm vs 24.5 mm; p < 0.001) than those undergoing TEVAR. Overall mortality since the introduction of TEVAR has dropped to 12.0% (p = 0.097). CONCLUSIONS: TEVAR and open repair should be viewed as complementary rather than competing modalities for the treatment of BTAI. Having both available allows selection of the most appropriate management technique for each patient, with subsequent improvement in outcomes.

PMID: 22541985 [PubMed - as supplied by publisher]

Intraparenchymal Versus Extracranial Ventricular Drain Intracranial Pressure Monitors in Traumatic Brain Injury: Less Is More?

J Am Coll Surg. 2012 Apr 26;

Authors: Kasotakis G, Michailidou M, Bramos A, Chang Y, Velmahos G, Alam H, King D, de Moya MA

Abstract

BACKGROUND: Management of severe traumatic brain injury has centered on continuous intracranial pressure (ICP) monitoring with intraparenchymal ICP monitors (IPM) or extracranial ventricular drains (EVD). Our hypothesis was that neurologic outcomes are unaffected by the type of ICP monitoring device. STUDY DESIGN: We reviewed 377 adult patients with traumatic brain injury requiring ICP monitoring. Primary outcome was Glasgow Outcome Score (GOS) 1 month after injury. Secondary outcomes included mortality, monitoring-related complications, and length of ICU and hospital stay. RESULTS: There were 253 patients managed with an IPM and 124 with an EVD. There was no difference in Glasgow Outcome Score (2.7 ± 1.3 vs 2.5 ± 1.3, p = 0.45), mortality (30.9% vs 32.2%, p = 0.82), and hospital length of stay (LOS) (15.6 ± 12.4 days vs 16.4 ± 10.7 days, p = 0.57). Device-related complications (11.9% vs 31.1%, p < 0.001), duration of ICP monitoring (3.8 ± 2.6 days vs 7.3 ± 5.6 days, p < 0.001), and ICU LOS (7.6 ± 5.6 days vs 9.5 ± 6.2 days, p = 0.004) were longer in the EVD group. Age, opening ICP, and size of midline shift were independent predictors for neurologic outcomes and mortality, when type and severity of brain injury, as well as overall injury severity were controlled for. Duration of ICP monitoring and opening ICP were independent predictors for hospital LOS and the former predicted prolonged ICU stay. Device-related complications were affected by type of device. CONCLUSIONS: Use of EVDs in adult traumatic brain injury patients is associated with prolonged ICP monitoring, ICU LOS, and more frequent device-related complications.

PMID: 22541986 [PubMed - as supplied by publisher]

Early Tracheostomy Is Associated With Improved Outcomes in Patients Who Require Prolonged Mechanical Ventilation after Cardiac Surgery.

J Am Coll Surg. 2012 Apr 26;

Authors: Devarajan J, Vydyanathan A, Xu M, Murthy SM, McCurry KR, Sessler DI, Sabik J, Bashour CA

Abstract

BACKGROUND: The best time to perform a tracheostomy in cardiac surgery patients who require prolonged postoperative mechanical ventilation remains unknown. The primary aim of this investigation was to determine if tracheostomy performed before postoperative day 10 improves patient outcomes. STUDY DESIGN: We conducted a retrospective review of prospectively collected patient information obtained from the Anesthesiology Institute Patient Registry on adult patients recovering from coronary artery bypass grafting and/or valve surgery. Demographic and comorbidity patient variables were obtained. Patients were divided into 2 groups based on the timing of their tracheostomy: early (less than 10 days) and late (14 to 28 days). The 2 patient groups were matched using propensity scores and compared on morbidity and in-hospital mortality outcomes. The primary outcomes measures were length of stay, morbidity, and in-hospital mortality. RESULTS: After propensity matching (n = 114 patients/group), early tracheostomy was associated with decreased in-hospital mortality (21.1% vs 40.4%, p = 0.002) and cardiac morbidity (14.0% vs 33.3%, p < 0.001), along with decreased ICU (median difference 7.2 days, p < 0.001) and hospital (median difference 7.5 days, p = 0.010) durations. The occurrence of sternal wound infection (6.0% vs 19.5%, p = 0.009) was less in the early tracheostomy group, but mediastinitis did not differ significantly (3.5% vs 7.0%, p = 0.24). CONCLUSIONS: Tracheostomy within 10 postoperative days in cardiac surgery patients who require prolonged mechanical ventilation was associated with decreased length of stay, morbidity, and mortality.

PMID: 22541987 [PubMed - as supplied by publisher]

An LED Light Source and Novel Fluorophore Combinations Improve Fluorescence Laparoscopic Detection of Metastatic Pancreatic Cancer in Orthotopic Mouse Models.

J Am Coll Surg. 2012 Apr 26;

Authors: Metildi CA, Kaushal S, Lee C, Hardamon CR, Snyder CS, Luiken GA, Talamini MA, Hoffman RM, Bouvet M

Abstract

BACKGROUND: The aim of this study was to improve fluorescence laparoscopy of pancreatic cancer in an orthotopic mouse model with the use of a light-emitting diode (LED) light source and optimal fluorophore combinations. STUDY DESIGN: Human pancreatic cancer models were established with fluorescent FG-RFP, MiaPaca2-GFP, BxPC-3-RFP, and BxPC-3 cancer cells implanted in 6-week-old female athymic mice. Two weeks postimplantation, diagnostic laparoscopy was performed with a Stryker L9000 LED light source or a Stryker X8000 xenon light source 24 hours after tail-vein injection of CEA antibodies conjugated with Alexa 488 or Alexa 555. Cancer lesions were detected and localized under each light mode. Intravital images were also obtained with the OV-100 Olympus and Maestro CRI Small Animal Imaging Systems, serving as a positive control. Tumors were collected for histologic analysis. RESULTS: Fluorescence laparoscopy with a 495-nm emission filter and an LED light source enabled real-time visualization of the fluorescence-labeled tumor deposits in the peritoneal cavity. The simultaneous use of different fluorophores (Alexa 488 and Alexa 555), conjugated to antibodies, brightened the fluorescence signal, enhancing detection of submillimeter lesions without compromising background illumination. Adjustments to the LED light source permitted simultaneous detection of tumor lesions of different fluorescent colors and surrounding structures with minimal autofluorescence. CONCLUSIONS: Using an LED light source with adjustments to the red, blue, and green wavelengths, it is possible to simultaneously identify tumor metastases expressing fluorescent proteins of different wavelengths, which greatly enhanced the signal without compromising background illumination. Development of this fluorescence laparoscopy technology for clinical use can improve staging and resection of pancreatic cancer.

PMID: 22542065 [PubMed - as supplied by publisher]

Adoption of Laparoscopy for Elective Colorectal Resection: A Report from the Surgical Care and Outcomes Assessment Program.

J Am Coll Surg. 2012 Apr 23;

Authors: , Kwon S, Billingham R, Farrokhi E, Florence M, Herzig D, Horvath K, Rogers T, Steele S, Symons R, Thirlby R, Whiteford M, Flum DR

Abstract

BACKGROUND: The purpose of this study was to evaluate the adoption of laparoscopic colon surgery and assess its impact in the community at large. STUDY DESIGN: The Surgical Care and Outcomes Assessment Program (SCOAP) is a quality improvement benchmarking initiative in the Northwest using medical record-based data. We evaluated the use of laparoscopy and a composite of adverse events (ie, death or clinical reintervention) for patients undergoing elective colorectal surgery at 48 hospitals from the 4(th) quarter of 2005 through 4(th) quarter of 2010. RESULTS: Of the 9,705 patients undergoing elective colorectal operations (mean age 60.6 ± 15.6 years; 55.2% women), 38.0% were performed laparoscopically (17.8% laparoscopic procedures converted to open). The use of laparoscopic procedures increased from 23.3% in 4(th) quarter of 2005 to 41.6% in 4(th) quarter of 2010 (trend during study period, p < 0.001). After adjustment (for age, sex, albumin levels, diabetes, body mass index, comorbidity index, cancer diagnosis, year, hospital bed size, and urban vs rural location), the risk of transfusions (odds ratio [OR] = 0.52; 95% CI, 0.39-0.7), wound infections (OR = 0.45; 95% CI, 0.34-0.61), and composite of adverse events (OR = 0.58; 95% CI, 0.43-0.79) were all significantly lower with laparoscopy. Within those hospitals that had been in SCOAP since 2006, hospitals where laparoscopy was most commonly used also had a substantial increase in the volume of all types of colon surgery (202 cases per hospital in 2010 from 112 cases per hospital in 2006, an 80.4% increase) and, in particular, the number of resections for noncancer diagnoses and right-sided pathology. CONCLUSIONS: The use of laparoscopic colorectal resection increased in the Northwest. Increased adoption of laparoscopic colectomies was associated with greater use of all types of colorectal surgery.

PMID: 22533998 [PubMed - as supplied by publisher]

Predictors of New Findings on Repeat Head CT Scan in Blunt Trauma Patients with an Initially Negative Head CT Scan.

J Am Coll Surg. 2012 Apr 11;

Authors: Muakkassa FF, Marley RA, Paranjape C, Horattas E, Salvator A, Muakkassa K

Abstract

BACKGROUND: Our goal was to determine the need for a repeat head CT scan when the initial CT was negative. STUDY DESIGN: Data were collected from January 1, 2002 to December 31, 2008. There were 281 patients admitted to the trauma center with an initial negative head CT, who had a repeat CT during the same hospitalization. Repeat CTs were categorized into negative/negative (NNG) and negative/positive (NPG) groups. RESULTS: There were 281 patients who underwent a repeat head CT for changes in neurologic status, persistent symptoms, follow-up, decreased mental status, or suspected bleed. Of these, 241 patients remained negative (NNG) and new abnormal findings were noted in 40 patients (NPG). There were no differences in sex (NNG, 63% males vs NPG, 75% females; p = 0.14) or average age (NNG, 51.6 ± 22.5 years vs NPG, 45.2 ± 24.6 years; p = 0.07). There was no difference in positive toxicology (NNG, 29% vs NPG, 30%; p = 0.94) or mechanism of injury (NNG, 51% motor vehicle crash [MVC] vs NPG, 62% MVC; p = 0.18). There was a significant difference in Injury Severity Score (ISS) (NNG, 10.7 ± 8.1 vs NPG, 17.9 ± 11.0; p = 0.0002) and initial Glasgow Coma Scale (GCS) (NNG, 12.7 ± 3.5 vs NPG, 10.9 ± 4.2; p = 0.006). Patients with an ISS > 15 and who were intubated were associated with an increased odds of having a positive repeat CT scan (odds ratio [OR] 2.6; 95%CI 1.2, 5.5 and OR 3.5; 95% CI, 1.7, 7.3, respectively). CONCLUSIONS: Patients with a high ISS score and/or those who are intubated have significantly higher odds of having a positive repeat head CT when repeated for follow-up or when clinically warranted.

PMID: 22502992 [PubMed - as supplied by publisher]

Hospital Costs Associated with Smoking in Veterans Undergoing General Surgery.

