Patient Readmission and Mortality after Colorectal Surgery for Colon Cancer: Impact of Length of Stay Relative to Other Clinical Factors.

J Am Coll Surg. 2012 Jan 28;

Authors: Schneider EB, Hyder O, Brooke BS, Efron J, Cameron JL, Edil BH, Schulick RD, Choti MA, Wolfgang CL, Pawlik TM

Abstract

BACKGROUND: Data on readmission as well as the potential impact of length of stay (LOS) after colectomy for colon cancer remain poorly defined. The objective of the current study was to evaluate risk factors associated with readmission among a nationwide cohort of patients after colorectal surgery. STUDY DESIGN: We identified 149,622 unique individuals from the Surveillance, Epidemiology, and End Results-Medicare dataset with a diagnosis of primary colorectal cancer who underwent colectomy between 1986 and 2005. In-hospital morbidity, mortality, LOS, and 30-day readmission were examined using univariate and multivariate logistic regression models. RESULTS: Primary surgical treatment consisted of right (37.4%), transverse (4.9%), left (10.5%), sigmoid (22.8%), abdominoperineal resection (7.3%), low anterior resection (5.6%), total colectomy (1.2%), or other/unspecified (10.3%). Mean patient age was 76.5 years and more patients were female (52.9%). The number of patients with multiple preoperative comorbidities increased over time (Charlson comorbidity score ≥3: 1986 to 1990, 52.5% vs 2001 to 2005, 63.1%; p < 0.001). Mean LOS was 11.7 days and morbidity and mortality were 36.5% and 4.2%, respectively. LOS decreased over time (1986 to 1990, 14.0 days; 1991 to 1995, 12.0 days; 1996 to 2000, 10.4 days; 2001 to 2005, 10.6 days; p < 0.001). In contrast, 30-day readmission rates increased (1986 to 1990, 10.2%; 1991 to 1995, 10.9%; 1996 to 2000, 12.4%; 2001 to 2005, 13.7%; p < 0.001). Factors associated with increased risk of readmission included LOS (odds ratio = 1.02), Charlson comorbidities ≥3 (odds ratio = 1.27), and postoperative complications (odds ratio = 1.17) (all p < 0.01). CONCLUSIONS: Readmission rates after colectomies have increased during the past 2 decades and mean LOS after this operation has declined. More research is needed to understand the balance and possible trade off between these hospital performance measures for all surgical procedures.

PMID: 22289517 [PubMed - as supplied by publisher]

Using the National Surgical Quality Improvement Program and the Tennessee Surgical Quality Collaborative to Improve Surgical Outcomes.

J Am Coll Surg. 2012 Jan 19;

Authors: Guillamondegui OD, Gunter OL, Hines L, Martin BJ, Gibson W, Clarke PC, Cecil WT, Cofer JB

Abstract

BACKGROUND: Led by the Tennessee Chapter of the American College of Surgeons, in May 2008 a 10-hospital collaborative was formed between the Tennessee Chapter of ACS, the Tennessee Hospital Association, and the BlueCross BlueShield of Tennessee Health Foundation. We hypothesized that by forming the Tennessee Surgical Quality Collaborative using the National Surgical Quality Improvement Program (NSQIP) system to share surgical process and outcomes data, overall patient surgical outcomes would improve. STUDY DESIGN: All NSQIP data from the 10-hospital collaborative for the time periods January to December 2009 (period 1) and January to December 2010 (period 2) were collected. Data on 20 categories of postoperative complications and 30-day mortality were compared between periods. Complication comparisons and hospital costs associated with complications were calculated per 10,000 procedures. Statistical analysis was performed by Z-test. RESULTS: There were 14,205 total surgical cases in period 1 and 14,901 surgical cases in period 2. Between periods (per 10,000 cases) there were significant improvements in superficial surgical site infections (-19%, p = 0.0005), on ventilator longer than 48 hours (-15%, p = 0.012), graft/prosthesis/flap failure (-60%, p < 0.0001), acute renal failure (-25%, p = 0.023), and wound disruption (-34%, p = 0.011). Although mortality (per 10,000) was higher in period 2 (237.6 vs 232.3), no statistical difference was noted. Net costs avoided between these periods were calculated as $2,197,543 per 10,000 general and vascular surgery cases. CONCLUSIONS: Data organization and scrutiny are the initial steps of process improvement. Participation in our regional surgical quality collaborative resulted in improved outcomes and reduced costs. Although the mechanisms for these changes are likely multifactorial, the collaborative establishes communication, process improvement, and frank discussion among the members as best practices are identified and shared and standardized processes are adopted.

PMID: 22265639 [PubMed - as supplied by publisher]

Abandoning Unilateral Parathyroidectomy: Why We Reversed Our Position after 15,000 Parathyroid Operations.

J Am Coll Surg. 2012 Jan 20;

Authors: Norman J, Lopez J, Politz D

Abstract

BACKGROUND: Our group championed the techniques and benefits of unilateral parathyroidectomy. As our experience has matured, it seems this limited operation might be appropriate only occasionally. METHODS: A single surgical group’s experience with 15,000 parathyroidectomies examined the ongoing differences between unilateral and bilateral techniques for 10-year failure/recurrence, multigland removal, operative times, and length of stay. RESULTS: With limited experience, 100% of operations were bilateral, decreasing to 32% by the 500(th) operation (p < 0.001), and long-term failure rates increased to 6%. Failures were 11 times more likely for unilateral explorations (p < 0.001 vs bilateral), causing gradual increases in bilateral explorations to 97% at the 14,000(th) operation (p < 0.001). Ten-year cure rates are unchanged for bilateral operations, and unilateral operations show continued slow recurrence rates of 5% (p < 0.001). Removal of more than one gland occurred 16 times more frequently when 4 glands were analyzed (p < 0.001), increasing cure rates to the current 99.4% (p < 0.001). Of 1,060 reoperations performed for failure at another institution, intraoperative parathyroid hormone levels fell >50% in 22% of patients, yet a second adenoma was subsequently found. Operative times decreased with experience; bilateral operations taking only 5.9 minutes longer on average (22.3 vs 16.4 minutes; p < 0.001), which is 25 minutes less than unilateral at the 500(th) operation (p < 0.001). By the 1,000(th) operation, incision size (2.5 ± 0.2 cm), anesthesia, and hospital stay (1.6 hours) were identical for unilateral and bilateral procedures. CONCLUSIONS: Regardless of surgical adjuncts (scanning, intraoperative parathyroid hormone), unilateral parathyroidectomy will carry a 1-year failure rate of 3% to 5% and a 10-year recurrence rate of 4% to 6%. Allowing rapid analysis of all 4 glands through the same 1-inch incision has caused us to all but abandon unilateral parathyroidectomy.

PMID: 22265807 [PubMed - as supplied by publisher]

Blunt Thoracic Aortic Injuries: Crossing the Rubicon.

J Am Coll Surg. 2012 Jan 20;

Authors: Demetriades D

PMID: 22265808 [PubMed - as supplied by publisher]

Invited commentary.

J Am Coll Surg. 2011 Dec;213(6):721

Authors: Jurkovich GJ

PMID: 22107918 [PubMed - indexed for MEDLINE]

Role of the lower esophageal sphincter on acid exposure revisited with high-resolution manometry.

J Am Coll Surg. 2011 Dec;213(6):743-50

Authors: Hoshino M, Sundaram A, Mittal SK

Abstract

BACKGROUND: The objective of this study was to investigate the role of lower esophageal sphincter (LES) length and pressure on acid exposure with high-resolution manometry (HRM).

STUDY DESIGN: After Institutional Review Board approval, a retrospective review of a prospectively maintained database identified patients who had undergone HRM and 24-hour pH studies. Abdominal LES length (AL) ≤1 cm and overall LES length ≤2 cm were considered inadequate. A new parameter called lower esophageal sphincter pressure integral (LESPI) was analyzed in this study. Distal esophageal acid exposure was analyzed in relation to LES parameters.

RESULTS: One hundred eight patients (inadequate AL, n = 54; inadequate overall LES length, n = 54) satisfied study criteria. Patients with inadequate AL had considerably lower LESPI and LES pressure. They also had more severe acid exposure and higher DeMeester score. However, inadequate overall LES length was not associated with abnormal acid exposure. Patients with a positive pH study had considerably lower LESPI than patients with a negative pH study. Inadequate AL and low LESPI (<400 mmHg/s/cm) had a synergistic effect on acid reflux. Multivariate logistic regression analysis identified inadequate AL, low LESPI, and male sex as predictors of a positive pH study.

CONCLUSIONS: Using HRM, inadequate AL (≤1cm) and low LESPI (<400 mmHg/s/cm) are associated with gastroesophageal reflux disease and appear to have a synergistic effect on the severity of distal esophageal acid exposure. LESPI, which is a function of both sphincter length and pressure, appears to be the most sensitive HRM parameter for distal esophageal acid exposure.

PMID: 22107919 [PubMed - indexed for MEDLINE]

Statins in Abdominal Surgery: A Systematic Review.

J Am Coll Surg. 2012 Jan 11;

Authors: Singh PP, Srinivasa S, Lemanu DP, Maccormick AD, Hill AG

PMID: 22244204 [PubMed - as supplied by publisher]

Bacterial Sepsis after Living Donor Liver Transplantation: The Impact of Early Enteral Nutrition.

J Am Coll Surg. 2012 Jan 11;

Authors: Ikegami T, Shirabe K, Yoshiya S, Yoshizumi T, Ninomiya M, Uchiyama H, Soejima Y, Maehara Y

Abstract

BACKGROUND: Bacterial sepsis is a significant problem that must be addressed after living donor liver transplantation (LDLT). STUDY DESIGN: A retrospective analysis of 346 adult-to-adult LDLT patients was performed. RESULTS: Forty-six patients (13.3%) experienced bacterial sepsis, with primary and secondary origins in 23.9% and 76.1%, respectively. Gram-negative bacteria accounted for 71.7% of the bacteria isolated. The 2-year cumulative graft survival rate in patients with bacterial sepsis was 45.7%. Patients with bacterial sepsis secondary to pneumonia (n = 12) had poorer 2-year graft survival rates (16.7%) than did those with primary or other types of secondary sepsis (p = 0.004). Multivariate analysis showed that intraoperative massive blood loss >10L (p < 0.001) and no enteral feeding started within 48 hours after transplantation (p = 0.005) were significant risk factors for bacterial sepsis. Among patients who received enteral nutrition, the incidences of bacterial sepsis in patients who received enteral nutrition within 48 hours (n = 135) or later than 48 hours (n = 57) were 5.9% and 21.0%, respectively (p = 0.002). The incidence of early graft loss was 8-fold higher in recipients with massive intraoperative blood loss without early enteral nutrition (p < 0.001). CONCLUSIONS: Early enteral nutrition was associated with significantly reduced risk of developing bacterial sepsis after LDLT.

PMID: 22244203 [PubMed - as supplied by publisher]

Total Mesorectal Excision with Intraoperative Assessment of Internal Anal Sphincter Innervation Provides New Insights into Neurogenic Incontinence.

J Am Coll Surg. 2012 Jan 11;

Authors: Kneist W, Kauff DW, Gockel I, Huppert S, Koch KP, Hoffmann KP, Lang H

Abstract

BACKGROUND: The aim of this prospective study was to assess internal anal sphincter (IAS) innervation in patients undergoing total mesorectal excision (TME) by intraoperative neuromonitoring (IONM). STUDY DESIGN: Fourteen patients underwent TME. IONM was carried out through pelvic splanchnic nerve stimulation under continuous electromyography of the IAS. Anorectal function was assessed with the digital rectal examination scoring system and a standardized questionnaire. RESULTS: Nine of 11 patients who underwent low anterior resection had positive IONM results, with stimulation-induced increased IAS electromyographic amplitudes (median 0.23 μV (interquartile range [IQR] 0.05, 0.56) vs median 0.89 μV (IQR 0.64, 1.88), p < 0.001) after TME. The patients with the positive IONM results were continent after stoma closure. Of 2 patients with negative IONM results, 1 had fecal incontinence after closure of the defunctioning stoma and received a permanent sigmoidostomy. In the other patient the defunctioning stoma was deemed permanent due to decreased anal sphincter function. In 3 patients who underwent abdominoperineal excision, IONM assessed denervation of the IAS after performance of the abdominal part. CONCLUSIONS: This study demonstrated that IONM of IAS innervation in rectal cancer patients is feasible and may predict neurogenic fecal incontinence.

PMID: 22244205 [PubMed - as supplied by publisher]

A Systematic Review and Meta-Analysis of Diagnostic Screening Criteria for Blunt Cerebrovascular Injuries.

J Am Coll Surg. 2012 Jan 11;

Authors: Franz RW, Willette PA, Wood MJ, Wright ML, Hartman JF

Abstract

BACKGROUND: Despite progress in diagnosing and managing blunt cerebrovascular injury (BCVI), controversy remains regarding the appropriate population to screen. A systematic review of published literature was conducted to summarize the overall incidence of BCVI and the various screening criteria used to detect BCVI. A meta-analysis was performed to evaluate which screening criteria may be associated with BCVI. Goals were to confirm inclusion of certain criteria in current screening protocols and possibly eliminate criteria not associated with BCVI. STUDY DESIGN: Studies published between January 1995 and April 2011 using digital subtraction angiography or CT angiography as a diagnostic modality and reporting overall BCVI incidence or prevalence of BCVI for specific screening criteria were examined. Screening criteria were analyzed using a random effects model to determine if an association with BCVI was present. RESULTS: The incidence range of BCVI was between 0.18% and 2.70% among approximately 122,176 blunt trauma admissions. The meta-analysis encompassed 418 BCVI and 22,568 non-BCVI patients. Of the 9 screening criteria analyzed, cervical spine (odds ratio [OR] 5.45; 95% CI 2.24 to 13.27; p < 0.0001) and thoracic (OR 1.98; 95% CI 1.35 to 2.92; p = 0.001) injuries demonstrated a significant association with BCVI. CONCLUSIONS: Patients with cervical spine and thoracic injuries had significantly greater likelihoods of BCVI compared with patients without these injuries. All patients with either injury should be screened for BCVI. Multivariate logistic regression analysis is needed to elucidate the possible impact of the combined presence of screening criteria, but it was not possible in our study due to limitations in data presentation. Standardized reporting of BCVI data is not established and is recommended to permit future collaboration.

PMID: 22244206 [PubMed - as supplied by publisher]

Management of Papillary Breast Lesions Diagnosed on Core-Needle Biopsy: Clinical Pathologic and Radiologic Analysis of 276 Cases with Surgical Follow-Up.

J Am Coll Surg. 2012 Jan 11;

Authors: Rizzo M, Linebarger J, Lowe MC, Pan L, Gabram SG, Vasquez L, Cohen MA, Mosunjac M

Abstract

BACKGROUND: Clinical management of papillary breast lesions (PBLs) remains controversial. The objective of this study was to identify pathologic and radiologic predictors of malignancy from a large cohort of PBLs diagnosed on core-needle biopsy (CNB). STUDY DESIGN: Retrospective review of the institutional pathology database identified all PBLs diagnosed from 2001 to 2009 and surgically excised within 6 months of diagnosis. PBLs were divided into intraductal papilloma (IDP) and IDP associated with atypical ductal or lobular hyperplasia (ADH/ALH). Surgical pathology of all lesions was reviewed and upgrade was defined as a change to a lesion of greater clinical significance, including ALH, ADH, lobular, or ductal carcinoma in situ (LCIS or DCIS), and invasive ducal carcinoma (IDC). RESULTS: We identified 276 patients (mean age 56 years; range 23 to 88 years) with PBLs on CNB. Seventy-nine patients (28.6%) upgraded to a lesion of greater clinical significance. Of the 234 (84.7%) had IDP only, 42 (17.9%) upgraded to ADH, and 21 (8.9%) to DCIS or IDC. Of the 42 (15.3%) patients with associated ADH or ALH on CNB, 16 (38.0%) upgraded to DCIS or IDC. The majority of patients (n = 173, 62.6%) had no breast symptoms. All patients had an abnormal mammogram and/or ultrasound that prompted the CNB. Among all clinical and radiographic variables analyzed, older age alone was predictive of upgrade. CONCLUSIONS: Frequent upgrade to a high-risk lesion or cancer is observed with IDPs diagnosed on CNB without adequate identifiable clinical and radiographic risk factors. Surgical excision should be performed for all IDPs to delineate subsequent clinical management.

