The American Journal of Surgery - Articles in Press

Prevention of postoperative peritoneal adhesions: a review of the literature - Corrected Proof

2010-09-03

Abstract: Background: Postoperative adhesions are a significant health problem with major implications on quality of life and health care expenses. The purpose of this review was to investigate the efficacy of preventative techniques and adhesion barriers and identify those patients who are most likely to benefit from these strategies.Methods: The National Library of Medicine, Medline, Embase, and Cochrane databases were used to identify articles related to postoperative adhesions.Results: Ileal pouch–anal anastomosis, open colectomy, and open gynecologic procedures are associated with the highest risk of adhesive small-bowel obstruction (class I evidence). Based on expert opinion (class III evidence) intraoperative preventative principles, such as meticulous hemostasis, avoiding excessive tissue dissection and ischemia, and reducing remaining surgical material have been published. Laparoscopic techniques, with the exception of appendicitis, result in fewer adhesions than open techniques (class I evidence). Available bioabsorbable barriers, such as hyaluronic acid/carboxymethylcellulose and icodextrin 4% solution, have been shown to reduce adhesions (class I evidence).Conclusions: Postoperative adhesions are a significant health problem with major implications on quality of life and health care. General intraoperative preventative techniques, laparoscopic techniques, and the use of bioabsorbable mechanical barriers in the appropriate cases reduce the incidence and severity of peritoneal adhesions.

Optimal trocar placement for ergonomic intracorporeal sewing and knotting in laparoscopic hiatal surgery - Corrected Proof

2010-07-20

Abstract: Background: Trocar placement presently is mostly empiric. Our goal was to define simple distances from bony landmarks to locate the optimal ergonomic placement of manipulation trocars for access to the lower esophagus and hiatal orifice, for suture placement, and knotting of the gastric fundus and crura. Hypothesizing that the ideal ergonomic principles of a manipulation angle of 60°, an elevation angle (αe) of 30° to 60°, and an intracorporeal/extracorporeal length ratio (I/E) of working instruments close to 1:1 are interrelated by simple trigonometric functions, the variations of each of these parameters were calculated in a dependent manner for 2 standard lengths of needle holders: 48.5 cm and 58.5 cm.Results: Trocar placement can be calculated easily according to simple formulas dependent on the αe, the distance from the sternoxiphoid junction to the median of the intertrocar span (d) and the vertical distance from the stenoxiphoid junction to the average distance between the apex of the hiatal orifice and the anterior aspect of the esophagus (XH'): when the αe is 30°: d is XH' √2 and when αe is 45°, d is XH'/√2. Likewise, when αe is 30° the intertrocar span (LR) is 2XH', half on either side of the optical axis (d), and when αe is 45°, LR is XH' √2, XH'/√2 on either side of the optical axis. The most ergonomic solution is to work with an αe of 40° to 45° by placing the 2 working (manipulation) trocars, between 10 and 14 cm caudad from the sternoxiphoid junction, between 10 and 12 cm on either side of the longitudinal axis corresponding to the optic-target axis. The shorter needle holder works best in this configuration because the I/E ratio will be between .8 and 1. If, however, the surgeon wants to work with an αe closer to 30°, then the longer needle holder should be used, and the trocars should be placed between 20 and 21 cm from the sternoxiphoid junction, 14.5 to 15 cm on either side of the optical axis. The I/E ratio will vary between 1 and 1.1. When a 1/1 I/E ratio was prioritized, the αe would be 40° and 32°, for the shorter and longer instruments, respectively. The deeper crural closure requires increasing the αe by 2° and 3°, respectively. Hyperlordosis, as obtained by placing a cushion under the patient's back, shortens the distances, allowing placement of the trocars closer to the sternoxiphoid junction.Conclusions: Based on ergonomic principles (manipulation angle, 60°; αe, 40°–45°; and an I/E ratio of working instruments, close to 1:1), simple trigonometric considerations allow easy calculation of the ideal placement of trocars corresponding to working instruments in hiatal surgery necessary for ergonomic dissection, suturing, and intracorporeal knotting. Ideal trocar placement is dependent only on the vertical depth of the target organ.