J Am Coll Surg. 2012 Apr 11;

Authors: Kamath AS, Vaughan Sarrazin M, Vander Weg MW, Cai X, Cullen J, Katz DA

Abstract

BACKGROUND: Approximately 30% of patients undergoing elective general surgery smoke cigarettes. The association between smoking status and hospital costs in general surgery patients is unknown. The objectives of this study were to compare total inpatient costs in current smokers, former smokers, and never smokers undergoing general surgical procedures in Veterans Affairs (VA) hospitals; and to determine whether the relationship between smoking and cost is mediated by postoperative complications. STUDY DESIGN: Patients undergoing general surgery during the period of October 1, 2005 to September 30, 2006 were identified in the VA Surgical Quality Improvement Program (VASQIP) data set. Inpatient costs were extracted from the VA Decision Support System (DSS). Relative surgical costs (incurred during index hospitalization and within 30 days of operation) for current and former smokers relative to never smokers, and possible mediators of the association between smoking status and cost were estimated using generalized linear regression models. Models were adjusted for preoperative and operative variables, accounting for clustering of costs at the hospital level. RESULTS: Of the 14,853 general surgical patients, 34% were current smokers, 39% were former smokers, and 27% were never smokers. After controlling for patient covariates, current smokers had significantly higher costs compared with never smokers: relative cost was 1.04 (95% Cl 1.00 to 1.07; p = 0.04); relative costs for former smokers did not differ significantly from those of never smokers: 1.02 (95% Cl 0.99 to 1.06; p = 0.14). The relationship between smoking and hospital costs for current smokers was partially mediated by postoperative respiratory complications. CONCLUSIONS: These findings complement emerging evidence recommending effective smoking cessation programs in general surgical patients and provide an estimate of the potential savings that could be accrued during the preoperative period.

PMID: 22502993 [PubMed - as supplied by publisher]

Intraoperative Resident Education for Robotic Laparoscopic Gastric Banding Surgery: A Pilot Study on the Safety of Stepwise Education.

J Am Coll Surg. 2012 Apr 20;

Authors: Hashimoto DA, Gomez ED, Danzer E, Edelson PK, Morris JB, Williams NN, Dumon KR

Abstract

BACKGROUND: Incorporation of robotic surgery into resident education poses questions regarding intraoperative teaching and patient care. This study aimed to evaluate the impact of gradually increasing resident console responsibility on resident competency and patient safety, in the presence of a proctor and bedside surgeon, for robotic laparoscopic-assisted gastric banding (R-LAGB) compared with the classical training model (CTM) of residents as first assistant. STUDY DESIGN: Eight clinical year 4 (CY4) residents completed 60 R-LAGB using a one-to-one proctored training model (PTM). R-LAGB was distilled into 7 key steps: gastroesophageal-junction dissection, gastrohepatic ligament dissection, retrogastric space creation, band placement, band closure, gastrogastric suturing, and port placement. Residents performed more complex steps after each case to gain competency in all aspects of the operation. Patient demographics, comorbidities, operative complications, operating times, and clinical outcomes were compared with a control group of 287 R-LAGB cases completed using the CTM (n = 15 CY4 residents). RESULTS: All residents using the PTM were able to successfully complete an R-LAGB as primary surgeon after a median of 8 operations (range 5 to 11); no residents in the CTM completed an R-LAGB as primary surgeon. Mean operative time was statistically greater in the PTM group (99.3 ± 22.1 minutes) vs CTM (91.5 ± 21.1 minutes) (p = 0.001). There were no intraoperative complications in either group; incidence of postoperative complications was similar between groups. CONCLUSIONS: All residents in the proctored setting claimed competence and have persistent console experience without significantly increasing procedure complications. PTM, otherwise known as stepwise education, is a safe, standardized method to train surgical residents in R-LAGB.

PMID: 22521438 [PubMed - as supplied by publisher]

Minimally Invasive Component Separation Results in Fewer Wound-Healing Complications than Open Component Separation for Large Ventral Hernia Repairs.

J Am Coll Surg. 2012 Apr 20;

Authors: Ghali S, Turza KC, Baumann DP, Butler CE

Abstract

BACKGROUND: Minimally invasive component separation (CS) with inlay bioprosthetic mesh (MICSIB) is a recently developed technique for abdominal wall reconstruction that preserves the rectus abdominis perforators and minimizes subcutaneous dead space using limited-access tunneled incisions. We hypothesized that MICSIB would result in better surgical outcomes than conventional open CS. STUDY DESIGN: All consecutive patients who underwent CS (open or minimally invasive) with inlay bioprosthetic mesh for ventral hernia repair from 2005 to 2010 were included in a retrospective analysis of prospectively collected data. Surgical outcomes, including wound-healing complications, hernia recurrences, and abdominal bulge/laxity rates, were compared between patient groups based on the type of CS repair, either MICSIB or open. RESULTS: Fifty-seven patients who underwent MICSIB and 50 who underwent open CS were included. Mean follow-ups were 15.2 ± 7.7 months and 20.7 ± 14.3 months, respectively. Mean fascial defect size was significantly larger in the MICSIB group (405.4 ± 193.6 cm(2) vs 273.8 ± 186.8 cm(2); p = 0.002). The incidences of skin dehiscence (11% vs 28%; p = 0.011), all wound-healing complications (14% vs 32%; p = 0.026), abdominal wall laxity/bulge (4% vs 14%; p = 0.056), and hernia recurrence (4% vs 8%; p = 0.3) were lower in the MICSIB group than in the open CS group. CONCLUSIONS: MICSIB resulted in fewer wound-healing complications than did open CS used for complex abdominal wall reconstructions. These findings are likely attributable to the preservation of paramedian skin vascularity and reduction in subcutaneous dead space with MICSIB. MICSIB should be considered for complex abdominal wall reconstructions, particularly in patients at increased risk of wound-healing complications.

PMID: 22521439 [PubMed - as supplied by publisher]

Routine Pedicular Lymphadenectomy for Colorectal Liver Metastases.

J Am Coll Surg. 2012 Apr 20;

Authors: Moszkowicz D, Cauchy F, Dokmak S, Belghiti J

PMID: 22521440 [PubMed - as supplied by publisher]

Laparoscopic Treatment for Choledochal Cysts with Stenosis of the Common Hepatic Duct.

J Am Coll Surg. 2012 Apr 20;

Authors: Wang J, Zhang W, Sun D, Zhang Q, Liu H, Xi D, Li A

PMID: 22521441 [PubMed - as supplied by publisher]

En Bloc Stapling Division of the Gastroesophageal Vessels Controlling Portal Hemodynamic Status in Living Donor Liver Transplantation.

J Am Coll Surg. 2012 Apr 20;

Authors: Ikegami T, Shirabe K, Yoshizumi T, Yoshiya S, Toshima T, Motomura T, Soejima Y, Uchiyama H, Maehara Y

PMID: 22521442 [PubMed - as supplied by publisher]

Development and Validation of a Bariatric Surgery Mortality Risk Calculator.

J Am Coll Surg. 2012 Apr 20;

Authors: Ramanan B, Gupta PK, Gupta H, Fang X, Forse RA

Abstract

BACKGROUND: While the epidemic of obesity continues to plague America, bariatric surgery is underused due to concerns for surgical risk among patients and referring physicians. A risk score estimating postoperative mortality (OS-MRS) exists, however, is limited by consideration of only 12 preoperative variables, failure to separate open and laparoscopic cases, a lack of robust statistical analyses, risk factors not being weighted, and being applicable to only gastric bypass surgery. The objective of this study was to develop a validated risk calculator for 30-day postoperative mortality after bariatric surgery. STUDY DESIGN: The National Surgical Quality Improvement Program (NSQIP) dataset (2006 to 2008) was used. Patients undergoing bariatric surgery for morbid obesity (n = 32,889) were divided into training (n = 21,891) and validation (n = 10,998) datasets. Multiple logistic regression analysis was performed on the training dataset. The model fit from the training dataset was maintained and was used to estimate mortality probabilities for all patients in the validation dataset. RESULTS: Thirty-day mortality was 0.14%. Seven independent predictors of mortality were identified: peripheral vascular disease, dyspnea, previous percutaneous coronary intervention, age, body mass index, chronic corticosteroid use, and type of bariatric surgery. This risk model was subsequently validated. The model performance was very similar between the training and the validation datasets (c-statistics, 0.80 and 0.82, respectively). The high c-statistics indicate excellent predictive performance. The risk model was used to develop an interactive risk calculator. CONCLUSIONS: This risk calculator has excellent predictive ability for mortality after bariatric procedures. It is anticipated that it will aid in surgical decision-making, informed patient consent, and in helping patients and referring physicians to assess the true bariatric surgical risk.

PMID: 22521443 [PubMed - as supplied by publisher]

Cervical and Upper Mediastinal Lymph Node Metastasis from Gastrointestinal and Pancreatic Neuroendocrine Tumors: True Incidence and Management.

J Am Coll Surg. 2012 Apr 20;

Authors: Wang YZ, Mayhall G, Anthony LB, Campeau RJ, Boudreaux JP, Woltering EA

Abstract

BACKGROUND: The incidence, clinical importance, and optimal management of cervical and upper mediastinal lymph node metastasis from gastrointestinal and pancreatic neuroendocrine tumors (NETS) are largely unknown. Historically, cervical nodes have been regarded as asymptomatic and ignored. We hypothesized that these lesions have clinical implications and should be removed surgically. STUDY DESIGN: Consecutive (111)In pentetreotide scans (OctreoScan) performed at our institution from May 2008 to October 2010 were reviewed to determine the incidence of cervical and upper mediastinal lymph node metastases among patients with gastrointestinal and pancreatic NETs. The charts of surgically treated patients were reviewed to evaluate the clinical importance of these metastases and the subsequent outcomes of their surgical treatment. RESULTS: A total of 161 NET patients presented with positive OctreoScans. Fourteen patients (8.7%) scanned positive for cervical and upper mediastinal lymph node metastasis. Nine patients underwent surgical exploration; 8 had successful removal of their metastatic nodes. Seven had clinical symptoms that resolved after surgery. CONCLUSIONS: Cervical and upper mediastinal lymph node metastases from gastrointestinal and pancreatic NETs were seen in up to 8.7% of patients. In the past, these metastases were assumed to be insignificant and ignored. Our study clearly demonstrates that most, if not all, such metastases are symptomatic and their clinical implications should not be overlooked. Notably, these metastases can be easily and safely resected using radioguided surgery.

PMID: 22521444 [PubMed - as supplied by publisher]

Racial Disparities and Sex-Based Outcomes Differences after Severe Injury.

