The American Journal of Surgery - Articles in Press

Transanal endoscopic microsurgery: safe for midrectal lesions in morbidly obese patients - Corrected Proof

2012-05-14

Abstract: Background: Transanal endoscopic microsurgery is a safe option for proximal rectal tumors in morbidly obese patients for whom transabdominal pelvic dissection often is fraught with morbidity. Methods: From a database of 318 patients who underwent transanal endoscopic microsurgery, we report a retrospective case-control study of 9 patients with a body mass index range of 35 to 66 with sessile rectal lesions 6 to 15 cm from the anal verge who underwent transanal endoscopic microsurgery. Case subjects were compared with 15 controls and matched for age, tumor type, and level of tumor. The average body mass index of controls was 30 (P < .001). By using t test analysis, perioperative outcomes (surgical time, blood loss, and hospital length of stay) and postoperative complications were compared. Results: Sessile tumors were located 7 to 11 cm from the anal verge with a diameter of 1 to 4 cm. Patient and tumor factors such as age, distal tumor margin from anal verge, and tumor diameter were not significantly different between case subjects and controls. Surgical blood loss, surgical time, and hospital length of stay were not significantly different between the 2 groups. One complication occurred among the cases. No complications occurred in the control group. All patients had complete surgical resections with negative margins. Conclusions: Transanal endoscopic microsurgery in morbidly obese patients is a safe, feasible, and a viable alternative to low anterior resection.

Utility of shock index calculation in combat casualty triage protocol? - Corrected Proof

2012-05-14

We read with great interest the article by Eastridge et al determining the relationship between systolic blood pressure (SBP), hypoperfusion, and mortality in the combat casualty. In a retrospective review of 7,180 patient records from the Joint Theater Trauma Registry from 2002 to 2009, emergency department (ED) SBP, base deficit, and mortality data were analyzed. Their analysis illustrated that an SBP of 100 mm Hg or less was a more clinically relevant definition of hypotension and hypoperfusion than 90 mm Hg in the combat-wounded. The authors discussed the physiology of the trauma patient suffering from severe hemorrhage, as far as it often is dynamic and may not reflect the true degree of hypoperfusion present owing to normal physiological compensatory mechanisms. Such physiological compensations thus can mask the true nature and severity of many traumatic injuries, leading to underappreciation of the severity of injury, undertriage, and increased mortality. We would like to go further into the debate and speculate that calculation of the shock index (SI) may be more useful for caregivers than SBP measurement toward the identification of combat casualties in the compensatory phase of shock. The SI is defined as the ratio of heart rate (HR) to SBP. This easily calculable score at the bedside normally ranges from .5 to .7 in healthy adults. Rady et al evaluated a SI cut-off point of .9 in a cohort of 275 adult patients presenting to an ED with stable vital signs. The authors found that a SI greater than .9 was associated with an illness that was treated immediately, admission to the hospital, and intensive therapy on admission. Compared with HR or SBP alone, the SI has been suggested to be a better measure of hemodynamic stability in the ED setting. The appeal of the SI is that it quantifies the relationship between HR and SBP to allow a more objective evaluation of hemodynamic status. A given set of vital signs may on initial interpretation appear unalarming, but calculation of SI adds additional perspective that could influence clinical decisions. To conclude, we would like to know if the authors, maybe based on their retrospective analysis of the Joint Theater Trauma Registry data, could test the usefulness of SI (with a cut-off value of .9) in initial battlefield medical treatment facility triage of the combat casualty, to improve determination of the patient's mode of transport, priority of treatment, destination for treatment, injury severity, mortality, and need for possible life-saving interventions.

Overexpression of LAPTM4B-35 is associated with poor prognosis in colorectal carcinoma - Corrected Proof

2012-05-14

Abstract: Background: The purpose of this study was to determine whether lysosome-associated protein transmembrane-4 beta (LAPTM4B) overexpression is associated with the prognosis in patients with colorectal cancer. Methods: LAPTM4B expression was evaluated in colorectal cancer patients by Western blot analysis and immunohistochemistry. Univariate and multivariate analyses were performed to determine the association between LAPTM4B expression and prognosis. Results: Among the 136 patients with colorectal cancer, 51 patients had low LAPTM4B expression, and 85 patients had high LAPTM4B expression. The sensitivity and specificity of LAPTM4B overexpression were 62.5% and 100%, respectively. The 5-year overall survival (OS) rates for patients with high and low LAPTM4B expression were 37.38% and 98.04%, respectively (hazard ratio = 22.774; 95% confidence interval [CI], 5.287–98.091; P < .0001). The 5-year disease-free survival rate was 21.15% for patients in the high-expression group and 91.82% for patients in the low-expression group (hazard ratio = 11.674; 95% CI, 3.562–38.263; P < .0001). Conclusions: LAPTM4B overexpression is an independent factor in colorectal cancer prognosis, and it may be an important potential biomarker.

Impact of incisional hernia on health-related quality of life and body image: a prospective cohort study - Corrected Proof

2012-05-14

Abstract: Background: We investigated the impact of incisional hernia (IH) on quality of life and body image. Methods: Open abdominal surgery patients were included in a prospective cohort study performed between 2007 and 2009 in an academic hospital. Main outcomes were incidence of IH after approximately 12 months and Short-Form 36 and body image questionnaire results. Results: There were 374 patients who were examined after a median follow-up period of 16 months (range, 10–24 mo). Seventy-five patients had developed IH (20%); 63 (84%) were symptomatic. Adjusted for age, sex, and Charlson Comorbidity Index score, patients with IH reported significantly lower mean scores for components physical functioning (P = .033), role physical (P = .002), and physical component summary (P = .010). A trend toward significance was found for general health (P = .061). Patients with IH reported significantly lower mean cosmetic scores (P = .002), and body image and total body image scores (both P < .001). Conclusions: Patients with IH reported lower mean scores on physical components of health-related quality of life and body image.

Routine peritoneal drainage of the surgical bed after elective distal pancreatectomy: is it necessary? - Corrected Proof

Elena M. Paulus, Ben L. Zarzaur, Stephen W. Behrman — 2012-05-14

Abstract: Background: Recent literature suggests that peritoneal drainage (PD) is not helpful after elective pancreatectomy and may be detrimental. Data specific to distal pancreatectomy (DP) have not received prior evaluation. Methods: We performed a retrospective review of patients who underwent DP. Factors examined included postoperative morbidity and the need for therapeutic intervention. Results: Sixty-nine patients had DP, 30 without PD. Thirty-four patients suffered 45 complications, most were intra-abdominal in nature. Twelve, 19, and 3 patients required radiologic drainage, reoperation, or both, respectively. There was no difference between groups relative to intra-abdominal complications or the need for therapeutic intervention. Of 39 patients undergoing PD, 19 had abdominal morbidity. The drain was useful in identifying and/or treating the complication in 3 patients. Conclusions: First, PD after DP does not confer a reduction in morbidity or the need for therapeutic intervention versus patients with no drains. Second, the presence of a drain infrequently was helpful in detecting complications. Third, a multi-institutional, randomized study is recommended.

True pancreaticoduodenal aneurysms with celiac stenosis or occlusion - Corrected Proof

Jason A. Brocker, Janae L. Maher, Randall W. Smith — 2012-05-14

Abstract: Background: Pancreaticoduodenal artery (PDA) aneurysms are rare, representing only 2% of all visceral artery aneurysms. True PDA aneurysms associated with celiac stenosis or occlusion make up an even smaller subset of this group. No relationship between aneurysm size and the likelihood of rupture of PDA aneurysms is apparent. PDA aneurysm rupture is associated with a mortality rate upwards of 50%; therefore, accepted practice is treatment upon diagnosis. There is debate in the literature on whether the treatment of coexisting celiac axis stenosis is necessary for the prevention of recurrence. Data Sources: Literature relating to PDA aneurysms associated with celiac stenosis or occlusion was identified by performing a PubMed keyword search. References from identified articles were also assessed for relevance. The current literature was then reviewed and summarized. Conclusions: Characteristics of this patient population are identified. Based on current evidence, our best practice recommendation for the treatment of coexisting celiac axis stenosis is provided.

