Showing papers in "American Journal of Surgery in 2002"

Multimodal strategies to improve surgical outcome.

Abstract: Objective: To evaluate the effect of modifying perioperative care in noncardiac surgical patients on morbidity, mortality, and other outcome measures. Background: New approaches in pain control, introduction of techniques that reduce the perioperative stress response, and the more frequent use of minimal invasive surgical access have been introduced over the past decade. The impact of these interventions, either alone or in combination, on perioperative outcome was evaluated. Methods: We searched Medline for the period of 1980 to the present using the key terms fast track surgery, accelerated care programs, postoperative complications and preoperative patient preparation; and we examined and discussed the articles that were identified to include in this review. This information was supplemented with our own research on the mediators of the stress response in surgical patients, the use of epidural anesthesia in elective operations, and pilot studies of fast track surgical procedures using the multimodality approach. Results: The introduction of newer approaches to perioperative care has reduced both morbidity and mortality in surgical patients. In the future, most elective operations will become day surgical procedures or require only 1 to 2 days of postoperative hospitalization. Reorganization of the perioperative team (anesthesiologists, surgeons, nurses, and physical therapists) will be essential to achieve successful fast track surgical programs. Conclusions: Understanding perioperative pathophysiology and implementation of care regimes to reduce the stress of an operation, will continue to accelerate rehabilitation associated with decreased hospitalization and increased satisfaction and safety after discharge. Developments and improvements of multimodal interventions within the context of "fast track" surgery programs represents the major challenge for the medical professionals working to achieve a "pain and risk free" perioperative course.

A meta-analysis of randomized controlled trials that compared neoadjuvant chemoradiation and surgery to surgery alone for resectable esophageal cancer

Abstract: Background Esophagectomy is a standard treatment for resectable esophageal cancer but relatively few patients are cured. Combining neoadjuvant chemoradiation with surgery may improve survival but treatment morbidity is a concern. We performed a meta-analysis of randomized controlled trials (RCTs) that compared the use of neoadjuvant chemoradiation and surgery with the use of surgery alone for esophageal cancer. Methods Medline and manual searches were done to identify all published RCTs that compared neoadjuvant chemoradiation and surgery with surgery alone for esophageal cancer. A random-effects model was used and the odds ratio (OR) was the principal measure of effect. Systematic quantitative review was done for outcomes unique to the neoadjuvant chemoradiation treatment group, such as pathological complete response. Results Nine RCTs that included 1,116 patients were selected with quality scores ranging from 1 to 3 (5-point Jadad scale). Odds ratio (95% confidence interval [CI]; P value), expressed as chemoradiation and surgery versus surgery alone (treatment versus control; values Conclusions Compared with surgery alone, neoadjuvant chemoradiation and surgery improved 3-year survival and reduced local-regional cancer recurrence. It was associated with a lower rate of esophageal resection, but a higher rate of complete (R0) resection. There was a nonsignificant trend toward increased treatment mortality with neoadjuvant chemoradiation. Concurrent administration of neoadjuvant chemotherapy and radiotherapy was superior to sequential chemoradiation treatment scheduling.

Surgical margins in patients with early-stage breast cancer treated with breast conservation therapy.

Abstract: Background Patients receiving breast conservation therapy have a lifelong risk of local recurrence. To minimize this risk, surgeons have explored various approaches to examining the surgical margins of the resection specimen. If tumor cells are found at the margin, there is a high probability that residual tumor remains in the surgical cavity. This review examines published reports about standard and innovative approaches to assessing surgical margins, the clinical significance of margin size, and risk factors for positive margins. Methods: Published literature abstracted in Medline was reviewed using the Gateway site from the National Library of Medicine. Conclusions It is still not clear whether obtaining a radical margin will decrease the rate of local recurrence after breast conserving surgery. What is clear is that it is absolutely unacceptable to have tumor cells directly at the cut edge of the excised specimen, regardless of the type of post-surgical adjuvant therapy.

Role of nitric oxide in wound repair

Abstract: After injury, wound healing is essential for recovery of the integrity of the body. It is a complex, sequential cascade of events. Nitric oxide (NO) is a small radical, formed from the amino acid L-arginine by three distinct isoforms of nitric oxide synthase. The inducible isoform (iNOS) is synthesized in the early phase of wound healing by inflammatory cells, mainly macrophages. However many cells participate in NO synthesis during the proliferative phase after wounding. NO released through iNOS regulates collagen formation, cell proliferation and wound contraction in distinct ways in animal models of wound healing. Although iNOS gene deletion delays, and arginine and NO administration improve healing, the exact mechanisms of action of NO on wound healing parameters are still unknown. The current review summarizes what is known about the role of NO in wound healing and points out path for further research.

The timing of fracture treatment in polytrauma patients: relevance of damage control orthopedic surgery.

Abstract: Information illustrating the benefits of fracture stabilization after multiple trauma has been gathering for almost a century. At the turn of the last century, the introduction of the Thomas splint clearly demonstrated the importance of skeletal stabilization in the management of these patients. The introduction of standardized surgical treatment for fractures in the early 1950s is considered today as the turning point in the care of the polytraumatized patient. With the knowledge acquired, the application of early operative fixation of fractures in severely injured patients in the 1980s has yielded to the concept of early total care of all fractures. Yet, in distinct patient subgroups with severe thoracic injuries and very high injury severity scores, this concept has been associated with adverse outcomes. Therefore, in a further era that began in the 1990s, a different approach has been favored for these subgroups. It recommends early (initial) temporary stabilization followed by secondary definitive osteosynthesis of major fractures in patients at high risk of developing systemic complications. In the last decade, attempts have been made to determine which patients benefit from early total care and which ones should undergo a secondary definitive approach. This manuscript provides a historical overview on the changing treatment of fractures and summarizes the evolution of "damage control orthopedic surgery."

