Showing papers in "Journal of The American College of Surgeons in 2002"

Perioperative single-dose glucocorticoid administration: pathophysiologic effects and clinical implications

Abstract: The antiinflammatory and immune-modulating effects of glucocorticoids (GCs) have been known for decades and have found extensive therapeutic use in a wide range of diseases of which inflammatory responses are a main feature. A surgical operation elicits a stress response of combined endocrine and inflammatory origin, where an excessive response can lead to increased functional demands on various organic systems, which subsequently might contribute to postoperative morbidity. Increased attention has evolved toward modulating potential deleterious responses. Because GCs might modulate several components of the inflammatory response to surgery, the aim of this review was to update knowledge on the effect of perioperative administration of a single dose of GC on surgical stress responses, postoperative organ dysfunctions, and morbidity in elective surgery with potential implications for clinical practice. Data were obtained by examining randomized clinical trials (RCTs) in which a single dose of GC was administrated systemically in immediate relation to surgery. We do not intend to discuss in depth either the molecular or cellular basis of action of GCs, recently reviewed elsewhere, nor to provide an overview of GC administration in septic or traumatized patients, or in GC-treated surgical patients. A recent metaanalysis concluded that perioperative administration of highdose methylprednisolone was not associated with major side effects. But the trials included consisted of major surgical procedures only, combined with studies in trauma and spinal cord injury, and only methylprednisolone administration was evaluated, including multiple administrations within 3 days of surgery. METHODS A Medline search (1966 to May 2001) was performed to identify all randomized, clinical trials published in English-language journals, in which a single dose of GC was administered systemically and perioperatively (defined as 12 hours before surgery, until the end of surgery; ie, before completion of incision closure) in elective surgical procedures, and where perioperative organ function, morbidity, or both were primary outcomes parameters. The search string consisted of the free text terms “glucocorticoid,” “glucocorticoids,” “dexamethasone,” “methylprednisolone,” “surgery,” and the medical subject headings “glucocorticoids” and “surgical procedures, operative.” All of the above search criteria were combined. The searches were limited to “English” in the language field and “randomized controlled trial” in the publication-type field. Additional studies were identified from review articles and articles cited in original papers. Abstracts, letters to the editor, and nonpublished data were not considered. No related Cochrane review relevant to this subject exists. Studies in patients with chronic GC treatment, patients receiving perioperative immune-suppressive therapy, multiple-dosage GC regimens, and patients receiving a local (at the surgical site) GC application were excluded. We evaluate the evidence of trials comparing GC administration to placebo treatment. In studies evaluating GC treatment against other active treatment and a placebo, only the GC-treated group versus the placebo group was considered.

Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes.

Abstract: BACKGROUND: Pelvic fractures are often associated with major intraabdominal injuries or severe bleeding from the fracture site. OBJECTIVE: To study the epidemiology of pelvic fractures and identify important risk factors for associated abdominal injuries, bleeding, need for angiographic embolization, and death. METHODS: Trauma registry study on pelvic fractures from blunt trauma. Stepwise logistic regression was used to identify risk factors of severe pelvic fractures, associated abdominal injuries, need for major blood transfusion, therapeutic embolization, and death from pelvic fracture. Adjusted relative risks and 95% confidence intervals were derived. RESULTS: There were 16,630 trauma registry patients with blunt trauma, of whom 1,545 (9.3%) had a pelvic fracture. The incidence of abdominal injuries was 16.5%, and the most common injured organs were the liver (6.1%) and the bladder and urethra (5.8%). In severe pelvic fractures (Abbreviated Injury Scale [AIS] ≥ 4), the incidence of associated intraabdominal injuries was 30.7%, and the most commonly injured organs were the bladder and urethra (14.6%). Among the risk factors studied, motor vehicle crash is the only notable risk factor negatively associated with severe pelvic fracture. Major risk factors for associated liver injury were motor vehicle crash and pelvis AIS ≥ 4. Risk factors of major blood loss were age > 16 years, pelvic AIS ≥ 4, angiographic embolization, and Injury Severity Score (ISS) > 25. Age > 55 years was the only predictor for associated aortic injury. Factors associated with therapeutic angiographic embolization were pelvic AIS ≥ 4 and ISS > 25. The overall mortality was 13.5%, but only 0.8% died as a direct result of pelvic fracture. The only pronounced risk factor associated with mortality was ISS > 25. CONCLUSIONS: Some epidemiological variables are important risk factors of severity of pelvic fractures, presence of associated abdominal injuries, blood loss, and need of angiography. These risk factors can help in selecting the most appropriate diagnostic and therapeutic interventions.

Assessing the predictive value of clinical complete response to neoadjuvant therapy for rectal cancer: an analysis of 488 patients.

Abstract: BACKGROUND: Patients with transmural or node-positive rectal cancer benefit from the addition of chemoradiation to surgical resection. Administration of the chemoradiation (combined modality therapy) preoperatively has gained popularity in recent years. Some patients undergo apparent complete tumor regression after preoperative combined modality therapy, and controversy exists about the proper management of these patients. Some investigators have proposed that such patients should simply be observed and not undergo resection. STUDY DESIGN: The purpose of this study was to determine the significance of clinical complete response to preoperative combined modality therapy. Specifically, we have attempted to determine the frequency with which a clinical complete response (based on the absence of detectable tumor on preoperative digital rectal examination and proctoscopy) correlates with a pathologic complete response (based on the absence of cancer cells in the resected specimen). A retrospective review of the clinical and pathologic characteristics of 488 patients from the Memorial Sloan-Kettering prospective colorectal database who received preoperative chemoradiation followed by resection for primary rectal cancer was performed. The indications for preoperative therapy included clinical or ultrasound T3 or T4 tumors or node-positive disease. RESULTS: The clinical complete response rate to preoperative therapy was 19%. All patients underwent resection subsequent to preoperative therapy regardless of response. The pathologic complete response rate among all patients was 10%. The pathologic complete response rate among clinical complete responders was 25%. Clinical complete response was a significant predictive factor for pathologic complete response, but the majority (75%) of clinical complete responders had persistent foci of tumor that were not detectable on preoperative examination or proctoscopy. CONCLUSIONS: Clinical complete response to preoperative therapy as determined by preoperative digital rectal examination and proctoscopy or EUA is not an accurate predictor of pathologic complete response. A significant percentage of clinical complete responders have persistent deep tumors or nodal involvement. We do not recommend making treatment decisions based solely on the absence of clinically palpable or visible tumor after chemoradiation. Our data suggest that all acceptable-risk patients with a diagnosis of primary rectal cancer should undergo resection, regardless of their response to preoperative therapy.

