Showing papers in "Annals of Surgery in 2012"
TL;DR: Two-step hepatic resection performing surgical exploration, PVL, and ISS results in a marked and rapid hypertrophy of functional liver tissue and enables curative resection of marginally resectable liver tumors or metastases in patients that might otherwise be regarded as palliative.
Abstract: Objective:To evaluate a new 2-step technique for obtaining adequate but short-term parenchymal hypertrophy in oncologic patients requiring extended right hepatic resection with limited functional reserve.Background:Patients presenting with primary or metastatic liver tumors often face the dilemma th
1,004 citations
TL;DR: A valid and reliable LARS score correlated to QoL is constructed–-a simple tool for quick clinical evaluation of the severity of LARS.
Abstract: Objective: The aim of this study was to develop and validate a scoring system for bowel dysfunction after low anterior resection (LAR) for rectal cancer, on the basis of symptoms and impact on quality of life (QoL). Background: LAR for rectal cancer often results in severe bowel dysfunction (LAR syndrome [LARS]) with incontinence, urgency, and frequent bowel movements. Several studies have investigated functional outcome, but the terminology is inconsistent hereby complicating comparison of results. Methods: Questionnaires regarding bowel function was sent to all 1143 LAR patients eligible for inclusion identified in the national Colorectal Cancer Database. Associations between items and QoL were computed by binomial regression analyses. The important items were selected and regression analysis was performed to find the adjusted risk ratios. Individual score values were designated items to form the LARS score, which was divided into “no LARS,” “minor LARS,” and “major LARS.” Validity was tested by receiver operating characteristic (ROC) curve and Spearman’s rank correlation and discriminant validity was tested by Student t tests. Results: A total of 961 patients returned completed questionnaires. The 5 most important items were “incontinence for flatus,” “incontinence for liquid stools,” “frequency,” “clustering,” and “urgency.” The range (0‐42) was divided into 0 to 20 (no LARS), 21 to 29 (minor LARS), and 30 to 42 (major LARS). The score showed good correlation and a high sensitivity (72.54%) and specificity (82.52%) for major LARS. Discriminant validity showed significant differences between groups with and without radiotherapy (P < 0.0001), tumor height more or less than 5 cm (P < 0.0001), and total mesorectal excision/ partial mesorectal excision (P = 0.0163). Conclusions: We have constructed a valid and reliable LARS score correlated to QoL—a simple tool for quick clinical evaluation of the severity of LARS. (Ann Surg 2012;255:922‐928)
719 citations
TL;DR: The MIE Ivor Lewis approach was associated with reduced recurrent laryngeal nerve injury and mortality of 0.9% and is now the preferred approach.
Abstract: Background:Esophagectomy is a complex operation and is associated with significant morbidity and mortality. In an attempt to lower morbidity, we have adopted a minimally invasive approach to esophagectomy.Objectives:Our primary objective was to evaluate the outcomes of minimally invasive esophagecto
689 citations
TL;DR: In this article, the effects of intravenous infusions of 0.9% saline and 0.4% plasma on renal blood flow velocity and perfusion in humans using magnetic resonance imaging (MRI).
Abstract: Objective:We compared the effects of intravenous infusions of 0.9% saline ([Cl−] 154 mmol/L) and Plasma-Lyte 148 ([Cl−] 98 mmol/L, Baxter Healthcare) on renal blood flow velocity and perfusion in humans using magnetic resonance imaging (MRI).Background:Animal experiments suggest that hyperchloremia
639 citations
TL;DR: Among hospitals in the Premier Perspective Database, the use of a calcium-free balanced crystalloid for replacement of fluid losses on the day of major surgery was associated with less postoperative morbidity than 0.9% saline.
Abstract: renal failure requiring dialysis (P < 0.001), blood transfusion (P < 0.001), electrolyte disturbance (P = 0.046), acidosis investigation (P < 0.001), and intervention (P = 0.02) were all more frequent in patients receiving 0.9% saline. Conclusions: Among hospitals in the Premier Perspective Database, the use of a calcium-free balanced crystalloid for replacement of fluid losses on the day of major surgery was associated with less postoperative morbidity than 0.9% saline. (Ann Surg 2012;255:821–829)
551 citations
TL;DR: This procedure may be able to overcome the shortcomings of “conventional” two-stage hepatectomy and result in an increased number of patients who could benefit from surgical treatment despite initially unresectable hepatic malignancies due to too small future liver remnant volume.
