The American Journal of Surgery - Articles in Press

False-negative fine-needle aspiration of thyroid nodules cannot be attributed to sampling error alone - Corrected Proof

Xiao-Min Yu, Priyesh N. Patel, Herbert Chen, Rebecca S. Sippel — 2012-01-30

Abstract: Background: The goal of this study was to determine whether sampling error was the major cause for false-negative fine needle aspiration (FNA) results for thyroid nodules. Methods: Patients who underwent preoperative FNA between 1994 and 2008 were identified, and the results were compared with surgical pathology findings. Other related variables including nodule number and size were also recorded. Results: Excluding the microcarcinomas, the false-negative rate was 4% (19/479). Sampling errors occurred in only 4 (21%) cases in which the malignant nodule was not actually biopsied. Of the other 15 cases, 8 (53%) were solitary nodules, 8 (53%) were ≥4 cm in size, and 5 (33%) had underlying thyroiditis. Because of the missed diagnosis, 9 patients (47%) had lobectomy only as the initial surgery, which then required a completion thyroidectomy. Conclusions: Sampling error is a minor cause for false-negative FNAs, suggesting that there are some inherent limitations to cytological evaluation of the thyroid.

Team spirit - Corrected Proof

Roxie M. Albrecht — 2012-01-27

It has been an honor to be able to work for this association, with the team of officers, with Marsha Langstraat, the prior Clearinghouse Director, our current meeting planners at LPetc, and so on. I value this association immensely. I treasure the family-friendly atmosphere, and I knew from my first meeting when I was a 2nd-year resident that this was going to be a yearly tradition no matter where I was or what was going on in my life. I enjoy the scientific sessions, case presentations, opportunities for residents, and the lifelong friendships that have developed from the meetings. I really am awestruck that I am giving an address to an association membership that I cherish so much and that has had so many great talented presidents who provided thoughtful and inspiring addresses. I hope that in this address I can pay due tribute to the association by blending in the contributions from some of the Midwest Surgery members who have inspired the components of leadership and team spirit.

The outcome after stent placement or surgery as the initial treatment for obstructive primary tumor in patients with stage IVU colon cancer - Corrected Proof

Won-Suk Lee, Jeong-Heum Baek, Jin Mo Kang, Sangtae Choi, Kwang An Kwon — 2012-01-24

Abstract: Background: It is still a matter of debate as to whether palliative resection of obstructive primary tumors may prolong the survival of patients with obstructive colon cancer and unresectable synchronous metastases. The main goal of this retrospective study was to compare the use of self-expanding metallic stents (SEMS) with open surgery for the palliation of patients with respect to survival, morbidity, and the time to start chemotherapy. Methods: Between January 2000 and January 2008, 88 consecutive patients (52 who underwent surgery and 36 who underwent SEMS insertion) with obstructive colon cancer and unresectable synchronous metastases were retrospectively evaluated. Results: The median hospital stay for all admissions was 7.2 days (range, 3–29 days) in the SEMS group and 12.3 days (range, 6–45 days) in the surgery group (P = .001). The incidence of stoma formation was significantly lower in the SEMS group than in the surgery group (16.7% vs 38.5%, respectively, P = .021). The median time to starting chemotherapy was significantly shorter in patients who underwent SEMS insertion compared with those who underwent surgery (8.1 vs 21.7 days, respectively, P = .001). The 1-year and 2-year survival rates were 44.2% and 21.27% in the surgery group and 16.7% and 2.8% in the SEMS group, respectively. The median survival for all patients was 15 months from the initiation of treatment (95% confidence interval, 6.0–19 months). Conclusions: Both procedures can be safely performed, but the choice of treatment should be individualized and discussed with a multidisciplinary team.

Towards optimizing perioperative colorectal care: outcomes for 1,000 consecutive laparoscopic colon procedures using enhanced recovery pathways - Corrected Proof

2012-01-24

Abstract: Background: Learning curves and efficiency concerns have slowed the integration of laparoscopy into colorectal practice. We evaluated our experience with laparoscopic colorectal (LC) surgery using enhanced recovery pathways (ERPs). Methods: One thousand consecutive LC procedures performed by 2 surgeons over a 5-year period using previously published, standardized ERPs were assessed. Results: The mean age was 59, and the mean body mass index was 29.5. Procedures included segmental colectomy (54%), proctectomy (19%), total colectomy (11%), ostomy (5%), and other procedures (11%). Diagnoses included malignancy (41%), diverticulitis (16%), inflammatory bowel disease (13%), and other (30%). The mean operative time was 151 minutes, and the mean blood loss was 55 mL. Conversion to an open surgery occurred in 5.8%, whereas 2.3% were performed using a hand-assist procedure. The mean hospital stay was 4.1 days (median 3), with a 6% readmission rate. Complications (20%) included mortality (0.3%), wound infection (4%), and anastomotic leak (1.4%). Conclusions: LC surgery with ERP offers excellent outcomes with efficient use of resources.

Endovascular repair of traumatic thoracic aortic tears - Corrected Proof

2012-01-24

Abstract: Background: Patients with thoracic aorta injuries (TAI) present a unique challenge. The purpose of this study was to review the outcomes of thoracic endovascular aortic repair (TEVAR) in patients with TAI. Methods: A retrospective chart review of all patients admitted for TEVAR for trauma was performed. Results: In a 5-year period, 19 patients (6 women and 13 men; average age, 42 y) were admitted to our trauma center with TAI. Mechanism of injury was a motor vehicle crash in 12 patients, motorcycle crash in 2 patients, automobile-pedestrian accident in 2 patients, 1 fall, 1 crush injury, and 1 stab wound to the back. A thoracic endograft was used in 6 patients and proximal aortic cuffs were used in 13 patients (68%). One patient (5%) died. There were no strokes, myocardial infarctions, paraplegia, or renal failure. Conclusions: TEVAR for TAI appears to be a safe option for patients with multiple injuries. TEVAR in young patients is still controversial because long-term endograft behavior is unknown.

Hürthle cell metaplasia on fine-needle aspiration biopsy is not by itself an indication for thyroid surgery - Corrected Proof

Kevin Hudak, Haggi Mazeh, Rebecca S. Sippel, Herbert Chen — 2012-01-24

Abstract: Introduction: The aim of this study was to assess the malignancy rate in patients with Hürthle cell metaplasia (HCM) on fine-needle aspiration biopsy (FNAB). Methods: The pathology results of patients with benign colloid (BC) and HCM on FNAB were compared using a prospective database. Results: One hundred fifty-three (65%) patients had BC on FNAB, and 82 (35%) had HCM. The mean nodule size was similar in both groups (25 ± 2 mm vs 26 mm ± 2 mm, P = .83). Malignancy was identified on the final pathology report in 21 (14%) versus 13 (16%) patients in the BC and HCM groups, respectively (P = .66). Of the patients with malignancy, the tumor was determined as microcarcinoma in 76% in the BC groups versus 85% in the HCM group (P = .48) and as incidental in 71% versus 85% (P = .39). Conclusions: A result of HCM on FNAB carries a similar rate of malignancy as BC and should not be treated differently. Most of the malignancies found were incidental microcarcinomas.

