Showing papers in "Journal of The American College of Surgeons in 2009"

Necrotizing fasciitis: current concepts and review of the literature.

Abstract: M T b d d w f b a s i f t n ecrotizing soft-tissue infection (NSTI) was first described y Hippocrates circa 500 BC, when he wrote, “Many were ttacked by the erysipelas all over the body when the excitng cause was a trivial accident . . . flesh, sinews, and bones ell away in large quantities . . . there were many deaths.” espite many advances in our understanding of this disease nd great improvements in medical care, the mortality asociated with NSTI has not changed in the last 30 years and emains 25% to 35%. Mortality is directly proportional to ime to intervention. In addition, prevalence of this disase is such that the average practitioner will see only one or wo cases in his or her career. Physicians cannot be suffiiently familiar with NSTI to proceed rapidly with accurate iagnosis and the necessary management. The purpose of his article is to provide an evidence-based review of the icrobiology, pathophysiology, diagnosis, and treatment f NSTI. Because there are no adequately powered, ranomized, and blinded studies, the recommendations are ased on retrospective and nonblinded study data vailable. NSTI was described as “hospital gangrene” by British aval surgeons in the 18th and 19th century. Dr Joseph ones, a Confederate Army surgeon, was the first person to escribe this disorder in a large group of patients in 1871, hen he reported on 2,642 cases and found a mortality rate f 46%. In 1883, the French physician, Jean Alfred ournier, described a similar NSTI of the perineum in five ale patients—a process that continues to bear his name. It s now described in both male and female patients. In the nsuing years, many other terms, such as necrotizing erysiplas, streptococcal gangrene, and suppurative fasciitis, have een also been used. Because the gas-forming organism, lostridium perfringens, can be associated with this infecion, it has also been referred to as “Clostridial gangrene” or gas gangrene.” In 1951, Dr Wilson proposed the term necrotizing fascitis to include both gas-forming and non gas-forming ne-

Colonic Anastomotic Leak: Risk Factors, Diagnosis, and Treatment

Abstract: P O s v l l i b t t r t a V s w o nastomotic dehiscence is one of the most dreaded comlications of operations of the large intestine. Breakdown f an anastomosis results in increased morbidity and morality and adversely affects length of stay, cost, and cancer ecurrence. Reported rates of anastomotic dehiscence vary etween 1% and 30%, although experienced colorectal urgeons often quote 3% to 6% as an acceptable overall eakage rate(Table 1). Despite a paucity of prospective andomized data, intuitively it would appear that emergent perations are at greater risk for anastomotic breakdown han those procedures performed electively. Confounding he issue is that there are differing opinions as to what risk actors have been proved to predict anastomotic dehisence. The aim of this review is to examine the currently dentified risk factors contributing to intestinal anastootic breakdown and delineate methods of diagnosis and reatment of this universally dreaded complication.

Intraoperative Transfusion of 1 U to 2 U Packed Red Blood Cells Is Associated with Increased 30-Day Mortality, Surgical-Site Infection, Pneumonia, and Sepsis in General Surgery Patients

Abstract: Background Transfusion of packed red blood cells (PRBCs) increases morbidity and mortality in select surgical specialty patients. The impact of low-volume, leukoreduced RBC transfusion on general surgery patients is less well understood. Study Design The American College of Surgeons National Surgical Quality Improvement Program participant use file was queried for general surgery patients recorded in 2005 to 2006 (n = 125,223). Thirty-day morbidity (21 uniformly defined complications) and mortality, demographic, preoperative, and intraoperative risk variables were obtained. Infectious complications and composite morbidity and mortality were stratified across intraoperative PRBCs units received. Multivariable logistic regression was used to assess influence of transfusion on outcomes, while adjusting for transfusion propensity, procedure type, wound class, operative duration, and 30+ patient risk factors. Results After adjustment for transfusion propensity, procedure group, wound class, operative duration, and all other important risk variables, 1 U PRBCs significantly (p Conclusions Intraoperative transfusion of PRBCs increases risk for mortality and several morbidities in general surgery patients. These risks, substantial for even 1 U, remain after adjustment for transfusion propensity and numerous risk factors available in the American College of Surgeons National Surgical Quality Improvement Program. Transfusion for mildly hypovolemic or anemic patients should be discouraged in light of these risks.

