Showing papers in "American Journal of Surgery in 2016"
TL;DR: There are still large gender gaps in surgery for trainees and academic leadership, and at the current rate of increase, women Full Professors will not achieve gender parity until in 2136.
Abstract: Background There have been many efforts to increase the number of women surgeons. We provide an update of women surgeon representation along the pathway to surgical academia. Methods Data was extracted from Association of American Medical Colleges FACTS and Faculty Administrative Management Online User System as well as GME annual reports starting in 1994 until the last year available for each. Results The proportion of graduating women medical students has increased on average .5% per year from 1994 to 2014. Women general surgery trainees have more than doubled in number over the same period but represented 38.3% of all general surgery trainees in 2014. Women Full Professors increased on average .3% from 1994 to 2015 but still make up less than 10% of all Full Professors. Conclusions Despite improvements over the past 20 years, there are still large gender gaps in surgery for trainees and academic leadership. At the current rate of increase, women Full Professors will not achieve gender parity until in 2136.
185 citations
TL;DR: Because of high heterogeneity among available studies and paradoxical outcomes of objective esophageal function tests, the exact effect of laparoscopic SG on the prevalence of GERD remains unanswered and surgeons should carefully evaluate preoperative GERD symptoms when choosing the proper bariatric technique.
Abstract: Background The effect of sleeve gastrectomy (SG) on the prevalence of gastroesophageal reflux disease (GERD) remains unclear. We aimed to outline the currently available literature. Data Sources All relevant databases were searched for publications examining the effect of laparoscopic SG on GERD. Primary outcome measure was change in prevalence of GERD symptoms, antireflux medication use, and esophageal function tests. Secondary outcomes were prevalence of new-onset GERD and esophagitis. Thirty-three articles were included. Eleven studies used questionnaires to assess changes in the prevalence of GERD symptoms, with a risk difference in prevalence of 4.3%. Eight studies used esophageal function tests, with paradoxical results. Pooled incidence of new-onset GERD symptoms was 20%, with a strong suggestion of heterogeneity. New-onset esophagitis ranged from 6.3% to 63.3%. Conclusions Because of high heterogeneity among available studies and paradoxical outcomes of objective esophageal function tests, the exact effect of laparoscopic SG on the prevalence of GERD remains unanswered. Surgeons should carefully evaluate preoperative GERD symptoms when choosing the proper bariatric technique.
182 citations
TL;DR: The reduction in ovarian and breast cancer risks using risk-reducing bilateral salpingo-oophorectomy has translated to improvement in survival and clinical management of patients at increased risk for breast cancer requires consideration of risk, patient preference, and quality of life.
Abstract: Background Mutations in BRCA1 or BRCA2 genes results in an elevated risk for developing both breast and ovarian cancers over the lifetime of affected carriers. General surgeons may be faced with questions about surgical risk reduction and survival benefit of prophylactic surgery. Methods A systematic literature review was performed using the electronic databases PubMed, OVID MEDLINE, and Scopus comparing prophylactic surgery vs observation with respect to breast and ovarian cancer risk reduction and mortality in BRCA mutation carriers. Results Bilateral risk-reducing mastectomy provides a 90% to 95% risk reduction in BRCA mutation carriers, although the data do not demonstrate improved mortality. The reduction in ovarian and breast cancer risks using risk-reducing bilateral salpingo-oophorectomy has translated to improvement in survival. Conclusions Clinical management of patients at increased risk for breast cancer requires consideration of risk, patient preference, and quality of life.
149 citations
TL;DR: In this paper, the impact of pre-hospital time and torso injury severity on survival was investigated in patients with high-grade torso injury, AIS grades ≥4, the degree anatomic disruption is associated with significant hemorrhage.
Abstract: Introduction The concept of the “Golden Hour” has been a time-honored tenet of prehospital trauma care, despite a paucity of data to substantiate its validity. Non-compressible torso hemorrhage has been demonstrated to be a significant cause of mortality in both military and civilian settings. We sought to characterize the impact of prehospital time and torso injury severity on survival. Furthermore, we hypothesized that time would be a significant determinant of mortality in patients with higher Abbreviated Injury Scale (AIS) grades of torso injury (AIS ≥ 4) and field hypotension (prehospital SBP ≤ 110 mmHg) as these injuries are commonly associated with hemorrhage. Methods Data for this analysis was generated from a registry of 2,523,394 injured patients entered into the National Trauma Data Bank Research Data Set from 2012 to 2014. Patients with torso injury were identified utilizing Abbreviated Injury Scale (AIS) for body regions 4 (Thorax) and 5 (Abdomen). Specific inclusion criteria for this study included pre-hospital time, prehospital SBP ≤110 mmHg, torso injury qualified by AIS and mortality. Patients with non-survivable torso injury (AIS = 6), severe head injuries (AIS ≥ 3), no signs of life in the field (SBP = 0), interfacility transfers, or those with any missing data elements were excluded. This classification methodology identified a composite cohort of 42,135 adult patients for analysis. Results The overall mortality rate of the study population was 7.9% (3326/42,135); Torso AIS and prehospital time were noted to be strong independent predictors of patient mortality in all population strata of the analysis (P Conclusion In patients with high-grade torso injury, AIS grades ≥4, the degree anatomic disruption is associated with significant hemorrhage. In our study, a precipitous rise in patient mortality was exhibited in this high-grade injury group at prehospital times
138 citations
TL;DR: There remain ongoing challenges for women in academic surgery including lack of gender equality, appropriate mentorship, and accommodations for surgeons with families and continued advancement of women in academics is dependent on addressing these concerns.
