Showing papers in "American Journal of Surgery in 2014"
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TL;DR: Measuring grit may identify those who are at greatest risk for poor psychological well-being in the future, and these residents may benefit from counseling to provide support and improve coping skills.
Abstract: Background The well-being of residents in general surgery is an important factor in their success within training programs. Consequently, it is important to identify individuals at risk for burnout and low levels of well-being as early as possible. The aim of this study was to test the hypothesis that resident well-being may be related to grit, a psychological factor defined as perseverance and passion for long-term goals. Methods One hundred forty-one residents across 9 surgical specialties at 1 academic medical center were surveyed; the response rate was 84%. Perseverance was measured using the Short Grit Scale. Resident well-being was measured with (1) burnout using the Maslach Burnout Inventory and (2) psychological well-being using the Dupuy Psychological General Well-Being Scale. Results Grit was predictive of later psychological well-being both as measured by the Maslach Burnout Inventory ( B = −.20, P = .05) and as measured by the Psychological General Well-Being Scale ( B = .27, P Conclusions Measuring grit may identify those who are at greatest risk for poor psychological well-being in the future. These residents may benefit from counseling to provide support and improve coping skills.
240 citations
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TL;DR: In view of the various alternatives and the lack of high-grade evidence, the treatment of distal colonic obstruction should be individually tailored to each patient.
Abstract: Background The management of colonic obstruction has changed in recent years. In distal obstruction, optimal treatment remains controversial, particularly after the appearance and use of colonic endoluminal stents. The purpose of this study was to review the current treatment of acute malignant large bowel obstruction according to the level of evidence of the available literature. Methods A systematic search was conducted in PubMed, MEDLINE, Embase, and Google Scholar for articles published through January 2013 to identify studies of large bowel obstruction and colorectal cancer. Included studies were randomized and nonrandomized controlled trials, reviews, systematic reviews, and meta-analysis. Results After a literature search of 1,768 titles and abstracts, 218 were selected for full-text assessment; 59 studies were ultimately included. Twenty-five studies of the diagnosis and treatment of obstruction and 34 studies of the use of stents were assessed. Conclusions In view of the various alternatives and the lack of high-grade evidence, the treatment of distal colonic obstruction should be individually tailored to each patient.
151 citations
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TL;DR: In this article, the authors determined the incidence rate, identified the risk factors, and described the clinical outcome of perioperative acute kidney injury (AKI) in patients undergoing noncardiac, nonvascular surgery (NCS).
Abstract: Background The aim of this study was to determine the incidence rate, identify the risk factors, and describe the clinical outcome of perioperative acute kidney injury (AKI) in patients undergoing noncardiac, nonvascular surgery (NCS). Methods A total of 1,200 adult consecutive patients undergoing NCS were prospectively evaluated. Patients with pre-existing renal dysfunction were excluded. The primary outcome of this study was perioperative AKI defined by the RIFLE (risk, injury, failure, loss of function, and end-stage kidney disease) criteria. Results Eighty-one patients (6.7%) met the AKI criteria. Multivariate analysis identified age, diabetes, revised cardiac risk index, and American Society of Anesthesiologists physical status as independent predictors of AKI. Patients with AKI had more cardiovascular (33.3% vs 11.3%, P P = .003) compared with patients without AKI. Conclusions Several preoperative predictors are found to be associated with AKI after NCS. Perioperative AKI is an independent risk factor for outcome after NCS.
139 citations
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TL;DR: Bariatiatric surgery may lead to lasting improvements in cognition, and Prospective studies with extended follow-ups should examine whether bariatric surgery can attenuate cognitive decline in severely obese patients.
Abstract: Background Bariatric surgery is associated with improved cognition, and it is possible that such improvements are found at extended follow-ups. We hypothesized that cognitive improvement would be maintained 3 years after bariatric surgery. Methods Fifty bariatric patients were recruited from the Longitudinal Assessment of Bariatric Surgery parent project. Participants completed a computerized cognitive test battery to assess cognitive function at 12 weeks, 12 months, 24 months, and 36 months after surgery. Results Repeated measures revealed main effects for attention, executive function, and memory. Attention improved up to 24 months and then slightly declined although it still fell within the average range at 36 months. Improvements in executive function reached their peak at 36 months after surgery. Short-term improvements in memory were maintained at 36 months. No main effect emerged for language. Conclusions Bariatric surgery may lead to lasting improvements in cognition. Prospective studies with extended follow-ups (eg, 10 years) should examine whether bariatric surgery can attenuate cognitive decline in severely obese patients.