Abstract: W e read with great interest the original article by Schnitzbauer et al,1 introducing a novel surgical procedure in oncological liver resection. This surgical approach has been devised for patients with initially unresectable liver malignancies because of too small future liver remnant. Using this procedure, the future liver remnant volume considerably increased only in a mean of 9 days (the median increased future liver remnant volume of 74%) and all patients (n = 25) succeeded in completion of the extended major hepatectomy. Thus, this procedure may be able to overcome the shortcomings of “conventional” two-stage hepatectomy.2–4 It has been known that the major reason for failure of two-stage hepatectomy is tumor progression during a waiting period of future liver remnant hypertrophy after portal vein occlusion. 5, 6 Therefore, this may be a groundbreaking surgical procedure resulting in an increased number of patients who could benefit from surgical treatment despite initially unresectable hepatic malignancies due to too small future liver remnant volume. Owing to the complexity of this procedure, however, it should be used with caution in clinical practice. The incidence of severe morbidity after this procedure is considerably high (27 events occurred in 9 of 25 patients; 36%), and a particularly high incidence rate of postoperative biliary fistula requiring percutaneous drainage is worthy of special mention (5 of 25 patients; 20%). Furthermore, 20% of patients who underwent hepaticojejunostomy required relaparotomy because of biliary leakage. Such a high rate of biliary complications may result from the complexity of procedures, suggesting that this procedure may not be applicable to patients requiring biliary reconstruction. In patients with hep-
543 citations
TL;DR: The improved complication profile of LDP, taken together with the lack of compromise of margin status, suggests that this technique is a reasonable approach in selected cancer patients.
Abstract: Objective: To compare laparoscopic distal pancreatectomy (LDP) versus open distal pancreatectomy (ODP) by using meta-analytical techniques. Background: LDP is increasingly performed as an alternative approach for distalpancreatectomyinselectedpatients.Multiplestudieshavetriedtoassess the safety and efficacy of LDP compared with ODP. Methods: A systematic review of the literature was performed to identify studies comparing LDP and ODP. Intraoperative outcomes, postoperative recovery, oncologic safety, and postoperative complications were evaluated. Meta-analysis was performed using a random-effects model. Results: Eighteen studies matched the selection criteria, including 1814 patients (43% laparoscopic, 57% open). LDP had lower blood loss by 355 mL (P < 0.001) and hospital length of stay by 4.0 days (P < 0.001). Overall complications were significantly lower in the laparoscopic group (33.9% vs 44.2%; odds ratio [OR] = 0.73, 95% confidence interval [CI] 0.57‐0.95), as was surgical site infection (2.9% vs 8.1%; OR = 0.45, 95% CI 0.24‐0.82). There was no difference in operative time, margin positivity, incidence of postoperative pancreatic fistula, and mortality. Conclusions: LDP has lower blood loss and reduced length of hospital stay. There was a lower risk of overall postoperative complications and wound infection, without a substantial increase in the operative time. Although a thorough evaluation of oncological outcomes was not possible, the rate of margin positivity was comparable to the open technique. The improved complication profile of LDP, taken together with the lack of compromise of margin status, suggests that this technique is a reasonable approach in selected cancer patients. (Ann Surg 2012;255:1048‐1059)
449 citations
TL;DR: This classification is the result of a consultative process amongst pancreatologists from 49 countries spanning North America, South America, Europe, Asia, Oceania, and Africa and provides a set of concise up-to-date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research.
Abstract: Objective To develop a new international classification of acute pancreatitis severity on the basis of a sound conceptual framework, comprehensive review of published evidence, and worldwide consultation. Background The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of pancreatologists but suboptimal because these definitions are based on empiric description of occurrences that are merely associated with severity. Methods A personal invitation to contribute to the development of a new international classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensivists, and radiologists who are currently active in clinical research on acute pancreatitis. The invitation was not limited to members of certain associations or residents of certain countries. A global Web-based survey was conducted and a dedicated international symposium was organized to bring contributors from different disciplines together and discuss the concept and definitions. Result The new international classification is based on the actual local and systemic determinants of severity, rather than description of events that are correlated with severity. The local determinant relates to whether there is (peri)pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another such that the presence of both infected (peri)pancreatic necrosis and persistent organ failure have a greater effect on severity than either determinant alone. The derivation of a classification based on the above principles results in 4 categories of severity-mild, moderate, severe, and critical. Conclusions This classification is the result of a consultative process amongst pancreatologists from 49 countries spanning North America, South America, Europe, Asia, Oceania, and Africa. It provides a set of concise up-to-date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research. This ensures that the determinant-based classification can be used in a uniform manner throughout the world.