Medical and surgical options in the treatment of severe obesity.

Abstract: Weight loss programs, diets, and drug therapy have not shown long-term effectiveness in treating morbid obesity. A 1992 statement from the National Institutes of Health Consensus Development Conference affirmed the superiority of surgical over nonsurgical approaches to this condition. Bariatric surgical procedures work in 1 of 2 ways: by restricting a patient’s ability to eat (restrictive procedures) or by interfering with ingested nutrient absorption ( malabsorptive procedures). Many of these procedures can be performed by a laparoscopic approach, which has been shown to reduce operative morbidity. In the United States, the primary operative choice for morbidly obese patients has recently shifted from vertical banded gastroplasty (VBG) to the Roux-en-Y gastric bypass (RYGBP). VBG, a purely restrictive procedure, has fallen into disfavor because of inadequate long-term weight loss. RYGBP combines restriction and malabsorption principles, and has been shown to induce greater weight loss than VBG. Other procedures currently being offered include laparoscopic adjustable gastric banding; biliopancreatic diversion (BPD), including the duodenal switch (BPD-DS) variation; and distal gastric bypass (DGBP). Laparoscopic adjustable gastric banding with the LAP-BAND system (INAMED Health, Santa Barbara, CA), a restrictive procedure involving placement of a silicone band around the upper stomach, was introduced in the early 1990s and approved by the US Food and Drug Administration for use in the United States in June 2001. Outside the United States, LAP-BAND surgery is the most commonly performed operation for severe obesity. The BPD, BPD-DS, and DGBP are all malabsorptive procedures offered primarily by laparotomy. They have been shown to induce good long-term weight loss but have a higher rate of adverse nutritional complications. Many safe and effective surgical options for severe obesity are available. More scientific appraisals comparing different procedures and open and laparoscopic approaches are needed. © 2002 Excerpta Medica Inc. All rights reserved. The problem of obesity has reached epidemic proportions in the United States. More than 50% of adults are obese or overweight, and 5% are severely obese (body mass index [BMI] of 35) [1]. Numerous studies have demonstrated a strong relation between BMI and the development of lifeimpairing comorbidities, such as hypertension, diabetes (type 2), atherosclerosis, sleep apnea, and osteoarthritis. Obesity is associated with a higher risk of cancer (breast, colon, uterine) and premature death. Patients with severe or morbid obesity (BMI 35), the focus of this review, are consequently most severely affected by the disease, have a poor quality of life, and thus have the greatest need for weight loss therapy. Numerous medical and surgical treatments for severe obesity have come and gone over the years, underscoring the challenge and complexity of obesity management. The intent of this review is to summarize the current status of medical and surgical options for the treatment of severe obesity.

Reversal of cancer-related wasting using oral supplementation with a combination of β-hydroxy-β-methylbutyrate, arginine, and glutamine

Abstract: Background: Cancer-related cachexia is caused by a diverse combination of accelerated protein breakdown and slowed protein synthesis. The hypothesis proposed in this study is that supplementation of specific nutrients known to positively support protein synthesis and reduce protein breakdown will reverse the cachexia process in advanced cancer patients. Methods: Patients with solid tumors who had demonstrated a weight loss of at least 5% were considered for the study. Patients were randomly assigned in a double-blind fashion to either an isonitrogenous control mixture of nonessential amino acids or an experimental treatment containing -hydroxy--methylbutyrate (3 g/d), L-arginine (14 g/d), and L-glutamine (14 g/d [HMB/Arg/Gln]). The primary outcomes measured were the change in body mass and fat-free mass (FFM), which were assessed at 0, 4, 8, 12, 16, 20, and 24 weeks. Results: Thirty-two patients (14 control, 18 HMB/Arg/Gln) were evaluated at the 4-week visit. The patients supplemented with HMB/ Arg/Gln gained 0.95 0.66 kg of body mass in 4 weeks, whereas control subjects lost 0.26 0.78 kg during the same time period. This gain was the result of a significant increase in FFM in the HMB/Arg/Gln-supplemented group (1.12 0.68 kg), whereas the subjects supplemented with the control lost 1.34 0.78 kg of FFM (P 0.02). The response to 24-weeks of supplementation was evaluated by an intent-to-treat statistical analysis. The effect of HMB/Arg/Gln on FFM increase was maintained over the 24 weeks (1.60 0.98 kg; quadratic contrast over time, P 0.05). There was no negative effect of treatment on the incidence of adverse effects or quality of life measures. Conclusions: The mixture of HMB/Arg/Gln was effective in increasing FFM of advanced (stage IV) cancer. The exact reasons for this improvement will require further investigation, but could be attributed to the observed effects of HMB on slowing rates of protein breakdown, with improvements in protein synthesis observed with arginine and glutamine. © 2002 Excerpta Medica, Inc. All rights reserved.