139 citations
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TL;DR: Leak and mortality rates after LRYGB and LSG were comparable and the appropriate procedure should be tailored based on patient factors, comorbidities, patient and surgeon comfort level, surgeon experience, and institutional outcomes.
Abstract: Background Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the current "gold standard" bariatric procedure in the United States. Laparoscopic sleeve gastrectomy (LSG) has recently become a commonly performed procedure for many reasons, including patients' perception that LSG has less complexity and invasiveness, and lower risk. Our objective was to review the literature and compare the leak rates, morbidity, and mortality for LRYGB versus LSG. Methods Publications from 2002 to 2012 with n greater than or equal to 25 and postoperative leak rate reported were included. Statistical analysis included chi-square according to patient number. Results Twenty-eight (10,906 patients) LRYGB and 33 (4,816 patients) LSG articles were evaluated. Leak rates after LRYGB versus LSG were 1.9% ( n = 206) versus 2.3% ( n = 110), respectively ( P = .077). Mortality rates were .4% (27/7,117) for LRYGB and .2% (7/3,594) for LSG ( P = .110). Timing from surgery to leak ranged from 1 to 12 days for LRYGB versus 1 to 35 days for LSG. Conclusions Leak and mortality rates after LRYGB and LSG were comparable. The appropriate procedure should be tailored based on patient factors, comorbidities, patient and surgeon comfort level, surgeon experience, and institutional outcomes.
138 citations
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TL;DR: Sublay repair seems the preferred technique for IH repair, although the majority of the included studies were retrospective studies, and it remains unclear which technique is superior.
Abstract: Background Incisional hernia (IH) remains a very frequent postoperative complication. The 2 techniques most frequently used are the onlay repair and sublay repair. However, it remains unclear which technique is superior. Data Sources A meta-analysis was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The quality of the nonrandomized studies was assessed using the Newcastle-Ottawa Scale. Results Of 178 articles, 10 articles (2 randomized controlled trials, 1 prospective study, and 7 retrospective studies) comprising a total of 1,948 patients (775 onlay operations and 1173 sublay operations) were selected. Two of the studies scored below 5 points on the Newcastle-Ottawa Scale and were not selected. A trend was observed for IH recurrence in favor of sublay repair (odds ratio=2.41; 95% confidence interval, .99 to 5.88; I 2 = 70%; P = .05). Surgical site infection occurred significantly less after sublay repair (odds ratio=2.42; 95% confidence interval, 1.02 to 5.74; I 2 = 16%; P = .05). No difference was observed regarding seroma and hematoma. Conclusions Although the majority of the included studies were retrospective studies, sublay repair seems the preferred technique for IH repair.
130 citations
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TL;DR: A multimodal assessment of operative performance is advocated, including metrics, the Objective Structured Assessment of Technical Skills, and critical step completion, only then can it be concluded that simulation skills are transferable to the live operative setting.
Abstract: Background Simulated surgical training offers a safe and accessible way of learning surgical procedures outside the operating room. Training programs have been developed using simulated laboratories to train surgical trainees to proficiency outside the operating room. Despite the global enthusiasm among educators to enhance training through simulation-based learning, it remains to be elucidated whether the skill set obtained is transferrable to the operating room. Methods Using standardized search methods, the authors searched the Cochrane Central Register of Controlled Trials, PubMed, Embase, and Web-Based Knowledge, as well as the reference lists of relevant articles, and retrieved all published randomized controlled trials. Results Sixteen randomized controlled trials involving 309 participants were identified to be suitable for qualitative analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The mean Consolidated Standards of Reporting Trials score was 16 (range, 12–22). The studies showed considerable clinical and methodologic diversity. Operative time improved consistently in all trials after training and was the only objective parameter measurable in the live setting. Studies that used the Objective Structured Assessment of Technical Skills as their primary outcome showed improved scores in 80% of trials, and studies that used performance indicators to assess participants all showed improved scores after simulation training in all of the trials, with 88% showing statistical significance. Conclusions The current literature consistently demonstrates the positive impact of simulation on operative time and predefined performance scores. However, these reproducible measures alone are insufficient to demonstrate transferability of skills from the laboratory to the operating room. The authors advocate a multimodal assessment, including metrics, the Objective Structured Assessment of Technical Skills, and critical step completion. This may provide a more complete assessment of operative performance. Only then can it be concluded that simulation skills are transferable to the live operative setting.
124 citations
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TL;DR: Strong stereotypes of surgery deterred students from a surgical career, and surgery must actively engage medical students to encourage participation and dispel negative stereotypes that are damaging recruitment into surgery.