424 citations
TL;DR: Smoking has a transient effect on the tissue microenvironment and a prolonged effect on inflammatory and reparative cell functions leading to delayed healing and complications and nicotine and nicotine replacement drugs seem to attenuate inflammation and enhance proliferation.
Abstract: Objective:The aim was to clarify how smoking and nicotine affects wound healing processes and to establish if smoking cessation and nicotine replacement therapy reverse the mechanisms involved.Background:Smoking is a recognized risk factor for healing complications after surgery, but the pathophysio
412 citations
TL;DR: Implementation of the WHO Surgical Checklist reduced in-hospital 30-day mortality and the impact on outcome was smaller than previously reported, although the effect depended crucially upon checklist compliance.
Abstract: Objective:To evaluate the effect of implementation of the WHO's Surgical Safety Checklist on mortality and to determine to what extent the potential effect was related to checklist compliance.Background:Marked reductions in postoperative complications after implementation of a surgical checklist hav
396 citations
TL;DR: The r-TEG data was clinically superior to results from 5 CCTs and identified patients with an increased risk of early RBC, plasma and platelet transfusions, and fibrinolysis.
Abstract: Objective:Injury and shock lead to alterations in conventional coagulation tests (CCTs). Recently, rapid thrombelastography (r-TEG) has become recognized as a comprehensive assessment of coagulation abnormalities. We have previously shown that admission r-TEG results are available faster than CCTs a
TL;DR: The development of the various types of staged hepatectomies is shown, representing one of the most promising advances in oncological liver surgery so far.
Abstract: opital Paul Brousse in Paris, France, with the introduction of sequential operations, referred to as “2-stage hepatectomy” to stepwise remove multiple liver tumors, with the aim of allowing the liver to regenerate between both procedures 4 Additional PVE was also used in a few patients Soon after, Daniel Jaeck and his colleagues from Strasbourg, France, developed another 2-stage approach for bilateral (predominantly right) tumor involvement Using routine right PVE, after the initial removal of tumors located in the left hemiliver, the resulting hypertrophy of the left part of the liver (free of tumor) allowed a safer curative right or extended-right hemihepatectomy 5 Finally, the group from Zurich modified this approach by applying concomitant right portal vein ligation with wedge resections of all left-sided tumors during the first surgery, followed a few weeks later by an extended righthepatectomy 1 Thismodificationwasbasedonevidencethatportalveinligationtriggersasimilar or better regenerative response than PVE 6,7 and could be safely applied, even in combination with partial hepatectomies of the left hemiliver In a few patients with intact primary neuroendocrine or colorectal tumors, Belghiti and colleagues have also used portal vein ligation along with resection of the primary tumor 8 In many patients, those developments led to the successful removal of multiple, often bilateral, liver lesions otherwise felt to be unresectable The drawback, however, was the need for long intervals between the 2 surgeries The earlier techniques, without the use of selective portal vein occlusion, required a delay of 2 to 13 months before completing the second hepatectomy 4 The majority of patients in whom this approach failed, did so because they had developed disease progression in the meantime 4 With the advent of PVE, this period was dramatically shortened to 2 to 4 months, 5 and with concomitant portal vein ligature to about 4 weeks 1 Other shortcomings included the insufficient hypertrophy of a putative remnant liver, preventing curative resection or, if performed, leading to postoperative failure due to “small for size” syndrome 3 In Figure 1, we show the development of the various types of staged hepatectomies The article in this issue of Annals of Surgery by Schnitzbauer and coworkers call out ref 9 introduces a novel concept representing one of the most promising advances in oncological liver surgery so far Contrary to many surgical innovations, this one was somehow developed by chance In 2007, Dr Hans Schlitt from Regensburg, Germany, was planning an extended right hepatectomy in a patient with perihilar cholangiocarcinoma, but he realized intraoperatively that the future cholestatic liver remnant was too small to sustain the patient postoperatively He took a good, but uncommon surgical decision, by performing only a selective hepatico-jejunostomy on the left biliary system For the optimal positioning of the hepatico-jejunostomy, he had to divide the liver parenchyma along the falciform ligament, thereby completely devascularizing segment IV, that is, an in-situ split as performed for pediatric liver transplantation Finally, he ligated the right portal vein to induce hypertrophy of segments II to III Out of curiosity, he performed a CT scan on postoperative day 8 and, to his surprise, found that the left liver had grown enormously He decided to proceed with the removal of the diseased liver The patient, who had been at risk of liver failure a week prior, tolerated the removal just fine After this successful case, Dr Schlitt deliberately applied this approach in a patient with extensive colorectal liver metastases and in another patient with a large cholangiocarcinoma The enthusiasm for this approach was then shared with other surgeons, mostly from Germany, who used
TL;DR: LDG can be performed safely with a shorter hospital stay and fewer complications than open surgery, and lymph node staging appears to be unaffected.