Abstract: Background The purpose of this study was to explore career satisfaction and advancement for women in academic surgery. Methods A 48-item web-based survey was emailed to women surgeons in academic centers across Canada, exploring career advancement, family planning, mentorship, discrimination, and career satisfaction. Results The survey response rate was 38% (81 of 212); 18% of participants felt they experienced gender discrimination in medical school, 36% in residency, 12% in fellowship, and 41% as staff surgeons. More than half felt that their gender had played a role in the career challenges they faced. Responses to open-ended questions suggested that many surgeons struggled to balance their academic careers with family life. Despite this, participants rated their career satisfaction very highly. Conclusions There remain ongoing challenges for women in academic surgery including lack of gender equality, appropriate mentorship, and accommodations for surgeons with families. Continued advancement of women in academic surgery is dependent on addressing these concerns.
131 citations
TL;DR: Quality of evidence supporting routine use of mesh cruroplasty is low and mesh should be used at surgeon discretion until additional studies evaluating symptomatic outcomes, quality of life, and long-term recurrence are available.
Abstract: Background Equipoise exists regarding whether mesh cruroplasty during laparoscopic large hiatal hernia repair improves symptomatic outcomes compared with suture repair. Data Source Systematic literature review (MEDLINE and EMBASE) identified 13 studies (1,194 patients; 521 suture and 673 mesh) comparing mesh versus suture cruroplasty during laparoscopic repair of large hiatal hernia. We abstracted data regarding symptom assessment, objective recurrence, and reoperation and performed meta-analysis. Conclusions The majority of studies reported significant symptom improvement. Data were insufficient to evaluate symptomatic versus asymptomatic recurrence. Time to evaluation was skewed toward longer follow-up after suture cruroplasty. Odds of recurrence (odds ratio .51, 95% confidence interval .30 to .87; overall P = .014) but not need for reoperation (odds ratio .42, 95% confidence interval .13 to 1.37; overall P = .149) were less after mesh cruroplasty. Quality of evidence supporting routine use of mesh cruroplasty is low. Mesh should be used at surgeon discretion until additional studies evaluating symptomatic outcomes, quality of life, and long-term recurrence are available.
121 citations
TL;DR: The extent of abdominal surgery mainly predicts the risk of chylous ascites, and conservative treatment has been shown to be effective in almost all cases and is the treatment of choice.
Abstract: Background Chylous leakage is a relevant clinical problem after major abdominal surgery leading to an increased length of stay. Data sources A systematic search of MEDLINE/PubMed and the Cochrane Library was performed according to the PRISMA statement. The search for the MeSH terms “chylous ascites” and/or “lymphatic fistula” retrieved a total of 2,348 articles, of which 36 full-text articles were reviewed by 2 independent investigators. Results Chylous ascites is described with an incidence of up to 11%, especially after pancreatic surgery. The incidence is increasing with the number of lymph nodes harvested. In patients treated with total parenteral nutrition, conservative treatment is demonstrated to be effective in up to 100% of cases. Conclusions The extent of abdominal surgery mainly predicts the risk of chylous ascites. Conservative treatment has been shown to be effective in almost all cases and is the treatment of choice.
113 citations
TL;DR: The administration of WSCA is a proven safe and effective treatment, correlated with a significant reduction in the need for surgery and in the length of hospital stay, and the test should be taken after at least 8 hours from administration.
Abstract: Background Adhesive small bowel obstructions are the most common postoperative causes of hospitalization. Several studies investigated the diagnostic and therapeutic role of water-soluble contrast agent (WSCA) in predicting the need for surgery, but there is no consensus. Methods A systematic review and meta-analysis was done of studies on diagnostic and therapeutic role of oral WSCA. Results WSCA had a sensitivity of 92% and a specificity of 93% in predicting resolution of obstruction without surgery; diagnostic accuracy increased significantly if abdominal X-rays were taken after 8 hours. The administration of oral WSCA reduced the need for surgery (odds ratio .55, P = .003), length of stay (weighted mean difference −2.18 days, P P Conclusions The administration of WSCA is accurate in predicting the need for surgery; the test should be taken after at least 8 hours from administration. WSCA is a proven safe and effective treatment, correlated with a significant reduction in the need for surgery and in the length of hospital stay.
