Showing papers in "Annals of Surgery in 2004"

Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.

Abstract: Growing demand for health care, rising costs, constrained resources, and evidence of variations in clinical practice have triggered interest in measuring and improving the quality of health care delivery. For a valuable quality assessment, relevant data on outcome must be obtained in a standardized and reproducible manner to allow comparison among different centers, between different therapies and within a center over time.1–3 Objective and reliable outcome data are increasingly requested by patients and payers (government or private insurance) to assess quality and costs of health care. Moreover, health policy makers point out that the availability of comparative data on individual hospital's and physician's performance represents a powerful market force, which may contribute to limit the costs of health care while improving quality.4 Conclusive assessments of surgical procedures remain limited by the lack of consensus on how to define complications and to stratify them by severity.1,5–8 In 1992, we proposed general principles to classify complications of surgery based on a therapy-oriented, 4-level severity grading.1 Subsequently, the severity grading was refined and applied to compare the results of laparoscopic versus open cholecystectomy9 and liver transplantation.10 This classification has also been used by others11–13 and was recently suggested to serve as the basis to assess the outcome of living related liver transplantation in the United States (J. Trotter, personal communication). However, the classification system has not yet been widely used in the surgical literature. The strength of the previous classification relied on the principle of grading complications based on the therapy used to treat the complication. This approach allows identification of most complications and prevents down-rating of major negative outcomes. This is particularly important in retrospective analyses. However, we felt that modifications were necessary, particularly in grading life-threatening complications and long-term disability due to a complication. We also felt that the duration of the hospital stay can no longer be used as a criterion to grade complications. Although definitions of negative outcomes rely to a large extend on subjective “value” appraisals, the grading system must be tested in a large cohort of patients. Finally, a classification is useful only if widely accepted and applied throughout different countries and surgical cultures. Such a validation was not done with the previous classification. Therefore, the aim of the current study was 3-fold: first, to propose an improved classification of surgical complications based on our experience gained with the previous classification1; second, to test this classification in a large cohort of patients who underwent general surgery; and third, to assess the reproducibility and acceptability of the classification through an international survey.

Recurrence and Outcomes Following Hepatic Resection, Radiofrequency Ablation, and Combined Resection/Ablation for Colorectal Liver Metastases

Abstract: Objective:To examine recurrence and survival rates for patients treated with hepatic resection only, radiofrequency ablation (RFA) plus resection or RFA only for colorectal liver metastases.Summary Background Data:Thermal destruction techniques, particularly RFA, have been rapidly accepted into surg

Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: long-term results.

Abstract: Multimodality approach is the preferred treatment strategy for distal rectal cancer, including radical surgery, radiotherapy and chemotherapy. A significant proportion of patients managed by surgery, performed according to established oncological principles, appear to benefit from chemoradiation (CRT) therapy either pre- or postoperatively in terms of survival and recurrence rates. Preoperative CRT may be associated with less acute toxicity, greater tumor response/sensitivity, and higher rates of sphincter-saving procedures when compared with postoperative course.1,2 Furthermore, tumor downstaging may lead to complete clinical response (defined as absence of residual primary tumor clinically detectable) or complete pathologic response (defined as absence of viable tumor cells after full pathologic examination of the resected specimen, pT0N0M0). These situations may be observed in 10% to 30% of patients treated by neoadjuvant CRT and may be referred as stage 0 disease.3–8 Surgical resection of the rectum may be associated with significant morbidity and mortality, and in these patients, with significant rates of stoma construction.9 Moreover, surgical resection may not lead to increased overall and disease-free survival in these patients. For this reason, it has been our policy to carefully follow these patients with complete clinical response assessed after 8 weeks of CRT completion by clinical, endoscopic, and radiologic studies without immediate surgery. Patients considered with incomplete clinical response are referred to radical surgery. Surprisingly, up to 7% of these patients may present complete pathologic response (pT0N0M0) without tumor cells during pathologic examination, despite incomplete clinical response characterized by a residual rectal ulcer.8 To determine the benefit of surgical resection in patients with stage 0 rectal cancer treated by preoperative CRT therapy, we compared long-term results of a group of patients with incomplete clinical response followed by radical surgery versus a group of patients with complete clinical response not operated on.

Long-term Follow-up of a Randomized Controlled Trial of Suture Versus Mesh Repair of Incisional Hernia