Effects of limited work hours on surgical training

Abstract: BACKGROUND: Legal mandates to reduce resident work hours have prompted changes in the structure of surgical training programs. Such changes have included modification of on-call schedules and the adoption of "night float" resident coverage. Little is known about the effects of these changes on surgical resident education and perceptions of quality of patient care. STUDY DESIGN: The surgical housestaff and faculty at a single institution completed a 21-point Likert survey. Subjects were asked to compare parameters of resident education, patient care, and resident quality of life before and after institution of a strict 80-hour work week resident training schedule. The number of hours worked per week before and after these changes were reported. American Board of Surgery In-Training Examination (ABSITE) scores were compared for the 2 years before and after implementation of this schedule. Total number of surgical cases performed by graduating chief residents were recorded and compared for the 3 years before and after the schedule changes. RESULTS: Resident work hours reduced significantly after schedule changes were implemented. A majority of surgical residents reported an improvement in quality of life, but residents and faculty perceived changes to have a negative impact on continuity of patient care. Mean ABSITE composite percentile scores significantly improved after the reduction of working hours. ABSITE scores for junior residents improved significantly; no significant differences were noted in scores for senior residents. CONCLUSIONS: Reduction in resident work hours has salutary effects on perception of quality of life and basic education for surgical residents. These benefits may come at the expense of patient care, particularly continuity of care. This study did not directly assess patient outcomes but the perceptions of caregivers suggest that patient care may be compromised. Further research is needed to assess the longterm effects of changes on both residents and patients.

Identifying patient preoperative risk factors and postoperative adverse events in administrative databases: results from the Department of Veterans Affairs National Surgical Quality Improvement Program.

Abstract: BACKGROUND: The Department of Veterans Affairs (DVA) National Surgical Quality Improvement Program (NSQIP) employs trained nurse data collectors to prospectively gather preoperative patient characteristics and 30-day postoperative outcomes for most major operations in 123 DVA hospitals to provide risk-adjusted outcomes to centers as quality indicators. It has been suggested that routine hospital discharge abstracts contain the same information and would provide accurate and complete data at much lower cost. STUDY DESIGN: With preoperative risks and 30-day outcomes recorded by trained data collectors as criteria standards, ICD-9-CM hospital discharge diagnosis codes in the Patient Treatment File (PTF) were tested for sensitivity and positive predictive value. ICD-9-CM codes for 61 preoperative patient characteristics and 21 postoperative adverse events were identified. RESULTS: Moderately good ICD-9-CM matches of descriptions were found for 37 NSQIP preoperative patient characteristics (61%); good data were available from other automated sources for another 15 (25%). ICD-9-CM coding was available for only 13 (45%) of the top 29 predictor variables. In only three (23%) was sensitivity and in only four (31%) was positive predictive value greater than 0.500. There were ICD-9-CM matches for all 21 NSQIP postoperative adverse events; multiple matches were appropriate for most. Postoperative occurrence was implied in only 41%; same breadth of clinical description in only 23%. In only four (7%) was sensitivity and only two (4%) was positive predictive value greater than 0.500. CONCLUSION: Sensitivity and positive predictive value of administrative data in comparison to NSQIP data were poor. We cannot recommend substitution of administrative data for NSQIP data methods.

Delta-shaped anastomosis in totally laparoscopic billroth I gastrectomy: New technique of intraabdominal gastroduodenostomy

Abstract: Recently, laparoscopic gastrectomy has become popular for the treatment of benign gastroduodenal diseases or early gastric carcinomas. Several procedures can now be performed intraabdominally because of advances in technology and surgical techniques, but Billroth I reconstruction after laparoscopic distal gastrectomy is commonly performed extraabdominally because of the complexity of intraabdominal anastomotic procedure. We have developed a new method of intraabdominal Billroth I anastomosis using only endoscopic linear staplers. Our procedure is simple, easy, and safe. In this article, we describe the technique and present the results of our initial trials.

The life-sustaining capacity of human polymerized hemoglobin when red cells might be unavailable.

Abstract: Background Human polymerized hemoglobin (PolyHeme, Northfield Laboratories, Evanston, IL) is a universally compatible, immediately available, disease-free, oxygen-carrying resuscitative fluid being developed as a red cell substitute for use in urgent blood loss. PolyHeme should be particularly useful when red cells may be temporarily unavailable. This article assesses survival at life-threatening RBC hemoglobin concentration ([Hb]) in massively bleeding patients who do not receive red cells. Study design There were 171 patients who received rapid infusion of 1 to 20 units (1,000 g, 10 L) of PolyHeme in lieu of red cells as initial oxygen-carrying replacement in trauma and urgent surgery. The protocol simulated the unavailability of red cells, and the progressive fall in RBC [Hb] in bleeding patients was quantified. Thirty-day mortality was compared with a historical control group of 300 surgical patients who refused red cells on religious grounds. Results A total of 171 patients received rapid infusion of 1 to 2 units (n = 45), 3 to 4 units (n = 45), 5 to 9 units (n = 47), or 10 to 20 units (n = 34) of PolyHeme. Forty patients had a nadir RBC [Hb] ≤3 g/dL (mean, 1.5 ± 0.7 g/dL). But total [Hb] was adequately maintained (mean, 6.8 ± 1.2 g/dL) because of plasma [Hb] added by PolyHeme. The 30-day mortality was 25.0% (10/40 patients) compared with 64.5% (20/31 patients) in historical control patients at these RBC [Hb] levels. Conclusions PolyHeme increases survival at life-threatening RBC [Hb] by maintaining total [Hb] in the absence of red cell transfusion. PolyHeme should be useful in the early treatment of urgent blood loss and resolve the dilemma of unavailability of red cells.

Surgeon volume as an indicator of outcomes after carotid endarterectomy: an effect independent of specialty practice and hospital volume.