Abstract: Objective:To perform a meta-analysis of high-quality published trials, randomized and observational, comparing laparoscopic distal gastrectomy (LDG) and open distal gastrectomy (ODG) for gastric cancer.Background:Controversy persists about the clinical utility of minimally invasive techniques for th
TL;DR: In patients with colorectal cancer undergoing surgery, ABTs are associated with adverse clinical outcomes, including increased mortality, and measures aimed at limiting the use of ABTs should be investigated further.
Abstract: OBJECTIVE: To determine the effect of allogeneic blood transfusion (ABT) on clinical outcomes in patients with colorectal cancer undergoing surgery. BACKGROUND: Perioperative ABTs may be associated with adverse clinical outcomes. METHODS: Systematic review of the literature with odds ratio (OR) and incidence rate ratio (IRR) meta-analyses of predefined clinical outcomes based on a MEDLINE search. RESULTS: In total, 20,795 colorectal cancer (CRC) patients observed for more than 59.2 ± 26.1 months (108,838 patient years) were included, of which 58.8% were transfused. ABT was associated with increased all-cause mortality OR = 1.72 (95% confidence interval [CI] 1.55-1.91, P < 0.001); I(2) = 23.3% (0-51.1) and IRR = 1.31 (1.23-1.39, P < 0.001), I(2) = 0.0% (0-37.0). ABT was also associated with increased ORs (95% CI, P) for cancer-related mortality of 1.71 (1.43-2.05, P <0.001), combined recurrence-metastasis-death 1.66 (1.41-1.97, P < 0.001), postoperative infection 3.27 (2.05-5.20, P < 0.001), and surgical reintervention 4.08 (2.18-7.62, <0.001). IRR (95% CI, P) was 1.45 (1.26-1.66, <0.001) for cancer-related mortality and 1.32 (1.19-1.46, <0.001) for recurrence-metastasis-death. Mean length of hospital stay was significantly longer in transfused compared with nontransfused patients (17.8 ± 4.8 vs 13.9 ± 4.7 days, P = 0.005). CONCLUSIONS: In patients with colorectal cancer (CRC) undergoing surgery, ABTs are associated with adverse clinical outcomes, including increased mortality. Measures aimed at limiting the use of ABTs should be investigated further.
TL;DR: When combined with salvage surgery, NOM appears to achieve similar local and distant disease control compared with patients with a pCR treated by rectal resection, and was successfully avoided in 81% of patients selected for NOM.
Abstract: Introduction:Nonoperative management (NOM) of rectal cancer after a complete clinical response (cCR) to neoadjuvant therapy is controversial. In this article, we retrospectively reviewed the outcomes of patients managed with selective NOM after a cCR to neoadjuvant treatment and compared these with
TL;DR: Important differences are demonstrated between ACS-NSQIP and Medicare claims data sets for measuring surgical complications, which potentially makes claims data suboptimal for evaluating surgical complications.
Abstract: Objectives:To compare the recording of 30-day postoperative complications between a national clinical registry and Medicare inpatient claims data and to determine whether the addition of outpatient claims data improves concordance with the clinical registry.Background:Policymakers are increasingly d
TL;DR: LS is feasible and has become an essential surgical technique that can minimize the loss of functional liver volume without reducing curability, although further technical advancements are needed to enhance the accuracy of the resection, especially for the superior/posterior segments.
