Primary Payer Status Affects Mortality for Major Surgical Operations.

Ann Surg. 2010 Jul 19;

Authors: Lapar DJ, Bhamidipati CM, Mery CM, Stukenborg GJ, Jones DR, Schirmer BD, Kron IL, Ailawadi G

OBJECTIVES:: Medicaid and Uninsured populations are a significant focus of current healthcare reform. We hypothesized that outcomes following major surgical operations in the United States is dependent on primary payer status. METHODS:: From 2003 to 2007, 893,658 major surgical operations were evaluated using the Nationwide Inpatient Sample (NIS) database: lung resection, esophagectomy, colectomy, pancreatectomy, gastrectomy, abdominal aortic aneurysm repair, hip replacement, and coronary artery bypass. Patients were stratified by primary payer status: Medicare (n = 491,829), Medicaid (n = 40,259), Private Insurance (n = 337,535), and Uninsured (n = 24,035). Multivariate regression models were applied to assess outcomes. RESULTS:: Unadjusted mortality for Medicare (4.4%; odds ratio [OR], 3.51), Medicaid (3.7%; OR, 2.86), and Uninsured (3.2%; OR, 2.51) patient groups were higher compared to Private Insurance groups (1.3%, P < 0.001). Mortality was lowest for Private Insurance patients independent of operation. After controlling for age, gender, income, geographic region, operation, and 30 comorbid conditions, Medicaid payer status was associated with the longest length of stay and highest total costs (P < 0.001). Medicaid (P < 0.001) and Uninsured (P < 0.001) payer status independently conferred the highest adjusted risks of mortality. CONCLUSIONS:: Medicaid and Uninsured payer status confers increased risk-adjusted mortality. Medicaid was further associated with the greatest adjusted length of stay and total costs despite risk factors or operation. These differences serve as an important proxy for larger socioeconomic and health system-related issues that could be targeted to improve surgical outcomes for US Patients.

PMID: 20647910 [PubMed - as supplied by publisher]

Reply:

Ann Surg. 2010 Jul 19;

Authors: Takeuchi H, Kitagawa Y

PMID: 20647911 [PubMed - as supplied by publisher]

Sentinel Lymph Node Biopsy in Esophageal Cancer: Has Its Time Come?

Ann Surg. 2010 Jul 19;

Authors: Zhang J, Chen H, Luketich JD

PMID: 20647912 [PubMed - as supplied by publisher]

Reply:

Ann Surg. 2010 Jul 19;

Authors: Rebollo Aguirre AC, Ramos-Font C

PMID: 20647913 [PubMed - as supplied by publisher]

Reply:

Ann Surg. 2010 Jul 19;

Authors: Kim YW, Kim NK

PMID: 20647914 [PubMed - as supplied by publisher]

F-18-Fluorodeoxiglucose Positron Emission Tomography for the Evaluation of Neoadjuvant Therapy Response in Esophageal Cancer.

Ann Surg. 2010 Jul 19;

Authors: Schmidt M, Bollschweiler E, Hölscher A

PMID: 20647915 [PubMed - as supplied by publisher]

Identifying the Minimum Number of Lymph Nodes Required to Ensure Adequate pN Staging: Kaplan-Meier Survival Analysis Versus Cox Regression Model.

Ann Surg. 2010 Jul 19;

Authors: Sun Z, Xu HM

PMID: 20647916 [PubMed - as supplied by publisher]

Reply:

Ann Surg. 2010 Jul 19;

Authors: Arriaga AF, Berry WR, Gawande AA

PMID: 20647917 [PubMed - as supplied by publisher]

Enhanced Recovery After Surgery (ERAS) Protocols Must Be Considered When Determining Optimal Perioperative Care in Colorectal Surgery.

Ann Surg. 2010 Jul 19;

Authors: Srinivasa S, Sammour T, Kahokehr A, Hill AG

PMID: 20647918 [PubMed - as supplied by publisher]

How to Achieve High-Quality Low-Cost Trauma Care.

Ann Surg. 2010 Jul 19;

Authors: Reed RL

PMID: 20647919 [PubMed - as supplied by publisher]

An Evaluation of Information Transfer Through the Continuum of Surgical Care: A Feasibility Study.

Ann Surg. 2010 Jul 19;

Authors: Nagpal K, Vats A, Ahmed K, Vincent C, Moorthy K

OBJECTIVE:: To evaluate information transfer and communication (ITC) across the surgical care pathway with the use of Information Transfer and Communication Assessment Tool for Surgery (ITCAS). BACKGROUND:: Communication failures are the leading cause of surgical errors and adverse events. It is vital to assess the ITC across the entire surgical continuum of care to understand the process, to study teams, and to prioritize the phases for intervention. METHODS:: Twenty patients undergoing major gastrointestinal procedures were followed through their entire surgical care, and ITC process was assessed using ITCAS. ITCAS consisted of 4 checklists for 4 phases of the surgical care. RESULTS:: ITC failures are distributed across the entire surgical continuum of care. Preprocedural teamwork and postoperative handover phases have the maximum number of ITC failures (61.7% and 52.4%, respectively). Moreover, it was found that information degrades as it crosses from one phase to another. Of patients, 75% had clinical incidents or adverse events because of ITC failures. CONCLUSIONS:: The study demonstrated that ITC failures are ubiquitous across surgical care pathway and there is an imminent need to modify current ITC practices. Standardization of ITC through use of checklists, protocols, or information technology is essential to reduce these communication failures.

PMID: 20647920 [PubMed - as supplied by publisher]

Effect of Body Mass Index on Groin Hernia Surgery.

Ann Surg. 2010 Jul 19;

Authors: Rosemar A, Angerås U, Rosengren A, Nordin P

OBJECTIVE:: To analyze the effect of underweight, overweight, and obesity in relation to clinical characteristics, the risk of postoperative complications, 30-day mortality, and reoperations for recurrence after groin hernia surgery. SUMMARY OF BACKGROUND DATA:: Groin hernia surgery is one of the most frequent operations performed in general surgery. Several studies have demonstrated a protective effect of overweight and obesity on the risk of developing primary groin hernia. However, obesity has also been suggested to increase the risk for recurrence of groin hernia. METHODS:: Through the Swedish Hernia Register, 49,094 primary groin hernia operations were identified between January 1, 2003 and December 31, 2007. Patients were divided into 4 body mass index (BMI) groups: BMI 1, <20 kg/m; BMI 2, 20 to 25 kg/m; BMI 3, 25-30 kg/m; and BMI 4, >30 kg/m. RESULTS:: Of the 49,094 patients, 3.5% had a BMI <20 kg/m and 5.2% were obese. Altogether, women constituted only 7.7% of the studied group, but among patients with BMI <20 kg/m that had surgical procedures for femoral hernia, 81.4% were women. The relation between BMI and postoperative complications was U-shaped and after adjustment for age, gender, and emergency procedure, patients with BMI <20 and >25 had a significant increased risk when compared with patients with BMI from 20 to 25. Reoperation for recurrence of groin hernia has an increased hazard ratio of 1.20 (95% confidence interval, 1.00-1.40) in overweight, which was particularly evident after open suture and preperitoneal mesh techniques. CONCLUSIONS:: In this large and unselected population of patients with a first surgical procedure for groin hernia a relative dominance of female and femoral hernias presented as an emergency condition was observed in the low BMI group. The prevalence of obesity was markedly low. Both lean and obese patients had an increased risk for postoperative complications.

PMID: 20647921 [PubMed - as supplied by publisher]

Are Injuries From Terror and War Similar?: A Comparison Study of Civilians and Soldiers.

Ann Surg. 2010 Jul 19;

Authors: Peleg K, Jaffe DH,

OBJECTIVE:: To compare injuries and hospital utilization and outcomes from terror and war for civilians and soldiers. SUMMARY BACKGROUND DATA:: Injuries from terror and war are not necessarily comparable, especially among civilians and soldiers. For example, civilians have less direct exposure to conflict and are unprepared for injury, whereas soldiers are psychologically and physically prepared for combat on battlefields that are often far from trauma centers. Evidence-based studies distinguishing and characterizing differences in injuries according to conflict type and population group are lacking. METHODS:: A retrospective study was performed using hospitalization data from the Israel National Trauma Registry (10/2000-12/2006). RESULTS:: Terror and war accounted for trauma hospitalizations among 1784 civilians and 802 soldiers. Most civilians (93%) were injured in terror and transferred to trauma centers by land, whereas soldiers were transferred by land and air. Critical injuries and injuries to multiple body regions were more likely in terror than war. Soldiers tended to present with less severe injuries from war than from terror. Rates of first admission to orthopedic surgery were greater for all casualties with the exception of civilians injured in terror who were equally likely to be admitted to the intensive care unit. In-hospital mortality was higher among terror (7%) than war (2%) casualties, and particularly among civilians. CONCLUSIONS:: This study provides evidence that substantial differences exist in injury characteristics and hospital resources required to treat civilians and soldiers injured in terror and war. Hospital preparedness and management should focus on treating combat injuries that result from specific causes-terror or war.

PMID: 20647922 [PubMed - as supplied by publisher]

Arguments for and Against a Career in Surgery: A Qualitative Analysis.

Ann Surg. 2010 Jul 19;

Authors: Businger A, Villiger P, Sommer C, Furrer M

OBJECTIVE:: To evaluate arguments given by board-certified surgeons in Switzerland for and against a career in surgery. BACKGROUND DATA:: Currently, the surgical profession in most Western countries is experiencing a labor shortage because of a declining interest in a surgical career among new graduates, a changed public opinion of medicine and its representatives, and as a consequence of the increasing influence of health economists and politicians on the professional independence of surgeons. Reports that focus primarily on the reasons that board-certified surgeons remain within the surgical profession are rare. METHODS:: Surgeons were asked to answer 2 questions concerning arguments for and against a career in surgery. Of 749 surgeons the arguments of 334 (44.6%) were analyzed using Mayring’s content analysis. The surgeons were also asked whether they would choose medicine as a career path again. RESULTS:: The 334 participating surgeons provided 790 statements for and 981 statements against a career in surgery. Fifty-nine surgeons (17.7%) would not choose medicine as a career again. Mayring’s content analysis of the statements yielded 10 categories with arguments both for and against a career in surgery. “Personal Experience in Daily Professional Life” (18.7%) was the top-ranked category in favor of a career in surgery, and “Specific Training Conditions” (20%) was the top-ranked category against the choice of such a career. Ordinal logistic regression showed that the category “Personal Experience in Daily Professional Life” (OR, 2.39; 95%CI, 1.13-5.07) was independently associated with again studying medicine, and the category “Work-life Balance” (OR, 0.37; 95%CI, 0.20-0.70) was associated with not studying medicine again. CONCLUSION:: This qualitative study revealed unfavorable working conditions and regulations as surgeons’ main complaints. It is concluded that new organizational frameworks and professional perspectives are required to retain qualified and motivated surgeons in the surgical profession.

PMID: 20647923 [PubMed - as supplied by publisher]

Liver-Assist Device With a Microfluidics-Based Vascular Bed in an Animal Model.

Ann Surg. 2010 Jul 19;

Authors: Hsu WM, Carraro A, Kulig KM, Miller ML, Kaazempur-Mofrad M, Weinberg E, Entabi F, Albadawi H, Watkins MT, Borenstein JT, Vacanti JP, Neville C

OBJECTIVE:: This study evaluates a novel liver-assist device platform with a microfluidics-modeled vascular network in a femoral arteriovenous shunt in rats. SUMMARY OF BACKGROUND DATA:: Liver-assist devices in clinical trials that use pumps to force separated plasma through packed beds of parenchymal cells exhibited significant necrosis with a negative impact on function. METHODS:: Microelectromechanical systems technology was used to design and fabricate a liver-assist device with a vascular network that supports a hepatic parenchymal compartment through a nanoporous membrane. Sixteen devices with rat primary hepatocytes and 12 with human HepG2/C3A cells were tested in athymic rats in a femoral arteriovenous shunt model. Several parenchymal tube configurations were evaluated for pressure profile and cell survival. The blood flow pattern and perfusion status of the devices was examined by laser Doppler scanning. Cell viability and serum protein secretion functions were assessed. RESULTS:: Femoral arteriovenous shunt was successfully established in all animals. Blood flow was homogeneous through the vascular bed and replicated native flow patterns. Survival of seeded liver cells was highly dependent on parenchymal chamber pressures. The tube configuration that generated the lowest pressure supported excellent cell survival and function. CONCLUSIONS:: This device is the first to incorporate a microfluidics network in the systemic circulatory system. The microvascular network supported viability and function of liver cells in a short-term ex vivo model. Parenchymal chamber pressure generated in an arteriovenous shunt model is a critical parameter that affects viability and must be considered in future designs. The microfluidics-based vascular network is a promising platform for generating a large-scale medical device capable of augmenting liver function in a clinical setting.

PMID: 20647924 [PubMed - as supplied by publisher]

Preoperative Hypoalbuminemia is an Independent Risk Factor for the Development of Surgical Site Infection Following Gastrointestinal Surgery: A Multi-Institutional Study.