Health care and socioeconomic impact of falls in the elderly - Corrected Proof

2012-01-19

Abstract: Background: Elderly falls are associated with long hospital stays, major morbidity, and mortality. We sought to examine the fate of patients ≥75 years of age admitted after falls. Methods: We reviewed all fall admissions in 2008. Causes, comorbidities, injuries, procedures, mortality, readmission, and costs were analyzed. Results: Seven hundred eight patients ≥75 years old were admitted after a fall, with 89% being simple falls. Short-term mortality was 6%. Male sex, atrial fibrillation, acute myocardial infarction, congestive heart failure (CHF), intracranial hemorrhage, hospital-acquired pneumonia, trigger events, Clostridium difficile, and intubation were predictors of death (P < .05). Thirty-day readmission occurred in 14%; CHF, craniotomy, and acute renal failure were predictive. The median cost of hospitalization was $11,000 with cardiac disease, anemia, major orthopedic and neurosurgical procedures, pneumonia, and intubation as predictive. Conclusions: Simple falls in the elderly have high morbidity, mortality, and costs. Methodologies for prevention are warranted and should be studied intensively.

Laparoscopic or open liver resection? Let systematic review decide it - Corrected Proof

Ahsan Rao, Ghaus Rao, Irfan Ahmed — 2012-01-16

Abstract: Background: Laparoscopic liver resection is increasingly being used for the excision of benign and malignant hepatic lesions. The aim of this study was to perform meta-analysis on the compiled data from available observational studies. Methods: All the studies comparing laparoscopic versus open liver resections were searched on the available databases. Data were analyzed using Review Manager software version 5.0 (The Cochrane Collaboration, Software Update, Oxford, UK). Results: There was a total of 2,466 patients: 1,161 (47.1%) in the laparoscopic group and 1,305 (52.9%) in the open group. The laparoscopic group was associated with a reduced overall complication rate (odds ratio = .35; 95% confidence interval [CI], .28–.45; P < .001; heterogeneity (HG): P = .51), fewer positive resection margins for malignant tumor resections (odds ratio = .38; CI, .20–.76; P = .006; HG: P = .52) and a decrease in the number of patients requiring blood transfusion (odds ratio = .36; CI, .23–.74; P < .001; HG: P = .30). Conclusions: Laparoscopic liver resection showed a reduced overall morbidity rate and favorable and comparable outcomes when compared with the open group. However, there is still a need for randomized controlled trials to compare laparoscopic versus open hepatic resection in benign and malignant lesions.

The role of laparoscopy and laparoscopic ultrasound in the preoperative staging of patients with resectable colorectal liver metastases: a meta-analysis - Corrected Proof

Deepak Hariharan, Vasilis Constantinides, Hemant M. Kocher, Paris P. Tekkis — 2012-01-16

Abstract: Background: The role of staging laparoscopy (SL) with laparoscopic ultrasound (LUS) in patients with resectable colorectal liver metastases (CRLM) remains controversial. Methods: A meta-analysis of all studies (from 1998 to the present) on the effect of SL/LUS in patients with potentially resectable CRLM with respect to alteration in surgical management was performed. Results: Twelve studies satisfied the inclusion criteria. A total of 1,047 patients underwent SL/LUS. The true yield of SL/LUS for CRLM was 19% (95% confidence interval [CI], 16%–22%), with a diagnostic odds ratio of 132 (95% CI, 56–310) and an overall sensitivity of 59% (95% CI, 53%–65%). Subgroup analysis for detection of other liver and peritoneal lesions showed a sensitivity of 59% (95% CI, 49%–67%) and 75% (95% CI, 63%–85%) respectively. There was major between-study heterogeneity for all analyses, with no obvious cause revealed by meta-regression. Conclusions: The true benefit of using SL/LUS universally seems limited. It appears more useful as an adjunct in patients when peritoneal disease is suspected.

Getting back to zero with nucleated red blood cells: following trends is not necessarily a bad thing - Corrected Proof

2012-01-16

Abstract: Background: The presence of nucleated red blood cells (NRBCs) has been identified as a poor prognostic indicator. We investigated the relationship of NRBC trends in patients with and without trauma. Methods: We retrospectively reviewed surgical intensive care unit admissions over 4 years, categorizing trauma and nontrauma patients and subdividing them into 3 groups: group A, all-zero NRBC; group B, positive NRBC value returning to zero; and group C, positive NRBC value that did not return to zero. We analyzed all groups for outcomes of length of stay and mortality. Results: Group A was the largest and had the shortest length of stay and least mortality. Group C had the highest mortality rate. No statistical difference was observed with mortality. Conclusions: Any positive NRBC was associated with poor outcome, and increasing NRBC was associated with increasing mortality. Trends in NRBC values showed that returning to zero was protective.

Calcium-lowering medications in patients with primary hyperparathyroidism: intraoperative findings and postoperative hypocalcemia - Corrected Proof

David F. Schneider, Gregory M. Day, Steven A. De Jong — 2012-01-16

Abstract: Background: We analyzed how calcium-lowering medications (CLMs) influenced surgical findings in patients with primary hyperparathyroidism. Methods: A retrospective review was conducted of 281 patients undergoing surgery for primary hyperparathyroidism. Logistic regression evaluated the relationship between CLM and surgical findings. A mixed-effects model determined the influence of CLMs on these curves. Results: We found that CLM (P = .018) and a higher serum calcium level (P = .018) were variables making 4-gland hyperplasia less likely. Analysis of intraoperative parathyroid hormone (IOPTH) plots revealed that CLMs altered the kinetics (P = .043). However, the 2 groups did not differ in the number of measurements necessary for a 50% decrease in IOPTH levels. Multivariate logistic regression also revealed that patients taking more than one CLM had an increased association with postoperative hypocalcemia (P = .018). Conclusions: Although CLM contributed to differences in IOPTH curves, their use does not require changing standard IOPTH protocol but should alert the surgeon to the risk of postoperative hypocalcemia.

Posterior and open anterior components separations: a comparative analysis - Corrected Proof

David M. Krpata, Jeffrey A. Blatnik, Yuri W. Novitsky, Michael J. Rosen — 2012-01-16

Abstract: Background: Anterior components separation (ACS) creates large lipocutaneous flaps to release the external oblique fascia often leading to major wound complications. Posterior components separation (PCS) involves the release of the posterior rectus sheath and transversus abdominis muscles. We hypothesized that PCS provides effective fascial advancement while reducing wound morbidity during abdominal wall reconstructions. Methods: A retrospective review of consecutive components separation performed by a single surgeon over 5 years. Results: One hundred eleven patients (56 ACS/55 PCS) were analyzed. The mean defect size was 472 and 531 cm2, respectively (P = .28). Five patients in each group required a bridging repair. Wound complications occurred in significantly more ACS than PCS patients (48.2% vs 25.5%, P = .01). The recurrence rate was also higher in the ACS group (14.3% vs 3.6%, P = .09). Conclusions: PCS provides equivalent myofascial advancement with significantly less wound morbidity when compared with ACS. Although further studies are needed, PCS has evolved as an important addition to the armamentarium of surgeons undertaking complex abdominal wall reconstructions.

Diversification and trends in biliary tree cancer among the three major ethnic groups in the state of New Mexico - Corrected Proof

Itzhak Nir, Charles L. Wiggins, Katherine Morris, Ashwani Rajput — 2012-01-12

Abstract: Background: New Mexico's population is composed of 45% non-Hispanic whites, 42% Hispanics, 10% American Indians, and 3% other minorities. The purpose of this study was to compare the trends of biliary tract cancer among these groups over the past 3 decades. Methods: The state's tumor registry was used to ascertain the incidence of gallbladder cancer, extrahepatic bile duct cancer, and intrahepatic bile duct cancer. Results: A total of 1,449 new biliary cancers were diagnosed between 1981 and 2008. The contemporary incidence of gallbladder cancer remains several times higher among American Indians than in other ethnicities: for men, 4.1%, 1.1%, and .8% for American Indians, Hispanics, and non-Hispanic whites, respectively, and for women, 8.1%, 2.1%, and 1.0%, respectively. Conclusions: Biliary malignancies are more prevalent among American Indians. Despite a decline in the incidence of gallbladder cancer among American Indians and Hispanics, it remains higher compared with the state's non-Hispanic white population.