Abstract: Background High-volume hospitals have been shown to have superior outcomes after carotid endarterectomy (CEA), but the contribution of surgeon volume and specialty practice to CEA outcomes in a national sample is unknown Study design Using the National Inpatient Sample for 1996 and 1997, 35,821 patients who underwent CEA (ICD-9-CM code 3812) and had data for unique surgeon identification were studied Surgeons were categorized in terms of annual CEA volume as low-volume surgeons ( 4 days) were the primary outcomes variables Unadjusted and case-mix adjusted analyses were performed Results The overall in-hospital mortality was 061% CEA was performed annually by high-volume surgeons in 52% of patients, by medium-volume surgeons in 30% of patients, and by low-volume surgeons in 18% of patients Observed mortality by surgeon volume was 044% for high-volume surgeons, 063% for medium-volume surgeons, and 11% for low-volume surgeons (p 65 years (OR = 20; 95% CI 13 to 31, p=0001), low-volume surgeon (OR = 19; 95% CI 14 to 25, p Conclusions More than 50% of the CEAs in the United States are performed by high-volume surgeons with superior outcomes Health policy efforts should focus on reducing the number of low-volume surgeons, regardless of surgeon specialty or total hospital CEA volume

Early complications after Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy: risk factors and management.

Abstract: BACKGROUND: Esophageal resection represents a major surgical and physiologic insult carrying major morbidity and mortality. We present the results of esophagectomy in a specialist unit with emphasis on early complications and their management. STUDY DESIGN: From January 4, 1990 through January 6, 2000, 228 patients have undergone Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy for malignancy under the care of one surgeon. The median age was 64 years (range 39 to 77 years), with a male to female ratio of 2.3:1 and a predominance of adenocarcinoma (n = 146) compared with squamous cell carcinoma (n = 75) and other tumors (n = 7). Detailed prospective data were collected on preoperative status, operative parameters, and postoperative complications. RESULTS: Median ICU stay was 1 day (range 1 to 47 days) and the median postoperative hospital stay in patients surviving surgery (n = 219) was 13 days (range 9 to 159 days). There were 119 separate postoperative complications occurring in 45% of patients (102 of 228), comprising predominantly pulmonary morbidity. Major respiratory complications (17%) were significantly associated with poor preoperative spirometry (p = 0.002) and a history of smoking (p = 0.03). Seven percent of patients (16 of 228) suffered cardiovascular or thromboembolic complications. Major surgical complications occurred in 10% of patients (22 of 228) including mediastinal leaks in 4%. Isolated anastomotic leaks (2%) were successfully treated conservatively in all cases; extensive leaks from ischemic gastric conduits (1%) or gastrotomy dehiscence (1%) underwent further exploration and either local repair or resection and exclusion. Reoperation for hemostasis was required in 3% (6 of 228) and only 1% of patients (2 of 228) developed chyle leaks. Thirty-day mortality was 2%, rising to 4% for in-hospital mortality. The nine fatalities were significantly older (p = 0.02) than those who survived and 67% (6 of 9) had suffered primary surgical complications. CONCLUSIONS: Overall morbidity after radical esophagectomy is high, but early recognition and aggressive management of complications can minimize subsequent mortality. Concentration of facilities and surgical expertise in specialist units together with more careful patient selection can decrease mortality further.

Prospective trial of a blood supply-based technique of pancreaticojejunostomy: effect on anastomotic failure in the Whipple procedure.

Abstract: BACKGROUND: Anastomotic failure at the pancreaticojejunostomy after a Whipple procedure, manifested either as a pancreatic fistula or intraabdominal abscess, is still an unacceptably common postoperative complication. STUDY DESIGN: A prospectively collected series of 123 patients underwent a Whipple procedure. During the pancreaticojejunostomy, the blood supply at the cut surface of the pancreas was evaluated, and if deemed inadequate, the pancreas was cut back 1.5 to 2.0 cm to improve the blood supply. The anastomosis was performed under magnification with meticulous technique. RESULTS: There were 123 Whipple procedures performed. In 47 (38%), the blood supply was considered inadequate and the pancreas was cut back. Postoperatively, there were 2 pancreatic fistulas (1.6%) and 2 intraabdominal abscesses (1.6%). There was 1 (0.8%) postoperative death from aspiration pneumonia. CONCLUSIONS: Pancreatic fistula, the most serious complication of the Whipple procedure, can be almost entirely eliminated by a technique that combines meticulous attention to placement and tying of sutures under magnification with optimization of blood supply to the anastomosis.

Gum chewing enhances early recovery from postoperative ileus after laparoscopic colectomy.

Abstract: BACKGROUND: Postoperative ileus limits early hospital discharge for patients who have undergone laparoscopic procedures. Sham feeding has been reported to enhance bowel motility. Here, the effect of gum chewing is evaluated as a convenient method to enhance postoperative recovery from ileus after laparoscopic colectomy. STUDY DESIGN: A total of 19 patients who underwent elective laparoscopic colectomy for colorectal cancer participated in the study. Each patient was randomly assigned to one of two groups: a gum-chewing group (n = 10, mean age 58.6 years, range 50 to 71 years) or a control group (n = 9, mean age 60.6 years, range 45 to 80 years). The patients in the gum-chewing group chewed gum three times a day from the first postoperative am until oral intake. The times of the first passage of flatus and defecation were recorded precisely. RESULTS: The first passage of flatus was seen, on average, on postoperative day 2.1 in the gum-chewing group and on day 3.2 in the control group (p CONCLUSIONS: Gum chewing aids early recovery from postoperative ileus and is an inexpensive and physiologic method for stimulating bowel motility. Gum chewing should be added as an adjunct treatment in postoperative care because it might contribute to shorter hospital stays.

Nonparasitic splenic cysts: pathogenesis, classification, and treatment.