PMID: 22244207 [PubMed - as supplied by publisher]

AUDIT-C Alcohol Screening Results and Postoperative Inpatient Health Care Use.

J Am Coll Surg. 2012 Jan 11;

Authors: Rubinsky AD, Sun H, Blough DK, Maynard C, Bryson CL, Harris AH, Hawkins EJ, Beste LA, Henderson WG, Hawn MT, Hughes G, Bishop MJ, Etzioni R, Tønnesen H, Kivlahan DR, Bradley KA

Abstract

BACKGROUND: Alcohol screening scores ≥5 on the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) up to a year before surgery have been associated with postoperative complications, but the association with postoperative health care use is unknown. This study evaluated whether AUDIT-C scores in the year before surgery were associated with postoperative hospital length of stay, total ICU days, return to the operating room, and hospital readmission. STUDY DESIGN: This cohort study included male Veterans Affairs patients who completed the AUDIT-C on mailed surveys (October 2003 through September 2006) and were hospitalized for nonemergent noncardiac major operations in the following year. Postoperative health care use was evaluated across 4 AUDIT-C risk groups (scores 0, 1 to 4, 5 to 8, and 9 to 12) using linear or logistic regression models adjusted for sociodemographics, smoking status, surgical category, relative value unit, and time from AUDIT-C to surgery. Patients with AUDIT-C scores indicating low-risk drinking (scores 1 to 4) were the referent group. RESULTS: Adjusted analyses revealed that among eligible surgical patients (n = 5,171), those with the highest AUDIT-C scores (ie, 9 to 12) had longer postoperative hospital length of stay (5.8 [95% CI, 5.0-6.7] vs 5.0 [95% CI, 4.7-5.3] days), more ICU days (4.5 [95% CI, 3.2-5.8] vs 2.8 [95% CI, 2.6-3.1] days), and increased probability of return to the operating room (10% [95% CI, 6-13%] vs 5% [95% CI, 4-6%]) in the 30 days after surgery, but not increased hospital readmission within 30 days postdischarge, relative to the low-risk group. CONCLUSIONS: AUDIT-C screening results could be used to identify patients at risk for increased postoperative health care use who might benefit from preoperative alcohol interventions.

PMID: 22244208 [PubMed - as supplied by publisher]

Argon Beam Coagulator: An Effective Adjunct to Stapled Pulmonary Tractotomy to Control Hemorrhage in Penetrating Pulmonary Injuries.

J Am Coll Surg. 2012 Jan 11;

Authors: Asensio JA, Mazzini FN, Gonzalo R, Iglesias E, Vu T

PMID: 22244209 [PubMed - as supplied by publisher]

Lymph Node Staging in Colorectal Cancer: Revisiting the Benchmark of at Least 12 Lymph Nodes in R0 Resection.

J Am Coll Surg. 2012 Jan 4;

Authors: Shia J, Wang H, Nash GM, Klimstra DS

PMID: 22225644 [PubMed - as supplied by publisher]

Nanoparticle Migration and Delivery of Paclitaxel to Regional Lymph Nodes in a Large Animal Model.

J Am Coll Surg. 2012 Jan 4;

Authors: Khullar OV, Griset AP, Gibbs-Strauss SL, Chirieac LR, Zubris KA, Frangioni JV, Grinstaff MW, Colson YL

Abstract

BACKGROUND: The aim of this study was to demonstrate feasibility of migration and in situ chemotherapy delivery to regional lymph nodes (LN) in a large animal model using an expansile polymer nanoparticle (eNP) delivery system. STUDY DESIGN: Dual-labeled 50-nm and 100-nm eNP were prepared by encapsulating an IR-813 near-infrared (NIR) fluorescent dye within coumarin-conjugated expansile polymer nanoparticles (NIR-C-eNP). NIR imaging and fluorescent microscopy were used to identify intralymphatic migration of NIR-nanoparticles to draining inguinal or mesenteric LN after injection in swine hind legs or intestine. Nanoparticle-mediated intranodal delivery of chemotherapy was subsequently assessed with Oregon Green paclitaxel-loaded NIR-eNP (NIR-OGpax-eNP). RESULTS: NIR imaging demonstrated direct lymphatic migration of 50-nm, but not 100-nm, NIR-C-eNP and NIR-OGpax-eNP to the draining regional LNs after intradermal injection in the hind leg or subserosal injection in intestine. Fluorescent microscopy demonstrated that IR-813 used for NIR real-time trafficking colocalized with both the coumarin-labeled polymer and paclitaxel chemotherapy and was identified within the subcapsular spaces of the draining LNs. These studies verify nodal migration of both nanoparticle and encapsulated payload, and confirm the feasibility of focusing chemotherapy delivery directly to regional nodes. CONCLUSIONS: Regionally-targeted intranodal chemotherapy can be delivered to draining LNs for both skin and solid organs using 50-nm paclitaxel-loaded eNP.

PMID: 22225645 [PubMed - as supplied by publisher]

Improving Access to Care: Breast Surgeons, the Gatekeepers to Breast Reconstruction.

J Am Coll Surg. 2012 Jan 4;

Authors: Preminger BA, Trencheva K, Chang CS, Chiang A, El-Tamer M, Ascherman J, Rohde C

Abstract

BACKGROUND: Fewer than half of patients undergo reconstruction after breast cancer treatment, despite its quality of life benefits. Earlier studies demonstrated that most general surgeons do not discuss reconstructive options with patients. The aim of this study was to examine the likelihood of reconstruction within a cohort of mastectomy patients and compare rates of reconstruction between those referred and not referred for plastic surgery evaluation. STUDY DESIGN: Retrospective review of the records of 471 consecutive patients between the ages of 19 and 94 years who underwent mastectomy between 2003 and 2007. Variables evaluated were age, body mass index, diabetes, laterality (unilateral vs bilateral), TNM staging, history of radiation, smoking history, insurance type, and race. RESULTS: Of 471 patients, 313 were referred for consultation with a plastic surgeon and 158 were not; 91.7% of those referred were reconstructed and 100% of those not referred were not reconstructed. The 2 groups differed considerably in terms of age (mean age 61.84 years in the nonreferred group vs 51.83 years in the referred group), body mass index (25.9 in referred group, 27 in nonreferred group), diabetes (15% in nonreferred group vs 3.5% in referred group), and laterality (14% of nonreferred group underwent bilateral mastectomies vs 26% of those referred). The groups did not differ significantly in terms of race or tobacco use. Those with private insurance were more likely to be reconstructed, but no independent effect of insurance type was seen on multivariate analysis. CONCLUSIONS: The breast surgeon’s decision to refer a patient for reconstruction significantly affects whether the patient will receive breast reconstruction. Factors that appear to influence the referral decision are age, diabetes, body mass index, and laterality of mastectomy (bilateral more than unilateral).

PMID: 22225646 [PubMed - as supplied by publisher]

An Online Spaced-Education Game to Teach and Assess Residents: A Multi-Institutional Prospective Trial.

J Am Coll Surg. 2012 Jan 4;

Authors: Kerfoot BP, Baker H

Abstract

BACKGROUND: While games are frequently used in resident education, there is little evidence supporting their efficacy. We investigated whether a spaced-education (SE) game can be both a reliable and valid method of assessing residents’ knowledge and an effective means of teaching core content. STUDY DESIGN: The SE game consisted of 100 validated multiple-choice questions and explanations on core urology content. Residents were sent 2 questions each day via email. Adaptive game mechanics re-sent the questions in 2 or 6 weeks if answered incorrectly and correctly, respectively. Questions expired if not answered on time (appointment dynamic). Residents retired questions by answering each correctly twice in a row (progression dynamic). Competition was fostered by posting relative performance among residents. Main outcomes measures were baseline scores (percentage of questions answered correctly on initial presentation) and completion scores (percentage of questions retired). RESULTS: Nine hundred thirty-one US and Canadian residents enrolled in the 45-week trial. Cronbach alpha reliability for the SE baseline scores was 0.87. Baseline scores (median 62%, interquartile range [IQR] 17%) correlated with scores on the 2008 American Urological Association in-service examination (ISE08), 2009 American Board of Urology qualifying examination (QE09), and ISE09 (r = 0.76, 0.46, and 0.64, respectively; all p < 0.001). Baseline scores varied by sex, country, medical degree, and year of training (all p ≤ 0.001). Completion scores (median 100%, IQR 2%) correlated with ISE08 and ISE09 scores (r = 0.35, p < 0.001 for both). Seventy-two percent of enrollees (667 of 931) requested to participate in future SE games. CONCLUSIONS: An SE game is a reliable and valid means to assess residents’ knowledge and is a well-accepted method by which residents can master core content.

PMID: 22225647 [PubMed - as supplied by publisher]

The Impact of Nontechnical Skills on Technical Performance in Surgery: A Systematic Review.

J Am Coll Surg. 2011 Dec 24;

Authors: Hull L, Arora S, Aggarwal R, Darzi A, Vincent C, Sevdalis N

Abstract

BACKGROUND: Failures in nontechnical and teamwork skills frequently lie at the heart of harm and near-misses in the operating room (OR). The purpose of this systematic review was to assess the impact of nontechnical skills on technical performance in surgery. STUDY DESIGN: MEDLINE, EMBASE, PsycINFO databases were searched, and 2,041 articles were identified. After limits were applied, 341 articles were retrieved for evaluation. Of these, 28 articles were accepted for this review. Data were extracted from the articles regarding sample population, study design and setting, measures of nontechnical skills and technical performance, study findings, and limitations. RESULTS: Of the 28 articles that met inclusion criteria, 21 articles assessed the impact of surgeons’ nontechnical skills on their technical performance. The evidence suggests that receiving feedback and effectively coping with stressful events in the OR has a beneficial impact on certain aspects of technical performance. Conversely, increased levels of fatigue are associated with detriments to surgical skill. One article assessed the impact of anesthesiologists’ nontechnical skills on anesthetic technical performance, finding a strong positive correlation between the 2 skill sets. Finally, 6 articles assessed the impact of multiple nontechnical skills of the entire OR team on surgical performance. A strong relationship between teamwork failure and technical error was empirically demonstrated in these studies. CONCLUSIONS: Evidence suggests that certain nontechnical aspects of performance can enhance or, if lacking, contribute to deterioration of surgeons’ technical performance. The precise extent of this effect remains to be elucidated.

PMID: 22200377 [PubMed - as supplied by publisher]

Meso-Pancreatectomy: New Surgical Technique for Wirsung Reconstruction.

J Am Coll Surg. 2011 Dec 20;

Authors: Di Benedetto F, D’Amico G, Ballarin R, Tarantino G, Cautero N, Pecchi A, Gerunda GE

PMID: 22192893 [PubMed - as supplied by publisher]

Clinical and Economic Comparison of Laparoscopic to Open Liver Resections Using a 2-to-1 Matched Pair Analysis: An Institutional Experience.

J Am Coll Surg. 2011 Dec 20;

Authors: Bhojani FD, Fox A, Pitzul K, Gallinger S, Wei A, Moulton CA, Okrainec A, Cleary SP

Abstract

BACKGROUND: Surgical resection of hepatic lesions is associated with intraoperative and postoperative morbidity and mortality. Our center has introduced a laparoscopic liver resection (LLR) program over the past 3 years. Our objective is to describe the initial clinical experience with LLR, including a detailed cost analysis. STUDY DESIGN: We evaluated all LLRs from 2006 to 2010. Each was matched to 2 open cases for number of segments removed, patient age, and background liver histology. Model for End-Stage Liver Disease (MELD) and the Charlson comorbidity index were calculated retrospectively. Nonparametric statistical analysis was used to compare surgical and economic outcomes. Analyses were performed including and excluding converted cases. RESULTS: Fifty-seven patients underwent attempted LLR. Demographic characteristics were similar between groups. Estimated blood loss was lower in the LLR vs the open liver resection (OLR) group, at 250 mL and 500 mL, respectively (p < 0.001). Median operating room times were 240 minutes and 270 minutes in the LLR and OLR groups, respectively (p = 0.14). Eight cases were converted to open (14%): 2 for bleeding, 2 for anatomic uncertainty, 1 for tumor size, 1 for margins, 1 for inability to localize the tumor, and 1 for adhesions. Median length of stay was lower for LLR at 5 days vs 6 days for OLR (p < 0.001). There was no difference in frequency of ICU admission, reoperation, 30-day emergency room visit, or 30-day readmission rates. Median overall cost for LLR was lower at $11,376 vs $12,523 for OLR (p = 0.077). CONCLUSIONS: Our experience suggests that LLR confers the clinical advantages of reduced operating room time, estimated blood loss, and length of stay while decreasing overall cost. LLR, therefore, appears to be a clinically and fiscally advantageous approach in properly selected patients.

PMID: 22192894 [PubMed - as supplied by publisher]

Obesity is an Independent Risk Factor for Death and Cardiac Complications after Carotid Endarterectomy.

J Am Coll Surg. 2011 Dec 20;

Authors: Jackson RS, Sidawy AN, Amdur RL, Macsata RA

Abstract

BACKGROUND: The role of obesity as a risk factor after carotid endarterectomy is not well-described. We undertook a study of the association of obesity with 30-day outcomes after carotid endarterectomy. STUDY DESIGN: After obtaining Institutional Review Board approval, we retrospectively analyzed prospectively collected data from carotid endarterectomies in the 2005-2006 Veterans Affairs Surgical Quality Improvement Program database. The association of body mass index (BMI; calculated as kg/m(2)) on 30-day outcomes was assessed using multivariable logistic regression. RESULTS: From 3,706 carotid endarterectomies, we excluded 22 for missing BMI and 39 for emergency status; 3,645 carotid endarterectomies were analyzed. BMI was underweight (<18.5) in 1.6%, normal (18.5 to 24.9) in 31.0%, overweight (25.0 to 29.9) in 40.8%, class I obese (30.0 to 34.9) in 19.3%, class II obese (35.0 to 39.9) in 5.8%, and class III obese (≥40) in 1.6%. On multivariable analysis, class II to III (odds ratio = 6.95; 95% CI, 1.89-25.58; p = 0.004)) obesity was associated with death, and class II to III obesity was associated with cardiac complications (odds ratio = 3.68; 95% CI, 1.27-10.66; p = 0.02) compared with normal weight. CONCLUSIONS: Obesity is an independent risk factor for death and cardiac complications after carotid endarterectomy. Surgeons should consider this when evaluating the risks and benefits of carotid endarterectomy in obese patients. Carotid artery stenting was not assessed, and future studies are needed to examine its role in management of obese patients.

PMID: 22192895 [PubMed - as supplied by publisher]

Application of Subcutaneous Talc after Axillary Dissection in a Porcine Model Safely Reduces Drain Duration and Prevents Seromas.