Ann Surg. 2010 Jul 19;

Authors: Hennessey DB, Burke JP, Ni-Dhonochu T, Shields C, Winter DC, Mealy K

BACKGROUND:: Surgical site infection (SSI) is an infection occurring in an incisional wound within 30 days of surgery and significantly effects patient recovery and hospital resources. OBJECTIVE:: This study sought to determine the relationship between preoperative serum albumin and SSI. METHODS:: A study of 524 patients who underwent gastrointestinal surgery in 4 institutions was performed. Patients were identified using a prospective SSI database and hospital records. Serum albumin was determined preoperatively in all patients. Hypoalbuminemia was defined as albumin <30 mg/dL. Data are presented as median (interquartile range) and a difference between groups was examined using Mann-Whitney U and Fisher exact test and multiple logistic regression analysis. RESULTS:: A total of 105 patients developed a SSI (20%). The median time to the development of SSI was 7 (5-10) days. Having an emergency procedure (P = 0.003), having a procedure over 3 hours in duration (P = 0.047), being American Society of Anaesthetics grade 3 (P = 0.03) and not receiving preoperative antibiotics (P = 0.007) were associated with SSI while having a laparoscopic procedure reduced the likelihood of SSI (P = 0.004). Patients who developed a SSI had a lower preoperative serum albumin (30 [25-34.5] vs. 36 [32-39], P < 0.001). On multivariate analysis, hypoalbuminemia was an independent risk factor for SSI development (relative risk, RR = 5.68, 95% confidence interval: 3.45-9.35, P < 0.001). Albumin <30 mg/dL was associated with an increased rate of deep versus superficial SSI (P = 0.002). The duration of inpatient stay was negatively correlated with preoperative albumin (R = -0.319, P < 0.001). CONCLUSIONS:: Hypoalbuminemia is an independent risk factor for the development of SSI following gastrointestinal surgery and is associated with deeper SSI and prolonged inpatient stay.

PMID: 20647925 [PubMed - as supplied by publisher]

Thoracoscopic-Assisted Esophagectomy for Esophageal Cancer: Analysis of Patterns and Prognostic Factors for Recurrence.

Ann Surg. 2010 Jul 19;

Authors: Thomson IG, Smithers BM, Gotley DC, Martin I, Thomas JM, Oʼrourke P, Barbour AP

OBJECTIVE:: The authors report the recurrence pattern of esophageal cancer after thoracoscopic-assisted esophagectomy (TAE), comparing it to the recurrence pattern after open surgery and identify prognostic factors for recurrence. SUMMARY OF BACKGROUND DATA:: To improve long-term survival for esophageal cancer radical surgery has been proposed increasingly, however, recurrent disease remains a problem. Opinion is divided as to the adequacy of resection possible using minimally invasive techniques with concerns that there may be an increased incidence in locoregional recurrence. METHODS:: A total of 221 patients who underwent esophagectomy at the Princess Alexandra Hospital without any neoadjuvant or adjuvant therapy were identified from a prospective database. Patients were followed up for the detection of symptomatic recurrence for a median of 59 months. RESULTS:: Within this group 165 patients underwent TAE and 56 an open transthoracic esophagectomy (TTE). The 5-year overall recurrence rate was 133/221 (60%). The 5-year rates of symptomatic first recurrence following TAE was 4%, 9%, and 47% for local, regional, and distant recurrence, respectively. The 5-year rates of symptomatic first recurrence following TTE was 5%, 18%, and 55% for local, regional, and distant recurrence, respectively. Operative approach was not a prognostic factor for any type of recurrence. Independent prognostic factors associated with locoregional recurrence were positive margins and number of positive nodes. Distant recurrence was associated with T stage, differentiation, tumor length >6 cm, and number of positive nodes. CONCLUSION:: Distant recurrence remains a significant problem in esophageal cancer. TAE achieved adequate locoregional control and compared favorably with open TTE.

PMID: 20647926 [PubMed - as supplied by publisher]

The Association Between Cost and Quality in Trauma: Is Greater Spending Associated With Higher-Quality Care?

Ann Surg. 2010 Jul 19;

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

OBJECTIVE:: To examine the association between trauma center quality and costs. BACKGROUND:: Current efforts to reduce health care costs and improve health care quality require a better understanding of the relationship between cost and quality. METHODS:: Using data from the Healthcare Cost and Utilization Projects Nationwide Inpatient Sample, we performed a retrospective observational study of 67,124 trauma patients admitted to 73 trauma centers. Generalized linear models were used to explore the association between hospital cost and in-hospital mortality, controlling for hospital and patient factors as follows: injury diagnoses, age, gender, mechanism of injury, comorbidities, teaching status, hospital ownership, geographic region, and hospital wages. RESULTS:: Patients treated in hospitals with low risk-adjusted mortality rates had significantly lower costs than those treated in average-quality hospitals. The relative cost of patients treated in high-quality hospitals was 0.78 (95% confidence interval: 0.64, 0.95) compared with average-quality hospitals. The cost of treating patients in average- and high-mortality trauma centers was similar. CONCLUSION:: In this study based on the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, the care of injured patients is less expensive in hospitals with lower risk-adjusted mortality rates. Hospitals with low risk-adjusted mortality rates have adjusted mortality rates that are 34% lower while spending nearly 22% less compared with average-quality hospitals.

PMID: 20647927 [PubMed - as supplied by publisher]

Influence of Preoperative Chemoradiotherapy on the Number of Lymph Nodes Retrieved in Rectal Cancer.

Ann Surg. 2010 Jul 19;

Authors: Ha YH, Jeong SY, Lim SB, Choi HS, Hong YS, Chang HJ, Kim DY, Jung KH, Park JG

OBJECTIVE:: To evaluate the relation of preoperative chemoradiotherapy to the number of lymph nodes retrieved in curative intent surgery for rectal cancer. SUMMARY BACKGROUND DATA:: Current guidelines recommend evaluation of least 12 to 14 lymph nodes in rectal cancer. It is well known that lymph nodes retrieval is affected by many factors. METHODS:: This was a retrospective study of 615 patients who underwent curative intent surgery for primary rectal cancer. Preoperative chemoradiotherapy involving 50.4 Gy fractionated radiotherapy and concurrent chemotherapy was performed in patients with locally advanced rectal cancer (clinically T3 or T4). We explored associations between the number of lymph nodes retrieved in the pathologic specimen and patient demographics (age, gender, body mass index [BMI]), treatment (surgeon, sphincter-saving, preoperative chemoradiotherapy), and tumor-related variables (location, stage, histology). After adjustment for other factors, we compared the mean number of obtained lymph nodes between patients treated with preoperative chemoradiotherapy and those treated without preoperative chemoradiotherapy. RESULTS:: Univariate analysis demonstrated that age, BMI, preoperative chemoradiotherapy, location, and stage significantly related the number of lymph nodes retrieved. Multivariate analysis revealed age, BMI, preoperative chemoradiotherapy, and stage as independent factors influencing the number of lymph nodes retrieved. The mean number of lymph nodes adjusted for age, BMI, and stage was significantly lower in patients treated with preoperative chemoradiotherapy than in those treated without preoperative chemoradiotherapy (14.5 vs. 21.5, P < 0.001). The reduction rate by preoperative chemoradiotherapy was 32.6% (7/21.5). In patients who underwent preoperative chemoradiotherapy, advanced age (P < 0.001) and high BMI (P = 0.037) were associated with decreased number of retrieved lymph nodes. CONCLUSIONS:: Preoperative chemoradiotherapy significantly decreased the number of retrieved lymph nodes by approximately 33%. Therefore, the recommended number of retrieved lymph nodes should be adjusted when rectal cancer is treated with preoperative chemoradiotherapy.

PMID: 20647928 [PubMed - as supplied by publisher]

Information Transfer and Communication in Surgery: A Systematic Review.

Ann Surg. 2010 Jul 19;

Authors: Nagpal K, Vats A, Lamb B, Ashrafian H, Sevdalis N, Vincent C, Moorthy K

OBJECTIVES:: We conducted a systematic review of published literature to gain a better understanding of interprofessional information transfer and communication (ITC) in hospital setting in the field of surgical and anesthetic care. BACKGROUND:: Communication breakdowns are a common cause of surgical errors and adverse events. DATA SOURCES:: Medline, Embase, PsycINFO, Cochrane Database of Systematic Reviews, and hand search of articles bibliography. STUDY SELECTION:: Of the 4027 citations identified through the initial electronic search and screened for possible inclusion, 110 articles were retained following title and abstract reviews. Of these, 38 were accepted for this review. DATA EXTRACTION:: Data were extracted from the studies about objectives, clinical domain, methodology including study design, sample population, tools for assessing communication, results, and limitations. RESULTS:: Information transfer failures are common in surgical care and are distributed across the continuum of care. They not only lead to errors in care provision but also lead to patient harm. Most of the articles have focused on ITC process in different phases especially in operating room. None of the studies have looked at whole of the surgical care process. No standard tool has been developed to capture the ITC process in different teams and to evaluate the effect of various communication interventions. Uses of standardized communication through checklist, proformas, and technology innovations have improved the ITC process, with an effect on clinical and patient outcomes. CONCLUSIONS:: ITC deficits adversely affect patient care. There is a need for standard measures to evaluate this process. Effective and standardized communication among healthcare professionals during the perioperative process facilitates surgical safety.

PMID: 20647929 [PubMed - as supplied by publisher]

Related Articles

Prospective study of health-related quality of life after Roux-en-Y bypass surgery for morbid obesity.

Br J Surg. 2010 Jul 19;

Authors: Chang CY, Huang CK, Chang YY, Tai CM, Lin JT, Wang JD

BACKGROUND:: The aim of this study was to evaluate the effects of Roux-en-$\font\ss=cmss10 scaled 1000 \hbox{Y}$ gastric bypass for morbid obesity on health-related quality of life (QOL) during the first year of follow-up. METHODS:: The World Health Organization Quality of Life-Brief (WHOQOL-BREF) was administered 1 month before operation, and at 1, 3, 6 and 12 months after surgery. Body mass index, co-morbidities and operation-related complications were measured at these times. A mixed-effect model was constructed to analyse repeated measurements and determine the relationships between body mass index, WHOQOL-BREF scores and other variables. RESULTS:: A total of 102 patients were enrolled. The mixed-effect model showed that the physical, psychological and social domains improved after bariatric surgery, with simultaneous reduction in weight and improvement in co-morbidities. There was a dip in scores in physical and psychological domains 3-6 months after surgery, significantly related to complications. All patients gradually improved between 6 and 12 months after surgery, reaching levels similar to those of healthy subjects. CONCLUSION:: Health-related QOL improved dramatically after bariatric surgery, dipped slightly between 3 and 6 months, and improved again up to the end of the first year. Copyright (c) 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 20645295 [PubMed - as supplied by publisher]

Related Articles

Prevention of venous thromboembolism after elective surgery is better influenced by judgement than by protocols.

Br J Surg. 2010 Jul 19;

Authors: Polk HC, Qadan M

PMID: 20645394 [PubMed - as supplied by publisher]

Related Articles

Hepatic ischaemia-reperfusion injury from bench to bedside.

Br J Surg. 2010 Jul 19;

Authors: Bahde R, Spiegel HU

BACKGROUND:: Vascular occlusion to prevent haemorrhage during liver resection causes ischaemia-reperfusion (IR) injury. Insights into the mechanisms of IR injury gathered from experimental models have contributed to the development of therapeutic approaches, some of which have already been tested in randomized clinical trials. METHODS:: The review was based on a PubMed search using the terms ‘ischemia AND hepatectomy’, ‘ischemia AND liver’, ‘hepatectomy AND drug treatment’, ‘liver AND intermittent clamping’ and ‘liver AND ischemic preconditioning’; only randomized controlled trials (RCTs) were included. RESULTS:: Twelve RCTs reported on ischaemic preconditioning and intermittent clamping. Both strategies seem to confer protection and allow extension of ischaemia time. Fourteen RCTs evaluating pharmacological interventions, including antioxidants, anti-inflammatory drugs, vasodilators, pharmacological preconditioning and glucose infusion, were identified. CONCLUSION:: Several strategies to prevent hepatic IR have been developed, but few have been incorporated into clinical practice. Although some pharmacological strategies showed promising results with improved clinical outcome there is not sufficient evidence to recommend them. Copyright (c) 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 20645395 [PubMed - as supplied by publisher]

Related Articles

Systematic review of the benefits and risks of neoadjuvant chemoradiation for oesophageal cancer.

Br J Surg. 2010 Jul 19;

Authors: Courrech Staal EF, Aleman BM, Boot H, van Velthuysen ML, van Tinteren H, van Sandick JW

BACKGROUND:: Surgery alone for locally advanced oesophageal cancer is associated with low cure rates. The benefits and risks of neoadjuvant chemoradiation for patients with oesophageal cancer were evaluated. METHODS:: A systematic review of publications between 2000 and 2008 on neoadjuvant chemoradiation for oesophageal cancer was undertaken. RESULTS:: Thirty-eight papers comprising 3640 patients met the inclusion criteria. Chemoradiation regimens varied widely with a predominance of 5-fluorouracil/cisplatin chemotherapy. Chemoradiation-related toxicity was reported in only ten studies and consisted mainly of neutropenia. The chemoradiation-related mortality rate was 2.3 per cent. The mean R0 resection rate and pathological complete response (pCR) rate were 88.4 and 25.8 per cent respectively. Postoperative morbidity was not uniformly reported. The in-hospital mortality rate after oesophagectomy following chemoradiation was 5.2 per cent. Five-year survival rates varied from 16 to 59 per cent in all patients and from 34 to 62 per cent in those with a pCR. Chemoradiation had a temporary negative effect on quality of life. CONCLUSION:: Neoadjuvant chemoradiation regimens for oesophageal cancer vary widely. Besides traditional outcome variables (such as survival), other parameters should be analysed (for example toxicity) to assess whether the risks of chemoradiation are sufficiently compensated for by the benefits. Copyright (c) 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 20645400 [PubMed - as supplied by publisher]

Malignant esophageal dysphagia palliation using insertion of a covered Ultraflex stent without fluoroscopy: a prospective observational study.