Abstract: Background
Recent years have seen a significant drop in applications to surgical residencies. Existing research has yet to explain how medical students make career decisions. This qualitative study explores students' perceptions of surgery and surgeons, and the influence of stereotypes on career decisions.
Methods
Exploratory questionnaires captured students' perceptions of surgeons and surgery. Questionnaire data informed individual interviews, exploring students' perceptions in depth. Rigorous qualitative interrogation of interviews identified emergent themes from which a cohesive analysis was synthesized.
Results
Respondents held uniform stereotypes of surgeons as self-confident and intimidating; surgery was competitive, masculine, and required sacrifice. To succeed in surgery, students felt they must fit these stereotypes, excluding those unwilling, or who felt unable, to conform. Deviating from the stereotypes required displaying such characteristics to a level exceptional even for surgery; consequently, surgery was neither an attractive nor realistic career option.
Conclusions
Strong stereotypes of surgery deterred students from a surgical career. As a field, surgery must actively engage medical students to encourage participation and dispel negative stereotypes that are damaging recruitment into surgery.
110 citations
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TL;DR: Surgeons should be prepared if they encounter Amyand's hernia because appropriate treatment ensures hernia repair without complications and with avoidance of recurrence, and the true prevalence seems lower than classically described.
Abstract: BACKGROUND: The presence of a vermiform appendix in an inguinal hernia sac is known as Amyand’s hernia. The aim of this systematic review was to gather information concerning its prevalence, clinical image, diagnosis, and treatment. DATA SOURCES: The MEDLINE database was thoroughly searched using the keyword ‘‘Amyand’s hernia.’’ Additional articles were gathered and evaluated. CONCLUSIONS: The true prevalence of Amyand’s hernia seems lower than classically described. Its usual clinical image is identical to that of an incarcerated hernia, and thus it is almost impossible to diagnose preoperatively, although ultrasound and computed tomography can help. Treatment includes hernioplasty with or without appendectomy and/or mesh repair depending on the vermiform appendix’s inflammation status, the patient’s general condition, and other factors. Amyand’s hernia generally has a good prognosis, although serious complications have been described. Surgeons should be prepared if they encounter Amyand’s hernia because appropriate treatment ensures hernia repair without complications and with avoidance of recurrence.
106 citations
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TL;DR: Brief training exercises can change teamwork and communication behaviors on ad hoc trauma teams and be sustained after a 3-week interval, though there was some loss of retention.
Abstract: BACKGROUND: Communication breakdowns and care coordination problems often cause preventable adverse patient care events, which can be especially acute in the trauma setting, in which ad hoc teams have little time for advanced planning. Existing teamwork curricula do not address the particular issues associated with ad hoc emergency teams providing trauma care. METHODS: Ad hoc trauma teams completed a preinstruction simulated trauma encounter and were provided with instruction on appropriate team behaviors and team communication. Teams completed a postinstruction simulated trauma encounter immediately afterward and 3 weeks later, then completed a questionnaire. Blinded raters rated videotapes of the simulations. RESULTS: Participants expressed high levels of satisfaction and intent to change practice after the intervention. Participants changed teamwork and communication behavior on the posttest, and changes were sustained after a 3-week interval, though there was some loss of retention. CONCLUSIONS: Brief training exercises can change teamwork and communication behaviors on ad hoc trauma teams.
100 citations
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TL;DR: The contribution of rib fractures to chronic pain and disability is significant but unpredictable with conventional injury descriptors.
Abstract: Background The contribution of rib fractures to chronic pain and disability is not well described. Methods Two hundred three patients with rib fractures were followed for 6 months. Chronic pain was assessed using the McGill Pain Questionnaire Pain Rating Index and Present Pain Intensity (PPI) scales. Disability was defined as a decrease in work or functional status. Results The prevalence of chronic pain was 22% and disability was 53%. Acute PPI predicted chronic pain. Associated injuries, bilateral rib fractures, injury severity score, and number of rib fractures were not predictive of chronic pain. No acute injury characteristics were predictive of disability. Among 89 patients with isolated rib fractures, the prevalence of chronic pain was 28% and of disability was 40%. No injury characteristics predicted chronic pain. Bilateral rib fractures and acute PPI predicted disability. Conclusion The contribution of rib fractures to chronic pain and disability is significant but unpredictable with conventional injury descriptors.
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TL;DR: The preoperative P/L ratio was identified as a prognostic marker for TTR in stage II and III CC patients and showed a trend toward decreased OS in univariate analysis.
