Showing papers in "Archives of Surgery in 2003"

Robotics in general surgery: personal experience in a large community hospital.

Abstract: Hypothesis Robotic technology is the most advanced development of minimally invasive surgery, but there are still some unresolved issues concerning its use in a clinical setting. Design The study describes the clinical experience of the Department of General Surgery, Misericordia Hospital, Grosseto, Italy, in robot-assisted surgery using the da Vinci Surgical System. Results Between October 2000 and November 2002, 193 patients underwent a minimally invasive robotic procedure (74 men and 119 women; mean age, 55.9 years [range, 16-91 years]). A total of 207 robotic surgical operations, including abdominal, thoracic and vascular procedures, were performed; 179 were single procedures, and 14 were double (2 operations on the same patient). There were 4 conversions to open surgery and 3 to conventional laparoscopy (conversion rate, 3.6%; 7 of 193 patients). The perioperative morbidity rate was 9.3% (18 of 193 patients), and 6 patients (3.1%) required a reoperation. The postoperative mortality rate was 1.5% (3 of 193 patients). Conclusions Our preliminary experience at a large community hospital suggests that robotic surgery is feasible in a clinical setting. Its daily use is safe and easily managed, and it expands the applications of minimally invasive surgery. However, the best indications still have to be defined, and the cost-benefit ratio must be evaluated. This report could serve as a basis for a future prospective, randomized trial.

One thousand fifty-six hepatectomies without mortality in 8 years.

Abstract: Background Despite improvements in diagnostic and surgical techniques, operative mortality associated with liver resection is still greater than 2% in most of the recent studies. Hypothesis By refining preoperative and postoperative care and surgical skills, liver resection mortality can be decreased to zero. Design Retrospective cohort study to analyze postoperative morbidity and mortality in 1056 consecutive hepatectomies performed at a single medical center during 8 years. Setting Tertiary referral center. Patients A total of 915 patients who underwent 1056 consecutive hepatic resections: 532 for hepatocellular carcinoma, 262 for other primary and secondary liver malignancies, 57 for biliary tract malignancy, 174 for living donor liver transplantation, and 31 for other benign diseases. Main Outcome Measures Operative mortality and morbidity rates. Results No operative mortality occurred. Major complications, as defined by postoperative radiologic or surgical intervention, occurred in 3% of patients with hepatocellular carcinoma, 8% with other liver malignancy, 28% with biliary malignancy, and 5% of living donor liver transplantation donors. Using multiple logistic regression, independent risk factors associated with major complications were operative blood loss of 1000 mL or greater for hepatocellular carcinoma and total bilirubin level of 1.0 mg/dL or greater (≥17 µmol/L) and operative time greater than 6 hours for other liver malignancy. No independent factors associated with major complications were identified for biliary malignancy or for living donor liver transplantation donors among the variables investigated in this study. Conclusions Liver resection can be performed without mortality provided that it is carried out in a high-volume medical center by well-trained hepatobiliary surgeons paying meticulous attention to the balance between the liver functional reserve and the volume of liver to be removed.

Complications After Laparoscopic Gastric Bypass: A Review of 3464 Cases

Abstract: Hypothesis The type and frequency of complications after open Roux-en-Y gastric bypass (GBP) have changed with the development of laparoscopic technique. Background The number of laparoscopic GBP cases performed in the United States has increased dramatically during the past several years. We compared the type and frequency of complications after laparoscopic and open GBP. Methods We searched MEDLINE from January 1, 1994, through December 31, 2002, using the keywords morbid obesity , laparoscopy , bariatric surgery , and gastric bypass . We selected studies on laparoscopic or open GBP with more than 50 patients and published in the English language for analysis. We excluded studies with reoperative Roux-en-Y GBP cases or other bariatric procedures. The type and frequency of postoperative complications were recorded from each study. We used χ 2 and Fisher exact tests to determine statistical significance. Results Ten laparoscopic GBP studies with 3464 patients and 8 open GBP studies with 2771 patients were considered. The mean of the reported average age for patients undergoing laparoscopic GBP was 41 years compared with 43 years for open GBP. The mean percentages of female patients were 87% for laparoscopic GBP and 82% for open GBP; the mean reported average body mass index (calculated as weight in kilograms divided by the square of height in meters), 48.7 and 49.5, respectively. Compared with open GBP, laparoscopic GBP was associated with a decrease in the frequency of iatrogenic splenectomy, wound infection, incisional hernia, and mortality; however, there was an increase in the frequency of early and late bowel obstruction, gastrointestinal tract hemorrhage, and stomal stenosis. There were no significant differences in the frequency of anastomotic leak, pulmonary embolism, or pneumonia. Conclusions The type and frequency of postoperative complications after laparoscopic and open GBP are different. Certain complications increase with laparoscopic GBP, probably owing to the learning curve of this complex procedure, whereas other complications decrease because of the advantages of the smaller access incision.

Incidental pancreatic cysts: clinicopathologic characteristics and comparison with symptomatic patients.

Abstract: Hypothesis: Widespread use of computed tomography and ultrasound has led to the identification of increasing numbers of patients with asymptomatic cystic lesions of the pancreas. Design: Retrospective case series of patients with pancreatic cystic lesions. Setting: University-affiliated tertiary care referral center. Patients: Two hundred twelve patients with pancreatic cystic lesions seen in our surgical practice during 5 years (April 1997-March 2002). Main Outcome Measures: Presence or absence of symptoms, cyst size and location, cytologic or pathologic diagnosis, surgical treatment, and outcome. Results: Seventy-eight (36.7%) of 212 patients were asymptomatic. Incidental cysts were smaller (3.3 3 ±1.9 vs 4.6 ±2.7 cm; P<.001) and were found in older patients (65±13 vs 56±15 years; P<.001). Seventy-eight percent of the asymptomatic patients and 87% of those with symptoms underwent surgery, with a single operative death in the entire group (0.5%). Seventeen percent of asymptomatic cysts were serous cystadenomas; 28%, mucinous cystic neoplasms; 27%, intraductal papillary mucinous neoplasms; and 2.5%, ductal adenocarcinomas. The respective numbers for symptomatic cysts were 7%, 16%, 40%, and 9%. Ten percent of asymptomatic patients had a variety of other cystic lesions, and in 12%, no definitive cytologic or pathologic diagnosis was obtained. Overall, 17% of asymptomatic patients had in situ or invasive cancer, and 42% had a premalignant lesion. When evaluated as a function of size, only 1 (3.5%) of 28 asymptomatic cysts smaller than 2 cm had cancer compared with 13 (26%) of 50 cysts larger than 2 cm (P=.04). The proportion of premalignant lesions, however, remained high in both groups (46% and 38%, respectively). Pseudocysts comprised only 3.8% of asymptomatic cysts compared with 19.4% of symptomatic cysts (P=.003). Conclusions: Incidental pancreatic cysts are common, occur in older patients, are smaller than symptomatic cysts, and are unlikely to be pseudocysts. More than half of them are either malignant or premalignant lesions and therefore cannot be dismissed.

Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy.

Abstract: Hypothesis Advances in specialized centers for pancreatic diseases have improved surgical morbidity and outcome. In the past, postoperative local complications (pancreatic fistulae) were causing most of the mortality. Now, more patients experience postoperative complications related to their comorbidity. Design To report a prospective audit of a single center's experience with pancreatic resection during an 8-year period. Setting Tertiary referral center focused on pancreatic diseases. Patients and Interventions Six hundred seventeen consecutive patients underwent pancreatectomy between November 1, 1993, and August 31, 2001. The series included 468 pancreatic head resections (76%), 25 total pancreatectomies (4%), 88 left-sided resections (14%), and 36 others (6%). Main Outcome Measures Morbidity after pancreatic resection. Results Postoperative in-hospital mortality was 1.6%, and the additional operation rate was 4.1%. Four patients died of surgical complications and 6 of systemic complications. Systemic morbidity was 18% and consisted primarily of cardiopulmonary complications (13%). The most frequent postoperative complication was delayed gastric emptying (14%), which caused significant prolongation of the hospital stay. No patients died of a postoperative pancreatic fistula, which occurred in 3.2%, and no completion pancreatectomies were necessary. Conclusions Pancreatic resections can be performed with considerable safety and a low rate of pancreatic complications. More patients die of systemic complications than in the past, which increases the demand for precise preoperative patient selection. Completion pancreatectomy should no longer be considered in patients with a pancreatic fistula.

Hospital Volume and Operative Mortality in Cancer Surgery: A National Study

Abstract: Background Although initiatives to regionalize cancer surgery are already under way, the relative importance of volume in cancer surgery is disputed. Hypothesis We examined surgical mortality with 8 cancer resections in the US population to better quantify the influence of hospital volume. Methods Using information from the all-payer Nationwide Inpatient Sample (1995-1997), we examined mortality with 8 cancer resections (N = 195 152). After dividing patients into 3 evenly sized volume groups based on hospital procedure volume (low, medium, and high), we used regression techniques to describe relationships between hospital volume and in-hospital mortality, adjusting for patient characteristics. Results Trends toward lower operative risks at high-volume hospitals were observed for 7 of the 8 procedures. However, differences between low- and highhigh-volume hospitals were statistically significant for only 3 operations (esophagectomy, 15.0% vs 6.5%; pancreatic resection, 13.1% vs 2.5%; and pulmonary lobectomy, 10.1% vs 8.9%, respectively). Although they did not reach statistical significance, absolute differences in mortality between low- and high-volume hospitals were greater than 1% for the following 3 procedures: gastrectomy, 8.7% vs 6.9%; cystectomy, 3.6% vs 2.5%; and pneumonectomy, 10.6% vs 8.9%, respectively. Mortality reductions for nephrectomy and colectomy were small. In general, in terms of absolute differences in mortality, the effect of volume was greatest in elderly patients. Conclusions Operative mortality decreases with increasing hospital volume for several cancer resections. However, volume may be most important in patients who are older and at higher risk.

Supranormal trauma resuscitation causes more cases of abdominal compartment syndrome.

Abstract: Hypothesis Normal resuscitation (oxygen delivery index [DO 2 I] ≥500 mL/min per square meter), compared with supranormal trauma resuscitation (DO 2 I ≥600 mL/min per square meter), requires less crystalloid volume, thus decreasing the incidence of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). Design Retrospective analysis of a prospective database. Setting Twenty-bed intensive care unit (ICU) in a regional level I trauma center. Patients Patients with major trauma (injury severity score >15, initial base deficit ≥6 mEq/L, or need for ≥6 units of packed red blood cells in the first 12 hours) or age 65 years or older with any 2 of the previous criteria. Interventions Shock/trauma resuscitation protocol: pulmonary artery catheter, gastric tonometry, urinary bladder pressure measurements, lactated Ringer infusion, packed red blood cell transfusion, and moderate inotrope support, as needed, in that sequence, to attain and maintain a DO 2 I greater than or equal to 600 mL/min per m 2 (16 months, ending January 1, 2001, n = 85) or a DO 2 I greater than or equal to 500 mL/min per square meter (16 months, starting January 1, 2001, n = 71) for the first 24 hours in the ICU. Main Outcome Measures: Lactated Ringer infusion volume (liters) at ICU admission, gastric partial carbon dioxide minus end-tidal carbon dioxide(GAP CO2 ), IAH (urinary bladder pressure measurements >20 mm Hg), ACS (urinary bladder pressure measurements >25 mm Hg with organ dysfunction), multiple organ failure, and mortality. Results Demographics, injury severity, and shock severity parameters were similar in both groups. The supranormal resuscitation group required more lactated Ringer infusion volume in the first 24 hours in the ICU (mean ± SD, 13 ± 2 vs 7 ± 1 L; P CO2 (16 ± 2 vs 7 ± 1 mm Hg; P P P P P Conclusion Supranormal resuscitation, compared with normal resuscitation, was associated with more lactated Ringer infusion, decreased intestinal perfusion (higher GAP CO2 ), and an increased incidence of IAH, ACS, multiple organ failure, and death.

Mechanisms and treatment of postoperative ileus.