Massive Transfusion Protocols: The Role of Aggressive Resuscitation Versus Product Ratio in Mortality Reduction

Abstract: Background Exsanguinating hemorrhage necessitating massive blood product transfusion is associated with high mortality rates. Recent data suggest that altering the fresh frozen plasma to packed red blood cell ratio (FFP:PRBC) results in significant mortality reductions. Our purpose was to evaluate mortality and blood product use in the context of a newly initiated massive transfusion protocol (MTP). Study Design In July 2005, our American College of Surgeons-verified Level I trauma center implemented an MTP supporting a 1:1.5 FFP:PRBC ratio, improved communications, and enhanced systems flow to optimize rapid blood product availability. During the 4 years surrounding protocol implementation, we reviewed data on trauma patients directly admitted through the emergency department and requiring 10 or more units PRBCs during the first 24 hours. Results For the 2 years before and subsequent to MTP initiation, there were 4,223 and 4,414 trauma activations, of which 40 and 37 patients, respectively, met study criteria. The FFP:PRBC ratios were identical, at 1:1.8 and 1:1.8 (p = 0.97). Despite no change in FFP:PRBC ratio, mortality decreased from 45% to 19% (p = 0.02). Other significant findings included decreased mean time to first product: cross-matched RBCs (115 to 71 minutes; p=0.02), FFP (254 to 169 minutes; p=0.04), and platelets (418 to 241 minutes; p=0.01). Conclusions MTP implementation is associated with mortality reductions that have been ascribed principally to increased plasma use and decreased FFP:PRBC ratios. Our study found a significant reduction in mortality despite unchanged FFP:PRBC ratios and equivalent overall mean numbers of transfusions. Our data underscore the importance of expeditious product availability and emphasize that massive transfusion is a complex process in which product ratio and time to transfusion represent only the beginning of understanding.

Vascular complications of orthotopic liver transplantation: experience in more than 4,200 patients.

Abstract: Background Thromboses of the hepatic artery (HAT) and portal vein (PVT) may complicate orthotopic liver transplantation (OLT) and result in graft loss and mortality. Revision and retransplantation are treatment options, but their longterm outcomes remain undefined. This study was undertaken to evaluate the incidence of major vascular complications after OLT, determine efficacy of therapies, and identify factors influencing longterm outcomes. Study Design All patients undergoing OLT from 1984 to 2007 were evaluated. Kaplan-Meier analysis was performed to define the effects of vascular complications on posttransplant survival. Anastomotic revision and arterial thrombolysis were compared with retransplantation as treatment for HAT. After 2002, porta hepatis dissection was initiated with early occlusion of common hepatic artery (CHA) inflow; its impact on HAT incidence was determined. Results From 1984 to 2007, 4,234 OLTs were performed. HAT occurred in 203 patients (5%) and PVT in 84 (2%). Graft survival was significantly reduced by HAT or PVT; patient survival was reduced only by PVT. Retransplantation for HAT improved patient survival over revision or thrombolysis in the first year but did not provide longterm survival advantage (56% versus 56% at 5 years; p=0.53). Patients with HAT had only 10% graft salvage with anastomotic revision or thrombolysis. HAT was significantly reduced with early CHA inflow occlusion (1.1% versus 3.7%; p=0.002). Factors increasing risk of HAT included pediatric recipients, liver cancer, and aberrant arterial anatomy requiring complex reconstruction. Conclusions Both HAT and PVT significantly reduce graft survival after OLT; PVT more adversely affects patient survival. Revision and thrombolysis rarely salvage grafts after HAT; retransplantation provides superior short-term, but not longterm, survival. Avoidance of vascular complications in OLT is critical, especially with today's scarcity of donor livers. Early atraumatic CHA occlusion significantly reduces the incidence of HAT.

Development of an American College of Surgeons National Surgery Quality Improvement Program: morbidity and mortality risk calculator for colorectal surgery.

Abstract: Background Surgical decision-making and informed patient consent both benefit from having accurate information about risk. But currently available risk estimating systems have one or more limitations associated with lack of specificity to operation type, size of sample (reliability), range of outcomes predicted, and appreciation of hospital effects. Study Design Data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) patients who underwent colorectal surgery in 2006 to 2007 were used to generate logistic prediction models for 30-day morbidity, serious morbidity, and mortality. Results for these three models were then used to construct a universal multivariable model to predict risk for all three outcomes. Model performance was externally validated against 2005 data. Results For 2006 to 2007, 28,863 patients were identified who underwent major colorectal operations at 182 hospitals. A single 15-variable predictor model exhibited discrimination (c-statistic) close to that observed for the separate models on all three outcomes. Similar discrimination was found when the 2006 to 2007 universal model was applied to 3,037 operations conducted in 2005 at 37 hospitals. Conclusions The ACS NSQIP colorectal risk calculator allows surgeons to preoperatively provide patients with detailed information about their personal risks of overall morbidity, serious morbidity, and mortality. Because ACS NSQIP can also categorize hospitals as performing better or worse than expected (or as expected), surgeons have the opportunity to adjust risk probabilities for patients at their institutions accordingly.

Elevated Breast Cancer Mortality in Women Younger than Age 40 Years Compared with Older Women Is Attributed to Poorer Survival in Early-Stage Disease

Abstract: Background We investigated differences in breast cancer mortality between younger (younger than 40 years of age) and older (40 years of age and older) women by stage at diagnosis to identify patient and tumor characteristics accounting for disparities. Study Design We conducted a retrospective study of women diagnosed with breast cancer in the 1988 to 2003 Surveillance, Epidemiology, and End Results Program data. Multivariate Cox regression models calculated adjusted hazard ratios (aHR) and 95% confidence intervals to compare overall and stage-specific breast cancer mortality in women younger than 40 years old and women 40 years and older, controlling for potential confounding variables identified in univariate tests. Results Of 243,012 breast cancer patients, 6.4% were younger than 40 years old, and 93.6% were 40 years of age or older. Compared with older women, younger women were more likely to be African American, single, diagnosed at later stages, and treated by mastectomy. Younger women had tumors that were more likely to be higher grade, larger size, estrogen receptor/progesterone receptor–negative, and lymph-node positive (p Conclusions Higher breast cancer mortality in younger women was attributed to poorer outcomes with early-stage disease. Additional studies should focus on specific tumor biology contributing to the increased mortality of younger women with early-stage breast cancer.