The relationship between motion analysis and surgical technical assessments

Abstract: Background: Recent attempts to gain a more objective measure of surgical technical skill include the use of structured checklists and motion analysis of surgeons’ hand movements. We aim to show whether a correlation exists between these two methods of assessment. Methods: Fifty subjects were recruited from four experience groups in general surgery, ranging from basic surgical trainees to consultants and were assessed performing a standardized laboratory-based task. Motion analysis using the Imperial College Surgical Assessment Device (ICSAD), which measures hand movements and time taken, and the Objective Structured Assessment of Technical Skill (OSATS) technique were used to measure skill. Results: Number of movements made, time taken, and global rating score discriminated between performance and experience group (Kruskal-Wallis, P <0.001, P <0.01, P <0.001, respectively). There was a significant correlation between movements made and global rating score (Spearman coefficient 0.53, P <0.01). Checklist scoring was not an accurate predictor of experience. Conclusions: There is a strong correlation between hand motion analysis using ICSAD and OSATS global rating assessments in this model.

Current aspects of mucosal immunology and its influence by nutrition.

Abstract: Background: A significant body of clinical literature demonstrates that enteral feeding significantly reduces the incidence of pneumonia compared to patients fed parenterally. An immunologic link between the gastrointestinal tract and respiratory tract is postulated via the common mucosal immune hypothesis. This hypothesis states that cells are sensitized within the Peyer’s patches of the small intestine and are subsequently distributed to submucosal locations in both intestinal and extra intestinal sites. This system is exquisitely sensitive to route and type of nutrition. Data Source: This review examines the laboratory data regarding cell numbers, cell phenotypes, cytokine profile, and immunologic function in both intestinal and extra intestinal sites in animals that have been administered either parenteral feeding or various types of enteral feeding. It also establishes links between a specific nutrient, glutamine, the enteric nervous system, by way of neuropeptides, and mucosal immunity. Conclusion: Progress in understanding relationships between nutrient availability, enteric nervous system stimulation, and nutrient delivery on mucosal immunity offers opportunities to explore immune systems previously not appreciated by clinicians and basic scientists. These opportunities offer new challenges to the physician scientist, basic scientist, and clinician to understand, manipulate, and apply these concepts to the critically ill patient population by favorably influencing immunologic barriers and the inflammatory response.

Changes in comorbidities and improvements in quality of life after LAP-BAND placement.

Abstract: Possibly the most important outcomes of bariatric surgery involve changes in obesity-related illness, quality of life (QOL), and psychologic well-being. Dramatic improvement or resolution of serious medical comorbidity accompanies the weight loss following laparoscopic adjustable gastric banding with the LAP-BAND (INAMED Health, Santa Barbara, CA). There are major improvements in the conditions of the metabolic syndrome, which is characterized by impaired glucose tolerance, dyslipidemia, and hypertension. Improvement in insulin sensitivity and pancreatic beta-cell function associated with weight loss induces remission in the majority of type 2 diabetics and reduces the risk of others developing type 2 diabetes. Improvement in dyslipidemia is characterized by raised high-density lipoprotein cholesterol and lower triglyceride concentrations. Together with lower blood pressure, these changes provide a substantial reduction in cardiovascular risk. Other medical conditions caused or aggravated by obesity are also significantly improved, including sleep apnea, daytime sleepiness, asthma, and gastroesophageal reflux. Weight loss is associated with improved fertility and more favorable pregnancy outcomes. All aspects of QOL improve substantially, especially physical disability, and post-weight-loss QOL measures approximate those of the general population. There are also major improvements in body image and reduction in depressive illness. These changes provide perhaps the most compelling data regarding the value of LAP-BAND surgery and underlie the great satisfaction experienced by patients.

Predictive factors for conversion of laparoscopic cholecystectomy.

Abstract: Background: Laparoscopic cholecystectomy has replaced open cholecystectomy for the treatment of gallbladder disease. However, certain cases still require conversion to open procedures. Identifying these patients at risk for conversion remains difficult. This study identifies risk factors that may predict conversion from a laparoscopic to an open procedure. Methods: From January 1996 to January 2000, a total of 1,347 laparoscopic cholecystectomies were performed at the Cleveland Clinic Foundation (CCF). A retrospective analysis of 34 parameters including patient demographics, clinical history, laboratory data, ultrasound results, and intraoperative details was performed. Stepwise, multivariate logistic regression was used to determine those variables predicting conversion of laparoscopic cholecystectomy. Results: Seventy-one (5.3%) laparoscopic cholecystectomies required conversion. Multivariate analysis revealed that for all cases, a white blood cell count >9 (2.9 greater odds ratio [OR] of conversion P = 0.006) and a gallbladder wall thickness >0.4 cm (7.2 OR, P 30 kg/m 2 (5.6 OR, P = 0.02) predicted conversion. For patients undergoing elective cholecystectomy, a body mass index >40 kg/m 2 (33.1 OR, P = 0.01) and a wall thickness >0.4 cm (24.7 OR, P 2 (5.3 OR, P = 0.01) predicted conversion in patients undergoing nonelective cholecystectomies. Conclusions: Obese patients with acute cholecystitis undergoing laparoscopic cholecystectomy have an increased chance of conversion. Likewise, patients with multiple comorbid diseases undergoing nonelective laparoscopic cholecystectomy are more likely to require conversion. Finally, in an elective laparoscopic cholecystectomy, morbidly obese patients with chronic cholecystitis and a thickened gallbladder wall are more likely to require conversion. These factors can help counsel patients undergoing laparoscopic cholecystectomy with regards to the probability of conversion to an open procedure.

Morbidity, mortality, and technical factors of distal pancreatectomy.