Abstract: OBJECTIVE: The objective of this study was to determine the best treatment of incisional hernia, taking into account recurrence, complications, discomfort, cosmetic result, and patient satisfaction. BACKGROUND: Long-term results of incisional hernia repair are lacking. Retrospective studies and the midterm results of this study indicate that mesh repair is superior to suture repair. However, many surgeons are still performing suture repair. METHODS: Between 1992 and 1998, a multicenter trial was performed, in which 181 eligible patients with a primary or first-time recurrent midline incisional hernia were randomly assigned to suture or mesh repair. In 2003, follow-up was updated. RESULTS: Median follow-up was 75 months for suture repair and 81 months for mesh repair patients. The 10-year cumulative rate of recurrence was 63% for suture repair and 32% for mesh repair (P < 0.001). Abdominal aneurysm (P = 0.01) and wound infection (P = 0.02) were identified as independent risk factors for recurrence. In patients with small incisional hernias, the recurrence rates were 67% after suture repair and 17% after mesh repair (P = 0.003). One hundred twenty-six patients completed long-term follow-up (median follow-up 98 months). In the mesh repair group, 17% suffered a complication, compared with 8% in the suture repair group (P = 0.17). Abdominal pain was more frequent in suture repair patients (P = 0.01), but there was no difference in scar pain, cosmetic result, and patient satisfaction. CONCLUSIONS: Mesh repair results in a lower recurrence rate and less abdominal pain and does not result in more complications than suture repair. Suture repair of incisional hernia should be abandoned.

Rescue surgery for unresectable colorectal liver metastases downstaged by chemotherapy: a model to predict long-term survival.

Abstract: Objective: To evaluate the long-term survival of patients resected for primarily unresectable colorectal liver metastases (CRLM) downstaged by systemic chemotherapy and to use prognostic factors of outcome for a model predictive of survival on a preoperative setting.

Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients.

Abstract: Objective: This study tested the hypothesis that weight-reduction (bariatric) surgery reduces long-term mortality in morbidly obese patients. Background: Obesity is a significant cause of morbidity and mortality. The impact of surgically induced, long-term weight loss on this mortality is unknown. Methods: We used an observational 2-cohort study. The treatment cohort (n = 1035) included patients having undergone bariatric surgery at the McGill University Health Centre between 1986 and 2002. The control group (n = 5746) included age- and gender-matched severely obese patients who had not undergone weight-reduction surgery identified from the Quebec provincial health insurance database. Subjects with medical conditions (other then morbid obesity) at cohort-inception into the study were excluded. The cohorts were followed for a maximum of 5 years from inception. Results: The cohorts were well matched for age, gender, and duration of follow-up. Bariatric surgery resulted in significant reduction in mean percent excess weight loss (67.1%, P < 0.001). Bariatric surgery patients had significant risk reductions for developing cardiovascular, cancer, endocrine, infectious, psychiatric, and mental disorders compared with controls, with the exception of hematologic (no difference) and digestive diseases (increased rates in the bariatric cohort). The mortality rate in the bariatric surgery cohort was 0.68% compared with 6.17% in controls (relative risk 0.11, 95% confidence interval 0.04-0.27), which translates to a reduction in the relative risk of death by 89%. Conclusions: This study shows that weight-loss surgery significantly decreases overall mortality as well as the development of new health-related conditions in morbidly obese patients.

Robotic Surgery: A Current Perspective

Abstract: Robotic surgery is a new and exciting emerging technology that is taking the surgical profession by storm. Up to this point, however, the race to acquire and incorporate this emerging technology has primarily been driven by the market. In addition, surgical robots have become the entry fee for centers wanting to be known for excellence in minimally invasive surgery despite the current lack of practical applications. Therefore, robotic devices seem to have more of a marketing role than a practical role. Whether or not robotic devices will grow into a more practical role remains to be seen. Our goal in writing this review is to provide an objective evaluation of this technology and to touch on some of the subjects that manufacturers of robots do not readily disclose. In this article we discuss the development and evolution of robotic surgery, review current robotic systems, review the current data, discuss the current role of robotics in surgery, and finally we discuss the possible roles of robotic surgery in the future. It is our hope that by the end of this article the reader will be able to make a more informed decision about robotic surgery before “chasing the market.”

Tumor progression while on chemotherapy: a contraindication to liver resection for multiple colorectal metastases?

Abstract: Hepatic resection is the only treatment that currently offers a chance of long-term survival in patients with colorectal metastases. It is associated with 5-year survival rates ranging from 25% to 41%.1–6 Among the prognostic factors affecting the outcome after liver resection, the number of metastases is one of the most commonly reported.2,3,5,7–11 At the time of diagnosis, it is also the major reason of unresectability. When liver resection is feasible, there is general agreement that patients with 4 or more metastatic nodules gain little benefit from liver resection,2,9–11 although some authors have found no effect of the number of lesions on prognosis.4,12 In our practice however, a high number of metastases has never been considered a contraindication to surgery provided that liver resection was potentially curative and that preoperative chemotherapy had been delivered to control or to downstage metastatic disease. In recent years, great improvements in the effectiveness of chemotherapy have been achieved for metastatic colorectal cancer. Response rate observed with 5-fluorouracil (5-FU) and leucovorin have been significantly increased by the combination with oxaliplatin and/or irinotecan and by changes in drug delivery.13–17 These higher response rates have played a key role in improving the resectability of hepatic metastases, allowing 15% to 20% of patients with initially unresectable tumors to be secondarily resected with reported 5-year survival rates of 30% to 40%.18,19 Irrespective of their initial resectability, our attitude has been to manage these patients by a combination of preoperative chemotherapy and surgery with the objective to treat the metastatic disease through a combined systemic and local approach. The rationale of this policy has been recently supported by the better prognosis obtained with neoadjuvant chemotherapy and surgery, as compared with immediate surgery in patients with multinodular colorectal liver metastases.20 No attention was paid in this latter study to the influence of the response to preoperative chemotherapy on the outcome following hepatic resection. The aim of the present study was to evaluate the role of this factor for the outcome of patients having multiple (≥4) metastases who underwent liver resection.