Surg Endosc. 2010 Jul 20;

Authors: Lazaraki G, Katsinelos P, Nakos A, Chatzimavroudis G, Pilpilidis I, Paikos D, Tzilves D, Katsos I

BACKGROUND: This study aimed to investigate the efficacy and safety of placing self-expandable metal stents (SEMSs) without fluoroscopy for palliation of malignant esophageal or esophagogastric strictures. METHODS: From January 2003 to June 2008, a prospective observational study investigated the placement of covered proximal-release Ultraflex stents without fluoroscopy in nonoperable malignant esophageal and esophagogastric strictures. The technical success as well as the early and late complications (perforation, migration, severe gastroesophageal reflux, hematemesis, and reobstruction due to tissue ingrowth or overgrowth) were recorded. Dysphagia before and after stent placement was scored on a 5-point scale. All the patients were observed monthly in the outpatient clinic or by telephone contact until death. RESULTS: The study enrolled 89 patients (16 women; mean age, 69.54 +/- 7.1 years) with dysphagia due to inoperable esophageal or esophagogastric malignant strictures (29 squamous cell cancers, 52 adenocarcinomas, and 8 obstructive malignant extrinsic compressions). The mean stricture length was 6.2 +/- 2.8 cm. Endoscopic deployment was achieved for 83 patients (93.2%), with accurate stent positioning in all the patients except one. An adequate relief of symptoms was noted for 82 of the patients (92.1%). During the follow-up period, 36 patients (43.4%) had recurrent dysphagia, caused by tumor overgrowth in 32 cases and stent migration in 4 cases, after an average time of 82 days (range 67-216 days). A stent-in-stent procedure was performed in 27 cases. For two patients, a third stent-in-stent needed to be placed after 85 and 216 days, respectively. CONCLUSION: In most cases, SEMSs can be accurately and safely positioned without fluoroscopy for palliative treatment of malignant esophageal dysphagia.

PMID: 20644961 [PubMed - as supplied by publisher]

The fear of transgastric cholecystectomy: misinterpretation of the biliary anatomy.

Surg Endosc. 2010 Jul 20;

Authors: Perretta S, Dallemagne B, Donatelli G, Mutter D, Marescaux J

INTRODUCTION: Prevention of injury during cholecystectomy relies on accurate dissection of the cystic duct and artery and avoidance of major biliary and vascular structures. The advent of natural orifice translumenal surgery (NOTES) has led to a new look into the biliary anatomy, especially Calot’s triangle. Here we show the clinical case of a NOTES transgastric cholecystectomy for uncomplicated cholelithiasis, in which misinterpretation of the biliary anatomy occurred. METHODS AND PROCEDURE: A 5-mm port was introduced at the umbilicus to ascertain the feasibility of transgastric cholecystectomy and to ensure safe gastrotomy creation and closure. Transgastric access was obtained using a percutaneous endoscopic gastrostomy (PEG)-like technique on the anterior mid body of the stomach to pass a 12-mm gastroscope (Karl Storz, Tuttlingen, Germany). The laparoscope was switched to a grasper for gallbladder retraction. Dissection was started close to the gallbladder using the endoscope at the junction between the infundibulum and what was thought to be the cystic duct. During dissection, the size and the orientation of the cystic duct appeared to be unclear. The decision was made to switch to a laparoscopic view to reorient the dissection plane and clarify the anatomy. At laparoscopy, dissection of the triangle of Calot, although started close to the gallbladder, appeared far too low. The common bile duct had been mistaken for the cystic duct. Once the biliary anatomy was clarified, the vision was switched back to the endoscope, but an additional 2-mm grasper was introduced to improve exposure while cholecystectomy was performed in a standard fashion. CONCLUSIONS: Specific anatomic distortions due to NOTES technique together with the lack of exposure provided by current methods of retraction tend to distort Calot’s triangle by flattening it rather than opening it out. At this stage, whenever the anatomy of the biliary tract is unclear, a temporary “conversion” to a laparoscopic view, more familiar to the surgeon’s eye, is recommended.

PMID: 20644962 [PubMed - as supplied by publisher]

Elective laparoscopic cholecystectomy in the presence of common bile duct stent.

Surg Endosc. 2010 Jul 20;

Authors: Nair MS, Uzzaman MM, Fafemi O, Athow A

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure done in patients with common bile duct (CBD) stones. Some clinicians insert a CBD stent at the time of ERCP. Such patients may then present for laparoscopic cholecystectomy (LC) with CBD stents in situ. The aim of this study was to examine the impact of the presence of a CBD stent on the outcome of elective LC. METHODS: This was a case-controlled study conducted from January 2005 to June 2008. The patients were divided into three comparable groups: group 1, those having LC preceded by ERCP; group 2, those having LC preceded by ERCP and stent insertion; and group 3, those having LC alone. RESULTS: Four hundred one LC procedures were performed, five of which were excluded (two had had previous upper abdominal surgery, two had isolated pancreatic stents, and one had the stent removed the day before surgery). Of the 396 patients studied, there were 31 patients in group 1, 35 patients in group 2, and 330 patients in group 3. The incidence of conversion, postoperative bile leak, operating time, and length of stay was significantly higher in Group 2 (p < 0.05). The incidence of conversion increased with the duration of in-situ stent placement (Spearman correlation coefficient = 0.34, p < 0.05). There was one case of abandoned cholecystectomy, two cases of CBD erosion, one case of CBD injury, and two cases of in-hospital mortality, all involving patients in group 2 only. CONCLUSIONS: We conclude that LC in the presence of CBD stents poses significant risk to patients, particularly if they are left in-situ for long periods of time. Caution should be exercised in stenting a CBD with an intact gallbladder, particularly in those awaiting cholecystectomy.

PMID: 20644963 [PubMed - as supplied by publisher]

Related Articles

Management of an Incidental Liver Mass.

Surg Clin North Am. 2010 Aug;90(4):699-718

Authors: Boutros C, Katz SC, Espat NJ

The increased use of sensitive imaging modalities has led to increased identification of the incidental liver mass (ILM). A combination of careful consideration of patient factors and imaging characteristics of the ILM enables clinicians to recommend a safe and efficient course of action. Using an algorithmic approach, this article includes pertinent clinical factors and the specific radiologic criteria of ILMs and discusses the indications for potential procedures. It is the aim of this article to assist with the development of an individualized strategy for each patient with an ILM.

PMID: 20637942 [PubMed - as supplied by publisher]

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Management of Benign Hepatic Tumors.

Surg Clin North Am. 2010 Aug;90(4):719-735

Authors: Buell JF, Tranchart H, Cannon R, Dagher I

Advances in imaging techniques will dramatically decrease the number of undiagnosed tumors. New molecular techniques should allow the identification of pathologic factors that are predictive of complicated forms. Surgery should be limited to symptomatic benign tumors or those who have a risk for complication (hemorrhage, rupture, or degeneration). When surgery is indicated, patients with benign disease are the best candidates for laparoscopy.

PMID: 20637943 [PubMed - as supplied by publisher]

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Current Management of Hepatic Trauma.

Surg Clin North Am. 2010 Aug;90(4):775-785

Authors: Piper GL, Peitzman AB

With the shift toward nonoperative management, most hepatic injuries are managed nonoperatively. On the other hand, up to two-thirds of high-grade hepatic injuries require laparotomy; these cases are technically difficult and challenging. Damage-control approaches, understanding of liver anatomy, and advances in technology have dramatically changed the approach to hepatic trauma, with improved outcomes. Anatomic or nonanatomic liver resection is required in 2% to 5% of liver injuries. Mortality with liver injury following resection is 9% with current advances.

PMID: 20637947 [PubMed - as supplied by publisher]

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Current Approach to Hepatocellular Carcinoma.

Surg Clin North Am. 2010 Aug;90(4):803-816

Authors: Abrams P, Marsh JW

Hepatocellular carcinoma (HCC) accounts for 80% of all primary liver cancers and ranks globally as the fourth leading cause of cancer-related death. Partial hepatectomy remains the best treatment option for select patients with HCC without cirrhosis. Liver transplantation is well established as the gold standard for patients with HCC and cirrhosis in the absence of extrahepatic spread and macrovascular invasion. Local regional therapy is indicated in select patients who are not surgical candidates, and its role as adjuvant therapy remains to be clarified by prospective studies.

PMID: 20637949 [PubMed - as supplied by publisher]

Excellent Prognosis for Patients with Solitary T1N0M0 Papillary Thyroid Carcinoma Who Underwent Thyroidectomy and Elective Lymph Node Dissection without Radioiodine Therapy: Reply to Letter.

World J Surg. 2010 Jul 20;

Authors: Ito Y, Miyauchi A

PMID: 20645088 [PubMed - as supplied by publisher]

The Accuracy of (18)[F]-Fluoro-2-Deoxy-D: -Glucose-Positron Emission Tomography/Computed Tomography, Ultrasonography, and Enhanced Computed Tomography Alone in the Preoperative Diagnosis of Cervical Lymph Node Metastasis in Patients with Papillary Thyroid Carcinoma.

World J Surg. 2010 Jul 20;

Authors: Morita S, Mizoguchi K, Suzuki M, Iizuka K

BACKGROUND: The aim of this study was to evaluate the accuracy of [(18)F]-fluoro-2-deoxy-D: -glucose-positron emission tomography/computed tomography, ultrasonography, and enhanced computed tomography alone in the preoperative diagnosis of lymph node metastasis in patients with papillary thyroid carcinoma. METHODS: In a prospective study performed between January 2007 and December 2009, 74 patients with a diagnosis of papillary thyroid carcinoma confirmed by fine-needle aspiration biopsy were referred to our institution for surgery. Preoperative assessment of metastasis in the central and lateral cervical lymph nodes was done using [(18)F]-fluoro-2-deoxy-D: -glucose-positron emission tomography/computed tomography, ultrasonography, and enhanced computed tomography. The results for each level of cervical node assessed using these methods were correlated with the pathology reports after surgery. We determined the sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy of the three methods for all levels of cervical lymph node. RESULTS: There were no significant differences in the diagnostic results obtained by [(18)F]-fluoro-2-deoxy-D: -glucose-positron emission tomography/computed tomography and enhanced computed tomography. However, ultrasonography images gave significantly better results than either [(18)F]-fluoro-2-deoxy-D: -glucose-positron emission tomography/computed tomography or enhanced computed tomography alone in identifying metastases on the basis of the level of cervical lymph node. In addition, the overall diagnostic accuracy tended to be higher for the lateral compartment than for the central compartment. CONCLUSIONS: Preoperative assessment by ultrasonography of metastases in the central and lateral cervical lymph nodes might be the best methodology for determining the extent of surgical resection required to remove metastatic lymph nodes adequately in patients with papillary thyroid carcinoma.

PMID: 20645089 [PubMed - as supplied by publisher]

Percutaneous Radiofrequency Ablation versus Partial Hepatectomy for Multicentric Small Hepatocellular Carcinomas: A Nonrandomized Comparative Study.

World J Surg. 2010 Jul 20;

Authors: Guo WX, Zhai B, Lai EC, Li N, Shi J, Lau WY, Wu MC, Cheng SQ

BACKGROUND: The aim of this study was to compare the results of percutaneous radiofrequency ablation (RFA) with those of partial hepatectomy (PH) in the treatment of multicentric small hepatocellular carcinomas (HCCs). With advances in RFA, it is not known whether the minimally invasive approach with percutaneous RFA could attain comparable survival outcomes but with a lower morbidity in patients with multicentric HCCs. METHODS: From January 2002 and December 2007, 159 patients who had two or three HCCs, with the largest tumor no more than 5 cm in diameter, had no major vascular invasion or extrahepatic metastases, and were treated with either PH (n = 73) or RFA (n = 86) were included in the study. RESULTS: There was no procedure-related mortality in both groups of patients. Major complications happened significantly more often after PH than after RFA (19.2 vs. 8.1%). The hospital stay was significantly longer after PH than after RFA (median = 9 vs. 3 days). The 1-, 3-, and 5-year overall survival rates for the PH and RFA groups were 91.8, 68.7, 44.5% and 94.2, 64.4, 21.2%, respectively. The corresponding disease-free survival rates for the two groups were 62.1, 33.6, 3.6% and 29.4, 2.7, 0%, respectively. The PH group had significantly longer overall survival and disease-free survival than the RFA group. CONCLUSIONS: PH resulted in better survival outcomes than RFA for patients with multicentric small HCCs. However, RFA had the benefits of lower procedure-related morbidity and shorter hospital stay.