Abstract: Background: Pancreatic leak is a major source of morbidity associated with pancreatic surgery. We sought to identify disease and technique-dependent factors associated with morbidity and mortality after distal pancreatectomy. Methods: Retrospective review of patients who underwent distal pancreatectomy during a 5-year period. Clinical, technical, and pathologic data were correlated with operative morbidity or mortality. Results: Fifty-one patients underwent distal pancreatectomy for primary pancreatic disease, extrapancreatic malignancy, or trauma. Overall perioperative mortality and morbidity rates were 4% and 47%, respectively. Pancreatic leak was the most common complication, occurring in 26% of patients. Overall complications and pancreatic leaks occurred more often after distal pancreatectomy for trauma and in patients with a sutured pancreatic stump closure. Conclusions: Distal pancreatectomy can be performed with a low rate of mortality, though pancreatic leak is a common cause of morbidity. The urgency of the procedure and the method of pancreatic stump closure may influence postoperative morbidity.

Sentinel lymph node biopsy results in less postoperative morbidity compared with axillary lymph node dissection for breast cancer

Abstract: Background: This study was designed to compare the postoperative morbidity and socioeconomic impact of sentinel lymph node biopsy (SLNB) with axillary lymph node dissection (ALND) in patients with early stage breast cancer. Methods: A prospective, nonrandomized, controlled study was designed to include patients who underwent breast conservation surgery and SLNB ± ALND. Group A consisted of patients who had a negative SLNB and did not go on to completion ALND. Group B consisted of patients who underwent a SLNB followed by a completion ALND because either (1) their sentinel node contained cancer or (2) they were within the validation phase of our institution’s sentinel lymph node protocol. Patients were evaluated with a questionnaire and underwent a standardized physical examination to determine arm circumference. Results: Data were obtained from 96 patients with a mean follow-up period of 15 months (range 8 to 29). Significant differences were seen in subjective measurements of arm complaints and arm numbness (P <0.001), with fewer complaints reported in group A. The difference in mid-bicep and antecubital fossa circumferences was significant when comparing the ratio of the procedure arm with the nonprocedure arm and when subtracting the nonprocedure arm from the procedure arm (P <0.003 and P <0.016, respectively) in favor of group A. Axillary surgery was performed as an outpatient procedure in 88% of group A patients, compared with 15% in group B (P <0.001). Furthermore, 71% of group A patients returned to “normal activity” in less than 4 days, in comparison with 7% of group B (P <0.001). Conclusions: SLNB results in less postoperative morbidity in terms of subjective arm complaints and mid-arm swelling. Expeditious return to work or normal activity after SLNB has potentially significant socioeconomic consequences.

Principles and practices for treatment of cutaneous wounds with cultured skin substitutes

Abstract: Background: Skin substitutes prepared from cultured skin cells and biopolymers may reduce requirements for donor skin autograft, and have been shown to be effective in treatment of excised burns, burn scars, and congenital skin lesions. Data Sources: Cultured skin substitutes (CSS) generate skin phenotypes (epidermal barrier, basement membrane) in the laboratory, and restore tissue function and systemic homeostasis. Healed skin is smooth, soft and strong, but develops irregular degrees of pigmentation. Quantitative analysis demonstrates that CSS closes 67 times the area of the donor skin, compared to less than 4 times for split-thickness skin autograft. Conclusions: CSS reduce requirements for donor skin autograft for closure of excised, full-thickness cutaneous wounds, and demonstrate qualitative outcome that is not different from meshed, split-thickness autograft. These results offer reductions in morbidity and mortality for the treatment of burns and chronic wounds, and for cutaneous reconstruction.

Secondary abdominal compartment syndrome is an elusive early complication of traumatic shock resuscitation.

Abstract: Background The term secondary abdominal compartment syndrome (ACS) has been applied to describe trauma patients who develop ACS but do not have abdominal injuries. The purpose of this study was to describe major trauma victims who developed secondary ACS during standardized shock resuscitation. Methods Our prospective database for standardized shock resuscitation was reviewed to obtain before and after abdominal decompression shock related data for secondary ACS patients. Focused chart review was done to confirm time-related outcomes. Results Over the 30 months period ending May 2001, 11 (9%) of 128 standardized shock resuscitation patients developed secondary ACS. All presented in severe shock (systolic blood pressure 85 ± 5 mm Hg, base deficit 8.6 ± 1.6 mEq/L), with severe injuries (injury severity score 28 ± 3) and required aggressive shock resuscitation (26 ± 2 units of blood, 38 ± 3 L crystalloid within 24 hours). All cases of secondary ACS were recognized and decompressed within 24 hours of hospital admission. After decompression, the bladder pressure and the systemic vascular resistance decreased, while the mean arterial pressure, cardiac index, and static lung compliance increased. The mortality rate was 54%. Those who died failed to respond to decompression with increased cardiac index and did not maintain decreased bladder pressure. Conclusions: Secondary ACS is an early but, if appropriately monitored, recognizable complication in patients with major nonabdominal trauma who require aggressive resuscitation.

Perceptions of women medical students and their influence on career choice.