Intraductal Papillary Mucinous Neoplasms of the Pancreas: An Updated Experience

Abstract: Objective:To update the authors’ experience with intraductal papillary mucinous neoplasms (IPMNs) of the pancreas.Background Data:IPMNs are intraductal mucin-producing cystic neoplasms of the pancreas with clear malignant potential. Since the authors’ 2001 report, the number of IPMNs resected at our

Proving the Value of Simulation in Laparoscopic Surgery

Abstract: Multiple pressures have stimulated the development of curricula to teach fundamental technical skills to surgeons in a laboratory setting. These include reduced resident work hours, increasing costs of operating room time, and the public and payers’ focus on medical errors and the ethics of learning basic skills on patients. In response to these demands, laparoscopic simulators have been developed using inanimate box trainers or computer-based virtual reality platforms.1,2 The goals of these simulator-based curricula are to provide an opportunity to learn and practice basic skills in a relaxed and inexpensive environment to attain a basic level of technical facility that can be transferred from the laboratory to the operating room environment. Laparoscopy has been an area where simulator curricula have attracted much interest because unique skills had to be learned not only by surgeons in training but also by surgeons in practice. This latter group had to develop a strategy to acquire novel skills and incorporate these skills into their clinical practice. Since simulator training requires an investment in both the equipment and time required for training, it is important that this investment be justified by providing proof of the value of simulators. The process to develop and prove the value of the MISTELS (McGill Inanimate System for Training and Evaluation of Laparoscopic Skills) physical laparoscopy simulator has followed a stepwise progression. First, the skills unique to laparoscopic surgery were identified, modeled into exercises that could be carried out in a physical simulator, and a measuring system (metrics) was developed for each exercise, providing a quantitative and objective assessment of performance based on efficiency and precision. Next, the metrics were evaluated for reliability and validity. The most important aspect of validity assessment was to evaluate the relationship of technical skill measured in the simulator to skill in the operating room. If this relationship was found to be robust, simulator performance could then be used to predict performance in the operating room. Once these steps had been completed, the simulator system could then be assessed as a means to verify that laparoscopic technical skill had reached a level thought necessary for the safe performance of basic laparoscopic surgery. In other words, we sought to determine whether the MISTELS score could be used as a summative assessment tool to separate a group that was considered competent from one that would not be considered competent purely from the technical-skill point of view. If so, the sensitivity, specificity, positive and negative predictive values could be determined. The purpose of this paper is to review the process used to develop the MISTELS physical laparoscopy simulator and to summarize the data accumulated over a series of experiments to prove its value as an effective tool to teach and evaluate the fundamental skills required in laparoscopic surgery. These new data are put in context with previously published preliminary data on the MISTELS system.

Main-Duct Intraductal Papillary Mucinous Neoplasms of the Pancreas: Clinical Predictors of Malignancy and Long-term Survival Following Resection

Abstract: Objective: To describe clinical characteristics and outcomes of a large cohort of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas affecting the main pancreatic duct.

Improving perioperative outcome expands the role of hepatectomy in management of benign and malignant hepatobiliary diseases: Analysis of 1222 consecutive patients from a prospective database

Abstract: Objective: To assess the trends in perioperative outcome of hepatectomy for hepatobiliary diseases. Methods: Data of 1222 consecutive patients who underwent hepatectomy for hepatobiliary diseases from July 1989 to June 2003 in a tertiary institution were collected prospectively. Perioperative outcome of patients in the first (group I) and second (group II) halves of this period was compared. Factors associated with morbidity and mortality were analyzed. Results: Diagnoses included hepatocellular carcinoma (n = 734), other liver cancers (n = 257), extrahepatic biliary malignancies (n = 43), hepatolithiasis (n = 101), benign liver tumors (n = 61), and other diseases (n = 26). The majority of patients (61.8%) underwent major hepatectomy of ≥3 segments. The overall hospital mortality and morbidity were 4.9% and 32.4%, respectively. The number of hepatectomies increased from 402 in group I to 820 in group II, partly as a result of more liberal patient selection. Group II had more elderly patients (P = 0.006), more patients with comorbid illnesses (P = 0.001), and significantly worse liver function. Nonetheless. group II had lower blood loss (median 750 versus 1450 mL, P < 0.001), perioperative transfusion (17.3°K, versus 67.7%, P < 0.0111), morbidity (30.0% versus 37.3%, P = 0.012), and hospital mortality (3.7% versus 7.5%, P = 0.004). On multivariate analysis, hypoalbuminemia, thrombocytopenia, elevated serum creatinine, major hepatic resection, and transfusion were the significant predictors of hospital mortality, whereas concomitant extrahepatic procedure, thrombocytopenia, and transfusion were the predictors of morbidity. Conclusions: Perioperative outcome has improved despite extending the indication of hepatectomy to more high-risk patients. The role of hepatectomy in the management of hepatobiliary diseases can be expanded. Reduced perioperative transfusion is the main contributory factor for improved outcome.