111 citations
TL;DR: REBOA is an effective method for achieving temporary aortic occlusion in trauma patients with noncompressible truncal hemorrhage and is correlated with increased blood pressure and temporary hemorrhage control in a vast majority of patients.
Abstract: Background Noncompressible truncal hemorrhage is a leading cause of potentially preventable death in trauma and acute care surgery patients. These patients are at high risk of exsanguination before potentially life-saving surgical intervention may be performed. Temporary aortic occlusion is an effective means of augmenting systolic blood pressure and perfusion of the heart and brain in these patients. Aortic occlusion temporarily controls distal bleeding until permanent hemostasis can be achieved. The traditional method for temporary aortic occlusion is via resuscitative thoracotomy with cross clamping of the descending aorta. While effective, resuscitative thoracotomy is highly invasive and may worsen blood loss, hypothermia, and coagulopathy by opening an otherwise uninjured body cavity. Resuscitative endovascular balloon occlusion of the aorta (REBOA) achieves temporary aortic occlusion using an occlusive balloon catheter that is introduced into the aorta via endovascular access of the common femoral artery. For this reason it is thought that REBOA could provide a less-invasive method for temporary aortic occlusion. Our purpose is to describe our experience with the implementation of REBOA at our Level 1 trauma center. Methods A retrospective case series describing all cases of REBOA performed at a prominent level 1 trauma center between October 2011 and September 2015. The study inclusion criteria were any patient that received a REBOA procedure in the acute phases after injury. There were no exclusion criteria. Data were collected from electronic medical records and the hospital's trauma registry. Results A total of 31 patients underwent REBOA during the study period. The median age of REBOA patients was 47 (interquartile range [IQR] = 27 to 63) and 77% were male. A majority (87%) of patients sustained blunt trauma. The median injury severity score was 34 (IQR = 22 to 42). The overall survival rate was 32% but varied greatly between subgroups. Balloon inflation resulted in a median increase in systolic blood pressure of 55-mm Hg (IQR 33 to 60), in cases where the data were available (n = 20). A return to spontaneous circulation was noted in 60% of patients who had arrested before REBOA (n = 10). Overall, early death by hemorrhage was 28% with only 2 deaths in the emergency department before reaching the operating room. Conclusions REBOA is an effective method for achieving temporary aortic occlusion in trauma patients with noncompressible truncal hemorrhage. Balloon inflation correlated with increased blood pressure and temporary hemorrhage control in a vast majority of patients.
99 citations
TL;DR: This preliminary study demonstrates that PROs offer a promising means of detecting long-term recurrence after incisional hernia repair, which can help facilitate quality improvement and research efforts.
Abstract: Background Assessing incisional hernia recurrence typically requires a clinical encounter We sought to determine if patient-reported outcomes (PROs) could detect long-term recurrence Methods Adult patients 1 to 5 years after incisional hernia repair were prospectively asked about recurrence, bulge, and pain at the original repair site Using dynamic abdominal sonography for hernia to detect recurrence, performance of each PRO was determined Multivariable regression was used to evaluate PRO association with recurrence Results Fifty-two patients enrolled with follow-up time 46 ± 13 months A patient-reported bulge was 85% sensitive, and 81% specific to detect recurrence Patients reporting no bulge and no pain had 0% chance of recurrence In multivariable analysis, patients reporting a bulge were 18 times more likely to have a recurrence than those without (95% confidence interval, 37 to 900; P Conclusions This preliminary study demonstrates that PROs offer a promising means of detecting long-term recurrence after incisional hernia repair, which can help facilitate quality improvement and research efforts
95 citations
TL;DR: Implementation of a flipped classroom in the surgery clerkship is feasible and results in high learner satisfaction, effective knowledge acquisition, and increased career interest in surgery with noninferior NBME performance.
Abstract: Background The flipped classroom has been proposed as an alternative curricular approach to traditional didactic lectures but has not been previously applied to a surgery clerkship. Methods A 1-year prospective cohort of students ( n = 89) enrolled in the surgery clerkship was taught using a flipped classroom approach. A historical cohort of students ( n = 92) taught with a traditional lecture curriculum was used for comparison. Pretest and post-test performance, end-of-clerkship surveys, and National Board of Medical Examiners (NBME) scores were analyzed to assess effectiveness. Results Mean pretest and post-test scores increased across all modules ( P P = .28). Mean ratings of career interest in surgery increased after curriculum completion (4.75 to 6.50, P Conclusions Implementation of a flipped classroom in the surgery clerkship is feasible and results in high learner satisfaction, effective knowledge acquisition, and increased career interest in surgery with noninferior NBME performance.