Abstract: Objective To review the pathogenesis and treatment of postoperative ileus. Data Sources Data collected for this review were identified from a MEDLINE database search of the English-language literature. The exact indexing terms were "postoperative ileus," "treatment," "etiology," and "pathophysiology." Previous review articles and pertinent references from those articles were also used. Study Selection All relevant studies were included. Only articles that were case presentations or that mentioned postoperative ileus in passing were excluded. Data Synthesis The pathogenesis of postoperative ileus is complex, with multiple factors contributing either simultaneously or at various times during the development of this entity. These factors include inhibitory effects of sympathetic input; release of hormones, neurotransmitters, and other mediators; an inflammatory reaction; and the effects of anesthetics and analgesics. Numerous treatments have been used to alleviate postoperative ileus without much success. Conclusions The etiology of postoperative ileus can best be described as multifactorial. A multimodality treatment approach should include limiting the administration of agents known to contribute to postoperative ileus (narcotics), using thoracic epidurals with local anesthetics when possible, and selectively applying nasogastric decompression.

The spectrum of pneumatosis intestinalis.

Abstract: Hypothesis: A review of the spectrum of illness associated with pneumatosis intestinalis enables us to identify the probable causes of, the best diagnostic approaches to, and the most appropriate treatments for this condition. Data Sources:A review of all published material in the Englishlanguageregardingpneumatosisintestinaliswas conducted using the PubMed and MEDLINE databases. Any relevant work referenced in those articles and not previously found or published before the limit of the search engine was also retrieved and reviewed. Study Selection: There were no exclusion criteria for publishedinformationrelevanttothetopic.Allofthestudies cited in the present review make a point that contributes to the portrayal of this condition. In circumstances in which the same point was made in several different studies, not all were cited herein. Data Extraction: All published material on pneumatosis intestinalis was considered. Information was extracted for preferentially selected ideas and theories supported in multiple studies. Data Synthesis: The collected information was organized by theory. Conclusions: Mucosal integrity, intraluminal pressure, bacterial flora, and intraluminal gas all interact in the formation of pneumatosis intestinalis. Radiography and computed tomography are the best diagnostic tests. Nonoperative management should be pursued in most patients,andunderlyingillnessesshouldbetreated.When acute complications appear, such as perforation, peritonitis, and necrotic bowel, surgery is indicated.

Breast cancer in pregnancy: a literature review.

Abstract: Hypothesis Breast cancer in pregnancy will increase as more women postpone childbearing until later in life. Objective To review the literature on diagnosis, staging, treatment, and prognosis. Design and Methods Articles were obtained from MEDLINE (1966-present) using the keywords breast, cancer, carcinoma , and pregnancy . Additional articles were sought using the references of those obtained. A total of 171 articles were found, 125 in English. More than 100 were reviewed, including 7 prospective and 40 retrospective studies, 6 case reports, and at least 47 review articles on various aspects of pregnancy and cancer. Data extraction was performed by 1 reviewer. Results Diagnostic delays are shorter than in the past but remain common. Mammography has a high false-negative rate during pregnancy. Biopsy or needle aspiration are needed for diagnosis and cannot be postponed until after delivery. Pregnancy-associated cancers tend to occur at a later stage and be estrogen receptor–negative. However, they carry a similar prognosis to other breast cancers when matched for stage and age. Although modified radical mastectomy is the traditional treatment, breast-conserving therapy is increasingly common. Therapeutic radiation is contraindicated, but chemotherapy is relatively safe after the first trimester. Tamoxifen should be avoided in the first trimester and possibly beyond. Conclusions Physicians should perform a thorough breast examination at the first prenatal visit and maintain a high index of suspicion for cancer. Patients who wish to continue their pregnancies have a growing array of treatment options.

Laparoscopic liver resection for subcapsular hepatocellular carcinoma complicating chronic liver disease.

Abstract: Hypothesis Laparoscopic liver resection for subcapsular hepatocellular carcinoma in patients with chronic liver disease is associated with lower morbidity than open resections. Design A case-comparison study. Setting A tertiary referral center. Patients and intervention From December 1, 1998, to November 30, 2000, 13 patients with chronic liver disease who underwent laparoscopic resection of hepatocellular carcinoma formed the laparoscopic group (LG). Tumors were 5 cm or smaller, subcapsular, and located in anterolateral segments (segments II-VI). A control group was created by matching each laparoscopic case with patients identical for liver disease, tumor size, and location and type of hepatectomy who underwent open liver resection. Fourteen patients fulfilled the criteria and formed the open group (OG). Main outcome measures Postoperative mortality and morbidity. Results One segment or less was resected in 21 patients and 2 in 6 patients. Operative duration and cumulative portal triad clamping times were longer in the LG (267 +/- 79 minutes vs 182 +/- 57 minutes, P =.006; 68 +/- 24 minutes vs 25 +/- 19 minutes, P =.006, respectively). Mortality rates were 0% in the LG and 14% (2/14) in the OG (P =.2). Postoperative liver failure and ascites occurred in 8% (1/13) in the LG and 36% (5/14) in the OG (P =.15). Surgical margin was not different in the 2 groups. Three-year survival was significantly higher in the LG (89% vs 55%; P =.04), but 3-year recurrence rates were similar (46% vs 44%). Conclusion Our study suggests that, despite longer operative and clamping times without clinical consequences, the rate of decompensation of liver disease could be lower after laparoscopy.

Improved outcome after extended gastric myotomy for achalasia.

Abstract: Hypothesis There is general agreement that a Heller myotomy should extend 6 to 7 cm above the gastroesophageal junction. Results of most previous studies have recommended that the myotomy extend 1 to 1.5 cm below the gastroesophageal junction. We speculated that the effectiveness of the operation could be improved if a longer, 3-cm myotomy was carried out below the gastroesophageal junction, as it would more completely obliterate the lower esophageal sphincter. We, therefore, changed our technique in 1998. Concurrently, we converted from a Dor fundoplication to a Toupet fundoplication. This study analyzes the results of our new strategy. Design A case series using a prospectively maintained database. Setting Tertiary referral center. Patients One hundred ten consecutive patients with achalasia undergoing laparoscopic Heller myotomy. Intervention We analyzed the course of 52 patients treated with a standard laparoscopic esophagogastric myotomy (1.5 cm in the stomach) and a Dor fundoplication between September 1, 1994, and August 31, 1998, and 58 treated with an extended gastric myotomy (3 cm below the gastroesophageal junction) and a Toupet fundoplication between September 1, 1998, and August 31, 2001. Main Outcome Measures Esophageal function testing (esophageal manometry and 24-hour pH monitoring), symptom questionnaire (frequency and severity), and postoperative interventions required. Results Postoperatively the lower esophageal sphincter pressure was significantly lower after extended gastric myotomy and a Toupet fundoplication vs standard myotomy and a Dor fundoplication (9.5 vs 15.8 mm Hg). Dysphagia was both less frequent (1.2 vs 2.1) and less severe (visual analog scale, 3.2 vs 5.3) after extended gastric myotomy and Toupet fundoplication. In the standard laparoscopic esophagogastric myotomy and a Dor fundoplication group, 9 patients (17%) had recurrent, severe dysphagia, which was treated by dilation in 5 patients and by reoperation in 4 patients. In the extended gastric myotomy and Toupet fundoplication group, 2 patients (3%) developed recurrent dysphagia that resolved with dilatation. There were no reoperations in the extended gastric myotomy and Toupet fundoplication group. No difference was noted in the frequency of heartburn (1.3 vs 1.7), regurgitation (0.3 vs 0.8), and chest pain (0.3 vs 0.6), nor was there a difference between the 2 groups in proximal (1.7% vs 2.3%) and distal (6.0% vs 5.9%) esophageal acid exposure. Conclusion An extended gastric myotomy (3 cm) more effectively disrupts the lower esophageal sphincter, thus improving the results of surgical therapy for achalasia for dysphagia without increasing the rate of abnormal gastroesophageal reflux provided that a Toupet fundoplication is added.