Collagen in the transversalis fascia of patients with inguinal hernia - Corrected Proof

G.. Pascual, J.M. Bellón — 2010-07-15

We read with interest the recent article by Casanova et al published in the July issue of The American Journal of Surgery. In this study, the authors analyzed type I and III collagen fibers in specimens of transversalis fascia (TF) taken from patients with indirect inguinal hernia and compared their findings with those observed in TF specimens obtained from nonherniated cadavers.

Determinants of outcome in elderly patients with positive sentinel lymph nodes - Corrected Proof

2010-07-09

Abstract: Background: Older women are less likely to receive standard of care treatment for breast cancer.Methods: We examined variables that affected the outcome of elderly patients ≥70 years old among 1,470 patients with invasive cancer with positive sentinel lymph nodes (SLNs).Results: Elderly patients were less likely to undergo mastectomy, completion axillary node dissection (ALND), adjuvant chemotherapy, and radiotherapy (RT) following breast-conserving therapy (BCT) compared with patients <70 years old. The 5-year risk of disease progression and cumulative incidence of breast cancer–specific deaths were not significantly different for both groups. On multivariate analysis, hormone receptor–negative status, number of metastatic lymph nodes, high nuclear grade, and tumor size were the factors independently associated with increased risk of disease progression.Conclusions: Tumor factors were the primary determinants of breast cancer outcomes in our cohort. Elderly patients are less likely to receive aggressive surgical interventions and adjuvant therapy because of perceived life expectancy.

Perioperative synbiotic treatment to prevent infectious complications in patients after elective living donor liver transplantation. A prospective randomized study - Corrected Proof

2010-07-09

Abstract: Background: Although the effect of synbiotic therapy using prebiotics and probiotics has been reported in hepatobiliary surgery, there are no reports of the effect on elective living-donor liver transplantation (LDLT).Methods: Fifty adult patients undergoing LDLT between September 2005 and June 2009 were randomized into a group receiving 2 days of preoperative and 2 weeks of postoperative synbiotic therapy (Bifidobacterium breve, Lactobacillus casei, and galactooligosaccharides [the BLO group]) and a group without synbiotic therapy (the control group). Postoperative infectious complications were recorded as well as fecal microflora before and after LDLT in each group.Results: Only 1 systemic infection occurred in the BLO group (4%), whereas the control group showed 6 infectious complications (24%), with 3 cases of sepsis and 3 urinary tract infections with Enterococcus spp (P = .033 vs BLO group). No other type of complication showed any difference between the groups.Conclusions: Infectious complications after elective LDLT significantly decreased with the perioperative administration of synbiotic therapy.

Patient attitudes to surgeons' attire in an outpatient clinic setting: substance over style - Corrected Proof

Roy Dewayne Edwards, Anne Teresa Saladyga, John Paul Schriver, Kurt Glenn Davis — 2010-07-01

Abstract: Background: It is believed that patients prefer that surgeons convey a professional appearance with traditional business attire and white laboratory coat. We performed a prospective study to assess patient opinions regarding traditional attire versus the wearing surgical scrubs in the outpatient setting.Methods: During a 5-month period, surgeons alternated wearing traditional clothing and surgical scrubs. Adult patients were given a questionnaire assessing their preferences regarding surgeons' clothing.Results: Six hundred twelve patients returned the questionnaire. The majority felt that scrubs were appropriate attire for physicians. Half of the patients felt that wearing white laboratory coats is necessary. A minority felt that their surgeon's dress affects their opinion regarding the care they received. There was no difference between responses regardless of the attire actually worn.Conclusions: Surgeon's clothing choice does not significantly influence patient's opinion of the care they receive. Patients do not have strong preferences for white coats or more traditional surgical attire.

Re: how to avoid unnecessary laparotomies in iatrogenic bile duct injuries? - Corrected Proof

Gennaro Nuzzo, Felice Giuliante, Francesco Ardito, Maria Vellone, Ivo Giovannini — 2010-07-01

We read with interest the letter by Grönroos on our article, “Advantages of multidisciplinary management of bile duct injuries occurring during cholecystectomy.” We definitely agree that nonsurgical procedures play a great role in the treatment of bile duct injuries and, among these, the rendez-vous technique is the most recently described. In our experience, nonsurgical treatments were performed in 36% of major bile duct injuries, and in 40% of all the patients, including the minor injuries. If we consider only the major injuries, in our experience surgery was the definitive treatment in 64% of patients (41 of 64), which is the same rate reported by Grönroos in Karvonen et al (64%; 14 of 22). Therefore, it seems that the general policy of our 2 centers is the same, and that reported laparotomies all were necessary.