Abstract: BACKGROUND: Nonparasitic splenic cysts (NPSCs) are uncommon lesions of the spleen, many being reported in anecdotal fashion. Early classifications of this disorder have been based on the presence or absence of an epithelial lining, indicating either a congenital or traumatic etiology. This criterion has led to confusion and mistaken reporting because the lining alone is not a reliable criterion. STUDY DESIGN: Over a 28-year period, the author has observed and studied 23 patients with NPSC. Special attention has been given to the role of trauma in the history, the nature (or absence) of a cyst lining, the gross pathology, and the preferred method of treatment. RESULTS: NPSC present as lesions with a very characteristic gross appearance and lining. The trabeculated interior can be lined with epidermoid, transitional, or mesothelial epithelium. Desquamation of the lining can lead to a spurious diagnosis, but careful search usually discloses the lining remnant. Although most NPSC in this series were treated by open partial splenectomy, the more recent approach by laparoscopic techniques offers great promise. CONCLUSIONS: A new classification of NPSC is offered, based on characteristic gross findings. NPSC are of congenital origin, with a lining derived from mesothelium. Trauma does not play a primary role in pathogenesis. Cysts that are symptomatic or over 5 cm in diameter should be removed by partial splenectomy or near-total cystectomy "decapsulation," either by the open or laparoscopic approach.

Attrition of advanced trauma life support (ATLS) skills among ATLS instructors and providers in Mexico

Abstract: Background Mexico has had the Advanced Trauma Life Support (ATLS) program since 1986. We assessed the attrition of ATLS skills among ATLS providers and instructors in this country. Study design Three groups (S, 16 students [new medical graduates enrolled for an ATLS course]; P, 33 providers; and I, 26 instructors [who had completed courses previously]) were evaluated. Group S read the manual before pretesting. Groups P and I were subdivided based on the length of time since the course had been completed: P1, less than 2 years (n = 22); P2, more than 2 years (n = 11); I1, less than 2 years (n = 16); and I2, more than 2 years (n = 10). Multiple-choice and psychomotor testing using ATLS scoring criteria were used. Affect was assessed post-ATLS for motivational factors, interactivity, and attitude toward trauma care. Results Multiple-choice test scores (means ± SD) out of a maximum of 40 were as follows: S, 24.3 ± 2.6; P1, 24.0 ± 5.7; P2, 21.3 ± 8.0; I1, 23.2 ± 8.2; and I2, 24.0 ± 7.2. Group S all passed the post-ATLS multiple-choice test (with correct answer percentages of 60.3% ± 6.6% pre-ATLS versus 88.8% ± 5.6% post-ATLS). An ATLS passing score of 80% correct answers was achieved in 2 of 33 for group P and 8 of 26 for group I (p Conclusions Reading the manual alone yields similar cognitive but inferior psychomotor performance compared with subjects who completed the course previously. The majority of previous providers and instructors did not obtain a passing score (80%) in the multiple-choice test, but all the new providers passed the post-ATLS multiple-choice test, suggesting major attrition of cognitive skills but maintenance of psychomotor skills. Instructors had superior cognitive performance versus providers with worsening performance over time, but clinical skills performance was maintained at an equally high level by all groups. A very positive attitude toward ATLS prevailed among all participants.

Incidence and management of Bile leakage after hepatic resection for malignant hepatic tumors

Abstract: Background Bile leakage is one of the frequent and disturbing complications of hepatic resection. Study design Clinical records of the 363 patients who underwent hepatic resections without biliary reconstruction for hepatic cancers between January 1994 and June 2001 were reviewed. Postoperative bile leakage was defined as continuous drainage with a bilirubin concentration of 20 mg/dL or 1,500 mg/d lasting 2 days. Leakage that continued longer than 2 weeks or that required surgical intervention was defined as uncontrollable. Differences in incidence and frequency of uncontrollable leakage for the different types of hepatic resection, tumors, and underlying liver disease were investigated. Outcomes after treatment for uncontrollable bile leakage were also reviewed. Results Postoperative bile leakage occurred in 26 of 363 patients (7.2%). Although the incidence in patients with cholangiocellular carcinoma (3/9 [33%]) was higher (p = 0.03) than in patients with hepatocellular carcinoma, rates of occurrence were similar among the different types of hepatic resection and underlying liver disease. Eight of the 26 patients (31%) had uncontrollable leakage. Two patients required reoperation to control leakage; one of these developed hepatic failure and died 2 months after surgery. Four patients underwent endoscopic nasobiliary drainage 21 to 34 days after hepatectomy, and the leakage resolved within 3 to 21 days. Fibrin glue sealing was effective in two patients whose leaking bile ducts were not connected to the common bile duct. Conclusions Although meticulous surgical technique can minimize the risk of postoperative bile leakage, some instances of leakage are unavoidable. Nonsurgical treatments, such as nasobiliary drainage or fibrin glue sealing, are preferable to reoperation.

Laparoscopic colorectal resection: a safe option for elderly patients

Abstract: Background Open colorectal surgery in the elderly has been associated with higher morbidity and mortality rates. The favorable short-term outcomes of laparosocopic colorectal resection might reduce the morbidity in elderly patients. This study compares results of elderly patients (aged 70 and above) who underwent laparoscopic colorectal resection with those having open surgery. Study design Consecutive patients aged 70 and above who had elective colorectal resection from June 2000 to December 2001 were included. Data concerning demographics, diseases, details of operations, and postoperative events were collected prospectively. Comparisons between results of laparoscopic surgery and open surgery were made. Results Sixty-five patients had laparoscopic colectomy and 89 had open surgery during the study period. Median ages were 77 years and 75 years in the open and laparoscopic groups, respectively. Presence of premorbid medical conditions, American Society of Anesthesiology score, and incidence of previous surgery were similar in the two groups. Median operative time was longer (180 minutes versus 135 minutes, p Conclusions Laparoscopic colorectal resection is a safe option for elderly patients and is associated with more favorable short-term outcomes in terms of earlier return of bowel function, earlier resumption of diet, and shorter hospital stay. It is also associated with less cardiopulmonary morbidity, which is an important complication after colorectal surgery in the elderly.

