Showing papers in "American Journal of Surgery in 2011"
TL;DR: High catastrophizing levels were found to be associated with increased pain severity, increased incidence of development of chronic pain, and poorer quality of life after surgery.
Abstract: Background Postsurgical pain is a major cause of delayed recovery and discharge after surgery. A significant proportion of patients develop chronic postsurgical pain, which affects their quality of life. Cognitive and psychological factors are reported to play a significant role in the severity of reported postsurgical pain. High levels of catastrophizing are associated with a heightened pain experience and appear to contribute to the development of chronic pain. This article describes the concept of pain catastrophizing, its association with postsurgical pain, and its potential role in the management of postsurgical pain and postsurgical quality of life. Methods Data for this review were identified from MEDLINE, EMBASE, and PsycINFO. Reference lists of selected articles were cross-searched for additional literature. Results High catastrophizing levels were found to be associated with increased pain severity, increased incidence of development of chronic pain, and poorer quality of life after surgery. There was no consensus on the relation between catastrophizing and analgesia consumption. Conclusions Identifying and reducing catastrophizing levels can help to optimize pain management in surgical patients.
244 citations
TL;DR: General intraoperative preventative techniques, laparoscopic techniques, and the use of bioabsorbable mechanical barriers in the appropriate cases reduce the incidence and severity of peritoneal adhesions.
Abstract: Background Postoperative adhesions are a significant health problem with major implications on quality of life and health care expenses. The purpose of this review was to investigate the efficacy of preventative techniques and adhesion barriers and identify those patients who are most likely to benefit from these strategies. Methods The National Library of Medicine, Medline, Embase, and Cochrane databases were used to identify articles related to postoperative adhesions. Results Ileal pouch–anal anastomosis, open colectomy, and open gynecologic procedures are associated with the highest risk of adhesive small-bowel obstruction (class I evidence). Based on expert opinion (class III evidence) intraoperative preventative principles, such as meticulous hemostasis, avoiding excessive tissue dissection and ischemia, and reducing remaining surgical material have been published. Laparoscopic techniques, with the exception of appendicitis, result in fewer adhesions than open techniques (class I evidence). Available bioabsorbable barriers, such as hyaluronic acid/carboxymethylcellulose and icodextrin 4% solution, have been shown to reduce adhesions (class I evidence). Conclusions Postoperative adhesions are a significant health problem with major implications on quality of life and health care. General intraoperative preventative techniques, laparoscopic techniques, and the use of bioabsorbable mechanical barriers in the appropriate cases reduce the incidence and severity of peritoneal adhesions.
235 citations
TL;DR: Evaluation of technical skill using current observational assessment tools is not reliable and valid at the specialist level, and future research needs to focus on further systematic tool development and analysis, especially at the Specialist level.
Abstract: Background Assessment by direct observation of procedural skills is an important source of constructive feedback. The aim of this study was to identify observational tools for technical skill assessment, to assess characteristics of these tools, and to assess their usefulness for assessment. Methods Included studies reported tools for observational assessment of technical skills. A total of 106 articles were included. Results Three main categories included global assessment scales evaluating generic skills (n = 29), task-specific methods assessing procedure-specific skills (n = 30), and combinations of tools evaluating both generic and task-specific skills (n = 47). In most studies, content validity was not evaluated using an accepted scientific method. All tools were assessed for inter-rater reliability and construct validity. Data on feasibility, acceptability, and educational impact were sparse. Conclusions There is evidence of validity and reliability for observational assessment tools at the trainee level. In most studies a comprehensive analysis of the tools was not achieved. Evaluation of technical skill using current observational assessment tools is not reliable and valid at the specialist level. Future research needs to focus on further systematic tool development and analysis, especially at the specialist level.
232 citations
TL;DR: A simple, brief preoperative frailty assessment accurately forecasts increased surgical hospital costs and postdischarge to 6-month healthcare costs after colorectal operations in older adults.
Abstract: Background The purpose of this study was to determine the relationship of frailty and 6-month postoperative costs. Methods Subjects aged ≥ 65 years undergoing elective colorectal operations were enrolled in a prospective observational study. Frailty was assessed by a validated measure of function, cognition, nutrition, comorbidity burden, and geriatric syndromes. Frailty was quantified by summing the number of positive characteristics in each subject. Results Sixty subjects (mean age, 75 ± 8 years) were studied. Inpatient mortality was 2% (n = 1). Overall, 40% of subjects (n = 24) were considered nonfrail, 22% (n = 13) were prefrail, and 38% (n = 22) were frail. With advancing frailty, hospital costs increased ( P P P P = .044). Conclusions A simple, brief preoperative frailty assessment accurately forecasts increased surgical hospital costs and postdischarge to 6-month healthcare costs after colorectal operations in older adults.
