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A Marriage of Databases Produces Knowledge Offspring
01 Dec 2013 06:00 am
No abstract available
A Novel Approach to Assessing Technical Competence of Colorectal Surgery Residents:
The Development and Evaluation of the Colorectal Objective Structured Assessment of
Technical Skill (COSATS)
01 Dec 2013 06:00 am
Objective: To develop and evaluate an objective method of technical skills assessment for graduating
subspecialists in colorectal (CR) surgery—the Colorectal Objective Structured Assessment of Technical
Skill (COSATS). Background: It may be reasonable for the public to assume that surgeons certified as
competent have had their technical skills assessed. However, technical skill, despite being the hallmark of a
surgeon, is not directly assessed at the time of certification by surgical boards. Methods: A procedurebased, multistation technical skills examination was developed to reflect a sample of the range of skills
necessary for CR surgical practice. These consisted of bench, virtual reality, and cadaveric models.
Reliability and construct validity were evaluated by comparing 10 graduating CR residents with 10
graduating general surgery (GS) residents from across North America. Expert CR surgeons, blinded to level
of training, evaluated performance using a task-specific checklist and a global rating scale. The mean global
rating score was used as the overall examination score and a passing score was set at “borderline
competent for CR practice.” Results: The global rating scale demonstrated acceptable interstation reliability
(0.69) for a homogeneous group of examinees. Both the overall checklist and global rating scores
effectively discriminated between CR and GS residents (P < 0.01), with 27% of the variance attributed to
level of training. Nine CR residents but only 3 GS residents were deemed competent. Conclusions: The
Colorectal Objective Structured Assessment of Technical Skill effectively discriminated between CR and GS
residents. With further validation, the Colorectal Objective Structured Assessment of Technical Skill could
be incorporated into the colorectal board examination where it would be the first attempt of a surgical
specialty to formally assess technical skill at the time of certification.
A Randomized Phase II Study of Immunization With Dendritic Cells Modified With
Poxvectors Encoding CEA and MUC1 Compared With the Same Poxvectors Plus GM-CSF
for Resected Metastatic Colorectal Cancer
01 Dec 2013 06:00 am
Objective: To determine whether 1 of 2 vaccines based on dendritic cells (DCs) and poxvectors encoding
CEA (carcinoembryonic antigen) and MUC1 (PANVAC) would lengthen survival in patients with resected
metastases of colorectal cancer (CRC). Background: Recurrences after complete resections of metastatic
CRC remain frequent. Immune responses to CRC are associated with fewer recurrences, suggesting a role
for cancer vaccines as adjuvant therapy. Both DCs and poxvectors are potent stimulators of immune
responses against cancer antigens. Methods: Patients, disease-free after CRC metastasectomy and
perioperative chemotherapy (n = 74), were randomized to injections of autologous DCs modified with
PANVAC (DC/PANVAC) or PANVAC with per injection GM-CSF (granulocyte-macrophage colonystimulating factor). Endpoints were recurrence-free survival overall survival, and rate of CEA-specific
immune responses. Clinical outcome was compared with that of an unvaccinated, contemporary group of
patients who had undergone CRC metastasectomy, received similar perioperative therapy, and would have
otherwise been eligible for the study. Results: Recurrence-free survival at 2 years was similar (47% and
55% for DC/PANVAC and PANVAC/GM-CSF, respectively) (χ2P = 0.48). At a median follow-up of 35.7
months, there were 2 of 37 deaths in the DC/PANVAC arm and 5 of 37 deaths in the PANVAC/GM-CSF
arm. The rate and magnitude of T-cell responses against CEA was statistically similar between study arms.
As a group, vaccinated patients had superior survival compared with the contemporary unvaccinated group.
Conclusions: Both DC and poxvector vaccines have similar activity. Survival was longer for vaccinated
patients than for a contemporary unvaccinated group, suggesting that a randomized trial of poxvector
vaccinations compared with standard follow-up after metastasectomy is warranted. (NCT00103142)
A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of
0.9% saline and plasma-lyte(R) 148 on renal blood flow velocity and renal cortical tissue
perfusion in healthy volunteers
01 Dec 2013 06:00 am
No abstract available
A small amount can make a difference: a prospective human study of the paradoxical
coagulation characteristics of hemothorax
01 Dec 2013 12:00 am
Abstract: Background: The evacuated hemothorax has been poorly described because it varies with time, it
has been found to be incoagulable, and its potential effect on the coagulation cascade during
autotransfusion is largely unknown.Methods: This is a prospective descriptive study of adult patients with
traumatic chest injury necessitating tube thoracostomy. Pleural and venous samples were analyzed for
coagulation, hematology, and electrolytes at 1 to 4 hours after drainage. Pleural samples were also
analyzed for their effect on the coagulation cascade via mixing studies.Results: Thirty-four subjects were
enrolled with a traumatic hemothorax. The following measured coagulation factors were significantly
depleted compared with venous blood: international normalized ratio (>9 vs 1.1) (P < .001) and activated
partial thromboplastin time (aPTT) (>180 vs 24.5 seconds) (P < .001). Mixing studies showed a dosedependent increase in coagulation dilutions through 1:8 (P < .05).Conclusions: An evacuated hemothorax
does not vary in composition significantly with time and is incoagulable alone. Mixing studies with
hemothorax plasma increased coagulation, raising safety concerns.
Alterations of Global Gastrointestinal Motility After Sleeve Gastrectomy: A Prospective
Study
01 Dec 2013 06:00 am
Objectives: To evaluate the role of sleeve gastrectomy (SG) in gastrointestinal motility. Background: SG is a
widely used bariatric operation leading to weight loss and early improvement of patient's metabolic profile.
Current data indicate faster postoperative gastric emptying, but detailed studies on alterations in small
bowel motility are missing. Design: We evaluated 21 morbidly obese patients who underwent laparoscopic
SG before and 4 months after the procedure. After consumption of a semisolid radiolabeled meal, their
gastric and intestinal transit times were studied with a gamma camera. Particularly the times of 10% gastric
emptying, 50% gastric emptying, maximal intestinal filling, 10% terminal ileum filling, duodenal to terminal
ileum transit, cecal filling initiation, and ileocecal valve transit (T ICVt) were studied pre- and
postoperatively. Results: Ten percent gastric emptying and 50% gastric emptying were decreased
postoperatively as well as maximal intestinal filling, indicating faster gastric emptying and intestinal filling.
Duodenal to terminal ileum transit and 10% terminal ileum filling also decreased as small bowel transit time
accelerated and the meal reached the terminal ileum more rapidly. Contrary opening of the ileocecal valve
and food transit through it were delayed, with postoperative increase in cecal filling initiation and T ICVt,
respectively. Conclusions: SG accelerates gastric emptying and small bowel transit of semisolids. In
addition, it delays the initiation of cecal filling and T ICVt. This early and prolonged contact of food with the
distal small bowel mucosa may explain the metabolic effects of SG occurring before substantial weight loss.
Alternative dosing of prophylactic enoxaparin in the trauma patient: is more the answer?
01 Dec 2013 12:00 am
Abstract: Background: Inadequate anti–factor Xa levels and increased venous thromboembolic events
occur in trauma patients receiving standard prophylactic enoxaparin dosing. The aim of this study was to
test the hypothesis that higher dosing (40 mg twice daily) would improve peak anti-Xa levels and decrease
venous thromboembolism.Methods: A retrospective review was performed of trauma patients who received
prophylactic enoxaparin and peak anti-Xa levels over 27 months. Patients were divided on the basis of
dose: group A received 30 mg twice daily, and group B received 40 mg twice daily. Demographics and rates
of venous thromboembolism were compared between dose groups and patients with inadequate or
adequate anti-Xa levels.Results: One hundred twenty-four patients were included, 90 in group A and 34 in
group B. Demographics were similar, except that patients in group B had a higher mean body weight.
Despite this, only 9% of group B patients had inadequate anti-Xa levels, compared with 33% of those in
group A (P = .01). Imaging studies were available in 69 patients and revealed 8 venous thromboembolic
events (P = NS, group A vs group B) with significantly more venous thromboembolic events occurring in
patients with low anti-Xa levels (P = .02).Conclusions: Although higher dosing of enoxaparin led to improved
anti-Xa levels, this did not equate to a statistical decrease in venous thromboembolism.
Assessing the Impact of a Sacral Resection on Morbidity and Survival After Extended
Radical Surgery for Locally Recurrent Rectal Cancer
01 Dec 2013 06:00 am
Objectives: To describe the experience of sacrectomy with extended radical resection in the treatment of
locally recurrent rectal cancer. Background: Resections of the bony pelvis, especially the sacrum, are
becoming more common as part of extended radical exenterations for patients with recurrent rectal cancer.
However, sacrectomy has been shown to carry a significant decrease in survival. Morbidity rates have been
associated with the level of the sacrectomy (ie, >S3 junction). Methods: An analysis was conducted using
prospective data from patients with recurrent rectal cancer who underwent pelvic exenteration involving
sacrectomy from July 1998 until June 2011. The impact of the proximal level of sacrectomy [low (≤S3) vs
high (≥S2–S3 disc)] was compared. Results: Of 240 exenteration patients, 79 underwent sacrectomy, with
49 for recurrent rectal cancer. An R0 margin was achieved in 36 (74%) patients. Achievement of clear
operative margins (R0) conferred a large and significant benefit for disease-free survival compared with R1
and R2 resections (median 45 months vs 19 and 8 months, respectively; P = 0.045). Complications were
reported in 40 (82%) patients, with major and minor complications in 19 (39%) and 38 (78%) patients,
respectively. The proximal level of the sacrectomy (high vs low) did not significantly impair the ability to
achieve a clear margin and was not associated with an increase in major or minor complications.
Conclusions: This large, single-center series has demonstrated that extended pelvic exenteration involving
sacrectomy has excellent R0 margins and survival rates for recurrent rectal cancer. A high sacrectomy has
comparable results with a more distal abdominosacral resection.