J Am Coll Surg. 2012 Apr 20;

Authors: Sperry JL, Vodovotz Y, Ferrell RE, Namas R, Chai YM, Feng QM, Jia WP, Forsythe RM, Peitzman AB, Billiar TR

Abstract

BACKGROUND: Controversy exists about the mechanisms responsible for sex-based outcomes differences post-injury. X-chromosome-linked immune response pathway polymorphisms represent a potential mechanism resulting in sex-based outcomes differences post-injury. The prevalence of these variants is known to differ across race. We sought to characterize racial differences and the strength of any sex-based dimorphism post-injury. STUDY DESIGN: A retrospective analysis was performed using data derived from the National Trauma Data Bank 7.1 (2002-2006). Blunt-injured adult (older than 15 years) patients, surviving >24 hours and with an Injury Severity Score >16 were analyzed (n = 244,371). Patients were stratified by race (Caucasian, black, Hispanic, Asian) and multivariable regression analysis was used to characterize the risk of mortality and the strength of protection associated with sex (female vs male). RESULTS: When stratified by race, multivariable models demonstrated Caucasian females had an 8.5% lower adjusted risk of mortality (odds ratio [OR] = 0.91; 95% CI, 0.88-0.95; p < 0.001) relative to Caucasian males, with no significant association found for Hispanics or blacks. An exaggerated survival benefit was afforded to Asian females relative to Asian males, having a >40% lower adjusted risk of mortality (OR = 0.59; 95% CI, 0.44-78; p < 0.001). Asian males had a >75% higher adjusted risk of mortality relative to non-Asian males (OR = 1.77; 95% CI, 1.5-2.0; p < 0.001), and no significant difference in the mortality risk was found for Asian females relative to non-Asian females. CONCLUSIONS: These results suggest that Asian race is associated with sex-based outcomes differences that are exaggerated, resulting from worse outcomes for Asian males. These racial disparities suggest a negative male X-chromosome-linked effect as the mechanism responsible for these sex-based outcomes differences.

PMID: 22521668 [PubMed - as supplied by publisher]

Age Does Not Affect Outcomes of Nonoperative Management of Blunt Splenic Trauma.

J Am Coll Surg. 2012 Apr 20;

Authors: Bhullar IS, Frykberg ER, Siragusa D, Chesire D, Paul J, Tepas JJ, Kerwin AJ

Abstract

BACKGROUND: The purpose of this study was to examine the effect of age on the outcomes of nonoperative management (NOM) of blunt splenic trauma (BST). STUDY DESIGN: The records of patients with BST, from July 2000 to December 2010 at a level I trauma center, were retrospectively reviewed using NTRACS (National Trauma Registry of the American College of Surgeons). Patients were divided into 2 age groups: 17 to 55 years and greater than 55 years. Stepwise logistic regression analysis was used to identify risk factors associated with failure of nonoperative management (FNOM). RESULTS: There were 539 hemodynamically stable patients with BST who underwent NOM. Of these, 459 were age 55 or less, and 80 were greater than 55. Overall, there was no significant difference in FNOM rate for patients age 55 or less vs greater than 55 (4% vs 5%, p = 0.73). This also held true when FNOM was analyzed by each grade: I (1% vs 3%, p = 0.38), II (2% vs 0%, p = 1.0), III (4% vs 0%, p = 1.0), IV (8% vs 20%, p = 0.33), and V (21% vs 50%, p = 0.47). The addition of angioembolization (AE) to high grade IV to V injuries significantly lowered the FNOM rate: age 55 or less (6% AE vs 28% NO-AE, p = 0.02); with a trend toward significance for age greater than 55 (0% AE vs 60% NO-AE, p = 0.2). Age was not a statistically significant independent risk factor for FNOM (p = 0.37). CONCLUSIONS: Age does not affect outcomes of NOM of BST. High grade (IV to V) injuries are not a contraindication to NOM for patients older than 55. As experience with AE grows in patients with high grade injury and age greater than 55, it may prove to be a valuable adjunct to NOM in this group of patients.

PMID: 22521669 [PubMed - as supplied by publisher]

Effect of Repetitive Loading on the Mechanical Properties of Biological Scaffold Materials.

J Am Coll Surg. 2012 Apr 20;

Authors: Pui CL, Tang ME, Annor AH, Ebersole GC, Frisella MM, Matthews BD, Deeken CR

Abstract

BACKGROUND: Coughing, bending, and lifting raise the pressure inside the abdomen, repetitively increasing stresses on the abdominal wall and the associated scaffold. The purpose of this study was to evaluate the effect of repetitive loading on biological scaffolds. It was hypothesized that exposure to repetitive loading would result in decreased tensile strength and that crosslinked scaffolds would resist these effects more effectively than non-crosslinked scaffolds. STUDY DESIGN: Nine materials were evaluated (porcine dermis: Permacol, CollaMend, Strattice, XenMatrix; human dermis: AlloMax, FlexHD; bovine pericardium: Veritas, PeriGuard; and porcine small intestine submucosa: Surgisis; in addition, Permacol, CollaMend, and PeriGuard are crosslinked). Ten specimens were hydrated and subjected to uniaxial tension to establish baseline properties. Thirty specimens were hydrated and subjected to 10, 100, or 1,000 loading cycles (n = 10 each). RESULTS: Tensile strength remained unchanged for CollaMend, XenMatrix, Veritas, and Surgisis during all cycles (p > 0.05). However, Strattice and AlloMax exhibited reduced tensile strength, and Permacol, FlexHD, and PeriGuard exhibited a slight increase in tensile strength with increasing number of cycles. Crosslinked bovine pericardium (PeriGuard) displayed greater tensile strength than non-crosslinked bovine pericardium (Veritas) and crosslinked porcine dermis (Permacol) exhibited greater tensile strength than non-crosslinked porcine dermis (Strattice, XenMatrix) during all cycles (p < 0.0001). CONCLUSIONS: Materials that rapidly lose strength after repetitive loading might not be appropriate in clinical scenarios involving elevated stresses, such as in patients with high body mass index or when replacing large areas of the abdominal wall without tissue reinforcement, although scaffolds that maintain initial tensile strength can be particularly advantageous.

PMID: 22521670 [PubMed - as supplied by publisher]

A Cost-Effectiveness Analysis of Early vs Late Reconstruction of Iatrogenic Bile Duct Injuries.

J Am Coll Surg. 2012 Apr 9;

Authors: Dageforde LA, Landman MP, Feurer ID, Poulose B, Pinson CW, Moore DE

Abstract

BACKGROUND: Controversy exists regarding the optimal timing of repair after iatrogenic bile duct injuries (BDI). Several studies advocate late repair (≥6 weeks after injury) with mandatory drainage and resolution of inflammation. Others indicate that early repair (<6 weeks after injury) produces comparable or superior clinical outcomes. Additionally, although most studies have reported inferior outcomes with primary surgeon repair, this practice continues. With disparate published recommendations and rising health care costs, decision analysis was used to examine the cost-effectiveness of BDI repair. STUDY DESIGN: A Markov model was developed to evaluate primary surgeon repair (PSR), late repair by a hepatobiliary surgeon (LHBS), and early repair by a hepatobiliary surgeon (EHBS). Baseline values and ranges were collected from the literature. Sensitivity analsyses were conducted to test the strength of the model and variability of parameters. RESULTS: The model demonstrated that EHBS was associated with lower costs, earlier return to normal activity, and better quality of life. Specifically, 1 year after repair, PSR yielded 0.53 quality adjusted life years (QALYs) ($120,000/QALY) and LHBS yielded 0.74 QALYs ($74,000/QALY); EHBS yielded 0.82 QALYs ($48,000/QALY). Sensitivity analyses supported these findings at clinically meaningful probabilities. CONCLUSIONS: This cost-effectiveness model demonstrates that early repair by a hepatobiliary surgeon is the superior strategy for the treatment of BDI in properly selected patients. Although there is little clinical difference between early and late repair, there is a great difference in cost and quality of life. Ideally, costs and quality of life should be considered in decisions regarding strategies of repair of injured bile ducts.

PMID: 22495064 [PubMed - as supplied by publisher]

A Systematic Review of the Effect of Institution and Surgeon Factors on Surgical Outcomes for Gastric Cancer.

J Am Coll Surg. 2012 Mar 27;

Authors: Mahar AL, McLeod RS, Kiss A, Paszat L, Coburn NG

PMID: 22459499 [PubMed - as supplied by publisher]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):398-9

Authors:

PMID: 22463879 [PubMed - in process]

Improved long-term survival of dialysis patients after near-total parathyroidectomy.

J Am Coll Surg. 2012 Apr;214(4):400-7

Authors: Sharma J, Raggi P, Kutner N, Bailey J, Zhang R, Huang Y, Herzog CA, Weber C

Abstract

BACKGROUND: Severe secondary hyperparathyroidism, which is associated with life-threatening complications, can develop in dialysis-dependent end-stage renal disease patients. The aim of this study was to compare short- and long-term mortality in dialysis patients who underwent near-total parathyroidectomy (NTPTX) and matched nonoperated controls.

STUDY DESIGN: We identified 150 dialysis patients who underwent NTPTX (1993-2009) at our institution and compared them with 1,044 nonoperated control patients identified in the US Renal Data System registry, matched for age, sex, race, diabetes as cause of kidney failure, years on dialysis, and dialysis modality. Survival outcomes were estimated using multivariable Cox proportional hazards models with stratification on the matching sets, adjusted for cardiovascular comorbidities, smoking, inability to ambulate/transfer, and payor status.

RESULTS: During a follow-up of a mean of 3.6 years (range 0.1 month to 16.4 years), NTPTX patients had a significant reduction in the long-term risk of all-cause death (hazard ratio = 0.68; 95% CI, 0.52-0.89; p = 0.006) compared with controls. Thirty-day mortality rates for NTPTX patients and controls were 246 vs 105 per 1,000 person-years (p = 0.21). In adjusted analyses, NTPTX patients had a 37% reduced risk of all-cause death and a 33% reduced risk of cardiovascular death compared with controls. A durable reduction in mean parathyroid hormone was observed after NTPTX; from 1,776 ± 1,416.6 pg/mL to 301 ± 285.7 pg/mL (p < 0.0001).

CONCLUSIONS: In our center, NTPTX in dialysis patients was associated with a significant reduction in long-term risk of death compared with matched control patients, without a significantly increased short-term risk.

PMID: 22463880 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):407-8

Authors:

PMID: 22463881 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):424-6

Authors:

PMID: 22463882 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):434-5

Authors:

PMID: 22463883 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):443-4

Authors:

PMID: 22463884 [PubMed - in process]

Prosthetic H-Graft Portacaval Shunts vs Transjugular Intrahepatic Portasystemic Stent Shunts: 18-Year Follow-Up of a Randomized Trial.

J Am Coll Surg. 2012 Apr;214(4):445-53

Authors: Rosemurgy AS, Frohman HA, Teta AF, Luberice K, Ross SB

Abstract

BACKGROUND: Widespread application of transjugular intrahepatic portasystemic shunt (TIPS) continues despite the lack of trials documenting efficacy superior to surgical shunting. Here we present an 18-year follow-up of a prospective randomized trial comparing TIPS with small-diameter prosthetic H-graft portacaval shunt (HGPCS) for portal decompression.

STUDY DESIGN: Beginning in 1993, patients were prospectively randomized to undergo either TIPS or HGPCS as definitive therapy for portal hypertension due to cirrhosis. Complications of shunting and long-term outcomes were noted. Failure of shunting was prospectively defined as the inability to place shunt, irreversible shunt occlusion, major variceal rehemorrhage, unanticipated liver transplantation, or death. Survival and shunt failure were compared using Kaplan-Meier curve analysis. Median data are reported.

RESULTS: Patient presentation, circumstances of shunting, causes of cirrhosis, severity of hepatic dysfunction (eg, Child’s class, Model for End-Stage Liver Disease score), and predicted survival after shunting did not differ between patients undergoing TIPS (n = 66) or HGPCS (n = 66). Survival was significantly longer after HGPCS for patients of Child’s class A (91 vs 19 months; p = 0.009) or class B (63 vs 21 months; p = 0.02). Shunt failure occurred later after HGPCS than TIPS (45 vs 22 months; p = 0.04).