228 citations
TL;DR: SILC was feasible and safe for properly selected patients in experienced hands and the median cosmetic score of SILC was significantly higher than at 3 months after surgery.
Abstract: Background This study aimed to compare the outcomes of single-incision laparoscopic cholecystectomy (SILC) versus conventional 4-port laparoscopic cholecystectomy (LC). Methods From November 2009 to August 2010, 51 patients with symptomatic gallstone or gallbladder polyps were randomized to SILC (n = 24) or 4-port LC (n = 27). Results Mean surgical time (43.5 vs 46.5 min), median blood loss (1 vs 1 mL) and mean hospital stay (1.5 vs 1.8 d) were similar for both the SILC and 4-port LC group. There were no open conversions and no major complications. The mean total wound length of the SILC group was significantly shorter (1.76 vs 2.25 cm). The median visual analogue pain score at 6 hours after surgery was similar (4.5 vs 4.0) but the SILC group had a significantly worse pain score on day 7 (1 vs 0). There was no difference in time to resume usual activity (mean, 5.6 vs 5.0 d). The median cosmetic score of SILC was significantly higher than at 3 months after surgery (7 vs 6). Conclusions SILC was feasible and safe for properly selected patients in experienced hands.
167 citations
TL;DR: Mechanisms of action that can be attributed to TNP therapy are an increase in blood flow, the promotion of angiogenesis, a reduction of wound surface area in certain types of wounds, a modulation of the inhibitory contents in wound fluid, and the induction of cell proliferation.
Abstract: Background Topical negative pressure (TNP) therapy has become a useful adjunct in the management of various types of wounds. However, the TNP system still has characteristics of a “black box” with uncertain efficacy for many users. We extensively examined the effectiveness of TNP therapy reported in research studies. Data sources A database search was undertaken, and over 400 peer-reviewed articles related to the use of TNP therapy (animal, human, and in vitro studies) were identified. Conclusions Almost all encountered studies were related to the use of the commercial VAC device (KCI Medical, United States). Mechanisms of action that can be attributed to TNP therapy are an increase in blood flow, the promotion of angiogenesis, a reduction of wound surface area in certain types of wounds, a modulation of the inhibitory contents in wound fluid, and the induction of cell proliferation. Edema reduction and bacterial clearance, mechanisms that were attributed to TNP therapy, were not proven in basic research.
166 citations
TL;DR: There has been a consistent decline in the rates of negative appendectomy in the United States, and this trend may be attributed to better diagnostics.
Abstract: Background Appendectomy remains one of the most common emergency surgical procedures encountered throughout the United States. With improvements in diagnostic techniques, the efficiency of diagnosis has increased over the years. However, the entity of negative appendectomies still poses a dilemma because these are associated with unnecessary risks and costs to both patients and institutions. This study was conducted to show current statistics and trends in negative appendectomy rates in the United States. Methods A retrospective analysis was conducted using data from the National Inpatient Sample from 1998 to 2007. Adult patients (>18 y) having undergone appendectomies were identified by the appropriate International Classification of Diseases 9th revision codes. Patients with incidental appendectomy and those with appendiceal pathologies, also identified by relevant International Classification of Diseases 9th revision codes, were excluded. The remaining patients represent those who underwent an appendectomy without appendiceal disease. The patients then were stratified according to sex, women were classified further into younger (18–45 y) and older (>45 y) based on child-bearing age. The primary diagnoses subsequently were categorized by sex to identify the most common conditions mistaken for appendiceal disease in the 2 groups. Results Between 1998 and 2007, there were 475,651 cases of appendectomy that were isolated. Of these, 56,252 were negative appendectomies (11.83%). There was a consistent decrease in the negative appendectomy rates from 14.7% in 1998 to 8.47% in 2007. Women accounted for 71.6% of cases of negative appendectomy, and men accounted for 28.4%. The mortality rate was 1.07%, men were associated with a higher rate of mortality (1.93% vs .74%; P Conclusions There has been a consistent decline in the rates of negative appendectomy. This trend may be attributed to better diagnostics. Gynecologic conditions involving the ovary are the most common to be misdiagnosed as appendiceal disease in women.
161 citations
TL;DR: Previous concerns related to surgical risks in patients on chronic steroid regimens appear valid and these results may assist in counselling patients regarding the increased risk of surgery.