Author Index
01 Dec 2013 12:00 am
Autologous Bone Marrow–Derived Cell Therapy in Patients With Critical Limb Ischemia: A
Meta-Analysis of Randomized Controlled Clinical Trials
01 Dec 2013 06:00 am
Background: Critical Limb Ischemia (CLI) is the most advanced stage of peripheral arterial disease and is
usually treated with bypass surgery or endovascular revascularization. However, a considerable proportion
of CLI patients are not eligible to these treatment strategies and amputation is often the only option left. In
the past decade, research has focused on bone marrow (BM)–derived cell-based strategies that aim at
neovascularization to improve limb perfusion. Individual studies did not convincingly prove efficacy of BMderived cell therapy in CLI patients thus far. Objectives: Perform a meta-analysis of all randomized
controlled trials (RCTs) available that studied BM-derived cell therapy compared to standard care with or
without placebo in CLI patients and provide summary efficacy data on this approach. Methods: A systematic
search in the electronic databases of Medline, Embase, and the Cochrane Controlled Trials Register was
performed. All studies were critically appraised and data were extracted and meta-analyzed using a
random-effects model. Major amputation and amputation-free survival were considered as the primary
endpoints. Results: A total of 12 RCTs jointly including 510 CLI patients were identified and analyzed. The
meta-analysis showed beneficial effects of BM-derived cell therapy on both subjective and surrogate
objective endpoints, that is, pain score, pain-free walking distance, ankle-brachial index, and
transcutaneous oxygen measurements (all P < 0.00001). Overall, the RCTs showed reduced amputation
rates in the therapeutic arms of the included trials with a relative risk (RR) on major amputation of 0.58
[95% confidence interval (CI), 0.40–0.84; P = 0.004]. However, when only the placebo-controlled RCTs
were considered, the beneficial effect on major amputation rates was considerably reduced and
nonsignificant (RR = 0.78; 95% CI, 0.40–1.51; P = 0.46). Amputation-free survival did not significantly differ
between the BM treated and the control group (RR = 1.16; 95% CI, 0.92–1.48; P = 0.22). Conclusions: This
meta-analysis underlines the promising potential of BM-derived cell therapy in CLI patients. Importantly, the
results of placebo-controlled and non–placebo-controlled RCTs seem to diverge, which stresses the
necessity to use placebo in the control arms of these trials. Future well-designed larger placebo-controlled
RCTs are needed and should include long-term follow-up data to assess durability of treatment effects.
Benefit of Systematic Segmentectomy of the Hepatocellular Carcinoma: Revisiting the Dye
Injection Method for Various Portal Vein Branches
01 Dec 2013 06:00 am
Background: Systematic segmentectomy is useful in treating small hepatocellular carcinoma in the cirrhotic
liver. However, accomplishment of an exact systematic segmentectomy still remains a challenging
procedure because of the variable anatomy of portal branches. We evaluated the usefulness of the dye
injection method for systematic segmentectomy, which focuses on the various patterns of portal vein (PV)
branches feeding the tumor. Methods: From January 2001 to May 2011, systematic segmentectomy by the
dye injection method was performed in 70 patients. We evaluated the efficiency of systematic
segmentectomy by ultrasonogram-guided dye injection into the portal branches that feed the tumor-bearing
segments. The type of tumor-feeding PV branch, perioperative outcome, and survival rates were analyzed
retrospectively. Results: There were variations in the PV branches that fed the masses in 70 patients in
whom the dye injection method for anatomical segmentectomy was tried. Forty masses (54.8%) were fed
by a single main PV branch (type 1), 17 masses (23.3%) by a couple of PV branches (type 2), and 11
masses (15.1%) were supplied partially by single PV branch (type 3). In 5 patients (7.1%), masses were
supplied by several small distributed PVs (type 4). For types 1 and 2, the tumor-bearing segments were
resected anatomically with the help of staining; type 3 was partially stained and as the opposite side was
not discrete, it was demarcated through counterstaining; and in type 4, dye injection could not be
performed. Anatomical systematic segmentectomy was obtained in types 1 to 3; however, nonanatomical
resection was inevitable for type 4. The 3- and 5-year overall survival rates were 80.5% and 67.2%,
respectively, and the 3- and 5-year disease-free survival rates were 61.5% and 42.5%, respectively. The
anatomical segmentectomy group showed better overall and disease-free survival than the nonanatomical
group, even though it is not significant statistically. Conclusion: Systematic segmentectomy by the dye
injection method overcomes the variation in PV tributaries in the segments and can be done according to
the natural branching pattern of PVs.
Blood transfusions in colorectal cancer surgery: incidence, outcomes, and predictive
factors: an American College of Surgeons National Surgical Quality Improvement Program
analysis
01 Dec 2013 12:00 am
Abstract: Background: Data analyzing the short-term outcomes and predictors of blood transfusions (BTs)
in colorectal cancer (CRC) surgery are limited.Methods: The American College of Surgeons National
Surgical Quality Improvement Program (2005 to 2010) was retrospectively reviewed for CRC cases
performed with or without BT. Patient demographics, comorbidities, and operative variables were analyzed.
Multivariate regression analysis was performed examining the effect of BT on outcomes. The LASSO
algorithm for logistic regression was used to build a predictive model for BT taking into account preoperative
and operative variables.Results: A total of 27,120 patients underwent CRC, and 3,815 (14.07%) had BTs.
Transfusions were associated with increased mortality (odds ratio [OR], 1.78), morbidity (OR, 2.38), length
of stay (mean difference, 3.52 days), pneumonia (OR, 2.70), and surgical-site infection (OR, 1.45). This
effect was “dose dependent,” as patients receiving ≥3 U of blood had increased morbidity (OR, 1.53),
lengths of stay (mean difference, 1.82 days), pneumonia (OR, 2.52), and surgical-site infections (OR, 1.60)
compared with those receiving 1 to 2 U. Predictors of BT were hematocrit <38%, open surgery,
proctectomy, low platelet count, American Society of Anesthesiologists class IV or V, total colectomy,
metastatic cancer, emergency, ascites, and infection. All P values were < .05.Conclusions: BTs are
associated with worse short-term outcomes after CRC surgery. Knowledge of predictive factors will help in
risk stratification and counseling.
CONSORT Compliance in Surgical Randomized Trials: Are We There Yet? A Systematic
Review
01 Dec 2013 06:00 am
Objective: We performed a systematic review assessing the reporting quality of trials of surgical
interventions, and explored associated trial level variables. Background: Randomized controlled trials
(RCTs) provide clinicians with the best evidence for the effects of interventions, but may not be reported
with necessary detail. Methods: In May 2009, 3 databases (MEDLINE, EMBASE, and CENTRAL) were
searched for RCTs that assessed a surgical intervention using a comprehensive electronic strategy
developed by the Cochrane Collaboration. The Consolidated Standards of Reporting Trials (CONSORT)
checklist was used as a measure of reporting quality. An overall CONSORT score was calculated and
expressed as a proportion. This was supplemented with domains related to external validity. We also
collected data on characteristics hypothesized to improve reporting quality, and exploratory regression was
performed to determine associations. Results: One hundred fifty recently published RCTs were included.
The most commonly represented surgical subspecialties were general (29%), orthopedic (23%), and
cardiothoracic (13%). Most (65%) were published in subspecialty surgical journals. Overall reporting quality
was low, with only 55% of CONSORT items addressed. Less than half of trials described adequate
methods for sample size calculation (45%), random sequence generation (43%), allocation concealment
(45%), and blinding (37%). The strongest associations with reporting quality were adequate methods
related to methodological domains, an author with an epidemiology/statistics degree, and a longer report
length. Conclusions: There remains much room for improvement for the reporting of surgical intervention
trials. Authors and journal editors should apply existing reporting guidelines, and guidelines specific to the
reporting of surgical interventions should be developed.
Contemporary management of abdominal surgical emergencies in infants and children
29 Nov 2013 09:20 am
Background Acute abdominal complaints in children are common presentations in the emergency
department. The aetiology, presentation, diagnosis and management often differ from those in adults.
Methods This review was based on expert paediatric surgical experience confirmed by evidence from the
literature obtained by searching PubMed and the Cochrane Library. Keywords used were the combinations
of ‘abdominal emergencies’, ‘acute abdomen’ and the disorders ‘acute appendicitis’, ‘intussusception’,
‘volvulus’, ‘Meckel's diverticulum’, ‘incarcerated inguinal hernia’, ‘testicular torsion’ and ‘ovarian torsion’ with
‘children’. Information was included from reviews, randomized clinical trials, meta-analyses, and prospective
and retrospective cohort studies. Results Presentation and symptoms of abdominal emergencies, especially
in young children, vary widely, which renders recognition of the underlying disorder and treatment
challenging. Critically targeted imaging techniques are becoming increasingly important in obtaining the
correct diagnosis without unnecessary delay. Minimally invasive techniques have become the method of
choice for the diagnosis and treatment of many abdominal emergencies in children. Conclusion Knowledge
of abdominal disorders in childhood, their specific presentation, diagnosis and treatment facilitates
management of children with acute abdomen in emergency departments. Imaging and minimally invasive
techniques are becoming increasingly important in the diagnosis of acute abdomen in children. Urgent
operation remains the cornerstone of therapy for most acute abdominal disorders.
Contents
01 Dec 2013 12:00 am
Determinants of surgical decision making: a national survey
01 Dec 2013 12:00 am
Abstract: Background: We conducted a national survey of general surgeons to address the association
between surgeon characteristics and the tendency to recommend surgery.Methods: We used a web-based
survey with 25 hypothetical clinical scenarios with clinical equipoise regarding the decision to operate. The
respondent-level tendency to operate (TTO) score was calculated as the average score over the 25
scenarios. Surgical volume was based on self-report. Linear regression models were used to evaluate the
associations between TTO, other covariates of interest, and surgical volume.Results: There were 907
respondents. The mean surgical TTO was 3.05 ± .43. Surgeons had significantly lower TTO scores when
responding to questions within their area of practice (P < .0001). There was no association between TTO
and malpractice concerns, financial incentives, or compensation structure.Conclusions: Surgeons
recommend intervention far less frequently within their area of specialization. Malpractice concerns, volume,
and financial compensation do not significantly affect surgical decision making.
Dilated Distal Esophagus: Optimal Position for Magnetic Sphincter Augmentation
01 Dec 2013 12:00 am
Due to the symptoms and the cancer risk among those with Barrett's esophagus, gastroesophageal reflux
disease (GERD) impairs the life quality and productivity of patients. Magnetic sphincter augmentation
(MSA) represents a novel laparoscopic method for surgical GERD treatment. The highly important study by
Bonavina and colleagues, which was published in a recent issue of the Journal of the American College of
Surgeons, reports 1.2- to 6-year follow-up data after MSA implant. Normalization of esophageal acid
exposure paralleled improvement of symptoms and life quality in approximately 90% to 93% of the patients
in the absence of proton pump inhibitor therapy. The MSA had to be removed in only 3 patients. So, when
performed in experienced hands, MSA represents an effective, but less invasive alternative to
fundoplication for the surgical treatment of GERD. The impact of our novel understanding regarding the
surgical anatomy of the esophagogastric junction (EGJ) for MSA placement remains to be seen.