Middle aortic syndrome: Distal thoracic and abdominal coarctation, a disorder with multiple etiologies

Abstract: BACKGROUND: Congenital coarctation of the thoracic aorta at the ligamentum arteriosum or the aortic arch is well recognized. But a much less common variety (0.5% to 2.0%) of aortic coarctation is located in the distal thoracic aorta, or abdominal aorta, or both and is often called "middle aortic syndrome" or "mid-aortic dysplastic syndrome." These types of aortic coarctation are most often secondary to a form of granulomatis vasculitis commonly known as Takayasu's disease in this country or aortitis syndrome in Japan. No single genesis explains every case and beside vasculitis as a cause, some are thought to be congenital in origin and others are associated with von Recklinghausen's disease. STUDY DESIGN: Eight patients with severe hypertension or claudication secondary to middle aortic coarctation were studied with aortograms and subsequently treated by vascular reconstruction procedures. RESULTS: Vascular reconstructions consisted of aortoaortic bypass, aortic resection with interposed grafting, reanastomotic resection of renal arteries into prosthetic grafts, and renal artery bypass with autogenous material. All eight patients' grafts have remained patent, with followups of 4 to 9 years, with relief of hypertension and claudication. Although Takayasu's disease can be progressive, aggressive surgical treatment in eight patients followed for 4 to 8 years postoperatively demonstrates that severe hypertension, claudication, or both are important indications for revascularization. CONCLUSIONS: Whatever the cause, assuming that active aortic inflammation has been medically treated and is in a burned-out state, patients with abdominal coarctation who have symptomatic renovascular hypertension, claudication, or both are good candidates for revascularization. Although surgical repair is more difficult than with congenital thoracic coarctation, because aortic walls are fibrotic and often also involve the renals, all eight of our patients had successful longterm correction of their hypertension and coarctation.

Laparoscopic resection of deep pelvic endometriosis with rectosigmoid involvement

Abstract: Background Adequate treatment of severe deep pelvic endometriosis requires complete excision of all implants, but formal bowel resection is not generally recommended. The purpose of this study was to describe our experience with planned complete laparoscopic management of deep pelvic endometriosis with bowel involvement. Study design All patients presenting to the Department of Obstetrics and Gynecology and the Department of Colorectal Surgery at our institution with stage IV endometriosis and bowel involvement from February 1998 to December 2001 were identified from a prospective database and were retrospectively analyzed. Data analysis included age, previous history of endometriosis, previous pregnancies, operative procedure, body mass index, operating room time, intra- and postoperative complications, length of stay, 30-day readmission, and pain relief. Laparoscopic excision of all visible disease was planned. Results The series consisted of 51 patients with median age of 34 years (range, 32 to 39 years), with history of earlier abdominal operation in 66.7%. Preoperative symptoms were present as dysmenorrhea (85.3%), dyspareunia (55.9%), rectal pain (41.2%), constipation (44.1%), rectal bleeding (14.7%), bloating (29.4%), and tenesmus (8.8%). Management of the bowel disease included superficial excision of serosal endometriosis implants (n = 26), bowel resection (n = 18), and disc excision (n = 5). Five patients required management of disease other than rectosigmoid involvement. Median operating room time was 187 minutes (range, 145 to 277 minutes), and the median length of stay was 2 days (range, 1 to 4 days). Thirty-three percent of excisions were outpatient procedures. Postoperative complications occurred in 10.3%: four cases (7.8%) were converted to formal laparotomy, and three patients (7.7%) were readmitted within 30 days. Only 7 of 47 patients with a uterus (14.9%) required abdominal hysterectomy or bilateral salpingo-oophorectomy. Postoperatively, 87% of patients reported a clinically significant improvement of their symptoms. Conclusions Though technically demanding, complete radical laparoscopic excision of endometriotic implants can be accomplished with preservation of the reproductive organs and appropriate use of bowel resection in the majority of patients. The surgeon or gynecologist who plans to perform laparoscopic excision of deep pelvic endometriosis should have the ability or access to expertise for laparoscopic partial or segmental bowel resection or plan to convert to laparotomy when faced with this disease location.

Overview of bariatric surgery.

Abstract: To know what is new, one must know what is old. Bariatric surgery has developed along three generic lines: malabsorptive, malabsorptive/restrictive, and purely restrictive. In addition, other metabolic surgical procedures—operations on normal organs to achieve a secondary, metabolic goal—have been used and are being tested. The new bariatric surgeon, in ever increasing numbers, is exemplified by the highly skilled minimally invasive surgeon, trained and experienced in the unique principles of pre-, intra-, and postoperative management of the obese patient. This overview explores seminal approaches in bariatric surgery; discusses new operations available to the bariatric surgeon; summarizes the prevalence data for morbid obesity; highlights the intrinsic medical, social, and economic problems of this disease; and offers predictions regarding the next decade in this field.

Spontaneous localized intestinal perforation in very-low-birth-weight infants: a distinct clinical entity different from necrotizing enterocolitis.

Abstract: Background Idiopathic spontaneous intestinal perforation (SIP), a distinct clinical entity different from necrotizing enterocolitis (NEC), has an increasing prevalence in very-low-birth-weight infants. The aims of our study were to define patient characteristics and potential risk factors for premature infants with SIP compared with infants subjected to surgical treatment for NEC. Study design The medical records of 29 premature infants with either SIP (n = 13) or NEC (n = 16) were reviewed retrospectively. Results Infants who experienced SIP were smaller at birth, had lower Apgar scores, and required more intensive neonatal resuscitation. An increased rate of premature rupture of membranes in infants with SIP (8/13 versus 6/16) was not associated with a higher rate of infection in mothers or infants. The onset of illness in SIP was significantly earlier than in NEC (p = 0.022). In contrast to patients with NEC (7/16), 11 of 13 patients in the SIP group had received indomethacin (p = 0.02). Bluish discoloration of the abdomen (8/13), a gasless abdomen (8/13), and the absence of pneumatosis intestinalis (0/13) were further significant markers in infants with SIP. At operation, SIP was always located in the terminal ileum in an antimesenteric position (13/13), and the remaining bowel appeared grossly normal. In most cases of SIP (10/13), the histologic investigation revealed an area of hemorrhagic necrosis without the typical coagulation necrosis seen predominantly in NEC. Conclusions Based on clinical presentation and radiologic and intraoperative findings, SIP is a distinct pathologic entity in very-low-birth-weight infants and can be differentiated from classic NEC. Detected early, SIP can be treated by simple procedures (sutures, or resection and primary anastomosis) with a low rate of morbidity and mortality.

Percutaneous transluminal angioplasty and stenting in the treatment of chronic mesenteric ischemia: results and longterm followup.