Outcomes of cytoreduction with hyperthermic intraperitoneal chemotherapy: our experience at a Midwest community hospital - Corrected Proof

2012-01-09

Abstract: Background: Most cytoreduction with hyperthermic intraperitoneal chemotherapy procedures are performed at academic tertiary referral centers with numerous surgical oncology faculty. The objective of this study was to review the postoperative morbidity and mortality data of our institution, a large community hospital. Methods: This was a retrospective cohort study of patients who underwent cytoreduction with hyperthermic intraperitoneal chemotherapy at a single institution. Two surgical oncologists performed all the procedures between May 2005 and June 2011. Results: We retrospectively analyzed 57 patients. The most common pathology being treated was pseudomyxoma peritonei (34 of 57; 59.6%), followed by colorectal cancer (9 of 57; 15.8%). Other types of cancer included peritoneal mesothelioma and gastric adenocarcinoma. The average surgery time was 6.9 hours. Approximately 51% of patients suffered grade 3 or 4 morbidity and there were no perioperative mortalities. Conclusions: Cytoreduction with hyperthermic intraperitoneal chemotherapy can be performed at our institution with comparable outcomes as academic referral centers.

Healthcare disparities in Asians and Pacific Islanders with hepatocellular cancer - Corrected Proof

2012-01-09

Abstract: Background: Hawaii has the highest incidence of hepatocellular cancer (HCC) in the United States and the largest proportion of Asians and Pacific Islanders. HCC studies generally combine these groups into 1 ethnicity, and we sought to examine differences between Asian and Pacific Islander subpopulations. Methods: Demographic, clinical, and treatment data for 617 patients with HCC (420 Asians, 114 whites, and 83 Pacific Islanders) were reviewed. Main outcome measures included HCC screening and liver transplantation. Results: Asian and Pacific Islander subgroups had significantly more immigrants, and age was different between groups. Compared with whites, Pacific Islanders and Filipinos had less HCC screening and liver transplantation procedures, fewer met Milan criteria, and a smaller proportion of those with Milan criteria actually underwent transplantation. Conclusions: There were significant differences in risk factors, clinical presentation, treatment, and access to care among Asian, Pacific Islander, and white patients with HCC. Future HCC studies may benefit from differentiating subgroups within Asian and Pacific Islander populations to better focus these efforts.

Acute prognosis of critically ill patients with secondary peritonitis: the impact of the number of surgical revisions, and of the duration of surgical therapy - Corrected Proof

2012-01-09

Abstract: Background: Duration of surgical therapy and the number of surgical revisions performed to control the focus may be important prognostic variables. Association of such time-dependent therapies with survival, however, has not yet been studied. Methods: We analyzed survival times of adult patients (n = 283) who were suffering from secondary peritonitis and associated organ failure. Cox-type additive hazard regression models were used to analyze associations of surgical variables with survival time. Results: Seventy-two patients (25.4%) survived the period of excess mortality after intensive care unit admission. A total of 79.5% of the 283 patients required one or more surgical revisions. Besides the underlying disease and disease severity at intensive care unit admission, there was a nonlinear smoothed association between a poorer outcome and the duration of surgical therapy, and the number of surgical revisions. For the latter, hazard ratios increased sharply between 1 and 5 revisions, and remained largely constant later on. Conclusions: In critically ill patients with peritonitis, a long therapy and the necessity for a high number of reoperations is related inversely to acute survival.

Expression of vascular endothelial growth factor-C in gastric carcinoma and the effect of its antisense gene transfection on the proliferation of human gastric cancer cell line SGC-7901 - Corrected Proof

Peng Zhu, Jianbo Zhang, Qi Chen, Jijian Wang, Yaxu Wang — 2012-01-09

Abstract: Purpose: The aim of this study was to investigate the relationship between the expression of vascular endothelial growth factor-C (VEGF-C) in gastric carcinoma and tumor lymphangiogenesis and to determine the effect of antisense–VEGF-C gene transfection on proliferation. Methods: Adjacent cancer tissues were collected from 72 gastric carcinoma cases and compared with 10 nongastric carcinoma tissues to detect the expression of VEGF-C and its messenger RNA (mRNA) and calculate the density of neonatal lymphatic microvessels. The in vitro–cultured gastric cancer cell line SGC-7901 was transfected with recombinant plasmid pCI-neo-anti VEGF-C. The expression in the transfected cells and the proliferation were determined. Results: The positive rate of VEGF-C mRNA in the lymph node metastasis tissues was 85.7% compared with negative controls (20%, P < .05). The density of lymphatic vessels in the metastasis group was 6.65 ± 1.57 compared with the negative group (3.75 ± 1.47, P < .05). Protein and mRNA of VEGF-C were reduced in transfected cells. Proliferation was inhibited as well. Conclusions: VEGF-C can increase the invasiveness of gastric cancer and promote lymphangiogenesis in adjacent tissues. Transfection with antisense VEGF-C can reduce the expression of VEGF-C and inhibit the proliferation. VEGF-C can inhibit the tumor growth and reduce its metastasis and recurrence.

Using manual dexterity to predict the quality of the final product in the small bowel anastomosis after a period of training - Corrected Proof

Dhalia Masud, Shabnam Undre, Ara Darzi — 2012-01-06

Abstract: Objective: The use of aptitude tests in the selection of surgeons has gained recent attention. Few have described its relevance in predicting the acquisition of surgical techniques. We aim to show whether assessing manual dexterity can predict the quality of the final product after a period of training. Methods: Thirty-six medical students had their manual dexterity assessed completed bench model small bowel anastomosis in 8 consecutive sessions. The fine details (accuracy (number of sutures that traversed full thickness) and number of sutures placed) and gross details (bowel apposition) of quality of final product was objectively assessed. Results: Manual dexterity correlated with grade only in the initial sessions (Pearson correlation coefficient, r = −.578, P < .01). There was no significant correlation with the fine details with any session. Conclusions: There was a correlation with manual dexterity and outcome measures in the initial sessions of training with grade only. This relationship was eliminated by the end of training sessions. This suggests that the outcome of procedures after a period of training cannot be predicted by measuring manual dexterity skills.

Long-term symptom relief and patient satisfaction after Heller myotomy and Toupet fundoplication for achalasia - Corrected Proof

2012-01-06

Abstract: Background: The goal of this study was to review the results, symptom relief, and patient satisfaction after laparoscopic Heller myotomy and Toupet fundoplication. Methods: A cohort of patients who underwent laparoscopic esophagomyotomy and a Toupet fundoplication was identified. A retrospective chart review was conducted and patients then were interviewed by telephone using a modified 5-point Likert scale. Results: Long-term follow-up data were obtained for 51 patients with a mean of 5.9 years. Thirty-two (63%) patients reported infrequent or no dysphagia. Chest pain, heartburn, or regurgitation were reported in 6 of 51 (12%) patients, 14 of 51 (27%) patients, and 11 of 51 (22%) patients, respectively. Two patients (3.9%) had pneumatic dilation and 1 patient underwent completion esophagectomy (1.9%). Thirty-three (33 of 51; 65%) patients were on acid-suppression therapy. Forty-one (80%) patients reported their overall satisfaction with the procedure was either excellent or good, and 46 of 51 (90%) patients stated they would undergo surgery again. Conclusions: Our data show acceptable long-term results.