Disruptive technology in the treatment of thoracic trauma
01 Dec 2013 12:00 am
Abstract: The care of patients with thoracic injuries has undergone monumental change over the past 25
years. Advances in technology have driven improvements in care, with obvious benefits to patients. In many
instances, new or “disruptive” technologies have unexpectedly displaced previously established standards
for the diagnosis and treatment of these potentially devastating injuries. Examples of disruptive technology
include the use of ultrasound technology for the diagnosis of cardiac tamponade and pneumothorax;
thoracoscopic techniques instead of thoracotomy, pulmonary tractotomy, and stapled lung resection;
endovascular repair of thoracic aortic injury; operative fixation of flail chest; and the enhanced availability of
extracorporeal lung support for severe respiratory failure. Surgeons must be prepared to recognize the
benefits, and limits, of novel technologies and incorporate these methods into day-to-day treatment
protocols.
Do Safety Checklists Improve Teamwork and Communication in the Operating Room? A
Systematic Review
01 Dec 2013 06:00 am
Objectives: The aim of this systematic review was to assess the impact of surgical safety checklists on the
quality of teamwork and communication in the operating room (OR). Background: Safety checklists have
been shown to impact positively on patient morbidity and mortality following surgery, but it is unclear
whether this clinical improvement is related to an improvement in OR teamwork and communication.
Methods: A systematic search strategy of MEDLINE, EMBASE, PsycINFO, Google Scholar, and the
Cochrane Database for Systematic Reviews was undertaken to obtain relevant articles. After de-duplication
and the addition of limits, 315 articles were screened for inclusion by 2 researchers and all articles meeting
a set of prespecified inclusion criteria were retained. Information regarding the type of checklist, study
design, assessment tools used, outcomes, and study limitations was extracted. Results: Twenty articles
formed the basis of this systematic review. All articles described an empirical study relating to a casespecific safety checklist for surgery as the primary intervention, with some measure of change/improvement
in teamwork and/or communication relating to its use. The methods for assessing teamwork and
communication varied greatly, including surveys, observations, interviews, and 360° assessments. The
evidence suggests that safety checklists improve the perceived quality of OR teamwork and communication
and reduce observable errors relating to poor team skills. This is likely to function through establishing an
open platform for communication at the start of a procedure: encouraging the sharing of critical case-related
information, promoting team coordination and decision making, flagging knowledge gaps, and enhancing
team cohesion. However, the evidence would also suggest that when used suboptimally or when individuals
have not bought in to the process, checklists may conversely have a negative impact on the function of the
team. Conclusions: Safety checklists are beneficial for OR teamwork and communication and this may be
one mechanism through which patient outcomes are improved. Future research should aim to further
elucidate the relationship between how safety checklists are used and team skills in the OR using more
consistent methodological approaches and utilizing validated measures of teamwork such that best practice
guidelines can be established.
Early diagnosis of necrotizing fasciitis
29 Nov 2013 09:20 am
Background Necrotizing fasciitis is a rapidly progressing skin infection characterized by necrosis of the
fascia and subcutaneous tissue, accompanied by severe systemic toxicity. The objective of this systematic
review was to identify clinical features and investigations that will aid early diagnosis. Methods A systematic
literature search of PubMed was undertaken using the keywords ‘necrotising fasciitis’, ‘necrotising skin
infection’, ‘diagnosis’ and ‘outcome’. Case series of 50 or more subjects with information on symptoms and
signs at initial presentation, investigations and clinical outcome were included. Results Nine case series
were selected, with a total of 1463 patients. Diabetes mellitus was a co-morbidity in 44·5 per cent of
patients. Contact with marine life or ingestion of seafood in patients with liver disease were risk factors in
some parts of Asia. The top three early presenting clinical features were: swelling (80·8 per cent), pain
(79·0 per cent) and erythema (70·7 per cent). These being non-specific features, initial misdiagnosis was
common and occurred in almost three-quarters of patients. Clinical features that helped early diagnosis
were: pain out of proportion to the physical findings; failure to improve despite broad-spectrum antibiotics;
presence of bullae in the skin; and gas in the soft tissue on plain X-ray (although this occurred in only 24·8
per cent of patients). Conclusion A high index of suspicion of necrotizing fasciitis is needed in a patient
presenting with cutaneous infection causing swelling, pain and erythema, with co-morbidity of diabetes or
liver disease. The presence of bullae, or gas on plain X-ray can be diagnostic. Early surgical exploration is
the best approach in the uncertain case.
Editorial Board
01 Dec 2013 12:00 am
Effect of Major and Minor Surgery on Plasma Levels of Arginine, Citrulline, Nitric Oxide
Metabolites, and Ornithine in Humans
01 Dec 2013 06:00 am
Objective: To determine the effect of surgical invasiveness on plasma levels of arginine, citrulline, ornithine,
and nitric oxide (NO) in humans. Background: Surgical trauma may have a profound effect on the
metabolism of NO. However, human studies reported both increased and decreased NO levels after
hemorrhagic shock. Arginine, citrulline, and ornithine are key amino acids involved in NO metabolism, but
studies evaluating these amino acids together with NO and during 2 types of surgery are lacking. This study
tests the hypothesis that major surgery has a more profound effect on plasma levels of arginine, citrulline,
NO, and ornithine than minor surgery. Methods: Fifteen patients undergoing minor surgery (vulvectomy)
and 13 patients undergoing major surgery (laparotomy) were prospectively followed up for 4 days. Plasma
was collected for evaluation of levels of arginine, citrulline, NO, and ornithine. Results: Throughout the
experiment, arginine levels did not significantly differ between experimental groups. Perioperative plasma
citrulline levels were significantly lower in the laparotomy group than in the vulvectomy group, whereas both
groups showed a decrease in citrulline levels at the end of the operation and 24 hours postoperatively.
Roughly the same pattern was seen for plasma NO and ornithine levels. However, ornithine levels in the
laparotomy group showed a more drastic decrease at the end of the operation and 24 hours postoperatively
than citrulline and NO levels. Conclusions: The level of surgical invasiveness has the most profound effect
on plasma levels of ornithine. In addition, heavier surgical trauma is paired with lower postoperative levels
of citrulline and NO metabolites than lighter surgery. It is suggested that surgical trauma stimulates the
laparotomy group to consume significantly more ornithine, possibly for use in wound healing.
Effect of Noise on Auditory Processing in the Operating Room
01 Dec 2013 12:00 am
We read with interest the article by Way and colleagues on the effect of noise on auditory processing in the
operating room (OR). Unfortunately, we have several concerns about this study.
Effect of Postoperative Complications on Adjuvant Chemotherapy Use for Stage III Colon
Cancer
01 Dec 2013 06:00 am
Objective: The National Quality Forum has endorsed a quality metric concerning the use of adjuvant
chemotherapy administration in stage III colon cancer, yet a substantial treatment gap exists. Our objective
was to evaluate the association of postoperative complications on the use of adjuvant therapy after
colectomy for cancer. Patients and Methods: Data from the American College of Surgeons National
Surgical Quality Improvement Program and National Cancer Data Base were linked to augment cancer
registry information with robust clinical data on comorbidities and postoperative complications (2006–2008).
The association of complications on adjuvant chemotherapy use was assessed using hierarchical
multivariable regression models. Results: From 126 hospitals, 2368 patients underwent resection for stage
III colon adenocarcinoma. Overall utilization of adjuvant chemotherapy was 63.2% (1497/2368). Of the 871
patients who did not receive chemotherapy, 652 met National Quality Forum exclusion criteria: death,
severe comorbidity, refusal of care, advanced age (≥80 years), or prior malignancy. Of the remaining 219
patients, 19.1% (42/219) had 1 or more serious postoperative complications (eg, pneumonia, pulmonary
failure). After accounting for the aforementioned potential explanations, the utilization rate was 87.2%
(1497/1716). The strongest predictors of adjuvant chemotherapy omission were prolonged postoperative
ventilation, renal failure, reintubation, and pneumonia (all Ps < 0.05). Superficial surgical site infection did
not decrease adjuvant therapy receipt but delayed the time to its use by 3-fold. Serious complications
increased time to chemotherapy by 65%. Abscess/anastomotic leak increased time to adjuvant
chemotherapy by more than 5-fold. Conclusions: Serious postoperative complications explained nearly 20%
of the adjuvant chemotherapy treatment gap for patients with stage III colon cancer. The use of clinical data
remains important when judging provider performance.
Goal directed fluid resuscitation decreases time for lactate clearance and facilitates early
fascial closure in damage control surgery
01 Dec 2013 12:00 am
Abstract: Background: Damage-control surgery frequently results in open abdomen. The objective of this
study was to determine whether resuscitation with goal-directed fluid therapy (GDT) using “dynamic”
hemodynamic indices via modern pulse contour analysis devices such as the FloTrac Vigileo monitor leads
to lower fluid requirements, subsequent quicker abdominal closure, and overall improved outcomes in these
patients.Methods: Patients admitted to the surgical intensive care unit with open abdomen were
retrospectively reviewed. Those resuscitated with Vigileo-guided GDT were matched to those resuscitated
by static clinical parameters.Results: Total fluid intake and vasopressor requirements were similar in both
groups. GDT with the Vigileo allowed earlier lactate clearance and reduced the number of days until
abdominal wall closure by an average of .99 days.Conclusions: Vigileo-mediated GDT did not affect fluid
volume or vasopressor use in open abdomen patients, but facilitated more effective resuscitation and
decreased the number of days to fascial closure, leading to shorter hospital stays. Vigileo-mediated GDT,
therefore, may improve overall outcomes in open abdomen patients.
Gut-Associated Biomarkers L-FABP, I-FABP, and TFF3 and LIT Score for Diagnosis of
Surgical Necrotizing Enterocolitis in Preterm Infants
01 Dec 2013 06:00 am
Objectives: To evaluate the use of gut barrier proteins, liver-fatty acid binding protein (L-FABP), intestinalfatty acid binding protein (I-FABP), and trefoil factor 3 (TFF3), as biomarkers for differentiating necrotizing
enterocolitis (NEC) from septicemic/control infants and to identify the most severely affected surgical NEC
from nonsurgical NEC infants. Background: Clinical features and routine radiologic investigations have low
diagnostic utilities in identifying surgical NEC patients. Methods: The diagnostic utilities of individual
biomarkers and the combination of biomarkers, the LIT score, were assessed among the NEC (n = 20),
septicemia (n = 40), and control groups (n = 40) in a case-control study for the identification of proven NEC
and surgical NEC infants. Results: Plasma concentrations of all gut barrier biomarkers and the LIT score
were significantly higher in the NEC than in the septicemia or control group (P < 0.01). Using median values
of biomarkers and the LIT score in the NEC group as cutoff values for identifying NEC from
septicemic/control cases, all had specificities of 95% or more and sensitivities of 50%. Significantly higher
levels of biomarkers and the LIT score were found in infants with surgical NEC than in nonsurgical NEC
cases (P ≤ 0.02). The median LIT score of 4.5 identified surgical NEC cases with sensitivity and specificity
of 83% and 100%%, respectively. A high LIT score of 6 identified nonsurvivors of NEC with sensitivity and
specificity of 78% and 91%, respectively. Conclusions: The LIT score can effectively differentiate surgical
NEC from nonsurgical NEC infants and nonsurvivors of NEC from survivors at the onset of clinical
presentation. Frontline neonatologists and surgeons may, therefore, target NEC infants who are most in
need of close monitoring and those who may benefit from early surgical intervention.