Roles for ghrelin in the regulation of appetite and body weight.

Abstract: Obesity is a global epidemic that has proven daunting to prevent and treat. The prevalences of obesity (body mass index [BMI] >30) and morbid obesity (BMI >40) among American adults are about 30% and 5%, respectively. 1 Obesity is so strongly associated with medical comorbidities and mortality that it has begun to overtake infectious diseases as the most significant contributor to ill health worldwide. 2,3 Overweight persons are also frequently stigmatized and consequently suffer from low self-esteem. Their motivation to achieve and maintain weight loss is often Herculean. In 1 study of 47 patients who had durably lost 45 kg or more after bariatric surgery, 100% preferred to be deaf, dyslexic, diabetic, or have heart disease rather than be obese again; leg amputation and blindness were preferred by 91.5% and 89.4%, respectively. 4 The traditional treatment paradigm of diet, exercise, and medication generally achieves no more than a 5% to 10% reduction in body weight, 5,6 and recidivism after such weight loss exceeds 90% within 5 years. 7,8 This failure arises because a robust homeostatic system of body weight regulation compensates for weight loss with increased hunger and decreased energy expenditure. 9-11 The molecular mediators of these compensatory responses to weight loss are potential targets for antiobesity treatments. Ghrelin is a potent orexigenic (appetite-stimulating) peptide that seems to participate in the adaptive response to weight loss. Therefore, ghrelin holds promise as a target for both medical and surgical approaches to obesity.

Relapse and Morbidity in Patients Undergoing Sentinel Lymph Node Biopsy Alone or With Axillary Dissection for Breast Cancer

Abstract: Hypothesis Axillary relapse in node-negative patients staged with sentinel lymph node (SLN) biopsy alone is no more frequent than in patients treated with standard axillary dissection. Morbidity is less for patients who had SLN biopsy. Design, Setting, and Patients Between October 14, 1997, and August 31, 2001, 1253 consecutive women with primary invasive breast cancer were prospectively entered into an SLN biopsy database. Completion axillary dissection was performed in 164 patients after SLN biopsy as part of a training protocol. Interventions Patients were contacted by questionnaire or telephone to determine breast cancer relapse; presence of arm lymphedema, arm pain, axillary infection, or seroma formation; and tumor recurrence or death. Main Outcome Measures χ 2 or Fisher exact tests and Wilcoxon rank sum tests were used to analyze categorical and continuous variables. Logistic regression was used to analyze morbidity. Results Of 1253 women, 894 (71%) were node negative by SLN biopsy alone (n = 730 [82%]) or SLN biopsy and completion axillary dissection (n = 164 [18%]). Questionnaires were completed by 776 patients (87%). Mean ± SD follow-up was 2.4 ± 0.9 years. Patients with axillary dissections reported a significantly higher occurrence of arm lymphedema (34%), arm pain (38%), seroma formation (24%), and infection (9%) vs SLN biopsy–only patients (6%, 14%, 7%, and 3%, respectively). One axillary relapse (0.1%) occurred during follow-up of 685 women who underwent SLN biopsy only. Conclusions With intermediate-term follow-up, there was 1 axillary recurrence in 685 SLN node-negative women, supporting use of SLN biopsy as an accurate method for staging breast cancer. Biopsy of the SLN was associated with significantly less morbidity than completion axillary dissection.

Risk Factors for Postoperative Infectious Complications in Noncolorectal Abdominal Surgery A Multivariate Analysis Based on a Prospective Multicenter Study of 4718 Patients

Abstract: Hypothesis Infectious complications are the main causes of postoperative morbidity in abdominal surgery. Identification of risk factors, which could be avoided in the perioperative period, may reduce the rate of postoperative infectious complications. Design A database was established from 3 prospective, randomized, multicenter studies. Multivariate analysis was performed using nonconditional logistic regression expressed as an odds ratio (OR). Setting Multicenter studies (ie, private medical centers, institutional hospitals, and university hospitals). Patients From June 1982 to September 1996, a database was established containing the information of 4718 patients who underwent noncolorectal abdominal surgery. Main Outcome Measures The dependent variables studied included surgical site infection (SSI) (divided into parietal and deep infectious complications with or without fistulas) and global infectious complications (SSI and extraparietal and abdominal infectious complications). Results The rate of global infectious complications was 13.3%; SSI, 4.05%; parietal infectious complications, 2.2%; deep infectious complications with fistulas, 2.18%; and deep infectious complications without fistulas, 1.38%. In multivariate analysis, the following 7 independent risk factors for global infectious complications have been identified: age (60-74 years, OR, 1.64; ≥75 years, OR, 1.45); being underweight (OR, 1.51); having cirrhosis (OR, 2.45), having a vertical abdominal incision (OR, 1.66); having a suture placed or an anastomis of the bowel (OR, 1.48) in the digestive tract; having a prolonged operative time (61-120 minutes, OR, 1.66; 121 minutes, OR, 2.72); and being categorized as having a class 4 surgical site (ie, obese patients or having a risk factor of a healing defect) (OR, 1.66). Ceftriaxone sodium therapy was identified as a protective factor (OR, 0.43). In multivariate analysis, the following 5 independent risk factors for SSI have been identified: the existence of a preoperative cutaneous abscess or cutaneous necrosis (OR, 4.75), having a suture placed or an anastomosis of the bowel (OR, 1.82) in the digestive tract, having postoperative abdominal drainage (OR, 2.15), undergoing a surgicial procedure for the treatment of cancer (OR, 1.74), and receiving curative anticoagulant therapy (OR, 3.33) postoperatively. Conclusions Our data show that risk factors for SSI and for global infectious complications are disparate. Indeed, only the placement of a suture or having an anastomosis of the bowel in the digestive tract is a risk factor for both SSI and global infections. Some of these factors may be modifiable before or during the surgical procedure to reduce the infection rate or to prevent postoperative complications.

