Showing papers in "Archives of Surgery in 2008"

Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication

Abstract: Objective To assess whether structured team briefings improve operating room communication. Design, Setting, and Participants This 13-month prospective study used a preintervention/postintervention design. All staff and trainees in the division of general surgery at a Canadian academic tertiary care hospital were invited to participate. Participants included 11 general surgeons, 24 surgical trainees, 41 operating room nurses, 28 anesthesiologists, and 24 anesthesia trainees. Intervention Surgeons, nurses, and anesthesiologists gathered before 302 patient procedures for a short team briefing structured by a checklist. Main Outcome Measure The primary outcome measure was the number of communication failures (late, inaccurate, unresolved, or exclusive communication) per procedure. Communication failures and their consequences were documented by 1 of 4 trained observers using a validated observational scale. Secondary outcomes were the number of checklist briefings that demonstrated “utility” (an effect on the knowledge or actions of the team) and participants' perceptions of the briefing experience. Results One hundred seventy-two procedures were observed (86 preintervention, 86 postintervention). The mean (SD) number of communication failures per procedure declined from 3.95 (3.20) before the intervention to 1.31 (1.53) after the intervention ( P Conclusions Interprofessional checklist briefings reduced the number of communication failures and promoted proactive and collaborative team communication.

Race and insurance status as risk factors for trauma mortality.

Abstract: Race and insurance status each independently predicts outcome disparities after trauma. African American, Hispanic, and uninsured patients have worse outcomes, but insurance status appears to have the stronger association with mortality after trauma.

Protective effects of epidural analgesia on pulmonary complications after abdominal and thoracic surgery: a meta-analysis.

Abstract: Objective To review the impact of epidural vs systemic analgesia on postoperative pulmonary complications. Data Sources Search of databases (1966 to March 2006) and bibliographies. Study Selection Inclusion criteria were randomized comparison of epidural vs systemic analgesia lasting 24 hours or longer postoperatively and reporting of pulmonary complications, lung function, or gas exchange. Fifty-eight trials (5904 patients) were included. Data Extraction Articles were reviewed and data extracted. Data were combined using fixed-effect and random-effects models. Data Synthesis The odds of pneumonia were decreased with epidural analgesia (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.43-0.68), independent of site of surgery or catheter insertion, duration of analgesia, or regimen. The effect was weaker in trials that used patient-controlled analgesia in controls (OR, 0.64; 95% CI, 0.49-0.83) compared with trials that did not (OR, 0.30; 95% CI, 0.18-0.49) and in larger studies (OR, 0.62; 95% CI, 0.47-0.81) compared with smaller studies (OR, 0.37; 95% CI, 0.23-0.58). From 1971-2006, the incidence of pneumonia with epidural analgesia remained about 8% but decreased from 34% to 12% with systemic analgesia ( P Conclusion Epidural analgesia protects against pneumonia following abdominal or thoracic surgery, although this beneficial effect has lessened over the last 35 years because of a decrease in the baseline risk.

Influence of resection margins and treatment on survival in patients with pancreatic cancer: Meta-analysis of randomized controlled trials

Abstract: Objective To assess the influence of resection margins and adjuvant chemoradiotherapy or chemotherapy on survival for patients with pancreatic cancer by meta-analysis of individual data from randomized controlled trials. Data Sources Structured MEDLINE search for published studies. Study Selection A meta-analysis of published randomized controlled trials and individual data. Data Extraction Individual data were obtained from 4 recently published trials (875 patients: 278 [32%] with R1 and 591 [68%] with R0 resections). Data Synthesis Kaplan-Meier estimates of survival were compared using log-rank analyses. Pooled hazard ratios of the effects of chemoradiotherapy and chemotherapy treatments on the risk of death were calculated separately and across groups according to resection margins status. Six hundred ninety-eight patients (80%) had died, with a median follow-up of 44 months in the surviving patients. Resection margin involvement was not a significant factor for survival (hazard ratio [HR], 1.10; 95% confidence interval [CI], 0.94-1.29; log-rank χ 2 = 1.4; P = .24). The 2- and 5-year survival rates, respectively, were 33% and 16% for R0 patients and 29% and 15% for R1 patients. Chemoradiotherapy in R1 patients resulted in a 28% reduction in the risk of death (HR, 0.72; 95% CI, 0.47-1.10) compared with a 19% increased risk in R0 patients (HR, 1.19; 95% CI, 0.95-1.49). Chemotherapy in R1 patients had a 4% increased risk of death (HR, 1.04; 95% CI, 0.78-1.40) compared with a 35% reduction in risk in the R0 subgroup (HR, 0.65; 95% CI, 0.53-0.80). Conclusion Adjuvant chemotherapy but not chemoradiotherapy should be the standard of care for patients with either R0 or R1 resections for pancreatic cancer.

Evaluating the degree of difficulty of laparoscopic colorectal surgery.

Abstract: Objective To quantify the degree of overall difficulty and the difficulty of each of the individual steps involved in the performance of laparoscopic colorectal procedures. The data should serve as a guide to surgeons in the early stages of their experience in laparoscopic colorectal surgery as to which procedures and steps to embark on first, to allow them to build experience in a stepwise fashion. Methods A mail-in survey of 35 experienced laparoscopic colorectal surgeons was conducted. Using a scale of 1 to 6, the surgeons were asked to rate the overall degree of difficulty of each of 12 laparoscopic colorectal procedures. Each procedure was then broken down into its key components (exposure, isolation of the vascular pedicle, dissection of the specimen, and anastomosis), and the raters were asked to individually grade each of these components for each intervention. An overall difficulty score was created for each procedure, as well as an individual difficulty score for each step. Results The response rate was 80%, representing a collective experience of approximately 6335 laparoscopic colorectal interventions. On the overall difficulty score, sigmoid colectomy achieved the lowest composite score of 2.0, while reversal of the Hartmann procedure scored the highest at 4.5. Analyzing the individual step complexity rating, mobilization of the splenic flexure scored highest, ahead of rectal mobilization. Vascular dissection scored significantly higher for right colectomy than for sigmoid resection, as did intracorporeal vs extracorporeal anastomosis for right colectomy. Conclusions The learning curve for laparoscopic colorectal surgery is steep. This survey can help surgeons in the early part of this curve in their initial choice of procedure and allow them to build experience in a stepwise manner. This will help to identify achievable goals and develop strategies for reducing operating times and improving patient outcome by selecting appropriate cases at the outset.