Hypercapnia and Acidosis During Open and Thoracoscopic Repair of Congenital
Diaphragmatic Hernia and Esophageal Atresia: Results of a Pilot Randomized Controlled
Trial
01 Dec 2013 06:00 am
Objective: We aimed to evaluate the effect of thoracoscopy in neonates on intraoperative arterial blood
gases, compared with open surgery. Background: Congenital diaphragmatic hernia (CDH) and esophageal
atresia with tracheoesophageal fistula (EA/TEF) can be repaired thoracoscopically, but this may cause
hypercapnia and acidosis, which are potentially harmful. Methods: This was a pilot randomized controlled
trial. The target number of 20 neonates (weight > 1.6 kg) were randomized to either open (5 CDH, 5
EA/TEF) or thoracoscopic (5 CDH, 5 EA/TEF) repair. Arterial blood gases were measured every 30 minutes
intraoperatively, and compared by multilevel modeling, presented as mean and difference (95% confidence
interval) from these predictions. Results: Overall, the intraoperative PaCO2 was 61 mm Hg in open and 83
mm Hg [difference 22 mm Hg (2 to 42); P = 0.036] in thoracoscopy and the pH was 7.24 in open and 7.13
[difference −0.11 (−0.20 to −0.01); P = 0.025] in thoracoscopy. The duration of hypercapnia and acidosis
was longer in thoracoscopy compared with that in open. For patients with CDH, thoracoscopy was
associated with a significant increase in intraoperative hypercapnia [open 68 mm Hg; thoracoscopy 96 mm
Hg; difference 28 mm Hg (8 to 48); P = 0.008] and severe acidosis [open 7.21; thoracoscopy 7.08;
difference −0.13 (−0.24 to −0.02); P = 0.018]. No significant difference in PaCO2, pH, or PaO2 was
observed in patients undergoing thoracoscopic repair of EA/TEF. Conclusions: This pilot randomized
controlled trial shows that thoracoscopic repair of CDH is associated with prolonged and severe
intraoperative hypercapnia and acidosis, compared with open surgery. These findings do not support the
use of thoracoscopy with CO2 insufflation and conventional ventilation for the repair of CDH, calling into
question the safety of this practice. The effect of thoracoscopy on blood gases during repair of EA/TEF in
neonates requires further evaluation. (ClinicalTrials.gov Identifier: NCT01467245)
IL-25 Improves IgA Levels During Parenteral Nutrition Through the JAK-STAT Pathway
01 Dec 2013 06:00 am
Introduction: Parenteral nutrition (PN) impairs mucosal immunity and increases the risk of infection in part
via lower IgA levels at mucosal surfaces. Transport of immunoglobulin A (IgA) across the mucosa to the gut
lumen depends on the epithelial transport protein, polymeric immunoglobulin receptor (pIgR), which is
reduced during PN. In vitro, studies demonstrate that IL-4 up-regulates pIgR production via Janus
kinase/signal transducers and activators of transcription (JAK/STAT) signaling. Because IL-4 stimulates IgA
and is reduced during PN, we hypothesized that the suppressed pIgR is a result of decreased JAK-1 and
STAT-6 phosphorylation. Because IL-4 is mediated by IL-25, we also hypothesized that PN + IL-25 would
restore luminal IgA by increasing phosphorylated JAK-1 and STAT-6, resulting in increased tissue pIgR and
luminal IgA. Method: Experiment 1: 2 days after intravenous cannulation, male Institute of Cancer Research
mice were randomized to chow (n = 11) or PN (n = 9). Experiment 2: 2 days after intravenous cannulation,
male Institute of Cancer Research mice were randomized to chow (n = 12), PN (n = 10), or PN + 0.7 μg of
exogenous IL-25 (n = 11) per day. After 5 days, distal ileum tissue was collected, homogenized, and protein
extracted for JAK-STAT expression levels using a phospho-specific antibody microarray. Tissue was
homogenized to measure pIgR expression via Western blot or fixed in 4% paraformaldehyde to measure
pIgR expression via immunohistochemistry. Small intestinal wash fluid was collected and IgA was quantified
using enzyme-linked immunosorbent assay. Results: Experiment 1: PN significantly reduced
phosphorylated JAK-1 and STAT-6 compared with chow. PN also decreased the tissue levels of the Th2
cytokines, IL-4 and IL-13, as well as pIgR, and luminal IgA compared with chow. Experiment 2: Exogenous
administration of PN + IL-25 increased the phosphorylated JAK-1 and STAT-6 compared with PN alone. IL25 completely restored expression of IL-13 to chow levels. IL-4, pIgR, IgA, and phosphorylated JAK-1 were
significantly increased with IL-25 treatment compared with PN but failed to reach levels measured in chow.
STAT-6 was significantly increased with IL-25 treatment compared with chow and PN. Conclusions: PN
significantly decreases the JAK-STAT pathway by reducing levels of phosphorylated STAT-6 and JAK-1.
Consistent with our previous work, sIgA, pIgR, and IL-4 decreased with PN, whereas the addition of IL-25 to
PN reversed these decreases and demonstrated the role of the JAK-STAT pathway in vivo during PN.
Impact of Preoperative Local Water-Filtered Infrared A Irradiation on Postoperative Wound
Healing: A Randomized Patient- and Observer-Blinded Controlled Clinical Trial
01 Dec 2013 06:00 am
Objective: In addition to a preoperative antibiotic single-shot prophylaxis, we tested the impact of a one-time
preoperative water-filtered infrared A irradiation (wIRA) on postoperative wound healing of patients.
Background: wIRA improves wound healing in postoperative settings. Methods: A total of 400 consecutive
patients undergoing gastrointestinal surgery were randomly assigned to the treatment group (A) or placebo
group (B). We applied wIRA for 20 minutes while patients were prepared for surgery. Patients and observer
were blinded to group assignment. Primary endpoints were surgical site infections (SSIs), wound healing,
and rate and level of pain within 30 days after surgery. Primary efficacy analysis was carried out on the
basis of an intention-to-treat (ITT) population and a full-analysis set (FAS). Missing values of primary
outcome variables were considered as SSIs and maximum pain levels in the ITT analysis, respectively.
Results: FAS: The incidence of SSI was 9 of 178 patients (5.1%) within group A compared with 22 of 182
(12.1%) within group B [P = 0.018; relative risk (RR) = 0.42; 95% CI: 0.18–0.93]. ITT: 32 of 200 (16%) SSIs
occurred within group A and 39 of 200 (20%) within group B (P = 0.248) with an RR of 0.74 (95% CI: 0.43–
1.28). The wIRA group showed lower postoperative pain at both the ITT (P = 0.092) and the FAS analysis
(P = 0.045). Conclusions: This trial indicates a clinically relevant benefit of one-time application of
preoperative wIRA as a supportive addition to prophylactic antibiotics. wIRA contributes to both reduced
SSI rates and postoperative pain but also effectively decreases morbidity and related expenses in the
health care system.
In Appreciation
01 Dec 2013 06:00 am
No abstract available
Increased Risk of Colorectal Cancer After Obesity Surgery
01 Dec 2013 06:00 am
Objective: The purpose was to determine whether obesity surgery is associated with a long-term increased
risk of colorectal cancer. Background: Long-term cancer risk after obesity surgery is not well characterized.
Preliminary epidemiological observations and human tissue biomarker studies recently suggested an
increased risk of colorectal cancer after obesity surgery. Methods: A nationwide retrospective registerbased cohort study in Sweden was conducted in 1980–2009. The long-term risk of colorectal cancer in
patients who underwent obesity surgery, and in an obese no surgery cohort, was compared with that of the
age-, sex- and calendar year-matched general background population between 1980 and 2009. Obese
individuals were stratified into an obesity surgery cohort and an obese no surgery cohort. The standardized
incidence ratio (SIR), with 95% confidence interval (CI), was calculated. Results: Of 77,111 obese patients,
15,095 constituted the obesity surgery cohort and 62,016 constituted the obese no surgery cohort. In the
obesity surgery cohort, we observed 70 patients with colorectal cancer, rendering an overall SIR of 1.60
(95% CI 1.25–2.02). The SIR for colorectal cancer increased with length of time after surgery, with a SIR of
2.00 (95% CI 1.48–2.64) after 10 years or more. In contrast, the overall SIR in the obese no surgery cohort
(containing 373 colorectal cancers) was 1.26 (95% CI 1.14–1.40) and remained stable with increasing
follow-up time. Conclusions: Obesity surgery seems to be associated with an increased risk of colorectal
cancer over time. These findings would prompt evaluation of colonoscopy surveillance for the increasingly
large population who undergo obesity surgery.
Innovations in geriatric trauma and resident research education: bridging the gap
01 Dec 2013 12:00 am
Abstract: The recent history of changes in the geriatric population in the US, the unique vulnerability to
different mechanisms of trauma and the need for innovative management strategies to address them are
discussed using the Geriatric “G-60” service as an illustration. The issue is not whether geriatric trauma “G60” is coming; G-60 is here. A short detour into my own research experience is presented not as
prescription but guidance for the development of futures cadres of surgeons. Resident research is not a
luxury but key to transforming knowledge from benchside to bedside and back.