Nonoperative treatment of blunt injury to solid abdominal organs: A prospective study

Abstract: Hypothesis Nonoperative management (nom) of injuries to the liver, spleen, and kidney is highly successful, as shown in retrospective studies, but needs prospective validation. patients in whom nom is likely to fail can be identified by specific criteria. Design Prospective observational study. Setting Academic level i trauma center at a county hospital. Patients Two hundred six patients with injuries to the liver (n = 99), spleen (n = 103), and/or kidney (n = 40). Main outcome measures Failure of nom. Results Fifty-seven patients (28%) underwent immediate operation; among the other 149, nom failed in 33 (22%). the rate of failure for spleen injury (34%) was higher than for liver (17%) or kidney injury (18%) ( P P P P P P = .08). we identified the following 4 independent risk factors of failure by means of stepwise logistic regression: nonliver (splenic or renal) injury, positive abdominal ultrasonography findings, amount of free fluid on ct of greater than 300 ml, and need for blood transfusion. according to a statistical model, the presence of all 4 independent risk factors predicted nom failure in 96% of the patients, and the absence of all predicted success in 98%. Conclusions In a prospective study, the rate of nom failure for solid abdominal organ injuries is higher than the rates reported in retrospective studies. nonoperative management is less likely to fail in liver injuries than in splenic or kidney injuries. use of nom should be exercised with caution if blood transfusion is needed, fluid is identified on the screening ultrasonogram, or a significant quantity of blood is discovered on ct.

Hepatic Resection in the United States: Indications, Outcomes, and Hospital Procedural Volumes From a Nationally Representative Database

Abstract: secondary metastases (52%), primary hepatic malignancy (16%), biliary tract malignancy (10%), and benign hepatic tumor (5%). High-volume hospitals had a mortality rate of 3.9% vs 7.6% at low-volume hospitals (P.001). In the multivariate analysis adjusting for patient case-mix, high-volume hospitals had a 40% lower risk of in-hospital mortality compared with low-volume hospitals(oddsratio,0.60;95%confidenceinterval,0.390.92; P=.02). Other predictors of mortality in the multivariate analysis included age older than 65 years, hepatic lobectomy (vs wedge resection), primary hepatic malignancy (vs metastases), and the severity of underlying liver disease. Conclusions: Hospital procedural volume is an important predictor of mortality after hepatic resection. Patients who require resection of primary and secondary liver tumors should be offered referral to a high-volume center.

Laparoscopic vs Open Colectomy: Outcomes Comparison Based on Large Nationwide Databases

Abstract: Hypothesis Laparoscopic colectomy has significant advantages over open colectomy in the treatment of diverticular disease with respect to the length of hospital stay, routine hospital discharge, and postoperative morbidity and mortality. Design Retrospective secondary data analysis. Patients and Setting Patients with primary International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes for laparoscopic (709 patients [3.8%]) and open sigmoid resection (17 735 patients [96.2%]) were selected from the 1998, 1999, and 2000 Nationwide Inpatient Samples. These databases represent 20% stratified probability samples of all US community hospital discharges. Sampling weights were used to allow generalization of the study findings to the overall US population. Multiple linear and logistic regression analyses were performed to assess the risk-adjusted association between the surgery type and patient outcomes. Main Outcome Measures Length of hospital stay, in-hospital complications, in-hospital mortality, and the rate of routine discharge. Results The patients had a mean age of 59.8 years; they were preponderantly white (89.1%) and female (54.0%). After adjusting for other covariates, laparoscopic sigmoidectomy was associated with a shorter mean hospital stay (laparoscopic sigmoidectomy vs open sigmoidectomy, 7.47 vs 9.37 days; P P = .03), a lower overall complication rate (odds ratio, 0.64; 95% confidence interval, 0.47-0.88; P = .007), and a higher routine hospital discharge rate (odds ratio, 2.21; 95% confidence interval, 1.51-3.21; P Conclusion Laparoscopic sigmoid resection in patients with diverticular disease has statistically and clinically significant advantages over open sigmoid resection with respect to the length of hospital stay, rate of routine hospital discharge, and postoperative in-hospital morbidity.

Differential diagnosis, investigation, and current treatment of lower limb lymphedema

Abstract: Hypothesis The causes and management of lower limb lymphedema in the Western population are different from those in the developing world. Objective To look at the differential diagnosis, methods of investigation, and available treatments for lower limb lymphedema in the West. Data Source A PubMed search was conducted for the years 1980-2002 with the keyword "lymphedema." English language and human subject abstracts only were analyzed, and only those articles dealing with lower limb lymphedema were further reviewed. Other articles were extracted from cross-referencing. Results Four hundred twenty-five review articles pertaining to lymphedema were initially examined. This review summarizes the findings of relevant articles along with our own practice regarding the management of lymphedema. Conclusions The common differential diagnosis in Western patients with lower limb swelling is secondary lymphedema, venous disease, lipedema, and adverse reaction to ipsilateral limb surgery. Lymphedema can be confirmed by a lymphoscintigram, computed tomography, magnetic resonance imaging, or ultrasound. The lymphatic anatomy is demonstrated with lymphoscintigraphy, which is particularly indicated if surgical intervention is being considered. The treatment of choice for lymphedema is multidisciplinary. In the first instance, combined physical therapy should be commenced (complete decongestive therapy), with surgery reserved for a small number of cases.

Multiple endocrine neoplasia type 2: evaluation of the genotype-phenotype relationship.