Abstract: Background Recent evidence indicates that tumor progression involves factors of systemic inflammation, such as platelets and lymphocytes. In this study, we investigated the prognostic relevance of the preoperative platelet to lymphocyte (P/L) ratio on time to recurrence (TTR) and overall survival (OS) in patients with stage II and III colon cancer (CC) who underwent curative resection. Methods In this retrospective study, 372 CC patients were included. Kaplan–Meier curves and multivariate Cox proportional models were calculated for TTR and OS. Results In univariate analysis, the elevated P/L ratio was significantly associated with decreased TTR (HR = 1.60, 95% CI=1.02 to 2.51, P = .040) and remained significant in multivariate analysis (HR = 1.65, 95% CI=1.05 to 2.58, P = .030), where HR and CI represent Hazard ratio and confidence interval, respectively. Patients with elevated P/L ratio showed a median TTR of 116 months. In contrast, patients with low P/L ratio had a median TTR of 132 months. In OS analysis, the elevated P/L ratio showed a trend toward decreased OS in univariate analysis (HR = 1.54, 95% CI=.95 to 2.48, P = .079). Conclusion In this study, we identified the preoperative P/L ratio as a prognostic marker for TTR in stage II and III CC patients.
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TL;DR: Both the guidelines were useful in the initial cross-sectional imaging evaluation of mucinous CLPs and the ICG 2012 guidelines were superior to the SCG guidelines.
Abstract: Background The Sendai Consensus Guidelines (SCG) were formulated in 2006 to guide the management of mucinous cystic lesions of the pancreas (CLPs) and were updated in 2012 (International Consensus Guidelines, ICG 2012). This study aims to evaluate the clinical utility of the ICG 2012 with the SCG based on initial cross-sectional imaging findings. Methods One hundred fourteen patients with mucinous CLPs were reviewed and classified according to the ICG 2012 as high risk (HR ICG2012 ), worrisome (W ICG2012 ), and low risk (LR ICG2012 ), and according to the SCG as high risk (HR SCG ) and low risk (LR SCG ). Results On univariate analysis, the presence of symptoms, obstructive jaundice, elevated serum carcinoembryonic antigen (CEA)/carbohydrate antigen (CA)19-9, solid component, main pancreatic duct ≥10 mm, and main pancreatic duct ≥5 mm was associated with high grade dysplasia/invasive carcinoma in all mucinous CLPs. Increasing number of HR SCG or HR ICG2012 features was associated with a significantly increased likelihood of malignancy. The positive predictive value of HR SCG and HR ICG2012 for high grade dysplasia/invasive carcinoma was 46% and 62.5% respectively. The negative predictive value of both LR SCG and LR ICG2012 was 100%. Conclusion Both the guidelines were useful in the initial cross-sectional imaging evaluation of mucinous CLPs. The ICG 2012 guidelines were superior to the SCG guidelines.
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TL;DR: Oncoplastic Lumpectomy is a safe alternative to standard lumpectomy for selected breast cancer patients and cosmetic satisfaction is similar between the groups.
Abstract: Background There is a lack of information regarding the safety, complication rate, and cosmetic outcome of oncoplastic breast conserving surgery. The purpose of this study is to evaluate and compare oncoplastic and nononcoplastic procedures. Methods A retrospective review was conducted of patients treated with oncoplastic or nononcoplastic lumpectomies. Immediate and long-term complication rates and cosmetic satisfaction were compared. Results Of the 142 surgeries, 58 were oncoplastic lumpectomies (40.8%). Oncoplastic patients were younger than nononcoplastic patients (60.9 vs 65.2 years, P = .043). Immediate complications were similar with the exception of nonhealing wounds (oncoplastic = 8.6% vs nononcoplastic=1.2%, P = .042). Cosmetic complaints were similar, but fat necrosis was more common in the oncoplastic group (25.9% vs 9.5%, P = .009). Time to radiation and number of future biopsies were similar between the groups. Conclusion Oncoplastic lumpectomy is a safe alternative to standard lumpectomy for selected breast cancer patients.
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TL;DR: This study identified several factors that could be useful to introduce preventive measures in high-risk patients with umbilical TSIH and analyzed the influence of several risk factors for this complication in a prospective series.