JACS CME Featured Articles, Volume 217, December 2013
01 Dec 2013 12:00 am
Risk analysis of early implant loss after immediate breast reconstruction: a review of 14,585 patients
Fischer JP, Wes AM, Tuggle III CT, et al
Lack of Preoperative Enteral Nutrition Reduces Gut-Associated Lymphoid Cell Numbers in
Colon Cancer Patients: A Possible Mechanism Underlying Increased Postoperative
Infectious Complications During Parenteral Nutrition
01 Dec 2013 06:00 am
Objective: To examine preoperative dietary influences on gut-associated lymphoid tissue (GALT) cell
number in the context of postoperative infectious complications. Background: There is little clinical evidence
regarding whether nutritional routes affect GALT size and/or phenotype. The influence of GALT atrophy on
clinical outcomes is also unclear. Method: Patients with complete obstruction of the colon due to a tumor
were excluded from this study. Study 1. Resected terminal ileum specimens, from 62 patients [preoperative
parenteral nutrition (PN): n = 15, preoperative oral feeding (OF): n = 47] who underwent right colectomy
during the period from 1997 to 2004 at our department, were immunohistochemically stained for counting
numbers of T, IgA-producing, and mature and immature dendritic cells (DCs) in the lamina propria (LP) and
intraepithelial space. Study 2. We reviewed 341 patients (PN: n = 99, OF: n = 242) with colon cancer who
underwent colectomy during this period for postoperative complications. Results: Study 1. T cell numbers in
the LP and intraepithelial space and IgA-producing cell number in the LP were significantly lower in the PN
than in the OF group. Mature DC number in the LP was significantly lower in the PN than in the OF group,
whereas total DC numbers (both mature and immature DC) were similar in the 2 groups. Study 2. The PN
group had significantly higher rates of total infectious complications, surgical site infection, pneumonia,
infectious colitis, and central venous catheter infection. Conclusions: Lack of enteral delivery of nutrients
reduces numbers of T and IgA-producing cells, as well as mature DCs, in GALT of colon cancer patients, as
it does in animal models. A close association between GALT changes and infectious complication morbidity
was confirmed.
Laparoscopic Cholecystocolostomy: A Novel Surgical Approach for the Treatment of
Progressive Familial Intrahepatic Cholestasis
01 Dec 2013 06:00 am
Objective: Conventionally, liver transplantation, ileoileal bypass, and partial external or internal biliary
diversion are used in the treatment of progressive familial intrahepatic cholestasis (PFIC). However,
postoperative recurrence, chronic diarrhea, and permanent stoma are the major concerns. We present a
novel approach of laparoscopic cholecystocolostomy with antireflux Y-loop for the management of children
with PFIC. Methods: Between August 2003 and April 2011, 20 children with PFIC (median age: 1.47 years;
range: 10.8 months to 5.11 years) successfully underwent laparoscopic cholecystocolostomies for bile
diversions. Gallbladder was incised longitudinally for cholecystocolostomy. Transverse colon was divided
proximal to splenic flexure. End-to-side anastomosis was established between distal transverse colon and
mid-descending colon. The mobilized splenic flexure and proximal descending colon, that is, the stem of the
Y-loop, was anastomosed to the gallbladder. Results: The mean operative time was 2.02 ± 0.18 hours
(range: 2–2.5 hours). The mean postoperative hospital stay was 8 days (range: 5–10 days). Average time
for full resumption of diet was 3 days (range: 2–4 days). Average Y-loop length was 17.65 cm (range: 15–
20 cm). The median follow-up period was 54 months (range: 12–104 months). All patients were jaundice
free after 7 to 20 days and pruritus subsided in 3 to 14 days. Liver function parameters significantly
improved postoperatively. Success rate (normalization of serum bile acids at postoperative 12 months) was
85%. No mortality or morbidities associated with diarrhea, cholangitis, or intrahepatic reflux were observed.
Conclusions: The novel approach of laparoscopic cholecystocolostomy offers a safe and effective treatment
option for PFIC in children with good success rates and minimal morbidity.
Laparoscopic Heller Myotomy Versus Endoscopic Balloon Dilatation for the Treatment of
Achalasia: A Network Meta-Analysis
01 Dec 2013 06:00 am
Objective: Comparison of short- and long-term effects after laparoscopic Heller myotomy (LHM) and
endoscopic balloon dilation (EBD) considering the need for retreatment. Background: Previously published
studies have indicated that LHM is the most effective treatment for Achalasia. In contrast to that a recent
randomized trial found EBD equivalent to LHM 2 years after initial treatment. Methods: A search in Medline,
PubMed, and Cochrane Central Register of Controlled Trials was conducted for prospective studies on
interventional achalasia therapy with predefined exclusion criteria. Data on success rates after the initial
and repeated treatment were extracted. An adjusted network meta-analysis and meta-regression analysis
was used, combined with a head-to-head comparison, for follow-up at 12, 24, and 60 months. Results:
Sixteen studies including results of 590 LHM and EBD patients were identified. Odds ratio (OR) was 2.20 at
12 months (95% confidence interval: 1.18–4.09; P = 0.01); 5.06 at 24 months (2.61–9.80; P < 0.00001) and
29.83 at 60 months (3.96–224.68; P = 0.001). LHM was also significantly superior for all time points when
therapy included re-treatments [OR = 4.83 (1.87–12.50), 19.61 (5.34–71.95), and 17.90 (2.17–147.98); P ≤
0.01 for all comparisons) Complication rates were not significantly different. Meta-regression analysis
showed that amount of dilations had a significant impact on treatment effects (P = 0.009). Every dilation (up
to 3) improved treatment effect by 11.9% (2.8%–21.8%). Conclusions: In this network meta-analysis, LHM
demonstrated superior short- and long-term efficacy and should be considered first-line treatment of
esophageal achalasia.
Maingot's Abdominal Operations
01 Dec 2013 06:00 am
No abstract available
Memorial to George F. Sheldon, MD
01 Dec 2013 06:00 am
No abstract available
Method of Reconstruction Governs Iron Metabolism After Gastrectomy for Patients With
Gastric Cancer
01 Dec 2013 06:00 am
Objective: Anemia after gastrectomy is commonly neglected by clinicians despite being an important and
frequent long-term metabolic sequela. We hypothesized that the incidence and timing of the occurrence of
iron deficiency after gastrectomy is closely associated with the extent of gastrectomy and the reconstruction
method, and we investigated the treatment outcomes of iron supplementation to understand iron
metabolism and determine the optimal reconstruction method after gastrectomy. Patients and Methods:
Using a prospective gastric cancer database, we identified 381 patients with early gastric cancer with
complete hematologic parameters who underwent gastrectomy between January 2004 and May 2008.
Kaplan-Meier methods, Cox regression, and logistic regression were used to evaluate the associations of
the extent of gastrectomy and reconstruction method with iron metabolism. Results: The prevalence of iron
deficiency 3 years after gastrectomy was 69.1%, and iron-deficiency anemia was observed in 31.0% of
patients. Iron deficiency developed in 64.8% and 90.5% of patients after distal gastrectomy and total
gastrectomy within 3 years after surgery (P < 0.0001), respectively. Iron deficiency was significantly more
frequent in women than in men (P < 0.0001) and after gastrojejunostomy than after gastroduodenostomy (P
< 0.0001). Serum ferritin levels were different according to the extent of gastrectomy and reconstruction
method. The proportion of patients treated for iron-deficiency anemia was also significantly different
according to the extent of gastrectomy (P = 0.020). Conclusions: Iron deficiency occurs in most patients
with gastric cancer after gastrectomy, and its incidence was different according to the extent of gastrectomy
and reconstruction method. To improve iron metabolism after distal gastrectomy, gastroduodenostomy
would be the method of reconstruction whenever possible.
Mild Obesity Is Protective After Severe Burn Injury
01 Dec 2013 06:00 am
Objective: To assess the impact of obesity on morbidity and mortality in severely burned patients.
Background: Despite the increasing number of people with obesity, little is known about the impact of
obesity on postburn outcomes. Methods: A total of 405 patients were prospectively enrolled as part of the
multicenter trial Inflammation and the Host Response to Injury Glue Grant with the following inclusion
criteria: 0 to 89 years of age, admitted within 96 hours after injury, and more than 20% total body surface
area burn requiring at least 1 surgical intervention. Body mass index was used in adult patients to stratify
according to World Health Organization definitions: less than 18.5 (underweight), 18.5 to 29.9 (normal
weight), 30 to 34.9 (obese I), 35 to 39.9 (obese II), and body mass index more than 40 (obese III). Pediatric
patients (2 to ≤18 years of age) were stratified by using the Centers for Disease Control and Prevention and
World Health Organization body mass index-for-age growth charts to obtain a percentile ranking and then
grouped as underweight (<5th percentile), normal weight (5th percentile to <95th percentile), and obese
(≥95th percentile). The primary outcome was mortality and secondary outcomes were clinical markers of
patient recovery, for example, multiorgan function, infections, sepsis, and length of stay. Results: A total of
273 patients had normal weight, 116 were obese, and 16 were underweight; underweight patients were
excluded from the analyses because of insufficient patient numbers. There were no differences in primary
and secondary outcomes when normal weight patients were compared with obese patients. Further
stratification in pediatric and adult patients showed similar results. However, when adult patients were
stratified in obesity categories, log-rank analysis showed improved survival in the obese I group and higher
mortality in the obese III group compared with obese I group (P < 0.05). Conclusions: Overall, obesity was
not associated with increased morbidity and mortality. Subgroup analysis revealed that patients with mild
obesity have the best survival, whereas morbidly obese patients have the highest mortality. (NCT00257244)
Neoadjuvant therapy and breast cancer surgery: a closer look at postoperative
complications
01 Dec 2013 12:00 am
Abstract: Background: Neoadjuvant therapy is important in the treatment of advanced breast
cancer.Methods: Postoperative complications in neoadjuvant patients were analyzed.Results: One hundred
forty patients underwent 148 breast cancer surgeries after neoadjuvant therapy: 28% breast-conserving
therapy procedures, 36% mastectomies, 28% mastectomies with immediate reconstruction, and 8%
mastectomies with delayed reconstruction. Forty-seven patients (34%) suffered 59 complications: 18% of
those undergoing breast-conserving therapy, 30% of those undergoing mastectomy, 44% of those
undergoing mastectomy with immediate reconstruction, and 67% of those undergoing mastectomy with
delayed reconstruction. Major complications occurred in 18% of patients. Skin loss occurred in 6% of
patients. One patient had partial nipple necrosis. Three patients suffered implant loss. One patient had deep
inferior epigastric artery perforator flap loss. Eleven hematomas and 5 infectious complications required
reoperation.Conclusions: Surgery after neoadjuvant therapy is safe, but careful counseling is warranted
given that 18% of patients experienced major complications. Complications rates are higher with
reconstruction, but feared complications of skin, nipple, implant, or flap loss were infrequent.