Abstract: Hypothesis Multiple endocrine neoplasia type 2 (MEN 2) is caused by RET proto-oncogene mutations and has a strong penetrance for medullary thyroid carcinoma (MTC). Subtypes are defined by the presence or absence of pheochromocytomas, hyperparathyroidism, and characteristic clinical stigmas. We hypothesize that specific RET mutations correlate with the MEN 2 phenotype and aggressiveness of MTC. Design Review of endocrine surgery database from 1951 through 2002. Setting Tertiary referral center. Patients Eighty-six patients from 47 kindreds were identified with MEN 2A, MEN 2B, or familial MTC. Patients were classified into 3 RET mutation risk groups: level 1, low risk for MTC (codons 609, 768, 790, 791, 804, and 891); level 2, intermediate risk (codons 611, 618, 620, and 634); and level 3, highest risk (codons 883 and 918). Main Outcome Measures Stage of MTC at diagnosis and at last follow-up and frequency of pheochromocytomas and hyperparathyroidism. Results RET analysis was complete for 71 patients from 39 kindreds. Multivariate analysis identified an increased likelihood of stage III or IV MTC at diagnosis with increasing age (odds ratio, 1.12 per year of age at thyroidectomy; 95% confidence interval, 1.07-1.17; P P Conclusion Specific RET mutations predict the phenotypic expression of disease and the MTC aggressiveness in patients with MEN 2, guiding the timing of thyroidectomy and screening for pheochromocytoma.

Morbidity and mortality of aggressive resection in patients with advanced neuroendocrine tumors

Abstract: Background There is considerable controversy about the treatment of patients with malignant advanced neuroendocrine tumors of the pancreas and duodenum. aggressive surgery remains a potentially efficacious antitumor therapy but is rarely performed because of its possible morbidity and mortality. Hypothesis Aggressive resection of advanced neuroendocrine tumors can be performed with acceptable morbidity and mortality rates and may lead to extended survival. Design The medical records of patients with advanced neuroendocrine tumors who underwent surgery between 1997 and 2002 by a single surgeon at the university of california, san francisco, were reviewed in an institutional review board–approved protocol. Main outcome measures Surgical procedure, pathologic characteristics, complications, mortality rates, and disease-free and overall survival rates were recorded. disease-free survival was defined as no tumor identified on radiological imaging studies and no detectable abnormal hormone levels. proportions were compared statistically using the fisher exact test. kaplan-meier curves were used to estimate survival rates. Results Twenty patients were identified (11 men and 9 women). of these, 10 (50%) had gastrinoma, 1 had insulinoma, and the remainder had nonfunctional tumors; 2 had multiple endocrine neoplasia type 1, and 1 had von hippel-lindau disease. the mean age was 55 years (range, 34-72 years). in 10 patients (50%), tumors were thought to be unresectable according to radiological imaging studies because of multiple bilobar liver metastases (n = 6), superior mesenteric vein invasion (n = 3), and extensive nodal metastases (n = 1). tumors were completely removed in 15 patients (75%). surgical procedures included 8 proximal pancreatectomies (pancreatoduodenectomy or whipple procedure), 3 total pancreatectomies, 9 distal pancreatectomies, and 3 tumor enucleations from the pancreatic head. superior mesenteric vein reconstruction was done in 3 patients. liver resections were done in 6 patients, and an extended periaortic node dissection was performed in 1. the spleen was removed in 11 patients, and the left kidney was removed as a result of tumor metastases in 2. eighteen patients had primary pancreatic tumors, and 2 had duodenal tumors; 2 patients with multiple endocrine neoplasia type 1 had both pancreatic and duodenal tumors. the mean tumor size was 8 cm (range, 0.5-23 cm). of the patients, 14 (70%) had lymph node metastases and 8 (40%) had liver metastases. the mean postoperative hospital stay was 11.5 days (range, 6-26 days). six patients (30%) had postoperative complications. there was a significantly greater incidence of pancreatic fistulas with enucleations compared with resections (P= .04). there were no operative deaths. the mean follow-up period was 19 months (range, 1-96 months); 18 patients (90%) are alive, 2 died of progressive tumor, and 12 (60%) are disease-free. the actuarial overall survival rate is 80% at 5 years, and disease-free survival rates indicate that all tumors will recur by the 7-year follow-up visit. Conclusions Aggressive surgery including pancreatectomy, splenectomy, superior mesenteric vein reconstruction, and liver resection can be done with acceptable morbidity and low mortality rates for patients with advanced neuroendocrine tumors. although survival rates following surgery are excellent, most patients will develop a recurrent tumor. these findings suggest that conventional contraindications to surgical resection, such as superior mesenteric vein invasion and nodal or distant metastases, should be reconsidered in patients with advanced neuroendocrine tumors.

Prevalence and predictors of asymptomatic liver disease in patients undergoing gastric bypass surgery.

Abstract: Background Nonalcoholic steatohepatitis (NASH) is a form of fatty liver disease that is increasingly recognized. There are limited data on the prevalence of NASH and the role of risk factors for NASH among the morbidly obese. Hypothesis The prevalence of asymptomatic NASH among morbidly obese patients undergoing gastric bypass surgery is high, and there are identifiable risk factors for NASH. Design Prospective case study. Setting University hospital. Patients Forty-eight consecutive patients undergoing gastric bypass surgery who had a concurrent open liver biopsy. Exclusion criteria included current consumption of more than 2 alcohol beverages monthly and known cirrhosis. A hepatopathologist blinded to clinical data reviewed biopsy specimens. Main Outcome Measures The presence of NASH or severe fibrosis, preoperative body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters), fasting triglyceride level, and presence of type 2 diabetes mellitus (DM). Results Patients (mean ± SD age, 42 ± 10 years; 33 women) had an initial mean BMI of 59.9 ± 12. Thirty-one patients (65%) had moderate to severe steatosis. Only 6 (12%) had advanced fibrosis. Sixteen (33%) had evidence of NASH. There was no difference in mean age, sex, BMI, or fasting triglyceride level between patients with and without NASH or advanced fibrosis. The odds of NASH were 128 times greater (95% confidence interval [CI], 5.2-3137.0) and the odds of severe fibrosis 75 times greater (95% CI, 4.5-1247.0) in patients with DM than in those without DM. Preoperative BMI was not independently associated with NASH (odds ratio, 1.01; 95% CI, 0.9-1.1) or severe fibrosis (odds ratio, 0.9; 95% CI, 0.86-1.02) after adjustment for DM. Conclusions Moderate to severe hepatic steatosis and NASH are common among individuals undergoing gastric bypass procedures. Diabetes mellitus but not BMI is associated with NASH and advanced hepatic fibrosis in these patients.