J Am Coll Surg. 2011 Dec 20;

Authors: Klima DA, Belyansky I, Tsirline VB, Lincourt AE, Lipford EH, Getz SB, Heniford BT

Abstract

BACKGROUND: Talc, the most common pleurodesis agent, has recently been shown to prevent seromas and decrease drain duration when placed subcutaneously after large subcutaneous dissection accompanying open ventral hernia repair. We hypothesized that talc would decrease drain duration and prevent seromas after axillary dissection without local or systemic side effects. STUDY DESIGN: Six pigs underwent full, bilateral axillary dissection (n 12 dissections). Three animals each had aerosolized small particle (SP) talc and large particle (LP) talc sprayed unilaterally (TALC) before closure, with the contralateral axillary dissection serving as the control (NOTALC). Functional status, wound complications, and drain duration were recorded. Local neurovascular structures and systemic organs were harvested at 28 days, processed with hematoxylin and eosin, and examined under normal and polarized light microscopy by blinded physicians. RESULTS: All pigs were back to baseline functional status by 72 hours. Two seromas (33%) were noted in the NOTALC dissections vs 0 in the TALC group (0%). Drain duration was significantly decreased in TALC vs NOTALC dissections (8.3 ± 2.7 vs 12.0 ± 3.2 days, p = 0.03), as was total drain volume (222.5 ± 127.1 mL vs 334.2 ± 137.9 mL, p = 0.02). Gross and histologic evaluation revealed neurovascular structures to be intact. Minimal splenic deposition of talc within macrophages without evidence of injury was identified in all specimens, with fewer deposits in the large particle talc group. Serum laboratory examination at time of harvest revealed all animals to have normal values. CONCLUSIONS: Direct application of talc throughout the wound after axillary dissection in pigs decreased drain duration and drain volume and prevented seroma formation. Gross, histologic, and serum laboratory evaluation demonstrated no talc-related local or systemic complications. Aerosolized talc is an effective and safe pretreatment to prevent seromas and hasten drain removal after axillary dissection.

PMID: 22192896 [PubMed - as supplied by publisher]

Use of Cholecystostomy Tubes in the Management of Patients with Primary Diagnosis of Acute Cholecystitis.

J Am Coll Surg. 2011 Dec 20;

Authors: Cherng N, Witkowski ET, Sneider EB, Wiseman JT, Lewis J, Litwin DE, Santry HP, Cahan M, Shah SA

Abstract

BACKGROUND: Management of patients with severe acute cholecystitis (AC) remains controversial. In settings where laparoscopic cholecystectomy (LC) can be technically challenging or medical risks are exceedingly high, surgeons can choose between different options, including LC conversion to open cholecystectomy or surgical cholecystostomy tube (CCT) placement, or initial percutaneous CCT. We reviewed our experience treating complicated AC with CCT at a tertiary-care academic medical center. STUDY DESIGN: All adult patients (n = 185) admitted with a primary diagnosis of AC and who received CCT from 2002 to 2010 were identified retrospectively through billing and diagnosis codes. RESULTS: Mean patient age was 71 years and 80% had ≥1 comorbidity (mean 2.6). Seventy-eight percent of CCTs were percutaneous CCT placement and 22% were surgical CCT placement. Median length of stay from CCT insertion to discharge was 4 days. The majority (57%) of patients eventually underwent cholecystectomy performed by 20 different surgeons in a median of 63 days post-CCT (range 3 to 1,055 days); of these, 86% underwent LC and 13% underwent open conversion or open cholecystectomy. In the radiology and surgical group, 50% and 80% underwent subsequent cholecystectomy, respectively, at a median of 63 and 60 days post-CCT. Whether surgical or percutaneous CCT placement, approximately the same proportion of patients (85% to 86%) underwent LC as definitive treatment. CONCLUSIONS: This 9-year experience shows that use of CCT in complicated AC can be a desirable alternative to open cholecystectomy that allows most patients to subsequently undergo LC. Additional studies are underway to determine the differences in cost, training paradigms, and quality of life in this increasingly high-risk surgical population.

PMID: 22192897 [PubMed - as supplied by publisher]

Creation and Implementation of an Emergency General Surgery Registry Modeled after the National Trauma Data Bank.

J Am Coll Surg. 2011 Dec 5;

Authors: Becher RD, Meredith JW, Chang MC, Hoth JJ, Beard HR, Miller PR

Abstract

BACKGROUND: As emergency general surgery (EGS) evolves, an EGS patient-tracking database (EGS registry [EGSR]) similar to the National Trauma Data Bank (NTDB) will be essential to study outcomes and improve care. The goal of this study was to establish diagnostic ICD-9 codes to define EGS patients. The hypothesis was that creating standardized ICD-9-based inclusion criteria would facilitate patient identification for an EGSR and aid in its ongoing development. STUDY DESIGN: We conducted a retrospective review of EGS admissions over a 9-month period to define ICD-9 diagnostic codes of patients admitted to our EGS service. Subsequently, prospective data were collected into the EGSR by testing ICD-9-based inclusion criteria over 1 month. Patient, hospital, and severity scoring variables, as well as quality assurance information, were identified. RESULTS: We identified 959 admissions to the EGS service over 9 months with 306 ICD-9 diagnosis codes that define EGS patients; the prospective population of the EGSR confirmed feasibility of ICD-9-based inclusion criteria. The EGSR captures 107 data points and 33 comorbidities per patient over 11 categories, akin to the 10 NTDB categories. CONCLUSIONS: Following the model of the NTDB, we have successfully completed creation and initial implementation of an EGSR by using ICD-9-based inclusion criteria. Our comprehensive EGSR creates a prospective data-collection modality to capture and define EGS patients. A uniform patient-tracking EGSR, akin to the NTDB, will advance the science of acute care surgery, improve EGS patient outcomes, and facilitate multi-institutional collaboration.

PMID: 22153352 [PubMed - as supplied by publisher]

Violation of the Rectus Complex Is Not a Contraindication to Component Separation for Abdominal Wall Reconstruction.

J Am Coll Surg. 2011 Dec 8;

Authors: Garvey PB, Bailey CM, Baumann DP, Liu J, Butler CE

Abstract

BACKGROUND: Component separation (CS) is an effective technique for reconstructing complex abdominal wall defects. Violation of the rectus abdominis complex is considered a contraindication for CS, but we hypothesized that patients have similar outcomes with or without rectus complex violation. STUDY DESIGN: We retrospectively studied all consecutive patients who underwent CS for abdominal wall reconstruction during 8 years and compared outcomes of patients with and without rectus violation. Primary outcomes measures included complications and hernia recurrence. Logistic regression analysis identified potential associations between patient, defect, and reconstructive characteristics and surgical outcomes. RESULTS: One hundred sixty-nine patients were included: 115 (68%) with and 54 (32%) without rectus violation. Mean follow-up was 21.3 ± 14.5 months. Patient and defect characteristics were similar, except for the rectus violation group having a higher body mass index. Overall complication rates were similar in the violation (24.3%) and nonviolation (24.0%) groups, as were the respective rates of recurrent hernia (7.8% vs 9.2%; p = 0.79), abdominal bulge (3.5% vs 5.6%; p = 0.71), skin dehiscence (20.0% vs 22.2%; p = 0.74), skin necrosis (6.1% vs 3.7%; p = 0.72), cellulitis (7.8% vs 9.2%; p = 0.75), and abscess (12.3% vs 9.2%; p = 0.58). Regression analysis demonstrated body mass index to be the only factor predictive of complications. CONCLUSIONS: CS surgical outcomes were similar whether or not the rectus complex was violated. To our knowledge, this study is the first to evaluate the effects of rectus violation on surgical outcomes in CS patients. Surgeons should not routinely avoid CS when the rectus complex is violated.

PMID: 22169002 [PubMed - as supplied by publisher]

Feasibility and Impact of a Case-Based Palliative Care Workshop for General Surgery Residents.

J Am Coll Surg. 2011 Dec 8;

Authors: Pernar LI, Peyre SE, Smink DS, Block SD, Cooper ZR

Abstract

BACKGROUND: The American Board of Surgery has emphasized that palliative care education should be included in surgical training. The few formal curricula for teaching palliative care, although effective, are time-intensive and have low longitudinal participation rates. The aim of this project was to design a feasible and effective palliative care intervention for general surgery residency training. STUDY DESIGN: A multidisciplinary group developed a 2-hour case-based palliative care workshop including a brief introductory didactic, 4 case-based scenarios, and role-playing exercises. Program effectiveness was assessed using pre- and 3 weeks post-workshop surveys to measure attitudes toward and knowledge of palliative care. Fisher’s exact test was used for data analysis; statistical significance was accepted at p < 0.05. RESULTS: Twenty-two (88%) residents attended the workshop and completed the baseline survey; 16 (72.7%) completed the post-workshop survey. The workshop changed residents’ attitudes to be more consistent with accepted palliative care principles. Statistically significant shifts were seen in attitudes about the use of total parenteral nutrition for malignant small bowel obstruction (31.8% disagree with use pre- vs 68.8% post-workshop; p < 0.0001); the use of surgical therapy for malignant small bowel obstruction (45.5% disagree pre- vs 68.8% post-workshop; p = 0.002); and that depression is normal in terminal illness (22.7% disagree pre- vs 43.8% post-workshop; p = 0.002). Residents also performed considerably better on knowledge questions about CPR, patient autonomy, and withdrawal of life-sustaining therapy. CONCLUSIONS: A brief, interactive workshop is effective in changing general surgery residents’ attitudes toward and knowledge of palliative care. The results demonstrate that a single teaching session is a useful intervention.

PMID: 22169003 [PubMed - as supplied by publisher]

A multisite assessment of the american college of surgeons committee on trauma field triage decision scheme for identifying seriously injured children and adults.

J Am Coll Surg. 2011 Dec;213(6):709-21

Authors: Newgard CD, Zive D, Holmes JF, Bulger EM, Staudenmayer K, Liao M, Rea T, Hsia RY, Wang NE, Fleischman R, Jui J, Mann NC, Haukoos JS, Sporer KA, Gubler KD, Hedges JR,

Abstract

BACKGROUND: The American College of Surgeons Committee on Trauma (ACSCOT) has developed and updated field trauma triage protocols for decades, yet the ability to identify major trauma patients remains unclear. We estimate the diagnostic value of the Field Triage Decision Scheme for identifying major trauma patients (Injury Severity Score [ISS] ≥ 16) in a large and diverse multisite cohort.

STUDY DESIGN: This was a retrospective cohort study of injured children and adults transported by 94 emergency medical services (EMS) agencies to 122 hospitals in 7 regions of the Western US from 2006 through 2008. Patients who met any of the field trauma triage criteria (per EMS personnel) were considered triage positive. Hospital outcomes measures were probabilistically linked to EMS records through trauma registries, state discharge data, and emergency department data. The primary outcome defining a “major trauma patient” was ISS ≥ 16.

RESULTS: There were 122,345 injured patients evaluated and transported by EMS over the 3-year period, 34.5% of whom met at least 1 triage criterion and 5.8% had ISS ≥ 16. The overall sensitivity and specificity of the criteria for identifying major trauma patients were 85.8% (95% CI 85.0% to 86.6%) and 68.7% (95% CI 68.4% to 68.9%), respectively. Triage sensitivity and specificity, respectively, differed by age: 84.1% and 66.4% (0 to 17 years); 89.5% and 64.3% (18 to 54 years); and 79.9% and 75.4% (≥55 years). Evaluating the diagnostic value of triage by hospital destination (transport to Level I/II trauma centers) did not substantially improve these findings.

CONCLUSIONS: The sensitivity of the Field Triage Decision Scheme for identifying major trauma patients is lower and specificity higher than previously described, particularly among elders.

PMID: 22107917 [PubMed - in process]

Patient Characteristics Associated with End-of-Life Decision Making in Critically Ill Surgical Patients.

J Am Coll Surg. 2011 Dec;213(6):766-70

Authors: Lissauer ME, Naranjo LS, Kirchoffner J, Scalea TM, Johnson SB

Abstract

BACKGROUND: Palliative care is an important and necessary humanistic facet of ICU care. Wide variations exist in selection and implementation of palliative care decisions. Understanding patient factors associated with these decisions is crucial.

STUDY DESIGN: Consecutive deaths (n = 151 patients) in a tertiary care surgical ICU during a 2-year period were reviewed. All data had been entered into the APACHE IV database. Patients were divided into groups: Withhold (WH), which included patients who had potentially lifesaving therapies withheld or withdrawn, and Full Care (FC), which included patients who had full resuscitative efforts before death. Patient factors including demographics, severity of illness, admission source, and history were compared between groups.

RESULTS: Of 151 patients, 111 (74%) had potentially lifesaving therapy withheld or withdrawn (WH group). Forty patients (26%) had full treatment, including CPR, until time of death (FC group). Compared with WH, FC patients had a higher degree of illness at ICU admission (APACHE IV score 103.4 ± 36.6 vs 90.6 ± 29.3; p < 0.02) and were less likely to be male (35% vs 62%; p < 0.005). There were no differences between groups with regard to age, requirement for intubation on admission, medical history, admission source (emergency room vs operating room vs recovery room) or the number of patients admitted status post emergent vs elective surgery or admitted for nonsurgical diagnoses. In a multivariable regression model, male sex (odds ratio = 3.22; 95% CI, 1.45-7.19) and severity of illness (odds ratio = 0.98; 95% CI, 0.97-0.99) retained independent associations with decisions to limit care.

CONCLUSIONS: Higher severity of illness and history play no role in the decision to limit care. Sex plays a strong and independent role. Factors influencing end-of-life care require additional study.

PMID: 22107920 [PubMed - in process]

Treatment options for graves’ disease.

J Am Coll Surg. 2011 Dec;213(6):806-8

Authors: Chaudhury PK, Angelos P, Pasieka JL,

PMID: 22107921 [PubMed - in process]

Prophylactic anticoagulation in patients with traumatic brain injury.

J Am Coll Surg. 2011 Dec;213(6):809

Authors: Petruska DA

PMID: 22107922 [PubMed - in process]

Reply.

J Am Coll Surg. 2011 Dec;213(6):809-10

Authors: Brasel KJ

PMID: 22107923 [PubMed - in process]

JACS CME Credit Featured Articles, Volume 213, December 2011.

J Am Coll Surg. 2011 Dec;213(6):812-4

Authors:

PMID: 22107924 [PubMed - in process]

Laparoscopic technique and initial experience with knotless, unidirectional barbed suture closure for staple-conserving, delta-shaped gastroduodenostomy after distal gastrectomy.

J Am Coll Surg. 2011 Dec;213(6):e39-45

Authors: Lee SW, Nomura E, Tokuhara T, Kawai M, Matsuhashi N, Yokoyama K, Fujioka H, Hiramatsu M, Okuda J, Uchiyama K

PMID: 22107925 [PubMed - in process]

Societal Costs of Inappropriate Emergency Department Thoracotomy.

J Am Coll Surg. 2011 Nov 21;

Authors: Passos EM, Engels PT, Doyle JD, Beckett A, Nascimento B, Rizoli SB, Tien HC

Abstract

BACKGROUND: Emergency department (ED) thoracotomy can be lifesaving. It can also lead to resource waste and exposure to blood-borne infections. We investigated the frequency with which ED thoracotomy was performed for inappropriate indications and the resulting societal costs. STUDY DESIGN: This retrospective cohort study examined all trauma patients admitted directly from the scene of injury from 1992 to 2009 who underwent ED thoracotomy. The main outcomes included inappropriate ED thoracotomy. Secondary outcomes included resource use and societal costs for performing ED thoracotomy for improper indications. Specifically, we analyzed for operating room use, blood transfusions, ICU and hospital stay, needlestick injuries, survivor rate, and neurological outcomes in this group. RESULTS: One hundred and twenty-three patients underwent ED thoracotomy during the study period. Of those, 63 (51%) were considered inappropriate. In this group, we observed no survivors, none became organ donors, 3 cases of needlestick injuries to health care providers occurred, and 335 U of blood products were used in their care. Also, 4 patients of 63 survived to the operating room and required a total of 6 separate operating room visits. Three of these patients had an ICU stay of 1 day and 1 died on day 5. CONCLUSIONS: ED thoracotomy should be reserved for potentially salvageable patients, but discouraged for other indications. From the societal point of view, inappropriate use of the procedure resulted in substantial costs and waste of resources, exposure of health care providers to possible blood-borne infections, and offered no survival benefit.