PMID: 20645090 [PubMed - as supplied by publisher]

Intraoperative Near-infrared Fluorescent Cholangiography (NIRFC) in Mouse Models of Bile Duct Injury: Reply.

World J Surg. 2010 Jul 20;

Authors: Figueiredo JL, Nahrendorf M, Vinegoni C, Weissleder R

PMID: 20645091 [PubMed - as supplied by publisher]

Marjolin’s Ulcers in sub-Saharan Africa.

World J Surg. 2010 Jul 20;

Authors: Nthumba PM

BACKGROUND: Cutaneous malignancies are considered rare among Africans. Trauma, its sequelae, and other chronic non-healing wounds are known to predispose to malignant degeneration. Not much is known of the demographics of Marjolin’s ulcers in sub-Saharan Africa. METHODS: Pathology records on patients suspected to have Marjolin’s ulcers submitted to the Pathology Department were extracted from a database of 75,124 specimens. A review of the English literature on Marjolin’s ulcers from Nigeria, a sub-Saharan country, was also performed. RESULTS: Of 210 specimens from suspected Marjolin’s ulcers, 167 records had a histological diagnosis of malignancy, with a male to female ratio of 1:1.4, and a mean age of 48 years (range: 4-97 years). There were 163 (97.6%) squamous cell carcinomas, 3 (1.8%) sarcomas, and 1 (0.6%) malignant melanoma. Burn scars, chronic ulcers, osteomyelitis, and “other” ulcers constituted 82 (49%), 70 (42%), 9 (5.4%), and 6 (3.6%), respectively. Subjects in six sub-Saharan Marjolin’s ulcer studies had a mean age between 36 and 42 years, with a mean latent period 16 years. CONCLUSIONS: Marjolin’s ulcers in sub-Saharan African have a shorter latent period, and they occur in younger patients. Provision of early stable wound cover is essential for prevention of malignant degeneration of scars, while early appropriate intervention is crucial in the treatment of chronic ulcers.

PMID: 20645092 [PubMed - as supplied by publisher]

Diagnostic Value of Inflammation Markers in Predicting Perforation in Acute Sigmoid Diverticulitis.

World J Surg. 2010 Jul 20;

Authors: Käser SA, Fankhauser G, Glauser PM, Toia D, Maurer CA

BACKGROUND: The importance of inflammation markers in predicting perforation in acute sigmoid diverticulitis is not well known. Predicting perforation by clinical examination alone may be hazardous. If perforation is suspected, then appropriate diagnostic tools such as computed tomography (CT) are indicated, and surgical intervention might be necessary. METHODS: A cohort of consecutive patients with acute sigmoid diverticulitis diagnosed by CT and with complete laboratory findings (n = 247) were retrospectively divided into two groups, one with perforation (n = 86) and another without (n = 161). The latest values of C-reactive protein (CRP), white blood cell count (WBC), and serum bilirubin, as well as the activity of the alkaline phosphatase (AP) measured during the 48 h period before the CT scan, were assessed. RESULTS: In the Wilcoxon rank sum test CRP and WBC correlate significantly (p < 0.05) with perforation in acute sigmoid diverticulitis, whereas the logistic regression model shows only CRP to correlate significantly (p = 0.001) with perforation. The sensitivities/specificities for perforation are 98%/5% for elevated CRP (>5 mg/l), 86%/27% for a CRP higher than 50 mg/l, 44%/81% for a CRP higher than 150 mg/l, 28%/93% for a CRP higher than 200 mg/l, 88%/44% for elevated WBC (>10 x 10(9)/l), 35%/90% for hyperbilirubinemia (>20 mumol/l), and 35%/91% for elevated AP (>110 U/l). CONCLUSIONS: A CRP below 50 mg/l suggests a perforation to be unlikely in acute sigmoid diverticulitis, whereas a CRP higher than 200 mg/l is a strong indicator of perforation.

PMID: 20645093 [PubMed - as supplied by publisher]

Risk Factors for Litigation Following Major Transectional Bile Duct Injury Sustained at Laparoscopic Cholecystectomy.

World J Surg. 2010 Jul 20;

Authors: Perera MT, Silva MA, Shah AJ, Hardstaff R, Bramhall SR, Issac J, Buckels JA, Mirza DF

BACKGROUND: Bile duct injuries after laparoscopic cholecystectomy often cause long-term morbidity, with a number of patients resorting to litigation. The present study aimed to analyze risk factors for litigation and to quantify the subsequent medicolegal burden. METHODS: A total of 67/106 patients (26 male) with major laparoscopic cholecystectomy bile duct injuries (LCBDI) and a minimum 2-year follow-up, replied to a questionnaire covering patient perception toward the complication, physical/psychological recovery, and subsequent litigation. These data were collated with prospectively collected data related to the LCBDI and subsequent management, and a multivariate regression model was designed to identify potential risk factors associated with litigation. RESULTS: Most patients felt they had been inadequately informed prior to surgery [47/67 (70%)] and after the LCBDI [50/67 (75%)], and a majority remained psychologically traumatized at the time of evaluation [50/67 (75%)]. Of these, 22 patients had started litigation by means of a “letter of demand” (LOD; n = 10) or prosecution (n = 12). Nineteen (19/22%) cases have been closed in favor of the plaintiff. There was no difference between the awards for LOD versus prosecution cases, and average compensation was pound40,800 versus pound89,875, respectively (p = n.s). On multivariate analysis, age < 52 years (p = 0.03), associated vascular injury (p = 0.014), immediate nonspecialist repair (p = 0.009), and perceived incomplete recovery following LCBDI (p = 0.017) were identified as independent predictors for possible litigation. CONCLUSIONS: On the basis of the present study, nearly one third of patients with major transectional LCBDI are likely to resort to litigation. Younger patients and those in whom repair is attempted prior to specialist referral are likely to initiate litigation.

PMID: 20645094 [PubMed - as supplied by publisher]

Evaluation of Need for Operative Intervention in Blunt Splenic Injury: Intraperitoneal Contrast Extravasation has an Increased Probability of Requiring Operative Intervention.

World J Surg. 2010 Jul 20;

Authors: Fu CY, Wu SC, Chen RJ, Chen YF, Wang YC, Huang HC, Huang JC, Lu CW, Lin WC

BACKGROUND: Angioembolization is an effective adjunct to the management of blunt splenic injuries (BSI) that are not surgically treated. However, in some cases patients are unable to undergo angioembolization due to changes in their hemodynamic condition. In this study we attempt to define the characteristics of patients who need angioembolization in high-grade BSI. METHODS: We retrospectively reviewed the charts of patients with BSI between January 2004 and June 2008. Patients with contrast extravasation (CE) on computed tomography (CT) scan were enrolled. The demographics, Injury Severity Score (ISS), Abbreviated Injury Scale (AIS), the amount of blood transfused, and the type of CE were analyzed. RESULTS: A total of 69 patients were enrolled. Patients with intraperitoneal CE in BSI required a higher rate of immediate operation due to changed hemodynamics. Furthermore, these patients displayed higher ISS and higher blood transfusion amounts. CONCLUSIONS: In BSI patients, intraperitoneal CE is associated with a higher possibility of requiring surgical intervention. Early surgical intervention should be considered in BSI patients with intraperitoneal CE or with ISS >/= 25.

PMID: 20645095 [PubMed - as supplied by publisher]

Compartment Surgery in Treatment Strategies for Retroperitoneal Sarcomas: A Single-center Experience.

World J Surg. 2010 Jul 20;

Authors: Santos CE, Correia MM, Thuler LC, Rosa BR, Accetta A, de Almeida Dias J, de Mello EL

BACKGROUND: Retroperitoneal sarcomas (RPS) are rare tumors and radical surgery is still the only curative treatment. We aim to estimate postoperative morbidity and mortality and identify significant prognostic factors for survival of patients with RPS and then evaluate the effect of en bloc resection on survival. METHODS: This was a retrospective follow-up study of 91 patients with RPS who underwent surgery at the Section of Abdominopelvic Surgery of the National Cancer Institute-Brazil (INCA) between June 1992 and January 2008. Overall and 2-, 5-, and 10-year disease-free survival rates were calculated and univariate and Cox multivariate analyses were performed. RESULTS: The most common complaints were abdominal pain and mass. Resection was possible in 83.5% and curative resection in 55.3%. Six patients died within the postoperative period (mortality = 6.6%) and 28 had complications (30.8%). Leiomyosarcomas and liposarcomas predominated, as well as G3. The median tumor diameter was 20.5 cm. There were 124 organs resected in association, with only 42 proven invaded. The 5-year overall survival and disease-free survival rates were 32.0 and 36.8%, respectively. Cell differentiation, curative or palliative resection, blood transfusion, and re-resection were significant variables. Compartment surgery had no impact on survival, but it increased the duration of surgery, the need for blood transfusion, and overall morbidity. CONCLUSIONS: This study suggests that early diagnosis and curative resection of retroperitoneal sarcomas can improve long-term survival. Adjacent organs with evidence of direct invasion must be removed en bloc; others should be spared.

PMID: 20645096 [PubMed - as supplied by publisher]

Long-Term Results of Esophagogastric Devascularization and Splenectomy Associated with Endoscopic Treatment in Schistosomal Portal Hypertension.

World J Surg. 2010 Jul 20;

Authors: Makdissi FF, Herman P, Pugliese V, de Cleva R, Saad WA, Cecconello I, D’Albuquerque LA

BACKGROUND: Esophagogastric devascularization and splenectomy (EGDS) is the most performed operation for prophylaxis of esophageal varices bleeding recurrence in hepatosplenic schistosomiasis. Lower rebleeding rates are obtained through the association of postoperative endoscopic treatment; however, there is a dearth of studies showing long-term results. METHODS: Clinical, laboratory, and endoscopic data of 97 patients submitted to EGDS with at least 5 years of follow-up, were analyzed. RESULTS: The mean follow-up was 116.4 months. Bleeding recurrence occurred in 24.7% of patients; however, this percentage was 14.6% when only variceal hemorrhage was considered. Bleeding recurrence occurred in four patients even after endoscopic evaluation demonstrated esophageal varices eradication. In the late follow-up we observed normalization of anemia, leukopenia, thrombocytopenia, hyperbilirubinemia, and a prothrombin activity time increase. No clinical or laboratory hepatic insufficiency was observed. CONCLUSIONS: The EGDS procedure with postoperative endoscopic treatment led to good clinical results and avoided hemorrhagic recurrence in 75.3% of schistosomal patients. There was improvement of laboratory measures of hepatic function, as well as correction of hypersplenism. Variceal hemorrhagic recurrence may occur even when esophageal varices eradication is reached.

PMID: 20645097 [PubMed - as supplied by publisher]

Hospitalization, Frequency of Interventions, and Quality of Life after Endoscopic, Surgical, or Conservative Treatment in Patients with Chronic Pancreatitis.

World J Surg. 2010 Jul 20;

Authors: Rutter K, Ferlitsch A, Sautner T, Püspök A, Götzinger P, Gangl A, Schindl M

OBJECTIVE: Patients with chronic pancreatitis usually have a long and debilitating history of disease with frequent hospital admissions, episodes of intractable pain and multiple interventions. The sequences of treatment at initial presentation, endoscopy, surgery, or conservative treatment may affect the time course and admissions needed for disease control, thereby determining quality of life and overall outcome. METHODS: A total of 292 patients with initial endoscopic, surgical, or conservative pharmacological treatment were retrospectively analyzed regarding frequency of interventions, days in hospital, symptom-free intervals, morbidity, and mortality. Quality of life (QoL) at the latest follow-up was measured by two standardized quality of life questionnaires (EORTC C30 and PAN26). RESULTS: Endoscopic treatment was initially performed in 150 (51.4%) patients, whereas 99 (33.9%) underwent surgery and 43 (14.7%) patients were treated conservatively at their initial presentation. Patients who underwent surgery had a significantly shorter time in the hospital (25.3 +/- 24.6, 34.4 +/- 35.1, 61.1 +/- 37.9; P < 0.001), fewer subsequent therapies (0.43 +/- 1.0, 2.1 +/- 2.4, 3.1 +/- 3.0; P </= 0.001), and a longer relapse-free interval (P = 0.004) compared with endoscopically treated patients. The overall complication rate was 32% both after surgery and endoscopy. Infectious-related complications occurred more often after surgical treatment (P </= 0.001), whereas patients after endoscopic intervention developed acute or chronic pancreatitis or pseudocyst formation (P = 0.023). CONCLUSIONS: Patients who undergo surgery as their initial treatment for chronic pancreatitis require less consecutive interventions, a shorter hospital stay, and have a better quality of life compared with any other treatment. Surgery should therefore be considered early for the treatment of chronic pancreatitis, when endoscopic or conservative treatment fails and patients require further intervention.

PMID: 20645098 [PubMed - as supplied by publisher]

Current Outcomes of Simultaneous Carotid Endarterectomy and Coronary Artery Bypass Graft Surgery in North America.

