The American Journal of Surgery

Consensus statement on the adoption of the COPE guidelines

2010-07-01

We the undersigned editors of the member journals of the Surgery Journal Editors Group (SJEG), in the furtherance of integrity in surgical and scientific publication, agree to adopt the guidelines established by the Committee on Publication Ethics (COPE). The COPE guidelines represent a means of addressing a variety of ethical concerns, including duplicate publication and authorship misconduct issues, which have, unfortunately, become more prevalent.

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

John M. Clarke — 2010-07-01

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

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

2010-07-01

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

Analysis of anatomic variants of mesenteric veins by 3-dimensional portography using multidetector-row computed tomography

2010-01-15

Abstract: Background: It is important to be aware of mesenteric venous variants to perform peripancreatic surgery. We investigated the usefulness of 3-dimensional (3-D) portography.Methods: Vessels were reconstructed using computer software in 102 patients undergoing multidetector-row computed tomography (MDCT) scheduled for gastrointestinal or hepatobiliary-pancreatic surgery.Results: The superior mesenteric vein (SMV) was composed of single and double trunks around the splenoportal confluence in 78 and 24 patients, respectively. The inferior mesenteric vein joined the splenic vein (68.5%), SMV (18.5%), and splenoportal confluence (7.6%). The left gastric vein joined the splenic vein (46.3%), portal vein (39.0%), and splenoportal confluence (14.7%). Seventy-nine patients showed a gastrocolic trunk, mostly composed of the right gastroepiploic vein and veins from the colonic hepatic flexure. Intraoperative findings were identical to 3-D diagnosis in 68 gastrectomized and 9 pancreatectomized patients.Conclusion: Although mesenteric venous tributaries are complex, 3-D portography is helpful for surgeons to safely perform peripancreatic surgery.

Long-term results after surgical treatment of nonparasitic hepatic cysts

2010-07-01

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

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

2010-07-01

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

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

2010-07-01

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

Conservative treatment of vascular prosthetic graft infection is associated with high mortality

2010-01-15

Abstract: Background: The aim of this study was to identify patient-related and/or disease-related factors that influence outcomes in patients with vascular prosthetic graft infections.Methods: Through the hospital patient administration system, between January 1997 and December 2007, a total of 44 patients were diagnosed with central prosthetic graft infections. Univariate and multivariate analyses were performed to define factors predictive of mortality.Results: Thirty-three men and 11 women (mean age, 71 years) were included. There was considerable comorbidity. Coagulase-negative Staphylococcus and S aureus were isolated in almost 50% of the patients. The mean follow-up duration was 5 years, during which 20 patients (46%) died. The main causes of death were related to vascular disease. Conservative treatment with antibiotics was the only variable with significant predictive value on multivariate analysis (hazard ratio, 3.62; 95% confidence interval, 1.17–11.24; P = .02).Conclusions: Conservative treatment of prosthetic graft infections was associated with high mortality; therefore, it should be limited to a specific group. Patients who are not capable of undergoing open repair may benefit from conservative management. Otherwise, aggressive open treatment seems indicated.

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

Wen-Yao Yin, Ming-Chi Lu, Ming-Che Lee, Su-Chin Liu, Teng-Yi Lin, Ning-Sheng Lai — 2010-07-01

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

Metabolic syndrome is an important factor for the evolution of prognosis of colorectal cancer: survival, recurrence, and liver metastasis

2010-01-15

Abstract: Background: Several studies have shown that metabolic syndrome (MS) was a risk factor for colorectal cancer, but few studies have reported the relationship between MS and the prognosis of colorectal cancer.Methods: Data were collected from 507 cases of colorectal carcinoma between January 2002 and March 2007 to establish the database. These patients were divided into 2 groups based on the presence of MS. We tested the prognostic value of MS in the patients. The risk of adverse events was examined by Cox proportional hazard modeling.Results: The rates of liver metastasis and tumor recurrence were higher in the group of patients with colorectal cancer accompanied by MS. Moreover, MS is one of the important elements that independently can influence the survival (colonic carcinoma: hazard ratio [HR], 1.633; 95% confidence interval [CI], 1.039–2.565; rectal carcinoma: HR, 1.939, 95% CI, 1.076–3.494) and liver metastasis (colonic carcinoma: HR, 2.619; 95% CI, 1.288–5.324; rectal carcinoma: HR, 2.814; 95% CI, .962–2.888) of both colonic and rectal carcinoma patients, and MS patients have the highest risk with worse survival and liver metastases compared with other parameters.Conclusions: The results suggest that MS may be an important prognostic factor for colorectal cancer, decreasing the incidence of MS may improve the therapeutic efficacy of colorectal cancer.