PMID: 22112417 [PubMed - as supplied by publisher]

Frequency of Subtypes of Biliary Intraductal Papillary Mucinous Neoplasm and Their MUC1, MUC2, and DPC4 Expression Patterns Differ from Pancreatic Intraductal Papillary Mucinous Neoplasm.

J Am Coll Surg. 2011 Nov 21;

Authors: Sclabas GM, Barton JG, Smyrk TC, Barrett DA, Khan S, Kendrick ML, Reid-Lombardo KM, Donohue JH, Nagorney DM, Que FG

Abstract

BACKGROUND: Biliary intraductal papillary mucinous neoplasm (B-IPMN) has been proposed as a unique clinicopathologic disease with distinct histopathologic features, although wide acceptance remains controversial. A recent consensus conference classified pancreatic IPMN (P-IPMN) into 4 subtypes (ie, gastric, intestinal, pancreatobiliary, oncocytic) based on morphologic appearance and mucin (MUC) staining properties. The aim of this study was to determine whether B-IPMN has similar histopathologic and immunologic subtypes to P-IPMN. STUDY DESIGN: Specific immunostaining for MUC1, MUC2, and deleted for pancreas cancer, locus 4 were performed on specimens from 19 patients with a histopathologic diagnosis of B-IPMN. Immunostaining patterns of B-IPMN were correlated with histopathology. RESULTS: Based on histopathology, the following subtypes of B-IPMN were identified: pancreatobiliary n = 9 (47%), intestinal n = 8 (42%), oncocytic n = 2 (11%), and gastric n = 0 (0%). Pancreatobiliary and oncocytic subtypes of B-IPMN were positive for MUC1 and negative for MUC2, and intestinal subtypes were positive for MUC2 and negative for MUC1. Thirteen of the 19 B-IPMN were associated with invasive carcinoma; loss of deleted for pancreas cancer, locus 4 was found in 6 of 13 invasive components and in 3 of 19 noninvasive components of B-IPMN. Five-year survival for patients with resected B-IPMN and invasive carcinoma was 38%, which is similar to that for resected P-IPMN with invasive carcinoma. CONCLUSIONS: Histopathologic subtypes and type-specific MUC expression patterns of B-IPMN resemble those of P-IPMN. MUC1 expression and/or absence of MUC2 expression, which correlate with aggressive features of P-IPMN, were found in B-IPMN and correlate with invasive B-IPMN. Loss of deleted for pancreas cancer, locus 4 parallels the findings observed in P-IPMN. These findings provide additional support that B-IPMN is a unique entity with similarities to main duct P-IPMN.

PMID: 22112419 [PubMed - as supplied by publisher]

Hepatocellular Carcinoma Within a Noncirrhotic, Nonfibrotic, Seronegative Liver: Surgical Approaches and Outcomes.

J Am Coll Surg. 2011 Nov 30;

Authors: Young AL, Adair R, Prasad KR, Toogood GJ, Lodge JP

Abstract

BACKGROUND: Hepatocellular carcinoma (HCC) most commonly arises in patients with chronic liver disease. Data on outcomes after liver resection in patients with noncirrhotic, nonfibrotic, seronegative, referred to as a “normal” liver are limited. We aimed to investigate differences in prognostic factors and outcomes between patients presenting with HCC arising in “normal” liver (NLHCC) and that arising in “diseased” liver (DLHCC). STUDY DESIGN: All patients undergoing resection for HCC between 1994 and 2008 were assessed. Multivariable analysis of clincopathologic data from the NLHCC group was performed by comparing them with data from the group who had surgery for DLHCC during this period. RESULTS: During the 15-year study period, 142 patients underwent liver resection for HCC: 81 for NLHCC and 61 for DLHCC. NLHCCs were more often solitary but were larger and required more major resections. There was no significant difference in survival outcomes between patients who had NLHCC or DLHCC, with overall and recurrence-free 5-year survivals of 60% and 51% in NLHCC and 55% and 33% in DLHCC, respectively. In patients with NLHCC, significant factors predicting overall survival were blood transfusion requirement (p = 0.003) and age (p = 0.009), and the only significant factor at predicting recurrence-free survival was presence of multiple tumors (p = 0.025). In contrast, in DLHCC, the only significant prognostic variables were a preoperative tumor biopsy (p = 0.017) or a high neutrophil-to-lymphocyte ratio (p = 0.001), both of which predicted a poorer recurrence-free survival. CONCLUSIONS: HCC presenting in patients with a normal background liver parenchyma appears to present a different spectrum of the disease. However, excellent outcomes can be achieved after liver resection, although this often requires the use of advanced techniques due to late presentation.

PMID: 22137823 [PubMed - as supplied by publisher]

Reduction in Corticosteroids Is Associated with Better Health-Related Quality of Life after Liver Transplantation.

J Am Coll Surg. 2011 Nov 30;

Authors: Zaydfudim V, Feurer ID, Landman MP, Moore DE, Wright JK, Pinson CW

Abstract

BACKGROUND: Corticosteroid use during post-transplant immunosuppression contributes to documented long-term complications in liver transplant recipients. However, the effects of steroids on post-transplant physical and mental health-related quality of life (HRQOL) have not been established. We aimed to test the association between steroid-based immunosuppression and post-transplant HRQOL in liver transplant recipients. STUDY DESIGN: We performed a retrospective analysis of prospective, longitudinal HRQOL measured using the Short Form 36 Health Survey physical and mental component summary scores, Beck Anxiety Inventory, and Center for Epidemiologic Studies Depression Scale. Steroid use (none, low [<10 mg/d], high [≥10 mg/d]) and temporally associated acute rejection (within previous 6 weeks, previous 7 to 12 weeks, and never or >12 weeks before HRQOL measurement) were determined at every post-transplant HRQOL data point. Linear mixed-effects models tested the effects of contemporaneous steroid use and dosing on post-transplant HRQOL. RESULTS: The sample included 186 adult liver transplant recipients (mean age 54 ± 8 years, 70% male) with pre- and at least 1 post-transplant HRQOL data point. Individual follow-up post-transplant averaged 21 ± 18 months (range 1 to 74 months). After controlling for pre-transplant HRQOL, time post-transplant, pre-transplant diagnosis group, and temporally associated episodes of rejection, post-transplant high-dose steroid use (≥10 mg/d) was associated with lower physical component summary (p < 0.001) and mental component summary (p = 0.049) scores and increased Beck Anxiety Inventory (p = 0.015) scores. Low-dose steroid use (<10 mg/d) was not associated with post-transplant HRQOL in any model (all p ≥ 0.28). CONCLUSIONS: High-dose steroid use for post-transplant immunosuppression in liver transplant recipients was associated with reduced physical and mental HRQOL, and increased symptoms of anxiety. There was an association between better HRQOL and steroid reduction to <10 mg/d in liver transplant recipients during a broad follow-up period.

PMID: 22137824 [PubMed - as supplied by publisher]

Effect of Program Type on the Training Experiences of 248 University, Community, and US Military-Based General Surgery Residencies.

J Am Coll Surg. 2011 Nov 8;

Authors: Sullivan MC, Sue G, Bucholz E, Yeo H, Bell RH, Roman SA, Sosa JA

Abstract

BACKGROUND: There is a paucity of research comparing resident training experiences of university, community, and military-affiliated surgical programs. STUDY DESIGN: We reviewed a cross-sectional national survey (NEARS) involving all US categorical general surgery residents (248 programs). Demographics and level of agreement regarding training experiences were collected. Statistical analysis included chi-square, ANOVA, and hierarchical logistic regression modeling (HLRM). RESULTS: There were 4,282 residents included (82.4% response rate). The majority (69%) trained in university programs. Types of programs differed by sex mix (p < 0.001), racial makeup (p = 0.005), marital status profile (p = 0.002), and parental status profile (p < 0.001). Community residents were most satisfied with their operative experience (community 84.5%, university 73.4%, military 62.4%; p < 0.001), most likely to feel their opinions are important (76.0% vs 69.4% vs 67.9%, respectively; p < 0.001), and least likely to believe attendings will think worse of them if residents asked for help with patient management (12.6% vs 15.9% vs 14.7%, respectively; p = 0.025). Military residents were least likely to report that surgical training is too long (military 7.4%, community 14.0%, university 23.8%; p < 0.001). On HLRM, community programs were independently associated with residents feeling their opinions are important (odds ratio [OR] 1.91; p < 0.001), and reporting satisfactory operative experience (OR 4.73; p < 0.001). Residents training at military programs (OR 0.23; p = 0.002) or community programs (OR 0.31; p < 0.001) were less likely to feel that surgical training is too long, or that attendings will think worse of them if asked for help with patient care (community OR 0.19; p < 0.001; military OR 0.27; p = 0.004). CONCLUSIONS: Residents at university, community, and military programs report distinct training experiences. These findings may inform programs of potential targeted strategies for enhanced support.

PMID: 22075109 [PubMed - as supplied by publisher]

Hyperglycemia Is Associated with Increased Risk of Morbidity and Mortality after Colectomy for Cancer.

J Am Coll Surg. 2011 Nov 11;

Authors: Jackson RS, Amdur RL, White JC, Macsata RA

Abstract

BACKGROUND: The relationship of hyperglycemia to general surgery outcomes is not well-understood. We studied the association of operative day and postoperative day 1 (POD1) blood glucose (BG) with outcomes after open colectomy for cancer. STUDY DESIGN: We retrospectively analyzed the 2000-2005 Veterans Affairs Surgical Quality Improvement Program database, linked with Veterans Affairs Decision Support System BG values. Median BG was categorized as hypoglycemic (<80 mg/dL); normoglycemic (BG 80-120 mg/dL); or mildly (BG 121-160 mg/dL), moderately (BG 161-200 mg/dL), or severely (BG >200 mg/dL) hyperglycemic. The relationship of BG to postoperative outcomes was assessed with multivariable logistic regression. RESULTS: We identified 9,638 colectomies. We excluded 511 procedures for emergency status or preoperative coma, mechanical ventilation, or sepsis. After excluding patients without recorded BG, we analyzed operative day and POD1 BG in 7,576 and 5,773 procedures, respectively. On multivariable analysis, operative day moderate hyperglycemia was associated with surgical site infection (odds ratio = 1.44; 95% CI, 1.10-1.87). POD1 severe hyperglycemia was associated with cardiac arrest (odds ratio = 2.31; 95% CI, 1.08-4.98) and death (odds ratio = 1.97; 95% CI, 1.23-3.15). POD1 mild (odds ratio = 2.20; 95% CI, 1.05-4.60), moderate (odds ratio = 3.44; 95% CI, 1.51-7.84), and severe (odds ratio = 3.94; 95% CI, 1.64-9.58) hyperglycemia and hypoglycemia (odds ratio = 6.74; 95% CI, 1.75-25.97) were associated with myocardial infarction. Associations were similar in diabetic and nondiabetic patients. CONCLUSIONS: Even mild hyperglycemia was associated with adverse outcomes after colectomy, suggesting that a perioperative BG target of 80 to 120 mg/dL, although avoiding hypoglycemia, might be appropriate. Randomized clinical trials are needed to confirm these findings.

PMID: 22079879 [PubMed - as supplied by publisher]

Ultrasound-Guided Core Biopsy: An Effective Method of Detecting Axillary Nodal Metastases.

J Am Coll Surg. 2011 Nov 11;

Authors: Solon JG, Power C, Al-Azawi D, Duke D, Hill AD

Abstract

BACKGROUND: Axillary nodal status is an important prognostic predictor in patients with breast cancer. This study evaluated the sensitivity and specificity of ultrasound-guided core biopsy (Ax US-CB) at detecting axillary nodal metastases in patients with primary breast cancer, thereby determining how often sentinel lymph node biopsy could be avoided in node positive patients. STUDY DESIGN: Records of patients presenting to a breast unit between January 2007 and June 2010 were reviewed retrospectively. Patients who underwent axillary ultrasonography with or without preoperative core biopsy were identified. Sensitivity, specificity, positive predictive value, and negative predictive value for ultrasonography and percutaneous biopsy were evaluated. RESULTS: Records of 718 patients were reviewed, with 445 fulfilling inclusion criteria. Forty-seven percent (n = 210/445) had nodal metastases, with 110 detected by Ax US-CB (sensitivity 52.4%, specificity 100%, positive predictive value 100%, negative predictive value 70.1%). Axillary ultrasonography without biopsy had sensitivity and specificity of 54.3% and 97%, respectively. Lymphovascular invasion was an independent predictor of nodal metastases (sensitivity 60.8%, specificity 80%). Ultrasound-guided core biopsy detected more than half of all nodal metastases, sparing more than one-quarter of all breast cancer patients an unnecessary sentinel lymph node biopsy. CONCLUSIONS: Axillary ultrasonography, when combined with core biopsy, is a valuable component of the management of patients with primary breast cancer. Its ability to definitively identify nodal metastases before surgical intervention can greatly facilitate a patient’s preoperative integrated treatment plan. In this regard, we believe our study adds considerably to the increasing data, which indicate the benefit of Ax US-CB in the preoperative detection of nodal metastases.

PMID: 22079880 [PubMed - as supplied by publisher]

Perfecting the Plate: Adding Cardioprotective Compounds to the Diet.

J Am Coll Surg. 2011 Nov 3;

Authors: Cordova AC, Sumpio BJ, Sumpio BE

PMID: 22055584 [PubMed - as supplied by publisher]

Management of Patients with Pancreatic Adenocarcinoma: National Trends in Patient Selection, Operative Management, and Use of Adjuvant Therapy.

J Am Coll Surg. 2011 Nov 3;

Authors: Mayo SC, Gilson MM, Herman JM, Cameron JL, Nathan H, Edil BH, Choti MA, Schulick RD, Wolfgang CL, Pawlik TM

Abstract

BACKGROUND: Surgical resection remains the only potentially curative option for patients with pancreatic adenocarcinoma (PAC). Advances in surgical technique and perioperative care have reduced perioperative mortality; however, temporal trends in perioperative morbidity and the use of adjuvant therapy on a population basis remain ill-defined. STUDY DESIGN: Using Surveillance, Epidemiology, and End Results-Medicare data, 2,461 patients with resected PAC were identified from 1991 to 2005. We examined trends in preoperative comorbidity indices, adjuvant treatment, type of pancreatic resection, and changes in morbidity and mortality during 4 time intervals (ie, 1991-1996, 1997-2000, 2001-2003, and 2003-2005). RESULTS: The majority of patients underwent pancreaticoduodenectomy (n = 1,945; 79%). There was a temporal increase in mean patient age (p < 0.05) and the number of patients with multiple preoperative comorbidities (Elixhauser comorbidities ≥3: 1991-1996, 10% vs 2003-2005, 26%; p < 0.001). Perioperative morbidity (53%) did not, however, change over time (p = 0.97) and 30-day mortality decreased by half (1991-1996: 6% vs 2003-2005: 3%; p = 0.04). Overall, 51% (n = 1,243) of patients received adjuvant therapy, with the majority receiving chemoradiation (n = 817; 33%). Among patients who received adjuvant therapy, factors associated with receipt of adjuvant chemotherapy alone relative to chemoradiation included older patient age (odds ratio = 1.75; p < 0.001) and ≥3 medical comorbidities (odds ratio = 1.57; p = 0.007). Receipt of adjuvant chemotherapy alone also increased over time (2003-2005 vs 1991-1996, odds ratio = 2.21; p < 0.001). CONCLUSIONS: Perioperative 30-day mortality associated with resection for PAC decreased by one-half from 1991 to 2005. Although patients undergoing resection for PAC were older and had more preoperative comorbidities, the incidence of perioperative complications remained stable. The relative use of adjuvant chemotherapy alone vs chemoradiation therapy for PAC has increased in the United States during the 15 years examined.