Commentary for an evidence-based medicine review of lymphadenectomy extent for gastric cancer - Corrected Proof

Sun Hu Yang, You Cheng Zhang — 2010-07-01

K. Slim and his colleagues question whether the American Journal of Surgery has actually endorsed the Quality of Reporting of Meta-analyses (QUOROM) statement and they did not see flow diagrams and funnel plot in our paper to assess publication bias. The QUOROM conference resulted in the QUOROM statement, a checklist, and a flow diagram. The checklist describes the preferred way to present the abstract, introduction, methods, results, and discussion sections of a report of a meta-analysis. It includes such procedures as searches, selection, validity assessment, data abstraction, study characteristics, and quantitative data synthesis, and in the results with “trial flow,” study characteristics, and quantitative data synthesis; research documentation was identified for 8 of the 18 items. The flow diagram provides information about both the numbers of randomized control trials (RCTs) identified, included, and excluded and the reasons for exclusion of trials. In our view, the checklist and flow diagram are the better way to finish meta-analyses for improving the quality of reporting of meta-analyses of clinical RCTs rather than the way to assess publication bias. Actually, these procedures have been elucidated in brief words in the results section of our paper.

Re: A historic perspective on the contributions of surgeons to the understanding of acute pancreatitis - Corrected Proof

Juan Mier — 2010-07-01

The article published in the September issue entitled “A historic perspective on the contributions of surgeons to the understanding of acute pancreatitis” in which the authors pursued a revision article, analyzed remarkable publications starting with papers dated in 1925 to the present day. However, there is insufficient information when the authors describe the timing of surgical intervention. The authors have not made any reference to the only prospective randomized trial comparing early versus late surgical treatment: “Early versus late necrcosectomy in severe acute pancreatitis,” which was published in the American Journal of Surgery in 1997. The aforementioned paper is repeatedly cited as the only prospective and important trial that appointed the crucial decision regarding when to operate in this complex acute illness. In the International Association of Pancreotology “Guidelines for the Surgical Treatment of Acute Pancreatitis,” there are 11 recommendations and the aforementioned article2 was placed as the sixth recommendation for the proper management of acute severe pancreatitis.

Biological scaffolds in reparative surgery for abdominal wall hernias - Corrected Proof

Manuel López-Cano, Manuel Armengol-Carrasco — 2010-07-01

The development of new biological prostheses for clinical use in abdominal wall reconstruction is an exciting and innovative field of research. The encouraging results of Pomahac and Aflaki using a porcine, dermal-derived bioprosthesis for treating complex abdominal wall defects recently published in The American Journal of Surgery invite reflection. Biological materials derived from human or animal sources are degraded gradually, inducing neovascularization and colonization by host cells that progressively cause a site-specific remodeling process until reconstruction of a new and mature autologous fascia is complete. Although this new generation of extracellular matrices may open a new era in the treatment of abdominal wall hernias, there are still many unanswered questions. What is the optimum pattern and density to balance durability of the biomaterial with cellular ingrowth and remodeling? Is cross-linked material better than non–cross-linked? What about recurrence and complications, especially in human beings? What happens if the hernia is a collagen disease in which the ingrowth and remodeling process could, theoretically, be performed with collagen of inferior quality? In addition, the cost of these materials is extremely high.

Visfatin and gallstone disease - Corrected Proof

Teoman Dogru, Muammer Kara, Cemal Nuri Ercin, Cihan Meral, Gökhan Erdem — 2010-06-28

Visfatin is a recently described adipose tissue–derived protein, which has insulin-mimetic actions. Adipocyte visfatin expression and plasma concentrations increase in some, but not all, forms of obesity, both in animals and humans. Visfatin exerts its insulin-mimetic action by binding to the insulin receptor, and there is evidence that it may contribute to the development of the metabolic syndrome.