Continued rationale of why hospital mortality is not an appropriate measure of trauma outcomes - Corrected Proof

2012-01-06

Abstract: Background: We hypothesized that standardized withdrawal of care (WOC) practices and an aggressive long-term acute care facility (LTAC) discharge protocol could change hospital mortality and national ranking among trauma centers. Study Design: Patients who died while admitted to the trauma service at a level 1 trauma center were classified as either an “LTAC candidate” or “not a LTAC candidate” at 4 time points before death. Results: A total of 216 patients died, and 48% had WOC. Hospital mortality was 3.3%. More than 26% of these qualified as LTAC candidates. The aggressive LTAC discharge protocol reduced hospital mortality by .9%. This was sufficient to move a trauma center into a lower quartile on the National Trauma DataBank benchmark report for 2009. Conlusions: It is possible to reduce hospital mortality and improve quality ranking with standardized WOC and LTAC discharge protocols. This highlights the importance of measuring outcomes beyond discharge.

Trends in the utilization of inguinal hernia repair techniques: a population-based study - Corrected Proof

2012-01-06

Abstract: Background: The use of inguinal hernia repair techniques in the community setting is poorly understood. Methods: A retrospective review of all inguinal hernia repairs performed on adult residents of Olmsted County, MN, from 1989 to 2008 was performed through the Rochester Epidemiology Project. Results: A total of 4,433 inguinal hernia repairs among 3,489 individuals were reviewed. Non–mesh-based repairs predominated in the late 1980s (94% in 1989), declined throughout the 1990s (40% in 1996), and are rarely used nowadays (4% in 2008). Open mesh-based repairs comprised 21% in 1990, peaked in 2001 with 72%, and declined to 55% in 2008. The adoption of laparoscopic repairs began in 1992 (6%) and has increased steadily to 41% in 2008 (P < .001). Conclusions: Although non–mesh-based repairs, once the predominant method, have been supplanted by open mesh-based techniques, nowadays the use of laparoscopic inguinal hernia repair techniques has increased substantially to nearly equal that of open mesh-based techniques.

The role of transcervical thymectomy in patients With hyperparathyroidism - Corrected Proof

Kellen Welch, Christopher R. McHenry — 2012-01-06

Abstract: Background: The most common location for supernumerary or ectopic parathyroid glands is the thymus. Methods: A review of patients who underwent parathyroidectomy for hyperparathyroidism from 1990 to 2010 was completed to determine indications for thymectomy, the yield of parathyroid tissue, and outcome of therapy. Results: Seventy of 379 patients with hyperparathyroidism underwent parathyroidectomy and transcervical thymectomy. Intrathymic parathyroid tissue was present in 23 (33%) patients, including supernumerary glands in 8 patients (11%). Indications for thymectomy were renal hyperparathyroidism in 35 patients (50%) and primary hyperparathyroidism with a missing inferior gland in 20 patients (29%), an ectopic adenoma in 9 patients (13%), hyperplasia in 5 patients (7%), and carcinoma in 1 patient (1%). Cure rates were similar (96% and 98%; P = not significant) and only transient hypocalcemia was higher (51% vs 24%, P < .05) after parathyroidectomy with thymectomy versus parathyroidectomy alone. Conclusions: Transcervical thymectomy results in a high yield of parathyroid tissue and is essential for cure of selected patients with hyperparathyroidism.

Surgery via natural orifices in human beings: yesterday, today, tomorrow - Corrected Proof

2011-12-30

Abstract: Background: We performed an evaluation of models, techniques, and applicability to the clinical setting of natural orifice surgery (mainly natural orifice transluminal endoscopic surgery [NOTES]) primarily in general surgery procedures. NOTES has attracted much attention recently for its potential to establish a completely alternative approach to the traditional surgical procedures performed entirely through a natural orifice. Beyond the potentially scar-free surgery and abolishment of dermal incision–related complications, the safety and efficacy of this new surgical technology must be evaluated. Methods: Studies were identified by searching MEDLINE, EMBASE, Cochrane Library, and Entrez PubMed from 2007 to February 2011. Most of the references were identified from 2009 to 2010. There were limitations as far as the population that was evaluated (only human beings, no cadavers or animals) was concerned, but there were no limitations concerning the level of evidence of the studies that were evaluated. Results: The studies that were deemed applicable for our review were published mainly from 2007 to 2010 (see Methods section). All the evaluated studies were conducted only in human beings. We studied the most common referred in the literature orifices such as vaginal, oral, gastric, esophageal, anal, or urethral. The optimal access route and method could not be established because of the different nature of each procedure. We mainly studied procedures in the field of general surgery such as cholecystectomy, intestinal cancers, renal cancers, appendectomy, mediastinoscopy, and peritoneoscopy. All procedures were feasible and most of them had an uneventful postoperative course. A number of technical problems were encountered, especially as far as pure NOTES procedures are concerned, which makes the need of developing new endoscopic instruments, to facilitate each approach, undeniable. Conclusions: NOTES is still in the early stages of development and more robust technologies will be needed to achieve reliable closure and overcome technical challenges. Well-designed studies in human beings need to be conducted to determine the safety and efficacy of NOTES in a clinical setting. Among these NOTES approaches, the transvaginal route seems less complicated because it virtually eliminates concerns for leakage and fistulas. The transvaginal approach further favors upper-abdominal surgeries because it provides better maneuverability to upper-abdominal organs (eg, liver, gallbladder, spleen, abdominal esophagus, and stomach). The stomach is considered one of the most promising targets because this large organ, once adequately mobilized, can be transected easily with a stapler. The majority of the approaches seem to be feasible even with the equipment used nowadays, but to achieve better results and wider applications to human beings, the need to develop new endoscopic instruments to facilitate each approach is necessary.

Laparoendoscopic single-site gastric bands versus standard multiport gastric bands: a comparison of technical learning curve measured by surgical time - Corrected Proof

Matthew Gawart, Sabine Dupitron, Rami Lutfi — 2011-12-30

Abstract: Background: We aimed to evaluate our learning curve comparing surgical time of laparoendoscopic single-site (LESS) banding with multiport laparoscopy. Methods: We performed a retrospective analysis of prospectively collected data comparing our first 48 LESS bands with our first 50 multiport laparoscopic bands at our institution. We then compared the first 24 LESS bands with the last 24 bands. Results: The average body mass index for the LESS group was significantly lower than for the laparoscopic group (43.19 vs 48.3; P < .0001). The surgical time was much faster toward the second half of our experience performing the LESS procedure (85.34 vs 68.8; P = .0055). LESS banding took significantly longer than our early traditional laparoscopic adjustable gastric banding (76.85 vs 64.4; P = .0015). Conclusions: We conclude that in experienced hands, single-incision banding is feasible and safe to perform. Long-term data are needed to prove that LESS banding is as good a surgery as traditional laparoscopic surgery.

Receptor changes in metachronous breast tumors—our experience of 10 years - Corrected Proof

2011-12-30

Abstract: Introduction: Patients with primary breast cancer (PBC) are at 2 to 6 times higher risk for developing synchronous and metachronous breast cancer (MBC). The pathology and behavior of MBC still remains unclear. Methods: We reviewed the charts of 108 women with MBC at our hospital over the past 10 years. Profile patterns of the estrogen receptor (ER), the progesterone receptor (PR), and Her2/neu receptors were explored. Results: Of 33 patients with ER+/PR+ in the primary tumor, 23 (70%) retained the status in MBC. Forty-five (92%) of 49 patients with ER−/PR− in the primary tumor remained the same in MBC. Most Her2− tumors (22/31, 71%) remained negative, but 50% (8/16) of Her2+ tumors became negative. Conclusions: Most MBC retained the ER/PR expression patterns irrespective of the treatment for the primary tumor, thus suggesting a common origin. Because MBCs tend to be triple negative and thus more aggressive, early detection and close surveillance techniques must be devised.