Effect of Duodenal–Jejunal Exclusion in a Non-obese Animal Model of Type 2 Diabetes: A New Perspective for an Old Disease

Abstract: Diabetes mellitus presently affects more than 150 million people worldwide,1 a number expected to double by the year 2025.2 More than 90% of patients suffer from the type 2 form,3 a progressive disorder associated with life-threatening complications and whose etiology remains still elusive. The resolution of type 2 diabetes has been observed as an additional outcome of surgical treatment of morbid obesity (body mass index [BMI] >40 kg/m2).4 Two procedures, the Roux-en-Y gastric bypass (RYGBP) and the biliopancreatic diversion (BPD), are more effective treatments for diabetes than other procedures5 and determine normal concentrations of plasma glucose, insulin, and glycosylated hemoglobin in 80–100% of morbidly obese patients.6–9 Because BMI is the dominant risk factor for diabetes10,11 and weight loss and hypocaloric diet reduce plasma glucose and improve insulin sensitivity in obese individuals,12 this antidiabetic effect of surgery has been interpreted as a conceivable result of the surgically induced weight loss and decreased caloric intake.13 Glycemic control, however, often occurs within days, long before significant weight loss,7,14,15 suggesting that the control of diabetes may be a direct effect of the operations rather than a secondary outcome of the amelioration of obesity-related abnormalities. Both the RYGBP and the BPD include, among other elements, the bypass of the duodenum and part of the jejunum (Fig. 1). Because several peptides released in this part of the bowel are involved in governing beta-cell function both in physiological16 and diabetic states,17,18 changes in the enteroinsular axis might explain their antidiabetic effect. FIGURE 1. Roux-en-Y gastric bypass (A) includes creation of a small gastric pouch while the jejunum is divided 30–50 cm distal to the ligament of Treitz. The distal limb of the jejunum is then anastomosed to the small gastric pouch and a jejuno–jejunostomy ... We speculated that if the control of diabetes is not a secondary outcome of the treatment of obesity but, rather, a direct effect of duodenal–jejunal exclusion, then similar results should also occur in nonobese individuals. To test this hypothesis, we studied the effect of a gastrojejunal bypass in Goto-Kakizaki (GK) rats, the most widely used animal model of nonobese type 2 diabetes.19 To specifically investigate the role of the duodenal–jejunal exclusion, avoiding possible influence from mechanical reduction of food intake and/or hormonal effects secondary to the bypass of the distal stomach, we performed a stomach-preserving gastrojejunal bypass leaving intact the original volume of the stomach (Fig. 2). FIGURE 2. Gastrojejunal bypass. The duodenum was separated from the stomach, and bowel continuity was interrupted at the level of the distal jejunum, (8 cm from the ligament of Treitz). The distal of the 2 limbs was directly connected to the stomach (gastrojejunal ...

The Early Effect of the Roux-en-Y Gastric Bypass on Hormones Involved in Body Weight Regulation and Glucose Metabolism

Abstract: Objective: To evaluate the early effect of Roux-en-Y (RYGB) gastric bypass on hormones involved in body weight regulation and glucose metabolism. Significant Background Data: The RYGB is an effective bariatric procedure for which the mechanism of action has not been elucidated yet. Reports of hormonal changes after RYGB suggest a possible endocrine effect of the operation; however, it is unknown whether these changes are the cause or rather the effect of surgically induced weight loss. We speculated that if the mechanism of action of the RYGB involves an endocrine effect, then hormonal changes should occur early after surgery, prior to substantial body weight changes. Methods: Ten patients with a mean preoperative body mass index (BMI) of 46.2 kg/m 2 (40 –53 kg/m 2 ) underwent laparoscopic RYGB. Six patients had type 2 diabetes treated by oral hypoglycemic agents. Preoperatively and 3 weeks following surgery, all patients were tested for fasting glucose, insulin, glucagon, insulinlike growth factor 1 (IGF-1), leptin, gastric inhibitory polypeptide (GIP), glucagon-like peptide-1 (GLP-1), cholecystokinin (CCK), adrenocorticotropic hormone (ACTH), corticosterone, and neuropeptide Y (NPY). Results: Changes in mean BMI were rather minimal (43.2 kg/m 2 ; P not significant), but there was a significant decrease in blood glucose (P 0.005), insulin (P 0.02), IGF-1 (P 0.05), leptin (P 0.001), and an increase in ACTH levels (P 0.01). The other hormones were not significantly changed by surgery. All the 6 diabetic patients had normal glucose and insulin levels and did not require medications after surgery. The RYGB reduced GIP levels in diabetic patients (P 0.01), whereas no changes in GIP levels were found in nondiabetics. Conclusions: Roux-en-Y gastric bypass determines considerable hormonal changes before significant BMI changes take place. These results support the hypothesis of an endocrine effect as the possible mechanism of action of RYGB. (Ann Surg 2004;240: 236 –242)

Five-year survival after resection of hepatic metastases from colorectal cancer in patients screened by positron emission tomography with F-18 fluorodeoxyglucose (FDG-PET).