TL;DR: There was a significant increase in the identification of BCVI following the adoption of expanded screening criteria, resulting in a substantial reduction of missed injuries.
Abstract: Background We implemented expanded screening criteria for blunt cerebrovascular injuries (BCVIs) in an attempt to capture the remaining 20% of patients not historically identified with earlier protocols. We hypothesized that these expanded criteria would capture the additional 20% of BCVI patients not previously identified. Methods Screening criteria for BCVI were expanded in 2011 after identifying new injury patterns. The study population included 4 years prior (2007 to 2010; classic) and following (2011 to 2014; expanded) implementation of expanded criteria. Results BCVIs were identified in 386 patients: 150 during the classic period (2.36% incidence) and 236 in the expanded period (2.99% incidence). In the expanded period, 155 patients were imaged based on classic screening criteria, 62 on expanded criteria (21 complex skull fractures, 20 upper rib fractures, 6 mandible fractures, 2 scalp degloving, 1 great vessel injury, and 12 combination), and 19 for other injuries and symptoms. Conclusions There was a significant increase in the identification of BCVI following the adoption of expanded screening criteria, resulting in a substantial reduction of missed injuries. Expanded criteria should be adopted when screening for BCVI.
TL;DR: Changes in the composition of procedural types suggest that LSG has become a popular alternative to gastric bypass and LGB, and the utilization of bariatric procedures has reached a plateau in the United States.
Abstract: Background Obesity is a global epidemic that has been increasing in prevalence. The only treatment method for durable weight loss is bariatric surgery. The aim of this study was to observe trends in usage and outcomes of bariatric operations used in the United States from 2008 to 2012. Methods Analysis was performed on bariatric surgery admissions from 2008 to 2012 based off of the Nationwide Inpatient Sample database. Data were selected from using International Classification of Disease, 9th Revision codes correlating to bariatric procedures for the purpose of obesity. Annual estimates and trends were reviewed for patient demographics, procedure type, patient outcomes, and length of stay (LOS). Results A total of 598,756 bariatric procedures were examined. Laparoscopic gastric bypass was the most commonly used surgical method in 2008 (58.2%). A decreasing trend in its use, and the use of laparoscopic gastric banding (LGB), was equipoised with increasing use of laparoscopic sleeve gastrectomy (LSG). Use of LSG accounted for 8.2% of procedures in 2011 and 39.6% in 2012. LGB and LSG had the lowest rates of complications, in-hospital morbidity and mortality, and the shortest LOS whereas open bypass and duodenal switch had the highest rates of complications, in-hospital morbidity and mortality, and longest LOSs. Overall rates of venous thromboembolism increased from .08% in 2008 to .215% in 2012. Respiratory complications decreased from 6.1% to 3.9%. There were no observed trends in rates of renal complications, visceral injury, bleeding, and infections. In-hospital morbidity decreased, whereas mortality rates were stable at .1%. Conclusions The utilization of bariatric procedures has reached a plateau in the United States. Changes in the composition of procedural types suggest that LSG has become a popular alternative to gastric bypass and LGB.
TL;DR: In this paper, a computer-aided search of the literature regarding SLNB in clinically node-positive breast cancer treated with NAC was carried out to identify the false negative rate (FNR), sentinel lymph node identification rate (IR), and axillary pathological complete response (pCR).
Abstract: BACKGROUND The use of sentinel lymph node biopsy (SLNB) following neoadjuvant chemotherapy (NAC) in patients presenting with clinically positive lymph nodes remains controversial. Methods A computer-aided search of the literature regarding SLNB in clinically node-positive breast cancer treated with NAC was carried out to identify the false negative rate (FNR), sentinel lymph node identification rate (IR), and axillary pathological complete response (pCR). Results Nineteen articles were used in the analysis yielding 3,398 patients. The pooled estimate of the FNR was 13% and that of the IR was 91%. The adjusted pCR rate was 47%. A trend toward significance was observed with only clinical stage N1 (cN1) disease whereby clinical stage N1 was associated with an increased pCR rate when compared to N2 or N3 disease ( P = .06). Conclusions SLNB after NAC in biopsy-proven node-positive patients results in reasonably acceptable FNR and IR, making it a valid alternative management strategy to axillary dissection. More refined patient selection and optimal techniques can improve the FNR and IR in this patient population.
TL;DR: Analysis showed no benefit of biologic over synthetic mesh for repair of potentially contaminated hernias with comparable surgical site complication rates and a hernia recurrence rate of 9% for biologic and9% for synthetic repair.