Mechanism, assessment, and incidence of male infertility after inguinal hernia surgery: a review of the preclinical and clinical literature - Corrected Proof

Hilâl Tekatli, Nelleke Schouten, Thijs van Dalen, Ine Burgmans, Niels Smakman — 2012-05-14

Abstract: Background: The treatment of inguinal hernia has changed considerably over the past 15 years. We reviewed the preclinical and clinical literature to find out the effect of inguinal hernia surgery on male fertility because it has been suggested that hernia surgery may impair testicular function and male fertility. Data Sources: A search on Embase, MEDLINE, and the Cochrane Library was performed to find related articles. Conclusions: Animal models show substantial effects of hernia repair on the structures in the spermatic cord, which is more pronounced in mesh repairs. Although the number of studies and the included numbers of patients were limited, clinical studies indicate that these potential adverse effects do not seem to have a clinical impact on male fertility in humans with inguinal hernias. Future clinical studies, preferably with bilateral patients, are necessary to investigate the clinical relevance of the effects of inguinal hernia and hernia surgery on male fertility.

Management of the focal nodular hyperplasia of the liver: evaluation of the surgical treatment comparing with observation only - Corrected Proof

2012-05-14

Abstract: Background: Long-term results of both surgery and observation for patients with focal nodular hyperplasia (FNH) in a large single-center experience do not exist. Accordingly, the aim of this study was to compare long-term outcomes in patients with FNH who underwent either elective hepatectomy or observation alone. Methods: A retrospective single-institution analysis of 185 patients with FNH, treated from 1990 to 2009, was performed. Results: Seventy-eight patients underwent elective hepatectomy and 107 patients observation alone, with a median follow-up period of 113 months. There was no perioperative mortality. Postoperative complications were recorded in 12 patients, and 92% of patients reported symptomatic reductions. Among observation patients, 9 (13%) developed additional symptoms; tumor enlargement was seen in 3 patients (4%). Conclusions: Elective liver resection for FNH is a safe procedure at high-volume centers. This single-center experience showed that 13% of observed patients had protracted symptoms. This justifies the therapeutic algorithm that elective surgery should be considered in symptomatic patients or in those with marked enlargement.

The role of sentinel lymph node biopsy in select sarcoma patients: a meta-analysis - Corrected Proof

2012-05-14

Abstract: Background: Sentinel lymph node (SLN) biopsy is a staging technique for occult lymph node disease. SLN biopsy has been applied to select patients with sarcoma, although the clinical utility remains uncertain. Methods: A PubMed/MEDLINE literature search was performed, and SLN biopsy outcomes were analyzed using a Bayesian meta-analytic approach to obtain point and interval estimates of rates of interest. Results: Sixteen studies involving SLN biopsy in patients with sarcoma were identified. Of 114 patients reported, 14 patients had positive SLNs (crude estimate, 12%; meta-analysis estimate, 17%). The meta-analysis false-negative rate was 29% (95% credible interval, 5%–59%). Recurrence and death rates in the SLN-positive group were higher than in the SLN-negative group. Conclusions: This investigation highlights the current role of SLN biopsy in select patients with sarcoma for tumor staging. Questions regarding the high false-negative rate and management of micrometastatic lymphatic disease in patients with sarcoma still exist.

Beta-blocker exposure in the absence of significant head injuries is associated with reduced mortality in critically ill patients - Corrected Proof

2012-05-14

Abstract: Background: The effect of β-blockade in trauma patients without significant head injuries is unknown. The purpose of this investigation was to determine the impact of β-blocker exposure on mortality in critically injured trauma patients who did not sustain significant head injuries. Methods: Critically ill trauma patients (Injury Severity Score ≥ 25) admitted to the surgical intensive care unit from January 2000 to December 2008 without severe traumatic brain injuries (head Abbreviated Injury Score ≥ 3) were included in this retrospective review. Patients who received β-blockers within 30 days of intensive care unit admission were compared with those who did not. The primary outcome measure evaluated was in-hospital mortality. Results: During the 9-year study period, 663 critically injured patients (Injury Severity Score ≥ 25) were admitted to the intensive care unit. Of these, 98 patients (14.8%) received β-blockers. Patients exposed to β-blockers had significantly lower in-hospital mortality (11.2% vs 19.3%, P = .006). Stepwise logistic regression identified β-blocker use as an independent protective factor for mortality (adjusted odds ratio, .37; P = .007) in critically injured patients. Conclusions: Beta-blocker exposure was associated with reduced mortality in critically injured patients without head injuries. Prospective validation of this finding is warranted.

Disability index in a randomized controlled trial of emergency sclerotherapy versus portacaval shunt for bleeding varices in cirrhosis - Corrected Proof

2012-05-11

Abstract: Background: Disability has not been studied after emergency treatment of bleeding esophageal varices (BEV). We created a disability index (DI) in a randomized controlled trial comparing emergency endoscopic therapy (EST) versus emergency portacaval shunt (EPCS). Methods: There were 211 unselected, consecutive patients with cirrhosis and acute BEV who were randomized to EST (n = 106) or EPCS (n = 105). Diagnostic work-up and treatment were performed within 8 hours. Ninety-six percent underwent more than 10 years follow-up evaluation. Disability was measured by assessing 9 factors to create a DI. Results: Ten-year survival was 8% after EST versus 51% after EPCS (P < .001). EPCS had a significantly better DI. The EST and EPCS values were as follows: liver function improvement: not applicable and ++; worsening liver function, ++ and not applicable; portal-systemic encephalopathy (PSE) incidence, 36 and 15; PSE episodes, 179 and 94; packed red blood cell units, 1,005 and 320; hospital readmissions, 387 and 292; and number of readmission days, 9.6 and 4.7. All of the P values were less than .001. Conclusions: EPCS resulted in a markedly better DI than EST, a significantly higher survival rate, better control of bleeding, and a lower incidence of PSE. EPCS is an effective first-line emergency treatment of BEV.

Palliative management for patients with subacute obstruction and stage IV unresectable rectosigmoid cancer: colostomy versus endoscopic stenting: final results of a prospective randomized trial - Corrected Proof

2012-05-11

Abstract: Background: Survival in patients with stage IV unresectable rectosigmoid cancer is significantly reduced, and when patients are seen with symptoms of obstruction, it is advisable to perform a diverting colostomy before acute obstruction occurs. The aim of this study was to compare the results of endoscopic stent placement with diverting proximal colostomy in patients with stage IV rectosigmoid cancer and symptoms of chronic subacute obstruction. Methods: In a prospective randomized trial, 22 patients with stage IV unresectable rectosigmoid cancer and symptoms of chronic subacute obstruction were randomized to either endoscopic placement of an expandable stent or diverting proximal colostomy. Patients were followed until death. Results: There was no case of mortality or major postoperative complications. Oral feeding and bowel function were restored within 24 hours after endoscopic stent placement and within 72 hours after diverting colostomy. Hospital stays were shorter (mean, 2.6 days) in patients with endoscopic stent placement than in those with diverting stomas (mean, 8.1 days) (P < .05). Mean long-term survival was 297 days (range, 125–612 days) in patients who had stents and 280 days (range, 135–591 days) in patients with stomas (P = NS). No case of mortality during follow-up was related to the procedures. All patients with stomas found them quite unacceptable. The same feelings were present in family members. None of the patients with stents or their family members found any inconvenience about the procedure. Conclusions: Endoscopic expandable stent placement offers a valid solution in patients with stage IV unresectable cancer and symptoms of chronic subacute obstruction, with shorter hospital stays. The procedure is much better accepted, psychologically and practically, by patients and their family members.