Abstract: BACKGROUND: The purpose of this study was to review the results of percutaneous transluminal angioplasty (PTA), stenting, or both in the treatment of patients who present with symptoms and angiographic findings most consistent with chronic mesenteric ischemia. STUDY DESIGN: A retrospective analysis of 33 consecutive patients from a single institution who underwent PTA, stenting, or both for treatment of symptoms most characteristic of chronic mesenteric ischemia was performed. RESULTS: There were 12 men and 21 women with a mean age of 63 years (range 40 to 89 years). Median weight loss was 28 lb (range 6 to 80 lb). Postprandial pain was present in 88% of the patients (29 of 33). All lesions treated were stenoses. PTA alone was performed in 21 patients (32 vessels), and PTA and stenting were performed in 12 patients (15 vessels). PTA was technically successful in 26 of 32 vessels (81.3%); PTA plus stenting was technically successful in 15 of 15 vessels (100%) (p = 0.073). Complete alleviation of symptoms occurred immediately in 27 of the patients (82%), and 2 patients (6%) had significant improvement in symptoms. There were four immediate clinical failures (12%): two patients were found to have occult malignancy and one had immediate relief of symptoms after surgical release of the median arcuate ligament. Followup data were obtained in all patients with clinically successful procedures (mean 38 months, median 25 months, range 1 to 123 months). Angiographic followup was available in 52% of the patients (15 of 29), at a mean of 20 months. The primary longterm clinical success rate was 83.3% (24 of 29). Four of the five patients with recurrent symptoms were successfully retreated with endovascular therapy. The primary assisted longterm clinical success rate was 96.6% (28 of 29). The 5-year survival rate was 76.1%. Major complications occurred in 13% of the procedures, with a 30-day mortality rate of 0%. CONCLUSIONS: Endovascular therapy for treatment of mesenteric arterial stenoses is effective in the treatment of patients with symptoms and angiographic findings characteristic of chronic mesenteric ischemia.

Selection criteria for hepatic resection in patients with large hepatocellular carcinoma larger than 10 cm in diameter.

Abstract: BACKGROUND: The role of hepatic resection for large hepatocellular carcinoma (HCC) larger than 10 cm remains unclear STUDY DESIGN: Perioperative and longterm outcomes of 120 patients with HCC larger than 10 cm who underwent resection (group A) were compared with 368 patients with smaller HCC (group B) The prognostic factors in group A were analyzed RESULTS: A higher proportion of patients underwent major hepatic resection in group A than in group B (90% versus 576%, p=0001), but the hospital mortality was similar (50% versus 46%, p=0874) Group A had worse longterm overall survival (median 188 months versus 628 months, p CONCLUSIONS: Hepatic resection is a safe and effective treatment for HCC larger than 10 cm when liver function reserve is satisfactory and when curative resection can be expected Patients with solitary HCC larger than 10 cm without macroscopic venous invasion can enjoy longterm survival after surgery, and we propose hepatic resection as a standard treatment for this group of patients

Transanal excision of locally advanced rectal cancers downstaged using neoadjuvant chemoradiotherapy

Abstract: BACKGROUND: Our institution has previously demonstrated a survival advantage conferred by preoperative neoadjuvant therapy for locally advanced rectal cancers. We now report our results using transanal excision as definitive surgical therapy in a selected group of patients who experienced significant downstaging of T3 rectal cancers after neoadjuvant therapy. STUDY DESIGN: Seventy-four patients diagnosed with locally advanced (T3) rectal cancers were treated with neoadjuvant chemoradiotherapy. After neoadjuvant therapy, 11 (14.9%) patients who had significant downstaging of their tumors were selected to undergo transanal excision of their residual rectal cancers. Intraoperative cryostat evaluation was used to confirm negative margin status, and all patients were subsequently followed with routine endoscopy, transrectal ultrasonography, and digital rectal examinations. RESULTS: Tumors were located between 1 cm and 7 cm from the anal verge (mean 4.3 ± 0.6 cm), and were located in lateral, anterior, and posterior positions. Mean followup was 55.2 ± 8.9 months (median 47.9 months). Imaging studies using CT, MRI, transrectal ultrasonography, or combination demonstrated suspicious lymph nodes in three patients. After neoadjuvant therapy, these lymph nodes were no longer demonstrated in two patients. There were no local recurrences, nodal metastases, or operative mortalities. One patient (9%) developed distant metastases (pulmonary nodules), and remains alive 30 months after transanal excision. One patient (9%) experienced sphincter laxity, which was successfully repaired, and is now asymptomatic. One patient (9%) developed postoperative urgency that resolved spontaneously. CONCLUSIONS: In patients who have initial bulky (T3) lesions, and experience significant downstaging after neoadjuvant chemoradiotherapy, transanal excision appears to be a safe and effective treatment, preserving sphincter function and avoiding laparotomy.

Risk factors for postthyroidectomy hypocalcemia

Abstract: Background Hypocalcemia is a common complication of thyroidectomy. The aim of this study was to evaluate the incidence of hypocalcemia after thyroid operation and its relation to clinical, biologic, and surgical factors. Study design A retrospective study of 265 patients who underwent unilateral (n = 50) or bilateral (n = 215) thyroidectomy between 1996 and 2000 was done to determine incidence and risk factors for hypocalcemia. Free thyroxine and thyrotropin levels were obtained before operation in 254 patients, together with preoperative and postoperative calcium and phosphorus levels. All patients were examined for age, gender, extent of thyroidectomy, initial versus reoperative neck operation, pathologic characteristics of resected thyroid tissue, substernal thyroid extension, and parathyroid resection and autotransplantation. Results Hypocalcemia, defined as a calcium level less than 2 mmol/L, occurred in 42 of 265 patients (16%), including 11 (4%) symptomatic patients who required vitamin D, calcium, or both for 2 to 6 weeks. Factors significantly predictive of postoperative hypocalcemia in univariate analysis included elevated free thyroxine level (p = 0.0064), bilateral thyroidectomy (p = 0.00064), parathyroid autotransplantation (p = 0.0128), and female gender (p = 0.0028). Independent risk factors on multivariate analysis were elevated free thyroxine level (p = 0.0476), bilateral thyroidectomy (p = 0.0338), and parathyroid autotransplantation (p = 0.0003). Conclusions Bilateral thyroidectomy, elevated free thyroxine level, and parathyroid autotransplantation are independent risk factors for postthyroidectomy hypocalcemia. Oral calcium supplements may be of value in this group of patients to enhance early hospital discharge.

Bleeding esophagogastric varices from extrahepatic portal hypertension: 40 years' experience with portal-systemic shunt.