Abstract: Background Preoperative steroid use has been associated with increased postoperative complications. We sought to establish these risks using data from the National Surgical Quality Improvement Program (NSQIP). Methods NSQIP public use files from 2005 to 2008 were analyzed for preoperative steroid use and postoperative adverse events. Results Of 635,265 patients identified, 20,434 (3.2%) used steroids preoperatively. Superficial surgical site infections (SSI) increased from 2.9% to 5% using steroids (odds ratio, 1.724). Deep SSIs increased from .8% to 1.8% (odds ratio, 2.353). Organ/space SSIs and dehiscence increased 2 to 3-fold with steroid use (odds ratios, 2.469 and 3.338, respectively). Mortality increased almost 4-fold (1.6% to 6.0%; odds ratio, 3.920). All results were significant (P Conclusions Previous concerns related to surgical risks in patients on chronic steroid regimens appear valid. These results may assist in counceling patients regarding the increased risk of surgery. They may also help the surgeon plan and modify the procedure if possible.
155 citations
Abstract: Background This study presents preliminary data from a prospective randomized multicenter, single-blinded trial of single-incision laparoscopic cholecystectomy (SILC) versus standard laparoscopic cholecystectomy (4PLC). Methods Patients with symptomatic gallstones, polyps, or biliary dyskinesia (ejection fraction Results Operating room time was longer with SILC (n = 50) versus 4PLC (n = 33). No differences were seen in blood loss, complications, or pain scores. Body image scores and cosmetic scores at 1, 2, 4, and 12 weeks were significantly higher for SILC. Satisfaction scores, however, were similar. Conclusions Preliminary results from this prospective trial showed SILC to be safe compared with 4PLC although operative times were longer. Cosmetic scores were higher for SILS compared with 4PLC. Satisfaction scores were similar although both groups reported a significantly higher preference towards SILC.
152 citations
TL;DR: Surgeons can accurately self-assess their technical skills in virtual reality LC and formal assessment with faculty members' input is required for nontechnical skills, for which surgeons lack insight into their behaviours.
Abstract: BACKGROUND: Accurate assessment is imperative for learning, feedback and progression. The aim of this study was to examine whether surgeons can accurately self-assess their technical and nontechnical skills compared with expert faculty members’ assessments. METHODS: Twenty-five surgeons performed a laparoscopic cholecystectomy (LC) in a simulated operating room. Technical and nontechnical performance was assessed by participants and faculty members using the validated Objective Structured Assessment of Technical Skills (OSATS) and the Non-Technical Skills for Surgeons scale (NOTSS). RESULTS: Assessment of technical performance correlated between self and faculty members’ ratings for experienced (median score, 30.0 vs 31.0; .831; P .001) and inexperienced (median score, 22.0 vs 28.0; .761; P .003) surgeons. Assessment of nontechnical skills between self and faculty members did not correlate for experienced surgeons (median score, 8.0 vs 10.5; .375; P .229) or their more inexperienced counterparts (median score, 9.0 vs 7.0; .018; P .953). CONCLUSIONS: Surgeons can accurately self-assess their technical skills in virtual reality LC. Conversely, formal assessment with faculty members’ input is required for nontechnical skills, for which surgeons lack insight into their behaviours.
139 citations
TL;DR: Patients undergoing IHR with concomitant intra-abdominal procedures have a greater than 6-fold increased hazard of subsequent mesh explantation.
Abstract: Background Prosthetic mesh used for incisional hernia repair (IHR) reduces hernia recurrence. Mesh infection results in significant morbidity and challenges for subsequent abdominal wall reconstruction. The risk factors that lead to mesh explantation are not well known. Methods This is a multisite cohort study of patients undergoing IHR at 16 Veterans Affairs hospitals from 1998 to 2002. Results Of the 1,071 mesh repairs, 55 (5.1%) had subsequent mesh explantation at a median of 7.3 months (interquartile range 1.4–22.2) after IHR with permanent mesh prosthesis. Infection was the most common reason for explantation (69%). No differences were observed by the type of repair. Adjusting for covariates, same-site concomitant surgery (hazard ratio [HR] = 6.3) and postoperative surgical site infection (HR = 6.5) were associated with mesh explantation. Conclusions Patients undergoing IHR with concomitant intra-abdominal procedures have a greater than 6-fold increased hazard of subsequent mesh explantation. Permanent prosthetic mesh should be used with caution in this setting.
TL;DR: Laroscopic anterior resection involving intracorporeal rectal transection and double-stapling technique (DST) anastomosis for rectal cancer is safe if performed using an appropriate technique.
Abstract: Background Laparoscopic rectal cancer surgery involving rectal division with intracorporeal stapling devices is technically difficult. This study aimed to identify risk factors for anastomotic leakage associated with laparoscopic anterior resection for rectal cancer. Methods We studied 363 patients who underwent laparoscopic anterior resection with intracorporeal rectal transection and double-stapling technique (DST) anastomosis for rectal cancer between July 2005 and February 2010. Twenty-two independent clinical variables were examined by univariate and multivariate analyses. The outcome of interest was clinical anastomotic leakage. Results Anastomotic leakage was identified in 13 (3.6%) patients. Multivariate analysis identified middle/lower rectal cancer (odds ratio, 9.446) and lack of pelvic drain (odds ratio, 3.814) as independent predictive factors for anastomotic leakage. The number of cartridges used for rectal division had no significant impact on anastomotic leakage. Conclusions Laparoscopic anterior resection involving intracorporeal rectal transection and DST anastomosis is safe if performed using an appropriate technique.