Abstract: OBJECTIVE To evaluate the surgical techniques necessary to complete total laparoscopic segmentectomy (LS) of all liver segments (I-VIII). BACKGROUND When compared to open surgery, preservation of functional hepatic volume may be more difficult during laparoscopic hepatectomy. LS is a possible alternative to hemihepatectomy, but laparoscopic surgical techniques to complete anatomically accurate segmentectomy have not yet been well established. METHODS Data of a total of 342 consecutive patients who underwent laparoscopic hepatectomy were reviewed. LS was defined as complete removal of the Couinaud's segment, in which the corresponding hepatic veins are exposed on the raw surface. The laparoscopic approach was facilitated by using intraoperative ultrasonography for each segment and by placing intercostal trocars to expose the root of the right hepatic vein for segmentectomy VII and VIII. RESULTS LS was completed in 62 patients: 36 segmentectomies (from I-VIII), 16 bisegmentectomies of the right lobe, and 10 subsegmentectomies were performed. Conversion to open surgery was required in 3 patients (IVa, VI, and VII). When 26 LS of the superior/posterior hepatic (sub)segments (I, IVa, VII, and VIII) were compared with the remaining 36 LS, the former group required a longer operation time (240 [132-390] minutes vs 155 [90-360]) minutes, P < 0.01) and showed an increased amount of blood loss (350 [20-1500] mL vs 100 [10-1100] mL, P = 0.02). CONCLUSIONS LS is feasible and has become an essential surgical technique that can minimize the loss of functional liver volume without reducing curability, although further technical advancements are needed to enhance the accuracy of the resection, especially for the superior/posterior segments.
TL;DR: This is the first randomized clinical trial favoring PA with diverting ileostomy over HP in patients with perforated diverticulitis, and the outcome after the initial colon resection did not show any significant differences.
Abstract: Objectives:To evaluate the outcome after Hartmann's procedure (HP) versus primary anastomosis (PA) with diverting ileostomy for perforated left-sided diverticulitis.Background:The surgical management of left-sided colonic perforation with purulent or fecal peritonitis remains controversial. PA with
TL;DR: There is significant though mild gastroesophageal reflux postoperatively in 46% of patients in 6-month pH studies, and the lower esophageAL sphincter shows normalized pressures and relaxation.
Abstract: Background Esophageal achalasia is most commonly treated with laparoscopic myotomy or endoscopic dilation. Per-oral endoscopic myotomy (POEM), an incisionless selective myotomy, has been described as a less invasive surgical treatment. This study presents 6-month physiological and symptomatic outcomes after POEM for achalasia. Methods Data on single-institution POEMs were collected prospectively. Pre- and postoperative symptoms were quantified with Eckardt scores. Objective testing (manometry, endoscopy, timed-barium swallow) was performed preoperatively and 6 months postoperatively. At 6 months, gastroesophageal reflux was evaluated by 24-hour pH testing. Pre-/postmyotomy data were compared using paired nonparametric statistics. Results Eighteen achalasia patients underwent POEMs between October 2010 and October 2011. The mean age was 59 ± 20 years and mean body mass index was 26 ± 5 kg/m. Six patients had prior dilations or Botox injections. Myotomy length was 9 cm (7-12 cm), and the median operating time was 135 minutes (90-260). There were 3 intraoperative complications: 2 gastric mucosotomies and 1 full-thickness esophagotomy, all repaired endoscopically with no sequelae. The median hospital stay was 1 day and median return to normal activity was 3 days (3-9 days). All patients had relief of dysphagia [dysphagia score ≤ 1 ("rare")]. Only 2 patients had Eckardt scores greater than 1, due to persistent noncardiac chest pain. At a mean follow-up of 11.4 months, dysphagia relief persisted for all patients. Postoperative manometry and timed barium swallows showed significant improvements in lower esophageal relaxation characteristics and esophageal emptying, respectively. Objective evidence of gastroesophageal reflux was seen in 46% patients postoperatively. Conclusions POEM is safe and effective. All patients had dysphagia relief, 83% having relief of noncardiac chest pain. There is significant though mild gastroesophageal reflux postoperatively in 46% of patients in 6-month pH studies. The lower esophageal sphincter shows normalized pressures and relaxation.