Abstract: Background: This article discusses the largest and longest experience reported to date of the use of portal-systemic shunt (PSS) to treat recurrent bleeding from esophagogastric varices caused by extrahepatic portal hypertension associated with portal vein thrombosis (PVT). Study Design: Two hundred consecutive children and adults with extrahepatic portal hypertension caused by PVT who were referred between 1958 and 1998 after recovering from at least two episodes of bleeding esophagogastric varices requiring blood transfusions were managed according to a well-defined and uniformly applied protocol. All but 14 of the 200 patients were eligible for and received 5 or more years of regular followup (93%); 166 were eligible for and received 10 or more years of regular followup (83%). Results: The etiology of PVT was unknown in 65% of patients. Identifiable causes of PVT were neonatal omphalitis in 30 patients (15%), umbilical vein catheterization in 14 patients (7%), and peritonitis in 14 patients (7%). The mean number of bleeding episodes before PSS was 5.4 (range 2 to 18). Liver biopsies showed normal morphology in all patients. The site of PVT was the portal vein alone in 134 patients (76%), the portal vein and adjacent superior mesenteric vein in 10 patients (5%), and the portal and splenic veins in 56 patients (28%). Postoperative survival to leave the hospital was 100%. Actuarial 5-year, 10-year, and 15-year survival rates were 99%, 97%, and 95%, respectively. Five patients (2.5%), all with central end-to-side splenorenal shunts, developed thrombosis of the PSS, and these were the only patients who had recurrent variceal bleeding. During 10 or more years of followup, 97% of the eligible patients were shown to have a patent shunt and were free of bleeding. No patient developed portal-systemic encephalopathy, liver function tests remained normal, liver biopsies in 100 patients showed normal architecture, hypersplenism was corrected. Conclusion: PSS is the only consistently effective therapy for bleeding esophagogastric varices from PVT and extrahepatic portal hypertension, resulting in many years of survival, freedom from recurrent bleeding, normal liver function, and no encephalopathy.

Assessment of basic endoscopic performance using a virtual reality simulator

Abstract: Background The objective of this study was to evaluate the effect of supervised training using a state-of-the-art virtual reality (VR) genitourinary endoscopy simulator on the basic endoscopic skills of novice endoscopists. Study design We evaluated 21 medical students performing an initial VR case scenario (pretest) requiring rigid cystoscopy, flexible ureteroscopy with laser lithotripsy, and basket retrieval of a proximal ureteral stone. All students were evaluated with objective parameters assessed by the VR simulator and by two experienced evaluators using a global rating scale. Students were then randomized to a control group receiving no further training or a training group, which received five supervised training sessions using the VR simulator. All students were then evaluated again in the same manner using the same case scenario (posttest). Results Comparing the results of pre- and posttests, no major differences were demonstrated for any variable in the control group. In the trained group, posttest results revealed statistically significant improvement from baseline in the following parameters: total procedure time (p = 0.002), time to introduce a ureteral guidewire (p = 0.039), self-evaluation (p Conclusions Students trained on the VR simulator demonstrated statistically significant improvement on repeat testing, but the control group showed no improvement. Endourologic training using VR simulation facilitates performance of basic endourologic tasks and might translate into better performance in the operating room.

Factors associated with conversion to laparotomy in patients undergoing laparoscopic appendectomy.

Abstract: BACKGROUND: Laparoscopic appendectomy (LA) has been increasingly adopted for its advantages over the open technique, but there is a possibility of conversion to open appendectomy (OA) if complications occur or the extent of inflammation prohibits successful dissection. This study aimed to identify the preoperative predictors for conversion from laparoscopic to open appendectomy. STUDY DESIGN: Medical records of 705 consecutive patients who underwent surgery for suspected appendicitis were reviewed retrospectively. LA was attempted in 595 patients by 25 different surgeons. Factors evaluated were age, gender, body mass index, previous abdominal surgery, previous appendicitis attack, pain, nausea, vomiting, fever, duration of symptoms, local or diffuse tenderness, leukocyte count and surgeon's experience in LA. RESULTS: Conversion to OA occurred in 58 patients (9.7%). The most common reason for conversion was dense adhesions due to inflammation, followed by localized perforation and diffuse peritonitis. Based on 261 patients evaluated by CT scan preoperatively, significant factors in the final multivariate analysis associated with conversion to OA were age ≥ 65 [Odds ratio (OR) = 3.78, 95% CI:1.11–12.84], diffuse tenderness on physical examination (OR = 11.32, 95% CI:1.32–96.62), and a surgeon with less experience in LA (≤ 10 operations, OR=3.38, 95% CI:1.02–11.17). The presence of significant fat stranding associated with fluid accumulation, inflammatory mass or localized abscess in CT scan also significantly increased the possibility of conversion (OR = 5.60, 95% CI:2.48–12.65). CONCLUSIONS: Identifying the potential factors for conversion preoperatively may assist the surgeons in making decisions concerning the management of patients with appendicitis and in the judicious use of LA.

Locoregional recurrence and survival after curative resection of adenocarcinoma of the colon.

Abstract: BACKGROUND: There is wide variability in reported locoregional recurrence rates after curative resection of adenocarcinoma of the intraperitoneal colon, and there is no universally accepted surgical technique regarding length of the resected specimen or extent of lymphadenectomy. The aim of this study was to determine the disease-free survival, locoregional failure, and perioperative morbidity of patients undergoing curative resection of colon adenocarcinoma. STUDY DESIGN: The records of 316 consecutive patients undergoing curative resection for primary adenocarcinoma of the intraperitoneal colon between 1990 and 1995 were reviewed. Locoregional recurrence was defined as disease at the anastomosis or in the adjacent mesentery, peritoneum, retroperitoneum, or carcinomatosis. The product-limit method (Kaplan-Meier) was used to analyze survival and tumor recurrence. RESULTS: The study population comprised 167 men and 149 women, mean age 70 ± 12 years (range 22 to 95 years). Median followup was 63 ± 25 months. Five-year disease-free survival was 84% overall. Disease-free survival paralleled tumor stage: stage I, 99% (n = 73); stage II, 87% (n = 151); stage III, 72% (n = 92). The predominant pattern of tumor recurrence was distant failure only. Overall locoregional recurrence (locoregional and locoregional plus distant) at 5 years was 4%. Locoregional recurrence paralleled tumor stage: stage I, 0%; stage II, 2%; stage III, 10%. Of the 12 patients who suffered locoregional recurrence, 9 (75%) had T4 primary tumors, N2 nodal disease, or both. Major and minor complications occurred in 93 patients (29%) including: anastomotic leak or intraabdominal abscess (n = 4, 1%); hemorrhage (n = 8, 3%); cardiac complications (n = 17, 5%); pulmonary embolism (n = 4, 1%); death (n = 2, 1%). Multivariate analysis (Cox proportional hazards) revealed that the only independent predictor of disease-free survival and locoregional control was tumor stage. CONCLUSION: Longterm survival and locoregional control can be achieved for patients with colon cancer, with low morbidity. In the absence of adjacent organ invasion and N2 nodal disease, locoregional recurrence should be a rare event. Just as for rectal cancer, the technical aspects of colectomy for colon cancer deserve renewed attention.