Abstract: Background Trocar site incisional hernia (TSIH) is a common complication after laparoscopic cholecystectomy. The aim of this study was to evaluate the prevalence of TSIH and analyze the influence of several risk factors for this complication in a prospective series. Methods From 2007 to 2008, a prospective observational study with 3 years of follow-up was performed including all consecutive patients with cholelithiasis who underwent elective laparoscopic cholecystectomy. A multivariate analysis was performed to identify risk factors for TSIH. Results Overall, 241 patients were included. During a median follow-up period of 46.8 months, 57 patients (25.9%) were diagnosed with umbilical TSIH by physical exam or ultrasound. The multivariate analysis revealed that incision enlargement (odds ratio [OR], 14.17; 95% confidence interval [CI], 3.61 to 55.51; P P P = .0038), and obesity (OR, 2.71; 95% CI, 1.28 to 5.75; P = .009) contributed to the risk for developing a TSIH. Conclusions Umbilical TSIH is highly prevalent. This study identified several factors that could be useful to introduce preventive measures in high-risk patients.
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TL;DR: Higher USMLE scores were associated with higher faculty evaluations and first-time board pass rates and caution might be indicated in using it as a single selection factor in surgical residency.
Abstract: Background Many programs rely extensively on United States Medical Licensing Examination (USMLE) scores for interviews/selection of surgical residents. However, their predictive ability remains controversial. We examined the association between USMLE scores and success in surgical residency. Methods We compared USMLE scores for 123 general surgical residents who trained in the past 20 years and their performance evaluation. Scores were normalized to the mean for the testing year and expressed as a ratio (1 = mean). Performances were evaluated by (1) rotation evaluations; (2) “dropouts;” (3) overall American Board of Surgery pass rate; (4) first-time American Board of Surgery pass rate; and (5) a retrospective comprehensive faculty evaluation. For the latter, 16 surgeons (average faculty tenure 22 years) rated residents on a 1 to 4 score (1 = fair; 4 = excellent). Results Rotation evaluations by faculty and “drop out” rates were not associated with USMLE score differences (dropouts had average above the mean). One hundred percent of general surgery practitioners achieved board certification regardless of USMLE score but trainees with an average above the mean had a higher first-time pass rate (P = .04). Data from the comprehensive faculty evaluations were conflicting: there was a moderate degree of correlation between board scores and faculty evaluations (r = .287, P = .001). However, a score above the mean was associated with a faculty ranking of 3 to 4 in only 51.7% of trainees. Conclusion Higher USMLE scores were associated with higher faculty evaluations and first-time board pass rates. However, their positive predictive value was only 50% for higher faculty evaluations and a high overall board pass rate can be achieved regardless of USMLE scores. USMLE Step 1 score is a valid tool for selecting residents but caution might be indicated in using it as a single selection factor.
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TL;DR: Compared with conventional laparoscopy, some types of robotic-assisted colorectal operations may offer advantages regarding postoperative length of stay and perioperative complications.
Abstract: Background Robotic assistance may offer unique advantages over conventional laparoscopy in colorectal operations. Methods This prospective observational study compared operative measures and postoperative outcomes between laparoscopic and robotic abdominal and pelvic resections for benign and malignant disease. Results From 2005 through 2012, 200 (58%) laparoscopic and 144 (42%) robotic operations were performed by a single surgeon. After adjustment for differences in demographics and disease processes using propensity score matching, all laparoscopic operations had a significantly shorter operative time ( P P = .01); and laparoscopic right colectomies had a higher risk for overall complications ( P = .03) and postoperative ileus ( P = .04). There were no significant differences in the outcomes of pelvic operations ( P = .15). Conclusions Compared with conventional laparoscopy, some types of robotic-assisted colorectal operations may offer advantages regarding postoperative length of stay and perioperative complications.
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TL;DR: Falling remains a source of considerable healthcare expenditure, especially among the elderly, and non-ground level falls account for 14% of cases and are associated with a significantly higher burden of injury and morbidity.
Abstract: Background Falls are a leading cause of unintentional injury among adults, especially those over 65 years of age. With increasing longevity and improving access to health care, falls are affecting a more mobile senior citizen population that does not fit the typical profile. We set out to evaluate the current nature of these falls in the elderly. Methods This is a 2-year retrospective chart review of all falls in patients 65 years or older at an urban Level I trauma center. Demographics, location and height of fall, associated injuries, and outcomes were obtained from chart review. Results There were 400 patients meeting inclusion criteria. The cohort had a mean age of 78.3 ± 8.8 years, 50% were male, and 72.5% had at least 1 comorbidity. Non–ground level falls (Non-GLF) were recorded in 56 patients (14%). These patients suffered a significantly higher injury burden. Non-GLF were associated with significantly higher intensive care unit length of stay (2.6 ± 5.6 vs 4.6 ± 6.7 days, P = .016) and a trend toward higher mortality than GLF. Conclusions Falls remain a source of considerable healthcare expenditure, especially among the elderly. Non-GLF account for 14% of cases and are associated with a significantly higher burden of injury and morbidity. Fall prevention strategies should include these active older individuals at risk of high-level falls.