Safety of methylene blue dye for lymphatic mapping in patients taking selective serotonin reuptake inhibitors - Corrected Proof

Miraj G. Shah-Khan, Jenna Lovely, Amy C. Degnim — 2012-05-11

Abstract: Methylene blue dye has an important role in lymphatic mapping for sentinel lymph node surgery. A recent safety announcement from the US Food and Drug Administration warned physicians about possible serious central nervous system reactions in patients on serotonergic medications who received intravenous methylene blue for the identification of parathyroid glands. This report summarizes evidence from the Food and Drug Administration's announcement and methylene blue pharmacokinetics. The authors conclude that the use of methylene blue dye at low doses for lymphatic mapping likely carries very little risk for serotonin neurotoxicity, although breast surgeons should be aware of this potential complication in the event of mental status or neuromuscular changes in patients after lymphatic mapping.

Influence of obesity on complications and costs after intestinal surgery - Corrected Proof

Heather Wakefield, Mary Vaughan-Sarrazin, Joseph J. Cullen — 2012-05-11

Abstract: Background: Obesity is a risk factor for many comorbid conditions that increase the cost of health care. We sought to examine the effect of obesity on surgical complications and cost in a group of patients undergoing intestinal surgery. Methods: Using the Veterans Affairs Surgical Quality Improvement Program (VASQIP), which includes clinical data abstracted from medical records for Veterans Affairs (VA) surgical patients, and the VA Decision Support System, which provides the costs of individual patient encounters on the basis of relative values assigned to intermediate products, we examined surgical complications and costs of care in 4,881 patients undergoing intestinal surgery in 2006. Patients were classified into 4 groups based on body mass index (BMI): malnourished (<18), normal weight (18–30), obesity class I to II (30–40), and obesity class III (>40). Patient endpoints included the occurrence of any complication and surgical costs incurred within 30 days of surgery. Endpoints were compared across the 4 BMI categories in unadjusted analyses and risk-adjusted analyses and hospital-level variation using multivariable models. Results: After controlling for patient risk factors and hospital-level variation, patients in obesity class I to II were 1.21 times more likely to have any complication and patients in obesity class III were 1.41 times more likely to have any complication when compared with normal-weight patients. Similarly, patients in obesity class I to II were 1.44 times more likely to develop a wound complication compared with normal-weight patients, and patients in class III were 1.84 times more likely to develop a wound complication and 1.55 times more likely to develop a respiratory complication compared with normal-weight patients. In contrast, costs were greatest for malnourished patients at $45,000 compared with normal-weight patients at $37,000. However, after controlling for patient risk factors and variation in costs attributable to the admitting hospital, there were no significant cost differences between the 4 BMI categories. Conclusions: Obesity leads to increased wound and respiratory complications in intestinal surgery. Nevertheless, obesity alone is not an independent risk factor for increased costs in intestinal surgery.

Secular trends in small-bowel obstruction and adhesiolysis in the United States: 1988–2007 - Corrected Proof

Frank I. Scott, Mark T. Osterman, Najjia N. Mahmoud, James D. Lewis — 2012-05-11

Abstract: Background: Postoperative adhesions are common after surgery and can cause small-bowel obstruction (SBO) and require adhesiolysis. The impact that laparoscopy and other surgical advances have had on rates of SBO and adhesiolysis remains controversial. This study examines trends in discharges from US hospitals for SBO and adhesiolysis from 1988 to 2007. Methods: We performed an analysis of secular trends for SBO and adhesiolysis, using the National Hospital Discharge Survey. Spearman correlation coefficients were calculated to assess trends over time. Results: Rates of SBO were stable over time (ρ = .140; P = .28). Adhesiolysis rates were stable over time (ρ = −.18; P = .17), although there were significant downward trends in patients older than age 65 (ρ = −.55; P = .01) and age 15 to 44 (ρ = −.84; P < .01). Conclusions: There has been no significant change in overall rates of SBO or adhesiolysis from 1988 to 2007. For adhesiolysis, there were decreasing trends when stratified by age. Further research is required to understand the factors associated with adhesion-related complications.

Statistical assessment of the clinical performance of the Masimo Radical-7 - Corrected Proof

Jonas A. Pologe, Monica Menschik — 2012-05-07

The recent article “Validation of Noninvasive Hemoglobin Measurements Using the Masimo Radical-7 SpHb Station” by Causey et al provides some much-needed data on the performance of the Masimo Radical-7 (Masimo Corporation, Irvine, CA) for the noninvasive measurement of total hemoglobin. The statistical analysis performed on these data, however, does not fully characterize the clinical behavior observed in this study.

Expansion of statistical analysis in noninvasive hemoglobin monitoring - Corrected Proof

Marlin Wayne Causey, Seth Miller, Matthew Martin — 2012-05-07

We appreciate the additional expanded analysis of our study entitled “Validation of Noninvasive Hemoglobin Measurements Using the Masimo Radical-7 SpHb Station.” However, we would strongly caution the reader that the results presented in the letter's Table 2 are speculative and not based on analysis of our actual raw data. Furthermore, it appears that both of the authors of the letter to the editor are representatives of companies involved in the manufacture and sale of alternative monitoring devices and caution about the obvious potential for bias and significant conflict of interest also must be raised.

National incidence and outcomes of postoperative urinary retention in the Surgical Care Improvement Project - Corrected Proof

Alex K. Wu, Andrew D. Auerbach, David S. Aaronson — 2012-05-07

Abstract: Background: The national incidence of postoperative urinary retention (POUR), its risk factors, and associated outcomes are not well understood. Methods: We identified patients undergoing one of the Surgical Care Improvement Project surgeries using the National Inpatient Sample. By using International Classification of Diseases, 9th revision, Clinical Modification codes (ICD-9-CM), we identified POUR and the outcomes urinary tract infection, noninfectious catheter-related complications, length of stay, and posthospitalization care. Multivariable analysis identified predictors of POUR and its associated outcomes. Results: A total of 415,409 patients, representing 2,077,045 nationally, underwent one of the Surgical Care Improvement Project procedures with 43,030 (2.1%) developing POUR. Age, sex, type of surgery, and medical comorbidities were predictive of POUR with a .71 area under the curve. Patients with POUR had greater odds of having urinary tract infections (odds ratio [OR], 2.3; 95% confidence interval [CI], 2.2–2.5), suffering catheter-related complications (OR, 5.2; 95% CI, 3.8–7.0), and needing additional posthospitalization care (OR, 1.3; 95% CI, 1.25–1.4), and they had a greater length of stay (.24 extra days). Conclusions: Patients at risk for POUR can be identified, and they may benefit from interventions to prevent POUR.

Systematic review and meta-analysis of electrocautery versus scalpel for surgical skin incisions - Corrected Proof

Lisa N.F. Aird, Carl J. Brown — 2012-04-27

Abstract: Background: The creation of surgical skin incisions has historically been performed using a cold scalpel. The use of electrocautery for this purpose has been controversial with respect to patient safety and surgical efficacy. A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to compare skin incisions made by electrocautery and a scalpel. Data Sources: A systematic electronic literature search was performed using 2 electronic databases (MEDLINE and PubMed), and the methodological quality of included publications was evaluated. Six RCTs were identified comparing electrocautery (n = 606) and a scalpel (n = 628) for skin incisions. Conclusions: No significant difference in wound infection rates or scar cosmesis was identified between the treatment groups. Electrocautery significantly reduced the incision time and postoperative wound pain. A trend toward less incisional blood loss from skin incisions made with electrocautery was noted. Electrocautery is a safe and effective method for performing surgical skin incisions.