Preoperative platelet–lymphocyte ratio in resected pancreatic ductal carcinoma: is it meaningful? - Corrected Proof

Ismael Domínguez, Carlos Fernández-del Castillo — 2010-06-28

The article by Smith and colleagues published in the April issue of the American Journal of Surgery describes preoperative platelet–lymphocyte (PL) ratio as an independent prognostic factor in resected pancreatic ductal carcinoma. The data were collected from a prospectively maintained database and included 110 cases of histologically confirmed pancreatic ductal carcinoma. It is a well-designed study with clear objectives and adequate sample selection, but there are some questions regarding its relevance.

Compliance with guidelines to prevent surgical site infections: As simple as 1-2-3? - Corrected Proof

2010-06-23

Abstract: Background: The purpose of this study was to assess predictive factors and compliance with surgical site infection (SSI) prevention guidelines at 2 county hospitals.Design: Chart review and analysis of laparotomy patients undergoing colorectal, hysterectomy, or abdominal vascular procedures over two 6-month periods 1 year apart and evaluation of safety climate using the Safety Attitudes Questionnaire (SAQ).Results: Overall compliance with all antibiotic prophylaxis guidelines was 62% (n = 442). Gynecologic surgery was an independent predictor of compliance with antibiotic prophylaxis guidelines in elective cases, and nonemergency status was an independent predictor when all cases were considered. Postoperative normothermia was predicted by hospital, procedure length, initial intraoperative temperature, and service. The SAQ had a 91% response rate. Contrary to expected, safety domain scores and agreement with statements on collaboration and teamwork were not predictive of compliance.Conclusion: Interventions to improve poor compliance with infection prevention guidelines must be multifaceted, hospital- and service-specific, and resilient during emergencies. Good safety and teamwork climate are not sufficient.

Improved detection does not fully explain the rising incidence of well-differentiated thyroid cancer: a population-based analysis - Corrected Proof

Luc G.T. Morris, David Myssiorek — 2010-06-21

Abstract: Background: The increasing incidence of thyroid cancer may be an artifact of increased diagnostic scrutiny, permitting detection of smaller, subclinical thyroid cancers. Our objective was to examine trends in the incidence of well-differentiated thyroid cancers with large size and adverse pathological features.Methods: Detailed population-based analysis of incidence trends in well-differentiated thyroid carcinoma (1973–2006) in the Surveillance Epidemiology and End Results (SEER) cancer registry, using weighted least squares and Joinpoint regression models.Results: The incidence of well-differentiated thyroid cancer (WDTC) in the United States has tripled since 1973 (P < .0001). Incidence trends differ significantly between geographic regions and racial groups. Large WDTCs, including those >4 cm or >6 cm, have more than doubled in incidence (P < .0001). Cancers with extrathyroidal extension and with cervical metastases have also more than doubled in incidence (P < .0001).Conclusions: While the model of improving screening does explain increased diagnoses of small thyroid cancers, significant rises in the incidence of large cancers, and cancers with clinically significant pathological adverse features, are harder to explain. Alternative hypotheses, including a true increase in cancer incidence, would seem to merit exploration.

Structured teaching versus experiential learning of palliative care for surgical residents - Corrected Proof

2010-06-10

Abstract: Background: Previous end-of-life and palliative care curricula for surgical residents have shown improved learner confidence, but have not measured cognitive knowledge or skill acquisition.Methods: A nonrandomized trial evaluated a structured palliative care curriculum for 7 postgraduate year 2 surgical residents (intervention group) compared with 6 postgraduate year 5 surgical residents (comparison group). Outcomes were measured using an 18-item knowledge test, a 20-minute objective structured clinical examination simulating an intensive care unit family conference, and a survey measuring self-confidence.Results: The mean knowledge test scores for the intervention group, both before and after undergoing the structured palliative care curriculum, were no different from the comparison group. There was also no difference in objective structured clinical examination scores between the 2 groups. The intervention group felt less comfortable managing pain, breaking bad news, or addressing ethical issues.Conclusions: Junior surgical residents have similar palliative care knowledge to senior residents without a palliative care curriculum. After participating in a palliative care curriculum, they have simulated skills that are similar to chief residents. However, self-confidence is lower among junior residents despite undergoing a palliative care curriculum.