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

2010-07-01

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

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

Hasan T. Kirat, Ravi P. Kiran, Lei Lian, Feza H. Remzi, Victor W. Fazio — 2010-07-01

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

Lessons learned from 416 cases of nipple discharge of the breast

Mary Morrogh, Anna Park, Elena B. Elkin, Tari A. King — 2010-01-15

Abstract: Background: For patients with nipple discharge (ND), surgical duct excision is often required to exclude underlying malignancy. Our objective was to define clinical predictors of malignancy and examine the utility of common preoperative studies.Study design: We retrospectively identified 475 patients presenting with a chief complaint of ND from 1995 to 2005; 416 (88%) were eligible for review.Results: Following standard evaluation (clinical breast examiation/mammogram/ultrasound), 129 of 416 (31%) were considered to have physiological ND and were managed expectantly, whereas 287 of 416 (69%) underwent further evaluation (cytology/ductography/magnetic resonance imaging) followed by biopsy ± surgery. Clinical features associated with pathological ND included bloody ND (adjusted odds ratio 3.7) and spontaneous ND (adjusted OR 3.2). Biopsy/surgery identified a causative lesion in 259 of 287 (90%), of which 37% were either malignant (n = 65) or high-risk (n = 30) lesions. The sole clinical predictor of malignant/high-risk lesion was a palpable mass (adjusted odds ratio 4.3). Preoperative evaluation identified 76 of 95 (80%) malignant/high-risk lesions, whereas 19 of 95 (20%) were identified by duct excision alone.Conclusions: Although clinical stratification alone reliably identified patients with pathological ND, neither the clinical characteristics nor preoperative studies can reliably distinguish between benign and malignant pathology. Surgical duct excision remains the gold standard to exclude underlying malignancy.

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

Hiram C. Polk — 2010-07-01

The culminating results of the work herein originated with a group affiliated with the Department of Surgery at the University of Louisville and stems from a research award from the Physicians' Foundation for Health Systems Excellence (PFHSE), to study the quality and safety measures in surgical specialty practices in 4 small hospitals in Kentucky and Indiana. Five hospitals were invited to participate and 4 immediately accepted, of which 1 dropped out of the study because of the unanticipated death of key administrative figures in the institution, but was replaced by the fifth hospital. We discovered substantial advantages to working in smaller hospital settings, especially in dealing with the small number of people who represented hospital administrations and/or finance; nursing personnel whose emphasis was in reporting on quality care; supervisors of operating rooms and recovery areas; anesthesiologists and nurse anesthetists; and surgical specialists in gynecologic, orthopedic, and general surgery.

A situational overview of surgical quality and safety in 2010

Hiram C. Polk, Margaret B. Tyson, Susan Galandiuk — 2010-07-01

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

A closer look at surgical quality measures across different surgical specialties

James M. Watkins, Motaz Qadan, Chris Battista, Hiram C. Polk — 2010-07-01

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

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

Paul Cronen, Motaz Qadan, Nathan Z. Hicks, Hiram C. Polk — 2010-07-01

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

Virtual partnerships: aligning hospital and surgeon incentives

Donald E. Fry, Michael Pine, Gregory Pine — 2010-07-01

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

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

Michael McCafferty, Eugene Shively, Paul Cronen — 2010-07-01

Michael McCafferty, M.D. (Louisville, KY): Dr Shively is going to lead our question and answer session. Eugene Shively, M.D. (Campbellsville, KY): I am starting with 2 controversial issues, and then we will open discussion widely. Most of you who have been with Quality Surgical Solutions for awhile know that we had a horrible problem with administrative data when we began in 1998. We originally tried to correlate data from health insurance companies with hospitals, and they did not correlate at all. Most people now understand that administrative data, if you collect the data, may not be accurate and certainly does not encompass the complete illness.

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

2010-07-01

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

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

2010-07-01

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

A novel technique for hepaticojejunostomy for nondilated bile ducts: a purse-string anastomosis with an intra-anastomotic biodegradable biliary stent

2010-01-15

Abstract: In non-dilated bile ducts, performing a well-functioning hepaticojejunal anastomosis (HJ) may be challenging. We investigated a novel technique for small-caliber HJ: a purse-string anastomosis with an intra-anastomotic biodegradable stent. HJ was performed randomly either conventionally with interrupted sutures without any stent (n = 5; conventional) or using the novel purse-string technique with a 4-mm caliber polylactide-barium sulfate biodegradable biliary stent (n = 4; pursestring + stent) in minipigs with bile ducts 3.5–4.0 mm in caliber. The anastomosis creation time was not different in the groups. In the conventional group 2 complications occurred: 1 early anastomotic leakage, and 1 late anastomotic stricture. The remaining animals (3/5 in conventional, and 4/4 in purse-string + stent group) had normal liver histology and function, and developed no signs of complications during the 6-month follow-up. All biodegradable stents disappeared by 3 months. At 6 months, the HJ caliber was smaller in the conventional (5 [1–9] mm) than in the purse-string + stent group (12 [4–15] mm; P < .05). We conclude that this novel HJ technique is easy and safe to perform, and ensures a well-functioning anastomosis in nondilated bile ducts.