Prevention of early-onset pneumonia in surgical patients by chemoprophylaxis - Corrected Proof

Jesus Diez-Sebastian, Rafael Herruzo, Juan Garcia-Caballero — 2012-04-26

Abstract: Background: The purpose of this study was to explore the impact of surgical antimicrobial chemoprophylaxis on the prevention of early-onset postsurgical pneumonia (EOPP) using a logistic regression model that included the principal risk or confusion factors associated with incidence of early-onset postsurgical pneumonia. Materials and Methods: The sample chosen corresponded to 13 years during which the epidemiological surveillance system was in place in the general and digestive surgery department (N = 13,024 patients) and was designed as a prospective cohort study. Risk factors associated with EOPP development were analyzed using a cohort-nested case-control study. Results: Cumulative incidence of EOPP in this series of patients was .6%, accounting for 24.7% of total nosocomial pneumonias. The multivariate model showed the following risks or confusion factors for EOPP: age, emergency admission, type of surgery, duration of surgical intervention, infection on admission, and antimicrobial chemoprophylaxis (administered, odds ratio = .18; 95% confidence interval, .09–.33). Conclusions: Surgical antimicrobial chemoprophylaxis was associated as an independent factor with incidence reduction of early-onset postsurgical pneumonia, and, aside from its known effect on surgical site infection, its administration, where indicated, is useful for the prevention of early-onset postsurgical pneumonia.

Educational feedback in the operating room: a gap between resident and faculty perceptions - Corrected Proof

2012-04-26

Abstract: Background: Immediate feedback regarding performance in the operating room remains a key component of resident education. The aim of this study was to assess resident and faculty perceptions regarding postoperative feedback. Methods: Anonymous surveys were distributed to residents and faculty members. Questions addressed the timing, amount, and specificity of feedback; satisfaction; and the definition and importance of feedback. Additional questions regarded the importance and frequency of feedback in 7 specific areas of surgical competency. Results: Resident satisfaction with timing, amount, and specificity of feedback was significantly lower than faculty satisfaction. Perceptions of the importance of feedback for each of the 7 specific areas did not differ. Faculty members' perceptions on the frequency of feedback were higher than residents' perception in all competencies of feedback (5-point scale, all P values = .001). Conclusions: There are significant differences between resident and faculty perceptions regarding postoperative feedback. Although faculty members believed they delivered appropriate amounts of timely, quality feedback, this perception was not shared by residents.

The role of the breast cancer surgeon in personalized cancer care: clinical utility of the 21-gene assay - Corrected Proof

Christine Laronga, Jay K. Harness, Matthew Dixon, Patrick I. Borgen — 2012-04-20

Abstract: Background: Breast cancer surgeons represent the first line of defense for many patients battling this disease. They often have the first contact to discuss treatment options with the patient after diagnosis. However, the potential impact of this consultation has evolved with the arrival of commercialized multigene prognostic and predictive tests that continue to reshape the landscape of breast cancer management, including modern surgical practice. Method: This review was compiled from peer-reviewed literature indexed in PubMed. Conclusions: The advent of genomic analysis has advanced the treatment and management of breast cancer toward the goal of personalized care. Therefore, the role of the surgeon now extends beyond extirpation of the tumor and includes an understanding of the biology of the disease as well as an appreciation of this new technology. Breast cancer surgeons should seize this opportunity to provide patients and colleagues with this information in an expeditious manner to optimize clinical outcomes.

Running sutures anchored with square knots are unreliable - Corrected Proof

2012-04-12

Abstract: Background: A previous study showed that running polypropylene sutures anchored with square knots retain only 75% of their strength compared with half hitches. The aim of this study was to investigate whether anchor knot geometry similarly affects the tensile strength of other types of sutures used in continuous closures. Methods: Monofilament and multifilament sutures (all 3-0) were anchored with either square knots or half hitches to 1 tensionometer post, and the running ends were secured to the other. The force required to break the running suture and the site of suture failure were recorded. Results: The running sutures anchored with square knots retained only 50% to 84% of the strength of the identical sutures secured with half hitches (P < .001). Conclusions: A running suture anchored with half hitches is stronger and safer in comparison with the same suture anchored with square knots. This study provokes a fundamental reconsideration of the use of square knots to anchor running sutures.

Commentary on “the role of the breast cancer surgeon in personalized cancer care: clinical utility of the 21-gene assay” - Corrected Proof

J. Dirk Iglehart, Monica G. Valero — 2012-04-12

In this issue of the American Journal of Surgery, Laronga et al reviews the trajectory and implications of breast cancer management in the era of “personalized medicine” by focusing on genetic profiling of breast tumors. Genetic profiling is a short-hand notation for technologies including gene expression measurement, gene copy number determination, and genomic sequencing. During the past 40 years, the diagnosis of breast cancer has evolved. The past 4 decades saw introduction of the estrogen receptor (ER) into clinical practice, the discovery and application of human epidermal growth factor receptor 2 (HER2) testing, the discovery and use of BRCA1 and BRCA2 testing, and the use of genetic profiling to understand and predict breast cancer behavior. These advances in science and technology have resulted in improved patient outcomes and quality of care. Along with these advances, using a multidisciplinary approach in breast cancer management accelerates the introduction of improvements in care, including individualized treatment. The importance of a correct pathologic and molecular diagnosis ensures both tailored and correct treatment. The promise of personalized medicine depends on both a correct histologic diagnosis, and on accurate molecular subtype determination.

Impact of axillary ultrasound and core needle biopsy on the utility of intraoperative frozen section analysis and treatment decision making in women with invasive breast cancer - Corrected Proof

2012-04-09

Abstract: Background: Our objective was to evaluate the impact of preoperative axillary ultrasound and core needle biopsy (CNB) on breast cancer treatment decision making. A secondary aim was to evaluate the impact on the utility of intraoperative sentinel lymph node (SLN) frozen section. Methods: A review of 84 patients with clinically negative axilla who underwent axillary ultrasound was performed. Sensitivity, specificity, and positive/negative predictive value for axillary ultrasound with CNB was calculated. Results: Thirty-one (37%) had suspicious nodes. Of 27 amenable to CNB, 12 (14%) were malignant, changing treatment plans. The sensitivity of ultrasound and CNB was 54% and specificity 100%; the positive and negative predictive values were 100% and 80%, respectively. In 41 patients with normal ultrasounds who underwent SLN frozen section, 10 (24%) were positive. Conclusions: Preoperative axillary ultrasound impacts treatment decision making in 14%. With a sensitivity of 54%, it is a useful adjunct to, but not replacement for, SLN biopsy. Frozen section remains of utility even after a negative axillary ultrasound.