World J Surg. 2010 Jul 20;

Authors: Prasad SM, Li S, Rankin JS, O’Brien SM, Gammie JS, Puskas JD, Shahian DM, Chedrawy EG, Massad MG

OBJECTIVE: Management of patients with concomitant carotid and coronary artery disease has been controversial. Divergent strategies have been employed, including simultaneous carotid endarterectomy and coronary bypass (SCC) versus various staged procedures. Although no strict comparison group is available, this study defines current outcomes of SCC, compared qualitatively to two reference categories. METHODS: Utilizing the STS database from 2003 to 2007, patients who had SCC were compared with patients with cerebrovascular disease who had coronary bypass (CABG) with prior carotid endarterectomy (CEA), and those with carotid Doppler stenosis >75% and no carotid intervention. Logistic regression analysis adjusted for differences in baseline characteristics and operative mortality (OM), and a composite of neurological complications (NC) was assessed. RESULTS: Of 745,769 patients who underwent isolated CABG with/without CEA, 108,212 (14 %) had cerebrovascular disease. Of this group, 5,732 (5%) underwent SCC. The SCC group had more males and lower preoperative risk factors. After statistical adjustment for all baseline differences, SCC had clinically and statistically higher OM and NC compared with any of the reference groups, with 20-40% higher event risk. CONCLUSIONS: Although no quantitative control group exists for comparison, SCC as recently performed in North America has a high risk compared with any of the reference groups. Suboptimal results associated with the SCC strategy suggest a need for quality improvement and research on the optimal management of patients with simultaneous carotid and coronary disease.

PMID: 20645099 [PubMed - as supplied by publisher]

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

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

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

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

PMID: 20644122 [PubMed - in process]

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

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

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

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

PMID: 20644123 [PubMed - in process]

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

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

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

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

PMID: 20644124 [PubMed - in process]

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

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

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

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

PMID: 20644125 [PubMed - in process]

Related Articles

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

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

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

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

PMID: 20644126 [PubMed - in process]

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

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

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

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

PMID: 20644127 [PubMed - in process]

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

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

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

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

PMID: 20644128 [PubMed - in process]

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

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

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

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

PMID: 20644129 [PubMed - in process]

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Motivations to pursue fellowships are gender neutral.

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

Authors: Borman KR, Biester TW, Rhodes RS

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

PMID: 20644130 [PubMed - in process]

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

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

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

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

PMID: 20644131 [PubMed - in process]

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

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

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

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

PMID: 20644132 [PubMed - in process]

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Autologous blood transfusion during emergency trauma operations.

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

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

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

PMID: 20644133 [PubMed - in process]

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

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

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

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

PMID: 20644134 [PubMed - in process]

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

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

Authors: Andreoni KA

PMID: 20644135 [PubMed - in process]

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Image of the month–quiz case.

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

Authors: Nguyen TK, Edil BH

PMID: 20644136 [PubMed - in process]

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Image of the month–quiz case.

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

Authors: Hong JJ, Schrump DS, Hughes MS

PMID: 20644137 [PubMed - in process]

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Panel discussion for symposium on safety and quality improvement in specialty surgery in smaller hospitals.

Am J Surg. 2010 Jul;200(1):e1-e14

Authors: McCafferty M, Shively E, Cronen P

PMID: 20637327 [PubMed - in process]

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Papillary carcinoma arising in subhyoid ectopic thyroid gland with no orthotopic thyroid tissue.

Am J Surg. 2010 Jul;200(1):e17-e18

Authors: Sevinç AI, Unek T, Canda AE, Guray M, Kocdor MA, Saydam S, Harmancıoglu O

Ectopic thyroid gland with no orthotopic thyroid tissue is extremely rare. The authors present a case of a follicular variant of papillary carcinoma developed from an ectopic thyroid gland with no orthotopic thyroid tissue.

PMID: 20637328 [PubMed - as supplied by publisher]

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Bile leak test by indocyanine green fluorescence images after hepatectomy.

Am J Surg. 2010 Jul;200(1):e19-e23

Authors: Sakaguchi T, Suzuki A, Unno N, Morita Y, Oishi K, Fukumoto K, Inaba K, Suzuki M, Tanaka H, Sagara D, Suzuki S, Nakamura S, Konno H

Bile leak remains a serious complication after hepatectomy. The conventional leak test by intrabiliary injection of normal saline solution is not sensitive. The authors present a new bile leak test using indocyanine green (ICG) fluorescence. After hepatic transection, ICG solution (.05 mg/mL) was intrabiliarily injected through a transcystic tube under distal common bile duct clamping, and fluorescent images were visualized using an infrared camera system. The ICG leak test was performed in 27 patients undergoing hepatectomy without biliary reconstruction. Bile leaks were intraoperatively found in 8 patients and fixed, resulting in no postoperative leaks. There was no adverse reaction to ICG. In contrast, postoperative bile leaks occurred in 2 of 32 patients who received the conventional leak test with normal saline solution between April 2007 and March 2008. The new bile leak test by ICG fluorography is useful to prevent postoperative bile leak.

PMID: 20637329 [PubMed - as supplied by publisher]

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Consensus statement on the adoption of the COPE guidelines.

Am J Surg. 2010 Jul;200(1):1

Authors:

PMID: 20637330 [PubMed - in process]

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Incisional hernia repair by fascial component separation: results in 128 cases and evolution of technique.

Am J Surg. 2010 Jul;200(1):2-8

Authors: Clarke JM

BACKGROUND: Most ventral incisional hernias are repaired using 1 of 2 principal techniques: (1) prosthetic repair (open or laparoscopic) and (2) primary reconstruction by fascial component separation. Primary midline restoration provides physiological advantages, and avoidance of mesh may reduce complications. This report describes 128 cases of incisional hernia repair by fascial release. Evolution of the technique produced modifications and fewer complications. METHODS: Fascial component separation was performed either by “classic” technique (broad skin flaps) in group 1 and by “perforator preservation” (fascial release through separate inferolateral incisions) in group 2. RESULTS: Mortality was .75% (1/128). Major complications occurred in 7 patients (5.5%). Total recurrence rate is 16% (21/128) with major recurrences in 9.3% (12/128). Both groups were statistically equivalent in demographics, comorbidities, and recurrences. Group 1 had significantly higher rates of skin necrosis (P < .001) and chronic pain (P = .003). CONCLUSIONS: Fascial component separation can provide satisfactory results in uncomplicated incisional hernias, but skin necrosis is prohibitive without perforator preservation.

PMID: 20637331 [PubMed - as supplied by publisher]

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Randomized comparison of Limberg flap versus modified primary closure for the treatment of pilonidal disease.

Am J Surg. 2010 Jul;200(1):9-14

Authors: Muzi MG, Milito G, Cadeddu F, Nigro C, Andreoli F, Amabile D, Farinon AM

BACKGROUND: The best surgical technique for sacrococcygeal pilonidal disease is still controversial. The aim of this randomized prospective trial was to compare both the results of Limberg flap procedure and primary closure. METHODS: A total of 260 patients with sacrococcygeal pilonidal disease were assigned randomly to undergo Limberg flap procedure or tension-free primary closure. RESULTS: Success of surgery was achieved in 84.62% of Limberg flap patients versus 77.69% of primary closure (P = .0793). Surgical time for primary closure was shorter. Wound infection was more frequent in the primary closure group (P = .0254), which experienced less postoperative pain (P < .0001). No significant difference was found in time off from work (P = .672) and wound dehiscence. Recurrence was observed in 3.84% versus 0% in the primary closure versus Limberg flap group (P = .153). CONCLUSIONS: Our results do not show a clear benefit for surgical management by Limberg flap or primary closure. Limberg flap showed less convalescence and wound infection; our technique of tension-free primary closure was a day case procedure, less painful, and shorter than Limberg flap.

PMID: 20637332 [PubMed - as supplied by publisher]

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Long-term results after surgical treatment of nonparasitic hepatic cysts.

Am J Surg. 2010 Jul;200(1):23-31

Authors: Loehe F, Globke B, Marnoto R, Bruns CJ, Graeb C, Winter H, Jauch KW, Angele MK

BACKGROUND: Studies evaluating surgical success in patients with benign liver cysts focus on cyst recurrence. The aim of this study was to evaluate the efficacy of surgical treatment with regard to clinical complaints. MATERIALS AND METHODS: Between 1995 and 2007, 99 patients (M:F 1:7.25) with symptomatic, benign, nonparasitic liver cysts (77 simple liver cysts [SLCs], 22 polycystic liver disease [PCLD]) underwent surgical treatment (77% laparoscopic surgery, 23% open surgery). Perioperative parameters (including morbidity) were evaluated. Moreover, a questionnaire was completed by 65 patients monitoring subjective complaints focusing on abdominal pain, vegetative symptoms, and dyspnea pre- and postoperatively (mean follow-up 76 months). RESULTS: Severe complications occurred in 7 patients. Abdominal pain, vegetative symptoms, and dyspnea were significantly improved in SLC patients. In PCLD patients abdominal pain and dyspnea were significantly decreased, whereas vegetative symptoms were unaffected by surgery. The symptom recurrence rate for SLC patients was significantly lower compared with PCLD patients (41% vs 66.6%). CONCLUSION: Indications for surgical treatment of PCLD should be well considered and limited to a selected group of patients.

PMID: 20637333 [PubMed - as supplied by publisher]

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Trends, outcomes, and predictors of open and conversion to open cholecystectomy in Veterans Health Administration hospitals.

Am J Surg. 2010 Jul;200(1):32-40

Authors: Kaafarani HM, Smith TS, Neumayer L, Berger DH, Depalma RG, Itani KM

BACKGROUND: Laparoscopic cholecystectomy (LC) accounts for more than 85% of cholecystectomies. Factors prompting open cholecystectomy (OC) or conversion from LC to OC (CONV) are not completely understood. METHODS: Prospectively collected data from the National Surgical Quality Improvement Program (NSQIP) were combined with administrative data to identify patients undergoing cholecystectomy from October 2005 to October 2008. Three cohorts were defined: LC, OC, and CONV. Using logistic hierarchical modeling, we identified predictors of the choice of OC and the decision to CONV. RESULTS: A total of 11,669 patients underwent cholecystectomy at 117 VA hospitals, including 9,530 LC (81.7%). While the rate of conversion from LC to OC remained stable over the study period (9.0% overall), the percentage of OC decreased from 11.5% in 2006 to 10.1% in 2007 and 8.9% in 2008 (P = .0002). Compared with LC, the OC cohort had more comorbidities (35 of 41 preoperative characteristics, all P <.05), a higher 30-day morbidity rate (18.7% vs 4.8%. P <.0001), and a higher 30-day mortality rate (2.4% vs .4%, P <.0001). American Society of Anesthesiologist (ASA) class, patient comorbidities (eg, ascites, bleeding disorders, pneumonia) and functional status predicted a choice of OC. Age, preoperative albumin, previous abdominal surgery and emergency status predicted OC and CONV (all P <.05). A higher hospital conversion rate was independently predictive of OC (odds ratio [1% rate increase]: 1.05 [1.02-1.07]; P = .0004). CONCLUSION: In the last 3 years, there has been a trend towards performing fewer OCs in VA hospitals. More patient comorbidities and higher hospital-level conversion rates are predictive of the choice to perform or convert to OC.

PMID: 20637334 [PubMed - in process]

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Serum thyroglobulin is a poor diagnostic biomarker of malignancy in follicular and Hurthle-cell neoplasms of the thyroid.

Am J Surg. 2010 Jul;200(1):41-46

Authors: Suh I, Vriens MR, Guerrero MA, Griffin A, Shen WT, Duh QY, Clark OH, Kebebew E

BACKGROUND: Serum thyroglobulin (Tg) is the most accurate biomarker for thyroid cancer recurrence. However, some clinicians measure preoperative Tg as a diagnostic cancer marker despite lack of supporting evidence. We examined whether Tg accurately predicts malignancy in follicular or Hürthle-cell neoplasms. METHODS: We reviewed 366 patients who underwent thyroidectomies for follicular/Hürthle-cell neoplasms. We compared Tg in malignant versus benign tumors by univariate and receiver-operator characteristic analyses. We also examined several Tg-derived indices that normalized Tg to known confounding factors including nodule size, thyroid function, and type of Tg assay. RESULTS: Thirty-nine patients met inclusion criteria for analysis. There were no differences between malignant (n = 16) and benign (n = 23) lesions in Tg or any of the normalized indexes. Receiver-operator characteristic analysis revealed an area under the curve of .59. Lesions with Tg levels greater than 500 mug/L had a positive predictive value of .75. CONCLUSIONS: Tg has poor accuracy for predicting malignancy in follicular or Hürthle-cell thyroid neoplasms.

PMID: 20637335 [PubMed - as supplied by publisher]

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A correlation between polyomavirus JC virus quantification and genotypes in renal transplantation.

Am J Surg. 2010 Jul;200(1):53-58

Authors: Yin WY, Lu MC, Lee MC, Liu SC, Lin TY, Lai NS

OBJECTIVE: To determine whether the John Cunningham virus (JCV) viral load and the multigenotypes in viruria are correlated with transplant patients. METHODS: The urine of 60 renal transplant patients and 60 healthy controls were screened. We used quantitative real-time polymerase chain reaction and capillary electrophoresis to assess viral load and genotype respectively. RESULTS: The incidence of viruria and viral load were higher in transplant patients with P = .0092 and P = .0094, respectively. The incidence of different genotype in transplant patients versus controls was 8.3% versus 13.3% for single genotype, 26.7% versus 5% for 2 genotypes, and 5% versus 0% for multigenotypes (P = .0004). The incidence of more than 2 genotypes was high in people with a high viral load and closely related with the transplant patients (P = .007). CONCLUSIONS: Not only viral load but also genotypes are important as a screening parameter to understand the immune milieu of the patients to prevent subsequent complications like polyomavirus nephropathy, infection, and malignancy.