CONCLUSIONS: Compared with TIPS, survival after HGPCS was superior for patients with better liver function (eg, Child’s class A or B). Shunt failure after HGPCS occurred later than after TIPS. Rather than TIPS, application of HGPCS is preferred for patients with complicated cirrhosis and better hepatic function.

PMID: 22463885 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):453-5

Authors:

PMID: 22463886 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):461-2

Authors:

PMID: 22463887 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):475-7

Authors:

PMID: 22463888 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):486-8

Authors:

PMID: 22463889 [PubMed - in process]

Five-year outcomes after oxandrolone administration in severely burned children: a randomized clinical trial of safety and efficacy.

J Am Coll Surg. 2012 Apr;214(4):489-502

Authors: Porro LJ, Herndon DN, Rodriguez NA, Jennings K, Klein GL, Mlcak RP, Meyer WJ, Lee JO, Suman OE, Finnerty CC

Abstract

BACKGROUND: Oxandrolone, an anabolic agent, has been administered for 1 year post burn with beneficial effects in pediatric patients. However, the long-lasting effects of this treatment have not been studied. This single-center prospective trial determined the long-term effects of 1 year of oxandrolone administration in severely burned children; assessments were continued for up to 4 years post therapy.

STUDY DESIGN: Patients 0 to 18 years old with burns covering >30% of the total body surface area were randomized to receive placebo (n = 152) or oxandrolone, 0.1 mg/kg twice daily for 12 months (n = 70). At hospital discharge, patients were randomized to a 12-week exercise program or to standard of care. Resting energy expenditure, standing height, weight, lean body mass, muscle strength, bone mineral content (BMC), cardiac work, rate pressure product, sexual maturation, and concentrations of serum inflammatory cytokines, hormones, and liver enzymes were monitored.

RESULTS: Oxandrolone substantially decreased resting energy expenditure and rate pressure product, increased insulin-like growth factor-1 secretion during the first year after burn injury, and, in combination with exercise, increased lean body mass and muscle strength considerably. Oxandrolone-treated children exhibited improved height percentile and BMC content compared with controls. The maximal effect of oxandrolone was found in children aged 7 to 18 years. No deleterious side effects were attributed to long-term administration.

CONCLUSIONS: Administration of oxandrolone improves long-term recovery of severely burned children in height, BMC, cardiac work, and muscle strength; the increase in BMC is likely to occur by means of insulin-like growth factor-1. These benefits persist for up to 5 years post burn.

PMID: 22463890 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):502-4

Authors:

PMID: 22463891 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):515-6

Authors:

PMID: 22463892 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):528-30

Authors:

PMID: 22463893 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):536-8

Authors:

PMID: 22463894 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):547-9

Authors:

PMID: 22463895 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):556-7

Authors:

PMID: 22463896 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):564-6

Authors:

PMID: 22463897 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):572-3

Authors:

PMID: 22463898 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):580-1

Authors:

PMID: 22463899 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):588-90

Authors:

PMID: 22463900 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):597-8

Authors:

PMID: 22463901 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):606-7

Authors:

PMID: 22463902 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):617-9

Authors:

PMID: 22463903 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):627-8

Authors:

PMID: 22463904 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):637-9

Authors:

PMID: 22463905 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):646-7

Authors:

PMID: 22463906 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):656-7

Authors:

PMID: 22463907 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):666-7

Authors:

PMID: 22463908 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):679-81

Authors:

PMID: 22463909 [PubMed - in process]

Surgical management of late sequelae in survivors of an episode of acute necrotizing pancreatitis.

J Am Coll Surg. 2012 Apr;214(4):682-8

Authors: Beck WC, Bhutani MS, Raju GS, Nealon WH

Abstract

BACKGROUND: After surviving an episode of acute necrotizing pancreatitis (ANP), a variety of late sequelae develop and require nonoperative or operative interventions. Persistent pancreatic fistula, fluid collections, recurrent pancreatitis, sepsis, pain, and intolerance of po intake are seen.

STUDY DESIGN: We have maintained records for all patients hospitalized from 1993 through 2010 with a diagnosis of ANP. Once discharged from hospital, patients were managed with routine clinic follow-up at close intervals and later at 6-month intervals. Using ERCP or magnetic resonance cholangiopancreatography, all patients’ pancreatic ducts were classified as type I (normal), type II (stricture), or type III (disconnected). Patients were monitored for the complications mentioned. Operations performed >8 weeks after the initial episode of ANP were defined as late and evaluated for operative mortality, morbidity, success in resolving symptoms/collections, and length of stay.

RESULTS: One hundred and ninety-seven patients with ANP were included. Seventy-one late operations were performed (59 drainage procedures/12 resections). Operative mortality was 1%, morbidity was 19%, and mean length of stay was 6.3 ± 5.6 days. Poor po intake was seen in 80% of operated patients and total parenteral nutrition dependence in 42%. Duct type correlated with pancreatic debridement, persistent fluid collection/fistula, pain, po intake intolerance, and late operation. Late operation successfully resolved symptoms and/or fluid collections in 96%. Recurrent pancreatitis was improved in 87% and eliminated in 78%.

CONCLUSIONS: Patients who require late operation after surviving an episode of ANP are more likely to have sustained ductal injuries and are likely to require operation for either pain or for inability to tolerate po intake. Operation can be performed safely with a low mortality.

PMID: 22463910 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):688-90

Authors:

PMID: 22463911 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):698-9

Authors:

PMID: 22463912 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):707-8

Authors:

PMID: 22463913 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):714-6

Authors:

PMID: 22463914 [PubMed - in process]

How does laparoscopic-assisted hepatic resection compare with the conventional open surgical approach?

J Am Coll Surg. 2012 Apr;214(4):717-23

Authors: Johnson LB, Graham JA, Weiner DA, Smirniotopoulos J

Abstract

BACKGROUND: Laparoscopic-assisted hepatic resection (LAHR) has been described as a safe and reliable means of liver resection for tumors or live-donor hepatectomy. Here we compare the outcomes in paired cohorts between patients undergoing open hepatic resection (OHR) and LAHR.

STUDY DESIGN: Two hundred and twelve patients who underwent either OHR or LAHR from March 2004 to July 2011 were analyzed to assess outcomes. During this time period, 124 patients underwent OHR and 88 underwent LAHR. Demographic and outcomes data were assessed.

RESULTS: In the total patient cohort, mean age found in both surgical arms was similar, as was the mean BMI. In addition, there was no difference in the cohort between those who underwent either minor or major hepatic resections (p = 0.52). Operatively, in the OHR arm the mean duration of the operation was 234 minutes and comparable with LAHR at 238 minutes (p = 0.75). There was also no difference in the mean lesion size in the OHR (5.72 cm) and LAHR (5.37 cm) groups (p = 0.55). Notably, there was no difference in the complication incidence rates, which were 10.5% (OHR) and 6.8% (LAHR) (p = 0.59). However, when analyzing for length of stay, there was a significant difference between the 2 arms; patients in OHR arm had longer stays than those in the LAHR arm (7.59 days vs 6.30 days, respectively; mean difference 1.29 days; 95% CI, 0.08-2.5; p = 0.036).

CONCLUSIONS: Although reduced surgical pain, improved cosmesis, and shortened hospital stays have been shown to correlate with laparoscopic abdominal procedures, our study indicates these marked advantages are also conferred to those undergoing LAHR. In addition, these findings demonstrate the use of LAHR and highlight the need for the addition of this technique to the liver surgeon’s skill set.

PMID: 22463915 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):723-5

Authors:

PMID: 22463916 [PubMed - in process]

Discussion.

J Am Coll Surg. 2012 Apr;214(4):732-3

Authors:

PMID: 22463917 [PubMed - in process]

JACS CME Featured Articles, Volume 214, April 2012.

J Am Coll Surg. 2012 Apr;214(4):734-7

Authors:

PMID: 22463918 [PubMed - in process]

Outcomes and Perception of Lung Surgery with Implementation of a Patient Video Education Module: A Prospective Cohort Study.

J Am Coll Surg. 2012 Mar 28;

Authors: Crabtree TD, Puri V, Bell JM, Bontumasi N, Patterson GA, Kreisel D, Krupnick AS, Meyers BF

Abstract

BACKGROUND: Although surgeons are constantly making efforts to improve efficiency of care, it is important to also optimize the patients’ understanding and satisfaction with their surgical experience. We investigated the effect of a preoperative educational video on patient outcomes and perception of surgery. STUDY DESIGN: An educational video was developed outlining preoperative, operative, and postoperative expectations for patients undergoing pulmonary resection. A prospective study was conducted with 150 patients undergoing surgery with routine preoperative discussion (control group, January 2008 to June 2009) and 150 patients who were provided a supplemental video module (video or study group, September 2009 to October 2010) in addition to routine discussion. Demographics and outcomes data were recorded. Patients completed a pain survey (McGill Questionnaire) and a standardized patient satisfaction survey at discharge and within 1 month of operation. RESULTS: The groups were similar in sex, age, comorbidities, and forced expiratory volume, 1 second, % predicted. Length of hospital stay (5.19 ± 7.4 days vs 4.31 ± 4.3 days; p = 0.2) and hospital readmission rates (12 of 134 [9%] vs 5 of 103 [4.9%]; p = 0.3) were similar for the 2 groups. At discharge, patients in the study group reported less pain at rest (0.98 ± 0.09) vs controls (1.39 ± 0.11) (p = 0.01) with no difference in pain with lifting or coughing. Patients in the study group reported better overall satisfaction with their operation (2.14 ± 0.07 vs 1.85 ± 0.07; p = 0.02), believed they were better prepared (2.01 ± 0.07 vs 1.70 ± 0.06; p = 0.006), and reported less anxiety about the surgical experience (2.79 ± 0.10 vs 2.24 ± 0.09; p = 0.0001). CONCLUSIONS: Implementation of a pulmonary resection education module improves patient preparedness, relieves anxiety, and improves pain perception. Additional development and dissemination of a comprehensive education program can improve patients’ experience with lung surgery and impact outcomes.

PMID: 22464659 [PubMed - as supplied by publisher]

Certification by the American Board of Surgery among US Medical School Graduates.

J Am Coll Surg. 2012 Mar 28;

Authors: Andriole DA, Jeffe DB

Abstract

BACKGROUND: We sought to identify variables associated with American Board of Medical Specialties (ABMS)-member board certification and lack thereof among US medical graduates who planned at medical school graduation to become certified in surgery and entered graduate medical education in general surgery. STUDY DESIGN: Deidentified, individualized records updated through March 2009 for all 1993-2000 US medical school matriculants who graduated by 2002, intended to become certified in surgery, and entered general surgery training were analyzed using multivariable logistic regression to identify variables associated with graduates’ board certification status, including American Board of Surgery (ABS)-board certified (BC), other ABMS-member-BC (other-BC) and non-BC. RESULTS: Of 3,373 graduates included in the study sample, 2,036 (60.4 %) were ABS-BC, 342 (10.1 %) were other-BC, and 995 (29.5 %) were non-BC. Graduates who were women, older than 26 years old at graduation, and initially failed US Medical Licensing Examination Step 2 Clinical Knowledge were more likely, and graduates who rated the quality of their surgery clerkship in medical school more highly were less likely, to be other-BC vs ABS-BC. Graduates who were women, under-represented minority race/ethnicity, Asian/Pacific Islander race/ethnicity, older than 28 years old at graduation, initially failed US Medical Licensing Examination Step l, initially failed or received low passing scores on US Medical Licensing Examination Step 2 Clinical Knowledge, and graduated in more recent years were more likely to be non-BC vs ABS-BC. CONCLUSIONS: Demographic and professional development variables were associated with ABMS-member BC status among US medical graduates who had intended at medical school graduation to become certified in surgery.