Abstract: Objective: To report the first 5-year overall survival results in patients with colorectal carcinoma metastatic to the liver who have undergone hepatic resection after staging with [ 18 F] fluoro-2-deoxy-D-glucose-positron emission tomography (FDG-PET). Background Data: The 5-year overall survival after hepatic resection for colorectal cancer metastases without preoperative FDG-PET has been established in 19 studies (6070 patients). The median 5-year overall survival rate in these studies is 30% and has not improved over time. FDG-PET detects unsuspected tumor in 25% of patients considered to have resectable hepatic metastasis by conventional staging. Methods: From March 1995 to June 2002, all patients having hepatic resection for colorectal cancer metastases had preoperative FDG-PET. A prospective database was maintained. Results: One hundred patients (56 men, 44 women) were studied. Metastases were synchronous in 52, single in 63, unilateral in 78, and 3 segments) in 75 and resection margins were ≥1 cm in 52. Median follow up was 31 months, with 12 actual greater than 5-year survivors. There was I postoperative death. The actuarial 5-year overall survival was 58% (95% confidence interval, 46-72%). Primary tumor grade was the only prognostic variable significantly correlated with overall survival. Conclusions: Screening by FDG-PET is associated with excellent postresection 5-year overall survival for patients undergoing resection of hepatic metastases from colorectal cancer. FDG-PET appears to define a new cohort of patients in whom tumor grade is a very important prognostic variable.

Prospective, Randomized, Multicenter, Controlled Trial of a Bioartificial Liver in Treating Acute Liver Failure

Abstract: Objective: The HepatAssist liver support system is an extracorpo-real porcine hepatocyte-based bioartificial liver (BAL). The safety and efficacy of the BAL were evaluated in a prospective. random-ized, controlled, multicenter trial in patients with severe acute liver failure. Summary Background Data: In experimental animals with acute liver failure, we demonstrated beneficial effects of the BAL. Similarly, Phase I trials of the BAL in acute liver failure patients yielded promising results. Methods: A total of 171 patients (86 control and 85 BAL) were enrolled. Patients with fulminant/subfulminant hepatic failure and primary nonfunction following liver transplantation were included. Data were analyzed with and without accounting for the following confounding factors: liver transplantation, time to transplant, disease etiology, disease severity, and treatment site. Results: For the entire patient population, survival at 30 days was 71% for BAL versus 62% for control (P = 0.26). After exclusion of primary nonfunction patients, survival was 73% for BAL Versus 59% for control (it = 147; P= 0.12). When Survival was analyzed accounting for confounding factors. in the entire patient Population, there was no difference between the 2 groups (risk ratio = 0.67; P = 0.13). However, survival in fulminant/subfulminant hepatic failure patients was significantly higher in the BAL compared with the control group (risk ratio 0.56: P = 0.048). Conclusions: This is the first prospective, randomized, controlled trial of an extracorporeal liver support system, demonstrating safety and improved survival in patients with fulminant/subfulminant hepatic failure.

Wound infection after elective colorectal resection.

Abstract: Introduction: Surgical site infection (SSI) is a potentially morbid and costly complication following major colorectal resection. In recent years, there has been growing attention placed on the accurate identification and monitoring of such surgical complications and their costs, measured in terms of increased morbidity to patients and increased financial costs to society. We hypothesize that incisional SSIs following elective colorectal resection are more frequent than is generally reported in the literature, that they can be predicated by measurable perioperative factors, and that they carry substantial morbidity and cost.

Cystic pancreatic neoplasms: observe or operate.

Abstract: Objective: The objectives of this analysis were to define the incidence, natural history, and predictors of neoplasia in pancreatic cysts to determine which patients can safely be observed and which should undergo an operation.