Control charts to identify adverse outcomes in elective colon resection - Corrected Proof

Donald E. Fry, Michael Pine, Barbara L. Jones, Roger J. Meimban — 2011-12-30

Abstract: Background: Control charts have been proposed for the measurement of quality in surgical care. Methods: For each of 181 study hospitals in the 2005 National Inpatient Sample of the Healthcare Cost and Utilization Project database, an average moving range control chart for risk-adjusted postoperative length of stay (RApoLOS) was created for patients discharged alive after elective colectomy. RApoLOS outliers using upper control limits of 2.0σ, 2.5σ, and 3.0σ were correlated to coded complications (CCs). Hospital costs were correlated to RApoLOS outliers and CCs. Results: Of 13,118 live discharges, 902 (6.9%) were outliers using a 3.0σ upper control limit, 1,350 (10.3%) were 2.5σ outliers, and 2,053 (15.7%) were 2.0σ outliers. CCs were identified in 92.7% of 3.0σ outliers, in 81.3% of 2.5σ outliers, and 70.6% of 2.0σ outliers. Increased costs were associated with RApoLOS outliers and poorly with CCs. Conclusions: Average moving range control charts for RApoLOS outliers are valid tools for measurement of surgical quality and costs.

Effects of vitamin D deficiency in critically ill surgical patients - Corrected Proof

2011-12-30

Abstract: Background: The incidence of vitamin D deficiency in critically ill patients is reported to be up to 50%, with a 3-fold increase in predicted mortality, but limited data exist concerning vitamin D deficiency in critically ill surgical patients. Methods: Sixty-six adult surgical intensive care unit patients who had 25-hydroxyvitamin D serum levels evaluated from January 2010 to February 2011 were prospectively identified. Patients were divided into groups according to vitamin D level (<20 vs ≥20 ng/mL). Results: Of the 66 patients evaluated, 49 (74%) had vitamin D levels < 20 ng/mL, and 17 (26%) had vitamin D levels ≥ 20 ng/mL. Patients with vitamin D levels < 20 versus ≥ 20 ng/mL had longer lengths of hospital stay. Lengths of intensive care unit stay were clinically longer, although not significant. Infection rates tended to be higher (P = .09), and a higher incidence of sepsis was seen in the patients with vitamin D levels < 20 ng/mL. Conclusions: Vitamin D levels < 20 ng/mL have a significant impact on length of stay, organ dysfunction, and infection rates. More data are needed on the value of supplementation to improve these outcomes.

The additional value of intraoperative parathyroid hormone assessment is marginal in patients with nonfamilial primary hyperparathyroidism: A prospective cohort study - Corrected Proof

2011-12-23

Abstract: Background: The success of minimally invasive parathyroidectomy is attributed to evolving preoperative imaging techniques and intraoperative parathyroid hormone (IOPTH) measurement. The additional value of IOPTH measurement in patients undergoing surgery for primary hyperparathyroidism (pHPT) was evaluated. Methods: Between 1999 and 2010 there were 119 patients who underwent surgery for pHPT at our institutions. In all patients, preoperative imaging was performed and IOPTH samples were collected prospectively but the results were not disclosed during surgery. Results: Postoperative calcium level normalized in 114 patients (96%). The 5 surgical failures represented the maximum yield of IOPTH sampling. Three of these patients would have been identified intraoperatively by an inadequate IOPTH decrease, whereas IOPTH decreased inaccurately in the other 2 patients. In addition, in 1 of these 3 patients no abnormal gland was found during minimally invasive parathyroidectomy and subsequent conventional neck exploration. Therefore, only 2 reoperations would have been prevented (1.7%). Conclusions: IOPTH would have changed the outcome in 2 patients, increasing the biochemical cure rate from 96% to 98%. We believe that although it can be helpful in certain cases, it may not be necessary routinely in patients treated for pHPT.

Retrievable inferior vena cava filters in trauma patients: factors that influence removal rate and an argument for institutional protocols - Corrected Proof

Roxie M. Albrecht, Tabitha Garwe, Sandra M. Carter, Adrian J. Maurer — 2011-12-23

Abstract: Background: Trauma patients at risk for pulmonary embolism, but with contraindications for anticoagulation therapy, often have retrievable inferior vena cava filters (RIVCF) placed. This study evaluated factors associated with the recovery rate of the device (RIVCFs) with the goal of developing an institutional protocol to ensure timely removal. Methods: This was a case-control study of 88 trauma patients who underwent RIVCF placement at a level 1 trauma center between 2006 and 2010. Results: The overall retrieval rate was 58%, declining from 89% in 2006 to 50% in 2009. Factors independently associated with filter nonretrieval included increasing age, increase in number of providers, comorbidity, hospital discharge from the intensive care unit, and discharge to a long-term acute care facility or skilled nursing facility. In 2010, a protocol was implemented and the retrieval rate increased to 73%. Conclusions: In a large institution where a number of providers may be responsible for filter management, implementation of a protocol appears to improve retrieval rates.

Surgeons' leadership in the operating room: an observational study - Corrected Proof

Sarah Henrickson Parker, Steven Yule, Rhona Flin, Aileen McKinley — 2011-12-19

Abstract: Background: There is widespread recognition in high-risk organizations that leadership is essential for efficient and safe team performance. However, there is limited empiric evidence identifying specific leadership skills and associated behaviors enacted by surgeons during surgery. Methods: Observational data on surgeons' intraoperative leadership behaviors were gathered during surgeries (n = 29) in 3 hospitals. Observations were coded using 7 leadership elements identified from the literature on surgeons' leadership. Surgeries were categorized by complexity using British United Provident Association ratings. Results: A total of 258 leadership behaviors were observed during more than 63 hours of observation. Surgeons most frequently showed guiding and supporting (33%), communicating and coordinating (20%), and task management behaviors (15%). In many instances the surgeons' leadership was directed to the room rather than to a specific team member. Surgeons engaged in leadership behaviors significantly more frequently during cases of high complexity compared with cases of lower complexity. Conclusions: This study is the first step in developing an empirically derived taxonomy to identify and classify surgeons' intraoperative leadership behaviors.

Pediatric melanomas and the atypical spitzoid melanocytic neoplasms - Corrected Proof

Sarah J. Hill, Keith A. Delman — 2011-12-19

Abstract: Cutaneous malignancies in the pediatric population are rare. Melanocytic neoplasms have garnered increased attention as the incidence of melanoma rises and as published analyses of biologically indeterminate lesions become more commonplace. Pediatric melanomas have been studied in several large cohort series; still, most of our assumptions for treatment stems from research in the adult population. Many clinicians speculate that pediatric melanomas may be biologically different from the same histological entity in adults given observed differences in metastatic potential and overall outcomes in children. Even more confounding are the atypical spitzoid lesions, which continue to spark debate in the oncology and dermatopathology literature with respect to classification, malignant potential, and recommended treatment course. In this article, recent literature addressing both atypical spitzoid melanocytic neoplasms and melanoma in the pediatric population is discussed.

Prognostic factors after liver resection for hepatocellular carcinoma: a single-center experience from China - Corrected Proof

2011-12-19

Abstract: Background: This study aimed to clarify the risk factors for survival and recurrence of hepatocellular carcinoma (HCC) in a cohort of Chinese HCC patients after hepatectomy and to compare 6 developed staging systems. Methods: A retrospective analysis was performed on 165 consecutive patients. The Kaplan–Meier method was used to calculate survival. Postoperative prognostic factors were evaluated using univariate and multivariate analyses. The overall predictive power of each staging system was evaluated by the area under the receiver operating characteristic curve. Results: The overall survival rates of 1, 3, and 5 years were 81.2%, 58.6%, and 56.7%, respectively, and the corresponding disease-free survival rates were 52.9%, 23.3%, and 15.5%, respectively. α-fetoprotein level and blood transfusion were correlated significantly with patients' overall survival, and portal vein thrombosis and tumor size (>5 cm) were correlated significantly with poor disease-free survival. Conclusions: The French staging system is better for predicting the prognosis of HCC patients receiving surgical treatment.