PMID: 22464660 [PubMed - as supplied by publisher]

Predictive Factors of Early Bowel Obstruction in Colon and Rectal Surgery: Data from the Nationwide Inpatient Sample, 2006-2008.

J Am Coll Surg. 2012 Mar 28;

Authors: Masoomi H, Kang CY, Chaudhry O, Pigazzi A, Mills S, Carmichael JC, Stamos MJ

Abstract

BACKGROUND: Early postoperative bowel obstruction is associated with considerable morbidity and mortality after colorectal surgery. We evaluated the impact of patient characteristics, patient comorbidities, pathology, resection site, surgical technique, admission type, and teaching hospital status on the incidence of in-hospital bowel obstruction after colorectal surgery. STUDY DESIGN: Using the Nationwide Inpatient Sample database, we examined the clinical data of patients who underwent colorectal resection from 2006 to 2008. Regression analyses were performed to identify factors predictive of in-hospital bowel obstruction. RESULTS: A total of 975,825 patients underwent colorectal resection during this period. Overall, the rate of postoperative bowel obstruction was 8.65% (elective surgery: 5.32% vs emergent surgery: 13.26%; p < 0.01). Bowel obstruction was less frequent after laparoscopic procedures compared with open procedures (6.61% vs 8.81%; p < 0.01). Using multivariate regression analysis, Crohn disease (adjusted odds ratio [AOR] = 12.32), emergent surgery (AOR = 2.54), malignant tumor (AOR = 1.84), diverticulitis (AOR = 1.45), age older than 65 years (AOR = 1.22), female sex (AOR = 1.14), history of alcohol abuse (AOR = 1.12), transverse colectomy (AOR = 1.11), peripheral vascular disease (AOR = 1.07), left colectomy (AOR = 1.06), chronic lung disease (AOR = 1.05), open procedure (AOR = 1.05), African-American race (AOR = 1.03), and teaching hospital (AOR = 1.02) were associated with a higher risk of in-hospital bowel obstruction. There was no association between hypertension, diabetes, congestive heart failure, chronic renal failure, liver disease, obesity, smoking, proctectomy or total colectomy, and early bowel obstruction. CONCLUSIONS: Early bowel obstruction is a relatively common complication after colorectal surgery. Crohn disease patients had a 12-fold higher incidence of early bowel obstruction, and emergent surgery and malignancy were relevant predictors of early bowel obstruction.

PMID: 22464661 [PubMed - as supplied by publisher]

Application of Total Care Time and Payment per Unit Time Model for Physician Reimbursement for Common General Surgery Operations.

J Am Coll Surg. 2012 Apr 5;

Authors: Chatterjee A, Holubar SD, Figy S, Chen L, Montagne SA, Rosen JM, Desimone JP

Abstract

BACKGROUND: The relative value unit system relies on subjective measures of physician input in the care of patients. A payment per unit time model incorporates surgeon reimbursement to the total care time spent in the operating room, postoperative in-house, and clinic time to define payment per unit time. We aimed to compare common general surgery operations by using the total care time and payment per unit time method in order to demonstrate a more objective measurement for physician reimbursement. STUDY DESIGN: Average total physician payment per case was obtained for 5 outpatient operations and 4 inpatient operations in general surgery. Total care time was defined as the sum of operative time, 30 minutes per hospital day, and 30 minutes per office visit for each operation. Payment per unit time was calculated by dividing the physician reimbursement per case by the total care time. RESULTS: Total care time, physician payment per case, and payment per unit time for each type of operation demonstrated that an average payment per time spent for inpatient operations was $455.73 and slightly more at $467.51 for outpatient operations. Partial colectomy with primary anastomosis had the longest total care time (8.98 hours) and the least payment per unit time ($188.52). Laparoscopic gastric bypass had the highest payment per time ($707.30). CONCLUSIONS: The total care time and payment per unit time method can be used as an adjunct to compare reimbursement among different operations on an institutional level as well as on a national level. Although many operations have similar payment trends based on time spent by the surgeon, payment differences using this methodology are seen and may be in need of further review.

PMID: 22483779 [PubMed - as supplied by publisher]

Infections Caused by Multidrug Resistant Organisms Are Not Associated with Overall, All-Cause Mortality in the Surgical Intensive Care Unit: The 20,000 Foot View.

J Am Coll Surg. 2012 Mar 13;

Authors: Rosenberger LH, Lapar DJ, Sawyer RG

Abstract

BACKGROUND: Resistant pathogens are increasingly common in the ICU, with controversy regarding their relationship to outcomes. We hypothesized that an increasing number of infections with resistant pathogens in our surgical ICU would not be associated with increased overall mortality. STUDY DESIGN: All ICU-acquired infections were prospectively identified between January 1, 2000 and December 31, 2009 in a single surgical ICU. Crude in-hospital, all-cause mortality data were obtained using a prospectively collected ICU database. Trends in rates were compared using linear regression. RESULTS: A total of 799 resistant pathogens were identified (257 gram-positive, 542 gram-negative) from a total of 3,024 isolated pathogens associated with 2,439 ICU-acquired infections. The most frequently identified resistant gram-positive and -negative pathogens (defined as resistant to at least 1 major class of antimicrobials) were methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa, respectively. Pathogens were most commonly isolated from the lung, blood, and urine. The crude mortality rate declined steadily from 2000 to 2009 (9.4% to 5.4%; equation for trend y = -0.11x + 8.26). Linear regression analysis of quarterly rates revealed a significant divergence in trends between increasing total resistant infections (equation for trend y = 0.34x + 13.02) and percentage resistant infections (equation for trend y = 0.36x + 18.66) when compared with a decreasing mortality (p = 0.0003, p < 0.0001, respectively). CONCLUSIONS: Despite a steady rise in the proportion of resistant bacterial infections in the ICU, crude mortality rates have decreased over time. The rates of resistant infections do not appear to be a significant factor in overall mortality in our surgical ICU patients.

PMID: 22421258 [PubMed - as supplied by publisher]

Thoracolaparoscopic Esophagectomy: Is the Prone Position a Safe Alternative to the Decubitus Position?

J Am Coll Surg. 2012 Mar 13;

Authors: Feng M, Shen Y, Wang H, Tan L, Zhang Y, Khan MA, Wang Q

Abstract

BACKGROUND: During the last few years, prone thoracoscopic esophagectomy has been increasingly adopted for thoracolaparoscopic esophagectomy (TLE). However, evidence for the prone position (PP) over the decubitus position (DP) during TLE is currently not strong enough to reach conclusions. STUDY DESIGN: From May 2009 to December 2010, we conducted thoracoscopic esophagectomies in the DP and then PP on consecutive patients admitted to our institution. TLE in DP was conducted from May 2009 to February 2010 and in PP from March 2010 to December 2010. Clinical features and operation characteristics of all patients were collected and compared to determine differences between the 2 groups. RESULTS: A total of 93 consecutive esophageal cancer patients were enrolled; Forty-one had their operations in DP and 52 in PP. There was no significant difference found between the 2 groups in age, sex, body mass index, tumor location, histological type, and TNM stage. When compared with DP, thoracoscopic esophagectomy in PP had a shorter operation duration (67 vs 77 minutes; p = 0.013), horter overall hospital stay (17.4 vs 11.4 days; p = 0.011), and yielded a larger number of lymph nodes (11.6 ± 4.0 vs 8.9 ± 4.9 on average; p = 0.005). Complication rates were similar between the 2 groups, with anastomotic leak developing in a significantly smaller number of patients in PP (7.7% vs 22.0%; p = 0.049). CONCLUSIONS: TLE in the PP is a feasible and safe alternative to DP and is potentially associated with fewer complications. Additional randomized studies are required to discuss the long-term prognostic value of this procedure.

PMID: 22421259 [PubMed - as supplied by publisher]

What Are the Real Rates of Postoperative Complications: Elucidating Inconsistencies Between Administrative and Clinical Data Sources.

J Am Coll Surg. 2012 Mar 13;

Authors: Koch CG, Li L, Hixson E, Tang A, Phillips S, Henderson JM

Abstract

BACKGROUND: Comparison of quality outcomes generated from administrative and clinical datasets have shown inconsistencies. Understanding this is important because data designed to drive performance improvement are used for public reporting of performance. We examined administrative and clinical data and 2 clinical data sources in 4 surgical morbidity outcomes. STUDY DESIGN: Patients who underwent operations between January 2009 and May 2010 had outcomes compared for postoperative hemorrhage, respiratory failure, deep vein thrombosis (DVT), and sepsis. Three data sources were examined: administrative (Agency for Healthcare Research and Quality [AHRQ] Patient Safety Indicators [PSIs]), a national clinical registry (National Surgical Quality Improvement Program [NSQIP]), and an institutional clinical registry (Cardiovascular Information Registry [CVIR]). Cohen’s Kappa (K) coefficient was used as a measure of agreement between data sources. RESULTS: For 4,583 patients common to AHRQ and NSQIP, concordance was poor for sepsis (K = 0.07) and hemorrhage (K = 0.14), moderate for respiratory failure (K = 0.30), and better concordance for DVT (K = 0.60). For 7,897 patients common to AHRQ and CVIR, concordance was poor for hemorrhage (K = 0.08), respiratory failure (K = 0.02), and sepsis (K = 0.16), and better for DVT (K = 0.55). For 886 patients common to NSQIP and CVIR, concordance was poor for sepsis (K=0.054), moderate for hemorrhage (K= 0.27) and respiratory failure (K=0.4), and better for DVT (K = 0.51). CONCLUSIONS: We demonstrate considerable discordance between data sources measuring the same postoperative events. The main contributor was difference in definitions, with additional contribution from data collection and management methods. Although any of these sources can be used for their original intent of performance improvement, this study emphasizes the shortcomings of using these sources for grading performance without standardizing definitions, data collection, and management.

PMID: 22421260 [PubMed - as supplied by publisher]

Hepatectomy for Noncolorectal Non-Neuroendocrine Metastatic Cancer: A Multi-Institutional Analysis.