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TL;DR: Intraoperative anastomotic drain placement was associated with earlier identification and resolution of anastmotic leak, and reinforcement of theAnastomosis with omentoplasty may reduce the incidence of anASTomotic leak by nearly 50%.
Abstract: Background Recently, endoscopic interventions (eg, esophageal stenting) have been successfully used for the management of intrathoracic leak. The purpose of this systematic review was to assess the safety and efficacy of techniques used in the management of intrathoracic anastomotic leak. Data Sources We performed a systematic review of MEDLINE, EMBASE, and PubMed to identify eligible studies analyzing management of intrathoracic esophageal leak following esophagectomy. Conclusions Intraoperative anastomotic drain placement was associated with earlier identification and resolution of anastomotic leak (mean 23.4 vs 80.7 days). In addition, reinforcement of the anastomosis with omentoplasty may reduce the incidence of anastomotic leak by nearly 50%. Endoscopic stent placement was associated with leak resolution in 72%; fatal complications were reported, however, and safety remains to be proven. Negative pressure therapy, a potentially useful tool, requires further study. If stenting and wound vacuum are used, undrained mediastinal contamination and persistent leak require surgical intervention.
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TL;DR: BMI was incrementally associated with wound-related complications, illustrating how the proliferation of obesity relates to a growing risk for surgical complications.
Abstract: BACKGROUND: Obese patients may face higher complication rates during surgical treatment of colon cancer. The aim of this study was to measure this effect at a high-volume tertiary care center. METHODS: All patients with colon cancer treated surgically at a single center from 2004 through 2011 were reviewed. Multivariate regression assessed relationships of complications and stay outcomes with body mass index (BMI) controlling for age, gender, comorbidity score, surgical approach, and history of smoking. RESULTS: In 1,048 included patients, BMI was a predictor of several complications in both laparoscopic and open procedures. For every increase of BMI by one World Health Organization category, the odds ratios were 1.61 (P ,.001) for wound infection and 1.54 (P ,.001) for slow healing. Additionally, right colectomies had an odds ratio of 3.23 (P 5 .017) for wound dehiscence. No further associations with BMI were found. CONCLUSIONS: BMI was incrementally associated with wound-related complications, illustrating how the proliferation of obesity relates to a growing risk for surgical complications. As the surgical community strives to improve the quality of care, patient-controllable factors will play an increasingly important role in cost containment and quality improvement.
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TL;DR: TAMIS using a disposable transanal access platform is a safe and effective method to remove rectal lesions in this case series.
Abstract: Background Transanal minimally invasive surgery (TAMIS), an alternative technique to transanal endoscopic microsurgery, was developed in 2009. Herein, we describe our initial experience using TAMIS for benign and malignant rectal neoplasia. Methods This is an institutional review board approved, retrospective case series report. Results TAMIS was performed in 32 patients for rectal adenoma (13), adenocarcinoma (16), and carcinoid (3). There were 14 women, with mean age 62 ± 15 years and body mass index 28 ± 5 kg/m2. Lesion size ranged from .5 to 8.5 cm, distance from the dentate line 1 to 11 cm, and circumference of the lesion 10% to 100%. The mean operative time was 123 ± 62 minutes. Mean hospital length of stay was 2.5 ± 2 days. Complications included urinary tract infection (1), Clostridium difficile diarrhea (1), atrial fibrillation (1), rectal stenosis (1), and rectal bleeding (1). Conclusion TAMIS using a disposable transanal access platform is a safe and effective method to remove rectal lesions in this case series.
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TL;DR: Low-pressure pneumoperitoneum is feasible and safe and results in reduced postoperative pain and near-equal operative time compared with standard- pressure pneum operitoneum and the reduced length of hospital stay.
Abstract: Background The feasibility and safety of low-pressure pneumoperitoneum in laparoscopic cholecystectomy remain unclear. Methods A meta-analysis of randomized controlled trials comparing low-pressure with standard-pressure pneumoperitoneum was performed. Results A total of 1,263 patients were included. Low-pressure pneumoperitoneum was associated with significantly decreased postoperative pain. The requirement for increased pressure was significantly greater in the low-pressure group (risk ratio=6.16; P P P = .01). No significant differences were found in surgical complications or conversion to open surgery. Conclusions Low-pressure pneumoperitoneum is feasible and safe and results in reduced postoperative pain and near-equal operative time compared with standard-pressure pneumoperitoneum. More studies are required to investigate the potential benefits of the reduced length of hospital stay.