Side-curtain air bag is a protective item: an effective necessity - Corrected Proof

2011-12-19

We read with interest the article ‘“Protection against head injuries should not be optional: a case for mandatory installation of side-curtain airbags”' by Lance et al published in The American Journal of Surgery in October 2010. The authors described side-impact crash and the effectiveness of a side-curtain bag to protect the head and neck. Although we have different traffic culture over the use of seat belts and the lack of standards regarding the safety and crashworthiness of vehicles in the vehicle industries such as front air bags in the Islamic Republic of Iran, we greatly agree with the case the authors made to have installation of these air bags mandated in all passenger vehicles. Road traffic injuries are a major public health problem. Among middle-income countries, the Islamic Republic of Iran has one of the highest mortality rates from road traffic injuries. During the year 2000, the Islamic Republic of Iran had one thirtieth of road traffic events in the world although the Islamic Republic of Iran just has one hundredth of the world population. In the Islamic Republic of Iran, major injuries are detected in high-velocity car-to-car accidents, and the highest mortality rate is seen in front-seat passengers because of head and neck injuries. The installation of front air bags in the Islamic Republic of Iran is not mandatory for most cars. In the Islamic Republic of Iran, the installation of air bags is offered by most main manufacturers as an option for drivers (but not for assistant drivers and backseat passengers) for safety protection in front impact motor vehicle accidents. Customers have to pay extra money (approximately US $500) to obtain air bags (front) as a safety device.

A randomized, double-blind, placebo-controlled study to assess the effect of recombinant human erythropoietin on functional outcomes in anemic, critically ill, trauma subjects: the Long Term Trauma Outcomes Study - Corrected Proof

2011-12-19

Abstract: Background: Achieving a higher hemoglobin (Hb) level might allow the anemic, critically ill, trauma patient to have an improved outcome during rehabilitation therapy. Methods: Patients with major blunt trauma orthopedic injuries were administered epoetin alfa or placebo weekly both in hospital and for up to 12 weeks after discharge or until the Hb level was >12.0 g/dL, whichever occurred first. The 36-question Short Form Health Assessment questionnaire (SF-36) was used to evaluate physical function (PF) outcomes at baseline, at hospital discharge, and at several time points posthospital discharge. Results: One hundred ninety-two patients were enrolled (epoetin alfa [n = 97], placebo [n = 95]). Hb increased from baseline to hospital discharge in both groups (epoetin alfa: 1.2 g/dL vs placebo: 0.9 g/dL), and transfusion requirements were similar between groups. Both groups showed improvements in SF-36 PF; there were no significant differences in the average of all posthospital discharge scores (epoetin alfa: 27.3 vs placebo 30.9; P = 0.38). Thromboembolic events were similar between groups. Conclusions: No differences were observed in physical function outcomes or safety in anemic, critically ill, trauma patients treated with epoetin alfa compared with placebo.

Treatment of small-bowel fistulae in the open abdomen - Corrected Proof

Kuzhiyamattathil Paulose Manjuraj, Hariharan Ramesh — 2011-12-19

We read the paper by D'Hondt et al with interest, and have the following concerns. First, how do the authors ensure that the negative pressure on the foam is not deflated by the application of the colostomy bag? This is especially the case if effluent seeps under the foam and adhesive drape. Although this may not happen in large fistulae with considerable protruding mucosa, it is a problem in to other fistulae.

Development of an intraoperative pathology consultation service at a free-standing ambulatory surgical center: clinical and economic impact for patients undergoing breast cancer surgery - Corrected Proof

2011-12-19

Abstract: Background: Second surgeries represent a significant detriment to breast cancer patients. We examined the impact an intraoperative pathology consultation service had on multiple facets of breast cancer surgery. Methods: We compared the 8 months before the establishment of a pathology laboratory, when intraoperative pathology consultation was not available, with the 8 months subsequent, when it was performed routinely. Results: The average number of surgeries per patient decreased from 1.5 to 1.23, and the number of patients requiring one surgery increased from 59% to 80%. Re-excisions decreased from 26% to 9%. Frozen section allowed 93% of node-positive patients to avoid a second surgery for axillary lymph node dissection. A cost analysis showed savings between $400 and $600 per breast cancer patient, even when accounting for fewer axillary lymph node dissections based on the American College of Surgeons Oncology Group Z0011 data. Conclusions: Incorporation of routine intraoperative margin/sentinel lymph node assessment at an outpatient breast surgery center is feasible, and results in significant clinical benefit to the patient. Use of frozen section decreased both the time and cost required to treat patients.

Assessment for frailty is useful for predicting morbidity in elderly patients undergoing colorectal cancer resection whose comorbidities are already optimized - Corrected Proof

Kok-Yang Tan, Yutaka J. Kawamura, Aika Tokomitsu, Terence Tang — 2011-12-19

Abstract: Background: The clinical syndrome of frailty identified through the assessment of weight loss, gait speed, grip strength, physical activity, and physical exhaustion has been used to identify patients with reduced reserves. We hypothesized that frailty is useful in predicting adverse outcomes in optimized elective elderly colorectal surgery patients. Methods: A prospective study was conducted at 2 centers (Singapore and Japan). All patients over 75 years of age undergoing colorectal resection were assessed for the presence of the syndrome of frailty. All these patients had already had their comorbidities optimized for surgery. The outcome measure was postoperative major complications (defined as Clavien-Dindo type II and above complications). Results: Eighty-three patients were studied from February 2008 to April 2010. The mean age was 81.5 years (range 75–93 years). The mean comorbidity index was 3.37 (range 0–11). Twenty-six (31.3%) patients were an American Society of Anesthesiologists (ASA) score of 3 and above. Chi-square analysis revealed that the odds ratio of postoperative major complications was 4.083 (95% confidence interval, 1.433–11.638) when the patient satisfied the criteria for frailty. Albumin <35, ASA >3, comorbidity index >5, and Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) scores were not predictive of postoperative major complications. Conclusions: Preliminary findings show that frailty is a potent adjunctive tool of predicting postoperative morbidity. Frailty can be used to identify elderly patients needing further optimization before major surgery.

Standard laparoscopic versus single-incision laparoscopic colectomy for cancer: Early results of a randomized prospective study - Corrected Proof

2011-12-19

Abstract: Background: Standard laparoscopic colectomy (SLC) for cancer is a safe, feasible, and oncologically effective procedure with better short-term and similar long-term results of open colectomy. Conversely, owing to technical difficulties in colonic resection and full mesenteric dissection, single-incision laparoscopic colectomy (SILC) has been considered unsuitable for oncologic purposes. We compared the technical feasibility and early clinical outcomes of SLC and SILC for cancer. Methods: In this prospective randomized clinical trial, 16 (50%) patients underwent SLC (10 left and 6 right) and 16 (50%) patients underwent SILC (8 left and 8 right). Results: Demographics, preoperative data, and characteristics of the tumor were similar. The mean number of resected lymph nodes was 16 ± 5 in the SLC and 18 ± 6 in the SILC group (P = NS). Surgical time was 124 ± 8 minutes and 147 ± 5 minutes, respectively (P = NS). Surgical mortality was nil and the major morbidity rate was 6.3% in both groups. Conclusions: SILC for cancer is a technically feasible and safe oncologic procedure with short-term results similar to those obtained with a traditional laparoscopic approach.