Operation Debrief: A SHARP Improvement in Performance Feedback in the Operating
Room
01 Dec 2013 06:00 am
Objectives: To explore the current status of performance feedback (debriefing) in the operating room and to
develop and evaluate an evidence-based, user-informed intervention termed “SHARP” to improve
debriefing in surgery. Background: Effective debriefing is a key educational technique for optimizing
learning in surgical settings. However, there is a lack of a debriefing culture within surgery. Few studies
have prospectively evaluated educational interventions to improve the quality and quantity of performance
feedback in surgery. Methods: This was a prospective pre- and post-study of 100 cases involving 22
trainers (attendings) and 30 surgical residents (postgraduate years 3–8). A trained researcher assessed the
quality of debriefings provided to the trainee using the validated Objective Structured Assessment of
Debriefing (OSAD) tool alongside ethnographic observation. Following the first 50 cases, an educational
intervention termed “SHARP” was introduced and measures repeated for a further 50 cases. User
satisfaction with SHARP was assessed via questionnaire. Twenty percent of the cases were observed
independently by a second researcher to test interrater reliability. Results: Interrater reliability for OSAD was
excellent (ICC = 0.994). Objective scores of debriefing (OSAD) improved significantly after the SHARP
intervention: median pre = 19 (range, 8–31); median post = 33 (range, 26–40), P < 0.001. Strong
correlations between observer (OSAD) and trainee rating of debriefing were obtained (median ρ = 0.566, P
< 0.01). Ethnographic observations also supported a significant improvement in both quality and style of
debriefings. Users reported high levels of satisfaction in terms of usefulness, feasibility, and
comprehensiveness of the SHARP tool. Conclusions: SHARP is an effective and efficient means of
improving performance feedback in the operating room. Its routine use should be promoted to optimize
workplace-based learning and foster a positive culture of debriefing and performance improvement within
surgery.
Operative Drainage Following Pancreatic Resection: Analysis of 1122 Patients Resected
Over 5 Years at a Single Institution
01 Dec 2013 06:00 am
Background: The only prospective randomized trial evaluating the use of intraperitoneal drainage following
pancreatic resection was published from our institution approximately 10 years ago. The current study
sought to evaluate the evolution of practice over the last 5 years. Patients and Methods: Between June
2006 and June 2011, there were 1122 resections performed. Six surgeons were evenly grouped and
compared by practice pattern: routine drainers (drains placed > 95%), selective drainers, and routine
nondrainers (drains placed ∼15%). Prospectively recorded preoperative, operative, and morbidity data were
assessed in uni- and multivariate models. Results: Our operative drainage rate was 49% and decreased
over time (62% 2006–2008 vs 37% 2009–2011, P < 0.001). Patients without operative drains had
significantly lower grade ≥3 overall morbidity (26% vs 33%; P = 0.01), shorter hospital stays (7 vs 8 days; P
< 0.01), fewer readmissions (20% vs 27%; P = 0.01), and lower rates of grade ≥3 pancreatic fistula (16% vs
20%; P = 0.05). Similar reoperation (both <1%), interventional radiology procedures (15% vs 19%; P = 0.1),
and mortality rates (2% vs 1%; P = 0.3) were seen in both groups. There were no differences between the
routine drainers group (n = 248) and the nondrainers group (n = 478) in grade ≥3 fistula or need for
interventional radiology-guided procedures. Conclusions: In this study, operative drains were used nearly
half of the time and were associated with longer hospital stay, and higher grade ≥3 morbidity, fistula, and
readmission rates. They did not decrease the need for reintervention or alter mortality rates. Routine
prophylactic drainage after pancreatic resection could be safely abandoned.
Operative Management of Rib Fractures in the Setting of Flail Chest: A Systematic Review
and Meta-Analysis
01 Dec 2013 06:00 am
Objective: To perform a systematic review and meta-analysis of studies comparing operative to
nonoperative therapy in adult FC patients. Outcomes were duration of mechanical ventilation (DMV),
intensive care unit length of stay (ICULOS), hospital length of stay (HLOS), mortality, incidence of
pneumonia, and tracheostomy. Background: Flail chest (FC) results in paradoxical chest wall movement,
altered respiratory mechanics, and frequent respiratory failure. Despite advances in ventilatory
management, FC remains associated with significant morbidity and mortality. Operative fixation of the flail
segment has been advocated as an adjunct to supportive care, but no definitive clinical trial exists to
delineate the role of surgery. Methods: A comprehensive search of 5 electronic databases was performed
to identify randomized controlled trials and observational studies (cohort or case-control). Pooled effect size
(ES) or relative risk (RR) was calculated using a fixed or random effects model, as appropriate. Results:
Nine studies with a total of 538 patients met inclusion criteria. Compared with control treatment, operative
management of FC was associated with shorter DMV [pooled ES: −4.52 days; 95% confidence interval (CI):
−5.54 to −3.50], ICULOS (−3.40 days; 95% CI: −6.01 to −0.79), HLOS (−3.82 days; 95% CI: −7.12 to
−0.54), and decreased mortality (pooled RR: 0.44; 95% CI: 0.28–0.69), pneumonia (0.45; 95% CI: 0.30–
0.69), and tracheostomy (0.25; 95% CI: 0.13–0.47). Conclusions: As compared with nonoperative therapy,
operative fixation of FC is associated with reductions in DMV, LOS, mortality, and complications associated
with prolonged MV. These findings support the need for an adequately powered clinical study to further
define the role of this intervention.
Peridural Analgesia May Affect Long-term Survival in Patients With Colorectal Cancer After
Surgery (PACO-RAS-Study): An Analysis of a Cancer Registry
01 Dec 2013 06:00 am
Objective: To determine the effect of peridural analgesia on long-term survival in patients who underwent
surgical treatment of colorectal carcinoma. Background: Clinical and animal studies suggest a potential
benefit of peridural analgesia on morbidity and mortality after cancer surgery. The effect of peridural
analgesia on long-term outcome after surgery for colorectal cancer remains undefined. Methods: From
2003 to 2009, there were 749 patients who underwent surgery for colorectal carcinoma under general
anesthesia with or without peridural analgesia. Clinical data were reviewed retrospectively and analyzed
with multivariate analysis and Kaplan-Meier plots. Results: There were 442 patients who received peridural
analgesia and 307 patients who did not receive peridural analgesia. A substantial survival benefit was
observed in patients who received peridural analgesia (5-year survival rate: peridural analgesia, 62%; no
peridural analgesia, 54%; P < 0.02). The hazard rate for death was decreased by 27% in patients who
received peridural analgesia. When peridural analgesia was included simultaneously in a Cox model with
the confounding factors age, American Society of Anesthesiologists classification, and stage, there was a
significant survival benefit in patients who received peridural analgesia. In patients with America Society of
Anesthesiologists classification 3 to 4, there was significantly greater survival with peridural analgesia than
without peridural analgesia (P < 0.009). Conclusions: Peridural analgesia may improve survival in patients
underwent surgery for colorectal carcinoma. The survival benefit with peridural analgesia was greater in
patients who had greater medical morbidity.
Pneumomediastinum: etiology and a guide to diagnosis and treatment
01 Dec 2013 12:00 am
Background: Pneumomediastinum may be associated with mediastinal organ injury. The aim of this study
was to identify predictive factors of mediastinal organ injury in patients with pneumomediastinum to guide
diagnosis and treatment.Methods: A retrospective review was conducted including patients aged ≥18 years
with Current Procedural Terminology code 518.1 (interstitial emphysema) from 2005–2011.Results: There
were 279 of 343 patients (81%) with and 64 of 343 (19%) without history of trauma. In the trauma
population, 13 patients (5%) were found to have mediastinal organ injuries, 10 (4%) had airway injuries, and
3 (1%) had esophageal injuries. In the nontrauma population, 36 patients (56%) had spontaneous
pneumomediastinum, esophageal injuries were seen in 17 (27%), pneumothorax in 9 (14%), and airway
injuries in 2 (3%). The predictors of esophageal injury were instrumentation (odds ratio [OR], 45.7; P <
.0001), pleural effusion (OR, 10.5; P < .0001), and vomiting (OR, 9.3; P < .0001). Previous instrumentation
was the most significant predictor of airway injury (OR, 9.05; P < .02).Conclusions: Mediastinal organ injury
in patients with pneumomediastinum is uncommon. Patients presenting with pneumomediastinum without a
history of instrumentation, pleural effusion, or vomiting most commonly do not have mediastinal organ
injuries.
Poly-ADP-Ribose-Polymerase Inhibition Ameliorates Hind Limb Ischemia Reperfusion
Injury in a Murine Model of Type 2 Diabetes
01 Dec 2013 06:00 am
Introduction: Diabetes is known to increase poly-ADP-ribose-polymerase (PARP) activity and
posttranslational poly-ADP-ribosylation of several regulatory proteins involved in inflammation and energy
metabolism. These experiments test the hypothesis that PARP inhibition will modulate hind limb ischemia
reperfusion (IR) in a mouse model of type-II diabetes and ameliorate the ribosylation and the
activity/transnuclear localization of the key glycolytic enzyme glyceraldehyde-3-phosphate dehydrogenase
(GAPDH). Methods: db/db mice underwent 1.5 hours of hind limb ischemia followed by 1, 7, or 24 hours of
reperfusion. The treatment group received the PARP inhibitor PJ34 (PJ34) over a 24-hour period; the
untreated group received Lactated Ringer (LR) at the same time points. IR muscles were analyzed for
indices of PARP activity, fiber injury, metabolic activity, inflammation, GAPDH activity/intracellular
localization, and poly-ADP-ribosylation of GAPDH. Results: PARP activity was significantly lower in the
PJ34-treated groups than in the Lactated Ringer group at 7 and 24 hours of reperfusion. There was
significantly less muscle fiber injury in the PJ34-treated group than in the Lactated Ringer-treated mice at
24 hours of reperfusion. PJ34 lowered levels of select proinflammatory molecules at 7 hours and 24 hours
of IR. There were significant increases in metabolic activity only at 24 hours of IR in the PJ34 group, which
temporally correlated with increase in GAPDH activity, decreased GAPDH poly-ADP-ribosylation, and
nuclear translocation of GAPDH. Conclusions: PJ34 reduced PARP activity, GAPDH ribosylation, and
GAPDH translocation; ameliorated muscle fiber injury; and increased metabolic activity after hind limb IR
injury in a murine model of type-II diabetes. PARP inhibition might be a therapeutic strategy after IR in
diabetic humans.
Predictors of outcome in palliative colonic stent placement for malignant obstruction
02 Dec 2013 08:06 am
Background Emergency surgery for large bowel obstruction carries significant morbidity and mortality. After
initially promising results, concerns have been raised over complication rates for self-expandable metal
stents (SEMS) in both the palliative and bridge-to-surgery settings. This article documents the technique
used at the authors' institution, and reports on success and complication rates, as well as identifying
predictors of endoscopic reintervention or surgical treatment. Methods Data were collected for a prospective
cohort of consecutive patients undergoing attempted colonoscopic SEMS insertion at a single institution
between 1998 and 2013. Multivariable logistic models were fitted to assess possible predictors of
endoscopic reintervention and surgical treatment. Results Palliative SEMS insertion was attempted in 146
patients. Primary colorectal cancer was the most common cause of obstruction (95·2 per cent). The
majority of patients (77·4 per cent) were treated in an acute setting, with a high technical success rate of
97·3 per cent. The perforation rate was 4·8 per cent and the 30-day procedural mortality rate 2·7 per cent.