Recurrence of Hepatocellular Carcinoma Following Liver Transplantation: A Review of Preoperative and Postoperative Prognostic Indicators

Abstract: Objective To review the preoperative and postoperative variables that predict hepatocellular carcinoma (HCC) recurrence following orthotopic liver transplantation (OLT). Data Sources A collective review of the literature was conducted by searching the MEDLINE database using several key words:hepatocellular carcinoma,recurrence,liver transplantation, andsalvage transplantation. Study Selection Reviews and original articles containing basic scientific observations and long-term clinical outcomes were included. Data Extraction Critical observations from peer-reviewed sources were incorporated in this review. Data Synthesis Overall, 11 studies were reviewed to determine the incidence of HCC recurrence following OLT and to identify prognostic variables of recurrence. Four studies were evaluated to determine the efficacy of salvage transplantation following liver resection. Conclusions Liver transplantation is a viable treatment option for select patients with HCC and end-stage liver disease. However, in approximately 20% of patients, recurrent HCC is the rate-limiting factor for long-term survival. Despite identification of clinical parameters that may stratify patients at high risk and exhaustive preoperative staging, cancer recurrence is likely the result of microscopic extrahepatic disease. With a desperate donor organ shortage, locoregional ablation techniques and resection are being employed in patients on the waiting list to serve as a bridge to OLT. Furthermore, some have advocated aggressive surgical resection of isolated metastasis in both the liver and extrahepatic viscera. Whether these creative strategies confer a survival advantage is unknown; it will require long-term follow-up to determine their efficacy.

Critical appraisal of 232 consecutive distal pancreatectomies with emphasis on risk factors, outcome, and management of the postoperative pancreatic fistula: a 21-year experience at a single institution.

Abstract: Objective To critically analyze a large single-institution experience with distal pancreatectomy (DP), with particular attention to the risk factors, outcome, and management of the postoperative pancreatic fistula (PF). Design Retrospective study. Setting Tertiary referral center. Patients A total of 232 consecutive patients with pancreatic or extrapancreatic disease necessitating DP over 21 years. Interventions Twenty-one patients underwent spleen-preserving DP, 117 underwent DP with splenectomy, and 94 underwent DP with multiorgan resection. Main Outcome Measures The perioperative and postoperative data of patients who underwent DP were analyzed. This included factors associated with postoperative morbidity with particular attention to the PF (defined by the International Study Group of Pancreatic Fistula) and changing trends in operative and perioperative data during the study period. Results The overall operative morbidity and mortality were 47% (107 patients) and 3% (7 patients), respectively. During the study period, the rates of resection increased from 3 cases to 23 per year, and increasingly these were performed for smaller and incidental lesions. The morbidity rate remained unchanged, but there was a decline in postoperative stay and the need for care in the intensive care unit. Pancreatic fistulas occurred in 72 patients (31%); 41 (18%) were grade A, 13 (6%) grade B, and 18 (8%) grade C. Increased weight, higher American Society of Anesthesiologists score, blood loss greater than 1 L, increased operation time, decreased albumin level, and sutured closure of the stump without main duct ligation were associated with a postoperative PF on univariate analysis. A DP with splenectomy was associated with a higher incidence of grade B or C PF and non–PF-related complications. Ninety-two percent of PFs were successfully managed nonoperatively. Clinical outcomes correlated well with PF grading, as evidenced by the progressive increase in outcome measures such as postoperative stay, readmissions, reoperations, radiologic interventions, and non–PF-related complications from grade A to C PFs. Conclusions Pancreatic fistula is the most common complication after DP and its incidence varies depending on the definition applied. Several risk factors for developing a PF were identified. Splenic preservation after DP is safe. The grade of a PF correlates well with clinical outcomes, and most PFs may be managed nonoperatively.

Hypoparathyroidism after total thyroidectomy: a prospective study.

Abstract: Hypothesis Combined measurement of intact parathyroid hormone (iPTH) and serum calcium (sCa) levels is useful for predicting postoperative hypocalcemia with minimal laboratory effort and low costs. Design Prospective analysis of 170 consecutive patients. Setting University hospital referral center. Patients One hundred seventy patients underwent total thyroidectomy. Defining hypoparathyroidism as albumin-adjusted sCa levels of less than 1.9 mmol/L with or without clinical symptoms or subnormal sCa levels (1.9-2.1 mmol/L) with neuromuscular symptoms, the influences of central lymph node dissection, experience of the surgeon, and parathyroid autotransplantation were observed. We measured the sCa and iPTH levels separately and in combination and the postoperative sCa slope to predict patients who were at risk of hypoparathyroidism. Main Outcome Measures Predictive values for iPTH and sCa levels were compared to identify postoperative hypoparathyroidism. Results Of the 170 study patients, 41 developed transient hypoparathyroidism and 2 developed permanent hypoparathyroidism. The morphologic features and function of the thyroid gland, central neck dissection, experience of the surgeon, and parathyroid autotransplantation did not influence development of postoperative hypoparathyroidism. The best sensitivity for predicting postoperative hypoparathyroidism was 97.7% for measurement of iPTH levels, and the best specificity was 96.1% for measurement of sCa levels. Negative and positive predictive values reached their best (99.0% and 86.0%, respectively) when we combined sCa and iPTH values. Conclusions Patients with iPTH levels of 15 pg/mL or less and sCa levels of 1.9 mmol/L or less are at increased risk of developing postoperative hypoparathyroidism. Measuring iPTH levels 24 hours after total thyroidectomy in combination with sCa levels on the second postoperative day allows the prediction of hypoparathyroidism with a high sensitivity, specificity, and positive predictive value.