J Am Coll Surg. 2012 Mar 15;

Authors: Groeschl RT, Nachmany I, Steel JL, Reddy SK, Glazer ES, de Jong MC, Pawlik TM, Geller DA, Tsung A, Marsh JW, Clary BM, Curley SA, Gamblin TC

Abstract

BACKGROUND: Although hepatic metastasectomy is well established for colorectal and neuroendocrine cancer, the approach to hepatic metastases from other sites is not well defined. We sought to examine the management of noncolorectal non-neuroendocrine liver metastases. STUDY DESIGN: A retrospective review from 4 major liver centers identified patients who underwent liver resection for noncolorectal non-neuroendocrine metastases between 1990 and 2009. The Kaplan-Meier method was used to analyze survival, and Cox regression models were used to examine prognostic variables. RESULTS: There were 420 patients available for analysis. Breast cancer (n = 115; 27%) was the most common primary malignancy, followed by sarcoma (n = 98; 23%), and genitourinary cancers (n = 92; 22%). Crude postoperative morbidity and mortality rates were 20% and 2%, respectively. Overall median survival was 49 months, and 1, 3, and 5-year Kaplan-Meier survival rates were 73%, 50%, and 31%. Survival was not significantly different between the various primary tumor types. Recurrent disease was found after hepatectomy in 66% of patients. In multivariable models, lymphovascular invasion (p = 0.05) and metastases ≥5 cm (p = 0.04) were independent predictors of poorer survival. Median survival was shorter for resections performed between 1990 and 1999 (n = 101, 32 months) when compared with resections between 2000 and 2009 (n = 319, 66 months; p = 0.003). CONCLUSIONS: Hepatic metastasectomy for noncolorectal non-neuroendocrine cancers is safe and feasible in selected patients. Lymphovascular invasion and metastases ≥5 cm were found to be associated with poorer survival. Patients undergoing metastasectomy in more recent years appear to be surviving longer, however, the reasons for this are not conclusively determined.

PMID: 22425166 [PubMed - as supplied by publisher]

Determinants of Adverse Events in Vascular Surgery.

J Am Coll Surg. 2012 Mar 14;

Authors: Hernandez-Boussard T, McDonald KM, Morton JM, Dalman RL, Bech FR

Abstract

BACKGROUND: Patient safety is a national priority. Patient Safety Indicators (PSIs) monitor potential adverse events during hospital stays. Surgical specialty PSI benchmarks do not exist, and are needed to account for differences in the range of procedures performed, reasons for the procedure, and differences in patient characteristics. A comprehensive profile of adverse events in vascular surgery was created. STUDY DESIGN: The Nationwide Inpatient Sample was queried for 8 vascular procedures using ICD-9-CM codes from 2005 to 2009. Factors associated with PSI development were evaluated in univariate and multivariate analyses. RESULTS: A total of 1,412,703 patients underwent a vascular procedure and a PSI developed in 5.2%. PSIs were more frequent in female, nonwhite patients with public payers (p < 0.01). Patients at mid and low-volume hospitals had greater odds of developing a PSI (odds ratio [OR] = 1.17; 95% CI, 1.10-1.23 and OR = 1.69; 95% CI, 1.53-1.87). Amputations had highest PSI risk-adjusted rate and carotid endarterectomy and endovascular abdominal aortic aneurysm repair had lower risk-adjusted rate (p < 0.0001). PSI risk-adjusted rate increased linearly by severity of patient indication: claudicants (OR = 0.40; 95% CI, 0.35-0.46), rest pain patients (OR = 0.78; 95% CI, 0.69-0.90), ulcer (OR = 1.20; 95% CI, 1.07-1.34), and gangrene patients (OR = 1.85; 95% CI, 1.66-2.06). CONCLUSIONS: Patient safety events in vascular surgery were high and varied by procedure, with amputations and open abdominal aortic aneurysm repair having considerably more potential adverse events. PSIs were associated with black race, public payer, and procedure indication. It is important to note the overall higher rates of PSIs occurring in vascular patients and to adjust benchmarks for this surgical specialty appropriately.

PMID: 22425449 [PubMed - as supplied by publisher]

Relevance of the C-Statistic When Evaluating Risk-Adjustment Models in Surgery.

J Am Coll Surg. 2012 Mar 20;

Authors: Merkow RP, Hall BL, Cohen ME, Dimick JB, Wang E, Chow WB, Ko CY, Bilimoria KY

Abstract

BACKGROUND: The measurement of hospital quality based on outcomes requires risk adjustment. The c-statistic is a popular tool used to judge model performance, but can be limited, particularly when evaluating specific operations in focused populations. Our objectives were to examine the interpretation and relevance of the c-statistic when used in models with increasingly similar case mix and to consider an alternative perspective on model calibration based on a graphical depiction of model fit. STUDY DESIGN: From the American College of Surgeons National Surgical Quality Improvement Program (2008-2009), patients were identified who underwent a general surgery procedure, and procedure groups were increasingly restricted: colorectal-all, colorectal-elective cases only, and colorectal-elective cancer cases only. Mortality and serious morbidity outcomes were evaluated using logistic regression-based risk adjustment, and model c-statistics and calibration curves were used to compare model performance. RESULTS: During the study period, 323,427 general, 47,605 colorectal-all, 39,860 colorectal-elective, and 21,680 colorectal cancer patients were studied. Mortality ranged from 1.0% in general surgery to 4.1% in the colorectal-all group, and serious morbidity ranged from 3.9% in general surgery to 12.4% in the colorectal-all procedural group. As case mix was restricted, c-statistics progressively declined from the general to the colorectal cancer surgery cohorts for both mortality and serious morbidity (mortality: 0.949 to 0.866; serious morbidity: 0.861 to 0.668). Calibration was evaluated graphically by examining predicted vs observed number of events over risk deciles. For both mortality and serious morbidity, there was no qualitative difference in calibration identified between the procedure groups. CONCLUSIONS: In the present study, we demonstrate how the c-statistic can become less informative and, in certain circumstances, can lead to incorrect model-based conclusions, as case mix is restricted and patients become more homogenous. Although it remains an important tool, caution is advised when the c-statistic is advanced as the sole measure of a model performance.

PMID: 22440055 [PubMed - as supplied by publisher]

Surgical Site Infection After Colon Surgery: National Healthcare Safety Network Risk Factors and Modeled Rates Compared with Published Risk Factors and Rates.

J Am Coll Surg. 2012 Mar 20;

Authors: Young H, Knepper B, Moore EE, Johnson JL, Mehler P, Price CS

PMID: 22440056 [PubMed - as supplied by publisher]

Serum Brain Naturietic Peptide Measurements Reflect Fluid Balance after Pancreatectomy.

J Am Coll Surg. 2012 Mar 20;

Authors: Berri RN, Sahai SK, Durand JB, Lin HY, Folloder J, Rozner MA, Gottumukkala V, Katz MH, Lee JE, Fleming JB

Abstract

BACKGROUND: Overaggressive fluid resuscitation in elderly patients requiring pancreatectomy can delay recovery and increase morbidity. Despite advancements, no accurate and reproducible methods exist to evaluate effective intravascular volume status in the postoperative setting. We hypothesized that sequential measurement of currently available serum proteins will indicate fluid balance. STUDY DESIGN: Clinicopathologic (n = 44) and echocardiogram (echo) data (n = 18) were collected on patients receiving pancreatectomy or diagnostic laparoscopy (n = 5). Measured fluid balance, serum BUN, creatinine (CR), and brain natriuretic peptide (BNP) levels were recorded on postoperative days (POD) 1 to 7 (only POD1 for diagnostic laparoscopy). ANOVA and bivariate random effect models examined the correlation between BNP and BUN/CR and fluid balance. Linear mixed-effect models examined the correlation between factors associated with vascular stiffness and BNP, BUN/CR, and fluid balance. RESULTS: On POD1 after diagnostic laparoscopy, the fluid balance was positive by 3,265 mL and was accompanied by a >300-point increase in BNP (p = 0.0083). After pancreatectomy, a similar increase in BNP (250 pg/mL) and fluid balance (4,492 mL) on POD1 was observed. During the return to euvolemia, the change in serum BNP levels correlated with fluid balance changes during POD 1 to 3 (p = 0.039), and BUN/CR levels correlated with fluid balance during POD 4 to 7. Patients with risk factors associated with cardiovascular stiffness or echo evidence of poor compliance experienced higher BNP during the postoperative period. CONCLUSIONS: Fluid loading at surgery is accompanied by an increase in serum BNP, and return to a balanced fluid state after pancreatectomy is paralleled by changes in BNP and BUN/CR levels.

PMID: 22440057 [PubMed - as supplied by publisher]

Pedunculated Gastric Conduit Interposition with Duodenal Transection after Salvage Esophagectomy: An Option for Increasing the Flexibility of the Gastric Conduit.

J Am Coll Surg. 2012 Mar 23;

Authors: Kosumi K, Baba Y, Watanabe M, Ida S, Nagai Y, Baba H

PMID: 22445198 [PubMed - as supplied by publisher]

Preoperative prediction of non-home discharge: a strategy to reduce resource use after cardiac surgery.

J Am Coll Surg. 2012 Feb;214(2):140-7

Authors: Pattakos G, Johnston DR, Houghtaling PL, Nowicki ER, Blackstone EH

Abstract

BACKGROUND: Patients requiring discharge to a continuing care facility after cardiac surgery (non-home discharge) frequently have prolonged hospital stays while arrangements are made for posthospital care. We hypothesized that preoperatively identifying patients likely to require non-home discharge would allow earlier discharge planning, shorten length of stay, and thereby reduce resource use. This study sought to develop a validated tool for preoperative planning of non-home discharge.

STUDY DESIGN: From October 2008 to December 2009, 4,243 patients were discharged alive after cardiac surgery at Cleveland Clinic. Of these, 4,031 resided in the 48 contiguous states or Alaska and formed the study cohort. Logistic regression analysis of non-home discharge was performed using preoperative data generally readily available at admission. A subsequent group of 2,005 patients discharged alive from December 2009 to July 2010 was used to validate this model.

RESULTS: Eighteen percent of patients had non-home discharge, which was predictable from data readily available at admission for cardiac surgery (C-statistic 0.88 for model development, 0.87 for model validation). The strongest predictors included intra-aortic balloon pumping (odds ratio [OR] 7.5; 95% confidence interval [CI] 1.7 to 32), emergency status (OR 3.7; CI 2.1 to 6.5), older age (p < 0.001), longer preoperative stays (p < 0.001), poor nutritional state (p < 0.001), a number of comorbidities, and descending thoracic aorta procedures (OR 4.3; 95% CI 2.5 to 7.4).

CONCLUSIONS: Non-home discharge can be easily predicted using data obtained during routine preoperative evaluation of cardiac surgical patients. We expect that early identification of patients at high risk for non-home discharge will allow for more intensive, personalized discharge planning, and will reduce wasted days and resource use.

PMID: 22265219 [PubMed - indexed for MEDLINE]

Routine upper gastrointestinal imaging is superior to clinical signs for detecting gastrojejunal leak after laparoscopic Roux-en-Y gastric bypass.

J Am Coll Surg. 2012 Feb;214(2):208-13

Authors: Leslie DB, Dorman RB, Anderson J, Serrot FJ, Kellogg TA, Buchwald H, Sampson BK, Slusarek BM, Ikramuddin S

Abstract

BACKGROUND: There are myriad symptoms and signs of gastrojejunal leak; prompt recognition is essential. Many surgeons use clinical predictors to guide selective use of upper gastrointestinal imaging (UGI). The appropriate practice remains undefined.

STUDY DESIGN: A review of patients who underwent primary laparoscopic Roux-en-Y gastric bypass between January 2002 and December 2008 was conducted. All underwent routine UGI studies on postoperative day 1. Actual gastrojejunal leak within 7 days of surgery (actual leak [AL], radiologic leaks), operative reports, patient charts, and postoperative vital signs were retrospectively reviewed.