Abstract: Background Repair of contaminated abdominal wall defects entails the dilemma of choosing between synthetic material, with its presumed risk of surgical site complications, and biologic material, a costly alternative with questionable durability. Data sources Thirty-two studies published between January 1990 and June 2015 on repair of (potentially) contaminated hernias with ≥25 patients were reviewed. Fifteen studies solely described hernia repair with biologic mesh, 6 nonabsorbable synthetic meshes, and 11 described various techniques. Surgical site complications and hernia recurrence rates were evaluated per degree of contamination and mesh type by calculating pooled proportions. Conclusions Analysis showed no benefit of biologic over synthetic mesh for repair of potentially contaminated hernias with comparable surgical site complication rates and a hernia recurrence rate of 9% for biologic and 9% for synthetic repair. Biologic mesh repair of contaminated defects showed considerable higher rates of surgical site complications and a hernia recurrence rate of 30%. As only 1 study on synthetic repair of contaminated hernias was available, surgical decision making in the approach of contaminated abdominal wall defects is hampered.
TL;DR: This study used the PubMed database to review the current literature to evaluate screening tools and interventions for surgically anxious patients and concluded psychiatric anxiety surveys are currently the most appropriate form of assessment for surgical anxiety.
Abstract: Background Preoperative surgical anxiety is an unpleasant and common reaction exhibited by patients who are scheduled for surgical procedures. Beyond emotional effects on the patient, it can also have negative repercussions on the surgery including longer hospital stays and poorer outcomes. Given the widespread impacts of preoperative anxiety, it is critical for surgeons to gain a better understanding of how to identify and reduce surgical anxiety in their patients. Data Sources This study used the PubMed database to review the current literature to evaluate screening tools and interventions for surgically anxious patients. Conclusions Psychiatric anxiety surveys are currently the most appropriate form of assessment for surgical anxiety. Patient education is important for preventing and reducing anxiety levels in patients. Both nonpharmacological and pharmacological interventions have been shown to be effective in reducing patient anxiety and treatment should be based on patient preference, resources available, and the surgeon’s experience.
TL;DR: Laroscopic adhesiolysis for ASBO seems to have clinically proven advantage over open approach, particularly in variables of duration of operation and iatrogenic enterotomies.
Abstract: Background and objective To evaluate whether surgical outcomes differ between laparoscopic vs open approach for adhesiolysis in patients presenting with adhesional small bowel obstruction (ASBO). Data source A systematic review of literature on published studies reporting the surgical outcomes after laparoscopic vs open adhesiolysis for ASBO was undertaken using the principles of meta-analysis. Results Fourteen comparative studies on 38,057 patients, evaluating the surgical outcomes in patients undergoing laparoscopic vs open adhesiolysis for ASBO were analyzed. Laparoscopic adhesiolysis resulted in the reduced risk of morbidity (P Conclusions Laparoscopic adhesiolysis for ASBO seems to have clinically proven advantage over open approach.
TL;DR: This current assessment of IBR using the American College of Surgeons-National Surgical Quality Improvement data sets demonstrates that non-Caucasian and older women (≥45 years) continue to receive IBR at lower rates despite the lack of association of added risk of surgical morbidity.
Abstract: Background Immediate breast reconstruction (IBR) rates continue to rise, yet recent patterns based on race, age, and patient comorbidities have not been adequately assessed. Methods Women undergoing mastectomy only or mastectomy with IBR from 2005 to 2011 were identified in the American College of Surgeons–National Surgical Quality Improvement (NSQIP) data sets. A multivariate logistic regression was performed to determine factors independently associated with receipt of IBR. Thirty-day surgical complication rates after IBR were also assessed. Results Rates of IBR increased significantly over the study period from 26% of patients in 2005 to 40% in 2011. Non-Caucasian race, older age (≥45 years), obesity, and presence of comorbid conditions including diabetes mellitus, current smoking, and cardiovascular disease were all negatively associated with receipt of IBR. Surgical complication rates after IBR were not predicted by non-Caucasian race, older age, or presence of diabetes mellitus. Conclusions This current assessment of IBR using the American College of Surgeons–National Surgical Quality Improvement data sets demonstrates that non-Caucasian and older women (≥45 years) continue to receive IBR at lower rates despite the lack of association of added risk of surgical morbidity.
TL;DR: Patients with rectal cancer under the age of 50 years have symptoms for a considerable period of time before seeking medical care and are referred in less timely manner to specialists, however, the delay in diagnosis did not adversely impact stage on presentation or 5-year survival.