Does Type of Pancreaticojejunostomy after Pancreaticoduodenectomy Decrease Rate of Pancreatic Fistula? A Randomized, Prospective, Dual-Institution Trial

Abstract: Background Pancreatic fistula (PF) is one of the most common complications after pancreaticoduodenectomy. There have been no large prospective randomized trials evaluating PF rates comparing invagination versus duct to mucosa pancreaticojejunostomy. We tested the hypothesis that a duct to mucosa pancreaticojejunostomy would reduce the PF rate. Study Design Between August 2006 and May 2008, 197 patients at two institutions underwent pancreaticoduodenectomy by a total of 8 experienced pancreatic surgeons as part of this prospective randomized trial (clinical trial no. NCT00359320). All patients were stratified by pancreatic texture and randomized to either an invagination or a duct to mucosa pancreaticojejunal anastomosis. Recorded variables included pancreatic duct diameter, operative time, blood loss, complications, and pathology. Primary end point was PF rate, as defined by the International Study Group on Pancreatic Fistula. Secondary end points included PF grade, postoperative length of hospital stay, other morbidities, and mortality. Results Rate of PF for the entire cohort was 17.8%. There were 23 fistulas (24%) in the duct to mucosa cohort and 12 fistulas (12%) in the invagination cohort (p Conclusions This dual-institution prospective randomized trial reveals considerably fewer fistulas with invagination compared with duct to mucosa pancreaticojejunostomy after pancreaticoduodenectomy. Results confirm increased PF rates in soft as compared with hard glands. Additional studies are needed to define the optimal technique of pancreatic reconstruction after pancreaticoduodenectomy.

Accelerated partial breast irradiation consensus statement from the American Society for Radiation Oncology (ASTRO).

Abstract: Purpose To present guidance for patients and physicians regarding the use of accelerated partial-breast irradiation (APBI), based on current published evidence complemented by expert opinion. Methods and Materials A systematic search of the National Library of Medicine's PubMed database yielded 645 candidate original research articles potentially applicable to APBI. Of these, 4 randomized trials and 38 prospective single-arm studies were identified. A Task Force composed of all authors synthesized the published evidence and, through a series of meetings, reached consensus regarding the recommendations contained herein. Results The Task Force proposed three patient groups: ( 1 ) a "suitable" group, for whom APBI outside of a clinical trial is acceptable, ( 2 ) a "cautionary" group, for whom caution and concern should be applied when considering APBI outside of a clinical trial, and ( 3 ) an "unsuitable" group, for whom APBI outside of a clinical trial is not generally considered warranted. Patients who choose treatment with APBI should be informed that whole-breast irradiation (WBI) is an established treatment with a much longer track record that has documented long-term effectiveness and safety. Conclusion Accelerated partial-breast irradiation is a new technology that may ultimately demonstrate long-term effectiveness and safety comparable to that of WBI for selected patients with early breast cancer. This consensus statement is intended to provide guidance regarding the use of APBI outside of a clinical trial and to serve as a framework to promote additional clinical investigations into the optimal role of APBI in the treatment of breast cancer.

Association of Routine Pretreatment Magnetic Resonance Imaging with Time to Surgery, Mastectomy Rate, and Margin Status

Abstract: Background The benefit of breast MRI for newly diagnosed breast cancer patients is uncertain. This study characterizes those receiving MRI versus those who did not, and reports on their short-term surgical outcomes, including time to operation, margin status, and mastectomy rate. Study Design All patients seen in a multidisciplinary breast cancer clinic from July 2004 to December 2006 were retrospectively reviewed. Patients were evaluated by a radiologist, a pathologist, and surgical, radiation, and medical oncologists. Results Among 577 patients, 130 had pretreatment MRIs. MRI use increased from 2004 (referent, 13%) versus 2005 (24%, p=0.014) and 2006 (27%, p=0.002). Patients having MRIs were younger (52.5 versus 59.0 years, p Conclusions Breast MRI use was not confined to any particular patient group. MRI use was not associated with improved margin status or BCT attempts, but was associated with a treatment delay and increased mastectomy rate. Without evidence of improved oncologic outcomes as a result, our study does not support the routine use of MRI to select patients or facilitate the performance of BCT.

Human polymerized hemoglobin for the treatment of hemorrhagic shock when blood is unavailable: the USA multicenter trial.