TL;DR: An SSI after colorectal surgery was a risk factor for the development of incisional hernia but was not a risk factors for small bowel obstruction in the population.
Abstract: Introduction The purpose of this study was to evaluate the long-term complications of surgical site infection (SSI) in the colorectal population, specifically its association with incisional hernia and small bowel obstruction. Methods Using standardized definitions of SSI, a retrospective review of patients undergoing transabdominal colorectal surgery from January 2002 to December 2005 was performed. Primary outcomes included incisional hernia and small bowel obstruction in patients with SSIs. Results A total of 443 patients were analyzed. The median surgical follow-up was 12 months (2–3,091 days). Infections were identified in 101 (23%) cases. There were 99 cases (22%) of incisional hernia and 32 cases (7%) of small bowel obstruction. Logistic regression revealed SSI to be independently associated with incisional hernia after adjusting for clinical covariates (adjusted odds ratio = 2.23, P = .003; 95% confidence interval, 1.3–3.8). Patients with incisional hernia were 1.9 times more likely to have had an SSI (36.3% vs 18.8%, P ≤ .01). They required a longer operative time (224 minutes vs 198 minutes, P = .03), had an increased body mass index (29.0 vs 26.8, P ≤ .01), and had increased estimated blood loss (363 vs 289, mL, P = .03). Small bowel obstruction was significantly associated with operations involving the rectum (11.5% in operations involving the rectum vs 5.9% in nonrectal operations, P = .05), increased estimated blood loss (409 ml vs 297 ml, P = .04), and red blood cell transfusion (15.5% with transfusion vs 5.7% without, P = .01). SSI was not an independent predictor of small bowel obstruction (adjusted odds ratio = 1.05, P = .91; 95% confidence interval, .45–2.5). Conclusions Patients with an SSI were 1.9 times more likely to have an incisional hernia than those without an SSI. An SSI after colorectal s urgery was a risk factor for the development of incisional hernia but was not a risk factor for small bowel obstruction in our population.
TL;DR: In this pilot trial, LESS cholecystectomy resulted in similar lengths of stay and improved cosmetic results and SF-36 Role Emotional scores but performed less well on pain immediately after surgery.
Abstract: Background In recent years, new devices providing multiple channels have made the performance of laparoscopic cholecystectomy through a single access site not only feasible but much easier The potential benefits of laparoendoscopic single-site (LESS) cholecystectomy may include scarless surgery, reduced postoperative pain, reduced postoperative length of stay, and improved postoperative quality of life There are no comparative data between LESS cholecystectomy and standard laparoscopic cholecystectomy (LC) available at present with which to quantify these benefits Methods This study was a prospective, randomized, dual-institutional pilot trial comparing LESS cholecystectomy with standard LC The primary end point was postoperative quality of life, measured as length of hospital stay, postoperative pain, cosmetic results, and SF-36 questionnaire scores Secondary end points included operative time, conversion to standard LC, difficulty of exposure, difficulty of dissection, and complication rate Results No significant differences in postoperative lengths of stay were found in the two groups Postoperative pain evaluation using a visual analogue scale showed significantly better outcomes in the standard LC arm on the same day of surgery ( P = 041) No differences in postoperative pain were found at the next visual analogue scale evaluation or in the postoperative administration of pain-relieving medications Cosmetic satisfaction was significantly higher in the LESS group at 1-month follow-up (mean, 945 ± 94% vs 86 ± 223%; median, 100% vs 90%; P = 025) Among the 8 scales of the SF-36 assessing patients' physical and mental health, scores on the Role Emotional scale were significantly better in the LESS group (mean, 8005 ± 2942 vs 6833 ± 2531; median, 100 vs 6667; P Conclusions In this pilot trial, LESS cholecystectomy resulted in similar lengths of stay and improved cosmetic results and SF-36 Role Emotional scores but performed less well on pain immediately after surgery A larger multicenter trial is needed to confirm and further investigate these results
TL;DR: Use of the triclosan-coated polyglactin 910 antimicrobial suture lead to reduction of surgical site infection and has an impact on saving health care resources.