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TL;DR: The application of enhanced postoperative recovery pathways in selected patients with perforated peptic ulcer disease who undergo laparoscopic Graham patch repair seems feasible.
Abstract: Background Enhanced recovery pathways are now widely used in elective surgical procedures. The feasibility of enhanced postoperative recovery pathways in emergency surgery for perforated peptic ulcer disease was investigated in this randomized controlled clinical trial. Methods Patients with perforated peptic ulcer disease who underwent laparoscopic repair were randomized into 2 groups. Group 1 patients were managed with standard postoperative care and group 2 patients with enhanced postoperative recovery pathways. The primary endpoints were the length of hospital stay and morbidity and mortality. Results Forty-seven patients were included in the study. There were 26 patients in group 1 and 21 in group 2. There were no significant differences in the morbidity and mortality rates, whereas the length of hospital stay was significantly shorter in group 2. Conclusions The application of enhanced postoperative recovery pathways in selected patients with perforated peptic ulcer disease who undergo laparoscopic Graham patch repair seems feasible.
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TL;DR: Prolonged waiting hours in PACU because of ICU bed shortage was associated with higher ICU mortality for critically surgical patients, and was not associated with mechanical ventilation days, ICU length of stay, and ICU cost.
Abstract: BACKGROUND: Shortageofbedsinintensivecareunits(ICUs)isanincreasingcommonphenomenon worldwide. Consequently, many critically ill patients have to be cared for in other hospital areas without specialized staff, such as general wards, emergency department, post anesthesia care unit (PACU). However, boarding critically ill patients in general wards or emergency department has been associated with higher mortality. The purpose of this study was to evaluate if a delay in ICU admission, waiting in PACU and managed by anesthesiologists, affects their ICU outcomes for critically surgical patients. METHODS: A retrospective cohort of adult critically surgical patients admitted to our ICU between January 2010 and June 2012 were analyzed. ICU admission was classified as either immediate or delayed (waiting in PACU). A general estimation equation was used to examine the relationship of PACU waiting hours before ICU admission with ICU outcomes by adjusting for age, patient sex, comorbidities, surgical categories, end time of operation, operation hours, and clinical conditions. RESULTS: A total of 2,279 critically surgical patients were evaluated. Two thousand ninety-four (91.9%) patients were immediately admitted and 185 (8.1%) patients had delayed ICU admission. There was a significant increase in ICU mortality rates with a delay in ICU admission (P ,.001). Prolonged waiting hours in PACU (R6 hours) was associated with higher ICU mortality (adjusted odds ratio 5.32; 95% confidence interval 1.25 to 22.60, P 5 .024). However, longer PACU waiting times was not associated with mechanical ventilation days, ICU length of stay, and ICU cost. CONCLUSION: Prolonged waiting hours in PACU because of ICU bed shortage was associated with higher ICU mortality for critically surgical patients.
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TL;DR: Benign papillary lesions diagnosed on Breast Imaging Reporting and Data System category 4 mammograms among asymptomatic women do not justify surgical excision.
Abstract: Background
Upgrade rates of high-risk breast lesions after screening mammography were examined.
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TL;DR: Standardized classification of errors in preventable trauma deaths most often involve clinical performance in the early phases of care and can be mitigated with universal strategies.
Abstract: BACKGROUND: Benchmarking and classification of avoidable errors in trauma care are difficult as most reports classify errors using variable locally derived schemes. We sought to classify errors in a large trauma population using standardized Joint Commission taxonomy. METHODS: All preventable/potentially preventable deaths identified at an urban, level-1 trauma center (January 2002 to December 2010) were abstracted from the trauma registry. Errors deemed avoidable were classified within the 5-node (impact, type, domain, cause, and prevention) Joint Commission taxonomy. RESULTS: Of the 377 deaths in 11,100 trauma contacts, 106 (7.7%) were preventable/potentially preventable deaths related to 142 avoidable errors. Most common error types were in clinical performance (inaccurate diagnosis). Error domain involved primarily the emergency department (therapeutic interventions), caused mostly by knowledge deficits. Communication improvement was the most common mitigation strategy. CONCLUSION: Standardized classification of errors in preventable trauma deaths most often involve clinical performance in the early phases of care and can be mitigated with universal strategies.