Abstract: Background The incidence of rectal cancer in younger patients continues to increase. Because most of these patients do not meet criteria for routine colorectal cancer screening, diagnosis may be delayed, potentially resulting in adverse outcomes. The aim of this study was to determine whether patients under the age of 50 years with rectal cancer have a delay in diagnosis and treatment leading to a worse overall prognosis. Methods A case control study of patients diagnosed with rectal adenocarcinoma in an academic medical center from 1997 to 2007 under 50 years of age were matched 1:1 to randomly selected patients over the age of 50 years by sex and date of diagnosis. Time to diagnosis, time to treatment, staging of the American Joint Committee on Cancer, and 5-year overall survival were compared. Results The overall time to treatment from symptom onset was 217 days for patients under the age of 50 years versus 29.5 days if over 50 years of age ( P P = .39 and P = .54, respectively). Conclusions Patients with rectal cancer under the age of 50 years have symptoms for a considerable period of time before seeking medical care and are referred in less timely manner to specialists. However, the delay in diagnosis did not adversely impact stage on presentation or 5-year survival.
TL;DR: Progress has been made in skills assessment, curricula development, debriefing and decision making in surgery, and a link between simulation training and patient outcomes remains elusive.
Abstract: Background Key research priorities for surgical simulation have been identified in recent years The aim of this study was to establish the progress that has been made within each research priority and what still remains to be achieved Methods Members of the Association for Surgical Education Simulation Committee conducted individualized literature reviews for each research priority that were brought together by an expert panel Results Excellent progress has been made in the assessment of individual and teamwork skills in simulation The best methods of feedback and debriefing have not yet been established Progress in answering more complex questions related to competence and transfer of training is slower than other questions A link between simulation training and patient outcomes remains elusive Conclusions Progress has been made in skills assessment, curricula development, debriefing and decision making in surgery The impact of simulation training on patient outcomes represents the focus of simulation research in the years to come
TL;DR: Large size itself is not a contraindication for PD, and PD is safe and sufficient even in GPLA patients.
Abstract: Background Large size is a predictor of failure of percutaneous drainage (PD) for pyogenic liver abscess (PLA). This article serves to establish the safety and sufficiency of PD in giant PLA (GPLA). Methods A retrospective review of all GPLA patients treated at a tertiary care academic hospital from 2001 to 2011 was performed. A GPLA is defined as an abscess greater than or equal to 10 cm size based on imaging. Results Forty patients (24 men, 60%) were treated for GPLA. All but 1 patient (98%) was managed with PD and the mean duration of drainage was 9 days (range 1 to 23 days). One patient underwent operative drainage. Three patients (7.7%) needed secondary procedures after the initial PD. One patient (2.6%) failed PD and subsequently underwent operative drainage. Among the patients who underwent PD, the overall morbidity was 25%; the median length of hospital stay was 13 days (range 5 to 31 days) and 1 (2.6%) mortality. Conclusions Large size itself is not a contraindication for PD. PD is safe and sufficient even in GPLA patients.
TL;DR: Although axillary dissection and certain comorbidities were associated with complicated lymphedema, breast reconstruction appeared unrelated and the health care burden of lympherema underscored here mandates further investigation into targeted, anticipatory management strategies for breast cancer-related lympheredema.
Abstract: Background Lymphedema can become a disabling condition necessitating inpatient care This study aimed to estimate complicated lymphedema incidence after breast cancer surgery and calculate associated hospital resource utilization Methods We identified adult women undergoing lumpectomy and/or mastectomy with axillary lymph node surgery between 2006 and 2012 using 5-state inpatient databases Patients were grouped according to the development of complicated lymphedema The primary outcomes were all-cause hospitalizations and health care charges within 2 years of surgery Multivariate regression models were used to compare outcomes Results Of 56,075 women included, 23% had at least 1 hospital admission for complicated lymphedema within 2 years of surgery Despite confounder adjustment, women with complicated lymphedema experienced 5 fold more all-cause (incidence rate ratio=502, 95% confidence interval: 476 to 529) admissions compared with women without lymphedema This resulted in substantially higher health care charges ($58,088 vs $31,819 per patient, P Conclusions Complicated lymphedema develops in a quantifiable number of patients The health care burden of lymphedema underscored here mandates further investigation into targeted, anticipatory management strategies for breast cancer–related lymphedema
TL;DR: A systematic review of transitional care interventions and their effect on hospital readmissions after surgery found improving discharge planning, patient education, and follow-up communication may reduce readmissions.
Abstract: Background Despite hospital readmission being a targeted quality metric, few studies have focused on the surgical patient population. We performed a systematic review of transitional care interventions and their effect on hospital readmissions after surgery. Data Sources PubMed was searched for studies evaluating transitional care interventions in surgical populations within the years 1995 to 2015. Of 3,527 abstracts identified, 3 randomized controlled trials and 7 observational cohort studies met inclusion criteria. Conclusions Discharge planning programs reduced readmissions by 11.5% ( P = .001), 12.5% ( P = .04), and 23% ( P = .26). Patient education interventions reduced readmissions by 14% ( P = .28) and 23.5% ( P P P = .023) and 4% ( P = .161), respectively. Therefore, improving discharge planning, patient education, and follow-up communication may reduce readmissions.