No predictors of early complications were identified, although patients with metastases and those who
received chemotherapy were more likely to have late complications. Some 30·8 per cent of patients
required at least one further intervention, with 11·0 per cent of the cohort requiring a stoma. Endoscopic
reintervention was largely successful. Conclusion SEMS offer a valid alternative to operative intervention in
the palliative management of malignant large bowel obstruction. Patients receiving chemotherapy are more
likely to receive endoscopic reintervention, which is largely successful.
Preoperative Alcohol Consumption and Postoperative Complications: A Systematic Review
and Meta-Analysis
01 Dec 2013 06:00 am
Objective: To systematically review and summarize the evidence of the association between preoperative
alcohol consumption and postoperative complications elaborated on complication type. Background:
Conclusions in studies on preoperative alcohol consumption and postoperative complications have been
inconsistent. Methods: A systematic review and meta-analysis based on a search in MEDLINE, EMBASE,
CINAHL, and PsycINFO citations. Included were original studies of the association between preoperative
alcohol consumption and postoperative complications occurring within 30 days of the operation. In total,
3676 studies were identified and reviewed for eligibility, and data were extracted. Forest plots and pooled
relative risks (RRs), including 95% confidence intervals (CIs), were estimated for several complication
types. Results: Fifty-five studies provided data for estimates. Preoperative alcohol consumption was
associated with an increased risk of various postoperative complications, including general morbidity (RR =
1.56; 95% CI: 1.31–1.87), general infections (RR = 1.73; 95% CI: 1.32–2.28), wound complications (RR =
1.23; 95% CI: 1.09–1.40), pulmonary complications (RR = 1.80; 95% CI: 1.30–2.49), prolonged stay at the
hospital (RR = 1.24; 95% CI: 1.18–1.31), and admission to intensive care unit (RR = 1.29; 95% CI: 1.03–
1.61). Clearly defined high alcohol consumption was associated with increased risk of postoperative
mortality (RR = 2.68; 95% CI: 1.50–4.78). Low to moderate preoperative alcohol consumption and
postoperative complications did not seem to be associated; however, very few studies were included in the
analyses hereof. Conclusions: Preoperative alcohol consumption was associated with an increased risk of
general postoperative morbidity, general infections, wound complications, pulmonary complications,
prolonged stay at the hospital, and admission to intensive care unit.
Preoperative Anemia Is an Independent Predictor of Postoperative Mortality and Adverse
Cardiac Events in Elderly Patients Undergoing Elective Vascular Operations
01 Dec 2013 06:00 am
Objective: The objective of this study was to assess the impact of preoperative anemia (hematocrit <39%)
on postoperative 30-day mortality and adverse cardiac events in patients 65 years or older undergoing
elective vascular procedures. Background: Preoperative anemia is associated with adverse outcomes after
cardiac surgery, but its association with postoperative outcomes after open and endovascular procedures is
not well established. Elderly patients have a decreased tolerance to anemia and are at high risk for
complications after vascular procedures. Methods: Patients (N = 31,857) were identified from the American
College of Surgeons' 2007–2009 National Surgical Quality Improvement Program—a prospective,
multicenter (>250) database maintained across the United States. The primary and secondary outcomes of
interest were 30-day mortality and a composite end point of death or cardiac event (cardiac arrest or
myocardial infarction), respectively. Results: Forty-seven percent of the study population was anemic.
Anemic patients had a postoperative mortality and cardiac event rate of 2.4% and 2.3% in contrast to the
1.2% and 1.2%, respectively, in patients with hematocrit within the normal range (P < 0.0001). On
multivariate analysis, we found a 4.2% (95% confidence interval, 1.9–6.5) increase in the adjusted risk of
30-day postoperative mortality for every percentage point of hematocrit decrease from the normal range.
Conclusions: The presence and degree of preoperative anemia are independently associated with 30-day
death and adverse cardiac events in patients 65 years or older undergoing elective open and endovascular
procedures. Identification and treatment of anemia should be important components of preoperative care for
patients undergoing vascular operations.
Preoperative Gemcitabine-Based Chemoradiation Therapy for Resectable and Borderline
Resectable Pancreatic Cancer
01 Dec 2013 06:00 am
Objective: To evaluate the outcome of preoperative gemcitabine-based chemoradiation therapy (CRT) for
resectable and borderline resectable pancreatic cancer (PC), with a focus on the differences in surgical
outcomes and patterns of recurrence between these 2 categories. Background: Various multimodal
treatment strategies have been proposed to improve the surgical outcomes of PC. Preoperative CRT and
subsequent surgery is one of the promising strategies for resectable (PC-R) and borderline resectable (PCBR) PC. Methods: A total of 268 patients with PC-R and PC-BR received preoperative gemcitabine-based
CRT. The numbers of PC-R and PC-BR cases were 188 and 80, respectively. We evaluated the following
comparisons between patients with PC-R and those with PC-BR: (1) resection rate, (2) rate of marginnegative resection, (3) survival, and (4) pattern of the treatment failure, including local recurrence,
peritoneal dissemination, and distant metastasis. Results: The resection rate of patients with PC-R (87%)
was higher than that of patients with PC-BR (54%) (P < 0.001). Pathological margin-negative resection was
achieved in 99% and 98% of the patients with PC-R and PC-BR, respectively. The 5-year survival rates of
the PC-R and PC-BR cases were 57% and 34%, respectively (P = 0.029). Although the 5-year cumulative
incidence of local recurrence was comparable in both groups (15% and 13%, respectively; P = 0.508), the
5-year cumulative incidence of peritoneal and distant recurrence was significantly higher in the patients with
PC-BR (43 and 76%) than in the patients with PC-R (17% and 43%). Conclusions: In the resected cases,
the locoregional control was comparable between patients with PC-R and PC-BR after preoperative CRT.
The survival rate for the patients with PC-BR was lower than the rate for those with PC-R due to a higher
incidence of peritoneal and distant recurrence in the patients with PC-BR. (UMIN000001804)
Prognostic Value of the New International Association for the Study of Lung
Cancer/American Thoracic Society/European Respiratory Society Lung Adenocarcinoma
Classification on Death and Recurrence in Completely Resected Stage I Lung
Adenocarcinoma
01 Dec 2013 06:00 am
Objective: This study investigated the prognostic value of the new International Association for the Study of
Lung Cancer, American Thoracic Society, and European Respiratory Society (IASLC/ATS/ERS) lung
adenocarcinoma classification in resected stage I lung adenocarcinoma. Methods: Histological classification
of 283 patients undergoing surgical resection for stage I lung adenocarcinoma was determined according to
the IASLC/ATS/ERS classification after comprehensive histological subtyping with recording of the
percentage of each histological component (lepidic, acinar, papillary, micropapillary, and solid) in 5%
increments. Their impact on overall survival, recurrence, and postrecurrence survival was investigated.
Results: The 5-year overall survival and recurrence-free rates were 81.6% and 76.9%, respectively. During
follow-up, 57 (20.1%) patients developed recurrence. The 2-year postrecurrence survival rate was 72.3%.
The solid predominant group is associated with significant more male sex, higher smoking exposure, larger
tumor size, and more poorly differentiated histological grade. Lepidic predominant group had significantly
better overall survival (P = 0.002). Micropapillary and solid predominant groups had significantly lower
probability of freedom from recurrence (P = 0.004). Older age (P = 0.039), visceral pleural invasion to the
surface (PL2) (P = 0.009), and high grade (micropapillary/solid predominant) of the new classification (P =
0.028) were predictors of recurrence in multivariate analysis. The solid predominant group tends to have
significantly worse postrecurrence survival (P = 0.074). Conclusions: The new adenocarcinoma
classification has significant impact on death and recurrence in stage I lung adenocarcinoma. Patients with
PL2 and micropapillary/solid predominant pattern have significant higher risk for recurrence. This
information is important for patient stratification for aggressive adjuvant chemoradiation therapy.
Readmission following open ventral hernia repair: incidence, indications, and predictors
01 Dec 2013 12:00 am
Abstract: Background: The aim of this study was to evaluate the incidence, indications, and predictive
factors of hospital readmission after open ventral hernia repair.Methods: A retrospective review of all open
ventral hernia repairs at a single institution from 2000 to 2010 was performed to assess readmissions
between 1 to 30, 1 to 90, and 91 to 365 days. Multivariate analysis was performed to identify independent
predictors of 30-day readmission.Results: Of the 888 patients, 75 (8%) were readmitted between 1 and 30
days, 97 (11%) between 1 and 90 days, and 78 (9%) between 91 and 365 days. Unplanned readmissions
related to the surgery constituted the majority of 1-day to 30-day and 1-day to 90-day readmissions (82%
and 74%, respectively) but not between 91 and 365 days (32%). Prior superficial or deep surgical-site
infection (odds ratio, 2.39; 95% confidence interval, 1.32 to 4.32) and duration of surgery (odds ratio, 1.35;
95% confidence interval, 1.05 to 1.73) were associated with 30-day readmission.Conclusions: Efforts to
reduce readmissions should be directed at modifiable risk factors for surgical-site infection and other
surgical complications, particularly among those with prior skin infections and longer durations of surgery.
Recombinant Human Thrombomodulin Suppresses Experimental Abdominal Aortic
Aneurysms Induced by Calcium Chloride in Mice
01 Dec 2013 06:00 am
Objective: To investigate whether recombinant thrombomodulin containing all the extracellular domains
(rTMD123) has therapeutic potential against aneurysm development. Summary Background Data: The
pathogenesis of abdominal aortic aneurysm (AAA) is characterized by chronic inflammation and proteolytic
degradation of extracellular matrix. Thrombomodulin, a transmembrane glycoprotein, exerts antiinflammatory activities such as inhibition of cytokine production and sequestration of proinflammatory highmobility group box 1 (HMGB1) to prevent it from engaging the receptor for advanced glycation end product
(RAGE) that may sustain inflammation and tissue damage. Methods: The in vivo effects of treatment and
posttreatment with rTMD123 on aortic dilatation were measured using the CaCl2-induced AAA model in
mice. Results: Characterization of the CaCl2-induced model revealed that HMGB1 and RAGE, both
localized mainly to macrophages, were persistently upregulated during a 28-day period of AAA
development. In vitro, rTMD123-HMGB1 interaction prevented HMGB1 binding to macrophages, thereby
prohibiting activation of HMGB1-RAGE signaling in macrophages. In vivo, short-term treatment with
rTMD123 upon AAA induction suppressed the levels of proinflammatory cytokines, HMGB1, and RAGE in
the aortic tissue; reduced the infiltrating macrophage number; and finally attenuated matrix
metalloproteinase production, extracellular matrix destruction, and AAA formation without disturbing
vascular calcification. Consistently, posttreatment with rTMD123 seven days after AAA induction alleviated
vascular inflammation and retarded AAA progression. Conclusions: These data suggest that rTMD123
confers protection against AAA development. The mechanism of action may be associated with reduction of
proinflammatory mediators, blockade of macrophage recruitment, and suppression of HMGB1-RAGE
signaling involved in aneurysm formation and downstream macrophage activation.