Open intraperitoneal versus retromuscular mesh repair for umbilical hernias less than 3cm diameter - Corrected Proof

2010-06-10

Abstract: Background: Mesh techniques are the preferable methods for repair of small ventral hernias, as a primary suture repair shows high recurrence rates. The aim of this prospective study was to compare the retromuscular sublay technique with the intraperitoneal underlay technique for primary umbilical hernias.Methods: From February 2004 to April 2007, all patients treated for umbilical hernias with maximum diameters of 3 cm were prospectively followed. During the first period of 15 months, all patients were treated with retromuscular repair using a large pore mesh (Vypro). After that period, for all patients, mesh repair using an intraperitoneal Ventralex patch was performed. All patients underwent general anesthesia. This analysis included 116 patients, of whom 56 had retromuscular repair (group I; mean age, 54.8 years; mean body mass index, 28.2 kg/m2) and 60 had open intraperitoneal repair (group II; mean age, 48.1 years; mean body mass index, 29.4 kg/m2). Operating time was evaluated as skin-to-skin time, and drain management was noted for both techniques. Follow-up was ≥2 years for all patients, and both early and late complications were registered, including seroma and hematoma formation, wound infection, fistula formation, and recurrence rates. Preoperative and postoperative pain was evaluated using a visual analogue scale (range, 0–10) on the day of the first outpatient visit; on postoperative days 1, 7, and 21; and after 1 year. Quality of life was estimated using the EQ-5D questionnaire 1 year after surgery. All data were analyzed using SPSS version 15 software. Wilcoxon's rank-sum test was used to analyze continuous variables, and repeated-measures analysis of variance was used for visual analogue scale scores. The χ2 test and Fisher's exact test were used to assess the differences between categorical data. P values < .05 were considered statistically significant.Results: The mean operative times were 79.9 minutes in group I and 33.9 minutes in group II (P < .001). The mean hospital stay was significantly longer in group I (3.8 vs 2.1 days, P < .001). Seromas and superficial wound infections in the early postoperative period were not different between both groups, although seromas occurred more frequent in the retromuscular group. Postoperative visual analogue scale scores were significantly lower with the intraperitoneal technique at all time points (P < .003, repeated-measures analysis of variance). However, 3 patients with the Ventralex patch had to be readmitted for severe pain. The recurrence rate was higher with the intraperitoneal repair (n = 5 [8.3%] vs n = 2 [3.6%]) than for the retromuscular mesh repair, but not statistically significant. Quality of life was comparable in the two groups after 1 year.Conclusions: The open intraperitoneal technique using a Ventralex mesh for umbilical hernias seems a very elegant and quick technique. However, possibly because of the less controllable mesh deployment, recurrence rates seem higher. In case open mesh repair is the preferred treatment, a retromuscular repair should be the first choice.

Stapler vs suture closure of pancreatic remnant after distal pancreatectomy: a meta-analysis - Corrected Proof

Wei Zhou, Ran Lv, Xianfa Wang, Yiping Mou, Xiujun Cai, Ingrid Herr — 2010-06-10

Abstract: Background: Suture closure and stapler closure of the pancreatic remnant after distal pancreatectomy are the techniques used most often. The ideal choice remains a matter of debate.Methods: Five bibliographic databases covering 1970 to July 2009 were searched.Results: Sixteen articles met the inclusion criteria. Stapler closure was performed in 671 patients, while suture closure was conducted in 1,615 patients. The pancreatic fistula rate ranged from 0% to 40.0% for stapler closure of the pancreatic stump and from 9.3% to 45.7% for the suture closure technique. There were no significant difference between the stapler and suture closure groups with respect to the pancreatic fistula formation rate (22.1% vs 31.2%; odds ratio, .85; 95% confidence interval, .66–1.08), although there was a trend toward favoring stapler closure. In 4 studies including 437 patients, stapler closure was associated with a trend (not statistically significant) toward a reduction in intra-abdominal abscess (odds ratio, .53; 95% confidence interval, .24–1.15).Conclusions: No significant differences occur between suture and stapler closure with respect to the pancreatic fistula or intra-abdominal abscess after distal pancreatectomy, though there is a trend favoring stapler closure.