TL;DR: RAN appears to be significantly easier for the surgeons and the results are comparable with the ones obtained with the pure laparoscopic technique.
Abstract: Background As compared with traditional laparoscopy, robotic-assisted surgery provides better EndoWrist instruments and three-dimensional visualization of the operative field. Studies published so far indicate that living donor nephrectomy using the robot-assisted technique is safe, feasible, and provides remarkable advantages for the patients. Methods From 5 papers reporting detailed descriptions of surgical technique for robotic assisted nephrectomy (RAN) in living donor kidney transplantation, we have gathered information about the surgical techniques as well as about patients’ intra- and postoperative outcome. Data from these articles were analyzed together with the data from our own experience (33 cases) so that the total number of analyzed cases was 292. Results In the analyzed populations, no case of donor death occurred, and no case developed complication above grade 2 of Clavien score. Perioperative complications occurred in 37 of the 292 patients (12.6%). Accidental acute hemorrhage occurred in 5 of the 292 cases (1.7%). The average overall intraoperative blood loss was 67.8 mL (range 10 to 1,500). The average warm ischemia time was 3.5 minutes (range .58 to 7.6). Conversion to the open technique occurred in only 4 cases (1.3%). The average overall operative time was 192 minutes (range 60 to 400). The average length of the hospital stay was 2.7 days (range 1 to 10). Conclusions Safety and feasibility of RAN are pointed out in all the reviewed article, both as hand-assisted and as totally robotic technique. RAN appears to be significantly easier for the surgeons and the results are comparable with the ones obtained with the pure laparoscopic technique.
TL;DR: Laroscopic groin hernia repair with bioglue mesh fixation was associated with a reduced incidence of chronic pain compared with mechanical fixation, without increasing morbidity or recurrence, and longer term data on recurrence are necessary.
Abstract: Background Evidence for open groin hernia repair demonstrates less pain with bioglue mesh fixation compared with invasive methods This study aimed to assess the short- and long-term effects of laparoscopic groin hernia repair with noninvasive and invasive mesh fixation Data Sources A systematic review of MEDLINE, CENTRAL, and OpenGrey was undertaken Randomized trials assessing the outcome of laparoscopic groin hernia repair with invasive and noninvasive fixation methods were considered for data synthesis Nine trials encompassing 1,454 patients subjected to laparoscopic hernia repair with mesh fixation using biologic or biosynthetic glue were identified Short-term data were inadequate for data synthesis Chronic pain was less frequently reported by patients subjected to repair with biologic glue fixation than with penetrating methods (odds ratio 46, 95% confidence interval 22 to 93) Duration of surgery, incidence of seroma/hematoma, morbidity, and recurrence were similar Conclusions Laparoscopic groin hernia repair with bioglue mesh fixation was associated with a reduced incidence of chronic pain compared with mechanical fixation, without increasing morbidity or recurrence Longer term data on recurrence are necessary
TL;DR: Women surgeons' ability to both identify and resist discrimination was hobbled by narratives of individualism, gender equality, and normative ideas of gender difference, suggesting that gender discrimination was pervasive in academic surgery.
Abstract: Background The number of women in surgery has steadily increased, yet their numbers in academic surgery positions and in high-ranking leadership roles remain low. To create strategies to address and improve this problem, it is essential to examine how gender plays into the advancement of a woman's career in academic surgery. Methods Focus group (1) and one-on-one qualitative interviews (8) were conducted with women academic surgeons from various subspecialties in a large university setting. Interviews examined women surgeons' accounts of their experiences as women in surgery. Audio-recorded data were transcribed verbatim and coded thematically. NVivo10 software was used for cross-referencing of data and categorization of data into themes. Results Focus group data suggested that gender discrimination was pervasive in academic surgery. However, in interviews, most interviewees strongly disavowed the possibility that their gender had any bearing on their professional lives. These surgeons attempted to distance themselves from the possibility of discrimination by suggesting that differences in men and women surgeons' experiences are due to personality issues and personal choices. However, their narratives highlighted deep contradiction; they both affirmed and denied the relevance of gender for their experience as surgeons. Conclusions As overt acts of discrimination become less acceptable in society, it does not necessarily disappear but rather manifests itself in covert forms. By disavowing and distancing themselves from discrimination, these women exposed the degree to which these issues continue to be pervasive in surgery. Women surgeons' ability to both identify and resist discrimination was hobbled by narratives of individualism, gender equality, and normative ideas of gender difference.