Real world efficacy of alvimopan on elective bowel resection patients: an analysis of statistical versus clinical significance - Corrected Proof

Sara L. Gaines, Kathryn Giroux, Stephanie Thomas, James S. Gregory — 2011-12-19

Abstract: Background: Alvimopan has been shown to shorten time to return of bowel function (RBF), thereby decreasing length of stay (LOS). The aim of this study was to assess the clinical significance of this effect on actual practice. Metjods: A retrospective and prospective study of elective bowel resection patients was performed. Surgeons were assigned to alvimopan users (treatment) or nonusers (control). Primary outcome measures included LOS, RBF, and total hospital cost (THC). Results: Mean RBF was 2.93 ± 1.22 days in the treatment group and 4.22 ± 1.81 days in the control group (P < .001). Mean LOS was 7 ± 2.6 days in the treatment group and 7.2 ± 2.2 days in the control group. Mean THC was $7,584 ± $4,770 in the treatment group and $7,310 ± $5,471 in the control group (P > .81). LOS decreased by 2.5 days compared with the historical controls, independent of alvimopan use. Conclusions: Alvimopan improved RBF but not LOS or THC. Reductions in average LOS of 1 day for ≤6 doses and 2 days if patients received >6 doses were needed to decrease THC.

Outcomes of small bowel obstruction in patients with previous gynecologic malignancies - Corrected Proof

2011-12-16

Abstract: Background: Features predictive of malignant small bowel obstructions among patients with previous gynecologic malignancies remain undetermined. Methods: Predictors of malignancy and mortality among patients with gynecologic malignancies and bowel obstructions were identified through a retrospective review of records. Results: Malignancy was noted among 69.8% of 189 patients included in the analysis. Advanced-stage cancer (P = .006, odds ratio [OR] = 6.62), ovarian malignancy (P = .001, OR = 25.64), and early-onset obstruction (P = .014) predicted malignant etiology, whereas chemotherapy (P < .001, OR = .02) or radiation therapy (P = .027, OR = .09) predicted benign obstruction. The average survival was 9 months versus 49 months for malignant and benign obstructions, respectively. Ovarian cancer (P = .009, hazard ratio [HR] = 4.45), anemia (P = .001, HR = 1.11), and renal dysfunction (P < .001, HR 1.81) impaired survival. Conclusions: Palliative care should be considered for patients with advanced-stage cancer, ovarian malignancy, and a shorter time interval between cancer diagnosis and bowel obstruction, especially in the setting of anemia and renal dysfunction.

Blunt cerebrovascular injuries in the child - Corrected Proof

2011-12-16

Abstract: Background: Although blunt cerebrovascular injuries (BCVIs) are a well-recognized sequela of trauma in adults, there have been few reports in children. The investigators questioned whether adult screening protocols are appropriate in the pediatric population. The purpose of this study was to describe the incidence, injury patterns, and stroke rates of pediatric patients sustaining BCVIs. Methods: Pediatric patients (aged ≤ 18 years) diagnosed with BCVIs at a regional level I trauma center and a pediatric level I trauma center since 1996 were reviewed. Results: Forty-five patients sustained BCVIs (60% male; mean age, 13 ± .7 years; mean Injury Severity Score, 23 ± 2). Three patients exsanguinated, and 10 presented with stroke; neurologic changes occurred 17 ± 6 hours after injury (range, 1–72 hours). Screening indications were present in 30%. Thirty-two asymptomatic patients were diagnosed. All but 1 received antithrombotic agents; 1 patient had neurologic deterioration despite heparinization. Comparing asymptomatic patients with those with stroke, there was a significant difference in age (15 vs 11 years). Conclusions: More than two-thirds of patients presenting with stroke did not have screening indications according to adult protocols. With the availability of noninvasive diagnostic imaging such as computed tomographic angiography, broader screening guidelines for children should be instituted.

Intraoperative stimulation neuromonitoring versus intraoperative continuous electromyographic neuromonitoring in total thyroidectomy: identifying laryngeal complications - Corrected Proof

2011-12-12

Abstract: Background: Laryngeal complications occur in thyroidectomies as a result of several factors, but especially because of nerve damage. We compared intraoperative stimulation neuromonitoring (IONM) with intraoperative continuous electromyographic neuromonitoring (IEM) to evaluate their ability to identify postoperative laryngeal complications. Methods: This prospective clinical trial included 174 patients (348 nerves) who had both IONM and IEM. We recorded age, sex, pathology, vocal fold motility, and complications. Results: IONM identified 334 nerves, whereas IEM identified 348. Five patients had transient laryngeal complications, 2 bilateral, and 3 unilateral recurrent laryngeal nerve paresis. In addition, in 2 patients IEM showed placement of the tracheal tube balloon on the vocal folds, which led to correction. Sensitivity and specificity were 96.48% and 100% for IONM and 100% and 100% for IEM, respectively. IONM had a positive predictive value of 100% and a negative predictive value of 36.84%. The positive and negative predictive values of IEM were 100%. Conclusions: Both techniques identify recurrent laryngeal nerve injuries; however, IEM seems to have an advantage concerning the nonsurgical laryngeal complications and may play a role in preventing morbidity.

Racial disparities in outcomes after appendectomy for acute appendicitis - Corrected Proof

John E. Scarborough, Kyla M. Bennett, Theodore N. Pappas — 2011-12-09

Abstract: Background: Although black patients with acute appendicitis have been shown to be less likely than whites to undergo laparoscopic appendectomy, it is unknown whether they suffer increased complications after surgical management of acute appendicitis. Methods: A retrospective analysis of all patients undergoing appendectomy for acute appendicitis from 2005 through 2009, using the National Surgical Quality Improvement Program database, was conducted. Rates of serious and overall morbidity were compared between blacks and whites, with adjustment for preoperative risk factors, the severity of appendicitis, and surgical approach. Results: Blacks were more likely than whites to suffer serious postoperative complications (4.8% vs 3.3%; adjusted odds ratio vs whites, 1.39; 95% confidence interval, 1.16–1.67; P = .0002) or any complication (8.4% vs 6.0%; adjusted odds ratio vs whites, 1.31; 95% confidence interval, 1.14–1.50; P = .0007). Conclusions: Racial disparities in postoperative outcomes exist for even a procedure as ubiquitous as appendectomy. More research is needed to determine the underlying reasons for these disparities.

Feasibility study of two-stage hepatectomy for bilobar liver metastases - Corrected Proof

Kaye A. Bowers, David O'Reilly, Giles E. Bond-Smith, Robert R. Hutchins — 2011-12-09

Abstract: Background: The aim of this study was to analyze the feasibility and early outcomes of 2-stage liver resection for bilobar metastases. Methods: Data from 39 consecutive patients undergoing 2-stage hepatectomy between 2004 and 2010 were prospectively collected. Results: The median age was 59 years (range, 33–79 years), and the ratio of men to women was 1.8:1. Metastases were colorectal carcinoma (n = 33), neuroendocrine tumors (n = 3), gastrointestinal stromal tumor (n = 1), ocular melanoma (n = 1), and salivary gland carcinoma (n = 1). Perioperative chemotherapy was given to 32 patients (82%). Twenty-nine patients (74%) underwent portal venous embolization. Radiofrequency ablation was used in 8 patients (21%). Twenty-seven patients (69%) successfully completed clearance. For the 1st and 2nd stages, the median lengths of stay were 11 days (range, 6–53 days) and 13 days (range, 6–44 days), and morbidity rates were 23% and 56%. Liver insufficiency occurred in 2 (5%) and 6 (22%) patients. Overall mortality was 2.6%. For colorectal metastases, median survival in successes versus failures was 24 versus 10 months (P = .03), and 3-year survival was 30% versus 0%. Conclusions: Two-stage hepatectomy is feasible, with 69% of patients achieving clearance with low mortality. Morbidity is significant, particularly transient hepatic insufficiency.