Abstract: Background Human polymerized hemoglobin (PolyHeme, Northfield Laboratories) is a universally compatible oxygen carrier developed to treat life-threatening anemia. This multicenter phase III trial was the first US study to assess survival of patients resuscitated with a hemoglobin-based oxygen carrier starting at the scene of injury. Study Design Injured patients with a systolic blood pressure≤90 mmHg were randomized to receive field resuscitation with PolyHeme or crystalloid. Study patients continued to receive up to 6 U of PolyHeme during the first 12 hours postinjury before receiving blood. Control patients received blood on arrival in the trauma center. This trial was conducted as a dual superiority/noninferiority primary end point. Results Seven hundred fourteen patients were enrolled at 29 urban Level I trauma centers (79% men; mean age 37.1 years). Injury mechanism was blunt trauma in 48%, and median transport time was 26 minutes. There was no significant difference between day 30 mortality in the as-randomized (13.4% PolyHeme versus 9.6% control) or per-protocol (11.1% PolyHeme versus 9.3% control) cohorts. Allogeneic blood use was lower in the PolyHeme group (68% versus 50% in the first 12 hours). The incidence of multiple organ failure was similar (7.4% PolyHeme versus 5.5% control). Adverse events (93% versus 88%; p=0.04) and serious adverse events (40% versus 35%; p=0.12), as anticipated, were frequent in the PolyHeme and control groups, respectively. Although myocardial infarction was reported by the investigators more frequently in the PolyHeme group (3% PolyHeme versus 1% control), a blinded committee of experts reviewed records of all enrolled patients and found no discernable difference between groups. Conclusions Patients resuscitated with PolyHeme, without stored blood for up to 6 U in 12 hours postinjury, had outcomes comparable with those for the standard of care. Although there were more adverse events in the PolyHeme group, the benefit-to-risk ratio of PolyHeme is favorable when blood is needed but not available.

Intensivist Use of Hand-Carried Ultrasonography to Measure IVC Collapsibility in Estimating Intravascular Volume Status: Correlations with CVP

Abstract: Background Volume status assessment is an important aspect of patient management in the surgical intensive care unit (SICU). Echocardiologist-performed measurement of IVC collapsibility index (IVC-CI) provides useful information about filling pressures, but is limited by its portability, cost, and availability. Intensivist-performed bedside ultrasonography (INBU) examinations have the potential to overcome these impediments. We used INBU to evaluate hemodynamic status of SICU patients, focusing on correlations between IVC-CI and CVP. Study Design Prospective evaluation of hemodynamic status was conducted on a convenience sample of SICU patients with a brief (3 to 10 minutes) INBU examination. INBU examinations were performed by noncardiologists after 3 hours of didactics in interpreting and acquiring two-dimensional and M-mode images, and ≥25 proctored examinations. IVC-CI measurements were compared with invasive CVP values. Results Of 124 enrolled patients, 101 had CVP catheters (55 men, mean age 58.3 years, 44.6% intubated). Of these, 18 patients had uninterpretable INBU examinations, leaving 83 patients with both CVP monitoring devices and INBU IVC evaluations. Patients in three IVC-CI ranges ( 0.60) demonstrated significant decrease in mean CVP as IVC-CI increased (p = 0.023). Although 40% of this group had a CVP >12 mmHg. Conversely, >60% of patients with IVC-CI >0.6 had CVP Conclusions Measurements of IVC-CI by INBU can provide a useful guide to noninvasive volume status assessment in SICU patients. IVC-CI appears to correlate best with CVP in the setting of low ( 0.60) collapsibility ranges. Additional studies are needed to confirm and expand on findings of this study.

Surgical Management of Solid-Pseudopapillary Neoplasms of the Pancreas (Franz or Hamoudi Tumors): A Large Single-Institutional Series

Abstract: Background Solid-pseudopapillary neoplasms (SPNs) are rare pancreatic tumors with malignant potential. Clinicopathologic characteristics and outcomes of patients with SPN were reviewed. Study Design Longterm outcomes were evaluated in patients with an SPN who were followed from 1970 to 2008. Results Thirty-seven patients were identified with an SPN. Thirty-three (89%) were women, and median age at diagnosis was 32 years. Most patients were symptomatic; the most common symptom was abdominal pain (81%). Thirty-six patients underwent resection; one patient with distant metastases was not operated on. There were no 30-day mortalities. Median tumor size was 4.5 cm. Thirty-four patients underwent an R0 resection, 1 had an R1 resection, and 1 had an R2 resection. Two patients had lymph node metastases, and one patient had perineural invasion. After resection, 34 (94%) patients remain alive. One patient died of unknown causes 9.4 years after resection, and another died of unrelated causes 25.6 years after operation. The patient with widespread disease who didn't have resection died 11 months after diagnosis. Thirty-five of the 36 patients having resection remained disease free, including those who died of unrelated causes (median followup, 4.8 years). One patient developed a recurrence 7.7 years after complete resection. She was treated with gemcitabine and remains alive 13.6 months after recurrence. Conclusions SPNs are rare neoplasms with malignant potential found primarily in young women. Formal surgical resection may be performed safely and is associated with longterm survival.