Experience with 208 resections for intraductal papillary mucinous neoplasm of the pancreas

Abstract: Hypothesis Intraductal papillary mucinous neoplasm (IPMN) is an increasingly recognized disease of the pancreas. We report our experience with pancreatic resection for IPMN. Design Retrospective review from 1992 through 2005 with additional independent histopathologic confirmation. Setting Mayo Clinic Rochester, a tertiary care center. Patients All patients who underwent primary resection for pancreatic IPMN. Main Outcome Measures Disease-specific operative outcomes, survival, and recurrence patterns. Results Of 208 patients (mean age, 66 years) with IPMN of the pancreas, 168 underwent partial pancreatectomy, and 40 underwent total pancreatectomy; 88 were classified as having adenoma, 38 as having borderline neoplasm, 19 as having carcinoma in situ, and 63 as having invasive carcinoma. The prevalence of a malignant neoplasm was 64% in patients with main duct IPMN compared with 18% in patients with branch duct IPMN. Re-resection of the initial pancreatic margin was necessary in 21% of patients. Final negative margins were achieved in 89% of patients. Five-year survival with noninvasive IPMN was 94%. Patients with invasive IPMN had a similar 5-year survival compared with a matched cohort with ductal adenocarcinoma (31% vs 24%;P = .26). In patients with invasive IPMN, 58% experienced disease recurrence. In patients with noninvasive IPMN, 10% experienced disease recurrence after partial pancreatectomy and 0% experienced disease recurrence after total pancreatectomy. Conclusions Patients with main duct IPMN or high-risk branch duct IPMN should be considered for targeted pancreatectomy. Invasive IPMN behaves as aggressively as ductal adenocarcinoma, but resection seems to provide the only potential for cure. Even with negative resection margins, the pancreatic remnant harbors a risk of recurrence and, thus, careful long-term surveillance is warranted.

Undertriage of Elderly Trauma Patients to State-Designated Trauma Centers

Abstract: Objective To determine whether age bias is a factor in triage errors. Design Retrospective analysis of 10 years (1995-2004) of prospectively collected data in the statewide Maryland Ambulance Information System followed by surveys of emergency medical services (EMS) and trauma center personnel at regional EMS conferences and level I trauma centers, respectively. Patients Trauma patients were defined as those who met American College of Surgeons physiology, injury, and/or mechanism criteria and were subjectively declared priority I status by EMS personnel. Main Outcome Measure Undertriage, defined as when trauma patients were not transported to a state-designated trauma center. Results The registry analysis identified 26 565 trauma patients. The undertriage rate was significantly higher in patients aged 65 years or older than in younger patients (49.9% vs 17.8%, P Conclusions Even when trauma is recognized and acknowledged by EMS, providers are consistently less likely to consider transporting elderly patients to a trauma center. Unconscious age bias, in both EMS in the field and receiving trauma center personnel, was identified as a possible cause.

Indwelling Urinary Catheter Use in the Postoperative Period: Analysis of the National Surgical Infection Prevention Project Data

Abstract: Objectives To describe the frequency and duration of perioperative catheter use and to determine the relationship between catheter use and postoperative outcomes. Design Retrospective cohort study. Setting Two thousand nine hundred sixty-five acute care US hospitals. Patients Medicare inpatients (N = 35 904) undergoing major surgery (coronary artery bypass and other open-chest cardiac operations; vascular surgery; general abdominal colorectal surgery; or hip or knee total joint arthroplasty) in 2001. Main Outcome Measure Postoperative urinary tract infection. Results Eighty-six percent of patients undergoing major operations had perioperative indwelling urinary catheters. Of these, 50% had catheters for longer than 2 days postoperatively. These patients were twice as likely to develop urinary tract infections than patients with catheterization of 2 days or less. In multivariate analyses, a postoperative catheterization longer than 2 days was associated with an increased likelihood of in-hospital urinary tract infection (hazard ratio, 1.21; 95% confidence interval [CI], 1.04-1.41) and 30-day mortality (parameter estimate, 0.54; 95% CI, 0.37-0.72) as well as a decreased likelihood of discharge to home (parameter estimate, − 0.57; 95% CI, − 0.64 to − 1.51). Conclusions Indwelling urinary catheters are routinely in place longer than 2 days postoperatively and may result in excess nosocomial infections. The association with adverse outcomes makes postoperative catheter duration a reasonable target of infection control and surgical quality-improvement initiatives.

A longitudinal analysis of the general surgery workforce in the United States, 1981-2005.

Abstract: Hypothesis The overall supply of general surgeons per 100 000 population has declined in the past 2 decades, and small and isolated rural areas of the United States continue to have relatively fewer general surgeons per 100 000 population than urban areas. Design Retrospective longitudinal analysis. Setting Clinically active general surgeons in the United States. Participants The American Medical Association's Physician Masterfiles from 1981, 1991, 2001, and 2005 were used to identify all clinically active general surgeons in the United States. Main Outcome Measures Number of general surgeons per 100 000 population and the age, sex, and locale of these surgeons. Results General surgeon to population ratios declined steadily across the study period, from 7.68 per 100 000 in 1981 to 5.69 per 100 000 in 2005. The overall urban ratio dropped from 8.04 to 5.85 (−27.24%) across the study period, and the overall rural ratio dropped from 6.36 to 5.02 (−21.07%). The average age of rural surgeons increased compared with their urban counterparts, and women were disproportionately concentrated in urban areas. Conclusions The overall number of general surgeons per 100 000 population has declined by 25.91% during the past 25 years. The decline has been most marked in urban areas. However, more remote rural areas continue to have significantly fewer general surgeons per 100 000 population. These findings have implications for training, recruiting, and retaining general surgeons.