Abstract: Background: Although women make up nearly half of medical school classes in the United States, just over 20% of residents in surgery are women (excluding obstetrics/gynecology). The objective of this study was to identify whether the proportion of women surgeons on the faculty who have frequent encounters with medical students during their surgery rotation influences the student’s perceptions about women surgeons or their career choice. Methods: Seven US medical schools with proportions of women surgeons on the fulltime faculty varying from 10% to 40% were selected to participate in this survey. Women medical students graduating in the spring of 2000 were asked to complete an anonymous 29 question survey designed to assess their perceptions of women surgeons’ career satisfaction. Demographic information about the students such as career choice, age, and marital status was also collected. The differences in responses between those schools with 40% women faculty and those with less than 15% were analyzed. Results: The overall response rate was 74% (305 of 413). Forty-five percent of students had daily or weekly contact with a woman surgery attending. There were no differences in perceptions of women surgeons’ career satisfaction for those students at schools with 40% women surgeons versus those with less than 15%. However, 21 of 24 (88%) students choosing surgery as a career were from the three schools with a greater number of women surgical role models (P <0.0001). Students who chose a career in surgery perceived the women faculty’s career satisfaction to be higher than did those students not choosing a surgical career (P <0.01). Conclusions: Women medical students perception of women surgeons’ career satisfaction did not appear to be affected by the proportion of women surgeons on the faculty at their medical school. However, their choice of surgery as a career was strongly associated with a higher proportion of women on the surgical faculty.

Intraoperative neuromonitoring of surgery for benign goiter

Abstract: Background: Recurrent laryngeal nerve (RLN) palsy is one of the most serious complications in thyroid surgery. No prospective studies are available that evaluate if the additional use of intraoperative neuromonitoring reduces the rate of RLN palsy. Methods: Between January 1 and December 31, 1998, surgery for histologically benign goiter with intraoperative identification with and without additional intraoperative RLN neuromonitoring was performed on 4,382 patients in 45 hospitals. Data were collected prospectively by questionnaire. Results: The rate of transient and permanent RLN palsy based on nerves at risk were 1.4% and 0.4% with intraoperative neuromonitoring. These rates were significantly lower (P <0.05) compared with intraoperative visual RLN identification without intraoperative neuromonitoring which resulted in rates of 2.1% and 0.8%, respectively. A multivariate logistic regression analysis confirmed that the use of intraoperative neuromonitoring decreases the rate of postoperative transient (P <0.008) and permanent (P <0.004) RLN palsies as an independent factor by 0.58 and 0.30, respectively. Conclusions: Intraoperative neuromonitoring of the RLN in thyroid surgery is recommended because of significantly lower rates of transient and permanent RLN palsy rates in comparison with conventional RLN identification.

Prevention of pancreatic anastomotic leakage after pancreaticoduodenectomy

Abstract: Background: Leakage at the pancreaticoenteric anastomosis remains a common and serious complication after pancreaticoduodenectomy. Over the past decade, various measures directed towards prevention of pancreatic leakage have been studied. This article reviews the available data on the efficacy of these measures. Data sources: The Medline database from 1990 to 2000 was searched for studies on the prevention of pancreatic anastomotic leakage, and the bibliographies of the articles were reviewed for additional references. Results: A meta-analysis of the results of prophylactic octreotide in preventing pancreatic fistula after pancreaticoduodenectomy from data available in three randomized controlled studies yielded an odds ratio of 1.08 (95% confidence interval 0.64 to 1.84). Pending further trials to clarify its role, the routine use of octreotide in pancreaticoduodenectomy cannot be recommended. Retrospective or nonrandomized prospective studies suggested that technical modifications such as duct-to-mucosa anastomosis, pancreaticogastrostomy and external pancreatic duct stenting may reduce the leakage rate, but there is a paucity of randomized trials. A randomized trial comparing pancreaticogastrostomy and pancreaticojejunostomy did not reveal a significant difference in the leakage rate. Conclusions: Further randomized controlled studies are required to determine the optimum technique of pancreaticoenteric anastomosis after pancreaticoduodenectomy.

Obesity and its surgical management

Abstract: Obesity is increasing in epidemic proportions world-wide. Even mild degrees of obesity have adverse health effects and are associated with diminished longevity. For this reason aggressive dietary intervention is recommended. Patients with body mass indices exceeding 40 have medically significant obesity in which the risk of serious health consequences is substantial, with concomitant significant reductions in life expectancy. For these patients, sustained weight loss rarely occurs with dietary intervention. For the appropriately selected patients, surgery is beneficial. Various operations have been proposed for the treatment of obesity, many of which proved to have serious complications precluding their efficacy. A National Institutes of Health Consensus Panel reviewed the indications and types of operations, concluding that the banded gastroplasty and gastric bypass were acceptable operations for treating seriously obese patients. Surgical treatment is associated with sustained weight loss for seriously obese patients who uniformly fail nonsurgical treatment. Following weight loss there is a high cure rate for diabetes and sleep apnea, with significant improvement in other complications of obesity such as hypertension and osteoarthritis.

Portal vein thrombosis after splenectomy.

Abstract: Background Portal vein thrombosis (PVT) has been described after splenectomy, but the factors associated with its development and the clinical outcomes are poorly characterized. Methods Case logs of four surgeons from 1996 to 2001 were retrospectively reviewed to identify cases of postsplenectomy PVT. Results: Eight cases of PVT (8%) among 101 splenectomies were identified. Indications for splenectomy in patients with PVT were myeloproliferative disease (n = 4), hemolytic anemia (n = 3), and myelodysplastic disorder (n = 1). All patients had splenomegaly (mean 1698 g, range 360 to 3150 g). Among 10 patients with myeloproliferative disease (MP), 4 patients (40%) developed PVT, compared with 4 of 12 patients (25%) with hemolytic anemia. Three of 4 patients (75%) with MP disease and spleen weight greater than 3,000 g developed PVT. Five patients developed PVT despite receiving prophylactic subcutaneous heparin postoperatively. Presenting symptoms included anorexia in 7 (88%), abdominal pain in 6 (75%), and both elevated leukocyte and platelet counts in 8 patients (100%). All diagnoses were made by contrast-enhanced computed tomography scan, and anticoagulation was initiated immediately. One patient died of intraabdominal sepsis; the others are alive with no clinical sequelae at 38 months of follow-up. Conclusions PVT is a relatively common complication of splenectomy in patients with splenomegaly. A high index of suspicion, early diagnosis by contrast-enhanced computed tomography, and prompt anticoagulation are key to a successful outcome.