TL;DR: Thirty-day mortality after noncardiac surgery can be accurately predicted using a simple and accurate risk score based on information readily available at the bedside, and this risk index may play a useful role in facilitating shared decision making, developing and implementing risk-reduction strategies, and guiding quality improvement efforts.
Abstract: Objective: To develop a 30-day mortality risk index for noncardiac surgery that can be used to communicate risk information to patients and guide clinical management at the “point-of-care,” and that can be used by surgeons and hospitals to internally audit their quality of care. Background: Clinicians rely on the Revised Cardiac Risk Index to quantify the risk of cardiac complications in patients undergoing noncardiac surgery. Because mortality from noncardiac causes accounts for many perioperative deaths, there is also a need for a simple bedside risk index to predict 30-day all-cause mortality after noncardiac surgery. Methods: Retrospective cohort study of 298,772 patients undergoing noncardiac surgery during 2005 to 2007 using the American College of Surgeons National Surgical Quality Improvement Program database. Results: The 9-point S-MPM (Surgical Mortality Probability Model) 30-day mortality risk index was derived empirically and includes three risk factors: ASA (American Society of Anesthesiologists) physical status, emergency status, and surgery risk class. Patients with ASA physical status I, II, III, IV or V were assigned either 0, 2, 4, 5, or 6 points, respectively; intermediate- or high-risk procedures were assigned 1 or 2 points, respectively; and emergency procedures were assigned 1 point. Patients with risk scores less than 5 had a predicted risk of mortality less than 0.50%, whereas patients with a risk score of 5 to 6 had a risk of mortality between 1.5% and 4.0%. Patients with a risk score greater than 6 had risk of mortality more than 10%. SMPM exhibited excellent discrimination (C statistic, 0.897) and acceptable calibration (Hosmer-Lemeshow statistic 13.0, P = 0.023) in the validation data set. Conclusions: Thirty-day mortality after noncardiac surgery can be accurately predicted using a simple and accurate risk score based on information readily available at the bedside. This risk index may play a useful role in facilitating shared decision making, developing and implementing risk-reduction strategies, and guiding quality improvement efforts. (Ann Surg 2012;255:696–702)
TL;DR: This randomized trial showed that immune function of HLA-DR in patients undergoing laparoscopic surgery with fast track care remains highest and may indicate a reason for the accelerated recovery of patients treated laparoscopically within a fast track program as described in the LAFA-Trial.
Abstract: Objective:To evaluate the effect of laparoscopic or open colectomy with fast track or standard perioperative care on patient's immune status and stress response after surgery.Methods:Patients with nonmetastasized colon cancer were randomized to laparoscopic or open colectomy with fast track or stand
TL;DR: Medicare payments around episodes of inpatient surgery are substantially higher at hospitals with high complications, suggesting that local, regional, and national efforts aimed at improving surgical quality may ultimately reduce costs and improve outcomes.
Abstract: Context: Payers,policymakers,andprofessionalorganizationshavelaunched a variety of initiatives aimed at improving hospital quality with inpatient surgery. Despite their obvious benefits for patients, the likely impact of these efforts on health care costs is uncertain. In this context, we examined relationships between hospital outcomes and expenditures in the US Medicare population. Methods: Using the 100% national claimsfiles, we identified all US hospitals performing coronary artery bypass graft, total hip replacement, abdominal aortic aneurysm repair, or colectomy procedures between 2005 and 2007. For each procedure, we ranked hospitals by their risk- and reliability-adjusted outcomes (complication and mortality rates, respectively) and sorted them into quintiles. We then examined relationships between hospital outcomes and risk-adjusted, 30-day episode payments. Results: There was a strong, positive correlation between hospital complication rates and episode payments for all procedures. With coronary artery bypass graft, for example, hospitals in the highest complication quintile had average payments that were $5353 per patient higher than at hospitals in the lowest quintile ($46,024 vs $40,671, P < 0.001). Payments to hospitals with highcomplicationrateswerealsohigherforcolectomy($2719perpatient),abdominal aortic aneurysm repair ($5279),and hipreplacement ($2436).Higher episode payments at lower-quality hospitals were attributable in large part to higher payments for the index hospitalization, although 30-day readmissions, physician services, and postdischarge ancillary care also contributed. Despite the strong association between hospital complication rates and payments, hospital mortality was not associated with expenditures. Conclusions: Medicare payments around episodes of inpatient surgery are substantially higher at hospitals with high complications. These findings suggest that local, regional, and national efforts aimed at improving surgical quality may ultimately reduce costs and improve outcomes.