The demographics of modern burn care: should most burns be cared for by non-burn surgeons? - Corrected Proof

Gary A. Vercruysse, Walter L. Ingram, David V. Feliciano — 2010-06-10

Abstract: Background: Minor burns represent .96% to 1.5% of emergency department visits, yet burn center referral is common. Analysis of the Grady Memorial Hospital Burn Center was conducted to examine the feasibility and savings if burns were managed locally with consultation as needed.Methods: Data on 776 consecutive admissions to Grady Memorial Hospital Burn Center between November 2005 and July 2007 were prospectively reviewed. National and international cohorts were compared.Results: Patients' mean age was 31 years, 69.8% were male, and 87% were insured. Thirty-nine percent were transfers. Seventy-six percent of transfers (51% of air transfers) and 70% of all admissions were for ≤10% total body surface area burns. Helicopter transport cost $12,500 and averaged 48 miles. Eighty percent of burns were hot water (scald), grease, or flame burns, and 31% required skin grafting.Conclusions: Most burns require assessment, debridement, and dressing changes. Grafting is rarely necessary. Patients are transferred because of a lack of training, and patients suffer economic burden and treatment delay. Savings could be realized were patients treated locally with select burn center referral. Video consultation and mentoring can help with triage and care of minor burns. Major burns require burn center referral. International practice reinforces these results.

Bassini and the vanished art of pure tissue inguinal hernioplasty - Corrected Proof

M. Tuveri, R. Demontis, E. Nicolò, S. Pisu — 2010-06-10

L.A. Danto, in a communication published in this journal, denounced the potential danger of all those surgical strategies meant to prevent the chronic inguinodynia arising after an inguinal hernia repair with the use of a prosthetic mesh, and the almost complete abandon of the traditional inguinal hernioplasty. As reported in many series, the incidence of postoperative inguinodynia is not the only increased complication after mesh hernioplasty. The nature and properties of the prosthetic material pose in fact a high risk of complications as protrusion, extrusion, infection and intestinal fistulization, and most importantly, once in place, is rigid, passive, adynamic, and aphysiological. In turn, this increase in complications seems not to have been counterbalanced by a long-lasting decrease in the recurrence rate.

Is oval flap reconstruction a good modification for treating pilonidal sinuses? - Corrected Proof

2010-06-10

Abstract: Background: Flap techniques are acceptable for the surgical treatment of pilonidal sinuses. This study assessed a new modification of the rhomboid flap technique.Methods: The study included 133 patients with pilonidal disease who were treated between April 2004 and April 2009. The pilonidal sinus was removed with an oval excision, and an oval head rhomboid flap was prepared to reduce flap necrosis.Results: The mean age of the patients was 27.4 ± 4.6 years (range, 13–80). The rate of minor postoperative complications was 11.3%. The mean hospital stay was 2.3 ± .8 days (range, 1–6). The rate of recurrence was 1.5%. Regarding cosmetic results, 116 (87%) patients were very pleased, 15 (11.2%) were pleased, and 5 (3%) were displeased. The mean follow-up period was 22.5 ± 12.4 months (range, 5–57).Conclusions: The oval flap reconstruction method is a recommended procedure that produces fewer ischemic flaps with a low rate of recurrence and acceptable cosmesis.

Duodenal polypoid lipoma with bleeding - Corrected Proof

2010-06-10

Abstract: Duodenal lipomas are rare; most are asymptomatic and are found incidentally via endoscopy or surgery. We report a case of duodenal polypoid lipoma with active bleeding. Although endoscopic treatment was scheduled initially, surgical intervention ultimately was indicated.

Laparoscopic colorectal surgery in elderly patients: a case-control study of 15 years of experience - Corrected Proof

2010-06-04

Abstract: Introduction: The aim of this study was to review the impact of age (≥75 years) on the short-term outcomes of laparoscopic colorectal surgery.Methods: Three hundred seventy-nine patients under 70 years of age and 91 patients 75 years and older were analyzed. Quantification of comorbidities was performed using the Charlson Weighted Comorbidity Index. Outcome measures were postoperative complications and 30-day mortality.Results: There was no difference in the occurrence of postoperative complications between the younger and older patients. Bivariate analysis revealed that patient age was not a risk factor of major complications (odds ratio = 1.2; 95% confidence interval, .6–2.3). Although bivariate analysis revealed that older age had a statistically significant odds ratio for 30-day mortality (odds ratio = 12.8; 95% confidence interval, 1.3–125.4), multivariate analysis revealed that it was a weighted comorbidity index score of 5 or more (P = .02) and long operative time (P = .01) that were independent predictors of 30-day mortality and not age per se.Conclusions: Age is not an independent predictor of morbidity and mortality in laparoscopic colorectal cancer surgery.