Plasma insulin and glucose time courses after biliary pancreatic diversion in morbidly obese patients with and without diabetes - Corrected Proof

Giuseppe Currò, Tommaso Centorrino, Vanessa Low, Giuseppe Navarra — 2012-04-06

Abstract: Background: The exact mechanism for the dramatic effect of surgical procedures for obesity on type 2 diabetes remains unknown. Methods: Five diabetic morbidly obese patients and 5 nondiabetic morbidly obese patients undergoing biliopancreatic diversion were compared retrospectively. A 75-g trans-gastrostomy glucose tolerance test was administered on the fifth day postoperatively and a standard 75-g oral glucose tolerance test was performed on the seventh day postoperatively, with blood sampling for measuring plasma glucose and insulin levels at 0, 30, 60, 90, 120, and 180 minutes. Results: All 5 diabetic patients were shown, at the same time, still to have diabetes or an impaired glucose tolerance test when tested through the biliopancreatic limb but patients were normal when tested through the new alimentary channel. No significant difference was seen in the nondiabetic patients. Conclusions: Biliopancreatic diversion can completely normalize the glycemic cycle in type 2 diabetes patients in the week after the intervention, even before any significant weight loss has occurred. The surgical procedure itself, designed to exclude most of the stomach, duodenum, and part of the jejunum, directly affects carbohydrate homeostasis.

Axillary ultrasound examination is useful for selecting patients optimally suited for sentinel lymph node biopsy after primary systemic chemotherapy - Corrected Proof

2012-04-06

Abstract: Background: Controversy surrounds the reliability of sentinel lymph node biopsy after primary systemic chemotherapy. In this study, we assessed axillary ultrasound for selecting patients most likely to optimally benefit from biopsy. Methods: The study included 87 patients who received primary systemic chemotherapy and underwent a sentinel lymph node biopsy followed by axillary lymph node dissection. Lymph nodes >10 mm in diameter, irregularly swollen, round, and homogeneously hypoechoic without an echo-rich center were considered axillary ultrasound positive. Results: In axillary ultrasound–negative patients before and after primary systemic chemotherapy, identification, sensitivity, and false-negative rates were 81%, 100%, and 0%, respectively. However, in patients whose lymph nodes converted from positive to negative after primary systemic chemotherapy, these values were 83%, 70.8%, and 29.2%, respectively. Conclusions: Axillary ultrasound–negative patients before and after primary systemic chemotherapy were suitable for sentinel lymph node biopsy. Axillary ultrasound should be used during primary systemic chemotherapy and before surgery.

The predictive value of preoperative carcinoembryonic antigen level in the prognosis of colon cancer - Corrected Proof

Hasan T. Kirat, Ersin Ozturk, Ian C. Lavery, Ravi P. Kiran — 2012-04-06

Abstract: Background: We evaluated factors associated with an increased preoperative carcinoembryonic antigen (CEA) level for colon cancer patients undergoing elective curative surgery and assessed whether this was associated with prognosis when accounting for other potential confounders. Methods: Prospectively accrued data of patients with stage I, II, and III colon cancer undergoing surgery (1980–2008) were retrieved retrospectively. Patients with a preoperative CEA level greater than 5 ng/mL (group B) were compared with those with a CEA level of 5 ng/mL or less (group A). Results: There were 651 patients (379 men) with a median age of 67 years (range, 21–94 y) and a median follow-up period of 5.9 years. Groups A (n = 451) and B (n = 200) had similar ages and tumor locations. Group B had larger tumors; more patients with T3 and N1/N2; and more patients with stage II/III tumors, and hence greater use of chemotherapy (P = .04). On multivariate analysis, patient age, tumor stage, and differentiation were associated with oncologic outcomes. A CEA level greater than 5 ng/mL was not associated independently with recurrence, recurrence-free survival (P = .47), or overall survival (P = .3). Conclusions: An increased preoperative CEA level is a marker for a more advanced tumor stage. For adequately staged patients, a high preoperative CEA level is not associated independently with oncologic outcomes.

An analysis of fine needle aspiration versus core needle biopsy in clinically palpable breast lesions: a report on the predictive values and a cost comparison - Corrected Proof

Sapna Nagar, Anthony Iacco, Thomas Riggs, William Kestenberg, Richard Keidan — 2012-04-05

Abstract: Background: Although fine-needle aspiration (FNA) is an established tool in the biopsy of breast masses, there has been a trend toward using core-needle biopsy (CNB). The aim of this study was to determine whether FNA has comparable predictive value with CNB and whether FNA is more cost effective. Methods: A retrospective review was conducted on 162 patients who underwent either FNA or CNB of palpable breast lesions and had histologic confirmation with surgical biopsy in calendar year 2005. Results: There were no false-positives or false-negatives in either group. The sensitivity, specificity, and positive predictive value for FNA were 89%, 98%, and 94%, respectively. CNB had sensitivity, specificity, and positive predictive value of 100%, 90%, and 93%, respectively. The cost to perform FNA was $166.34, compared with $477.92 for CNB. Conclusions: FNA and CNB had comparable predictive value, with FNA being more cost effective.

Positron emission tomography in hepatobiliary and pancreatic malignancies: a review - Corrected Proof

Billy Y. Lan, Sandi A. Kwee, Linda L. Wong — 2012-04-05

Abstract: Background: The prognosis for hepatobiliary and pancreatic malignancies is dismal. Surgery remains the primary curative option, but unresectable disease is often discovered during operative exploration. Positron emission tomography (PET) provides unique biological information different from current imaging modalities. The role of PET in detecting hepatobiliary and pancreatic malignancies has not yet been established. The purpose of this article was to review the literature on the use of PET in hepatobiliary and pancreatic malignancies. Data Sources: We performed an extensive search on PubMed using PET and hepatocellular, pancreatic, gallbladder, and cholangiocarcinoma as keywords, excluding articles not written in English or on nonhuman subjects, case reports, and series with <5 patients. Conclusions: Although PET has shown usefulness in the diagnosis of certain cancers, current literature cautions against the use of PET for determining malignant potential of primary liver and pancreatic lesions. Literature on PET more strongly supports clinical roles for restaging of hepatobiliary and pancreatic malignancies, and for identifying metastatic disease.

Complications nearly double the cost of care after pancreaticoduodenectomy - Corrected Proof

2012-04-05

Abstract: Background: Despite considerable data focused on the morbidity of pancreaticoduodenectomy (PD), the financial impact of complications has been infrequently analyzed. This study evaluates the impact of the most common complications associated with PD on the cost of care. Additionally, we identified cost centers that were significantly affected by complications. Methods: A retrospective analysis of a prospective database in a network of community-based teaching hospitals was performed. All patients (n = 145) who underwent PD were included for years 2005 to 2009. Of these, 144 had complete in-hospital cost data. Complications were assessed and classified into major and minor categories according to Dindo et al. Forty-nine cost centers were analyzed for their association with the cost of complications. Univariate and multivariate linear regression analyses were performed. Significance was reported for P < .05. Results: The median cost for PD was $30,937. Patients with major complications had significantly higher median cost compared with those without ($56,224 vs $29,038; P < .001). Independent predictors of increased cost included reoperation; sepsis; pancreatic fistula; bile leak; delayed gastric emptying; and pulmonary, renal, and thromboembolic complications. Cost center analysis showed significant added charges for patients with major complications for blood bank ($1,018), clinical laboratory ($3,731), a computed tomography scan ($4,742), diagnostic imaging ($697), intensive care unit ($4,986), pharmacy ($33,850) and respiratory therapy ($1,090) (P < .05, all). Conclusions: This study identified the major complications of PD, which are significantly associated with a higher cost. Substantial cost center increases were associated with major complications, particularly in pharmacy ($33,850). Measures aimed at limiting complications through centralization of care or care pathways may reduce the overall cost of care for patients after pancreatic resection.