Intraoperative fluorescent cholangiography using indocyanine green: a biliary road map for safe surgery.

Abstract: F T i m k c 8 nlike blood vessels, the biliary tract lies in the Glissonian heath and is buried in the perivascular connective tissue, o it is difficult to clearly visualize and isolate it during epatobiliary surgery. Intraoperative cholangiography IOC), which was originally introduced by Mirizzi in 937, has been widely used to delineate the biliary tract natomy in this setting. For example, routine IOC was ecently recommended during cholecystectomy to prevent ile duct injury. IOC is also considered an essential proedure during donor hepatectomy because it enables the ile duct to be divided at the appropriate level to ensure ider and fewer residual orifices. But conventional raiographic IOC is disadvantageous in that it exposes the atient and the medical staff to radiation and usually reuires a large and expensive C-arm fluoroscopy machine nd the additional human resources involved. Recently, intraoperative angiography using a fluorescent maging technique with IV injection of indocyanine green ICG) has been used to assess coronary artery bypass graft atency. This technique is based on the principle that CG binds to plasma proteins and that protein-bound ICG mits light with a peak wavelength of about 830 nm when lluminated with near-infrared light. Because human ile also contains plasma proteins that bind with ICG, we ypothesized that fluorescent images of the biliary tract ould be obtained with intrabiliary injection of ICG. We lso hypothesized that IV injection of ICG would provide luorescent images of the biliary tract without necessitating

The briefing, intraoperative teaching, debriefing model for teaching in the operating room.

Abstract: r he need for a more deliberate approach to operating room eaching becomes more imperative as duty hour restricions limit the exposure residents have to the operating oom. A good model for deliberate teaching in the operatng room would focus the teacher on setting objectives for he learner’s performance, providing immediate and speific feedback, and providing guidance for future practice. he ideal model would allow surgeons to achieve these ducational goals within the context of their already existng practice. We propose a model for teaching in the operting room that fosters good educational practice, takes dvantage of the naturally existing observation and teachng opportunities available to the teaching surgeon, and fits asily into the surgeon’s existing routine. Surgical residency, as Atul Gawandedescribed it, coninues to depend on “the wonderful, time-honored, throatonstricting method of learning-by-doing on the job trainng . . ..” Reznick and MacRae concurred, stating that olume is the hallmark of surgical training. “Learning by oing” rests on the belief that experience alone will lead to earning. This is a pure discovery model of learning, preised on the idea that through practice and self directed earning, students will develop appropriate rules and unerstandings to guide future practice. Mayer made the onvincing case that pure, unguided discovery learning is neffective and inefficient, does not guarantee that students ill even come in contact with the needed learning opporunities, and does not guarantee that students will learn the ules that guide future practice. He reviewed three lines of esearch in which students were called on to learn, either hrough pure discovery learning or through guided discovry learning. In guided discovery learning, an expert proides the novice with preparatory information before the xperience and offers verbal and perhaps manual guidance uring the experience and feedback afterward. In each case, he students using guided discovery learning learned more uickly, more accurately, and were more likely to remember

Evidence-based approach to cholangiocarcinoma: a systematic review of the current literature.

Abstract: adjusted mortality rate increased from 0.07 per 100,000 in 1973 to 0.69 per 100,000 in 1997, with average age at presentation in the 7th decade of life and male-to-female ratio of 1.5. 9 Extrahepatic CC In the United States, age-adjusted incidence of extrahepatic CC (ECC) is 1.2 per 100,000 in men and 0.8 per 100,000 in women 10 and has decreased by 14% compared with two decades earlier. ECC usually present in the 7th decade of life.

The volume-outcomes effect in hepato-pancreato-biliary surgery: hospital versus surgeon contributions and specificity of the relationship.

Abstract: Background Although the relationship between hepato-pancreato-biliary (HPB) procedure volume and outcomes is established, the relative importance of hospital and surgeon effects and the specificity of the volume-outcomes effect remain ill-defined. We sought to comprehensively characterize the hospital and surgeon volume-outcomes relationships in high-risk HPB surgery. Study Design The 1998 to 2005 State Inpatient Databases for Florida, Maryland, and New York were used to identify patients undergoing complex HPB surgery and to quantify hospital and surgeon procedure volumes. The effects of hospital and surgeon procedure volumes on casemix-adjusted inpatient mortality were analyzed using multilevel logistic regression models. Results For hepatic resection, hospital procedure volume predicted mortality (high versus low volume, odds ratio [OR] 0.48, p=0.04), but surgeon volume did not (p=0.42). For pancreatic resection, in contrast, both hospital (OR 0.32, p Conclusions In HPB surgery, the relative contributions of hospital versus surgeon volume vary according to the specific procedure in question. In addition, the association between hospital or surgeon volume and in-hospital mortality is very specific to the procedure in question. High-volume expertise in one area of HPB surgery does not translate into improved outcomes for related procedures. These data may have implications for quality assessment and improvement, patient referral, and HPB surgical training.