Abstract: Background Surgical site infection is a common complication of surgery. Its morbidities range from delayed healing to systemic sepsis. It has impact on the economy and health care resources. Methods This study was a prospective, randomized, double-blinded, controlled multicenter study aimed to compare triclosan-coated polyglactin 910 sutures with polyglactin 910 sutures for the reduction of surgical site infections. This article details the results from the Cairo University center. A total of 450 patients who had undergone different surgical procedures were enrolled; 230 were enrolled in the study group and 220 were enrolled in the control group. Results The study group and the control group were comparable regarding risk factors for surgical site infection. Surgical site infection incidence was 7% in the study group and 15% in the control group ( P = .011). The mean extended stay as a result of infection was 3.71 days, with an average cost $91 US per day. Conclusions Use of the triclosan-coated polyglactin 910 antimicrobial suture lead to reduction of surgical site infection and has an impact on saving health care resources. The triclosan-coated polyglactin 910 antimicrobial suture could save $1,517,727 yearly in this single center.
TL;DR: Despite hospital differences in treatment, primarily in critical care interventions, patient age and severity of disease were the main predictors of mortality, and significant center differences occur in patient populations, etiology, and microbiology of NSTIs, even within a concentrated region.
Abstract: Background Necrotizing soft-tissue infections (NSTIs) are rare and highly lethal. Methods A retrospective chart review of patients with NSTIs treated at 6 academic hospitals in Texas between January 1, 2004 and December 31, 2007. Patient demographics, presentation, microbiology, treatment, and outcome were recorded. Analysis of variance, chi-square test, and logistic regression analysis were performed. Results Mortality rates varied between hospitals from 9% to 25% (n = 296). There was significant interhospital variation in patient characteristics, microbiology, and etiology of NSTIs. Despite hospital differences in treatment, primarily in critical care interventions, patient age and severity of disease (reflected by shock requiring vasopressors and renal failure postoperatively) were the main predictors of mortality. Conclusions Significant center differences occur in patient populations, etiology, and microbiology of NSTIs, even within a concentrated region. Management should be based on these characteristics given that adjunctive treatments are unproven and variations in outcome are likely because of patient disease at presentation.
TL;DR: Infectious complications after elective LDLT significantly decreased with the perioperative administration of synbiotic therapy, compared with the control group.
Abstract: Background Although the effect of synbiotic therapy using prebiotics and probiotics has been reported in hepatobiliary surgery, there are no reports of the effect on elective living-donor liver transplantation (LDLT). Methods Fifty adult patients undergoing LDLT between September 2005 and June 2009 were randomized into a group receiving 2 days of preoperative and 2 weeks of postoperative synbiotic therapy ( Bifidobacterium breve , Lactobacillus casei , and galactooligosaccharides [the BLO group]) and a group without synbiotic therapy (the control group). Postoperative infectious complications were recorded as well as fecal microflora before and after LDLT in each group. Results Only 1 systemic infection occurred in the BLO group (4%), whereas the control group showed 6 infectious complications (24%), with 3 cases of sepsis and 3 urinary tract infections with Enterococcus spp ( P = .033 vs BLO group). No other type of complication showed any difference between the groups. Conclusions Infectious complications after elective LDLT significantly decreased with the perioperative administration of synbiotic therapy.
TL;DR: Clinical trials show the addition of the oral antibiotic bowel preparation to appropriate systemic preoperative preventive antibiotics provide the lowest rates of SSI, but oral antibiotic preparation and systemicPreoperative antibiotics are superior when compared with systemic antibiotics alone.
Abstract: Background Colon preparation for elective colon resection to reduce surgical site infection (SSI) remains controversial. Methods A review of the published literature was undertaken to define evidence-based practices for colon preparation for elective colon resection. Results Seventy years of surgical literature has documented that mechanical bowel preparation alone does not reduce SSI. A body of clinical trials has documented the benefits of oral antibiotic bowel preparation compared with a placebo in the reduction of SSI. Clinical trials show the addition of the oral antibiotic bowel preparation to appropriate systemic preoperative preventive antibiotics provide the lowest rates of SSI. Conclusions Mechanical bowel preparation alone does not reduce rates of SSI, but oral antibiotic preparation and systemic preoperative antibiotics are superior when compared with systemic antibiotics alone. Additional clinical trials are necessary to define the best combined overall mechanical and oral antibiotic regimen for elective colon surgery.
TL;DR: In this article, the effect of Aloe vera (Av) on acute radiation-delayed wound healing was investigated in radiation-exposed rats compared with radiation-only and control rats.