Enteral nutrition and the risk of mortality and infectious complications in patients with severe acute pancreatitis: a meta-analysis of randomized trials.

Abstract: Objective To compare the effect of enteral vs parenteral nutrition in patients with severe acute pancreatitis for clinically relevant outcomes. Data Sources A computerized literature search was performed in the MEDLINE, EMBASE, and Cochrane databases for articles published from January 1, 1966, until December 15, 2006. Study Selection From 253 publications screened, 5 randomized controlled trials comparing enteral and parenteral nutrition in patients with predicted severe acute pancreatitis met the inclusion criteria. Data Extraction Information on study design, patient characteristics, and acute pancreatitis outcomes were independently extracted by two of us using a standardized protocol. Data Synthesis A meta-analysis of randomized controlled trials was performed using a random-effects model. Enteral feeding reduced the risk of infectious complications (relative risk, 0.47; 95% confidence interval, 0.28-0.77; P P = .02), and mortality (0.32; 0.11-0.98; P = .03). The risk reduction for organ failure was not statistically significant (0.67; 0.30-1.52; P = .34). Conclusions Enteral nutrition results in clinically relevant and statistically significant risk reduction for infectious complications, pancreatic infections, and mortality in patients with predicted severe acute pancreatitis.

Hospital-Associated Costs Due to Surgical Site Infection After Breast Surgery

Abstract: Objective To determine the attributable costs associated with surgical site infection (SSI) following breast surgery. Design and Setting Cost analysis of a retrospective cohort in a tertiary care university hospital. Patients All persons who underwent breast surgery other than breast-conserving surgery from July 1, 1999, through June 30, 2002. Main Outcome Measures Surgical site infection and hospital costs. Costs included all those incurred in the original surgical admission and any readmission(s) within 1 year of surgery, inflation adjusted to US dollars in 2004. Results Surgical site infection was identified in 50 women during the original surgical admission or at readmission to the hospital within 1 year of surgery (N = 949). The incidence of SSI was 12.4% following mastectomy with immediate implant reconstruction, 6.2% following mastectomy with immediate reconstruction using a transverse rectus abdominis myocutaneous flap, 4.4% following mastectomy only, and 1.1% following breast reduction surgery. Of the SSI cases, 96.0% were identified at readmission to the hospital. Patients with SSI had crude median costs of $16 882 compared with $6123 for uninfected patients. After adjusting for the type of surgical procedure(s), breast cancer stage, and other variables associated with significantly increased costs using feasible generalized least squares, the attributable cost of SSI after breast surgery was $4091 (95% confidence interval, $2839-$5533). Conclusions Surgical site infection after breast cancer surgical procedures was more common than expected for clean surgery and more common than SSI after non–cancer-related breast surgical procedures. Knowledge of the attributable costs of SSI in this patient population can be used to justify infection control interventions to reduce the risk of infection.

Surgical management and outcomes of 165 colonoscopic perforations from a single institution.

Abstract: Background: Increasing use of colonoscopy is making iatrogenic perforations more common. We herein present our experience with operative management of colonoscopic-related perforations. Design: Retrospective review (1980-2006). Setting: Tertiary referral center. Patients: A total of 258248 colonoscopies performed in patients, from which we identified 180 iatrogenic perforations (incidence, 0.07%). Of these, 165 perforations were managed operatively. Results: Patients underwent primary repair (29%), resection with primary anastomosis (33%), or fecal diversion (38%). Patients presenting within 24 hours (78%) were more likely to have minimal peritoneal contamination (64 patients [50%] vs 6 [17%];P=.01) and to undergo primary repair or resection with anastomosis (86 [67%] patients vs 13 [36%]; P.01). Patients presenting after 24 hours (22%) were more likely to have feculentcontamination(16patients[44%]vs4[11%];P=.02) andtoreceiveanostomy(23patients[64%]vs43[33%]; P=.02). The sigmoid colon was the most frequent site of perforation, followed by the cecum (53% and 24%, respectively;P.001);bluntortorqueinjuryexceededpolypectomy and thermal injuries (55% vs 27% and 18%, respectively;P.001). Patients with blunt injuries were more likely to receive a stoma than were those with polypectomy and thermal perforations (44 patients vs 9 and 9,respectively;P=.02),aswerepatientswithfeculentperitonitis compared with those with moderate and minimal soilage (28 patients [78%] vs 28 [42%] and 6 [10%] respectively;P=.002).Operativemorbiditywas36%,with amortalityrateof7%.Multivariateanalysisindicatedthat bluntinjuries,poorbowelpreparation,corticosteroiduse, andbeingyoungerthan67yearswereriskfactorsforpostoperative morbidity (P.01); no factors correlated with death.

A massive transfusion protocol to decrease blood component use and costs.

Abstract: Hypothesis A massive transfusion protocol (MTP) decreases the use of blood components, as well as turnaround times, costs, and mortality. Design Retrospective before-and-after cohort study. Setting Academic level I urban trauma center. Patients and Methods Blood component use was compared in 132 patients during a 2-year period following the implementation of an MTP; 46 patients who were treated the previous year served as historical control subjects. Intervention Introduction of an MTP that included recombinant factor VIIa for patients with exsanguinating hemorrhage. Main Outcome Measures The amount of each blood component transfused, turnaround times, blood bank and hospital charges, and mortality rates. Results After introduction of the MTP, there was a significant decrease in packed red blood cells, plasma, and platelet use. The turnaround time for the first shipment was less than 10 minutes, and the time between the first and second shipments was reduced from 42 to 18 minutes, compared with historical controls. The decreased use of blood products represented a savings of $2270 per patient or an annual savings of $200 000, despite increased costs for recombinant factor VIIa. There was no difference in mortality in either group; it remained around 50%. Thromboembolic complications did not increase, despite a significant increase in the use of recombinant factor VIIa. Conclusions The MTP resulted in a reduction in the use of blood components with improved turnaround times and significant savings. Mortality was unaffected. The use of recombinant factor VIIa did not increase thromboembolic complications in these patients.