The age of transfused blood predicts hematocrit response among critically ill surgical patients - Corrected Proof

2012-04-02

Abstract: Background: In vitro data suggest that erythrocytes undergo storage time-dependent degradation, eventuating in hemolysis. We hypothesize that transfusion of old blood, as compared with newer blood, results in a smaller increment in hematocrit. Methods: We performed an analysis of packed red blood cell transfusions administered in the surgical intensive care unit. Age of blood was analyzed as continuous, dichotomized at 14 days (old vs new), and grouped by weeks old. Results: A total of 136 U of packed red blood cells were given to 52 patients; 110 (80.9%) were 14 days old or more. A linear, inverse correlation was observed between the age of blood and the increment in hematocrit (r2 = −.18, P = .04). The increment in hematocrit was greater after transfusion of new as compared with old blood (5.6% vs 3.5%, respectively; P = .005). A linear relationship also was observed between the age of transfused blood in weeks and the increment in hematocrit (P = .02). Conclusions: There is an inverse relationship between the age of blood and the increment in hematocrit. The age of blood should be considered before transfusion of surgical patients with intensive care unit anemia.

Femoral vessel blood flow dynamics after totally extraperitoneal versus Stoppa procedure in bilateral inguinal hernias: the need for evidence-based surgery - Corrected Proof

Alberto Mangano, Stefano Rausei, Gianlorenzo Dionigi — 2012-04-02

We read with interest the article published by Ozmen et al. The authors are to be commended for their aim to conduct a prospective randomized trial on 64 patients with bilateral groin hernias, and to assess via Doppler ultrasonography the effect of prosthetic material on the velocity and diameters of the femoral vein and artery, comparing a laparoscopic totally extraperitoneal (n = 32 patients) versus an open preperitoneal procedure (n = 32 patients). This is a topic of interest because the mesh fibrosis and scar contraction could be a theoretical cause of regional blood flow impairment (potentially causing events such as venous stasis and deep venous thrombosis).

Comparison of the prognostic value of tumour and patient related factors in patients undergoing potentially curative resection of gastric cancer - Corrected Proof

2012-03-26

Abstract: Background: There is increasing evidence that the patient-related systemic inflammatory response is a powerful prognostic factor. The aim of the present study was to compare the prognostic value of selected markers of the systemic inflammatory response in patients undergoing resection of gastric cancer. Methods: One hundred twenty patients undergoing resection of gastric cancer, had measurements of various systemic inflammatory markers in addition to tumor-related factors. From these, the modified Glasgow Prognostic Score (mGPS), neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, and metastatic lymph node ratio were calculated. Results: On multivariate analysis, only the ratio of positive to total lymph nodes (hazard ratio, 2.29%; 95% confidence interval, 1.57%–3.33%; P < .001) and the mGPS (hazard ratio, 2.23%; 95% confidence interval, 1.40%–3.54%; P = .001) were independently associated with cancer-specific survival in patients with gastric cancer. An increase in the mGPS was associated with a higher neutrophil/lymphocyte ratio (P < .05) and poorer survival (P < .001). Conclusions: The present study indicates that the mGPS, an acute-phase, protein-based prognostic score, is a superior predictor of cancer survival compared with the cellular components of the systemic inflammatory response in patients undergoing resection of gastric cancer.

Recurrence and virulence of colonic diverticulitis in immunocompromised patients - Corrected Proof

2012-03-26

Abstract: Background: To evaluate the probability of recurrence and the virulence of colonic diverticulitis correlated with immunocompromised status. Methods: Nine hundred thirty-one patients admitted in a single tertiary referral university hospital over a 14-year period were included. Patients were divided into 2 groups: group 1, 166 immunosuppressed patients, and group 2, 765 nonimmunosuppressed patients. The variables studied were sex, age, American Society of Anesthesiologist status, reasons of immunosuppression (eg, chronic use of corticosteroids, transplant recipients, and diseases affecting the immune system), severity of the diverticulitis episode, recurrence, emergency and elective surgery, and morbidity and mortality rates. Results: Two hundred thirteen patients underwent an emergency operation during the first hospitalization and 26 patients in further episodes. One hundred thirty-six patients developed 1 or more recurrent episodes of diverticulitis. The overall recurrence rate was similar in both groups. Patients in group 1 with a severe first episode presented significantly higher rates of recurrence and severity without needing more emergency surgery. Mortality after emergency surgery was 33.3% in group 1 and 15.9% in group 2 (P = .004). Conclusions: After successful medical treatment of acute diverticulitis, patients with immunosuppression need not be advised to have an elective sigmoidectomy.

The combat experience of military surgical assets in Iraq and Afghanistan: a historical review - Corrected Proof

Andrew J. Schoenfeld — 2012-03-22

Abstract: Background: The Forward Surgical Team and Combat Support Hospital have been used extensively only during the past decade in Iraq and Afghanistan. The scope of their operational experience and historical development remain to be described. Methods: The literature was searched to obtain publications regarding the historical development of Forward Surgical Teams and Combat Support Hospitals, as well as their surgical experiences in Iraq and Afghanistan. Relevant publications were reviewed in full and their results summarized. Results: The doctrine behind the use of modern military surgical assets was not well developed at the start of the Iraq and Afghanistan conflicts. The Forward Surgical Team and Combat Support Hospital were used in practice only over the past decade. Because of the nature of these conflicts, both types of modern military surgical assets have not been used as intended and such units have operated in various roles, including combat support elements and civilian medical treatment facilities. Conclusions: As more research comes to light, a better appreciation for the future of American military medicine and surgery will develop.

A modified laparoscopic sleeve gastrectomy for the treatment of diabetes mellitus type 2 and metabolic syndrome in obesity - Corrected Proof

2012-03-14

Abstract: Background: Ghrelin is a gastrointestinal peptide hormone (a 28–amino acid peptide) produced primarily by X/A cells in the oxyntic glands of the stomach fundus and cells lining the duodenum cavern. It suppresses insulin secretion and action and commands a significant role in regulating food intake. The aim of the present study was to show that modified laparoscopic sleeve gastrectomy (MLSG), in which a significant part of the gastric fundus and body of the stomach is removed up to 1 inch from the pylorus vein, may contribute to decreasing circulating ghrelin levels. Methods: A study population consisting of 150 individuals was monitored after undergoing a MLSG, with individuals chosen based on a documented history of diabetes mellitus type 2 and metabolic syndrome, clinical results determining a body mass index (BMI) of 35 to 60 kg/m2, peptide C level greater than 1, negative anti-glutamic acid decarboxylase, negative anti-insulin, and confirmed stability of drug/insulin treatment and glycosylated hemoglobin greater than 6.5% for at least 24 and 3 months, respectively, before enrollment. Results: Twenty-four months after surgery, 150 patients (86.6%) presented with normal glycemic levels between 77 and 99 mg/dL. All patients improved average serum insulin levels by 9 mU/L and average glycosylated hemoglobin levels by 5.1% (normal range, 4%–6%). All patients tested negative for Helicobacter pylori and stopped using insulin, with 3 patients prescribed twice-daily use of an oral hypoglycemiant. In 14% of cases, patients experienced partial hair loss with low serum zinc levels and were prescribed oral zinc reposition and topical hair stimulants. The average weight loss recorded was 44.6% for patients with a BMI less than 45 kg/m2 and 58% for patients with a BMI greater than 50 kg/m2. Conclusions: The MLSG is a safe procedure with a low morbidity rate (2.7%) (4 cases of fistula and 2 of bleeding) and no surgical mortality in this study. This surgery can promote control of diabetes mellitus type 2 and aid the treatment of exogenous overweight and morbidly obese individuals. The results of this study show that only through resection of the ghrelin-producing gastric area can most obesity cases and diabetes type II conditions be reverted to nonobese and controlled diabetes.