Patterns of Initial Recurrence in Completely Resected Gastric Adenocarcinoma

Abstract: Long-term survival after potentially curative gastrectomy for advanced gastric cancer in the United States remains poor. In an American College of Surgeons survey, the overall 5-year survival for patients with completely resected gastric adenocarcinoma was 14%, but the majority of patients presented with advanced stage disease.1 More recent series in the United States have demonstrated that more patients present with early stage disease and that overall survival is improving. In a recent series of R0 resections from our institution, less than half the patients had stage III or IV disease and the overall 5-year survival was 49%.2 Nonetheless, patients with advanced stage disease continue to have recurrence at high rates, and overall recurrence rates are related to T and N staging. Improving operative technique and perioperative care have decreased operative mortality and morbidity, but have not improved stage-specific cancer survival. A number of prospective trials have been unable to prove a survival advantage for more extensive gastric resections3–5 or for more extensive lymphadenectomy.6,7 It is likely that, in addition to a standard R0 resection, improvements in adjuvant therapy will be necessary for improved cancer-specific outcomes in high-risk patients. A recent trial comparing gastrectomy with or without chemoradiation demonstrated a significant survival advantage for adjuvant therapy.8 Because adjuvant therapy focuses on specific areas of potential recurrence (locoregional, peritoneal, or distant/systemic), understanding and predicting the pattern of recurrence is critical to planning adjuvant strategies. Data on recurrence patterns have been variable, in part because of differences in tumor biology, primary treatment, as well as the mode and timing of recurrence detection. Autopsy series typically describe endstage disease, often reporting untreated or undertreated patients, and are not representative of the early recurrence pattern. Although controversial, autopsy studies probably do not reflect the true biology of recurrence, but rather the end-stage of undertreated cancer.9–12 Planned “second-look” laparotomy was probably the best attempt to document early locoregional and peritoneal recurrence. However, it was performed in an era that lacked the modern radiologic capabilities that allowed diagnosis of early distant recurrence,13 and is currently unjustified. Clinical series may lack some accuracy in reliably detecting locoregional or peritoneal recurrences, but define the situation in which clinical decisions are made. Lastly, little is known about what clinicopathologic factors are associated with specific patterns of recurrence. The goal of this study was to review recurrence patterns in a recent series of patients with documented recurrence after a complete resection of gastric adenocarcinoma at a single institution and to assess factors potentially predictive of the clinically detected pattern of recurrence.

A Two-Stage Hepatectomy Procedure Combined With Portal Vein Embolization to Achieve Curative Resection for Initially Unresectable Multiple and Bilobar Colorectal Liver Metastases

Abstract: Liver resection has been recognized as the treatment of choice for patients with colorectal liver metastases (CLM), offering long-term survival and the only hope for cure.1–3 However, hepatectomy can be performed only in approximately 10% to 20% of patients with CLM.4 In the majority of cases, liver surgery is contraindicated due to too small future remnant liver (FRL).5–7 During the last years, new multidisciplinary therapies have been proposed to increase safely the resectability rate in patients with initially nonresectable CLM. They include portal vein embolization (PVE),8–10 systemic or arterial hepatic neoadjuvant chemotherapy,11,12 transarterial neoadjuvant immunochemotherapy,13 and local tumoral destruction.14,15 However, these adjuvant therapies do not allow to achieve a curative resection in all patients and particularly in patients with multiple bilobar CLM (MBCLM). In these patients, the resection of MBCLM would result in a too small FRL. A 2-stage hepatectomy procedure (TSHP) without PVE was advocated to treat patients with unresectable multiple metastases.16 However, after resection of MBCLM, high mortality (9%–15%) was reported.16,17 Liver failure due to insufficient functional volume of the FRL is the main cause of postoperative mortality. Preoperative PVE has been proposed to induce compensatory hypertrophy of the FRL.8,9 Some successful cases undergoing right hepatectomy and simultaneous left hemiliver wedge resections after PVE have been reported in patients with MBCLM.18 However, growth of metastatic nodules in the FRL after PVE can be more rapid than that of the nontumoral remnant hepatic parenchyma.19 Therefore, metastases located in the FRL should be ideally resected before PVE in a first-stage hepatectomy; a major hepatic resection can then be performed, after PVE, in a second-stage hepatectomy. Therefore, a new strategy design has been developed to treat patients with initially unresectable MBCLM. Our preliminary results were previously reported.20 The present study reports feasibility, surgical outcome, recurrence rate, and long-term survival of patients presenting initially unresectable MBCLM undergoing a TSHP combined with PVE.

Heller Myotomy Versus Heller Myotomy With Dor Fundoplication for Achalasia: A Prospective Randomized Double-Blind Clinical Trial