Factors predicting survival after intraperitoneal hyperthermic chemotherapy with mitomycin C after cytoreductive surgery for patients with peritoneal carcinomatosis.

Abstract: Hypothesis Certain clinicopathologic factors predict improved survival after cytoreductive surgery and intraperitoneal hyperthermic chemotherapy for peritoneal carcinomatosis Design Prospective clinical trial Setting Surgical oncology service at a university academic hospital Patients A population of 109 consecutive patients with peritoneal carcinomatosis treated between December 1991 and November 1997 Intervention All patients underwent resection of gross disease followed by 2-hour intraoperative perfusion of mitomycin C (20-40 mg) into the peritoneal cavity at a temperature of 405°C Main Outcome Measures Clinicopathologic factors that independently predicted improved overall survival rates Results Overall survival at 1 and 3 years was 61% and 33%, respectively With median follow-up of 52 months, median overall survival was 16 months Four factors were significant independent predictors of improved survival by multivariate analysis: nonadenocarcinoma histologic features ( P = 001), the appendix as a primary site ( P = 003), the absence of hepatic parenchymal metastases ( P = 01), and complete resection of all gross disease (R1/0 resection) ( P P Conclusions Patients with peritoneal carcinomatosis have a uniformly poor prognosis However, in select patients, the natural history of this disease condition may be altered by using the multimodality approach of cytoreductive surgery and intraperitoneal hyperthermic chemotherapy These results require confirmation in prospective randomized studies

High success with nonoperative management of blunt hepatic trauma: the liver is a sturdy organ.

Abstract: Hypothesis Nonoperative management of liver injuries (NOMLI) is highly successful and rarely leads to adverse events. Design Prospective observational study. Setting High-volume academic level I trauma center. Patients For 26 months, 78 consecutive unselected patients with liver injuries were followed up prospectively. In the absence of hemodynamic instability or signs of hollow visceral trauma, NOMLI was offered irrespective of the magnitude of the liver injury. Main Outcome Measure Failure of NOMLI, defined as a laparotomy after an initial decision to treat the patient nonoperatively. Results Of the 78 patients, 23 (29%) were operated on immediately, but only 12 (15%) for bleeding from the liver. All 12 patients required packing in addition to other maneuvers (hepatorrhaphy [n = 8], resection [n = 4], and liver isolation [n = 1]). Of the remaining 55 patients selected for NOMLI, the method failed in 8 for reasons unrelated to the liver injury: 2 underwent a splenectomy, 1 underwent a nephrectomy, 1 had a small-bowel repair, 1 underwent abdominal decompression for abdominal compartment syndrome, and 3 underwent a nontherapeutic laparotomy. The success rate of NOMLI was 85% (47 of 55 patients), but the liver-specific success rate was 100%. Compared with those in whom NOMLI was successful, patients in whom it failed had a higher Injury Severity Score and underwent more blood transfusions, but they had similar liver injury grades. In total, 66 (85%) of liver injuries did not bleed significantly. No adverse events were attributed to NOMLI. Conclusions Nonoperative management of liver injuries is safe and effective regardless of the grade of liver injury. Failure of NOMLI is caused by associated abdominal injuries and not the liver. Fluid and blood requirements, the degree of injury severity, and the presence of other abdominal organ injuries may help predict failure.

Axillary dissection is not required for all patients with breast cancer and positive sentinel nodes.

Abstract: Hypothesis Sentinel node (SN) biopsy for breast cancer enhances staging sensitivity, often demonstrating only micrometastases ( Design Prospective cohort study, median 32-month follow-up. Setting Multidisciplinary breast cancer centers. Patients Forty-six women having SN metastases diagnosed between May 1, 1996, and September 1, 2001, who refused ALND or were recommended to omit ALND owing to serious comorbid conditions. Interventions Isosulfan blue dye–directed SN biopsy. Axillary lymph node dissection was not performed. Standard breast irradiation was given. Adjuvant systemic therapy was provided as determined by an oncologist. Interval clinical evaluation was performed. Main Outcome Measure Axillary and systemic failure rates. Results Mean patient age was 61.6 years (age range, 36-92 years). Mean tumor size was 1.65 cm (range, 0.4-5.5 cm). Thirty-five (76%) of 46 tumors were ductal carcinomas and 39 (87%) of 45 were estrogen receptor–positive. A mean of 2.6 SNs were identified (median, 2; range, 1-7). Thirty-nine patients (85%) had a single positive SN; the remaining 7 patients (15%) had 2 positive SNs. Seven patients (15%) had macrometastases (>2 mm); 16 (35%) had micrometastases ( Conclusions Patients with SN metastases who did not have ALND had a low incidence of regional failure. To confirm this observation, we suggest that patients with SN metastases are ideal candidates for trials evaluating the necessity of ALND.

Surgical Treatment of Appendiceal Mucocele

Abstract: Hypothesis Clinical presentation of appendiceal mucocele is related to malignancy and can influence surgical approach. Design Retrospective study. Setting Tertiary referral center. Patients All cases of primary appendiceal mucoceles (simple mucocele, cystadenoma, cystadenocarcinoma) diagnosed between 1976 and 2000 were reviewed. There were 135 patients, 74 of whom were female. Mean age at diagnosis was 59 years. Mean follow-up was more than 6 years. Interventions A total of 129 patients underwent surgery, consisting of appendectomy (22 patients), right hemicolectomy (25 patients), or more extensive procedures (82 patients). Main Outcome Measures Clinical, diagnostic, and surgical variables were statistically compared with postoperative morbidity and mortality and the presence of malignancy. P Results The presence of symptoms was associated with malignancy (58% vs 15%, P P = .005) and weight loss (77% vs 31%, P = .002). Abdominal mass was also associated with malignancy (86% vs 25%, P P P P Conclusions A number of clinical, diagnostic, and intraoperative findings are associated with malignant mucoceles. All mucoceles greater than 2 cm should be excised to remove premalignant lesions.

Gastrojejunostomy during laparoscopic gastric bypass: analysis of 3 techniques.