Abstract: Background Delayed wound healing is a significant clinical problem in patients who have had previous irradiation. This study investigated the effectiveness of Aloe vera (Av) on acute radiation-delayed wound healing. Methods The effect of Av was studied in radiation-exposed rats compared with radiation-only and control rats. Skin wounds were excised on the back of rats after 3 days of local radiation. Wound size was measured on days 0, 3, 6, 9, and 12 after wounding. Wound tissues were examined histologically and the expressions of transforming growth factor β-1 (TGF-β-1) and basic fibroblast growth factor (bFGF) were examined by immunohistochemistry and reverse-transcription polymerase chain reaction. Results Wound contraction was accelerated significantly by Av on days 6 and 12 after wounding. Furthermore, the inflammatory cell infiltration, fibroblast proliferation, collagen deposition, angiogenesis, and the expression levels of TGF-β-1 and bFGF were significantly higher in the radiation plus Av group compared with the radiation-only group. Conclusions These data showed the potential application of Av to improve the acute radiation-delayed wound healing by increasing TGF-β-1 and bFGF production.
TL;DR: The Masimo Radical-7 SpHb Station (Masimo Corporation, Irvine, CA) has been shown by its manufacturers to provide accurate non-invasive hemoglobin measurements in physiologically normal patients as discussed by the authors.
Abstract: BACKGROUND: Hemoglobin levels must be obtained through blood draws, which are invasive, time-consuming, and provide only 1 data point at a time rather than continuous measurements. The Masimo Radical-7 SpHb Station (Masimo Corporation, Irvine, CA) has been shown by its manufacturers to provide accurate noninvasive hemoglobin measurements in physiologically normal patients. The objective of this study was to validate noninvasive hemoglobin measurements using the Masimo Radical-7 device. METHODS: Data were prospectively collected in 2 cohorts of patients: major operations requiring hemodynamic monitoring (operating room [OR]) and critically ill patients (intensive care unit [ICU]). Noninvasive hemoglobin measurements (SpHb) were recorded and were then compared with laboratory hemoglobin measurements. RESULTS: Data were collected on 60 patients (OR = 25 and ICU = 45). The overall correlation of the Masimo SpHb and the laboratory Hb was .77 (P < .001) in the OR group with a mean difference of .29 g/dL (95% confidence interval [CI], .08-.49). The overall correlation in the ICU group was .67 (P < .001) with a mean difference of .05 g/dL (95% CI, -.22 to -.31). CONCLUSIONS: Noninvasive hemoglobin monitoring is a new technology that correlated with laboratory values and supports the continued study of noninvasive hemoglobin monitoring.
TL;DR: Simulation training provides a more rapid acquisition of competence in surgical technique and before/after scores were significantly improved in the MISTELS and LAP Mentor groups.
Abstract: Background The efficacy of laparoscopy simulators remains controversial. Methods This was a comparative prospective study that evaluated the impact of simulator training on technical competence during a real surgical procedure. Residents were divided into 3 groups: the Mcgill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) group, training on a simple simulator; LAP Mentor group, training on a virtual simulator; and control group. An initial evaluation was made by a validated score during a laparoscopic cholecystectomy. Each resident was then trained for 1 month. A second evaluation was then performed. Results Before/after scores were significantly improved in the MISTELS ( P = .042) and LAP Mentor ( P = .026) groups. It was not the case in the control group. There was a better progression in the MISTELS ( P = .026) and LAP Mentor ( P = .007) groups than in the control group. There was no significant difference between the MISTELS and LAP Mentor groups. Conclusions Simulator training provides a more rapid acquisition of competence in surgical technique.
TL;DR: This methodology can be used to increase understanding of the impact of stress on team performance in the OR and reveals differences across team members' stress levels as surgery unfolds.
Abstract: Background Although effective teamwork is fundamental to patient safety in the operating room (OR), acute stress increasingly is recognized as detrimental for teamwork. This study concurrently assessed teamwork and stress levels experienced by OR team members. Methods Data were collected in real time in 20 elective surgical cases. The validated Observational Teamwork Assessment for Surgery was used to assess teamwork, whereas stress was assessed using the validated State-Trait Anxiety Inventory. Results Teamwork was overall above the scale midpoint, with higher scores preoperatively than in subsequent phases of the procedure, and also higher ratings for anesthetic subteams compared with surgical and nursing subteams (all P Conclusions The study offers a feasible method for concurrently assessing stress and teamwork in the OR and reveals differences across team members' stress levels as surgery unfolds. This methodology can be used to increase understanding of the impact of stress on team performance in the OR.
TL;DR: The difficult task of predicting the malignant potential of a pheochromocytoma has yet to be answered definitively, but all the studies presented give an idea of what to look for in these tumors at the time of diagnosis.
Abstract: Background Pheochromocytomas are rare catecholamine-secreting tumors. Approximately 10 percent of pheochromocytomas are malignant. Traditionally, there has been no reliable method available to predict the malignant potential of pheochromocytoma. However, recent research has increased focus on differentiating at the time of surgery/diagnosis those pheochromocytoma tumors which have malignant potential. In this review, we discuss the current information known of malignant pheochromocytomas. Data sources The PubMed database was searched for articles on malignant pheochromocytoma published between 1993 and 2010. Conclusions The difficult task of predicting the malignant potential of a pheochromocytoma has yet to be answered definitively. However, all the studies presented give an idea of what we may look for in these tumors at the time of diagnosis. We have provided an algorithm based on the most current information known. A much larger study should be performed to test many of these theories with enough power to determine a standard of care.