Self-reporting of height and weight: valid and reliable identification of malnutrition in preoperative patients - Corrected Proof

2012-02-27

Abstract: Background: Preoperative screening for malnutrition has become mandatory in The Netherlands. A sensitive method to diagnose malnutrition would save time and improve effectiveness. Methods: A prospective cross-sectional study of 488 adult elective preoperative outpatients was performed. The accuracy of self-reported height and weight was compared with measured data and 3 commonly used malnutrition screening tools. Interobserver agreement was calculated by the intraclass correlation coefficient, studied in Bland and Altman plots, and analyzed by using Cohen's κ statistic. Accuracy was expressed in sensitivity, specificity, and false-negative rates. Results: Differences between self-reported and measured data were significant, but clinically irrelevant, because only 1 patient was falsely identified as well nourished. Intraclass correlation coefficient for height, weight, and body mass index was high (.97–.99). Bland–Altman plots showed that the mean ± standard deviation differences and 95% limits of agreement between both methods were as follows: height, .0096 m (±.0262, −.0417 to +.0609 m); weight, −1.28 kg (±2.29, −5.76 to +3.20 kg); body mass index, −.72 kg/m2 (±1.11, −2.92 to +1.46 kg/m2). The κ coefficient was .84 (95% confidence interval, .75–.94). Sensitivity was .97 and specificity was .98. Sensitivity and false-negative rates of self-reported data were better overall compared with the screening tools. Conclusions: Self-reported data provide highly sensitive information to diagnose malnutrition in preoperative outpatients.

Effects of duodenal-jejunal exclusion on beta cell function and hormonal regulation in Goto-Kakizaki rats - Corrected Proof

2012-02-20

Abstract: Background: The aim of our work was to investigate the hormones that control glycemic status and in vitro β-cell function in diabetes mellitus after a duodenal-jejunal exclusion in Goto-Kakizaki rats (Taconic, Denmark). Methods: Twenty-three rats (age, 12–14 wk) were randomized as follows: group 1 (n = 14), no intervention (control); or group 2 (n = 9), duodenal-jejunal exclusion. Results: In group 2, levels of glucagon and leptin were lower than in group 1 at 1 week and at 8 weeks. Glucagon-like peptide 1 levels had a significant increase at 8 weeks from basal value in group 2 and this value was higher than in group 1. The insulin secretion at 60 minutes in group 2 was higher than in group 1 (group 1, 12.9 ± 12.0 μg/L vs group 2, 41.9 ± 36.3 μg/L; P < .05). Messenger RNA (mRNA) expression of insulin at 2 months was higher in the rat pancreas of the experimental group than in the control group (group 1, .99 ± .48 mRNA amount vs group 2, 1.66 ± .33 mRNA amount; P < .05). Conclusions: Gastrojejunal bypass in this model improves glucose ratios, with a significant increase of glucagon-like peptide 1 and decrease of homeostasis model assessment, glucagon, and leptin levels after surgery. This type of surgery improves mRNA insulin expression in pancreatic islets and insulin secretion as well.

Is double-gloving really protective? A comparison between the glove perforation rate among perioperative nurses with single and double gloves during surgery - Corrected Proof

Yue Ping Guo, Po Ming Wong, Yi Li, Peggy Pui Lai Or — 2012-02-20

Abstract: Background: Surgical teams rely on surgical gloves as a barrier to protect themselves against blood-borne pathogenic infections during surgery. Double-gloving is adopted by surgeons to tackle the problem of glove perforation. Nevertheless, double-gloving is not practiced commonly by operating room nurses and there are only limited studies about double-gloving that targets only perioperative nurses. The aim of this research was to assess the effectiveness of double-gloving in protecting perioperative nurses by comparing the frequency of glove perforation between single-gloving and double-gloving groups. Methods: A prospective and randomized study was performed. Nurses were assigned randomly to single-gloved and double-gloved groups for comparison of the glove perforation rate. Water-leakage and air-inflation tests were used to detect glove perforation. Results: Glove perforations was detected in 10 of 112 sets of single-gloves (8.9%) and 12 of 106 sets of outer gloves in the double-gloved group (11.3%). There was no inner double-glove perforation (0%). Glove perforations were found in 6 and 4 of the 112 sets of single-gloves for the first assistants (5.36%) and the scrub nurses (3.57%), and 5 and 7 of 106 sets of outer gloves in the double-gloved group for the first assistants (4.72%) and the scrub nurses (6.60%), respectively. The average occurrence of perforation was 69.8 minutes (range, 20–110 min) after the beginning of surgery. The sites of perforation were localized mostly on the left middle finger (42%) and the left ring finger (33.3%). Conclusions: Based on the findings of the study, double-gloving is indeed effective in protecting operating room nurses against blood-borne pathogen exposure. It should be introduced as a routine practice.

A comparison of ambulatory perioperative times in hospitals and freestanding centers - Corrected Proof

Brionna Hair, Peter Hussey, Barbara Wynn — 2012-02-20

Abstract: Background: The volume of surgical procedures performed in ambulatory surgical centers has increased rapidly. Methods: Ambulatory surgical visits of Medicare beneficiaries were compared for hospital-based and freestanding ambulatory surgical centers (ASCs). The main outcomes were time in surgery, time in operating room, time in postoperative care, and total perioperative time. Results: The mean total perioperative time for all procedures examined was 39% shorter in freestanding ASCs then in hospital-based ASCs (83 vs 135 min; P < .01); surgery time was 37% shorter (19 vs 30 min; P < .01), operating room time was 37% shorter (34 vs 54 min; P < .01), and postoperative time was 35% shorter (48 vs 74 min; P < .01). Conclusions: Perioperative times were significantly shorter in freestanding ASCs than in hospital-based ASCs. It is unclear how much of the difference was the result of efficiency versus patient selection.

Construction of an evidence-based, graduated training curriculum for D-box, a webcam-based laparoscopic basic skills trainer box - Corrected Proof

Anders J. Debes, Rajesh Aggarwal, Indran Balasundaram, Morten B.J. Jacobsen — 2012-02-16

Abstract: Background: Surgical training programs are now including simulators as training tools for teaching laparoscopic surgery. The aim of this study was to develop a standardized, graduated, and evidence-based curriculum for the newly developed D-box (D-box Medical, Lier, Norway) for training basic laparoscopic skills. Methods: Eighteen interns with no laparoscopic experience completed a training program on the D-box consisting of 8 sessions of 5 tasks with assessment on a sixth task. Performance was measured by the use of 3-dimensional electromagnetic tracking of hand movements, path length, and time taken. Ten experienced surgeons (>100 laparoscopic surgeries, median 250) were recruited for establishing benchmark criteria. Results: Significant learning curves were obtained for all construct valid parameters for tasks 4 (P < .005) and 5 (P < .005) and reached plateau levels between the fifth and sixth session. Within the 8 sessions of this study, between 50% and 89% of the interns reached benchmark criteria on tasks 4 and 5. Conclusions: Benchmark criteria and an evidence-based curriculum have been developed for the D-box. The curriculum is aimed at training and assessing surgical novices in basic laparoscopic skills.