PMID: 22055585 [PubMed - as supplied by publisher]

Decision Making about Surgery for Early-Stage Breast Cancer.

J Am Coll Surg. 2011 Nov 4;

Authors: Lee CN, Chang Y, Adimorah N, Belkora JK, Moy B, Partridge AH, Ollila DW, Sepucha KR

Abstract

BACKGROUND: Practice variation in breast cancer surgery has raised concerns about the quality of treatment decisions. We sought to evaluate the quality of decisions about surgery for early-stage breast cancer by measuring patient knowledge, concordance between goals and treatments, and involvement in decisions. STUDY DESIGN: A mailed survey of stage I/II breast cancer survivors was conducted at 4 sites. The Decision Quality Instrument measured knowledge, goals, and involvement in decisions. A multivariable logistic regression model of treatment was developed. The model-predicted probability of mastectomy was compared with treatment received for each patient. Concordance was defined as having mastectomy and predicted probability >0.5 or partial mastectomy and predicted probability <0.5. Frequency of discussion about partial mastectomy was compared with discussion about mastectomy using chi-square tests. RESULTS: Four hundred and forty patients participated (59% response rate). Mean overall knowledge was 52.7%; 45.9% knew that local recurrence risk is higher after breast conservation and 55.7% knew that survival is equivalent for the 2 options. Most participants (89.0%) had treatment concordant with their goals. Participants preferring mastectomy had lower concordance (80.5%) than those preferring partial mastectomy (92.6%; p = 0.001). Participants reported more frequent discussion of partial mastectomy and its advantages than of mastectomy, and 48.6% reported being asked their preference. CONCLUSIONS: Breast cancer survivors had major knowledge deficits, and those preferring mastectomy were less likely to have treatment concordant with goals. Patients perceived that discussions focused on partial mastectomy, and many were not asked their preference. Improvements in the quality of decisions about breast cancer surgery are needed.

PMID: 22056355 [PubMed - as supplied by publisher]

Three-Component Intraperitoneal Mesh Fixation for Laparoscopic Repair of Anterior Parasternal Costodiaphragmatic Hernias.

J Am Coll Surg. 2011 Nov 4;

Authors: von Rahden BH, Spor L, Germer CT, Dietz UA

PMID: 22056356 [PubMed - as supplied by publisher]

Two Tall Poppies and the Discovery of Helicobacter Pylori.

J Am Coll Surg. 2011 Nov 4;

Authors: Copeland CE, Stahlfeld K

PMID: 22056357 [PubMed - as supplied by publisher]

Comparison of Healing Parameters in Porcine Full-Thickness Wounds Transplanted with Skin Micrografts, Split-Thickness Skin Grafts, and Cultured Keratinocytes.

J Am Coll Surg. 2011 Oct 19;

Authors: Kiwanuka E, Hackl F, Philip J, Caterson EJ, E Junker JP, Eriksson E

Abstract

BACKGROUND: Transplantation of skin micrografts (MGs), split-thickness skin grafts (STSGs), or cultured autologous keratinocytes (CKs) enhances the healing of large full-thickness wounds. This study compares these methods in a porcine wound model, investigating the utility of micrograft transplantation in skin restoration. STUDY DESIGN: Full-thickness wounds were created on Yorkshire pigs and assigned to one of the following treatment groups: MGs, STSGs, CKs, wet nontransplanted, or dry nontransplanted. Dry wounds were covered with gauze and the other groups’ wounds were enclosed in a polyurethane chamber containing saline. Biopsies were collected 6, 12, and 18 days after wounding. Quantitative and qualitative wound healing parameters including macroscopic scar appearance, wound contraction, neoepidermal maturation, rete ridge formation, granulation tissue thickness and width, and scar tissue formation were studied. RESULTS: Transplanted wounds scored lower on the Vancouver Scar Scale compared with nontransplanted wounds, indicating a better healing outcome. All transplanted wounds exhibited significantly lower contraction compared with nontransplanted wounds. Wounds transplanted with either MGs, STSGs, or CKs showed a significant increase in re-epithelialization compared with nontransplanted wounds. Wounds transplanted with MGs or STSGs exhibited improved epidermal healing compared with nongrafted wounds. Furthermore, transplantation with STSGs or MGs led to less scar tissue formation compared with the nontransplanted wounds. No significant impact on scar formation was observed after transplantation of CKs. CONCLUSIONS: Qualitative and quantitative measurements collected from full-thickness porcine wounds show that transplantation of MGs improve wound healing parameters and is comparable to treatment with STSGs.

PMID: 22018809 [PubMed - as supplied by publisher]

Novel Procedure of Circular Stapler-Guided Nasogastric Tube Insertion during Esophageal Reconstruction.

J Am Coll Surg. 2011 Oct 19;

Authors: Tanaka N, Miyazaki T, Ozawa D, Suzuki S, Yokobori T, Inose T, Sohda M, Asao T, Kato H, Kuwano H

PMID: 22018810 [PubMed - as supplied by publisher]

Reply.

J Am Coll Surg. 2011 Oct 19;

Authors: Wong JH, Lum SS, Morgan JW

PMID: 22018811 [PubMed - as supplied by publisher]

Evaluation of biologic meshes in a porcine model of ventral incisional hernia repair.

J Am Coll Surg. 2011 Nov;213(5):691

Authors: Delaney JP, Gaertner WB

PMID: 22036581 [PubMed - in process]

Reply.

J Am Coll Surg. 2011 Nov;213(5):692

Authors: Deeken CR, Melman L, Jenkins ED, Greco SC, Frisella MM, Matthews BD

PMID: 22036582 [PubMed - in process]

Antivenom use for copperhead envenomations.

J Am Coll Surg. 2011 Nov;213(5):692-3

Authors: Bebarta VS, Morrissey R, Mirkin D

PMID: 22036583 [PubMed - in process]

Reply.

J Am Coll Surg. 2011 Nov;213(5):693-4

Authors: Walker JP, Morrison RL

PMID: 22036584 [PubMed - in process]

JACS CME Credit Featured Articles, Volume 213, November 2011.

J Am Coll Surg. 2011 Nov;213(5):695-7

Authors:

PMID: 22036585 [PubMed - in process]

Is the New Seventh AJCC/UICC Staging System Appropriate for Patients with Gastric Cancer?

J Am Coll Surg. 2011 Oct 29;

Authors: Yoon HM, Ryu KW, Nam BH, Cho SJ, Park SR, Lee JY, Lee JH, Kook MC, Choi IJ, Kim YW

Abstract

BACKGROUND: The purpose of this study was to compare the clinical usefulness of the seventh Union Internationale Contre le Cancer/American Joint Committee on Cancer (AJCC/UICC) staging system vs the sixth AJCC/UICC staging system in patients with gastric cancer. STUDY DESIGN: Included were 1,799 patients who underwent surgery for gastric cancer between January 2001 and June 2005 at the National Cancer Center (South Korea). For the sixth and seventh AJCC/UICC staging systems, survival outcomes stratified by stage, by T classification, and by N classification were summarized using Kaplan-Meier curves and compared statistically using a log rank test; survival differences were quantified using hazard ratios estimated from a Cox regression model. The 2 systems were compared in terms of prognostic performances using the linear trend chi-square test, likelihood ratio chi-square test, and Akaike information criterion (AIC) in the Cox regression analysis. RESULTS: Significant survival differences between each stage were not found using the seventh staging system, especially for stages IB, IIA, and IIB (p = 0.14 and p = 0.11). The sixth staging system had higher linear trend chi-square score and likelihood ratio chi-square score, which means better discriminatory ability, monotonicity, and homogeneity, and had smaller AIC, which indicates better optimistic prognostic stratification, especially in the N classification. The modified staging system combining the T classification of the seventh AJCC/UICC system and the N classification of the sixth system showed better prognostic performance compared with each separate version (sixth or seventh) of the staging system. CONCLUSIONS: The seventh AJCC/UICC staging system is not more clinically useful than the sixth system in surgically treated patients with gastric cancer because of an inappropriate N classification. A new TNM system is required with a different N classification.

PMID: 22036661 [PubMed - as supplied by publisher]

Laparoscopic Distal Gastrectomy with an Intracorporeal Gastroduodenostomy Using a Circular Stapler.

J Am Coll Surg. 2011 Oct 29;

Authors: Kim HI, Woo Y, Hyoung WJ

PMID: 22036662 [PubMed - as supplied by publisher]

Perioperative Safety and Volume: Outcomes Relationships in Bariatric Surgery: A Study of 32,000 Patients.

J Am Coll Surg. 2011 Oct 12;

Authors: Gould JC, Kent KC, Wan Y, Rajamanickam V, Leverson G, Campos GM

Abstract

BACKGROUND: Accreditation of Centers of Excellence in bariatric surgery requires a hospital volume of more than 125 procedures/year. There is no evidence-based rationale for this specific threshold. Our objective was to evaluate the contemporary perioperative safety of bariatric surgery and to characterize the relationship between volume and outcomes. STUDY DESIGN: We queried the Nationwide Inpatient Sample 2005-2007 for open and laparoscopic bariatric procedures, complications, and death. RESULTS: Thirty-two thousand five hundred and nine bariatric procedures were identified (21% open bypass [Open], 58% laparoscopic bypass [Lap], 21% laparoscopic gastric band [Band]). Inpatient overall mortality was low (total 0.12%, Open 0.3%, Lap 0.09%, Band 0.02%; p < 0.05 for all comparisons). Inpatient complications were more prevalent (total 3.9%, Open 5.9%, Lap 4%, Band 1.6%, p < 0.01 for all comparisons). For all 3 procedures, using a combined end point of mortality and major complications, a volume-outcomes relationship was evident for hospitals. This relationship appeared linear with no clear point that maximally differentiated high- and low-volume centers. CONCLUSIONS: Using a nationwide dataset and bariatric procedure-specific data, we have demonstrated that bariatric surgery mortality and complication rates are very low. A definite volume-outcomes relationship exists when hospital-level data are analyzed, but there is no inflection point to justify selecting a specific volume threshold to determine Centers of Excellence. Low-volume centers with extremely low complication rates can be identified and, conversely, there are high-volume centers with elevated rates of complication.

PMID: 21996483 [PubMed - as supplied by publisher]

A Stepwise Approach and Early Clinical Experience in Peroral Endoscopic Myotomy for the Treatment of Achalasia and Esophageal Motility Disorders.

J Am Coll Surg. 2011 Oct 12;

Authors: Swanström LL, Rieder E, Dunst CM

Abstract

BACKGROUND: Peroral endoscopic myotomy (POEM) has recently been described in humans as a treatment for achalasia. This concept has evolved from developments in natural orifice translumenal endoscopic surgery (NOTES) and has the potential to become an important therapeutic option. We describe our approach as well as our initial clinical experience as part of an ongoing study treating achalasia patients with POEM. STUDY DESIGN: Five patients (mean age 64 ± 11 years) with esophageal motility disorders were enrolled in an IRB-approved study and underwent POEM. This completely endoscopic procedure involved a midesophageal mucosal incision, a submucosal tunnel onto the gastric cardia, and selective division of the circular and sling fibers at the lower esophageal sphincter. The mucosal entry was closed by conventional hemostatic clips. All patients had postoperative esophagograms before discharge and initial clinical follow-up 2 weeks postoperatively. RESULTS: All (5 of 5) patients successfully underwent POEM treatment, and the myotomy had a median length of 7 cm (range 6 to 12 cm). After the procedure, smooth passage of the endoscope through the gastroesophageal junction was observed in all patients. Operative time ranged from 120 to 240 minutes. No leaks were detected in the swallow studies and mean length of stay was 1.2 ± 0.4 days. No clinical complications were observed, and at the initial follow-up, all patients reported dysphagia relief without reflux symptoms. CONCLUSIONS: Our initial experience with the POEM procedure demonstrates its operative safety, and early clinical results have shown good results. Although further evaluation and long-term data are mandatory, POEM could become the treatment of choice for symptomatic achalasia.

PMID: 21996484 [PubMed - as supplied by publisher]

Novel Technique of Total Pancreatectomy Before Autologous Islet Transplants in Chronic Pancreatitis Patients.

J Am Coll Surg. 2011 Oct 12;

Authors: Desai CS, Stephenson DA, Khan KM, Jie T, Gruessner AC, Rilo HL, Gruessner RW

PMID: 21996486 [PubMed - as supplied by publisher]

Laparoscopic Transdiaphragmatic Pericardial Window: Getting to the Heart of the Matter.

J Am Coll Surg. 2011 Oct 12;

Authors: Smith CA, Galante JM, Pierce JL, Scherer LA

Abstract

BACKGROUND: Penetrating wounds to the upper abdomen and lower precordium mandate exclusion of intra-abdominal and cardiac injuries. The most sensitive test to exclude cardiac injury is direct visualization of the pericardial fluid. Since 2001, we have examined the abdomen and performed transdiaphragmatic (central tendon) pericardial window via laparoscopy in stable patients at risk for both cardiac and peritoneal injuries. STUDY DESIGN: At our Level I trauma center we reviewed consecutive patients who underwent evaluation of pericardial fluid after trauma between 2001 and 2008 and identified those patients in whom laparoscopic pericardial window was performed. We collected data on demographics, technique, findings, complications, and follow-up. RESULTS: There were 393 patients who underwent diagnostic laparoscopy. Of those, 38 patients received laparoscopic transdiaphragmatic pericardial window. Six cardiac injuries (15.8%) were identified with 5 penetrating injuries to the right ventricle and 1 myocardial contusion. All 5 right ventricular injuries required median sternotomy for injury repair. None of the patients had significant hemodynamic compromise during operation. The pericardial window was left open in all patients, with no morbidity. The average length of stay for patients without chest tubes and a negative window was less than 24 hours. For patients with chest tubes, length of stay was 4.6 days. The interquartile range for follow-up was 21.5 to 315 days. CONCLUSIONS: Diagnostic laparoscopy with transdiaphragmatic pericardial window allows for thorough evaluation of both abdominal and cardiac injuries with a resultant short length of stay and no morbidity or mortality. In this, the largest series in the literature, laparoscopic pericardial window was a safe and effective modality to evaluate hemodynamically stable patients who are at risk for both cardiac and abdominal injuries.

PMID: 21996485 [PubMed - as supplied by publisher]

Age, Comorbidity, and Breast Cancer Severity: Impact on Receipt of Definitive Local Therapy and Rate of Recurrence among Older Women with Early-Stage Breast Cancer.