Negative pressure wound therapy: a vacuum of evidence?

Abstract: Objective To systematically examine the clinical effectiveness and safety of negative pressure wound therapy (NPWT) compared with conventional wound therapy. Data Sources MEDLINE, EMBASE, CINAHL, and the Cochrane Library were searched. Manufacturers were contacted, and trial registries were screened. Study Selection Randomized controlled trials (RCTs) and non-RCTs comparing NPWT and conventional therapy for acute or chronic wounds were included in this review. The main outcomes of interest were wound-healing variables. After screening 255 full-text articles, 17 studies remained. In addition, 19 unpublished trials were found, of which 5 had been prematurely terminated. Data Extraction Two reviewers independently extracted data and assessed methodologic quality in a standardized manner. Data Synthesis Seven RCTs (n = 324) and 10 non-RCTs (n = 278) met the inclusion criteria. The overall methodologic quality of the trials was poor. Significant differences in favor of NPWT for time to wound closure or incidence of wound closure were shown in 2 of 5 RCTs and 2 of 4 non-RCTs. A meta-analysis of changes in wound size that included 4 RCTs and 2 non-RCTs favored NPWT (standardized mean difference: RCTs, −0.57; non-RCTs, −1.30). Conclusions Although there is some indication that NPWT may improve wound healing, the body of evidence available is insufficient to clearly prove an additional clinical benefit of NPWT. The large number of prematurely terminated and unpublished trials is reason for concern.

Optimizing the total skin-sparing mastectomy.

Abstract: Hypothesis Dissection of subnipple tissue to spare the entire skin envelope of the breast (total skin-sparing mastectomy) is a feasible option in appropriately selected patients and yields an excellent final cosmetic outcome. Design Prospective surgical technique outcomes study. Setting University-based breast care referral center. Patients Total skin-sparing mastectomy with preservation of the nipple-areola complex was performed in 64 breasts in 43 women. Indications for total skin-sparing mastectomy included prophylaxis (n = 29), invasive carcinoma (n = 24), and ductal carcinoma in situ (n = 11). Interventions Preoperative magnetic resonance imaging was used to select patients and to confirm absence of disease within 2 cm of the nipple. Nipple tissue was serially sectioned at pathologic analysis. Circumareolar/nipple-areola free graft, inframammary, crescentic mastopexy, areola crossing, and radial incisions were used. Immediate reconstruction was performed with implant or tissue expander placement or latissimus dorsi muscle, transverse rectus abdominis muscle, or deep inferior epigastric perforator muscle flaps. Main Outcome Measures Nipple-areola complex skin survival, implant loss, skin flap necrosis, wound infection, and occult neoplasm. Results Nipple-areola complex skin survival was complete in 80% of patients (n = 51) and partial in 16% (n = 10); it was highest with the radial incision at 97% survival (n = 34). Occult ductal carcinoma in situ in the nipple-areola complex was found in 2 patients (3%), and the affected nipple-areola complex was subsequently removed. Other complications included implant loss, total skin-sparing skin flap necrosis, and infection. Although follow-up is limited, no patients have exhibited cancer recurrence. Conclusions Total skin-sparing mastectomy is a viable surgical option in selected patients with breast neoplasm and those who choose prophylactic mastectomy, and may increase the willingness of women to consider mastectomy to reduce their risk of breast cancer.

Comparison of outcomes after restorative proctocolectomy with or without defunctioning ileostomy.

Abstract: Objective To evaluate postoperative adverse events and functional outcomes of patients undergoing restorative proctocolectomy with or without proximal diversion. Data Sources The literature was searched by means of MEDLINE, Embase, Ovid, and Cochrane databases for all studies published from 1978 through July 15, 2005. Study Selection Comparative (randomized and nonrandomized) studies evaluating outcomes after restorative proctocolectomy with or without ileostomy were included. Data Extraction Three authors independently extracted data by using operative variables, early and late adverse events, and functional outcomes between the 2 groups. Trials were assessed by means of the modified Newcastle-Ottawa Score. Random-effects meta-analytical techniques were used for analysis. Data Synthesis The review included 17 studies comprising 1486 patients (765 without ileostomy and 721 with ileostomy). There were no significant differences in functional outcomes between the 2 groups. The development of pouch-related leak was significantly higher in the no-ileostomy group (odds ratio, 2.37;P = .002). Small-bowel obstruction was more common in the stoma group but was not statistically significant (odds ratio, 0.65). The development of anastomotic stricture favored the no-stoma group (odds ratio, 0.31;P = .045). On sensitivity analysis, pelvic sepsis was significantly less common in patients whose ileostomies were defunctioned; however, this finding was not mirrored by a significant difference in ileal pouch failure in this subgroup. Conclusions Restorative proctocolectomy without a diverting ileostomy resulted in functional outcomes similar to those of surgery with proximal diversion but was associated with an increased risk of anastomotic leak. Diverting ileostomy should be omitted in carefully selected patients only.

Colorectal liver metastases: recurrence and survival following hepatic resection, radiofrequency ablation, and combined resection-radiofrequency ablation.

Abstract: Hypothesis Although radiofrequency ablation (RFA) is increasingly an accepted option for patients with colorectal liver metastases, patients treated with resection vs RFA may have different tumor biology profiles, which might confound the relationship between choice of liver-directed therapy and outcome. Design Retrospective review of a prospectively collected database. Setting Major hepatobiliary center. Patients Between January 1, 1999, and August 30, 2006, 258 patients with colorectal liver metastases underwent hepatic resection with or without RFA. Main Outcome Measures Evaluation of outcome following resection alone, combined resection-RFA, and RFA alone using 3 statistical methods (paired-match control, Cox proportional hazards multivariate model, and propensity index) to identify and adjust for potential confounding variables. Results The median number of hepatic lesions was 2, and the median size of the largest lesion was 3.0 cm. One hundred ninety-two patients (74.4%) underwent resection alone, 55 patients (21.3%) underwent resection-RFA, and 11 patients (4.3%) underwent RFA alone. Patients who underwent resection-RFA had significantly increased risk of extrahepatic failure at 1 year vs patients who underwent resection alone or RFA alone ( P Conclusion Although results of matched control and multivariate analyses suggested that RFA with or without resection was associated with worse outcome, propensity score methods revealed that the resection-RFA and resection-alone groups were different with regard to baseline tumor and treatment-related factors, making causal inferences about the efficacy of RFA unreliable.