Abstract: Since the first report of laparoscopic Heller myotomy in 1991 by Shimi et al1 and thoracoscopic Heller myotomy by Pellegrini et al2 in 1992, minimally invasive techniques have been increasingly used for the treatment of achalasia. Many surgeons have noticed a distinct change in the referral patterns for treatment of achalasia now that minimally invasive techniques are available. Patti and colleagues3 in 2002 reported that during the past decade, their center at the University of California, San Francisco, saw a marked increase in the number of patients who were referred for laparoscopic Heller myotomy with a corresponding decrease in use of pneumatic balloon dilation or botulinum toxin injection. Laparoscopic Heller myotomy is the preferred treatment at Vanderbilt, and we have previously reported our results and technique.4 A great deal of controversy exists over the appropriate use of antireflux procedures to prevent reflux after myotomy. The arguments for using a partial antireflux procedure with laparoscopic Heller myotomy have been summarized nicely by Peters,5 and the arguments against the routine use of an antireflux procedure were presented by our group during a Society for Surgery of the Alimentary Tract symposium in 2000.6 A recent meta-analysis of laparoscopic Heller myotomy with or without antireflux procedure from 1991 to 2001 was performed by Lyass et al.7 Pathologic acid exposure was identified by 24-hour pH studies in 7.9% of 489 patients who underwent Heller with partial fundoplication. Forty-seven patients who had previously undergone Heller without antireflux procedure were studied with 24-hour pH monitoring and only 4, or 10%, of the 40 patients had pathologic acid exposure. This meta-analysis concluded “based on the reported data in human subjects that no recommendations could be made regarding the efficacy of partial antireflux procedures in protecting against pathologic gastroesophageal reflux (GER) after esophageal Heller myotomy.” We have completed a study that randomized 43 patients with achalasia to Heller myotomy alone or to Heller myotomy plus Dor fundoplication. The study was designed as a double-blind, parallel-group randomized trial to test the null hypothesis that the addition of Dor fundoplication will not alter the incidence of pathologic GER in these patients.

Laparoscopic Versus Open Appendectomy: Outcomes Comparison Based on a Large Administrative Database

Abstract: Objective: To compare length of hospital stay, in-hospital complications, in-hospital mortality, and rate of routine discharge between laparoscopic and open appendectomy based on a representative, nationwide database.

Radiofrequency ablation of small hepatocellular carcinoma in cirrhotic patients awaiting liver transplantation: a prospective study.

Abstract: Objective: Determine the histologic response-rate (complete versus partial tumor extinction) after single radiofrequency ablation (RFA) of small hepatocellular carcinoma (HCC) arising in cirrhosis. Investigate possible predictors of response and assess efficacy and safety of RFA as a bridge to liver transplantation (OLT).

Updated population-based review of carcinoid tumors.

Abstract: Carcinoid tumors are the most frequently occurring neuroendocrine tumors of the gastrointestinal tract and have been an area of continual interest in the field of general surgery. These tumors are derived predominately from enterochromaffin or Kulchitsky's cells and have diverse pathologic findings that typically correspond to the site of origin and hormone-secreting ability.1 Despite advances in the diagnosis and treatment of these tumors, several aspects remain unknown, and 3 of these areas are the focus of this report. First, the true incidence rate for carcinoid tumors is currently unclear. Although reports have estimated rates to be 1 per 100,000 individuals, other studies have found carcinoids in approximately 1% of necropsies.2,3 As many previous research studies reflect single institution data, the actual incidence rates (population-based) for carcinoid tumors overall and per individual anatomic sites are unknown. Second, the reported anatomic distribution of primary carcinoid tumors varies depending on the source of data quoted. Although, many textbooks cite the appendix as the most common site in the gastrointestinal tract, they disagree widely as to the actual percentage. For example, Schwartz states that the appendix accounts for 46% of gastrointestinal carcinoids, Greenfield comments that it accounts for >50%, and Cameron states that as many as 85% are attributed to the appendix.4–6 The majority of these articles describe data derived from the 1960s.7 While some more contemporary articles support the idea that the appendix is the most common site, there are several studies identifying other locations as being more frequent. Jetmore et al found that the rectum was the most frequent site for gastrointestinal carcinoid tumors, accounting for 55% of the tumors treated at their facility between the years 1958 and 1990.8 These inconsistencies regarding the incidence rates for the anatomic locations may be due to the relatively rare occurrence of this tumor as well the influence of patient selection and specific institutional biases. As such, this issue remains unresolved. Finally, while it has been established that survival rates differ widely on the basis of the origin of the carcinoid tumor, most of this work has also been obtained from single institutional experiences. To date, the overall survival rates in the population for individual anatomic sites remain unknown. This study examines a nationwide population-based cancer registry to address 3 specific aims: (1) to measure the incidence of carcinoids over the past 25 years, (2) to determine the distribution of these tumor throughout the gastrointestinal tract and note trends over time, and (3) to determine survival rates for the most common tumor sites.

Anterior resection for rectal cancer with mesorectal excision: a prospective evaluation of 622 patients.

Abstract: Objective: This study aims to review the operative results and oncological outcomes of anterior resection for rectal and rectosigmoid cancer. Comparison was made between patients with total mesorectal excision (TME) for mid and distal cancer and partial mesorectal excision (PME) for proximal cancer, when a 4- to 5-cm mesorectal margin could be achieved. Risk factors for local recurrence and survival were also analyzed.

Thromboembolism after trauma: an analysis of 1602 episodes from the American College of Surgeons National Trauma Data Bank.

Abstract: Objective: Venous thromboembolic events (VTE) are potentially preventable causes of morbidity and mortality after injury. We hypothesized that the current clinical incidence of VTE is relatively low and that VTE risk factors could be identified.