J Am Coll Surg. 2011 Oct 17;

Authors: Field TS, Bosco JL, Prout MN, Gold HT, Cutrona S, Pawloski PA, Yood MU, Quinn VP, Thwin SS, Silliman RA

Abstract

BACKGROUND: The definitive local therapy options for early-stage breast cancer are mastectomy and breast-conserving surgery followed by radiation therapy. Older women and those with comorbidities frequently receive breast-conserving surgery alone. The interaction of age and comorbidity with breast cancer severity and their impact on receipt of definitive therapy have not been well-studied. STUDY DESIGN: In a cohort of 1,837 women aged 65 years and older receiving treatment for early-stage breast cancer in 6 integrated health care delivery systems in 1990-1994 and followed for 10 years, we examined predictors of receiving nondefinitive local therapy and assessed the impact on breast cancer recurrence within levels of severity, defined as level of risk for recurrence. RESULTS: Age and comorbidity were associated with receipt of nondefinitive therapy. Compared with those at low risk, women at the highest risk were less likely to receive nondefinitive therapy (odds ratio = 0.32; 95% CI, 0.22-0.47), and women at moderate risk were about half as likely (odds ratio = 0.54; 95% CI, 0.35-0.84). Nondefinitive local therapy was associated with higher rates of recurrence among women at moderate (hazard ratio = 5.1; 95% CI, 1.9-13.5) and low risk (hazard ratio = 3.2; 95% CI, 1.1-8.9). The association among women at high risk was weak (hazard ratio = 1.3; 95% CI, 0.75-2.1). CONCLUSIONS: Among these older women with early-stage breast cancer, decisions about therapy partially balanced breast cancer severity against age and comorbidity. However, even among women at low risk, omitting definitive local therapy was associated with increased recurrence.

PMID: 22014658 [PubMed - as supplied by publisher]

Nonlocalizing Imaging Studies for Hyperparathyroidism: Where to Explore First?

J Am Coll Surg. 2011 Oct 17;

Authors: Amin AL, Wang TS, Wade TJ, Quiroz FA, Hellman RS, Evans DB, Yen TW

Abstract

BACKGROUND: For patients with primary hyperparathyroidism (pHPT), imaging studies are obtained to facilitate minimally invasive parathyroidectomy. If imaging studies are nonlocalizing, it is not known if exploration should begin on a particular side or gland location. STUDY DESIGN: A retrospective review of a prospective parathyroid database was performed. The cohort consists of pHPT patients who underwent initial parathyroidectomy between December 1999 and July 2010 and had all preoperative imaging studies reported as nonlocalizing (negative or indeterminate). RESULTS: Of 880 patients, 151 (17%) had nonlocalizing imaging studies. Reasons for starting exploration on a particular side were identified in 78 (52%) patients and included concomitant thyroid pathology (53%), suspicion on surgeon re-review of imaging (38%), or earlier thyroidectomy (9%). Exploration began on the right in 52%, the left in 42%, and was unknown in 6%. The surgeon had suspicion on imaging in 30 patients and correctly started on the side of pathology in 19 (63%). Hyperfunctioning glands were in eutopic locations in 144 patients (95%) and 3 had intrathyroidal glands. In 111 patients (74%) with single gland disease, median adenoma weight was 320 mg (range 80 to 8,210 mg). There was no difference in adenoma laterality (p = 0.7) or location (p = 0.8). Intraoperative parathyroid hormone criteria were met in 145 (96%) patients and 149 are eucalcemic at last follow-up; 2 (0.7%) patients have persistent disease. CONCLUSIONS: In pHPT patients with nonlocalizing imaging, hyperfunctioning glands are not more frequently located on a particular side or anatomic position. Eutopic location is common and intraoperative parathyroid hormone monitoring should be used to guide the extent of surgery.

PMID: 22014659 [PubMed - as supplied by publisher]

Future of Surgery: Accountable Care Organizations and the End of Private Practice?

J Am Coll Surg. 2011 Oct 5;

Authors: Chu DZ

PMID: 21978429 [PubMed - as supplied by publisher]

Future of Surgery: Accountable Care Organizations and the End of Private Practice?

J Am Coll Surg. 2011 Oct 5;

Authors: Chu DZ

PMID: 21978429 [PubMed - as supplied by publisher]

Immunogenicity and Safety of Re-Exposure to Recombinant Human Thrombin in Surgical Hemostasis.

J Am Coll Surg. 2011 Sep 27;

Authors: Singla NK, Gasparis AP, Ballard JL, Baron JM, Butine MD, Pribble JP, Alexander WA,

Abstract

BACKGROUND: This Phase 4, open-label study evaluated the immunogenicity and safety of a second exposure to recombinant human thrombin (rThrombin) in adult patients with previous exposure to rThrombin. STUDY DESIGN: Topical rThrombin was applied as a hemostatic aid during a surgical procedure (day 1). Adverse events and clinical laboratory abnormalities were monitored to day 29 (study end). Immunogenicity samples were collected on days 1 and 29. Thirty-one patients were treated at 9 study sites; 30 patients completed the study. RESULTS: Mean age was 59.5 years; 61.3% of patients were male. Study operations types included spinal (n = 23 of 31; 74.2%), arterial reconstruction or peripheral arterial bypass (n = 4; 12.9%), arteriovenous vascular access procedure (n = 3; 9.7%), and other (n = 1; 3.2%). A median of 10 mL rThrombin (1,000 IU/mL; range 5 to 60 mL) was prepared per patient. Median elapsed time since previous rThrombin exposure was 1.3 years (range 19 days to 3.3 years). Recombinant human thrombin was not observed to be immunogenic; no patients (n = 0 of 30, 0%; 95% CI 0.0%, 11.6%) became positive for anti-rThrombin product antibodies at day 29, approximately 1 month after the second exposure to rThrombin. The most commonly reported adverse events were procedural pain (n = 23 of 31, 74.2%), constipation (n = 8, 25.8%), and nausea (n = 8, 25.8%) All adverse events and clinical laboratory abnormalities were considered unrelated to treatment. For the majority of patients, maximal severity of any adverse event was mild or moderate. CONCLUSIONS: The immunogenicity and safety results of this Phase 4 rThrombin trial suggest that patients with known previous exposure may be safely re-exposed to topical rThrombin.

PMID: 21958507 [PubMed - as supplied by publisher]

Laparoscopic Left Hepatectomy with Extraparenchymal Inflow Control.

J Am Coll Surg. 2011 Sep 27;

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

PMID: 21958508 [PubMed - as supplied by publisher]

Commonwealth of Massachusetts Board of Registration in Medicine Expert Panel on Immediate Implant-Based Breast Reconstruction Following Mastectomy for Cancer: Executive Summary, June 2011.

J Am Coll Surg. 2011 Sep 27;

Authors: Lee BT, Duggan MM, Keenan MT, Kamatkar S, Quinlan RM, Hergrueter CA, Hertl MC, Shin JH, Truppin NB, Chun YS,

PMID: 21958509 [PubMed - as supplied by publisher]

Racial, Ethnic, and Insurance Status Disparities in Use of Posthospitalization Care after Trauma.

J Am Coll Surg. 2011 Sep 27;

Authors: Englum BR, Villegas C, Bolorunduro O, Haut ER, Cornwell EE, Efron DT, Haider AH

Abstract

BACKGROUND: Posthospitalization care is important for recovery after trauma. Disadvantaged populations, like racial or ethnic minorities and the uninsured, make up substantial percentages of trauma patients, but their use of posthospitalization facilities is unknown. STUDY DESIGN: This study analyzed National Trauma Data Bank admissions from 2007 for 18- to 64-year-olds and estimated relative risk ratios (RRR) of discharge to posthospitalization facilities-home, home health, rehabilitation, or nursing facility-by race, ethnicity, and insurance. Multinomial logistic regression adjusted for patient characteristics including age, sex, Injury Severity Score, mechanism of injury, and length of stay, among others. RESULTS: There were 136,239 patients who met inclusion criteria with data for analysis. Most patients were discharged home (78.9%); fewer went to home health (3.3%), rehabilitation (5.0%), and nursing facilities (5.4%). When compared with white patients in adjusted analysis, relative risk ratios of discharge to rehabilitation were 0.61 (95% CI 0.56, 0.66) and 0.44 (95% CI 0.40, 0.49) for blacks and Hispanics, respectively. Compared with privately insured white patients, Hispanics had lower rates of discharge to rehabilitation whether privately insured (RRR 0.45, 95% CI 0.40, 0.52), publicly insured (RRR 0.51, 95% CI 0.42, 0.61), or uninsured (RRR 0.20, 95% CI 0.17, 0.24). Black patients had similarly low rates: private (RRR 0.63, 95% CI 0.56, 0.71), public (RRR 0.72, 95% CI 0.63, 0.82), or uninsured (RRR 0.27, 95% CI 0.23, 0.32). Relative risk ratios of discharge to home health or nursing facilities showed similar trends among blacks and Hispanics regardless of insurance, except for black patients with insurance whose discharge to nursing facilities was similar to their white counterparts. CONCLUSIONS: Disadvantaged populations have more limited use of posthospitalization care such as rehabilitation after trauma, suggesting a potential improvement in trauma care for the underprivileged.

PMID: 21958511 [PubMed - as supplied by publisher]

Urinary Tract Infection after Colon and Rectal Resections: More Common than Predicted by Risk-Adjustment Models.

J Am Coll Surg. 2011 Sep 22;

Authors: Regenbogen SE, Read TE, Roberts PL, Marcello PW, Schoetz DJ, Ricciardi R

Abstract

BACKGROUND: Urinary tract infections (UTIs) are the most common hospital-acquired infections in the United States. We hypothesized that the risk of UTI after colorectal surgery exceeds the risk after other gastrointestinal operations. STUDY DESIGN: We used National Surgical Quality Improvement Program (NSQIP) data from 2005 to 2008 to compute rates of UTI after colorectal resections and other gastrointestinal and general surgery. We used a validated multivariate UTI prediction model to compare risk-adjusted rates of UTI by type of procedure. Then we identified predictors of UTI after colorectal resection using stepwise logistic regression models. RESULTS: Crude UTI rates were significantly greater after colorectal resection (4.1%) than after other gastrointestinal (1.8%) or nongastrointestinal procedures (1.2%; all p < 0.001). Even using standard risk-adjustment from the NSQIP, rates of UTI were significantly higher after segmental colectomy (2.8%; 95% CI 2.5% to 3.2%), total colectomy (3.5%; 95% CI 2.9% to 4.3%), proctectomy (3.5%, 95% CI 3.1% to 4.2%), proctocolectomy (4.6%, 95% CI 3.8% to 5.7%), and abdominoperineal resection (5.6%, 95% CI 4.6% to 6.8%) than after noncolorectal gastrointestinal surgery (2.6%, 95% CI 2.2% to 2.9%). Factors associated with UTI after colorectal resections include age, sex, functional status, American Society of Anesthesiologists class, and resection type. CONCLUSIONS: Colorectal resections incur substantial risk of postoperative UTI, exceeding rates predicted by the NSQIP model. Because of their patients’ unanticipated high incidence of UTI, surgeons with a specialty interest in colorectal surgery risk being flagged as “high outliers,” particularly if they perform many rectal resections. A simple set of risk factors discriminates 10-fold differences in the rate of UTI after colorectal resection.

PMID: 21945417 [PubMed - as supplied by publisher]

A Novel Data-Driven Prognostic Model for Staging of Colorectal Cancer.

J Am Coll Surg. 2011 Sep 16;

Authors: Manilich EA, Kiran RP, Radivoyevitch T, Lavery I, Fazio VW, Remzi FH

Abstract

BACKGROUND: The aim of this study was to develop a novel prognostic model that captures complex interplay among clinical and histologic factors to predict survival of patients with colorectal cancer after a radical potentially curative resection. STUDY DESIGN: Survival data of 2,505 colon cancer and 2,430 rectal cancer patients undergoing radical colorectal resection between 1969 and 2007 were analyzed by random forest technology. The effect of TNM and non-TNM factors such as histologic grade, lymph node ratio (number positive/number resected), type of operation, neoadjuvant and adjuvant treatment, American Society of Anesthesiologists (ASA) class, and age in staging and prognosis were evaluated. A forest of 1,000 random survival trees was grown using log-rank splitting. Competing risk-adjusted random survival forest methods were used to maximize survival prediction and produce importance measures of the predictor variables. RESULTS: Competing risk-adjusted 5-year survival after resection of colon and rectal cancer was dominated by pT stage (ie, tumor infiltration depth) and lymph node ratio. Increased lymph node ratio was associated with worse survival within the same pT stage for both colon and rectal cancer patients. Whereas survival for colon cancer was affected by ASA grade, the type of resection and neoadjuvant therapy had a strong effect on rectal cancer survival. A similar pattern in predicted survival rates was observed for patients with fewer than 12 lymph nodes examined. Our model suggests that lymph node ratio remains a significant predictor of survival in this group. CONCLUSIONS: A novel data-driven methodology predicts the survival times of patients with colorectal cancer and identifies patterns of cancer characteristics. The methods lead to stage groupings that could redefine the composition of TNM in a simple and orderly way. The higher predictive power of lymph node ratio as compared with traditional pN lymph node stage has specific implications and may address the important question of accuracy of staging in patients when fewer than 12 nodes are identified in the resection specimen.

PMID: 21925905 [PubMed - as supplied by publisher]

Mast Cells Play a Critical Role in the Systemic Inflammatory Response and End-Organ Injury Resulting from Trauma.

J Am Coll Surg. 2011 Sep 13;

Authors: Cai C, Cao Z, Loughran PA, Kim S, Darwiche S, Korff S, Billiar TR

Abstract

BACKGROUND: Much of the morbidity after trauma results from excessive activation of the innate immune system. This is manifested as a systemic inflammatory response and associated end-organ damage. Although mast cells are known to be important in many immune responses, their role in the systemic response to severe trauma is unknown. STUDY DESIGN: C57BL/6J-KitW-sh/BsmJ (mast cell deficient) and wild type mice were subjected to 1.5 hours of hemorrhagic shock plus bilateral femur fracture and soft tissue injury (HS/T), followed by resuscitation at 4.5 hours. Blood withdrawal volumes, mean arterial pressures, circulating cytokine, chemokine, high mobility group box-1 (HMGB-1), double strain DNA (dsDNA), transaminase levels, and histology in liver and lung were compared between groups. RESULTS: Mast cell deficient mice exhibited greater hemodynamic stability than wild type mice. At baseline, the mast cell deficient mice exhibited no difference in any of the organ injury or inflammatory markers measured. As expected, wild type mice subjected to HS/T exhibited end-organ damage manifested by marked increases in circulating alanine transaminase, aspartate aminotransferase, and dsDNA levels, as well as histologic evidence of tissue necrosis. In clear contrast, mast cell deficient mice exhibited almost no tissue damage. Similarly, the magnitude of increased circulating cytokine and chemokine induced by HS/T was much less in the mast cell deficient mice than in the wild type group. CONCLUSIONS: Mast cell deficiency resulted in a damped systemic inflammatory response, greatly attenuated multiple organ injury, and more stable hemodynamics in HS/T. So mast cells appear to be a critical component of the initial host response to severe injury.

PMID: 21920785 [PubMed - as supplied by publisher]

Feeding Tube Insertion Through the Round Ligament of Liver: A Safe Approach to Placing a Feeding Tube for Retrosternal Gastric Tube Reconstruction after Esophagectomy.

J Am Coll Surg. 2011 Sep 8;

Authors: Watanabe M, Etoh K, Nagai Y, Baba Y, Iwatsuki M, Ishimoto T, Sakamoto Y, Miyamoto Y, Yoshida N, Baba H

PMID: 21906963 [PubMed - as supplied by publisher]

Safety-Net Burden Hospitals and Likelihood of Curative-Intent Surgery for Non-Small Cell Lung Cancer.