Impact of preoperative briefings on operating room delays: a preliminary report.

Abstract: Hypothesis Preoperative briefings have the potential to reduce operating room (OR) delays through improved teamwork and communication. Design Pre-post study. Setting Tertiary academic center. Participants Surgeons, anesthesiologists, nurses, and other OR personnel. Intervention An OR briefings program was implemented after training all OR staff in how to conduct preoperative briefings through in-service training sessions. During the preoperative briefings, the attending surgeon led OR personnel in a 2-minute discussion using a standardized format designed to familiarize caregivers with each other and the operative plan before each surgical procedure. Main Outcome Measures The OR Briefings Assessment Tool was distributed to OR personnel at the end of each operation. Survey items questioned OR personnel about unexpected delays during each procedure and the relationship between communication breakdowns and delays. Responses were compared before and after the initiation of the preoperative briefings program. Results The use of preoperative briefings was associated with a 31% reduction in unexpected delays; 36% of OR personnel reported delays in the preintervention period, and 25% reported delays in the postintervention period ( P P P Conclusions Preoperative briefings reduced unexpected delays in the OR by 31% and decreased the frequency of communication breakdowns that lead to delays. Preoperative briefings have the potential to increase OR efficiency and thereby improve quality of care and reduce cost.

Predictors of mortality after colectomy for fulminant Clostridium difficile colitis.

Abstract: Objectives To present, to our knowledge, the largest experience with colectomy for fulminant Clostridium difficile colitis and to propose factors significant in predicting mortality. Design Retrospective medical record review. Setting University teaching hospital. Patients Seventy-three patients undergoing colectomy between 1994 and 2005 for C difficile –associated pseudomembranous colitis. Main Outcome Measures Preoperative predictors of in-hospital mortality. Results Seventy-three of 5718 cases (1.3%) of C difficile colitis required colectomy. Mean age was 68 years. In-hospital mortality was 34% (n = 25). Eighty-six percent (n = 63) of patients received a subtotal colectomy. Patients presented with diarrhea (84%; n = 61), abdominal pain (75%; n = 55), and ileus (16%; n = 12). Mean duration of symptoms was 7 days followed by 4 days of medical treatment prior to colectomy. On univariate analysis, an admitting diagnosis other than C difficile ( P = .049), vasopressor requirement ( P = .001), intubation ( P = .001), and mental status changes ( P P = .007) was significantly higher and length of medical management (6.4 vs 3.0 days; P = .006) was significantly longer in the mortality group. Platelet counts (169 × 10 3 /μL vs 261 × 10 3 /μL [to convert to × 10 9 /L, multiply by 1]; P = .04) were significantly lower in the mortality group. On multivariate analysis, vasopressor requirement ( P = .04; odds ratio, 5.0), mental status changes ( P = .002; odds ratio, 12.6), and treatment length ( P = .002; odds ratio, 1.4) remained significant predictors of mortality. Conclusions Colectomy for C difficile colitis carries a substantial mortality regardless of patient age and white blood cell count. Preoperative vasopressor requirement, mental status changes, and length of medical treatment significantly predict mortality.

Requirement of perioperative stress doses of corticosteroids: a systematic review of the literature

Abstract: Objective To determine the requirement for perioperative supplemental (stress) doses of corticosteroids in patients receiving long-term corticosteroid therapy and undergoing a surgical procedure. Corticosteroids are among the most commonly prescribed medications and will predictably result in suppression of the hypothalamic-pituitary-adrenal axis with long-term use. Patients receiving therapeutic dosages of corticosteroids frequently require surgery; these patients are almost universally treated with stress doses of corticosteroids during the perioperative period. Data Sources MEDLINE, EMBASE, Cochrane Register of Controlled Trials, and citation review of relevant primary and review articles. Study Selection Randomized controlled trials (RCTs) comparing stress doses of corticosteroids with placebo and cohort studies that followed up patients after surgery in which perioperative stress doses of corticosteroids were not administered. Data Extraction Data were abstracted on the study design, study size, study setting, patient population, dosage and duration of previous corticosteroid therapy, adrenal function testing results, surgical intervention, corticosteroid dosing regimen, intraoperative and postoperative hemodynamic profile, and incidence of adrenal crisis. Data Synthesis Nine studies met our inclusion criteria, including 2 RCTs and 7 cohort studies. These studies enrolled a total of 315 patients who underwent 389 surgical procedures. In the 2 RCTs, there was no difference in the hemodynamic profile between patients receiving stress doses of corticosteroids compared with patients receiving only their usual daily dose of corticosteroid. In the 5 cohort studies in which patients continued to receive their usual daily dose of corticosteroid without the addition of stress doses, no patient developed unexplained hypotension or adrenal crisis. One patient in each of the 2 cohort studies (5% and 1% of the cohort) in which the usual daily dose of corticosteroid was stopped 48 and 36 hours before surgery developed unexplained hypotension; both of these patients responded to hydrocortisone and fluid administration. Conclusions Patients receiving therapeutic doses of corticosteroids who undergo a surgical procedure do not routinely require stress doses of corticosteroids so long as they continue to receive their usual daily dose of corticosteroid. Adrenal function testing is not required in these patients because the test is overly sensitive and does not predict which patient will develop an adrenal crisis. Patients receiving physiologic replacement doses of corticosteroids owing to primary disease of the hypothalamic-pituitary-adrenal axis, however, require supplemental doses of corticosteroids in the perioperative period.