A 60-year literature review of stump appendicitis: the need for a critical view - Corrected Proof

Anuradha Subramanian, Mike K. Liang — 2011-12-08

Abstract: Background: Stump appendicitis is an underreported and poorly defined condition. It is the development of obstruction and inflammation of the residual appendix after appendectomy. This is a review of the basic clinical, pathological, and surgical significance of stump appendicitis, and the “critical view” required for prevention. Data Sources: PubMed MEDLINE search was performed using terms “stump appendicitis” and “retained appendix” to obtain reported cases of stump appendicitis. Sixty-one cases were identified. Each case was charted based on 14 variables. Data were analyzed. Conclusions: Stump appendicitis warrants early detection. Patients can present with abdominal pain, nausea, and vomiting. A prior history of appendectomy can delay the diagnosis. A diagnosis can be made with an abdominal ultrasound or computed tomography scan. If treated early, laparoscopic or open completion appendectomy can be performed. If diagnosis is delayed and perforation is found, extensive resection is often required. A “critical view,” as described in this article, is key for prevention.

Preventing seroma formation after axillary dissection for breast cancer: a randomized clinical trial - Corrected Proof

2011-12-08

Abstract: Background: Seroma formation after axillary dissection remains the most common early sequel to breast cancer surgery. Different surgical approaches have been performed to reduce seroma collection. Therefore, we aimed to assess the outcome of patients operated on using an ultrasound scalpel according to a standardized operative technique before accepting it as a routine procedure. Methods: A randomized controlled trial was designed to compare the outcome of patients undergoing breast surgery and axillary dissection using either standard scalpel blades, scissors, ligations, and electrocautery or the ultrasound scalpel only. Each arm of the trial consisted of 30 patients. Results: A statistically significant benefit in terms of axillary and chest wall drainage volume, the number of axilla seromas, intraoperative bleeding, and hospitalization stay was recorded in the harmonic scalpel group. No significant differences were found between the 2 groups in terms of operative time. Finally, no postoperative hematoma, wound infections, and chest wall seroma were observed. Conclusions: The use of the harmonic scalpel was shown to reduce the magnitude of seromas in axilla and hospitalization stay. The harmonic scalpel can be used alone in axillary dissection with a safe and effective hemostasis. Our results must be confirmed by larger series.

Current management practice of breast borderline lesions—need for further research and guidelines - Corrected Proof

Eran Nizri, Schlomo Schneebaum, Joseph M. Klausner, Tehillah S. Menes — 2011-12-08

Abstract: Background: Breast borderline lesions are usually diagnosed on needle biopsies of imaging abnormalities. The natural history of these lesions is unclear, and the literature is divided on appropriate management. It was hypothesized that management varies among surgeons and may be associated with surgeon and practice characteristics. Methods: A survey of 477 members of the American Society of Breast Surgeons was completed. Results were analyzed according to various surgeon and practice characteristics. Results: Most respondents recommended routine excision for atypical ductal and lobular hyperplasia. Excision of radial scars and papillomas was much more variable, with only 50% recommending routine excision. Results differed by surgical dedication to breast surgery and fellowship training. Management of atypical ductal or lobular hyperplasia found at the margin varied significantly. The lack of a routine tumor board, low breast case volume, and low percentage of breast cases were associated with routine excision in these cases. Conclusions: Breast borderline lesions pose a clinical dilemma, with practice varying greatly among surgeons.

Re: appendectomy in pregnancy: evaluation of the risks of a negative appendectomy - Corrected Proof

2011-12-08

We read with great interest the article from Ito et al. The authors analyzed a cohort of 968 consecutive female patients who underwent an appendectomy in a 10-year period in a single institution and identified 87 pregnant patients. They analyzed the postoperative and obstetric outcomes and concluded that a negative appendectomy (NA) during pregnancy is not free of risk to the fetus; therefore, they recommended careful assessment to avoid unnecessary surgical exploration. A few issues merit further discussion. The reported incidence of fetal demise was higher in the perforated group compared with other groups, and this finding is quite obvious. Also, the perforated group had the highest rate of preterm delivery within 30 days after surgery. However, when recommending to carefully evaluate the risk and benefits of the policy of early appendectomy during pregnancy, by contrast it could be argued that a late diagnosis and a delayed surgical exploration and treatment may significantly increase the risk of perforation. In fact, when looking at the authors' data and comparing the preterm delivery rate and fetal demise incidence in the nonperforated groups (NA and inflamed), these rates are quite low (respectively, preterm delivery rate within 30 days was 7% [2 cases] in the NA group and 2% [1 case] in inflamed and fetal demise was 3% [1 case] in NA and 2% [1 case] in the inflamed group) and moreover are not significantly different among the NA and inflamed groups. Furthermore, when comparing these rates of the incidence of fetal complications (demise and preterm delivery), these surgically treated pregnant patients show the same or even a lower incidence of complications than observed in the general population. It is notable because the reported rate of preterm births is 10.6% of all births in North America and 6.2% in Europe. This rate was even higher in 2004 (the same period of the present study population), reaching 12.4%. As mentioned in the article by Mathews and Mc Dorman, the incidence of miscarriage was 6.86 infant deaths per 1,000 live births in 2005, with the greatest incidence of miscarriage in the first trimester (10%–15%) followed by the 2nd (up to 5%) and 3rd trimester (<1%). These rates are roughly comparable to the 3% and 2% fetal demise rate reported within appendectomized patients enrolled in the present study. A truly statistically significant increase of morbidity and fetal complications is only observed when perforation occurs.

Response to letter to the editor: do pregnant women have improved outcomes after traumatic brain injury - Corrected Proof

Cherisse Berry, James Mirocha, Ali Salim — 2011-12-08

We would like to thank Dr Wright and colleagues for their well thought-out critique of our study, which found that pregnant patients with moderate to severe traumatic brain injury (TBI) showed no statistically significant difference in mortality compared with their nonpregnant counterparts. Dr Wright challenges our conclusions because of the number of limitations that our study has and suggests that our conclusions are not supported by our data. First, we would like to acknowledge the significant contributions made by Dr Wright and colleagues from the ProTECT trial, and we are all awaiting the results of the ProTECT III clinical trial. However, although we agree with some of the comments regarding the limitations of our retrospective study, many of which have already been mentioned in the article, we firmly stand by the results from our study, which represents the largest study to date evaluating the association between pregnant women with isolated moderate to severe TBI and mortality.

Assessment of the learning curve for pancreaticoduodenectomy - Corrected Proof

2011-11-14

Abstract: Background: Experience with the Whipple procedure has been associated with improved outcomes, but the learning curve for this complex procedure is not well defined.Methods: Outcomes with 162 consecutive Whipple procedures during the 1st 11.5 years of practice was documented in a prospective database. A period of low (≤11/y) and high (≥23/y) case volume was compared using the Wilcoxon rank-sum test and Fisher exact test.Results: With low case volume, blood loss was higher (800 vs 400 mL, P = .001), more patients were transfused (44% vs 18%, P = .027), there were more complications (58% vs 46%, P = .0337), and a longer length of stay (10 vs 7 days, P = .006). There was only 1 mortality (.7%).Conclusions: Frequent repetition of the Whipple procedure is associated with an improvement in quantifiable quality benchmarks, and improvement continues with extensive experience. However, with proper training and the right environment, this procedure can be performed during the learning curve with acceptable outcomes.