TL;DR: Simultaneous breast and lymphatic reconstruction is an ideal option for patients who suffer from lymphedema after mastectomy and axillary dissection and is found to induce the regrowth of lymphatic network in the axilla.
Abstract: OBJECTIVE Postoperative lymphedema after breast cancer surgery is a challenging problem. Recently, a novel microvascular lymph node transfer technique provided a fresh hope for patients with lymphedema. We aimed to combine this new method with the standard breast reconstruction. METHODS During 2008-2010, we performed free lower abdominal flap breast reconstruction in 87 patients. For all patients with lymphedema symptoms (n = 9), we used a modified lower abdominal reconstruction flap containing lymph nodes and lymphatic vessels surrounding the superficial circumflex vessel pedicle. Operation time, donor site morbidity, and postoperative recovery between the 2 groups (lymphedema breast reconstruction and breast reconstruction) were compared. The effect on the postoperative lymphatic vessel function was examined. RESULTS The average operation time was 426 minutes in the lymphedema breast reconstruction group and 391 minutes in the breast reconstruction group. The postoperative abdominal seroma formation was increased in patients with lymphedema. Postoperative lymphoscintigraphy demonstrated at least some improvement in lymphatic vessel function in 5 of 6 patients with lymphedema. The upper limb perimeter decreased in 7 of 9 patients. Physiotherapy and compression was no longer needed in 3 of 9 patients. Importantly, we found that human lymph nodes express high levels of endogenous lymphatic vessel growth factors. Transfer of the lymph nodes and the resulting endogenous growth factor expression may thereby induce the regrowth of lymphatic network in the axilla. No edema problems were detected in the lymph node donor area. CONCLUSION Simultaneous breast and lymphatic reconstruction is an ideal option for patients who suffer from lymphedema after mastectomy and axillary dissection.
TL;DR: Checklists are effective and economic tools that decrease mortality and morbidity in surgery and further research in particular relating to implementation is needed.
Abstract: OBJECTIVE: : A systematic literature review was conducted to assess the effectiveness of, compliance with, and critical factors for the implementation of safety checklists in surgery.
BACKGROUND: : With the aim of increasing patient safety, checklists have gained growing attention. Information about effectiveness, compliance, and critical factors for implementation is crucial for whether and which of the available instruments to use.
DATA SOURCES: : Medline including Premedline (OvidSP), Embase, and Cochrane Collaboration Library, hand search, a search of reference lists of key articles, and tables of content.
STUDY SELECTION: : Electronic databases returned 4997 citations, of which 84 articles were chosen for full-text review. Finally, 22 articles were included in this review.
DATA EXTRACTION: : Data relating to care setting, study methods and design, sample population, survey response rate, type of checklist, aim, effectiveness, compliance, attitudes, and critical factors were extracted from the studies. A random effects meta-analysis of effectiveness data was conducted if 2 or more studies reported a specified outcome.
RESULTS: : With the use of checklists, the relative risk for mortality is 0.57 [95% confidence interval (CI): 0.42-0.76] and for any complications 0.63 (95% CI: 0.58-0.67). The overall compliance rate ranged from 12% to 100% (mean: 75%) and for the Time Out from 70% to 100% (mean: 91%).
CONCLUSIONS: : Checklists are effective and economic tools that decrease mortality and morbidity. Compliance of surgical staff with checklists was good overall. Further research in particular relating to implementation is needed.
TL;DR: A systematic review of 404 published cases of Castleman's disease found surgery is the gold standard for treatment of unicentric Castelman's disease and the role of debulking surgery in human immunodeficiency virus (−) MCD needs to be evaluated in prospective studies.
Abstract: Objectives:We undertook a systematic review of 404 published cases of Castleman's disease to identify the role of the surgeon beyond assistance in tissue-based diagnosis.Background:Castleman's disease is a rare primary disease of the lymph node caused by infection with herpesviridae. Little is known
TL;DR: Although many factors associated with lower risk of burnout were also associated with achieving a high overall QOL, notable differences were observed, indicating surgeons' need to employ a broader repertoire of wellness promotion practices if they desire to move beyond neutral and achieve high well-being.