J Am Coll Surg. 2011 Aug 29;

Authors: Virgo KS, Little AG, Fedewa SA, Chen AY, Flanders WD, Ward EM

Abstract

BACKGROUND: Black patients are less likely to undergo surgery for early-stage non-small cell lung cancer (NSCLC) compared with white patients, and are more likely to undergo resection at low-volume hospitals. However, little is known about the relationship between hospital safety-net burden and the likelihood of curative-intent surgery for black and white patients. This study analyzes whether hospital safety-net burden is associated with curative-intent surgery among adult early-stage NSCLC patients treated at facilities accredited by the American College of Surgeons Commission on Cancer. STUDY DESIGN: Adult patients diagnosed with invasive initial primary early-stage (TNM I-II) NSCLC during 2003-2005 were obtained from the National Cancer Data Base. Curative-intent surgery included anatomic resection, wedge resection, and segmentectomy. Hospital safety-net burden was defined as the percent of cancer patients per facility that were Medicaid-insured or uninsured. Generalized estimating equations and linear mixed models were used to control for clustering by facility. RESULTS: Of 52,853 evaluable patients, those treated at high safety-net burden facilities were significantly less likely (unadjusted p < 0.0001) to undergo curative-intent surgery than patients treated at low safety-net burden facilities. Controlling for patient and other facility characteristics, high safety-net burden remained significantly associated (p < 0.0001) with reduced likelihood of curative-intent surgery overall (odds ratio = 0.69; 95% CI, 0.62-0.77) and in black- and white-only models (odds ratio = 0.59, 95% CI, 0.48-0.73; odds ratio = 0.71; 95% CI, 0.63-0.80, respectively). CONCLUSIONS: Both black and white adult patients treated for early-stage NSCLC at high safety-net burden facilities are less likely to undergo curative-intent surgery than those treated at low safety-net burden facilities. Innovative solutions are needed to ensure quality cancer care at high safety-net burden facilities.

PMID: 21907598 [PubMed - as supplied by publisher]

Personal Consequences of Malpractice Lawsuits on American Surgeons.

J Am Coll Surg. 2011 Sep 2;

Authors: Balch CM, Oreskovich MR, Dyrbye LN, Colaiano JM, Satele DV, Sloan JA, Shanafelt TD

Abstract

BACKGROUND: Our objective was to identify the prevalence of recent malpractice litigation against American surgeons and evaluate associations with personal well-being. Although malpractice lawsuits are often filed against American surgeons, the personal consequences with respect to burnout, depression, and career satisfaction are poorly understood. STUDY DESIGN: Members of the American College of Surgeons were sent an anonymous, cross-sectional survey in October 2010. Surgeons were asked if they had been involved in a malpractice suit during 2 previous years. The survey also evaluated demographic variables, practice characteristics, career satisfaction, burnout, and quality of life. RESULTS: Of the approximately 25,073 surgeons sampled, 7,164 (29%) returned surveys. Involvement in a recent malpractice suit was reported by 1,764 of 7,164 (24.6%) responding surgeons. Surgeons involved in a recent malpractice suit were younger, worked longer hours, had more night call, and were more likely to be in private practice (all p <0.0001). Recent malpractice suits were strongly related to burnout (p < 0.0001), depression (p < 0.0001), and recent thoughts of suicide (p < 0.0001) among surgeons. In multivariable modeling, both depression (odds ratio = 1.273; p = 0.0003) and burnout (odds ratio = 1.168; p = 0.0306) were independently associated with a recent malpractice suit after controlling for all other personal and professional characteristics. Hours worked, nights on call, subspecialty, and practice setting were also independently associated with recent malpractice suits. Surgeons who had experienced a recent malpractice suit reported less career satisfaction and were less likely to recommend a surgical or medical career to their children (p < 0.0001). CONCLUSIONS: Malpractice lawsuits are common and have potentially profound personal consequences for US surgeons. Additional research is needed to identify individual, organizational, and societal interventions to support surgeons subjected to malpractice litigation.

PMID: 21890381 [PubMed - as supplied by publisher]

Proposed Competencies in Geriatric Patient Care for Use in Assessment for Initial and Continued Board Certification of Surgical Specialists.

J Am Coll Surg. 2011 Sep 2;

Authors: Bell RH, Drach GW, Rosenthal RA

PMID: 21890382 [PubMed - as supplied by publisher]

Proposed Competencies in Geriatric Patient Care for Use in Assessment for Initial and Continued Board Certification of Surgical Specialists.

J Am Coll Surg. 2011 Sep 2;

Authors: Bell RH, Drach GW, Rosenthal RA

PMID: 21890382 [PubMed - as supplied by publisher]

Proposed Competencies in Geriatric Patient Care for Use in Assessment for Initial and Continued Board Certification of Surgical Specialists.

J Am Coll Surg. 2011 Sep 2;

Authors: Bell RH, Drach GW, Rosenthal RA

PMID: 21890382 [PubMed - as supplied by publisher]

The Impact of Incidental Identification on the Stage at Presentation of Lower Gastrointestinal Carcinoids.

J Am Coll Surg. 2011 Aug 29;

Authors: Buitrago D, Trencheva K, Zarnegar R, Finnerty B, Aldailami H, Lee SW, Sonoda T, Milsom JW, Fahey TJ

Abstract

BACKGROUND: Over the past 3 decades, there has been a significant increase in the incidence of gastrointestinal carcinoid tumors in the United States. Incidentally discovered carcinoids in the lower gastrointestinal tract have probably contributed to this increase. In this study we aimed to compare the clinicopathologic characteristics of incidentally discovered carcinoids of the small and large bowel with those identified as a result of symptoms. STUDY DESIGN: We performed a retrospective review of 58 consecutive patients with nonappendiceal gastrointestinal carcinoids: 30 small bowel and 28 large bowel. We compared asymptomatic patients with lower gastrointestinal tract carcinoids identified by routine colonoscopy with those identified as a result of symptoms. RESULTS: Twenty-eight (48.3%) incidentally identified carcinoids (15 small bowel and 13 large bowel) were compared with 30 (51.7%) symptomatic carcinoids. Incidental ileal carcinoids were similar in size (mean ± SD, 1.3 ± 0.61 vs 1.7 ± 1.13, p = 0.45) and incidence of lymph node metastases (12 in 15 vs 9 in 15, p = 0.43) to symptomatic ileal carcinoids. However, incidental ileal carcinoids had a lower incidence of distant metastases (1 in 15 vs 7 in 15, p = 0.035) compared with symptomatic ileal carcinoids. There was no difference in tumor size, extent of lymph node metastases, or distant metastases between incidental and symptomatic large bowel carcinoids. CONCLUSIONS: Ileal carcinoids identified at screening colonoscopy are associated with a significantly decreased incidence of distant metastases compared with those identified after development of symptoms, despite similar size and extent of lymph node metastases. However, incidental large bowel carcinoids appear to have similar staging to those identified as a result of symptoms.

PMID: 21880512 [PubMed - as supplied by publisher]

Postoperative Morbidity Index: A Quantitative Measure of Severity of Postoperative Complications.

J Am Coll Surg. 2011 Aug 24;

Authors: Strasberg SM, Hall BL

Abstract

BACKGROUND: Postoperative complications are key outcomes of surgical procedures, but currently there is no uniform quantitative measure of complication severity. The purpose of this study was to evaluate and establish feasibility of quantitative morbidity scores for several common abdominal surgical procedures. STUDY DESIGN: Using American College of Surgeons’ National Surgical Quality Improvement Program data, complications were identified in 5 common abdominal procedures for one institution in 2005-2008, including inguinal hernia, appendectomy, laparoscopic colectomy, hepatectomy, and pancreaticoduodenectomy. Complications were graded by the 6-level “expanded” Accordion Severity Grading System. Quantification was performed using severity scores described previously. RESULTS: Six hundred and seventy-six procedures were identified, including 88 patients (13.84%) who had complications and 5 patients (0.79%) who died. After severity weighting, the postoperative morbidity index (PMI) for each procedure was derived. An index of 0 would indicate no complication in any patient and an index of 1.000 would indicate that all operated patients died. PMIs were hernia repair 0.005; appendectomy 0.031; laparoscopic colectomy 0.082; hepatectomy 0.145; and pancreaticoduodenectomy 0.150. PMI of hepatectomy was greatly affected by the presence of a second procedure, ie, 0.070 without a second procedure and 0.427 with a second procedure. Weighted severity spectragrams were developed, portraying the impact of each grade of complication on overall morbidity. CONCLUSIONS: Quantification of severity of postoperative complications is possible using American College of Surgeons’ National Surgical Quality Improvement Program methods and the Accordion Severity Grading System. Procedural PMI can be useful in assessing surgical outcomes. Certain limitations, particularly the need for risk adjustment, still need to be addressed.

PMID: 21871822 [PubMed - as supplied by publisher]

Perioperative Pharmacologic Prophylaxis for Venous Thromboembolism in Colorectal Surgery.

J Am Coll Surg. 2011 Aug 24;

Authors: Kwon S, Meissner M, Symons R, Steele S, Thirlby R, Billingham R, Flum DR,

Abstract

BACKGROUND: To determine the effectiveness of pharmacologic prophylaxis in preventing clinically relevant venous thromboembolic (VTE) events and deaths after surgery. The Surgical Care Improvement Project recommends that VTE pharmacologic prophylaxis be given within 24 hours of the operation. The bulk of evidence supporting this recommendation uses radiographic end points. STUDY DESIGN: The Surgical Care and Outcomes Assessment Program is a Washington State quality improvement initiative with data linked to hospital admission/discharge and vital status records. We compared the rates of death, clinically relevant VTE, and a composite adverse event (CAE) in the 90 days after elective, colon/rectal resections, based on receipt of pharmacologic prophylaxis (within 24 hours of surgery) at 36 Surgical Care and Outcomes Assessment Program hospitals (2005-2009). RESULTS: Of 4,195 (mean age 61.1 ± 15.6 years; 54.1% women) patients, 56.5% received pharmacologic prophylaxis. Ninety-day death (2.5% vs 1.6%; p = 0.03), VTE (1.8% vs 1.1%; p = 0.04), and CAE (4.2% vs 2.5%; p = .002) were lower in those who received pharmacologic prophylaxis. After adjustment for patient and procedure characteristics, the odds were 36% lower for CAE (odds ratio = 0.64; 95% CI, 0.44-0.93) with pharmacologic prophylaxis. In any given quarter, hospitals where patients more often received pharmacologic prophylaxis (highest tertile of use) had the lowest rates of CAE (2.3% vs 3.6%; p = 0.05) compared with hospitals in the lowest tertile. CONCLUSIONS: Using clinical end points, this study demonstrates the effectiveness of VTE pharmacologic prophylaxis in patients having elective colorectal surgery. Hospitals that used pharmacologic prophylaxis more often had the lowest rates of adverse events.

PMID: 21871823 [PubMed - as supplied by publisher]

Staging Laparoscopy in the Management of Gastric Cancer: A Population-Based Analysis.

J Am Coll Surg. 2011 Aug 25;

Authors: Karanicolas PJ, Elkin EB, Jacks LM, Atoria CL, Strong VE, Brennan MF, Coit DG

Abstract

BACKGROUND: Staging laparoscopy can detect radiographically occult peritoneal metastases and prevent futile laparotomy in patients with gastric adenocarcinoma. We sought to assess the use of staging laparoscopy for gastric adenocarcinoma in a cohort of older patients and to compare outcomes after laparoscopy alone with nontherapeutic laparotomy. STUDY DESIGN: Using Surveillance, Epidemiology and End Results (SEER) population-based cancer registry data linked with Medicare claims, we identified patients aged 65 or older diagnosed with gastric adenocarcinoma between 1998 and 2005. We defined staging laparoscopy as a laparoscopic procedure from 1 month before the date of diagnosis until death and futile laparotomy as a laparotomy in the absence of a therapeutic intervention. We examined trends in the use of staging laparoscopy and compared outcomes between patients who underwent staging laparoscopy alone and those who had a futile laparotomy. RESULTS: Of 11,759 patients with gastric adenocarcinoma, 6,388 (54.3%) had at least 1 surgical procedure. Staging laparoscopy was performed in 506 (7.9%) patients who had any surgery, and 151 (29.8%) of these patients did not have a subsequent therapeutic intervention. Patients who underwent staging laparoscopy alone had a significantly lower rate of in-hospital mortality (5.3% vs 13.1%, p < 0.001) and shorter length of hospitalization (2 vs 10 days, p < 0.001) than patients who had futile laparotomy. CONCLUSIONS: Our findings in this large, population-based cohort suggest that staging laparoscopy is used infrequently in the management of older patients with gastric adenocarcinoma. Increased use of staging laparoscopy could reduce the substantial morbidity and mortality associated with nontherapeutic laparotomy.

PMID: 21872497 [PubMed - as supplied by publisher]

Overuse of CT in Patients with Complicated Gallstone Disease.

J Am Coll Surg. 2011 Aug 20;

Authors: Benarroch-Gampel J, Boyd CA, Sheffield KM, Townsend CM, Riall TS

Abstract

BACKGROUND: When compared with ultrasound, CT scans are more expensive, have substantial radiation exposure and lower sensitivity, specificity, positive, and negative predictive values for patients with gallstone disease. STUDY DESIGN: We reviewed data on patients emergently admitted with complicated gallstone disease between January 2005 and May 2010. Use of CT and ultrasound imaging on admission was described. Multivariate logistic regression was used to evaluate factors predicting receipt of CT. RESULTS: Five hundred and sixty-two consecutive patients presented emergently with complicated gallstone disease. Mean age was 45 years. Seventy-two percent of patients were female, 46% were white, and 41% were Hispanic. Seventy-two percent of patients had an ultrasound during the initial evaluation and 41% had a CT. Both studies were performed in 25% of patients (n = 141), 16% (n = 93) had CT only, and 47% (n = 259) had ultrasound only. CT was performed first in 67% of those who underwent both studies. Evening imaging (7 pm-7 am, odds ratio [OR] = 4.44; 95% CI, 2.88-6.85), increased age (OR = 1.14 per 5-year increase; 95% CI, 1.07-1.21), leukocytosis (OR = 1.67; 95% CI, 1.10-2.53), and hyperamylasemia (OR = 2.02; 95% CI, 1.16-3.51) predicted use of CT. CONCLUSIONS: Our study demonstrates the overuse of CT in evaluation of complicated gallstone disease. Evening imaging was the biggest predictor of CT use, suggesting that CT is performed not to clarify the diagnosis, but rather a surrogate for the indicated study. Surgeons and emergency physicians should be trained to perform right upper quadrant ultrasound to avoid unnecessary studies in the appropriate clinical setting.

PMID: 21862355 [PubMed - as supplied by publisher]

Postoperative Quality of Life: Development and Validation of the “Dysfunction after Upper Gastrointestinal Surgery” Scoring System.

J Am Coll Surg. 2011 Aug 20;

Authors: Nakamura M, Hosoya Y, Umeshita K, Yano M, Doki Y, Miyashiro I, Dannoue H, Mori M, Kishi K, Lefor AT

Abstract

BACKGROUND: Although postoperative quality of life is an important outcomes measure, few tools exist to evaluate patients specifically after upper gastrointestinal surgery. The previously developed Dysfunction After Upper Gastrointestinal Surgery (DAUGS)32 scoring system has been further refined to include just 20 items. This study was undertaken to validate the refined evaluation tool. STUDY DESIGN: The study was performed as a survey, administered to patients after upper gastrointestinal resection at 3 separate institutions. RESULTS: The DAUGS20 score after gastrectomy (n = 662) was 27.8 and that after esophagectomy (n = 221) was 36.1, showing a significant difference (p < 0.05). The score after distal gastrectomy (n = 282) was 25.4 and that after total gastrectomy (n = 149) was 32.0, showing a significant (p < 0.05) difference. The α coefficient of all items on the DAUGS20 system was 0.904 and Cronbach’s α coefficients of the subscales were 0.612 to 0.856, demonstrating high reliability of this evaluation tool. In addition, 7 factors were extracted from the 20 items using definitive factor analysis, to verify validity. CONCLUSIONS: Patient quality of life should be evaluated as an outcomes measure after surgical resection for cancer, just as overall survival is analyzed. The DAUGS20 score is reliable, has validity in the evaluation of postoperative patients, and is a valuable tool to assess patient quality of life after upper gastrointestinal surgery for cancer.