Weight loss and early and late complications--the international experience.

Abstract: Following its introduction in 1993, the LAP-BAND (INAMED Health, Santa Barbara, CA) has been used extensively across the world for the treatment of obesity, and data on safety and effectiveness are now available. This review draws on the literature and our own clinical patient base to provide an overview of the early and late problems associated with LAP-BAND placement and its effects on weight loss. It has proved to be a remarkably safe procedure. A report analyzing international data on laparoscopic adjustable gastric bands identified 3 deaths in 5,827 patients (approximately 1 in 2,000). In our series of 1,120 patients, there have been no deaths and no life-threatening perioperative complications. Significant early complications occurred in 17 (1.5%) of our patients; late problems have been more common, particularly during our early experience. Prolapse of the stomach through the band occurred in 125 (25%) of our first 500 patients but has occurred in only 28 (4.7%) of our last 600 patients. Erosion of the band into the stomach occurred in 34 patients (3%); all occurred in the first 500 patients. No erosions have occurred in the last 600 patients. Both problems are treated laparoscopically by removal and replacement. Combined international data show that weight loss after LAP-BAND placement is characterized by steady progressive weight loss over a 2- to 3-year period, followed by stable weight out to 6 years. This pattern reflects the benefit of adjustability. For the international series, the percent excess weight loss (%EWL) at 2 years has been between 52% and 65%. In our series, %EWL at 5 years and 6 years was 54% and 57%, respectively. The LAP-BAND is proving to be extremely safe, able to facilitate good weight loss, and able to maintain weight loss over time.

Percutaneous transhepatic cholecystostomy and delayed laparoscopic cholecystectomy in critically ill patients with acute calculus cholecystitis

Abstract: Background: The ultimate therapy for acute cholecystitis is cholecystectomy. However, in critically ill elderly patients the mortality of emergency cholecystectomy may reach up to 30%. Open cholecystostomy performed under local anesthesia was considered to be the procedure of choice for treatment of acute cholecystitis in high-risk patients. In recent years, ultrasound- or computed tomography (CT)-guided percutaneous transhepatic cholecystostomy (PTHC) replaced open cholecystostomy for the treatment of acute cholecystitis in critically ill patients. Methods: The aim of the present study was to evaluate the results of a 5-year protocol using PTHC followed by delayed laparoscopic cholecystectomy for the treatment of acute cholecystitis in critically ill patients. We reviewed the charts of 55 patients who underwent PTHC at the Hadassah University Hospital Mount Scopus during the years 1994 to 1999. Results: The main indications for PTHC among this group of severely sick and high-risk patients was biliary sepsis and septic shock in 23 patients (42%); and severe comorbidities in 32 patients (58%). The median age was 74 (32 to 98) years, 33 were female and 22 male. Successful biliary drainage by PTHC was achieved in 54 of 55 (98%) of the patients. The majority of the patients (31 of 55) were drained transhepaticlly under CT guidance. The rest, (24 of 55) were drained using ultrasound guidance followed by cholecystography for verification. Complications included hepatic bleeding that required surgical intervention in 1 patient and dislodgment of the catheter in 9 patients that was reinserted in 2 patients. Three patients died of multisystem organ failure 12 to 50 days following the procedure. The remaining 52 patients recovered well with a mean hospital stay of 15.5 ± 11.4 days. Thirty-one patients were able to undergo delayed surgery: 28 underwent laparoscopic cholecystectomy of whom 4 (14%) were converted to open cholecystectomy. This was compared with a 1.9% conversion rate in 1,498 elective laparoscopic cholecystectomies performed at the same time period (P = 0.012). Another 3 patients underwent planned open cholecystectomy, 1 urgent and 2 combined with other abdominal procedures. There was no surgery associated mortality, severe morbidity, or bile duct injury. Conclusions: The use of PTHC in critically ill patients with acute cholecystitis is both safe and effective.

Acute surgical emergencies in inflammatory bowel disease.

Abstract: Background: Acute surgical emergencies in patients with inflammatory bowel disease may carry a substantial morbidity, but fortunately today, a low mortality. The aim of this review is to delineate the treatment of acute surgical emergencies that occur in patients with ulcerative colitis and Crohn’s disease. Methods: Suitable English language reports were identified using PubMed search. Results: Inflammatory bowel disease can present in numerous ways as an acute surgical emergency. These include toxic colitis, hemorrhage, perforation, intra-abdominal masses or abscesses with sepsis, and intestinal obstruction. Toxic colitis and perforation are best managed with intestinal resection and fecal diversion. Hemorrhage in ulcerative colitis initially requires colectomy with rectal preservation and ileostomy. In Crohn’s disease hemorrhage is often focal and localization and segmental resection are performed. Intra-abdominal abscesses should initially be attempted by computed tomography-guided percutaneous drainage followed subsequently by definitive resection. Perianal disease requires abscess drainage with minimal tissue trauma. Intestinal obstruction should be initially managed nonoperatively, with surgery reserved for complete obstruction or intractability. Conclusions: Acute surgical emergencies in patients with inflammatory bowel disease are rare and can have a high morbidity. With a multidisciplinary approach, morbidity can be reduced and patients can have a rapid return and improved quality of life.