Risk Factors for Anastomotic Leakage after Laparoscopic Intracorporeal Colorectal Anastomosis with a Double Stapling Technique

Abstract: Background Laparoscopic rectal transection carries the risk of anastomotic leakage because of its technical difficulty and long staple line with an inadequate cutting angle. Our objective was to investigate the risk factors affecting anastomotic leakage after laparoscopic intracorporeal colorectal anastomosis with a double stapling technique. Study Design Between November 2006 and September 2008, 270 consecutive patients underwent laparoscopic sigmoidectomy and anterior resection with double stapling technique for distal sigmoid and rectal cancer. Data were collected prospectively. Univariate and multivariate analyses were performed to determine risk factors for anastomotic leakage. Additionally, we evaluated the relationship between the number of stapler firings and clinical parameters. Results Anastomotic leakage was noted in 17 (6.3%) of 270 patients. In univariate analyses, tumor location (p = 0.021), operation time (p = 0.025), number of stapler firings (p = 0.040), and diameter of the circular stapler (p = 0.022) were significant risk factors for anastomotic leakage. Multivariate analyses showed that middle or lower rectal cancer was an independent factor affecting anastomotic leakage (p = 0.013). The number of stapler firings increased significantly in men (p = 0.023), in patients with a tumor at a lower level (p = 0.034), and in those with longer operation times (p Conclusions A reduction in the number of linear stapler firings is necessary to avoid anastomotic leakage after laparoscopic colorectal anastomosis with a double stapling technique. We recommend that a diverting ileostomy is mandatory in patients with middle and lower rectal cancer where multiple linear staplers were used.

Enteric Fistulas: Principles of Management

Abstract: In the past decade, surgeons have seen a quiet but dramatic shift in clinical patterns of enteric fistulas. Despite advances in nutritional care, infection control, and surgical technique, an enterocutaneous fistula (ECF) remains a source of considerable morbidity and mortality. In addition, wide adoption of damage control and the open abdomen in trauma and emergency surgery have confronted surgeons with a new and especially vicious adversary: the enteroatmospheric (or exposed) fistula (EAF). These fistulas, occurring in the midst of an open abdominal wound, are very difficult to control and present a particularly lethal challenge. Such EAFs might well be the most common type of enteric fistula facing surgeons today. Yet this shift in clinical patterns from the classic ECF to the new EAF is still totally disregarded in major surgical texts. The aim of this review is to present current principles in the management of enteric fistulas. Additionally, we will demonstrate how traditional principles of managing enteric fistulas help us to better understand the physiology and natural history of EAFs and to deal effectively with this new challenge.

Simultaneous Versus Staged Resection for Synchronous Colorectal Cancer Liver Metastases

Abstract: BACKGROUND: The aim of this study was to compare postoperative outcomes of patients with synchronous colorectal liver metastases treated with either simultaneous or staged colectomy and hepatectomy. STUDY DESIGN: From July 1997 to June 2008, a review of our 1,344-patient prospective hepato-pancreaticobiliary database identified 230 patients treated surgically for primary adenocarcinoma of the large bowel and synchronous hepatic metastasis. Clinicopathologic, operative, and perioperative data, complications, and grade of complications (grade 1, minor, to grade 5, death) were reviewed to evaluate selection criteria, operative methods, and perioperative outcomes. Chisquare and proportional hazard model were used to evaluate predictors of outcomes. RESULTS: Seventy patients underwent simultaneous resection of colon primary and liver metastasis in a single operation; 160 patients underwent staged operations. Simultaneous resections were similar for size (median 4 cm versus 3.7 cm) and number (median 3 cm versus 3 cm) of liver metastases. Major liver resections (3 Couinaud segments) were similar between staged and simultaneous (32% versus 33%, respectively), as was type of colectomy (p 0.2). Complication rates and severity were similar in both groups: 39 of 70 patients (56%) in the simultaneous groupexperienced63complicationsversus88of160patients(55%)with162complicationsin the staged group (p 0.24). Multivariate analysis identified blood transfusion as a predictor of complication (odds ratio 2.98, p 0.001). Patients having simultaneous resection required fewer days in the hospital (median 10 days versus 18 days, p 0.001). CONCLUSIONS: By avoiding a second laparotomy, simultaneous colon and hepatic resection reduces overall hospitalstay,withnodifferenceinmorbidityandmortalityratesorinseverityofcomplications, comparedwithstagedresection.Simultaneousresectionisanacceptableoptioninpatientswith resectable synchronous colorectal metastasis. (J Am Coll Surg 2009;208:842–852. © 2009 by the American College of Surgeons) Synchronous liver metastasis, commonly defined as liver metastasis occurring within 12 months of the colon primary, represents 13% to 25% of 90,000 newly diagnosed colorectal liver metastases. 1,2 Through the expansion of multidisciplinary care with advances in surgical training, surgical techniques (laparoscopy and ablation), anesthetic management, and chemotherapy, the overall survival of

Operations for Intrahepatic Cholangiocarcinoma: Single-Institution Experience of 158 Patients