PMID: 21862356 [PubMed - as supplied by publisher]

Pushing the Envelope Beyond a Centimeter in Rectal Cancer: Oncologic Implications of Close, But Negative Margins.

J Am Coll Surg. 2011 Aug 18;

Authors: Fitzgerald TL, Brinkley J, Zervos EE

Abstract

BACKGROUND: The treatment of rectal cancer has improved significantly over the last century. Advances in surgical and adjuvant therapy coupled with a better understanding of the natural history have allowed for acceptance of progressively diminished margins for distal neoplasms. In order to better define oncologically safe distal margins, we performed a meta-analysis of the existing world’s literature. STUDY DESIGN: Studies were identified on Medline and ISI Web of Science using key words rectal cancer and margin. Studies were excluded if specific margins and local recurrence rates could not be extracted. All analyses were performed using Comprehensive Meta-Analysis Software (Biostat). RESULTS: Twenty-one studies reported outcomes in relationship to distal margins. Seventeen studies, 4,885 patients, reported outcomes with margins of less than 1 cm. Analysis of all studies indicated a nonsignificant trend favoring greater margins. However, in order to understand distal margins in the context of current care standards, additional analyses were performed. Thirteen studies reported application of total mesorectal excision and/or radiation. There was no significant difference in local recurrence rates for margins less than1 cm. In the 4 studies that reported neither total mesorectal excision nor radiation, a margin greater than1 cm was favored. Increased recurrence rates and decreased survival were associated with positive final margins. CONCLUSIONS: When total mesorectal excision is combined with radiotherapy, excellent local control can be expected with sphincter preservation for distal rectal cancers when margins are less than 1 cm, as long as final pathologic margins are negative.

PMID: 21856181 [PubMed - as supplied by publisher]

Hepatic Arterial Infusion of Doxorubicin-Loaded Microsphere for Treatment of Hepatocellular Cancer: A Multi-Institutional Registry.

J Am Coll Surg. 2011 Aug 17;

Authors: Martin RC, Rustein L, Enguix DP, Palmero J, Carvalheiro V, Urbano J, Valdata A, Kralj I, Bosnjakovic P, Tatum C

Abstract

BACKGROUND: Hepatic intra-arterial therapy for unresectable hepatocellular cancer (HCC) has been shown to improve overall survival, but can have significant toxicity. A recent prospective randomized controlled trial demonstrated superior response rates and significantly less morbidity and doxorubicin-related adverse events with drug-eluting beads with doxorubicin (DEBDOX) compared with conventional chemoembolization. The aim of this study was to confirm the efficacy of DEBDOX for the treatment of unresectable HCC. STUDY DESIGN: This open-label, multicenter, multinational single-arm study included 118 intermediate-staged HCC patients who were not candidates for transplantation or resection. Patients received DEBDOX at each treatment. Complications and response rates to treatment were analyzed. RESULTS: There were 118 patients who received a total of 186 DEBDOX treatments with a median total treatment dose of 75 mg (range 38 to 150 mg), and median overall total hepatic exposure of 150 mg (range 150 to 600 mg). Five lesions were targeted, with a median size of 5.3 cm (range 1.0 to 16.9 cm). Severe adverse events related to liver dysfunction were seen after 4% of treatments. Overall survival was a median of 14.2 months (range 5 to 30 months), with progression-free survival of 13 months and hepatic-specific progression-free survival of 16 months. Okuda class less than 1 at time of treatment, reduction of alpha-fetoprotein of 1,000 ng/mL at the first post-treatment evaluation, delivery of more than 200 mg doxorubicin, and less than 25% liver involvement were all predictors of favorable overall survival assessed by multivariable analyses. CONCLUSIONS: Hepatic intra-arterial injection of DEBDOX is safe and effective in the treatment of HCC, as demonstrated by a minimal complication rate and robust and durable tumor response.

PMID: 21856182 [PubMed - as supplied by publisher]

Appendectomy During Pregnancy: Follow-Up of Progeny.

J Am Coll Surg. 2011 Aug 18;

Authors: Choi JJ, Mustafa R, Lynn ET, Divino CM

Abstract

BACKGROUND: The incidence of appendicitis in pregnant patients is 0.04% to 0.20%, making it the most common nonobstetric surgical procedure in pregnancy. This study examines whether an appendectomy during any stage of pregnancy affects future development of motor, sensory, and social skills of the progeny. STUDY DESIGN: A prospective survey was administered to women who underwent an appendectomy during pregnancy at Mount Sinai Hospital from 2000 to 2009. The survey, which ranged from 1 to 9 years postpartum, consisted of questions about motor, sensory, and social development of their progeny, based on established pediatric milestones. Data were collected from the medical records of mother and child. Additional follow-up was gathered from outpatient and emergency room records. RESULTS: Fifty-two pregnant patients underwent an appendectomy during our study period. All pregnancies continued to full term with the exception of one fetal death due to extreme prematurity. Twenty-nine patients completed the follow-up survey, making the yield response rate 55.8%. There were 7 (26.9%), 14 (48.3%), and 8 (27.6%) appendectomies in the first, second, and third trimesters, respectively. Mean follow-up time was 47.2 months (range 13 to 117 months) after delivery. None of the children exhibited any developmental delay by their third year of life. Timing of the surgery (trimester) had no effect on child development. CONCLUSIONS: Appendectomy during pregnancy is not associated with developmental delays in children, regardless of which trimester the procedure was performed. All children in this study had normal motor, sensory, and social development by 3 years of age.

PMID: 21856183 [PubMed - as supplied by publisher]

Phyllodes Tumors: Race-Related Differences.

J Am Coll Surg. 2011 Aug 17;

Authors: Pimiento JM, V Gadgil P, Santillan AA, Lee MC, Esposito NN, Kiluk JV, Khakpour N, Hartley TL, Yeh IT, Laronga C

Abstract

BACKGROUND: Phyllodes tumors (PT) are rare breast malignancies accounting for 0.5% to 1% of all breast tumors. PT have unpredictable behavior, with recurrence rates as high as 40%. A dearth of information exists about racial differences; elucidation of these differences is the objective of this study. STUDY DESIGN: A retrospective review of patients treated for PT at either Moffitt Cancer Center or University of Texas Health Science Center San Antonio from 1999 to 2010. RESULTS: Of the 124 patients, 71 (57%) were treated at Moffitt Cancer Center and 53 (42%) at University of Texas Health Science Center San Antonio. Mean age at diagnosis was 44 years (15 to 70 years). Thirty-three patients required mastectomy. Combining both cohorts, 42% of the patients were Caucasian, 43% were Hispanic, and 12% were black. Tumors were benign in 49% patients, borderline in 35%, and malignant in 16%, with a higher percentage of borderline and malignant tumors in Hispanic patients (p < 0.01). Hispanic patients tended to have larger tumors and higher mitotic rates (p = 0.01; p = 0.03). At a median follow-up time of 13 months, the local recurrence rate (6.4%) was associated with tumor size, tumor grade, mitotic rate, and close margin status (<2 mm) (p <0.01; p = 0.01; p = 0.01; p = 0.04). However, these findings did not translate into a survival difference by race. CONCLUSIONS: In this multi-institutional review of PT we found substantial pathologic differences by race with higher-grade tumors present more often in Hispanic patients. These differences did not substantially affect outcomes at short-term follow-up. Further investigation into additional molecular, biologic factors, geographic impact, and socioeconomic factors is needed to more clearly delineate this finding.

PMID: 21856184 [PubMed - as supplied by publisher]

Patterns of Surgical Care and Health Disparities of Treating Pediatric Finger Amputation Injuries in the United States.

J Am Coll Surg. 2011 Aug 17;

Authors: Squitieri L, Reichert H, Kim HM, Steggerda J, Chung KC

Abstract

BACKGROUND: Digital amputation in children is a very strong indication for replantation, but little is known about the epidemiology and distribution of care for pediatric finger amputation injuries in the United States. The specific aims of this study were to examine trends in the surgical management of pediatric finger amputation injuries in the United States from 2000 to 2006, and to identify potential treatment disparities among various demographic groups. STUDY DESIGN: Data from the 2000, 2003, and 2006 Healthcare Cost and Utilization Project Kids’ Inpatient Database were used to identify discharge records containing at least one ICD-9-CM procedure code corresponding to digit amputation or replantation. National estimates were generated using weighted frequency calculations, and a weighted logistic regression model was used to examine the influence of various demographic factors on treatment. RESULTS: There were 1,321 weighted discharge records that satisfied our inclusion criteria. From 2000 to 2006, the rate of attempted digit replantation for pediatric finger amputation injuries has remained stable at approximately 40%. The majority of injuries were treated at nonchildren’s (86%) and teaching (76%) hospitals; 52% of digit replantations were performed at hospitals with a volume of 1 to 2 digit replantations per year. We found that blacks (odds ratio [OR] 0.47), Hispanics (OR 0.37), and children without insurance (OR 0.38) were less likely to receive attempted replantation (all p < 0.05), even after controlling for potential confounding factors. CONCLUSIONS: The proportion of pediatric digit amputation injuries managed by replantation remained stable between 2000 and 2006. Whites and children with private health insurance were more likely to receive replantation than blacks, Hispanics, and children without health insurance, even after controlling for confounding factors.

PMID: 21856185 [PubMed - as supplied by publisher]

Thrombospondin-2 Gene Silencing in Human Aortic Smooth Muscle Cells Improves Cell Attachment.

J Am Coll Surg. 2011 Aug 11;

Authors: Yoshida S, Nabzdyk CS, Pradhan L, Logerfo FW

BACKGROUND: Despite decades of research, anastomotic intimal hyperplasia remains a major cause of delayed prosthetic arterial graft failure. Previously, we reported profound upregulation of thrombospondin-2 (TSP-2) mRNA in neointimal smooth muscle cells after prosthetic arterial bypass graft placement. TSP-2 is an antiangiogenic matricellular protein with specific functions yet unknown. In this study, we hypothesized that inhibition of TSP-2 in human aortic smooth muscle cells (HAoSMCs) would reduce cell proliferation and migration in vitro, providing a therapeutic target to mitigate intimal hyperplasia. STUDY DESIGN: HAoSMCs were transfected with TSP-2 small interfering ribonucleic acid (siRNA) using a commercial transfection reagent. Gene silencing was evaluated using semiquantitative real-time polymerase chain reaction. ELISA was used to measure TSP-2 protein levels in cell culture supernatants. Cell migration and proliferation were assessed using scratch wound assays and alamar blue assays, respectively. Attachment assays were performed to assess the effect of TSP-2 silencing on HAoSMC adhesion to fibronectin. RESULTS: TSP-2 siRNA achieved consistent target gene silencing at 48 hours post-transfection in HAoSMCs. This single transfection allowed suppression of TSP-2 protein expression for more than 30 days. TSP-2 gene silencing did not affect HAoSMC migration or proliferation. MMP-2 levels were also unaffected by changes in TSP-2 protein levels. However, HAoSMC attachment to fibronectin improved significantly in cells treated with TSP-2 siRNA. CONCLUSIONS: siRNA-mediated TSP-2 silencing of human aortic HAoSMCs improved cell attachment but had no effect on cell migration or proliferation. The effect on cell attachment was unrelated to changes in MMP activity.

PMID: 21840228 [PubMed - as supplied by publisher]

Readmission after Major Pancreatic Resection: A Necessary Evil?

J Am Coll Surg. 2011 Aug 12;

Authors: Kent TS, Sachs TE, Callery MP, Vollmer Jr CM

BACKGROUND: Hospital readmission is under increased scrutiny as a quality metric for surgical performance, yet its relevance after elective, high-acuity operations is poorly understood. We sought to define the clinical nature and economic impact of readmission after major pancreatic resection. STUDY DESIGN: From 2001 to 2009, 578 pancreatic resections followed standardized perioperative care. Clinical and economic outcomes were evaluated and predictors of readmission were identified by regression analysis. RESULTS: One hundred and eleven (19%) patients required readmission within 30 days (median 8 days post discharge), with only 12 more readmitted between 31 and 90 days. Twenty-three (21%) patients were readmitted multiple times. Reasons for readmission were procedure-specific complications (48%), general postoperative complications/infections (18.0%), failure to thrive (12%), or medical problems (9%). An additional 14% were readmitted solely for diagnostic evaluation of symptoms without cause. Neither preoperative demographics/acuity nor intraoperative factors influenced readmission. Instead, readmission was predicted by any (odds ratio = 2.24) or major (odds ratio = 2.19) complications, and clinically relevant (odds ratio = 5.05) or latent (odds ratio = 4.04) pancreatic fistula. Patient survival was negatively, but not significantly, associated with readmissions. Overall hospital stay and costs were markedly affected by readmission, as readmitted patients cost an average of $16,000 more. CONCLUSIONS: In this practice-based analysis, readmissions after pancreatic resection were frequent, early, costly, and largely related to procedure-specific complications. As initial hospital stay continues to decline in high-acuity surgery, readmissions might be required for optimal management of complications, which often manifest later in the recovery course. Clinical pathway deviations predict potential readmissions, and might prompt adjustments in management and disposition of patients at risk for returning to the hospital.

PMID: 21840738 [PubMed - as supplied by publisher]

Preventative Measures for Lymphedema: Separating Fact from Fiction.

J Am Coll Surg. 2011 Jul 27;

Authors: Cemal Y, Pusic A, Mehrara BJ

PMID: 21802319 [PubMed - as supplied by publisher]

Invited commentary.

J Am Coll Surg. 2011 Aug;213(2):218-9

Authors: Berger DH

PMID: 21787988 [PubMed - in process]

Discussion.

J Am Coll Surg. 2011 Aug;213(2):317-8

Authors:

PMID: 21787989 [PubMed - in process]

Mounting evidence supports universal surveillance for MRSA in preoperative patients.

J Am Coll Surg. 2011 Aug;213(2):335-6

Authors: Kavanagh K, Abusalem S

PMID: 21787990 [PubMed - in process]

Another perspective on motorcycle helmet use.

J Am Coll Surg. 2011 Aug;213(2):336-7

Authors: Langland-Orban B, Flint L

PMID: 21787991 [PubMed - in process]

Reply.

J Am Coll Surg. 2011 Aug;213(2):337-8

Authors: Crompton JG, Haider AH

PMID: 21787992 [PubMed - in process]

The Shah’s Spleen.

J Am Coll Surg. 2011 Aug;213(2):338

Authors: Khonsari S

PMID: 21787993 [PubMed - in process]

The Shah’s Spleen.

J Am Coll Surg. 2011 Aug;213(2):338-9

Authors: Thorbjarnarson B

PMID: 21787994 [PubMed - in process]

Reply.

J Am Coll Surg. 2011 Aug;213(2):340-1

Authors: Morgenstern L

PMID: 21787995 [PubMed - in process]

The Shah’s Spleen.

J Am Coll Surg. 2011 Aug;213(2):340

Authors: Cervantes J, Baley I

PMID: 21787996 [PubMed - in process]

JACS CME Credit Featured Articles, Volume 213, August 2011.

J Am Coll Surg. 2011 Aug;213(2):342-4

Authors:

PMID: 21787997 [PubMed - in process]