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TL;DR: There is higher female representation in the Program Director position than Chair position (P = .002) in General Surgery, Otolaryngology, and Orthopedics and this discrepancy warrants further investigation.
Abstract: Background Sex disparity in the Program Director role has not been studied. The goal of this study is to evaluate the percentage of women in Chair and Program Director positions. We hypothesize that there is a higher percentage of women in the Program Director role than Chair role. Methods An Internet search identified Chairs, Program Directors, Associate Program Directors, and Division Chiefs. Statistical analysis compared percentages of women in these roles at all institutions, academic/community programs, and regions. Results There is higher female representation in the Program Director position than Chair position ( P = .002) in General Surgery, Otolaryngology, and Orthopedics. More women are Associate Program Directors than Division Chiefs (23.6% vs 9.8%, P ≤ .001). Academic and community programs are no different. In the West, a greater percentage of women are Chairs as compared with the other regions ( P ≤ .002). Conclusions There are higher rates of women in Program Director position than Department Chair position. This discrepancy warrants further investigation.
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TL;DR: The role of vagotomy in the management of PUD has a rich history but predated pharmacologic control of acid and understanding of the role of Helicobacter pylori in the disease, so the current role ofvagotomy is significantly limited.
Abstract: Background Given the rise of medical treatment for peptic ulcer disease (PUD), surgical treatment is necessary only in select cases and emergencies. The authors assess the current relevance of surgical vagotomy to treat PUD and its complications. Data Sources Although historically significant, selective and highly selective vagotomy is very technically challenging, and highly selective vagotomy has a relatively narrow indication and high recurrence rates. Vagotomy and gastrectomy is associated with significant side effects. Two types of vagotomy remain relevant, within a narrow scope. Truncal vagotomy and pyloroplasty is safe and efficacious through a laparoscopic approach in certain emergent cases. Vagotomy and Roux-en-Y gastrojejunostomy can be used to treat severe PUD refractory to medical management. Conclusions The role of vagotomy in the management of PUD has a rich history but predated pharmacologic control of acid and understanding of the role of Helicobacter pylori in the disease. Thus, the current role of vagotomy is significantly limited. Specifically, the emergent use of truncal vagotomy is warranted for patients who are either resistant or allergic to proton pump inhibitors.
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TL;DR: The laparoscopic technique in the treatment of recurrent inguinal hernia was associated with less wound infection rates and a faster recovery to normal activity, whereas other complication rates, including the re-recurrence rate, were comparable between these 2 methods.
Abstract: Background The aim of this meta-analysis was to compare the effectiveness and complications of the laparoscopic procedure and open techniques in the treatment of recurrent inguinal hernias. Methods The electronic databases MEDLINE, Embase, PubMed, and Cochrane Library were used to search for randomized controlled trials and comparative trials about laparoscopic and open procedures on recurrent inguinal hernia repair from January 1999 to September 2012. Results A total of 1,311 patients enrolled into 6 randomized controlled trials and 5 comparative studies were included in this meta-analysis. Our pooled data showed that the laparoscopic procedure was associated with a lower incidence of wound infection and a shorter sick leave. However, there were no differences in other complication rates or the operation time between the 2 methods. Conclusions The laparoscopic technique in the treatment of recurrent inguinal hernia was associated with less wound infection rates and a faster recovery to normal activity, whereas other complication rates, including the re-recurrence rate, were comparable between these 2 methods. Laparoscopic and open procedures could be performed with equal operation time.
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TL;DR: A preclinical elective in surgery was developed, which served as an organized curriculum for junior medical students to experience surgery through a paired resident-mentorship model and incorporates elements that have been shown to positively influence student decision making in surgical career choice.
Abstract: Background The predicted shortage of surgeons is of growing concern with declining medical student interest in surgical careers. We hypothesized that earlier exposure to operative experiences and the establishment of resident mentors through a preclinical elective would enhance student confidence and interest in surgery. Methods We developed a preclinical elective in surgery, which served as an organized curriculum for junior medical students to experience surgery through a paired resident-mentorship model. We assessed student exposure and confidence with clinical activities before and after the elective (N = 24, 100% response rate). We compared these students with a cohort of peers not enrolled in the elective (N = 147, 67% response rate). Results We found significantly improved confidence (2.8 vs 4.4) and clinical exposure (2.4 vs 4.3) before versus after the elective, with precourse scores equal to matched peers. Conclusions This elective incorporates elements that have been shown to positively influence student decision making in surgical career choice. The mentorship model promotes residents as educators, whereas the elective provides a means for early identification of students interested in surgery.