Abstract: Background Intrahepatic cholangiocarcinoma (ICC) is a rare primary liver malignancy. Until now, outcomes and prognostic factors after liver resection for these tumors have not been well-documented. Study Design Between April 1998 and December 2006, a total of 158 patients underwent surgical exploration in our institution for intended liver resection of ICC. Prospectively collected data of patients undergoing liver resection (n = 83) were analyzed with regard to preoperative findings, operative details, perioperative morbidity and mortality, pathologic findings, outcomes measured by tumor recurrence and survival, and prognostic factors for outcomes. Results Tumors were solitary in 47 patients. R0 resections were achieved in 53 patients. Vascular infiltration and lymph node metastasis were detected in 41% and 34%, respectively. After resection, the calculated 1-, 3-, and 5-year-survival rates were 71%, 38%, and 21%, respectively, with corresponding rates of 83%, 50%, and 30% in R0 resections. For 14 variables evaluated, only gender (p = 0.008), Union Internationale Contre le Cancer stage (p = 0.014), and R classification (p = 0.001) showed predictive value in the multivariate Cox proportional hazard regression. Conclusions Results presented outline that an R0 resection leads to substantially prolonged survival in ICC and represents the considerable input of the surgeon to the outcomes of these patients. Union Internationale Contre le Cancer stage remains an important factor.

Single-Incision Laparoscopic Cholecystectomy Using Conventional Instruments: Early Experience in Comparison with the Gold Standard

Abstract: Background The aim of this pilot study was to describe our initial experience with single-incision laparoscopic cholecystectomy (SILC) using conventional laparoscopic equipment in comparison with concurrent patients undergoing conventional multiincision laparoscopic cholecystectomy. Study Design During the 7-month study period, data from all consecutive patients undergoing SILC by two surgeons were retrospectively analyzed and compared with data from patients undergoing conventional laparoscopic cholecystectomy by the same surgeons during the same time period. Outcomes measures included completion rate of attempted SILC, operative time, length of hospital stay, postoperative pain, and assessment of complications. Results From 51 laparoscopic cholecystectomies performed during the study period, 29 were attempted using single-incision technique and 22 were performed using the conventional four incisions. Of the attempted SILC cases, 14 (48%) were successfully completed, with the remainder requiring one to three additional skin incisions. There were no conversions to open in either group. Operative time was significantly longer in SILC cases compared with conventional laparoscopic cholecystectomy (85 versus 67 minutes; p=0.01). There was a tendency toward greater postoperative pain in the SILC group. No substantial difference in complications was identified. Conclusions SILC using conventional laparoscopic instrumentation is an effective alternative to standard four-incision laparoscopic cholecystectomy in selected patients. Development of a standardized technique and additional experience is needed for more consistent success. Additional studies of SILC are needed to demonstrate safety, define selection criteria, and determine any benefits over conventional laparoscopic cholecystectomy.

Results of a national survey of surgical resident interest in international experience, electives, and volunteerism.

Abstract: Background Data are emerging about the essential nature of sustainable global surgical care and interest among North American surgeons. Currently, there is no formal mechanism for US surgical residents to participate in international training opportunities. A small, single-institution survey found that general surgery residents at New York University are highly motivated to pursue international training. But little research has addressed the attitudes of North American residents about international training. The goal of this study was to acquire a broader understanding of surgical resident interest in international training. Study Design A structured questionnaire was administered anonymously and voluntarily to all American College of Surgeons resident members. Results Seven hundred twenty-four residents completed surveys. Ninety-four percent of respondents planned careers in general surgery. Ninety-two percent of respondents were interested in an international elective, and 82% would prioritize the experience over all or some other electives. Fifty-four percent and 73% of respondents would be willing to use vacation and participate even if cases were not counted for graduation requirements, respectively. Educational indebtedness was high among respondents (50% of respondents carried ≥$100,000 debt). Despite debt, 85% of respondents plan to volunteer while in practice. The most frequent barriers identified by respondents were financial (61%) and logistic (66%). Conclusions American College of Surgeons resident members are highly motivated to acquire international training experience, with many planning to volunteer in the future. A consensus among stakeholders in North American surgical education is needed to further explore international training within surgical residency.

Patient-reported Outcomes of Breast Reconstruction after Mastectomy: a Systematic Review

Abstract: Breast reconstruction is commonly utilized after mastectomy for breast cancer and is generally felt to improve women’s quality of life and well-being.1 However, most studies that have evaluated breast reconstruction have focused on outcomes that may not be relevant to patients or that are of interest primarily to surgeons (such as fat necrosis, symmetry without clothing),2–4 and many studies have not compared outcomes of breast reconstruction to outcomes of mastectomy only. In addition, recent findings of large geographic variations in rates of breast reconstruction have called into question the appropriateness of who gets breast reconstruction.5–8 Thus, our understanding of the impact of breast reconstruction on women’s lives remains somewhat limited. The purpose of this systematic review is to evaluate studies examining patient-reported outcomes of breast reconstruction after mastectomy for breast cancer, compared to mastectomy only.