PMID: 20637336 [PubMed - as supplied by publisher]

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Outpatient surgery performed in an ambulatory surgery center versus a hospital: comparison of perioperative time intervals.

Am J Surg. 2010 Jul;200(1):64-67

Authors: Trentman TL, Mueller JT, Gray RJ, Pockaj BA, Simula DV

BACKGROUND: In 2005, the authors’ ambulatory surgery center (ASC) was closed, and the breast operations performed there were integrated into the hospital. This change allowed a comparison of perioperative time intervals for patients undergoing these procedures at an outpatient facility versus a hospital. METHODS: The records of 92 patients who underwent breast operations at the ASC between January 2004 and December 2005 were compared with those of 92 patients who underwent outpatient breast operations at the hospital starting January 2006. Anesthetic techniques, recovery room events, and perioperative time intervals were analyzed. RESULTS: Age and recovery room times were similar. Complications were negligible at both facilities. The preoperative, operating room entry to incision, and total facility time intervals significantly increased when breast cases were moved back to the hospital setting. CONCLUSIONS: These data demonstrate significantly shorter perioperative time intervals at the ASC. Incorporating time-saving practices from the outpatient setting could contribute to greater hospital productivity.

PMID: 20637337 [PubMed - as supplied by publisher]

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Influence of stapler size used at ileal pouch-anal anastomosis on anastomotic leak, stricture, long-term functional outcomes, and quality of life.

Am J Surg. 2010 Jul;200(1):68-72

Authors: Kirat HT, Kiran RP, Lian L, Remzi FH, Fazio VW

BACKGROUND: The aim of this study was to evaluate whether stapler size used at ileal pouch-anal anastomosis (IPAA) influences outcomes. METHODS: Data of patients undergoing stapled IPAA (1983-2007) were obtained. Differences between groups A (stapler size 28-29 mm) and B (31-33 mm) for pre- and perioperative factors, stricture, leak, quality of life (QOL), and function were compared. Associations between stapler size and stricture or leak were assessed with a multivariable Cox model. RESULTS: Groups A (n = 1,221) and B (n = 899) had comparable age, diagnosis, body mass index (BMI), and albumin level. Group B had more males (P < .001) but fewer patients with ileostomy (P < .001). There was no significant difference in rates of leak (4.5% vs 6.2%, P = .08) or stricture (1.9% vs 2.7%, P = .1) for groups A and B. On multivariate analysis, female gender was associated with stricture, while greater BMI and male gender were associated with leak. Group A had greater urgency at 1 year and nighttime pad use at 15 years. The other determinants of function and QOL were similar. CONCLUSIONS: There was no significant association between the size of stapler used at IPAA and long-term complications.

PMID: 20637338 [PubMed - as supplied by publisher]

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Introduction: safety and quality improvement in specialty surgery in smaller hospitals.

Am J Surg. 2010 Jul;200(1):81

Authors: Polk HC

PMID: 20637339 [PubMed - in process]

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A situational overview of surgical quality and safety in 2010.

Am J Surg. 2010 Jul;200(1):82-89

Authors: Polk HC, Tyson MB, Galandiuk S

BACKGROUND: Surgical safety and quality initiatives have now moved to the front of the agenda for contemporary surgery. METHODS: Sixty-two surgical specialists began to study quality and cost control in 1998, and those efforts grew into a Centers for Medicare and Medicaid Services-funded pilot study of the Surgical Care Improvement Project in 2004. Subsequent symposia and studies evolved. RESULTS: A greater awareness of the issues and methods for meaningful improvement of surgical safety in nearly 25,000 specialty surgeries have been described in numerous peer-reviewed publications. CONCLUSIONS: Surgeon-initiated efforts have led to marked improvements in multiple specialties and in many small and large hospitals and academic training centers.

PMID: 20637340 [PubMed - as supplied by publisher]

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A closer look at surgical quality measures across different surgical specialties.

Am J Surg. 2010 Jul;200(1):90-96

Authors: Watkins JM, Qadan M, Battista C, Polk HC

BACKGROUND: Most studies of surgical quality improvement have been performed in large and/or teaching hospitals; the efficacy of safety and quality efforts in smaller hospitals have not been reported. METHODS: Four smaller hospitals joined a collaborative to study process measures through an expanded surgical time-out and some outcomes. The data were collected in real time. RESULTS: Well-performing hospitals (all 4) improved further but variably. Gynecologic and orthopedic surgeons performed more consistently in most measures than did general surgeons. CONCLUSIONS: These small hospitals readily accepted a time-out-based real-time data collection and with their surgical staff improved in most parameters.

PMID: 20637341 [PubMed - as supplied by publisher]

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Standards of surgery beyond metropolitan centers: a fresh look at perioperative quality measures in small-town America.

Am J Surg. 2010 Jul;200(1):97-104

Authors: Cronen P, Qadan M, Hicks NZ, Polk HC

BACKGROUND: Surgical quality measures have room for improvement in both large- and small-town hospitals. METHODS: We sought concurrence of surgical specialists (general, orthopedic, gynecologic) to study accepted quality and safety parameters using a surgical time-out-based platform. RESULTS: Surgeons and hospitalists participated promptly and actively and recorded enhanced performance measures compared with prior work and within the period of study. Practice patterns varied, and interchange among participating hospitals was helpful. CONCLUSIONS: Smaller institutions are more nimble than larger ones and developed interchangeable ideas for improvement. Surgical process measures improved such that all 4 hospitals are concerned about and committed to maintaining the gains.

PMID: 20637342 [PubMed - as supplied by publisher]

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Virtual partnerships: aligning hospital and surgeon incentives.

Am J Surg. 2010 Jul;200(1):105-110

Authors: Fry DE, Pine M, Pine G

BACKGROUND: Payment schemes exist for health care in the United States that are perverse and, in many cases, antithetical to the goals of all concerned. A fundamental reorganization will be required if care is to be broadened and sensible economies achieved. METHODS: For some time, we have experimented intellectually with reorganization of the specialist/hospital axis in contemporary medical care, seeking a more functional relationship among the parties (ie, doctors, nurses, hospitals, and their patients). RESULTS: A virtual partnership between surgical specialists and the hospital provides many of the favored factors for productive and mutually respected care for patients with a feasible method for limiting costs. CONCLUSIONS: A virtual partnership, as exemplified for 3 major surgeries, could create a relationship that benefits the patient, the surgical specialist, the hospital, and the ethical payer.

PMID: 20637343 [PubMed - as supplied by publisher]

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Bacterial translocation and infected pancreatic necrosis in acute necrotizing pancreatitis derives from small bowel rather than from colon.

Am J Surg. 2010 Jul;200(1):111-117

Authors: Fritz S, Hackert T, Hartwig W, Rossmanith F, Strobel O, Schneider L, Will-Schweiger K, Kommerell M, Büchler MW, Werner J

BACKGROUND: The clinical course of acute necrotizing pancreatitis (ANP) is determined by the superinfection of pancreatic necrosis. To date, the pathophysiology of the underlying bacterial translocation is poorly understood. The present study investigated the bacterial source of translocation. METHODS: A terminal loop ileostomy was applied in rats. Selective digestive decontamination (SDD) of either the small bowel or the colon was performed. After 3 days of SDD, severe ANP was induced. At 24 hours, bacterial translocation was assessed by cultures of bowel mucosa, mesenteric lymph nodes, and pancreas using a scoring system (0-4). RESULTS: Without SDD, pancreatic infection was present in all cases with an average score of 2.67. Colon SDD reduced pancreatic superinfection to 1.67 (not significant). SDD of the small bowel significantly reduced superinfection to 1.0 (P < .005). CONCLUSIONS: Bacterial translocation from the colon is less frequent than translocation from the small bowel. Thus, the small bowel seems to be the major source of enteral bacteria in infected pancreatic necrosis.

PMID: 20637344 [PubMed - as supplied by publisher]

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Preventing intraperitoneal adhesions with atorvastatin and sodium hyaluronate/carboxymethylcellulose: a comparative study in rats.

Am J Surg. 2010 Jul;200(1):118-123

Authors: Lalountas MA, Ballas KD, Skouras C, Asteriou C, Kontoulis T, Pissas D, Triantafyllou A, Sakantamis AK

OBJECTIVES: The aim of this study was to compare the effectiveness of atorvastatin with the sodium hyaluronate/carboxymethylcellulose (HA/CMC, Seprafilm; Genzyme; Genzyme Biosurgery Corporation, Cambridge, MA) in preventing postoperative intraperitoneal adhesion formation in rats. METHODS: Sixty Wistar rats underwent a laparotomy, and adhesions A were induced by cecal abrasion. The animals were divided into 4 groups: group 1, control A; group 2, (A + atorvastatin); group 3, (A + HA/CMC), and group 4, (A + atorvastatin + HA/CMC). The atorvastatin (groups 2 and 4) and HA/CMC (groups 3 and 4) were administered intraperitoneally before the abdominal wall was closed. After 14 days, adhesions were classified by 2 independent surgeons. RESULTS: The adhesion scores (mean +/- standard deviation) for groups 1, 2, 3, and 4 were 2.93 +/- .59, 1.85 +/- 1.07, 1.80 +/- .86, and 1.93 +/- .70, respectively. The differences in adhesion scores among all 3 preventive groups (groups 2, 3, and 4) were statistically significant when compared with the control group (P = .005, P = .002, and P = .009, respectively). CONCLUSIONS: These data suggest that atorvastatin, administered intraperitoneally, is as effective as HA/CMC without an expectable additive effect in preventing postoperative adhesions in rats.

PMID: 20637345 [PubMed - as supplied by publisher]

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Surgical implications of B-Raf(V600E) mutation in fine-needle aspiration of thyroid nodules.

Am J Surg. 2010 Jul;200(1):136-143

Authors: Mekel M, Nucera C, Hodin RA, Parangi S

BACKGROUND: Management of patients with thyroid nodules is based on establishing an accurate diagnosis; however, differentiating benign from malignant lesions preoperatively is not always possible using current cytological techniques. Novel molecular testing on cytological material could lead to clearer treatment algorithms. B-Raf(V600E) mutation is the most common genetic alteration in thyroid cancer, specifically found in papillary thyroid cancer (PTC), and usually reported to be associated with aggressive disease. DATA SOURCE: A literature search using PubMed identified all the pertinent literature on the identification and utilization of the B-Raf(V600E) mutation in thyroid cancer. CONCLUSIONS: The utility of using B-Raf mutation testing for nodules with indeterminate cytology is limited since many of those nodules (benign and malignant) do not harbor B-Raf mutations. However, when the pathologist sees cytological features suspicious for PTC, B-Raf(V600E) mutation analysis may enhance the assessment of preoperative risks for PTC, directing a more aggressive initial surgical management when appropriate.

PMID: 20637346 [PubMed - as supplied by publisher]

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Elective laparoscopic sigmoid resection for diverticular disease has fewer complications than conventional surgery: a meta-analysis.

Am J Surg. 2010 Jul;200(1):144-161

Authors: Siddiqui MR, Sajid MS, Qureshi S, Cheek E, Baig MK

BACKGROUND: We performed a meta-analysis of published literature comparing the complications after open and laparoscopic elective sigmoidectomy for diverticular disease. METHODS: Electronic databases were searched from January 1991 to March 2009. A systematic review was performed to obtain a summative outcome. RESULTS: Nineteen comparative studies involving 2,383 patients were analyzed. There were 1,014 patients in the laparoscopic group and 1,369 patients in the open group. There was no significant heterogeneity among any of the complications analyzed. Patients in the laparoscopic sigmoid resection group had fewer wound infections (fixed effects model: risk ratio [RR], .54; 95% confidence interval [CI], .36-.80; z, -3.05; P < .01; random effects model: RR, .59; 95% CI, .39-.89; z, -2.54; P < .05), blood transfusions (fixed effects model: RR, .25; 95% CI, .10-.60; z, -3.10; P < .01; random effects model: RR, .28; 95% CI, .11-.68; z, -2.81; P < .01), and ileus rates (fixed effects model: RR, .37; 95% CI, .20-.66; z, -3.34; P = .001; random effects model: RR, .37; 95% CI, .20-.68; z, -3.21; P = .001) compared with open sigmoid resections. No difference was seen for medical complications, need for rehospitalization, and reoperation. CONCLUSIONS: Laparoscopic sigmoid resection is safe and has fewer postoperative surgical complications. This approach should be considered for elective cases, however, more randomized controlled trials are required to strengthen the evidence.

PMID: 20637347 [PubMed - as supplied by publisher]

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The use of a lightly preserved cadaver and full thickness pig skin to teach technical skills on the surgery clerkship-a response to the economic pressures facing academic medicine today.