Prevalence of pain in patients 1 year after major trauma.

Abstract: Objectives To describe the prevalence of pain in a large cohort of trauma patients 1 year after injury and to examine personal, injury, and treatment factors that predict the presence of chronic pain in these patients. Setting Sixty-nine hospitals in 14 states in the United States. Patients There were 3047 patients (10 371 weighted) aged 18 to 84 years who were admitted to the hospital because of acute trauma and survived to 12 months after injury. Main Outcome Measure Pain 12 months after injury measured with the Chronic Pain Grade Scale. Results At 12 months after injury, 62.7% of patients reported injury-related pain. Most patients had pain in more than 1 body region, and the mean (SD) severity of pain in the last month was 5.5 (4.8) on a 10-point scale. The reported presence of pain varied with age and was more common in women and those who had untreated depression before injury. Pain at 3 months was predictive of both the presence and higher severity of pain at 12 months. Lower pain severity was reported by patients with a college education and those with no previous functional limitations. Conclusions Most trauma patients have moderately severe pain from their injuries 1 year later. Earlier and more intensive interventions to treat pain in trauma patients may be needed.

Nipple-sparing mastectomy update: one hundred forty-nine procedures and clinical outcomes.

Abstract: Objectives To describe our experience with patients who underwent the nipple-sparing mastectomy procedure developed and standardized at our institution and to report clinical outcomes for those patients with a breast cancer diagnosis. Design Prospective study for consecutive nipple-sparing mastectomy procedures. Setting Multidisciplinary breast center at a large tertiary care facility. Patients One hundred ten consecutive patients underwent nipple-sparing mastectomy between July 2001 and June 2007. Intervention Nipple-sparing mastectomy was offered to carefully screened patients; the nipple-areola tissue was cored and sent for histologic frozen-section analysis intraoperatively. Main Outcome Measures Assessment of nipple-areola cored tissue for neoplastic involvement; postoperative stability of retained nipple-areola complex; and clinical outcomes. Results Data were available for 149 nipple-sparing mastectomies performed on 110 patients. No procedure performed for prevention had neoplastic involvement of the cored nipple-areola tissue, while 9 procedures performed for breast cancer treatment were found to have neoplastic involvement. Postoperatively, 2 patients had partial loss of the nipple-areola complex due to sloughing and a third patient developed an infection that required surgical removal of the nipple-areola complex. Among patients with breast cancer, none with ductal carcinoma in situ has developed a recurrence, while 4 patients with infiltrating breast cancer have, including 2 patients with distant metastases only, a third with a chest wall recurrence, and a fourth with an axillary recurrence. Conclusion A low incidence of neoplastic involvement of the nipple-areola cored tissue leads to successful completion of nipple-sparing mastectomy for most patients.

Factors Associated With Weight Loss After Gastric Bypass

Abstract: Background Gastric bypass (GBP) is the most common operation performed in the United States for morbid obesity. However, weight loss is poor in 10% to 15% of patients. We sought to determine the independent factors associated with poor weight loss after GBP. Design Prospective cohort study. We examined demographic, operative, and follow-up data by means of multivariate analysis. Variables investigated were age, sex, race, marital and insurance status, initial weight and body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared), comorbidities (diabetes mellitus, hypertension, joint disease, sleep apnea, hyperlipidemia, and psychiatric disease), laparoscopic vs open surgery, gastric pouch area, gastrojejunostomy technique, and alimentary limb length. Setting University tertiary referral center. Patients All patients at our institution who underwent GBP from January 1, 2003, through July 30, 2006. Main Outcome Measures Weight loss at 12 months defined as poor (≤40% excess weight loss) or good (>40% excess weight loss). Results Follow-up data at 12 months were available for 310 of the 361 patients (85.9%) undergoing GBP during the study period. Mean preoperative BMI was 52 (range, 36-108). Mean BMI and excess weight loss at follow-up were 34 (range, 17-74) and 60% (range, 8%-117%), respectively. Thirty-eight patients (12.3%) had poor weight loss. Of the 4 variables associated with poor weight loss in the univariate analysis (greater initial weight, diabetes, open approach, and larger pouch size), only diabetes (odds ratio, 3.09; 95% confidence interval, 1.35-7.09 [ P = .007]) and larger pouch size (odds ratio, 2.77;95% confidence interval, 1.81-4.22 [ P Conclusions Gastric bypass results in substantial weight loss in most patients. Diabetes and larger pouch size are independently associated with poor weight loss after GBP.

Portal vein ligation as an efficient method of increasing the future liver remnant volume in the surgical treatment of colorectal metastases.

Abstract: Objective To compare the volumetric increase of segments 2 and 3, segment 4, and the caudate lobe after portal vein ligation (PVL) and portal vein embolization (PVE). The small size of the remnant liver and chemotherapy-induced liver injury increase the risk of postoperative hepatic insufficiency after major hepatic resection for colorectal liver metastases. Portal vein ligation has been suggested to be less effective than embolization in inducing hypertrophy of the remnant liver. Design, Setting, and Patients We retrospectively reviewed 48 patients with colorectal liver metastases who underwent PVL (n = 17) or PVE (n = 31) at the Istituto per la Ricerca e la Cura del Cancro or the Institut Paoli-Calmette from March 1, 2000, through August 31, 2006. Main Outcome Measures To compare the volume increase of segments 2 and 3, segment 4, and of the caudate lobe in patients who have undergone PVL or PVE in preparation for a major hepatic resection. Results There were no deaths related to PVE or PVL. Portal vein ligation was associated with resection of synchronous colorectal cancer in 16 patients. Resection of a liver metastasis in the remnant liver was performed in 11 patients. The median estimated baseline volume of segments 2 and 3 was 17.7% in the PVL group and 17.5% in the PVE group (P = .72). After PVL or PVE, it increased to 26.9% and 24.7%, respectively (P = .95), for volumetric increases of 43.1% and 53.4%, respectively (P = .39). The volumetric increases of segment 4 and the caudate lobe were similar. Conclusion Portal vein ligation is as effective as PVE in inducing hypertrophy of the remnant liver volume.