TL;DR: Interventions to improve poor compliance with infection prevention guidelines must be multifaceted, hospital- and service-specific, and resilient during emergencies.
Abstract: Background The purpose of this study was to assess predictive factors and compliance with surgical site infection (SSI) prevention guidelines at 2 county hospitals. Design Chart review and analysis of laparotomy patients undergoing colorectal, hysterectomy, or abdominal vascular procedures over two 6-month periods 1 year apart and evaluation of safety climate using the Safety Attitudes Questionnaire (SAQ). Results Overall compliance with all antibiotic prophylaxis guidelines was 62% (n = 442). Gynecologic surgery was an independent predictor of compliance with antibiotic prophylaxis guidelines in elective cases, and nonemergency status was an independent predictor when all cases were considered. Postoperative normothermia was predicted by hospital, procedure length, initial intraoperative temperature, and service. The SAQ had a 91% response rate. Contrary to expected, safety domain scores and agreement with statements on collaboration and teamwork were not predictive of compliance. Conclusion Interventions to improve poor compliance with infection prevention guidelines must be multifaceted, hospital- and service-specific, and resilient during emergencies. Good safety and teamwork climate are not sufficient.
TL;DR: A new scoring system (the Munich score) was established to predict survival, which discriminates 3 groups with low, intermediate, and high risk for poor outcomes (median survival, 90, 31, and 14 months, respectively, P < .001).
Abstract: Background The aim of this single-center study was to analyze factors predicting long-term outcomes following surgical resection of pulmonary metastases in patients with renal cell carcinoma. Methods Two hundred two consecutive patients entered the study. Overall survival was analyzed by the Kaplan-Meier method. Multivariate analysis was performed using Cox regression models. Results In 175 cases (87%), curative resection of the pulmonary metastases was achievable, with median survival of 43 months. Multivariate analysis revealed complete metastasectomy (R0), metastasis size >3 cm, positive nodal status of the primary tumor, synchronous metastases, pleural infiltration, and tumor-infiltrated hilar or mediastinal lymph nodes as independent prognostic factors for survival. On the basis of these findings, a new scoring system (the Munich score) was established to predict survival, which discriminates 3 groups with low, intermediate, and high risk for poor outcomes (median survival, 90, 31, and 14 months, respectively, P Conclusions The aim of the Munich score is to define patients with low, intermediate, and high risk for poor survival and will help identify patients who may benefit from further adjuvant therapy.
TL;DR: This post hoc analysis of a prospective randomized trial that included patients ages 18 to 70 years with melanomas 1 mm or greater in Breslow thickness found anatomic location of the primary melanoma was an important independent predictor of SLN status and prognosis.
Abstract: Background Breslow thickness, ulceration, and sentinel lymph node (SLN) status are well established as the most important prognostic factors for patients with cutaneous melanoma. Anatomic location of the primary tumor is generally considered to play a minor role in determining prognosis compared with these other factors. This analysis was performed to better define the influence of anatomic location of the primary melanoma on prognosis. Methods In this post hoc analysis of a prospective randomized trial that included patients ages 18 to 70 years with melanomas 1 mm or greater in Breslow thickness, all patients underwent SLN biopsy and completion lymphadenectomy if tumor-positive SLN were found. Kaplan–Meier survival analysis and univariate and multivariate analyses were performed to evaluate factors predictive of disease-free survival (DFS), local and in-transit recurrence-free survival (LITRFS), and overall survival (OS). Results A total of 2,500 patients were included in this analysis with a median follow-up period of 68 months. Anatomic locations included head, neck, trunk, upper extremity, and lower extremity. Age, Breslow thickness, and percentage of patients with a positive SLN were significantly different by anatomic location on univariate analysis, as were positive SLN status, presence of regression, sex, and histologic subtype (P Conclusions Anatomic location of the primary melanoma is an important independent predictor of SLN status and prognosis. Patients with primary melanomas of the head/neck and trunk have a worse prognosis than primary melanomas of other anatomic locations.
TL;DR: Patients choosing BMs are younger, have equivalent rates of reoperation because of reconstruction complications, and are significantly more satisfied with their decision than those who chose UM.