Achieving R0 resection for locally advanced gastric cancer : is it worth the risk of multiorgan resection?

Abstract: BACKGROUND: In gastric adenocarcinoma, only complete resection (R0) translates into survival benefit. Given the potential for increased morbidity and mortality from multiple organ resection we asked the question as to whether extended (multiple organ) resection was justified for advanced gastric cancer. STUDY DESIGN: From July 1985 to July 2000, 1,283 patients underwent gastric resection for adenocarcinoma at Memorial Sloan-Kettering Cancer Center, and were entered and followed in a prospectively recorded database. Four hundred eighteen patients (33%) underwent primary resection and had one or more organs resected in addition to the stomach. Eight hundred twenty-six patients (64%) underwent gastrectomy alone, with 39 patients (3%) not undergoing gastrectomy. Clinicopathologic, operative, and morbidity data were evaluated in this group. Complications were categorized by severity on a scale from 0 to 5, 0 being no complication to 5 being death. Chi-square analysis and the logistic regression method were used to compare and estimate factors significantly associated with having a complication. RESULTS: Three hundred thirty-seven patients had a single additional organ resected, 63 had two organs, and 18 had three organs. Five hundred eighty complications occurred in 33% of patients (404 of 1,283). The perioperative mortality was 4% (48 patients). Logistic regression identified the number of organs resected, two or greater, to be predictive of complications (RR 2.0), as well as age greater than 70 years old (RR 1.57). When excluding minor complications (values 1 and 2), only the number of organs resected (RR 3.8) was a major factor for severe complications (values 3, 4, and 5). CONCLUSIONS: Resection of two or more adjacent organs in advanced gastric adenocarcinoma is associated with a greater risk of developing a complication. The use of a graded surgical complication scale is needed for better reporting and comparison of complications. Achieving an R0 resection should still be considered the goal, even in locally advanced gastric cancer, but resection of additional organs should be performed judiciously.

Predictors of mortality in adult trauma patients: the physiologic trauma score is equivalent to the Trauma and Injury Severity Score.

Abstract: Background: Several statistical models (Trauma and Injury Severity Score [TRISS], New Injury Severity Score [NISS], and the International Classification of Disease, Ninth Revision-based Injury Severity Score [ICISS]) have been developed over the recent decades in an attempt to accurately predict outcomes in trauma patients. The anatomic portion of these models makes them difficult to use when performing a rapid initial trauma assessment. We sought to determine if a Physiologic Trauma Score, using the systemic inflammatory response syndrome (SIRS) score in combination with other commonly used indices, could accurately predict mortality in trauma. Study Design: Prospective data were analyzed in 9,539 trauma patients evaluated at a Level I Trauma Center over a 30-month period (January 1997 to July 1999). A SIRS score (1 to 4) was calculated on admission (1 point for each: temperature >38°C or 90 beats per minute, respiratory rate >20 breaths per minute, neutrophil count > 12,000 or Results: The study cohort of 9,539 trauma patients (of which 7,602 patients had complete data for trauma score calculations) had a mean ISS of 9 ± 9 (SD) and mean age of 37 ± 17 years. SIRS (SIRS score ≥ 2) was present in 2,165 of 7,602 patients (28.5%). In single-variable models, TRISS and ISS were most predictive of outcomes. A multiple-variable model, Physiologic Trauma Score combining SIRS score with Glasgow Coma Score and age (Hosmer-Lemenshow chi-square = 4.74) was similar to TRISS and superior to ISS in predicting mortality. The addition of ISS to this model did not significantly improve its predictive ability. Conclusions: A new statistical model (Physiologic Trauma Score), including only physiologic variables (admission SIRS score combined with Glasgow Coma Score and age) and easily calculated at the patient bedside, accurately predicts mortality in trauma patients. The predictive ability of this model is comparable to other complex models that use both anatomic and physiologic data (TRISS, ISS, and ICISS).

Ethical regulations for innovative surgery: the last frontier?

Abstract: Background: There are no clear federal regulations governing innovative surgery, even though general guidelines regulating research with human subjects do exist. We hypothesized that US surgeons are unaware of Department of Health and Human Services regulations, rarely seek IRB review, generally oppose outside regulation of innovative surgery, and are uncertain what constitutes innovation and research. These circumstances, if true, would pose a significant ethical problem and present potential harm to patients as unwitting subjects of research. Study Design: In a pilot study we reviewed 527 issues of US surgical and medical journals, selecting 59 articles published between 1992 and 2000, that described innovative surgery. Corresponding authors from university hospitals (71%) and other facilities (29%) were sent an anonymous questionnaire. Results: The survey was conducted between November 2000 and May 2001. Twenty-one questionnaires were returned, completed with responses, constituting a 35% overall response rate. Fourteen authors confirmed their work was research, yet only six had sought prior IRB review. The majority of authors (15 of 21) did not submit their protocol to IRB. Only seven authors had mentioned the innovative nature of the procedure in the informed consent form. Seven authors claimed familiarity with Office for Human Research Protections definitions of research and human subject. Two-thirds of the respondents stated that government regulations for the protection of human subjects of innovative surgery would not be appropriate. Conclusions: The current system of definitions, ethical theories, and voluntary professional guidelines may be inadequate to meet the challenge of surgical innovation. Further research is proposed to examine the adequacy of the existing guidelines.