Treatment and outcome of patients with intracystic papillary carcinoma of the breast

Abstract: Background: Intracystic papillary carcinoma (IPC) of the breast is a rare form of noninvasive breast cancer. An appreciation of associated pathology with IPC may be critical in surgical decision-making. Methods The medical records of all patients with IPC treated between 1985 and 2001 were retrospectively reviewed. Three patient groups were identified according to the pathologic features of the primary tumor: IPC alone, IPC with associated ductal carcinoma in situ (DCIS), and IPC with associated invasion with or without DCIS. Types of treatment and outcomes were compared between groups. Results: Forty patients were treated for IPC during the study period. Fourteen had pure IPC, 13 had IPC with DCIS, and 13 had IPC with invasion. The incidence of recurrence and the likelihood of dying of IPC did not differ between the three groups regardless of the type of surgery (mastectomy or segmental mastectomy) performed and whether radiation therapy was administered. The disease-specific survival rate was 100%. Conclusions When IPC is identified, it is frequently associated with DCIS and or invasion. Standard therapy should be based on associated pathology. The role of radiation therapy in pure IPC remains to be determined.

An assessment of vertical banded gastroplasty-Roux-en-Y gastric bypass for the treatment of morbid obesity.

Abstract: Objective: To analyze retrospectively the mortality, morbidity, and weight loss of a specific form of gastric bypass for the treatment of morbid obesity. The technique incorporates a small pouch along the lesser curvature of the stomach, an outlet restricted by a nondistensible band and a Roux-en-Y gastric bypass. Material and methods: We analyzed 652 consecutive patients with no previous bariatric surgery who underwent our present form of gastric bypass. Parameters used to evaluate the technique included mortality, weight loss at 5 years and complications. The operation is a combination of vertical banded gastroplasty and Roux-en-Y gastric bypass (VBG-RGB). The patients followed up to 5 years had an initial weight of 140 kg [range, 94 to 288] and a BMI of 50 [range, 38 to 86]. Superobese individuals (BMI of 60 [range, 48 to 86]) made up 42% of the group. Results: There was an early reoperation rate of 0.5%. The incidence of late complications that required reoperation was 0.5%. There were 2 deaths in the study from pulmonary embolism for a mortality of 0.3%. At 5 years, the patients had lost an average of 58kg [range, 14 to 143] and had a percentage excess weight loss of 77 [range, 32 to 108]. Their BMI was reduced to 29 kg/m 2 [range, 20 to 43] and 93% lost more than 50% of the excess weight. Conclusions: VBG-RGB is effective in producing superior weight loss in morbid and superobese patients and has a low mortality and morbidity. We recommend this procedure without reservations.

Fine-needle aspiration of clinically suspicious palpable breast masses with histopathologic correlation.

Abstract: Background: The purpose of this study was to compare the diagnostic accuracy of fine-needle aspiration (FNA) of clinically suspicious palpable breast masses in women younger and older than 40 years of age. Methods All women who had FNA biopsy with subsequent tissue biopsy were included. The cytologic diagnoses were classified into three groups: malignant, suspicious, or benign. Histopathologic correlation was based on either a needle core biopsy, an excisional biopsy, or a mastectomy specimen. Results A total of 1,158 fine-needle aspirations performed between 1982 and 2000, on women being evaluated for a clinically palpable breast mass were included in the study. The patients were divided into two groups: group I consisted of 231 patients aged 40 years and younger, and group II consisted of 927 patients aged 41 years and older. In group I there were 117 (51%) malignant FNA diagnoses, and only 1 (1%) false-positive case, subsequently diagnosed on histopathologic material as an atypical papillomatosis. There were 20 (9%) cases diagnosed as suspicious on FNA. On histopathology 10 were malignant, and 10 were benign. Of the 91 (39%) cases interpreted as benign, only 1 (1%) was a false negative. In group II, which comprised 927 patients, there were 693 (74%) malignant FNA diagnoses, and 3 (less than 1%) false-positive cases, which on follow-up histopathologic examination revealed 2 atypical ductal hyperplasias and 1 atypical papilloma. There were 90 (10%) cases diagnosed as suspicious on FNA. On histopathology, 68 were malignant and 22 were benign. Of the 131 (14%) lesions interpreted as benign, there were 18 false-negative cases (14%), which included 17 infiltrating carcinomas and 1 ductal carcinoma in-situ. Twelve (1%) of the cases were inadequate for the study. Conclusions The sensitivity, specificity, and positive predictive values were remarkably high and comparable in both groups: group I had 99% sensitivity, 99% positive predictive value, 99% specificity, and 99% negative predictive value; and group II had 98% sensitivity, 97% specificity, 99% positive predictive value, and 86% negative predictive value. The overall rate of false-positive (less than 1%) and false-negative cases (9%) is comparable with published literature. Suspicious cases should be further evaluated, as our study revealed more than 50% to be malignant. The incidence of malignancy in patients presenting with a clinically palpable breast mass with follow-up biopsy was 51% in patients aged 40 years and younger and 74% in patients aged 41 years and older. Fine-needle aspiration is an excellent diagnostic tool in assessing clinically palpable breast masses.

The extent of the problem of obesity.