Abstract: BACKGROUND: Numerous studies have reported increasing rates of contralateral prophylactic mastectomies (CPMs). Understanding patient rationale for the surgical choice may provide insight into this trend. METHODS: A questionnaire was mailed to 350 mastectomy patients identified from a community health system tumor registry. RESULTS: Two hundred fifty questionnaires were received; of these, 237 had undergone mastectomy. Fifty-two percent had unilateral mastectomy (UM), and 43% had bilateral mastectomies (BMs) (6% for bilateral disease). Women younger than 60 years of age were more likely to choose BM (P = .0046). Those who had CPM were significantly more likely to make the same surgical decision (P < .0001). Reconstruction was performed in 52%, with BM patients more likely to undergo reconstruction (P = .009). Twenty-three (19%) needed unanticipated reoperation for reconstruction complications. CPM had equivalent rates of unanticipated surgery versus UM (P = .64). CONCLUSIONS: Patients choosing BMs are younger, have equivalent rates of reoperation because of reconstruction complications, and are significantly more satisfied with their decision than those who chose UM.
TL;DR: The Karydakis flap procedure should be chosen instead of the Limberg flap for treating uncomplicated SPD because of its lower postoperative complication rate, lower pain scores, shorter operation time and length of hospital stay, and good cosmetic satisfaction.
Abstract: Background Pilonidal sinus is a common disease that mostly affects young people. Although various surgical techniques have been described for treating sacrococcygeal pilonidal disease (SPD), controversy still exists as to the best surgical technique. The purpose of this study was to compare the efficiency and short-term and long-term results of the Karydakis flap with that of the Limberg flap for treating SPD. Methods In this prospective randomized study, 269 patients with SPD were recruited to undergo either the Karydakis flap (n = 135) or the Limberg flap (n = 134) procedure between September 2004 and September 2008. Results The mean operative time for the Karydakis group (42.32 ± 8.64 minutes) was shorter than that for the Limberg group (50.14 ± 6.96 minutes) ( P = .01). The complication rate for the Karydakis group (n = 15 [11.1%]) was lower than that for the Limberg group (n = 28 [20.8%]) ( P = .029). The visual analogue scale score for postoperative pain at the operation site on the 30th day was lower in the Karydakis group than in the Limberg group (2.22 ± 1.01 vs 3.23 ± 1.14, P = .01). The visual analogue scale score for satisfaction with the cosmetic appearance of the scars in the Karydakis group was 7.08 ± 1.75, whereas it was 3.16 ± 1.40 in the Limberg group at the 3rd month ( P = .01). Length of hospital stay was significantly shorter in the Karydakis group than in the Limberg group (3.40 ± .94 vs 3.8 ± 1.19 days, P = .03). Only 4 patients in the Karydakis group developed recurrence (3%), whereas 9 patients (6.9%) did so in the Limberg group ( P = .151). Conclusions The Karydakis flap procedure should be chosen instead of the Limberg flap for treating uncomplicated SPD because of its lower postoperative complication rate, lower pain scores, shorter operation time and length of hospital stay, and good cosmetic satisfaction. However, no differences existed between the 2 surgical procedures in terms of recurrence prevention.
TL;DR: The Delphi method allowed the determination of consensus regarding the essential steps to be included in a tool designed to measure technical competence in LCS.
Abstract: Background Laparoscopic colorectal surgery (LCS) is an advanced procedure for which no objective tools exist to assess technical skill. The aim of this study was to determine expert consensus regarding items required on a rating scale for LCS, using a Delphi technique. Methods Experts rated the substeps of LCS from 1 to 5. Responses were returned to the panel until consensus (Cronbach's α ≥ .80) was reached. Substeps that 80% of experts rated as ≥4 were included in the final instrument. Results Initially, α values were .81 for sigmoid colectomy, .77 for right (medial-to-lateral) colectomy, and .74 for the lateral-to-medial approach. In the second round, α values were .83 for medial-to-lateral right colectomy and .82 for lateral-to-medial colectomy. Conclusions The Delphi method allowed the determination of consensus regarding the essential steps to be included in a tool designed to measure technical competence in LCS.
TL;DR: The preoperative measurement of an inflammation-based prognostic score can demonstrate a strict stratification for the prognosis of patients with gastric carcinoma.
Abstract: Background The significance of the Glasgow prognostic score (GPS), an inflammation-based prognostic score, as an indicator of aggressiveness in gastric carcinoma has not been investigated fully. Methods Two hundred thirty-two patients with gastric carcinoma were enrolled. Patients who had both an elevated C-reactive protein (>1.0 mg/dL) and hypoalbuminemia ( Results There existed a significant difference between the survival of adjacent groups of patients when examined using the TGPS ( P = .05 for TGPS 0 vs 1 and P = .006 for TGPS 1 vs 2). Multivariate analysis based on TGPS demonstrated that TGPS ( P = .020) and tumor stage ( P = .0007) proved to be independent prognostic indicators for worse prognosis. Conclusions The preoperative measurement of an inflammation-based prognostic score can demonstrate a strict stratification for the prognosis of patients with gastric carcinoma.