RESULTS: There were 2,099 operations. Eight ALs (0.43%) occurred without associated mortality. UGI was positive in 7 AL patients and falsely positive in 6 patients. The AL patients underwent laparoscopy on postoperative days 1 and 3 (n = 5 and n = 1, respectively), laparotomy on postoperative day 3 (n = 1), and peritoneal drainage (n = 1). False-positive UGIs prompted laparoscopy (n = 3) and close observation (n = 3). Pulse was 100 to 120 beats per minute in 2 patients and fever (>38.5°C) was present in 0 AL patients. AL patients had osteogenesis imperfecta (n = 1), macronodular cirrhosis (n = 1), positive bubble test (n = 3), and concomitant splenectomy (n = 1). No jejunojejunostomy leaks were identified.

CONCLUSIONS: Routine UGI after laparoscopic Roux-en-Y gastric bypass has greater sensitivity than clinical signs for detecting gastrojejunal leak. Delay in the diagnosis of leakage can impact mortality, and this suggests that indications for routine UGI might still exist. Tachycardia is not a reliable early marker of leak. There might be risk factors for leak in addition to vital signs, including patient medical history or intraoperative events, which should prompt routine UGI on postoperative day 1.

PMID: 22265221 [PubMed - indexed for MEDLINE]

Advanced concept of anatomic resection of the liver: preservation of subsegment during right paramedian sectoriectomy.

J Am Coll Surg. 2012 Feb;214(2):e5-7

Authors: Cristino H, Hashimoto T, Takamoto T, Miyazaki T, Maruyama Y, Inoue K, Ogata S, Makuuchi M

PMID: 22265223 [PubMed - indexed for MEDLINE]

Effect of peritoneal lavage with clindamycin-gentamicin solution on infections after elective colorectal cancer surgery.

J Am Coll Surg. 2012 Feb;214(2):202-7

Authors: Ruiz-Tovar J, Santos J, Arroyo A, Llavero C, Armañanzas L, López-Delgado A, Frangi A, Alcaide MJ, Candela F, Calpena R

Abstract

BACKGROUND: Colorectal surgery may lead to infections because despite meticulous aseptic measures, extravasation of microorganisms from the colon lumen is unavoidable.

STUDY DESIGN: A prospective, randomized study was performed between January 2010 and December 2010. Patient inclusion criteria were a diagnosis of colorectal neoplasms and plans to undergo an elective curative operation. Patients were divided into 2 groups: Group 1 (intra-abdominal irrigation with normal saline) and Group 2 (intraperitoneal irrigation with a solution of 240 mg gentamicin and 600 mg clindamycin). The occurrence of wound infections and intra-abdominal abscesses were investigated. After the anastomosis, a microbiologic sample of the peritoneal surface was obtained (sample 1). A second sample was collected after irrigation with normal saline (sample 2). Finally, the peritoneal cavity was irrigated with a gentamicin-clindamycin solution and a third sample was obtained (sample 3).

RESULTS: There were 103 patients analyzed: 51 in Group 1 and 52 in Group 2. There were no significant differences between the groups in age, sex, comorbidities, or type of colorectal surgery performed. Wound infection rates were 14% in Group 1 and 4% in Group 2 (p = 0.009; odds ratio [OR] 4.94; 95% CI 1.27 to 19.19). Intra-abdominal abscess rates were 6% in Group 1 and 0% in Group 2 (p = 0.014; OR 2.14; 95% CI 1.13 to 3.57). The culture of sample 1 was positive in 68% of the cases, sample 2 was positive in 59%, and sample 3 in 4%.

CONCLUSIONS: Antibiotic lavage of the peritoneum is associated with a lower incidence of intra-abdominal abscesses and wound infections.

PMID: 22265220 [PubMed - indexed for MEDLINE]

Mortality after Elective Colon Resection: The Search for Outcomes that Define Quality in Surgical Practice.

J Am Coll Surg. 2012 Mar 5;

Authors: Billeter AT, Polk HC, Hohmann SF, Qadan M, Fry DE, Jorden JR, McCafferty MH, Galandiuk S

Abstract

BACKGROUND: Process measures constitute the focal point of surgical quality studies. High levels of compliance with such processes have not correlated with improved outcomes. Wide ranges of reported hospital death rates led us to hypothesize that survival after elective colon resection would be a legitimate outcomes measure for quality of surgical practice. STUDY DESIGN: We studied risk-adjusted hospital mortality rates of 85,260 patients in teaching hospitals as reported to the University HealthSystem Consortium (UHC) January 1, 2005 to March 31, 2011. Data were analyzed by institution and surgeon (deidentified). There were 34,504 patients from the HealthCare Utilization Project (HCUP, 2007-2008), who provided a comparison group for nonteaching hospitals. Surgeons with less than 1 year of reported data were excluded. RESULTS: Elective colon resection mortality rates were densely concentrated around 1.56% for teaching hospitals and at 1.08% for defined surgeons. HCUP data demonstrated a 1.38% nonteaching hospital mortality rate. Neither hospital nor surgeon volume were determinants of mortality, and lower volume entities displayed the widest mortality variations. Among 193 teaching hospitals, there were 6 outliers (4.1%), defined as >2 standard deviations (SDs) above the mean. Similarly, 32 of 681 individual surgeons (4.7%) had a risk-adjusted hospital mortality rate >2SDs above the mean. CONCLUSIONS: Elective colon resection is a safe procedure in both teaching hospitals and nonteaching hospitals, with an impressively homogenous mean mortality rate of 1.56% in teaching hospitals, and 1.38% in nonteaching hospitals. We reject our original hypothesis because the data do not sufficiently discriminate to permit the use of death after elective colon resection as a differentiating quality measure; however, the data do identify individual poor performers. Poor performing institutions/surgeons should seek extramural guidance to improve their outcomes or discontinue performing such operations.

PMID: 22397975 [PubMed - as supplied by publisher]

Acute Care Surgery: Impact on Practice and Economics of Elective Surgeons.

J Am Coll Surg. 2012 Mar 5;

Authors: Miller PR, Wildman EA, Chang MC, Meredith JW

Abstract

BACKGROUND: The creation of an acute care surgery service provides a rich operative experience for acute care surgeons. Elective surgeons typically have concerns about whether their practice volume will be restored with elective cases. Acute care surgery has financial implications for both groups. The aim of this project is to examine the impact in terms of work relative value units (wRVUs), collections, and cases in both groups with creation of an acute care surgery service at our institution. STUDY DESIGN: Work RVUs, collections, and case volume were examined from departmental records for 2 groups before and after acute care surgery service creation. The service began on September 1, 2008. Before this time, emergency surgical consults went to the general surgeon on call. After this date, all emergency consults were seen by acute care surgeons. RESULTS: The number of operations performed by the acute care surgery group increased significantly when the mean of the 2 years after institution of acute care surgery were compared with the mean of the 2 years preceding the service creation (1,639 vs 790/year; p = 0.007). There was no change in total operations done by the elective surgery group (2,763 vs 2,496/year: p = 0.13). Elective caseload, however, did increase by 23% in the elective surgery group. In the acute care surgery group, wRVUs increased by 140% and elective surgery group wRVUs decreased by 8%. Collections increased in both groups (acute care surgery 129%, elective surgery 7%) and the combined collections of the groups increased by $2,138,00 in the year after service creation. CONCLUSIONS: Acute care surgery service creation took emergency business from the elective surgery group, but this was almost immediately replaced with elective cases. This resulted in higher collections for both groups and a resultant significant increase in collections in aggregate.

PMID: 22397976 [PubMed - as supplied by publisher]

Total Pancreatectomy and Islet Autotransplantation for Chronic Pancreatitis.

J Am Coll Surg. 2012 Mar 5;

Authors: Sutherland DE, Radosevich DM, Bellin MD, Hering BJ, Beilman GJ, Dunn TB, Chinnakotla S, Vickers SM, Bland B, Appakalai B, Freeman ML, Pruett TL

Abstract

BACKGROUND: Total pancreatectomy (TP) with intraportal islet autotransplantation (IAT) can relieve pain and preserve β-cell mass in patients with chronic pancreatitis (CP) when other therapies fail. We report on a >30-year single-center series. STUDY DESIGN: Four hundred and nine patients (including 53 children, 5 to 18 years) with CP underwent TP-IAT from February 1977 to September 2011 (etiology: idiopathic, 41%; Sphincter of Oddi dysfunction/biliary, 9%; genetic, 14%; divisum, 17%; alcohol, 7%; and other, 12%; mean age was 35.3 years, 74% were female; 21% has earlier operations, including 9% Puestow procedure, 6% Whipple, 7% distal pancreatectomy, and 2% other). Islet function was classified as insulin independent for those on no insulin; partial, if known C-peptide positive or euglycemic on once-daily insulin; and insulin dependent if on standard basal-bolus diabetic regimen. A 36-item Short Form (SF-36) survey for quality of life was completed by patients before and in serial follow-up since 2007, with an integrated survey that was added in 2008. RESULTS: Actuarial patient survival post TP-IAT was 96% in adults and 98% in children (1 year) and 89% and 98% (5 years). Complications requiring relaparotomy occurred in 15.9% and bleeding (9.5%) was the most common complication. IAT function was achieved in 90% (C-peptide >0.6 ng/mL). At 3 years, 30% were insulin independent (25% in adults, 55% in children) and 33% had partial function. Mean hemoglobin A1c was <7.0% in 82%. Earlier pancreas surgery lowered islet yield (2,712 vs 4,077/kg; p = 0.003). Islet yield (<2,500/kg [36%]; 2,501 to 5,000/kg [39%]; >5,000/kg [24%]) correlated with degree of function with insulin-independent rates at 3 years of 12%, 22%, and 72%, and rates of partial function 33%, 62%, and 24%. All patients had pain before TP-IAT and nearly all were on daily narcotics. After TP-IAT, 85% had pain improvement. By 2 years, 59% had ceased narcotics. All children were on narcotics before, 39% at follow-up; pain improved in 94%; and 67% became pain-free. In the SF-36 survey, there was significant improvement from baseline in all dimensions, including the Physical and Mental Component Summaries (p < 0.01), whether on narcotics or not. CONCLUSIONS: TP can ameliorate pain and improve quality of life in otherwise refractory CP patients, even if narcotic withdrawal is delayed or incomplete because of earlier long-term use. IAT preserves meaningful islet function in most patients and substantial islet function in more than two thirds of patients, with insulin independence occurring in one quarter of adults and half the children.

PMID: 22397977 [PubMed - as supplied by publisher]

Hunter Holmes McGuire: Much More than Stonewall Jackson’s Surgeon.

J Am Coll Surg. 2012 Feb 28;

Authors: Haisch CE

PMID: 22381591 [PubMed - as supplied by publisher]

Permissive Hypercapnia in the Management of Congenital Diaphragmatic Hernia: Our Institutional Experience.