Worsening severity of vitamin D deficiency is associated with increased length of stay, surgical intensive care unit cost, and mortality rate in surgical intensive care unit patients - Corrected Proof

L. Ray Matthews, Yusuf Ahmed, Kenneth L. Wilson, Diane D. Griggs, Omar K. Danner — 2012-02-13

Abstract: Background: >Vitamin D deficiency is the most common nutritional deficiency in the United States. It is seldom measured or recognized, and rarely is treated, particularly in critically ill patients. The purpose of this study was to investigate the prevalence and impact of vitamin D deficiency in surgical intensive care unit patients. We hypothesized that severe vitamin D deficiency increases the length of stay, mortality rate, and cost in critically ill patients admitted to surgical intensive care units. Methods: We performed a prospective observational study of vitamin D status on 258 consecutive patients admitted to the Surgical Intensive Care Unit at Grady Memorial Hospital between August 2009 and January 2010. Vitamin D levels (25 [OH]2 vitamin-D3) were measured by high-pressure liquid chromatography and tandem mass spectrometry. Vitamin D deficiency was defined as follows: severe deficiency was categorized as less than 13 ng/mL; moderate deficiency was categorized as 14 to 26 ng/mL; mild deficiency was categorized as 27 to 39 ng/mL; and normal levels were categorized as greater than 40 ng/mL. Results: Of the 258 patients evaluated, 70.2% (181) were men, and 29.8% (77) were women; 57.6% (148) were African American and 32.4% (109) were Caucasian. A total of 138 (53.5%) patients had severe vitamin D deficiency, 96 (37.2%) had moderate deficiency, 18 (7.0%) had mild deficiency, and 3 (1.2%) of the patients had normal vitamin D levels. The mean length of stay in the Surgical Intensive Care Unit for the severe vitamin D–deficient group was 13.33 ± 19.5 days versus 7.29 ± 15.3 days and 5.17 ± 6.5 days for the moderate and mild vitamin D-deficient groups, respectively, which was clinically significant (P = .002). The mean treatment cost during the patient stay in the surgical intensive care unit was $51,413.33 ± $75,123.00 for the severe vitamin D–deficient group, $28,123.65 ± $59,752.00 for the moderate group, and $20,414.11 ± $25,714.30 for the mild vitamin D–deficient group, which also was clinically significant (P = .027). More importantly, the mortality rate for the severe vitamin D–deficient group was 17 (12.3%) versus 11 (11.5%) in the moderate group (P = .125). Because no deaths occurred in the mildly or normal vitamin D–deficient groups, we compared the mortality rate between severe/moderate and mild/normal vitamin D groups (P = .047). Conclusions: In univariate analysis, severe and moderate vitamin D deficiency was related inversely to the length of stay in the surgical intensive care unit (r = .194; P = .001), related inversely to surgical intensive care unit treatment cost (r = .194; P = .001) and mortality (r = .125; P = .023), compared with the mild vitamin D–deficient group, after adjusting for age, sex, race, and comorbidities (myocardial infarctions, acute renal failure, and pneumonia); the length of stay, surgical intensive care unit cost, and mortality remained significantly associated with vitamin D deficiency.

Commentary on: feasibility study of two-stage hepatectomy for bilobar liver metastases - Corrected Proof

Jean-Nicolas Vauthey, Daniel Erik Abbott — 2012-02-13

Bowers et al present another interesting report detailing their experience with 2-stage hepatectomy for metastatic liver tumors. In this series, 39 patients with various histologic primary malignancies underwent hepatic resection with curative intent, using radiofrequency ablation in 21% of patients. Nearly 70% of patients were able to complete the 2-stage approach with resection of all macroscopic disease, whereas a minority of patients progressed between stages and did not complete the second hepatectomy. This success rate is consistent with other large series, in which between 69% and 76% of patients were able to complete the 2-stage scheme. The reported morbidity and mortality profile was reasonable, with an overall mortality rate of 2.6% (1 death due to hepatic insufficiency). The investigators demonstrate a significant survival advantage for those whose disease did not progress after first-stage hepatectomy (median survival, 24 vs 10 months).

Heparin protects against septic mortality via apoE-antagonism - Corrected Proof

Pratibha Khosla, Ph.D. — 2012-02-13

I read with interest the article by Chuang et al, “Heparin protects against septic mortality via apoE-antagonism.” Sepsis is the major cause of death in intensive care units, despite enormous efforts in the development of antimicrobial therapies; therefore, the article was of great interest to me. However, the study had certain limitations that I would like to bring to the kind notice of the authors.

Disparity in the management of Graves' disease observed at an urban county hospital; a decade-long experience - Corrected Proof

2012-02-10

Abstract: Background: The objective of this study was to determine whether health care disparities exist in management of Graves' disease. Methods: Patients treated for Graves' disease from 1999 to 2009 were divided into medical and surgical treatment groups. A comparative analysis of age, sex, race, health insurance, and income was completed. Address and/or zip code were geocoded and median income was determined from census data. Results: A total of 634 patients were treated for Graves' disease; 535 (84%) medically and 99 (16%) surgically. Mean age (40 ± 15 vs 43 ± 11 y), percentage of women (84% vs 91%), and racial distribution were similar in the 2 groups (P > .05). In the surgical group, median income was lower ($31,530 vs $34,404; P = .07) and 52% of patients were uninsured compared with 30% of patients treated medically (P < .0001). Conclusions: A disproportionate number of uninsured patients underwent thyroidectomy for Graves' disease. Social and economic factors may have a role in determining definitive therapy for Graves' disease.

Re: “Colon preparation and surgical site infection” - Corrected Proof

E. Patchen Dellinger — 2012-02-10

I write to commend Dr Fry on a timely and important review of the subject of mechanical and oral antibiotic preparation of the colon for colon operations. As Dr Fry so correctly pointed out, there has been some gross misunderstanding of the evidence in this field and misinterpretation of a literature that correctly points out that mechanical bowel preparation is not beneficial in the absence of oral antibiotics. This had led to a recent article on a “bundle” for colectomies that actually resulted in an increase in surgical site infections when the bundle included the abandonment of mechanical and antibiotic preparation of the colon. I write to support Dr Fry's message but also to add 2 important references to his list that provide additional evidence. The first is a Cochrane review by Nelson et al that specifically examined the issue of oral antibiotics, intravenous systemic antibiotics, or the combination of both for colectomies and concluded that the combination of oral plus systemic antibiotics results in a lower rate of surgical site infections than either alone.

Reply to the commentary: Should we, not could we? A commentary on “Pyloric valve transposition as substitute for a colostomy in humans: a preliminary report” - Corrected Proof

Abhijit Chandra — 2012-02-10

I read the commentary by Dr Fleshman with great interest. Although I agree with him that our report demonstrates the technical feasibility of pyloric valve (PV) transposition as an anal sphincter and that the long-term outcomes of the procedure have yet to be assessed, I wish to clarify other related issues raised in his commentary.

Author's reply - Corrected Proof

Harry S. Goldsmith — 2012-02-10

I welcome Dr Fleshman's comments about my report “Pyloric Valve Transposition as Substitute for a Colostomy in Humans: A Preliminary Report” and his follow-up article, “Should We, Not Could We? A Commentary on ‘Pyloric Valve Transposition as Substitute for a Colostomy in Humans: A Preliminary Report.' ” Should, as he used in his title, expresses moral obligation, and I would make clear that pyloric valve transposition (PVT) was never considered an obligation for the development of this operation. Dr Fleshman stated “that the procedure needs to be evaluated carefully before endorsing the procedure.” It was never assumed that the operation should be routinely performed before it was carefully evaluated, and, as is designated in the title of the report, it clearly is a “preliminary report.”

A resident perspective on increasing duty-hour limitations - Corrected Proof

Robert M. Cannon, Michael E. Egger, Matthew C. Bozeman — 2012-02-10

We read the recent group of editorials regarding the quality of surgical resident training with great interest. The Accreditation Council for Graduate Medical Education duty-hour limitations imposed in 2003 were initiated primarily to achieve 2 goals: to improve resident quality of life and to protect patients from the perceived danger of care delivered by sleep-deprived physicians. New limitations that went into effect in July 2011 are even more restrictive, particularly for interns. In this era of evidence-based medicine, we should look to the evidence for support of the duty-hour limitations. The evidence, however, is lacking with regards to improvement in patient outcomes resulting from these limits. In fact, there has been no high-quality study showing improved quality of care in surgical patients because of duty-hour limitations.