TL;DR: Investigation of the cause of death based on timing and type of fracture and Injury Severity Score found mortality is unavoidable in a small group of patients with hemorrhage being the commonest cause of early death but isolated pelvic hemorrhage rare.
Abstract: Background Mortality in patients sustaining pelvic fractures has been reported to be 4% to 15%. We sought to investigate the cause of death based on timing and evaluate if type of fracture and Injury Severity Score have an influence on the survival time. Methods Sixty-nine patients of eight hundred sixty seven with a pelvic fracture who died during their hospital admission were included. Fractures were classified using the Arbeitsgemeinschaft Osteosynthesefragen/Orthopaedic Trauma Association system. Cause determined by autopsy in 48/69. Results The leading cause of death within 6 hours was abdominal and pelvic hemorrhage; 6 to 24 hours head injury, and greater than 24 hours multiple organ dysfunction syndrome. Survival time did not correlate between fracture type (P Conclusions Despite the advances made in acute management of the traumatized patient in the emergency department, mortality is unavoidable in a small group of patients with hemorrhage being the commonest cause of early death but isolated pelvic hemorrhage rare.
TL;DR: Frailty is a significant factor in morbidity and mortality after hepatectomy and use of the modified frailty index allows for feasibility of data collection in a busy clinical setting.
Abstract: Background An aging surgical population places an increasing burden on surgeons to accurately risk stratify and counsel patients. Preoperative frailty assessments are a promising new modality to better evaluate patients but can often be time consuming. Data regarding frailty and hepatectomy outcomes have not been published to date. Method Using the National Surgical Quality Improvement Project database, we examined hepatectomy patients 2005 to 11 and correlated frailty scores with outcomes of major morbidity, mortality, and extended length of stay, using a previously validated modified frailty index score. Frailty was compared against age, American Society of Anesthesiologists class, and other common risk variables. Results Multivariate regression identified frailty as the strongest predictor of Clavien 4 complications (OR = 40.0, 95% CI = 15.2 to 105.0), and mortality (OR = 26.4, 95% CI = 7.7 to 88.2). As the frailty score increased, there was a statistically significant increase in Clavien 4 complications, mortality, and extended length of stay (P Conclusions Frailty is a significant factor in morbidity and mortality after hepatectomy. Use of the modified frailty index allows for feasibility of data collection in a busy clinical setting.
TL;DR: The salutary benefits of undertaking pancreaticoduodenectomy at a high- volume hospital are transferred to a low-volume hospital when high-volume surgeons relocate.
Abstract: Background High-volume hospitals are purported to provide “best” outcomes. We undertook this study to evaluate the outcomes after pancreaticoduodenectomy when high-volume surgeons relocate to a low-volume hospital (ie, no pancreaticoduodenectomies in >5 years). Methods Outcomes after the last 50 pancreaticoduodenectomies undertaken at a high-volume hospital in 2012 (ie, before relocation) were compared with the outcomes after the first 50 pancreaticoduodenectomies undertaken at a low-volume hospital (ie, after relocation) in 2012 to 2013. Results Patients undergoing pancreaticoduodenectomies at a high-volume vs a low-volume hospital were not different by age or sex. Patients who underwent pancreaticoduodenectomy at the low-volume hospital had shorter operations with less blood loss, spent less time in the intensive care unit, and had shorter length of stay (P Conclusions The salutary benefits of undertaking pancreaticoduodenectomy at a high-volume hospital are transferred to a low-volume hospital when high-volume surgeons relocate. The “best” results follow high-volume surgeons.
TL;DR: The use of Crowd-Sourced Assessment of Technical Skills as a reliable, basic tool to standardize the evaluation of technical skills in general surgery is proposed.
Abstract: Background Objective, unbiased assessment of surgical skills remains a challenge in surgical education. We sought to evaluate the feasibility and reliability of Crowd-Sourced Assessment of Technical Skills. Methods Seven volunteer general surgery interns were given time for training and then testing, on laparoscopic peg transfer, precision cutting, and intracorporeal knot-tying. Six faculty experts (FEs) and 203 Amazon.com Mechanical Turk crowd workers (CWs) evaluated 21 deidentified video clips using the Global Objective Assessment of Laparoscopic Skills validated rating instrument. Results Within 19 hours and 15 minutes we received 662 eligible ratings from 203 CWs and 126 ratings from 6 FEs over 10 days. FE video ratings were of borderline internal consistency (Krippendorff's alpha=.55). FE ratings were highly correlated with CW ratings (Pearson's correlation coefficient=.78, P Conclusion We propose the use of Crowd-Sourced Assessment of Technical Skills as a reliable, basic tool to standardize the evaluation of technical skills in general surgery.