Am J Surg. 2010 Jul;200(1):162-166

Authors: Dimaggio PJ, Waer AL, Desmarais TJ, Sozanski J, Timmerman H, Lopez JA, Poskus DM, Tatum J, Adamas-Rappaport WJ

BACKGROUND: In response to declining instruction in technical skills, the authors instituted a novel method to teach basic procedural skills to medical students beginning the surgery clerkship. METHODS: Sixty-three medical students participated in a skills training laboratory. The first part of the laboratory taught basic suturing skills, and the second involved a cadaver with pig skin grafted to different anatomic locations. Clinical scenarios were simulated, and students performed essential procedural skills. RESULTS: Students learned most of their suturing skills in the laboratory skills sessions, compared with the emergency room or the operating room (P = .01). Students reported that the laboratory allowed them greater opportunity to participate in the emergency room and operating room. Students also felt that the suture laboratory contributed greatly to their skills in wound closure. Finally, 90% of students had never received instruction on suturing, and only 12% had performed any procedural skills before beginning the surgery rotation. CONCLUSIONS: The laboratory described is an effective way of insuring that necessary technical skills are imparted during the surgery rotation.

PMID: 20637348 [PubMed - as supplied by publisher]

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Educational value of the operating room experience during a core surgical clerkship.

Am J Surg. 2010 Jul;200(1):167-172

Authors: Irani JL, Greenberg JA, Blanco MA, Greenberg CC, Ashley S, Lipsitz SR, Hafler JP, Breen E

BACKGROUND: The amount and content of medical student teaching in the operating room and its alignment with clerkship goals was unknown. METHODS: A qualitative research design using field observations, followed by qualitative and quantitative data coding and analysis. RESULTS: A mean of 9.8% of the total case time (range 1.6%-20.2%) was spent teaching clerkship goals. Teaching strategies based on basic principles of learning were used during a mean of 66% of the total case time (range 30%-99%). The most common teaching strategy was active student participation (28%) followed by command (14%) and lecture (13%). Educational experience in the OR was rated 4.0 (out of 5) by faculty and 3.3 by students. No correlation existed between student satisfaction and time actively participating in the operation or time spent teaching to clerkship goals (P = .66, P = .95, respectively). CONCLUSION: Teaching in the OR is more focused on technical aspects of the operation than the goals of a core surgery clerkship.

PMID: 20637349 [PubMed - as supplied by publisher]

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Morphea of the breast-an uncommon cause of breast erythema.

Am J Surg. 2010 Jul;200(1):173-176

Authors: Clark CJ, Wechter D

BACKGROUND: Breast-associated morphea (BAM) can mimic benign and malignant inflammatory breast disorders. The aim of the current study was to document our experience with this rare sclerosing dermatologic disorder. METHOD: We conducted a retrospective study at a single institution of all patients who had pathological diagnosis of morphea between January 1995 and October 2007. RESULTS: We identified 15 patients with pathological evidence of morphea involving the breast. Two thirds of these patients were initially misdiagnosed with inflammatory breast cancer or breast infections. While 2 patients had previous exposure to external beam radiation, the remaining patients had no identifiable predisposing risk factors. BAM resulted in limited morbidity and did not result in significant disfiguration. Treatment included topical steroids, topical calcineurin inhibitor, and surgical excision. CONCLUSIONS: Our experience with BAM emphasizes the benefit of early tissue biopsy in patients with unexplained breast erythema to confirm a clinical diagnosis and thus guide subsequent therapeutic interventions.

PMID: 20637350 [PubMed - as supplied by publisher]

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Retrieval of immature oocytes from unstimulated ovaries followed by in vitro maturation and vitrification: A novel strategy of fertility preservation for breast cancer patients.

Am J Surg. 2010 Jul;200(1):177-183

Authors: Huang JY, Chian RC, Gilbert L, Fleiszer D, Holzer H, Dermitas E, Elizur SE, Gidoni Y, Levin D, Son WY, Tan SL

BACKGROUND: We report a novel fertility preservation strategy that may be useful for young breast cancer patients who present with time constraints or concerns about the effect of ovarian stimulation. METHODS: The protocol involves retrieval of immature oocyte from unstimulated ovaries followed by in vitro maturation (IVM), and vitrification of oocytes or embryos. RESULTS: Thirty-eight patients (age 24-45 years) underwent vitrification of oocytes (n = 18) or embryos (n = 20). The mean ages were 33.1 +/- 5.0 years and 34.7 +/- 4.8 years, respectively. The mean days required to complete the egg collection was 13 days. The median numbers of vitrified oocytes and embryos per retrieval were 7 (range 1-22) and 4 (range 1-13), respectively. CONCLUSIONS: The strategy of immature oocyte retrieval without ovarian stimulation followed by IVM and oocyte or embryo vitrification, which does not increase the serum estradiol level and delay cancer treatment, represents an attractive option of fertility preservation for many breast cancer patients.

PMID: 20637351 [PubMed - as supplied by publisher]

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Optimal trocar placement for ergonomic intracorporeal sewing and knotting in laparoscopic hiatal surgery.

Am J Surg. 2010 Jul 15;

Authors: Fingerhut A, Hanna GB, Veyrie N, Ferzli G, Millat B, Alexakis N, Leandros E

BACKGROUND: Trocar placement presently is mostly empiric. Our goal was to define simple distances from bony landmarks to locate the optimal ergonomic placement of manipulation trocars for access to the lower esophagus and hiatal orifice, for suture placement, and knotting of the gastric fundus and crura. Hypothesizing that the ideal ergonomic principles of a manipulation angle of 60 degrees , an elevation angle (alpha(e)) of 30 degrees to 60 degrees , and an intracorporeal/extracorporeal length ratio (I/E) of working instruments close to 1:1 are interrelated by simple trigonometric functions, the variations of each of these parameters were calculated in a dependent manner for 2 standard lengths of needle holders: 48.5 cm and 58.5 cm. RESULTS: Trocar placement can be calculated easily according to simple formulas dependent on the alpha(e), the distance from the sternoxiphoid junction to the median of the intertrocar span (d) and the vertical distance from the stenoxiphoid junction to the average distance between the apex of the hiatal orifice and the anterior aspect of the esophagus (XH’): when the alpha(e) is 30 degrees : d is XH’ radical2 and when alpha(e) is 45 degrees , d is XH’/ radical2. Likewise, when alpha(e) is 30 degrees the intertrocar span (LR) is 2XH’, half on either side of the optical axis (d), and when alpha(e) is 45 degrees , LR is XH’ radical2, XH’/ radical2 on either side of the optical axis. The most ergonomic solution is to work with an alpha(e) of 40 degrees to 45 degrees by placing the 2 working (manipulation) trocars, between 10 and 14 cm caudad from the sternoxiphoid junction, between 10 and 12 cm on either side of the longitudinal axis corresponding to the optic-target axis. The shorter needle holder works best in this configuration because the I/E ratio will be between .8 and 1. If, however, the surgeon wants to work with an alpha(e) closer to 30 degrees , then the longer needle holder should be used, and the trocars should be placed between 20 and 21 cm from the sternoxiphoid junction, 14.5 to 15 cm on either side of the optical axis. The I/E ratio will vary between 1 and 1.1. When a 1/1 I/E ratio was prioritized, the alpha(e) would be 40 degrees and 32 degrees , for the shorter and longer instruments, respectively. The deeper crural closure requires increasing the alpha(e) by 2 degrees and 3 degrees , respectively. Hyperlordosis, as obtained by placing a cushion under the patient’s back, shortens the distances, allowing placement of the trocars closer to the sternoxiphoid junction. CONCLUSIONS: Based on ergonomic principles (manipulation angle, 60 degrees ; alpha(e), 40 degrees -45 degrees ; and an I/E ratio of working instruments, close to 1:1), simple trigonometric considerations allow easy calculation of the ideal placement of trocars corresponding to working instruments in hiatal surgery necessary for ergonomic dissection, suturing, and intracorporeal knotting. Ideal trocar placement is dependent only on the vertical depth of the target organ.

PMID: 20638045 [PubMed - as supplied by publisher]

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Comparison of three mathematical models for predicting the risk of additional axillary nodal metastases after positive sentinel lymph node biopsy in early breast cancer.

Br J Surg. 2010 Jul 16;

Authors: Moghaddam Y, Falzon M, Fulford L, Williams NR, Keshtgar MR

BACKGROUND:: Women with breast cancer and a positive axillary sentinel lymph node (SLN) are recommended to undergo complete axillary lymph node dissection; however, further nodal disease is not always present. Mathematical models have been constructed to determine the risk of metastatic disease; three of these were evaluated independently. METHODS:: Data from 108 women with breast cancer who had a positive SLN biopsy and completion axillary lymph node dissection were used. Measurements of additional parameters over those usually determined (such as size of SLN metastasis) were assessed under the supervision of two pathologists. These data were used to determine the predicted risk of non-SLN metastases using three mathematical models (from Memorial Sloan-Kettering Cancer Center (MSKCC), Cambridge University and Stanford University) and a comparison made with the observed findings. Analyses were made using the area under the receiver operating characteristic (ROC) curve (AUC). RESULTS:: Some 53 (49.1 per cent) of 108 patients had a positive non-sentinel axillary lymph node metastasis. The AUC values were 0.63, 0.72 and 0.67 for the MSKCC, Cambridge and Stanford nomograms respectively. CONCLUSION:: This independent comparison found no significant difference between the models, although the Cambridge model had the advantage of requiring fewer measurements with a more accurate predictive performance. Copyright (c) 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 20641049 [PubMed - as supplied by publisher]

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Value of Memorial Sloan-Kettering Cancer Center nomogram in clinical decision making for sentinel lymph node-positive breast cancer.

Br J Surg. 2010 Jul 16;

Authors: van den Hoven I, Kuijt GP, Voogd AC, van Beek MW, Roumen RM

BACKGROUND:: The aim of this study was to determine the value of the Memorial Sloan-Kettering Cancer Center (MSKCC) nomogram for individual decision making in a Dutch cohort of women with breast cancer with a positive sentinel lymph node (SLN) but at low risk of additional nodal metastases. METHODS:: Data were collected on 168 patients with a positive SLN who underwent completion axillary lymph node dissection. The predicted probability of non-SLN metastases was calculated for each patient, using the MSKCC nomogram. Specificity and false-negative rates were calculated for subgroups with a predicted risk of no more than 5, 10 or 15 per cent. A receiver operating characteristic (ROC) curve was constructed and the area under the curve (AUC) calculated. RESULTS:: The discrimination of the MSKCC nomogram, measured by the AUC, was 0.68. For low predicted probability cut-off values of no more than 5, 10 and 15 per cent, the false-negative rates were 20, 14 and 19 per cent, and the specificities were 4, 27 and 32 per cent, respectively. The low-risk category (5 per cent or less) consisted of only 3.0 per cent of the study population. CONCLUSION:: The performance of the MSKCC nomogram was insufficient to make it a useful tool for individual decision making in this cohort of women with SLN-positive breast cancer. Copyright (c) 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 20641050 [PubMed - as supplied by publisher]

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Critical appraisal of single port access cholecystectomy.

Br J Surg. 2010 Jul 16;

Authors: Allemann P, Schafer M, Demartines N

BACKGROUND:: Single port access (SPA) cholecystectomy is a new concept in laparoscopic surgery. A review of existing results was performed to evaluate critically the current state of SPA with specific reference to feasibility, safety, learning curve, indications and cost-effectiveness. METHODS:: All papers identified in MEDLINE until 15 February 2010 and all other relevant papers obtained from cited references were reviewed, without any language restriction. Case reports and series of fewer than three patients were excluded. RESULTS:: After selection, 24 studies including 895 patients were analysed. None was randomized. Feasibility seems to be established, with a conversion rate of 2 per cent. SPA was not standardized and there was much technical variation. The learning curve could not be determined. Median follow-up time was 3 (range 0.25-12) months. The overall published complication rate was 5.4 per cent and the biliary complication rate 0.7 per cent. The rate of umbilical complications ranged from 2 to 10 per cent. CONCLUSION:: SPA cholecystectomy seems feasible, but standardization, safety and the real benefits for patients need further assessment. Uncontrolled wide adoption of this approach may be responsible for a rise in biliary complications. Copyright (c) 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 20641051 [PubMed - as supplied by publisher]

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Total parathyroidectomy without autotransplantation for renal hyperparathyroidism.

Br J Surg. 2010 Jul 16;

Authors: Coulston JE, Egan R, Willis E, Morgan JD

BACKGROUND:: Parathyroidectomy is the standard treatment for renal hyperparathyroidism although controversy exists about the optimal surgical procedure. Total parathyroidectomy without either autotransplantation or thymectomy is one suggested approach. This study reviewed the medium- to long-term results of this procedure. METHODS:: A retrospective review was undertaken of patients undergoing total parathyroidectomy between August 2000 and March 2009. The procedure was performed by a single surgeon and median follow-up was 31 (range 1-120) months. RESULTS:: Data were obtained on 115 patients with no re-explorations for bleeding or clinical recurrent laryngeal nerve injuries. The rate of postoperative hypocalcaemia on the day after surgery was 15.7 per cent. Thirty-three patients (28.7 per cent) had an undetectable parathyroid hormone level at the end of follow-up. Fourteen patients (12.2 per cent) developed recurrent hyperparathyroidism with a median parathyroid hormone level of 35.4 (range 5.4-200.0) pmol/l. The reoperation rate was 3.5 per cent. Thymectomy tissue, taken if all four glands could not be identified, revealed no parathyroid glands. CONCLUSION:: Total parathyroidectomy alone has minimal associated morbidity or mortality, and a good medium- to long-term clinical outcome with a low recurrence rate. Copyright (c) 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 20641052 [PubMed - as supplied by publisher]

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Systematic review and meta-analysis of laparoscopic Nissen (posterior total) versus Toupet (posterior partial) fundoplication for gastro-oesophageal reflux disease.