J Am Coll Surg. 2012 Feb 28;

Authors: Guidry CA, Hranjec T, Rodgers BM, Kane B, McGahren ED

Abstract

BACKGROUND: Congenital diaphragmatic hernia (CDH) is a potentially lethal anomaly associated with pulmonary hypoplasia and persistent pulmonary hypertension. Permissive hypercapnia is a strategy designed to reduce lung injury from mechanical ventilation in infants. It has been shown to be a potentially superior method of ventilator management for patients with CDH. In 2001, the Divisions of Neonatology and Pediatric Surgery at the University of Virginia Children’s Hospital established permissive hypercapnia as the management strategy for treatment of CDH. We hypothesized that permissive hypercapnia would be associated with improved outcomes in this patient population. STUDY DESIGN: This retrospective review compares outcomes of infants treated for CDH in the extracorporeal membrane oxygenation (ECMO) era before and after initiation of permissive hypercapnia at a single institution. Outcomes were compared using univariate statistical analysis. RESULTS: Ninety-one patients were available for analysis and were divided into 2 groups: 42 (Group 1) treated before and 49 (Group 2) treated after implementation of permissive hypercapnia. Survival was higher in Group 2 (85.8% vs 54.8%; p = 0.001; relative risk [RR] 3.17). Morbidity was lower in Group 2 and approached statistical significance (65.3% vs 83.3%; p = 0.052). Patients in Group 2 were repaired later, had a lower rate of ECMO use, and were extubated earlier. There was no difference in hospital stay. CONCLUSIONS: The use of permissive hypercapnia for infants with CDH was associated with decreased mortality, a longer period of ventilation before repair with a shorter period of ventilation after repair, a lower rate of ECMO use, and no lengthening of hospital stay. Permissive hypercapnia remains the standard of care for ventilation of infants with CDH at our institution.

PMID: 22381592 [PubMed - as supplied by publisher]

Robotic Transaxillary Thyroidectomy: An Examination of the First One Hundred Cases.

J Am Coll Surg. 2012 Feb 21;

Authors: Kandil EH, Noureldine SI, Yao L, Slakey DP

Abstract

BACKGROUND: The influence of minimally invasive options has led to the application of new evolving techniques in thyroid surgery to eliminate visible neck scars. Here, we describe one author’s experience with transaxillary robotic thyroidectomy and examine the effect of experience on determining the learning curve and improvements over time in operative performance. STUDY DESIGN: With IRB approval, a prospective analysis of our surgical experience was performed. All patients underwent robotic transaxillary thyroidectomy by a single surgeon between September 2009 and June 2011. Principal outcomes measures included length of hospital stay, incidence of complications, and effect of obesity on outcomes. RESULTS: One hundred consecutive operations were performed on 91 patients. Sixty-nine hemithyroidectomy, 22 total or near-total thyroidectomy, and 9 completion thyroidectomy procedures were performed. Of patients who underwent hemithyroidectomy, 21.7% were discharged within 4 hours; the remaining patients were discharged within 23 hours. Mean operative time for hemithyroidectomy was 108.1 ± 60.5 minutes, and for total or near-total thyroidectomy, mean operative time was 118.1 ± 51.3 minutes. Mean robot docking time was 9.1 ± 2.2 minutes for all cases. Obesity contributed to prolonged total operative time. Improvement in the length of time to perform components of the procedure was noted after 45 cases. Two cases required conversion to a cervical approach. There were no instances of permanent vocal cord palsy on postoperative laryngoscopy. CONCLUSIONS: Here we report the largest experience of robotic gasless thyroid surgery in the United States. This novel technique provides excellent cosmetic results and can be performed as an outpatient procedure in selected group of patients. It is feasible and safe, however, has a lengthy learning curve.

PMID: 22360981 [PubMed - as supplied by publisher]

Ex Vivo Interleukin-12-Priming During CD8(+) T Cell Activation Dramatically Improves Adoptive T Cell Transfer Antitumor Efficacy in a Lymphodepleted Host.

J Am Coll Surg. 2012 Feb 21;

Authors: Rubinstein MP, Cloud CA, Garrett TE, Moore CJ, Schwartz KM, Johnson CB, Craig DH, Salem ML, Paulos CM, Cole DJ

Abstract

BACKGROUND: Clinical application of adoptive T cell therapy has been hindered by an inability to generate adequate numbers of nontolerized, functionally active, tumor-specific T cells, which can persist in vivo. In order to address this, we evaluated the impact of interleukin (IL)-12 signaling during tumor-specific CD8(+) T cell priming in terms of persistence and antitumor efficacy using an established B16 melanoma tumor adoptive therapy model. STUDY DESIGN: B6 mice were injected subcutaneously with B16 melanoma tumor cells. On day 12 of tumor growth, mice were preconditioned with cyclophosphamide (4mg dose, intraperitoneally), and 1 day later were treated by adoptive transfer of tumor-specific pmel-1 CD8(+) T cells primed ex vivo 3 days earlier with both IL-12 and antigen (hGP100(25-33) peptide) or antigen only. Tumors were measured biweekly, and infused donor T cells were analyzed for persistence, localization to the tumor, phenotype, and effector function. RESULTS: Adoptive transfer of tumor-specific CD8(+) T cells primed with IL-12 was significantly more effective in reducing tumor burden in mice preconditioned with cyclophosphamide compared with transfer of T cells primed without IL-12. This enhanced antitumor response was associated with increased frequencies of infused T cells in the periphery and tumor as well as elevated expression of effector molecules including granzyme B and interferon-γ (IFNγ). CONCLUSIONS: Our findings demonstrate that ex vivo priming of tumor-specific CD8(+) T cells with IL-12 dramatically improves their in vivo persistence and therapeutic ability on transfer to tumor-bearing mice. These findings can be directly applied as novel clinical trial strategies.

PMID: 22360982 [PubMed - as supplied by publisher]

Predictable Closure of the Abdominoperineal Resection Defect: A Novel Two-Team Approach.

J Am Coll Surg. 2012 Feb 21;

Authors: Arnold PB, Lahr CJ, Mitchell ME, Griffith JL, Salloum N, Walker MR, Bhatti SL, Powers AJ, McCraw JB

Abstract

BACKGROUND: Primary closure of the perineum at the time of abdominoperineal resection (APR) is seldom successful. Several factors are known to adversely affect healing, including neoadjuvant chemoradiation, tension, contamination, and fluid collection. This study evaluates a 2-team approach for resection and routine perineal closure in a single stage. STUDY DESIGN: After tumor resection, the abdominal and perineal closures are performed simultaneously by 2 separate teams. A competent closure of the perineal defect is achieved with bilateral V-to-Y inferior gluteal artery perforator fasciocutaneous flaps (BIGAP) mobilizing buttock skin, fat, and gluteal muscle fascia for inset into the defect. No muscle is elevated with the flaps and no attempt is made to obliterate the deepest aspects of the pelvic defect. RESULTS: Beginning in August 2010, 18 consecutive patients who underwent APR for distal rectal (n = 14) and anal carcinoma (n = 4) were included in the study. All patients had received neoadjuvant chemoradiation therapy. Primary healing was achieved in 16 of 18 patients with a completely tension-free closure. One patient required debridement and secondary closure. Another patient had an unresectable tumor, which invaded the flap closure. Minor healing problems were seen in 7 patients. CONCLUSIONS: BIGAP flaps provide sufficient tissue to predictably provide primary closure of the perineal defect. Perineal wound healing morbidity is dramatically reduced compared with primary simple closure of this defect. Early results indicate that this method of perineal closure offers a straightforward and predictable method that is comparable in efficacy to other methods using pedicled flaps for perineal closure.

PMID: 22360983 [PubMed - as supplied by publisher]

Liver Transplantation with Preservation of the Inferior Vena Cava: Lessons Learned through 2,000 Cases.

J Am Coll Surg. 2012 Feb 22;

Authors: Levi DM, Pararas N, Tzakis AG, Nishida S, Tryphonopoulos P, Gonzalez-Pinto I, Tekin A, Selvaggi G, Livingstone AS

Abstract

BACKGROUND: We aim to demonstrate the utility and efficacy of the “piggyback technique” (PBT); liver transplant (LT) with caval preservation. STUDY DESIGN: Adult LTs were performed with intent to use the PBT except in cases of juxtacaval malignancy or technical difficulty. Hepatic venous outflow was established between the donor suprahepatic cava and the joined ostia of all recipient suprahepatic veins. Technical variants with the donor cava and recipient retrohepatic cava were used as needed. The experience was divided into 2 eras: E1 (1994-2002), E2 (2002-2010). RESULTS: We completed 945 of 1080 LTs in E1 (87.5%) and 851 of 920 LTs in E2 (92.5%) using the PBT. Thirty day mortality was 4.6% in E1, 3% in E2 (p = 0.02) with 2 intra-operative deaths in E1. One, 3, 5 year patient survival was 83.7, 75.6, 69.3% in E1 vs. 86, 78.4, 73.8% in E2 (p = 0.057). Graft survival was 77.7, 69, 62.3% in E1 vs. 84, 76.2, 71.2% in E2 (p < 0.0001). Median operative time and hospital length of stay improved in E2 (p < 0.0001, 0.0001). Outflow variants were used more frequently in E2 (11.3% vs. 6.1%). Nine patients (0.5%) developed outflow obstruction, 6 in E1, and 3 in E2. Twice, it was recognized and corrected intraoperatively. Seven patients presented with refractory ascites. Six were successfully treated (4 balloon dilatation, 2 surgical revision), one patient died after attempted dilatation. CONCLUSIONS: The PBT can be used as the preferred technique in adult LT. With experience, the technique was used more frequently, with more variants, with improved outcomes. Outflow obstruction was a rare complication.

PMID: 22364695 [PubMed - as supplied by publisher]

Invited commentary.

J Am Coll Surg. 2012 Mar;214(3):276-9

Authors: Decker MR, Greenberg CC

PMID: 22365505 [PubMed - in process]

Is chlorhexidine-alcohol more effective than povidone-iodine?

J Am Coll Surg. 2012 Mar;214(3):374-6

Authors: Dixon E, Cheadle WG, Khadaroo RG,

PMID: 22365506 [PubMed - in process]

Nipple micro-anatomy: ductal epithelial types.

J Am Coll Surg. 2012 Mar;214(3):377

Authors: Askew JB

PMID: 22365507 [PubMed - in process]

Is it time to lower the recommended screening age for colorectal cancer?

J Am Coll Surg. 2012 Mar;214(3):377-8

Authors: Schellerer VS, Hohenberger W, Croner RS

PMID: 22365508 [PubMed - in process]

Reply.

J Am Coll Surg. 2012 Mar;214(3):378-9

Authors: Davis DM

PMID: 22365509 [PubMed - in process]

Evaluating the Validity of CT in Complicated Gallstone Disease.

J Am Coll Surg. 2012 Mar;214(3):379-80

Authors: Fujita T

PMID: 22365510 [PubMed - in process]

Reply.

J Am Coll Surg. 2012 Mar;214(3):380-1

Authors: Benarroch-Gampel J, Sheffield KM, Riall TS

PMID: 22365511 [PubMed - in process]

JACS CME Credit Featured Articles, Volume 214, March 2012.

J Am Coll Surg. 2012 Mar;214(3):382-3

Authors:

PMID: 22365512 [PubMed - in process]

Correction.

J Am Coll Surg. 2012 Mar;214(3):384

Authors:

PMID: 22365513 [PubMed - in process]

Looking to the Future on the Shoulder of Giants.

J Am Coll Surg. 2012 Feb 24;

Authors: Meredith JW

PMID: 22366490 [PubMed - as supplied by publisher]