Nationwide Volume and Mortality after Elective Surgery in Cirrhotic Patients

Abstract: Background The outcomes after elective surgery in patients with cirrhosis have not been well studied. Study Design We used the Nationwide Inpatient Sample (NIS) to identify all patients undergoing elective surgery for four index operations (cholecystectomy, colectomy, abdominal aortic aneurysm repair, and coronary artery bypass grafting) from 1998 to 2005. Elixhauser comorbidity measures were used to characterize patients' disease burden. Three distinct groups were created based on severity of liver disease: patients without cirrhosis (NON-CIRR), those with cirrhosis (CIRR), and patients with cirrhosis complicated by portal hypertension (PHTN). In-hospital mortality was the primary endpoint. Results There were 22,569 patients with cirrhosis (of whom 4,214 had PHTN) who underwent 1 of the 4 index operations compared with approximately 2.8 million patients without cirrhosis having these operations. Patients with CIRR or PHTN were more likely to be women (49.5% versus 44.0%, p Conclusions In-hospital mortality, length of stay, and total hospital charges are significantly higher after elective surgery in cirrhotic patients, even in the absence of portal hypertension. Careful decision-making about surgery in these patients is critical as the nationwide increase in hepatitis C and cirrhosis continues.

Prognostic implications of isolated tumor cells and micrometastases in sentinel nodes of patients with invasive breast cancer: 10-year analysis of patients enrolled in the prospective East Carolina University/Anne Arundel Medical Center Sentinel Node Multicenter Study.

Abstract: Background Sentinel lymph node biopsy (SLNB) is a more sensitive and accurate nodal staging procedure than axillary lymph node dissection (ALND). Because of increased pathologic evaluation in the sentinel node era, more nodal micrometastases (MIC) (> 0.2 mm to 2 mm) and isolated tumor cells (ITC; ≤ 0.2 mm) have been identified. We present the 10-year analysis of our prospective SLN study, focusing on regional axillary node status and distant metastases in patients with nodal ITC and MIC. Study Design From 1996 to 2005, breast cancer patients were enrolled in an Institutional Review Board-approved, multicenter study. SLNs were examined at multiple levels by hematoxylin and eosin; most (85%) hematoxylin and eosin-negative SLNs were also examined by cytokeratin immunohistochemistry. Data from 1,259 patients with invasive breast cancer and in whom an SLN was found were reviewed for this analysis. Results Of the 1,259 patients, 893 (71%) had negative SLNs, 25 (2%) had ITCs, 57 (5%) had MIC, and 284 (23%) had positive SLNs. None of the 13 patients with ITCs who underwent an ALND had additional positive nodes, compared with 27% (11 of 41) of patients with MIC. At a mean followup of 4.9 years, the distant recurrence rates for SLN-negative, ITC, MIC, and SLN-positive groups were 6%, 8%, 14%, and 21%, respectively. The presence of MIC in the SLN was associated with a significantly shorter disease-free interval than was SLN negativity (p Conclusions This prospective breast cancer study found that sentinel node MIC, but not ITCs, were associated with additional positive nodes and with distant recurrence. These data suggest that ALND may be unnecessary in patients with ITCs. But ALND and more aggressive adjuvant therapy should be considered in patients with SLN micrometastases.

Using Objective Structured Assessment of Technical Skills to Evaluate a Basic Skills Simulation Curriculum for First-Year Surgical Residents

Abstract: Background In response to new Accreditation Council for Graduate Medical Education requirements about simulation skill laboratories, programs are incorporating simulation into residents' training. Despite substantial research on simulators, few data exist to support the effectiveness of simulation skills curricula. We report on an Objective Structured Assessment of Technical Skills (OSATS) used to assess residents' needs and evaluate a curriculum designed to increase proficiency. Study Design The five-session (10-week) curriculum covered asepsis, skin preparation, gowning, gloving, knot-tying, suturing, and excision. Performance on a 20-minute OSATS station was measured by unblinded raters using a task-specific checklist and seven global rating scales. Interns' pre-post improvement was assessed using paired t -tests. PGY2 and PGY3 residents were used as nonequivalent controls; their scores set a benchmark for PGY1 residents postcurriculum. Percentage of possible points earned was compared with a 75% "needs" criterion; ANOVA was used to assess group differences at the p Results Seven PGY2 and 6 PGY3 residents took the OSATS; 24 of 25 PGY1s completed both the baseline and postcurriculum OSATS. At baseline, PGY1 mean percent correct total score was 49%; they performed considerably below PGY2 (68%) and PGY3 (74%) residents. PGY1 scores improved significantly after 10 weeks (p ≤ 0.001). When their postcurriculum scores were compared with PGY2 and PGY3 resident benchmarks, there were no significant differences in checklist (p = 0.38), global item (p = 0.29), or total scores (p = 0.45). Conclusions Our results suggest that the simulation curriculum helped PGY1 residents attain basic surgical skills at levels consistent with PGY2 and PGY3 residents as measured by an OSATS. Only PGY3 residents performed at the 75% criterion.