Reliability of Evaluating Hospital Quality by Colorectal Surgical Site Infection Type
01 Dec 2013 06:00 am
Objective: To determine whether risk-adjusted colorectal SSI rates are statistically reliable as hospital
quality measures. Background: Policymakers use surgical site infections (SSI) for public reporting of
hospital quality and pay-for-performance because they are a relatively common and costly cause of patient
morbidity. Methods: Patients who underwent a colorectal procedure in 2009 were identified from the
American College of Surgeons National Surgical Quality Improvement Program. We developed hierarchical
multivariate logistic models for (1) superficial SSI, (2) deep/organ-space SSI, and (3) “any SSI” and
compared how each model ranked hospital-level risk-adjusted performance. Statistical reliability of hospital
quality measurements was estimated on a scale from 0 to 1; with 0 indicating that apparent variation
between a hospital's quality measurement and the average hospital is statistically unreliable, and 1
indicating that any observed variation is due to a real difference in performance. Results: Mean reliability of
hospital-level quality measurements was 0.650 for superficial, 0.404 for deep/organ-space, and 0.586 for
“any SSI.” Lower reliability was accounted for by relatively little variation in risk-adjusted SSI rates between
hospitals and insufficient numbers of colorectal cases submitted by individual hospitals. In 2009, we
estimate that 22.1% of all US hospitals performed a sufficient number of colorectal cases to report
superficial SSI rates at a high standard of statistical reliability and 1.0% did for deep/organ-space SSI.
Conclusions: As currently constructed, colorectal SSI quality measures might not meet a high standard of
statistical reliability for most hospitals, limiting their ability to confidently differentiate high and low
performance. Despite an expectation of improving statistical power, combining superficial and deep/organspace SSI into an “any SSI” measure worsens reliability.
Reply
01 Dec 2013 12:00 am
The authors appreciate the concerns raised by Drs MacLean, Dixon, and Ball in their recent letter regarding
our investigation, “Effect of noise on auditory processing in the operating room.” This investigation, as
clearly stated in the manuscript, was intended to be a preliminary investigation that attempted to replicate
as closely as possible listening performance in the operating room.
Southwestern Surgical Congress presidential address 2013
01 Dec 2013 12:00 am
I deeply appreciate the honor of serving as president of the SWSC [Southwestern Surgical Congress] this
year. I have thoroughly enjoyed my almost 20 years with the SWSC. During my time with the Congress, I
have been impressed with its commitment to its mission, the education of surgeons at all levels of practice
and training. I wish to express my thanks to members who helped me grow within the Congress. Dr Scott
Peterson, Dr Maria Allo, Dr Ed Nelson, and Dr Ernie Dunn were constant resources during my time as a
member of the council and of the executive committee. Thanks to Dr Russell Postier for his counsel when I
became president-elect and then president of the Congress. A special thanks to Dr Jim Edney, who has
been a source for me throughout my time with the Congress and who has devoted a great deal of energy
helping make the SWSC a viable organization and making our annual meetings such a success. The
continued success of the Congress is a reflection of the willing participation of so many members. The
culture of the Congress also permits comfortable interaction among all who attend the annual meeting, part
of the “recharging of our batteries” that is so important in our profession. The Congress is also fortunate to
have Nonie Lowry, Jill Kawulok, and others at LP who made this year much easier for me than I perhaps
have made it for them. Some of what I will present today will be provocative, with the intent to stimulate
meaningful discussions.
Splenectomy for Massive Splenomegaly: Long-Term Results and Risks for Mortality
01 Dec 2013 06:00 am
Objective: To evaluate long-term outcomes after splenectomy for massive splenomegaly in a series of 222
consecutive patients. Background: Splenectomy for massive splenomegaly (>1500 g) provides palliation but
is associated with a high rate of perioperative complications in a population of patients with advanced
hematological malignancies. Predictive factors for survival and whether the palliative goals are achieved in
the long-term are not well defined. Methods: Patients with various hematological disorders who underwent
splenectomy between 1998 and 2009 were followed until death or for at least 2 years. Linear and logistic
regression analyses were used to ascertain the impact of demographical factors, diagnoses, and
preoperative transfusion parameters on the postoperative survival. Results: Splenectomy for massive
splenomegaly was performed most commonly for non-Hodgkin lymphoma (48%) and myeloid metaplasia
(31%). Mean ± standard deviation splenic weight was 2731 ± 1393 g (range, 1500–13,085 g). Average
operating time was 115 minutes, with a range from 46 to 346 minutes. Thirty-day mortality was 1.8%, and
the complication rate was 20%. The most common complications were hemorrhage (9%) and portal venous
thrombosis (9.9%). Relief from pressure-related symptoms was achieved in 98.5%, and durable remission
of anemia and thrombocytopenia persisted in half of the patients at 2 years. Sex, age, and intraoperative
blood loss were not significantly associated with survival. Preoperative need for red blood cell and platelet
transfusions were the most significant risk factors associated with decreased survival. Conclusions:
Splenectomy for massive splenomegaly can be performed safely and offers durable palliation. Preoperative
transfusion requirement is an indicator of hematological disease severity and predictor of decreased
survival.
Strategies to improve the outcome of emergency surgery for perforated peptic ulcer
29 Nov 2013 09:22 am
Background Perforated peptic ulcer (PPU) is a common surgical emergency that carries high mortality and
morbidity rates. Globally, one-quarter of a million people die from peptic ulcer disease each year. Strategies
to improve outcomes are needed. Methods PubMed was searched for evidence related to the surgical
treatment of patients with PPU. The clinical registries of trials were examined for other available or ongoing
studies. Randomized clinical trials (RCTs), systematic reviews and meta-analyses were preferred. Results
Deaths from peptic ulcer disease eclipse those of several other common emergencies. The reported
incidence of PPU is 3·8–14 per 100 000 and the mortality rate is 10–25 per cent. The possibility of nonoperative management has been assessed in one small RCT of 83 patients, with success in 29 (73 per
cent) of 40, and only in patients aged less than 70 years. Adherence to a perioperative sepsis protocol
decreased mortality in a cohort study, with a relative risk (RR) reduction of 0·63 (95 per cent confidence
interval (c.i.) 0·41 to 0·97). Based on meta-analysis of three RCTs (315 patients), laparoscopic and open
surgery for PPU are equivalent, but patient selection remains a challenge. Eradication of Helicobacter pylori
after surgical repair of PPI reduces both the short-term (RR 2·97, 95 per cent c.i. 1·06 to 8·29) and 1-year
(RR 1·49, 1·10 to 2·03) risk of ulcer recurrence. Conclusion Mortality and morbidity from PPU can be
reduced by adherence to perioperative strategies.
Subject Index
01 Dec 2013 12:00 am
Surgery of the Thyroid and Parathyroid Glands
01 Dec 2013 06:00 am
No abstract available
Surgical Therapy for Early Hepatocellular Carcinoma in the Modern Era: A 10-Year SEERMedicare Analysis
01 Dec 2013 06:00 am
Objective: We sought to quantify the use of and analyze factors predictive of receipt of surgical therapy for
early hepatocellular carcinoma (HCC). Background: The incidence of HCC is increasing, and the options for
surgical therapy for early HCC have expanded, but the use of surgical therapy for early HCC has not been
examined in a modern cohort. Methods: A retrospective cohort study was performed using data from the
1998–2007 Surveillance, Epidemiology, and End Results-Medicare linked database. Data were analyzed
for patients 66 years of age and older with early HCC (tumors ≤5 cm without metastatic disease, nodal
metastasis, extrahepatic extension, or major vascular invasion). Both Surveillance, Epidemiology, and End
Results and Medicare data were used to ascertain receipt of therapy as well as comorbidity burden and
other patient and hospital variables. Multivariable logistic regression models were used to analyze factors
associated with receipt of therapy. Results: Our selection criteria identified 1745 patients for this study. Most
patients had tumors between 2 and 5 cm in size (n = 1440, 83%). Solitary tumors (n = 1121, 64%) were
more common than multiple tumors (n = 624, 36%). A total of 820 patients (47%) with early HCC received
no surgical therapy. Among 741 patients with solitary, unilobar tumors and microscopic confirmation of
HCC, 246 (33%) received no surgical therapy. Of 535 patients with no liver-related comorbidities, 273
(51%) did not receive surgical therapy. In multivariable analysis, patient age, income, tumor factors, liverrelated comorbidities, and hospital factors were associated with receipt of surgical therapy. Conclusions:
Although some patients with early HCC may not be candidates for surgical therapy, these data suggest that
there is a significant missed opportunity to improve survival of patients with early HCC through the use of
surgical therapy.
Systematic review of emergency laparoscopic colorectal resection
28 Nov 2013 04:31 am
Background Laparoscopic surgery (LS) has become standard practice for a range of elective general
surgical operations. Its role in emergency general surgery is gaining momentum. This study aimed to
assess the outcomes of LS compared with open surgery (OS) for colorectal resections in the emergency
setting. Methods A systematic review was performed of studies reporting outcomes of laparoscopic
colorectal resections in the acute or emergency setting in patients aged over 18 years, between January
1966 and January 2013. Results Twenty-two studies were included, providing outcomes for 5557 patients:
932 laparoscopic and 4625 open emergency resections. Median (range) operating time was 184 (63–444)
min for LS versus 148 (61–231) min for OS. Median (range) length of stay was 10 (3–23) and 15 (6–33)
days in the LS and OS groups respectively. The overall median (range) complication rate was 27·8 (0–33·3)
and 48·3 (9–72) per cent respectively. There were insufficient data to detect differences in reoperation and
readmission rates. Conclusion Emergency laparoscopic colorectal resection, where technically feasible, has
better short-term outcomes than open resection.
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