Abstract: Hypothesis Although perceived as a more technically demanding and time-consuming technique, the hand-sewn gastrojejunostomy during laparoscopic Roux-en-Y gastric bypass (RYGB) is associated with fewer complications and lower costs than stapled techniques. Design A retrospective medical record review of prospectively collected data. Setting University hospital. Patients One hundred eight consecutive patients undergoing laparoscopic RYGB between January 1, 1999, and December 31, 2001. Intervention Three techniques were compared: hand-sewn anastomosis (HSA), circular-stapled anastomosis (CSA), and linear-stapled anastomosis (LSA). Main Outcome Measures Operative costs, including the cost of stapling devices, the cost of sutures, and operative times, were compared. Rates of anastomotic strictures, leaks, marginal ulcers, bleeding, and wound infections were determined. Results Eighty-seven patients underwent HSA; 13, CSA; and 8, LSA. Supply costs per patient were higher for CSA ($955) and LSA ($435) than for HSA ($2) ( P P P P Conclusions In this experience, hand-sewn gastrojejunostomy during laparoscopic RYGB reduced operating room supply costs and was completed faster than stapled techniques. However, these differences may reflect the learning curve because these techniques were used early in our experience. Lower postoperative stricture and wound infection rates seem to be the primary benefits of the HSA technique.

Predictors of complication and suboptimal weight loss after laparoscopic Roux-en-Y gastric bypass: a series of 188 patients.

Abstract: Hypothesis An analysis of patients undergoing laparoscopic Roux-en-Y gastric bypass (RYGB) may identify factors predictive of complication and of suboptimal weight loss. Design Inception cohort. Setting Metropolitan university hospital. Patients One hundred eighty-eight consecutive patients with severe obesity who met National Institutes of Health consensus guidelines for bariatric surgery. Interventions Laparoscopic RYGB. Main Outcome Measures Complications requiring therapeutic intervention and percentage of excess body weight lost at 1 year after surgery. Results Of the 188 patients who underwent laparoscopic RYGB, 50 (26.6%) developed complications that required an invasive therapeutic intervention, including 2 deaths. The average follow-up was 351 days (range, 89-1019 days). Multivariate analysis by stepwise logistic regression identified surgeon experience, sleep apnea ( P = .003; odds ratio, 3.0; 95% confidence interval, 1.3-7.1), and hypertension ( P = .07; odds ratio, 2.0; 95% confidence interval, 1.0-4.0) as predictors of complications. The most common complication requiring therapeutic intervention was stricture at the gastrojejunal anastomosis, occurring in 27 patients (14.4%). Of the 115 patients who underwent surgery more than 1 year previously, 1-year follow-up data were available for 93 (81%). The body mass index (weight in kilograms divided by the square of height in meters) decreased from 53 ± 8 preoperatively to 35 ± 6 at 1 year. The mean ± SD percentage of excess body weight lost at 1 year was 61% ± 14%. Diabetes mellitus was negatively correlated with percentage of excess body weight lost at 1 year ( P = .06). Conclusions Surgeon experience, sleep apnea, and hypertension are associated with complications after laparoscopic RYGB. Diabetes mellitus may be associated with poorer postoperative weight loss.

Utility of tumor markers in determining resectability of pancreatic cancer.

Abstract: Hypothesis: Despite advances in preoperative radiologic imaging, a significant fraction of potentially resectable pancreatic cancers are found to be unresectable at laparotomy. We tested the hypothesis that preoperative serum levels of CA19-9 (cancer antigen) and carcinoembryonic antigen will identify patients with unresectable pancreatic cancer despite radiologic staging demonstrating resectable disease. Design and Setting: Academic tertiary care referral center. Patients: From March 1, 1996, to July 31, 2002, 125 patients were identified who underwent surgical exploration for potentially resectable pancreatic cancer based on a preoperative computed tomographic scan; in 89 of them a preoperative tumor marker had been measured. Main Outcome Measures: Preoperative tumor markers (CA19-9 and carcinoembryonic antigen) were correlated with extent of disease at exploration. As CA19-9 is excreted in the biliary system, CA19-9 adjusted for the degree of hyperbilirubinemia was determined and analyzed. Results: Of the 89 patients, 40 (45%) had localized disease and underwent resection, 25 (28%) had locally advanced (unresectable) disease, and 24 (27%) had metastatic disease. The mean adjusted CA19-9 level was significantly lower in those with localized disease than those with locally advanced (63 vs 592; P=.003) or metastatic (63 vs 1387; P<.001) disease. When a threshold adjusted CA19-9 level of 150 was used, the positive predictive value for determination of unresectable disease was 88%. Carcinoembryonic antigen level was not correlated with extent of disease. Conclusions: Among the patients with resectable pancreatic cancer based on preoperative imaging studies, those with abnormally high serum levels of CA19-9 may have unresectable disease. These patients may benefit from additional staging modalities such as diagnostic laparoscopy to avoid unnecessary laparotomy.

Hyperbaric oxygen for treating wounds: a systematic review of the literature.

Abstract: Objective To determine whether hyperbaric oxygen (HBO) therapy is an effective adjunct treatment for hypoxic wounds. Methods We identified studies from technology assessment reports on HBO and a MEDLINE search from mid-1998 to August 2001. We accepted randomized controlled trials (RCTs), cohorts, and case series that reported original data, included at least 5 patients, evaluated the use of HBO for wound care, and reported clinical outcomes. Demographics, wound conditions, HBO regimen, adverse events, and major clinical outcomes were extracted from each study. Results Fifty-seven studies, 7 RCTs, 16 nonrandomized studies, and 34 case series involving more than 2000 patients are included in this review. None of the studies used wound tissue hypoxia as a patient inclusion criterion. The study results suggest that HBO may be beneficial as an adjunctive therapy for chronic nonhealing diabetic wounds, compromised skin grafts, osteoradionecrosis, soft tissue radionecrosis, and gas gangrene compared with standard wound care alone. Serious adverse events associated with HBO include seizures and pressure-related traumas, such as pneumothorax. A few deaths in the studies were associated with these adverse events. Conclusions The overall study quality is poor, with inadequate or no controls in most studies. The studies suggest that HBO may be helpful for some wounds, but there is insufficient evidence to ascertain the appropriate time to initiate therapy and to establish criteria that determine whether patients will benefit. Serious adverse events may occur. High-quality RCTs that evaluate the short- and long-term risks and benefits of HBO are necessary to better inform clinical decisions.