Br J Surg. 2010 Jul 16;

Authors: Broeders JA, Mauritz FA, Ahmed Ali U, Draaisma WA, Ruurda JP, Gooszen HG, Smout AJ, Broeders IA, Hazebroek EJ

BACKGROUND:: Laparoscopic Nissen fundoplication (LNF) is currently considered the surgical approach of choice for gastro-oesophageal reflux disease (GORD). Laparoscopic Toupet fundoplication (LTF) has been said to reduce troublesome dysphagia and gas-related symptoms. A systematic review and meta-analysis of randomized clinical trials (RCTs) was performed to compare LNF and LTF. METHODS:: Four electronic databases (MEDLINE, Embase, Cochrane Library and ISI Web of Knowledge CPCI-S) were searched and the methodological quality of included trials was evaluated. Outcomes included recurrent pathological acid exposure, oesophagitis, dysphagia, dilatation for dysphagia and reoperation rate. Results were pooled in meta-analyses as risk ratios (RRs) and weighted mean differences. RESULTS:: Seven eligible RCTs comparing LNF (n = 404) with LTF (n = 388) were identified. LNF was associated with a significantly higher prevalence of postoperative dysphagia (RR 1.61 (95 per cent confidence interval 1.06 to 2.44); P = 0.02) and dilatation for dysphagia (RR 2.45 (1.06 to 5.68); P = 0.04). There were more surgical reinterventions after LNF (RR 2.19 (1.09 to 4.40); P = 0.03), but no differences regarding recurrent pathological acid exposure (RR 1.26 (0.82 to 1.95); P = 0.29), oesophagitis (RR 1.20 (0.78 to 1.85); P = 0.40), subjective reflux recurrence, patient satisfaction, operating time or in-hospital complications. Inability to belch (RR 2.04 (1.19 to 3.49); P = 0.009) and gas bloating (RR 1.58 (1.21 to 2.05); P < 0.001) were more prevalent after LNF. CONCLUSION:: LTF reduces postoperative dysphagia and dilatation for dysphagia compared with LNF. Reoperation rate and prevalence of gas-related symptoms were lower after LTF, with similar reflux control. These results provide level 1a support for the use of LTF as the posterior fundoplication of choice for GORD. Copyright (c) 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 20641062 [PubMed - as supplied by publisher]

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Origin of presacral local recurrence after rectal cancer treatment.

Br J Surg. 2010 Jul 16;

Authors: Kusters M, Wallner C, Lange MM, Deruiter MC, van de Velde CJ, Moriya Y, Rutten HJ

BACKGROUND:: The objective of this study was to obtain detailed anatomical information about the lateral lymph nodes, in order to determine whether they might play a role in presacral local recurrence of rectal cancer after total mesorectal excision without lateral lymph node dissection. METHODS:: Ten serially sectioned human fetal pelvises were studied at high magnification and a three-dimensional reconstruction of the fetal pelvis was made. RESULTS:: Examination of the histological sections and the three-dimensional reconstruction showed that lateral lymph node tissue comprises a major proportion of the pelvic tissue volume. There were no lymph nodes located in the presacral area. Connections between the mesorectal and extramesorectal lymph node system were found in all fetal pelvises, located below the peritoneal reflection on the anterolateral side of the fetal rectum. At this site middle rectal vessels passed to and from the mesorectum, and branches of the autonomic nervous system bridge to innervate the rectal wall. CONCLUSION:: The findings of this study support the hypothesis that tumour recurrence might arise from lateral lymph nodes. Copyright (c) 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 20641063 [PubMed - as supplied by publisher]

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Systematic review and meta-analysis of steatosis as a risk factor in major hepatic resection.

Br J Surg. 2010 Jul 16;

Authors: de Meijer VE, Kalish BT, Puder M, Ijzermans JN

BACKGROUND:: The risk of major hepatic resection in patients with hepatic steatosis remains controversial. A meta-analysis was performed to establish the best estimate of the impact of steatosis on patient outcome following major hepatic surgery. METHODS:: A systematic search was performed following Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. Risk ratios (RRs) for complication and mortality rates were calculated for patients with no, less than 30 per cent and at least 30 per cent steatosis, and a meta-analysis was carried out. RESULTS:: Of six observational studies identified, four including a total of 1000 patients were subjected to meta-analysis; two others were tabulated separately. Compared with patients without steatosis, those with less than 30 per cent and at least 30 per cent steatosis had a significantly increased risk of postoperative complications, with a RR of 1.53 (95 per cent confidence interval (c.i.) 1.27 to 1.85) and 2.01 (1.66 to 2.44) respectively. Patients with at least 30 per cent steatosis had an increased risk of postoperative death (RR 2.79, 95 per cent c.i. 1.19 to 6.51). CONCLUSION:: Patients with steatosis had an up to twofold increased risk of postoperative complications, and those with excessive steatosis had an almost threefold increased risk of death. Copyright (c) 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

PMID: 20641066 [PubMed - as supplied by publisher]

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Neuroendocrine Liver Metastases.

Surg Clin North Am. 2010 Aug;90(4):853-861

Authors: Reddy SK, Clary BM

This review summarizes regional strategies for management of neuroendocrine liver metastases (NLM), including hepatic resection, ablation, liver transplantation, and hepatic arterial embolization/chemoembolization. Despite early disease recurrence and/or progression, resection of NLM with or without combined ablation provides long-term survival and symptom improvement. When complete resection of gross liver disease is not feasible, resection as a tumor debulking strategy should be considered in patients with extreme hormonal symptoms refractory to other treatments or with tumors in locations that would affect short-term quality of life. Hepatic arterial embolization with or without local instillation of chemotherapy may induce disease response, symptomatic improvement, and prolonged survival in patients with unresectable NLM. Early disease recurrence, high postoperative mortality, the absence of extensive experience, and lack of universal indications for organ allocation preclude orthotopic liver transplantation as an option for most patients with unresectable NLM.

PMID: 20637952 [PubMed - as supplied by publisher]

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Hepatic Tumor Ablation.

Surg Clin North Am. 2010 Aug;90(4):863-876

Authors: Sindram D, Lau KN, Martinie JB, Iannitti DA

Ablation of liver tumors is part of a multimodality liver-directed strategy in the treatment of various tumors. The goal of ablation is complete tumor destruction, and ultimately improvement of quality and quantity of life for the patient. Technology is evolving rapidly, with important improvements in efficacy. The current state of ablation technology and indications for ablation are described in this review.

PMID: 20637953 [PubMed - as supplied by publisher]

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Fulminant Hepatic Failure: When to Transplant.

Surg Clin North Am. 2010 Aug;90(4):877-889

Authors: Khanna A, Hemming AW

Fulminant hepatic failure is a life-threatening condition that can lead to rapid deterioration and death if timely treatment is not instituted. Many patients recover with supportive care. Patients with deteriorating signs and laboratory parameters require prompt assessment and listing for liver transplantation. Outcome following transplantation is a function of severity of illness before transplantation, timeliness of liver transplantation and graft quality and function. With appropriate immunosuppression and close follow-up most patients can lead near normal lives following liver transplantation.

PMID: 20637954 [PubMed - as supplied by publisher]

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Lymph Node Involvement and Surgical Approach in Parathyroid Cancer.

World J Surg. 2010 Jul 17;

Authors: Schulte KM, Talat N, Miell J, Moniz C, Sinha P, Diaz-Cano S

BACKGROUND: The best surgical approach to parathyroid cancer is disputed. Recommendations vary and are built on incoherent evidence. High rates of recurrence and death require an in-depth review of underlying findings. METHODS: This retrospective study includes 11 patients with parathyroid cancer who underwent surgery with central and/or lateral neck dissection by a single surgeon between 2005 and 2010. The diagnosis was based on histopathological criteria in all patients. Patterns of lymph node and soft tissue involvement of these and formerly reported patients were analysed based on full-text review of all published cases of parathyroid cancer. RESULTS: In this series only 1 of 11 patients (9.1%) manifested lymph node metastasis. In the literature, lymph node metastases have been reported in only 6.5% of 972 published patients, or in 32.1% of the 196 in whom lymph node involvement was assessed by the authors. They were, with few exceptions, localised in the central compartment. Recurrence in soft tissue is more frequent than in locoregional lymph nodes. CONCLUSION: Oncological en bloc clearance of the central compartment with meticulous removal of all possibly involved soft tissues, including a systematic central lymph node resection, may improve outcomes and should be included in the routine approach to the suspicious parathyroid lesion. There is no need for a prophylactic lateral neck dissection.

PMID: 20640422 [PubMed - as supplied by publisher]

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Enteric Fistulation After Renal Artery Reconstruction: A Systematic Literature Review.

World J Surg. 2010 Jul 17;

Authors: Bergqvist D, Björck M

A systematic literature review has revealed 14 cases of arterioenteric fistulation after renovascular reconstruction. Among the 14 patients, 9 had thrombotic occlusion of the reconstruction and 5 underwent nephrectomy, but neither procedure prevented fistulation. There was a dominance of right-sided bypass reconstructions. All patients but one suffered from gastrointestinal bleeding; 3 died before operation and 5 had herald bleeds. Three died as a direct result of surgery. Various technical solutions were used, and the follow-up time was clearly unsatisfactory; in only 2 patients was the follow-up longer than 1 year. Arterioenteric fistulation is a serious complication, associated with a highmortality rate and a high incidence of kidney loss among survivors.

PMID: 20640423 [PubMed - as supplied by publisher]

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Collagen in the transversalis fascia of patients with inguinal hernia.

Am J Surg. 2010 Jul 12;

Authors: Pascual G, Bellón JM

PMID: 20630494 [PubMed - as supplied by publisher]

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Giant Solitary Fibrous Tumor of the Pleura: An Analysis of Five Patients.

World J Surg. 2010 Jul 14;

Authors: Guo J, Chu X, Sun YE, Zhang L, Zhou N

BACKGROUND: Solitary fibrous tumor of the pleura (SFTP) represents a clinical entity rarely encountered, especially in giant forms. Complete surgical resection for giant tumor of pleura is a challenge. The aim of this article is to present five new cases of giant SFTP, and to discuss their clinical characteristics and the treatment strategy of such neoplasms. METHODS: We performed a retrospective review of the clinical records of five patients who underwent surgery for a huge SFTP (>18 cm in diameter) between 2007 and 2009. RESULTS: Four patients were symptomatic. All five patients underwent angiography and embolization of the tumor-supplying vessels within 24 h of surgery. All giant tumors were removed completely by extended postlateral thoracotomy with moderate intraoperative bleeding. Two wedge resections and one lobectomy were performed in three cases where the parenchyma had been encroached. Tumors in three patients were pathologically benign; those in the other two were malignant. The symptoms disappeared in all cases after surgery. CONCLUSIONS: Complete resection remains the mainstay of cure for giant SFTP. We recommend preoperative angiography and embolization for giant SFTP which can reduce the risk of hemorrhage and can contribute to piecemeal removal for radical excision.

PMID: 20628740 [PubMed - as supplied by publisher]

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Clinical Outcomes of Patients with Papillary Thyroid Carcinoma after the Detection of Distant Recurrence.

World J Surg. 2010 Jul 14;

Authors: Ito Y, Higashiyama T, Takamura Y, Kobayashi K, Miya A, Miyauchi A

PURPOSE: Papillary thyroid carcinoma generally has an excellent prognosis but can have recurrence to the distant organs that is often life-threatening. To date, prognosis and prognostic factors of papillary carcinoma have been intensively investigated, but our knowledge regarding prognosis after the detection of distant recurrence remains inadequate. METHODS: We investigated the prognosis and prognostic factors of papillary carcinoma after distant recurrence was detected during follow-up in a series of 105 patients who underwent locally curative surgery between 1987 and 2004. RESULTS: To date, 30 patients (29%) have died of carcinoma, and the 5-year and 10-year cause-specific survival (CSS) rates after the detection of distant recurrence were 71 and 50%, respectively. Patients aged 55 years or older at recurrence or with massive extrathyroid extension of primary lesions demonstrated a significantly worse CSS. On multivariate analysis, these two parameters were recognized as independent prognostic factors. Gender, tumor size, and lymph node metastasis did not affect patient prognosis. Uptake of radioactive iodine (RAI) to distant metastasis was not significantly linked to CSS, but none of the patients younger than aged 55 years showing RAI uptake died of carcinoma. Appearance of distant recurrence to organs other than lung also predicted a dire prognosis. CONCLUSIONS: Age at recurrence and extrathyroid extension of primary lesions were significantly related to patient prognosis after the detection of distant recurrence. RAI therapy is effective, especially for younger patients, if metastatic lesions show RAI uptake.

PMID: 20628741 [PubMed - as supplied by publisher]