Systems Approaches to Surgical Quality and Safety: From Concept to Measurement

Abstract: Research into surgical outcomes has primarily focused on the role of patient pathophysiological risk factors, and on the skills of the individual surgeon. The outcome of surgery is, however, also dependent on the quality of care received throughout the patient's stay in hospital and the performance of a considerable number of health professionals, all of whom are influenced by the environment in which they work. Drawing on the wider literature on safety and quality in healthcare, and recent papers on surgery, this article argues for a much wider assessment of factors that may be relevant to surgical outcome. In particular we suggest the development of an “operation profile” to capture all the salient features of a surgical operation. The aims of this initiative are: to expand operative assessment beyond patient factors and the technical skills of the surgeon; to extend assessment of surgical skills beyond bench models to the operating theater; to provide a basis for assessing interventions and to provide a deeper understanding of surgical outcomes

Anastomotic leakage is predictive of diminished survival after potentially curative resection for colorectal cancer.

Abstract: Anastomotic leakage is a serious complication following restorative resection for colorectal cancer (CRC). Its reported prevalence varies as widely as from 1% to 39%, but comparisons are difficult because of a lack of standardized definition.1 Leakage may present as generalized peritonitis requiring abdominal reoperation, as a more localized collection that may discharge, or as a subclinical leak detected merely on contrast radiology. Hitherto those without peritonitis have been generally considered to be of less consequence. Several factors have been shown to have independent prognostic significance for survival following potentially curative resection for CRC.2–7 However, there are only a few reports on the association between anastomotic leakage and long-term survival.8–11 The aim of this study was to examine the relationship between anastomotic leakage and both overall survival and cancer-specific survival in our patients.

Evidence-based value of prophylactic drainage in gastrointestinal surgery: a systematic review and meta-analyses.

Abstract: Objective: To determine the evidence-based value of prophylactic drainage in gastrointestinal (GI) surgery. Methods: An electronic search of the Medline database from 1966 to 2004 was performed to identify articles comparing prophylactic drainage with no drainage in GI surgery. The studies were reviewed and classified according to their quality of evidence using the grading system proposed by the Oxford Centre for Evidence-based Medicine. Seventeen randomized controlled trials (RCTs) were found for hepato-pancreatico-biliary surgery, none for upper GI tract, and 13 for lower GI tract surgery. If sufficient RCTs were identified, we performed a meta-analysis to characterize the drain effect using the random-effects model. Results: There is evidence of level la that drains do not reduce complications after hepatic, colonic, or rectal resection with primary anastomosis and appendectomy for any stage of appendicitis. Drains were even harmful after hepatic resection in chronic liver disease and appendectomy. In the absence of RCTs, there is a consensus (evidence level 5) about the necessity of prophylactic drainage after esophageal resection and total gastrectomy due to the potential fatal outcome in case of anastomotic and gastric leakage. Conclusion: Many GI operations can be performed safely without prophylactic drainage. Drains should be omitted after hepatic, colonic, or rectal resection with primary anastomosis and appendectomy for any stage of appendicitis (recommendation grade A), whereas prophylactic drainage remains indicated after esophageal resection and total gastrectomy (recommendation grade D). For many other GI procedures, especially involving the upper GI tract, there is a further demand for well-designed RCTs to clarify the value of prophylactic drainage.

A Prospective Study of Common Bile Duct Calculi in Patients Undergoing Laparoscopic Cholecystectomy: Natural History of Choledocholithiasis Revisited

Abstract: Although laparoscopic cholecystectomy has been widely adopted as the procedure of choice for gallbladder removal, there is uncertainty about the management of common bile duct calculi in this setting. This is particularly so for those patients where choledocholithiasis is not predicted by preoperative imaging, usually ultrasonography of the biliary tree. In such circumstances many surgeons do not perform routine operative cholangiography, and clinical experience suggests that the frequency of subsequent symptoms or complications from biliary calculi is low and in the order of 2–3%. This is 30–50% less than that predicted by operative cholangiography, suggesting overdiagnosis, spontaneous passage, or silent persistence of many common duct calculi. A significant proportion of patients may therefore undergo unnecessary biliary instrumentation with its inherent morbidity and mortality.1–5 Where a confident diagnosis of choledocholithiasis was made, 20–50% patients who underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP) had no demonstrable calculi.6–11 Similarly, almost 20–40% of patients who have bile duct filling defects at per-operative cholangiography have either a negative surgical bile duct exploration or a negative postoperative ERCP.12–14 Patient selection for biliary intervention has been flawed partly because of the lack of a sensitive noninvasive imaging modality and also because the incidence and natural history of asymptomatic common bile duct calculi has not been determined in patients selected for laparoscopic cholecystectomy. In this study of patients undergoing laparoscopic cholecystectomy, we prospectively define the true incidence of common bile duct calculi and their early natural history by undertaking intraoperative cholangiography and delayed postoperative cholangiography in those who had demonstrable intraoperative filling defects in their bile ducts.