Surgical aspects of fulminant Clostridium difficile Colitis

Parag Butala, Celia M. Divino — 2010-04-22

Abstract: Background: Clostridium difficile–associated disease (CDAD) is responsible for the majority of nosocomial diarrhea, and fulminant C difficile colitis can have mortality upwards of 80%. Early identification and treatment of fulminant C difficile colitis is critical to patient care, but timing of surgical intervention remains difficult. This review summarizes the epidemiology, predictors of development, and management of fulminant C difficile colitis.Methods: A literature search was conducted between January 1989 and May 2009 using the keywords “clostridium difficile colitis” or “fulminant clostridium difficile colitis” and “surgery.” Articles not in English, those not involving human subjects, and case reports were excluded.Conclusion: Early diagnosis and treatment with subtotal colectomy and end ileostomy is critical in reducing the mortality associated with fulminant colitis. Patients who have a history of inflammatory bowel disease (IBD), recent surgery, prior treatment with intravenous immunoglobulin (IVIG), vasopressor requirements, leukocytosis, or increased lactate should have early surgical consultation and operative intervention.

Surgical implications of B-RafV600E mutation in fine-needle aspiration of thyroid nodules

Michal Mekel, Carmelo Nucera, Richard A. Hodin, Sareh Parangi — 2010-07-01

Abstract: Background: Management of patients with thyroid nodules is based on establishing an accurate diagnosis; however, differentiating benign from malignant lesions preoperatively is not always possible using current cytological techniques. Novel molecular testing on cytological material could lead to clearer treatment algorithms. B-RafV600E mutation is the most common genetic alteration in thyroid cancer, specifically found in papillary thyroid cancer (PTC), and usually reported to be associated with aggressive disease.Data source: A literature search using PubMed identified all the pertinent literature on the identification and utilization of the B-RafV600E mutation in thyroid cancer.Conclusions: The utility of using B-Raf mutation testing for nodules with indeterminate cytology is limited since many of those nodules (benign and malignant) do not harbor B-Raf mutations. However, when the pathologist sees cytological features suspicious for PTC, B-RafV600E mutation analysis may enhance the assessment of preoperative risks for PTC, directing a more aggressive initial surgical management when appropriate.

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

Muhammad Rafay Sameem Siddiqui, M.S. Sajid, S. Qureshi, E. Cheek, M.K. Baig — 2010-07-01

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

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

2010-07-01

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

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

2010-07-01

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

Morphea of the breast—an uncommon cause of breast erythema

Clancy J. Clark, Debra Wechter — 2010-07-01

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

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

2010-07-01

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

Ogilvie transition to colonic perforation

Andreas M. Kaiser — 2010-04-21

Abstract: A pair of 2 serial abdominal images show Ogilvie syndrome in a patient after cardiac surgery with the subtle but classic x-ray transition from a nonperforated to a perforated colon.

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

2010-07-01

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

Giant Meckel's diverticulitis: a rare condition complicating pregnancy

2010-04-22

Abstract: A 33-year-old pregnant woman presented with peritonitis at the right iliac fossa. Preoperative ultrasonography identified an 8-cm tubular structure at the tender point that was mistaken as appendicitis. Emergency operation finally confirmed a 12-cm giant Meckel's diverticulum with genuine inflammation and imminent perforation. The patient made an uneventful recovery after Meckel's diverticulectomy.

Extended left hepatectomy of the left and middle hepatic venous drainage areas along the anterior fissure

2010-04-22

Abstract: Background: Extended left hepatectomy including the middle hepatic vein (MHV) may potentially induce right paramedian sector congestion of the remnant liver.Methods: To prevent venous congestion in the right paramedian sector, we performed extended left hepatectomy including the left hemiliver and anterior segment, which drain into the MHV and left hepatic vein (LHV), for 15 patients.Results: In 11 of 15 patients (73%), temporary clamping of the common trunk of the MHV and LHV and the proper hepatic artery provided the anterior fissure. Regeneration rate of the middle segment was similar to that of the right lateral sector (10.8% vs 11.2%) on postoperative computed tomography (CT) after 3 months.Conclusions: This procedure could represent a useful method for preventing postoperative venous congestion.

Bile leak test by indocyanine green fluorescence images after hepatectomy

2010-07-01

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

Editorial Advisory Board

2010-07-01

The American Journal of Surgery

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Extended left hepatectomy of the left and middle hepatic venous drainage areas along the anterior fissure

Bile leak test by indocyanine green fluorescence images after hepatectomy

Editorial Advisory Board

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