Abstract: The prevalence of obesity is increasing worldwide. In the United States, in 1999, 27% of adults had a body mass index >30 kg/m(2), almost double the prevalence of 20 years earlier. The estimated mortality from obesity-related diseases in the United States is approximately 300,000 annually and growing. In the future, mortality related to obesity is expected to exceed that of smoking. Numerous diseases are caused or made worse by obesity. These include type 2 diabetes; hypertension; dyslipidemia; ischemic heart disease; stroke; obstructive sleep apnea; asthma; nonalcoholic steatohepatitis; gastroesophageal reflux disease; degenerative joint disease of the back, hips, knees, and feet; infertility and polycystic ovary syndrome; various malignancies; and depression. Type 2 diabetes is perhaps the most visible obesity-related problem. Present in at least 14 million Americans, it leads to serious complications and premature death. It is largely caused by obesity, and is generally cured by weight loss. The quality of life of the obese is markedly reduced, and the costs to health care systems are great. Preventive programs have yet to affect the rising prevalence. An effective solution is needed.

US experience with the LAP-BAND system

Abstract: Laparoscopic adjustable gastric banding is the most commonly performed operation for morbid obesity in Europe and Australia and has been shown to result in significant long-term weight loss. The US Food and Drug Administration (FDA)‐monitored clinical trial results with the LAP-BAND system (INAMED Health, Santa Barbara, CA) did not reproduce the results of studies performed elsewhere in the world. This article reviews data from the first and second FDA clinical trials as well as data from continuing US clinical experience. Four American surgeons at 4 centers have performed more than 500 LAP-BAND procedures not included in the first 2 FDA clinical trials. Of these patients, 115 have been followed for at least 9 months, and 43 have been followed for at least 12 months. A retrospective analysis of prospective data gathered from these patients is presented. The percent excess weight loss was 35.6% at 9 months and 41.6% at 12 months. The average body mass index decreased from 47.5 to 38.8 in 9 months and from 47.5 to 37.3 in 12 months. There were no deaths related to the insertion of the device. Of 15 complications requiring operative management (13%) in 12 patients, there were 8 port displacements or tubing breaks (7%), 2 elective explantations (2%), 2 cases of gastric prolapse (2%), 1 gastric pouch dilatation (1%), 1 port abscess (1%), and 1 hemorrhage (1%). Clinical experience with the LAP-BAND system in the United States shows the device to be a safe and effective treatment for morbid obesity, with results comparable to the international data. The combination of proper surgical technique and close patient follow-up with frequent band adjustments, performed in a comprehensive bariatric program setting, may make the LAP-BAND system a powerful surgical tool in the treatment of morbid obesity. © 2002 Excerpta Medica Inc. All rights reserved.

Innovation in surgery: the rules of evidence.

Abstract: The intellectual infrastructures of evidence-based medicine (EBM) are the levels of evidence and the grades of recommendation for the following types of research articles: therapy/prevention, etiology/harm, prognosis, diagnosis, differential diagnosis/symptom prevalence study, economic analysis/decision analysis. The levels of evidence for therapy (1 to 5) progress from systematic reviews (with homogeneity) of randomized control trials (RCT) of high quality, level 1, to level 5-expert opinion without explicit critical appraisal, or based on physiology, bench research, or "first principles." The grades of recommendation (A, B, C, D) are founded on the quality of the evidence defined by its level. These grades are aimed at helping clinicians understand the source from whence came statements in, for example, guidelines. The development of surgical procedures and their introduction into practice has not depended upon the RCT but rather upon an enthusiast performing a case series, sometimes with clearly defined results. Should all operations and procedures be evaluated by an RCT? Clearly not, and the levels of evidence support this quite clearly with the "all or none" research category as level 1c. This relates to frequent clinical situations requiring a solution often immediate, eg, pus, a ruptured aneurysm, a sucking chest wound, that do not lend themselves to a trial, as the control regimen (doing nothing) would lead to death. Techniques evolve with experience usually based on an understanding of pathophysiology. At what point should an RCT enter into the resolution of surgical therapies? Can observational studies correctly designed and carried out do the job? Two new study classifications have been introduced: in level 1, category c "all or none" studies; and in level 2, category c "outcomes" research. In neither is there much definition. Are these the areas into which the evaluation of new surgical procedures and technology should be placed? The surgical community is faced with dramatic changes in technology and evolving techniques, and needs to define the rules of evidence applicable to their discipline with the same rigor that the EBM gurus have used, in order for surgeons to define evidence-based surgical practice.

A step-by-step guide to placement of the LAP-BAND adjustable gastric banding system.

Abstract: The early promise of laparoscopic adjustable gastric banding was tempered by reports of high rates of gastric herniation or prolapse. These complications are a function of the operative technique used early on. At the time, in the early 1990s, the LAP-BAND device (INAMED Health, Santa Barbara, CA) was placed lower on the stomach, near the first short gastric vessel. The required perigastric dissection was difficult and variable in its extent, depending on the width of the stomach and where the surgeon began the dissection. To combat these problems, a new surgical method for placement of the band has evolved. Called the pars flaccida technique, it emphasizes minimal dissection and placement of the LAP-BAND out of the lesser sac. This leads to a higher position of the band, away from the body of the stomach. The technique serves to make band placement simple, safe, reproducible, and easily teachable, as well as to decrease the rate of gastric herniation or prolapse. Keeping the band out of the lesser sac, away from the peristalsing stomach, minimizing dissection of the attachments to the stomach, paying strict attention to gastric-to-gastric suturing, and leaving all fluid out of the band until at least 6 weeks after surgery appear to be the most important factors in reducing the incidence of this complication.