Abstract: Objective:To evaluate the health habits, routine medical care practices, and personal wellness strategies of American surgeons and explore associations with burnout and quality of life (QOL).Background:Burnout and low mental QOL are common among US surgeons and seem to adversely affect quality of ca
TL;DR: Plasma miRNAs provide reliable and noninvasive markers for CRC and miR-21 seems uniquely promising as a plasma biomarker for CRC, warrants study in larger cohorts.
Abstract: Objectives:The main objective of this study was to investigate the potential use of circulating microRNAs (miRNAs) as biomarkers of sporadic colorectal cancer (CRC).Background:CRC, a leading cause of death, is curable if detected early. There is an unmet need for an accurate, noninvasive biomarker o
TL;DR: Suture repair of parastomal hernia repair should be abandoned because of increased recurrence rates and the use of mesh in parastomies is safe with a low overall rate of mesh infection.
Abstract: Background Parastomal hernias are a frequent complication of enterostomies that require surgical treatment in approximately half of patients. This systematic review aimed to evaluate and compare the safety and effectiveness of the surgical techniques available for parastomal hernia repair. Methods Systematic review was performed in accordance with PRISMA. Assessment of methodological quality and selection of studies of parastomal hernia repair was done with a modified MINORS. Subgroups were formed for each surgical technique. Primary outcome was recurrence after at least 1-year follow-up. Secondary outcomes were mortality and postoperative morbidity. Outcomes were analyzed using weighted pooled proportions and logistic regression. Results Thirty studies were included with the majority retrospective. Suture repair resulted in a significantly increased recurrence rate when compared with mesh repair (odds ratio [OR] 8.9, 95% confidence interval [CI] 5.2-15.1; P Conclusions Suture repair of parastomal hernia should be abandoned because of increased recurrence rates. The use of mesh in parastomal hernia repair significantly reduces recurrence rates and is safe with a low overall rate of mesh infection. In laparoscopic repair, the Sugarbaker technique is superior over the keyhole technique showing fewer recurrences.
TL;DR: Higher plasma levels of aPC upon admission are predictive of poor clinical outcomes after major trauma, and after activation, patients who fail to recover physiologic plasma values of PC have an increased propensity to later nosocomial lung infection.
Abstract: Background:Recent studies have identified an acute traumatic coagulopathy that is present on admission to the hospital and is independent of iatrogenic causes. We have previously reported that this coagulopathy is due to the association of severe injury and shock and is characterized by a decrease i
TL;DR: These multi-institutional data represent a large experience of PD without the biases typically of single center studies, and factors related to infection, nutritional status, and delayed gastric emptying were the most common reasons for readmission after PD.
Abstract: OBJECTIVE AND BACKGROUND:: Morbidity, mortality, and length of hospital stay after pancreaticoduodenectomy (PD) have significantly decreased over recent decades. Despite this progress, early readmission rates after PD have been reported as high as 50%. Few reports have delineated factors associated with readmission after PD. METHODS:: The medical records of 6 high-volume institutions were reviewed for patients who underwent PD between 2005 and 2010. Data collection included patient characteristics, medical comorbidities, and perioperative factors. Analysis included readmissions up to 90 days after PD. RESULTS:: A total of 1302 patients underwent PD across all institutions. The 30-day and 90-day readmission rates were 15% and 19%, respectively. The most common reasons for 30-day readmission included infectious complications (n = 65) and delayed gastric emptying (n = 29). The most common reasons for readmission after 90 days included wound infections and intra-abdominal abscess (n = 75) and failure to thrive (n = 38). On multivariate analysis, factors associated with higher readmission rates included a preoperative diagnosis of chronic pancreatitis, higher transfusion requirements, and postoperative complications including intra-abdominal abscess and pancreatic fistula (all P < 0.02). Factors not associated with higher readmission rates included advanced age, body mass index, cardiovascular/pulmonary comorbidities, diabetes, steroid use, Whipple type (standard vs pylorus preserving PD), preoperative endobiliary stenting, and vascular reconstruction. CONCLUSIONS:: These multi-institutional data represent a large experience of PD without the biases typically of single center studies. Factors related to infection, nutritional status, and delayed gastric emptying were the most common reasons for readmission after PD. Postoperative complications including pancreatic fistula predicted higher rates of readmission.