Gastrointestinal tract recovery in patients undergoing bowel resection: results of a randomized trial of alvimopan and placebo with a standardized accelerated postoperative care pathway.

Abstract: Objective To investigate the efficacy and safety of alvimopan, 12 mg, administered orally 30 to 90 minutes preoperatively and twice daily postoperatively in conjunction with a standardized accelerated postoperative care pathway for managing postoperative ileus after bowel resection. Design, Setting, and Patients This multicenter, randomized, placebo-controlled, double-blind, phase 3 trial enrolled adult patients undergoing partial bowel resection with primary anastomosis by laparotomy and scheduled to receive intravenous, opioid-based, patient-controlled analgesia. A standardized accelerated postoperative care pathway including early ambulation, oral feeding, and postoperative nasogastric tube removal was used to facilitate gastrointestinal (GI) tract recovery in all of the patients. Main Outcome Measures The primary end point was time to GI-2 recovery (toleration of solid food and first bowel movement). Secondary end points included time to GI-3 recovery (toleration of solid food and first flatus or bowel movement), hospital discharge order written, and actual hospital discharge. Postoperative length of hospital stay based on calendar day of hospital discharge order written, opioid consumption, and overall postoperative ileus–related morbidity were recorded. Results Alvimopan, 12 mg, was well tolerated and significantly accelerated GI-2 recovery, GI-3 recovery, and actual hospital discharge compared with a standardized accelerated postoperative care pathway alone (hazard ratio = 1.5, 1.5, and 1.4, respectively; P Conclusions Alvimopan, 12 mg, administered 30 to 90 minutes before and twice daily after bowel resection is well tolerated, accelerates GI tract recovery, and reduces postoperative ileus–related morbidity without compromising opioid analgesia. Trial Registration clinicaltrials.gov Identifier:NCT00205842

Hypertonic resuscitation of hypovolemic shock after blunt trauma: a randomized controlled trial.

Abstract: Background The leading cause of late mortality after trauma is multiple organ failure syndrome, due to a dysfunctional inflammatory response early after injury. Preclinical studies demonstrate that hypertonicity alters the activation of inflammatory cells, leading to reduction in organ injury. The purpose of this study was to evaluate the effect of hypertonicity on organ injury after blunt trauma. Design Double-blind, randomized controlled trial from October 1, 2003, to August 31, 2005. Setting Prehospital enrollment at a single level I trauma center. Patients Patients older than 17 years with blunt trauma and prehospital hypotension (systolic blood pressure, ≤ 90 mm Hg). Interventions Treatment with 250 mL of 7.5% hypertonic saline and 6% dextran 70 (HSD) vs lactated Ringer solution (LRS). Main Outcome Measures The primary end point was survival without acute respiratory distress syndrome (ARDS) at 28 days. Cox proportional hazards regression was used to adjust for confounding factors. A preplanned subset analysis was performed for patients requiring 10 U or more of packed red blood cells in the first 24 hours. Results A total of 209 patients were enrolled (110 in the HSD group and 99 in the LRS group). The study was stopped for futility after the second interim analysis. Intent-to-treat analysis demonstrated no significant difference in ARDS-free survival (hazard ratio, 1.01; 95% confidence interval, 0.63-1.60). There was improved ARDS-free survival in the subset (19% of the population) requiring 10 U or more of packed red blood cells (hazard ratio, 2.18; 95% confidence interval, 1.09-4.36). Conclusions Although no significant difference in ARDS-free survival was demonstrated overall, there was benefit in the subgroup of patients requiring 10 U or more of packed red blood cells in the first 24 hours. Massive transfusion may be a better predictor of ARDS than prehospital hypotension. The use of HSD may offer maximum benefit in patients at highest risk of ARDS. Trial Registration clinicaltrials.gov Identifier:NCT00113685

Hepatectomy for Stage B and Stage C Hepatocellular Carcinoma in the Barcelona Clinic Liver Cancer Classification: Results of a Prospective Analysis

Abstract: Hypothesis Using an algorithm for selection of patients with hepatocellular carcinoma (HCC) for surgery, Barcelona Clinic Liver Cancer (BCLC) classification stage B and stage C disease is not a contraindication. Design Prospective cohort study. Setting University tertiary care hospital. Patients Among 163 consecutive patients with HCC, 120 (73.6%) underwent surgery; 113 of 120 (94.2%) underwent resection. Of 113 patients, 61 (54.0%) had BCLC stage 0 or A disease, 24 (21.2%) had stage B disease, and 28 (24.8%) had stage C disease. Interventions Surgical strategy was based on the relationship of the tumor to the intrahepatic vascular structures on intraoperative ultrasonography. Main Outcome Measures Mortality, morbidity, rate of cut edge local recurrences, and long-term outcome were evaluated. P Results Hospital mortality was 0.9%. The overall morbidity was 27.4%, and major morbidity was 3.5%. After a median follow-up of 24 months (range, 1-65 months), there was no cut edge recurrence. For patients with BCLC stages 0 or A, B, and C disease, the 3-year overall survival rates were 81%, 67%, and 74%, respectively ( P =.24); the 3-year disease-free survival rates were 30%, 35%, and 15%, respectively ( P =.85); and the 3-year hepatic disease-free survival rates were 39%, 44%, and 17%, respectively ( P =.79). Conclusions Patients with BCLC stage B and stage C HCC can tolerate hepatic resection with low mortality, acceptable morbidity, and survival benefits if resection is performed under strict intraoperative ultrasonographic guidance. These results should prompt revision of the BCLC recommendations.