Transfer of training in the development of intracorporeal suturing skill in medical student novices: a prospective randomized trial - Corrected Proof

Claude Muresan, Tommy H. Lee, Jacob Seagull, Adrian E. Park — 2010-05-10

Abstract: Background: To help optimize the use of limited resources in trainee education, we developed a prospective randomized trial to determine the most effective means of teaching laparoscopic suturing to novices.Methods: Forty-one medical students received rudimentary instruction in intracorporeal suturing, then were pretested on a pig enterotomy model. They then were posttested after completion of 1 of 4 training arms: laparoscopic suturing, laparoscopic drills, open suturing, and virtual reality (VR) drills. Tests were scored for speed, accuracy, knot quality, and mental workload (National Aeronautics and Space Administration [NASA] Task Load Index).Results: Paired t tests were used. Task time was improved in all groups except the VR group. Knot quality improved only in the open or laparoscopic suturing groups. Mental workload improved only for those practicing on a physical laparoscopic trainer.Conclusions: For novice trainees, the efficacy of VR training is questionable. In contrast, the other training methods had benefits in terms of time, quality, and perceived workload.

Changes in acid–base balance during electrolytic ablation in an ex vivo perfused liver model - Corrected Proof

2010-05-10

Abstract: Background: Electrolytic ablation (EA) destroys tissues through extreme pH changes in the local microenvironment. An ex vivo perfused liver model was used to assess the systemic effects of EA on the acid–base balance without the influence of compensatory organs (lungs and kidneys).Methods: Eleven pigs were perfused extracorporeally at 39°C with autologous blood; 4 also underwent EA after 1 hour of reperfusion. Arterial blood samples were obtained hourly.Results: pH and CO2 levels did not change throughout the experiments. A significant increase of HCO3-, anion gap, base excess, and lactate was present after the third hour. No differences were observed between EA experiments and controls.Conclusions: EA does not alter the acid–base balance even when the confounding influence of compensatory organs is removed. Such findings should be considered when planning ablations in patients with renal failure or respiratory diseases in which EA could avoid undesirable metabolic changes.

Intracellular oxygenation and cytochrome oxidase C activity in ischemic preconditioning of steatotic rabbit liver - Corrected Proof

2010-04-22

Abstract: Background: Mild to moderate steatotic livers are used as marginal donors in liver transplantation. Very little is known about the mechanisms of ischemia reperfusion (IR) injury (IRI) in fatty liver. This study aimed to establish whether cytochrome oxidase C (COX) activity is compromised by IRI in fatty liver and whether ischemic preconditioning (IPC) can protect COX activity.Methods: New Zealand rabbits were fed on a high-cholesterol diet for 8 weeks to induce moderate hepatic steatosis. Three groups were tested. The IR group underwent 60 minutes of ischemia, followed by 7 hours of reperfusion. The IPC group (IPC + IR) underwent 5 minutes of ischemia, followed by 10 minutes of reperfusion and then 60 minutes of ischemia and 7 hours of reperfusion. The control group (sham) underwent the same surgical procedure, but ischemia was not induced. Deoxyhemoglobin, oxyhemoglobin, and change in the redox state of COX was continuously monitored in vivo by near-infrared spectroscopy. COX and citrate synthase (CS) activity assays were carried out on liver biopsy specimens in vitro. Bile was collected continuously during the procedure and analyzed using proton nuclear magnetic resonance spectroscopy.Results: The IR group had decreased COX activity and tissue oxygenation represented by deoxyhemoglobin, oxyhemoglobin, COX, and elevated redox ratios of lactate/pyruvate and β-hydroxybutarate/acetoacetate in vivo and a decrease in COX and CS activity in vitro. The IPC + IR group showed higher levels of all measured parameters in vivo and showed a smaller decrease in COX and CS activity in vitro.Conclusion: This study shows that IRI affects COX activity in fatty livers. This is attenuated by IPC.

A prospective randomized controlled trial to compare Pringle maneuver, hemihepatic vascular inflow occlusion, and main portal vein inflow occlusion in partial hepatectomy - Corrected Proof

2010-04-22

Abstract: Background: Blood loss during liver resection and the need for perioperative blood transfusions have negative impact on perioperative morbidity, mortality, and long-term outcomes.Methods: A randomized controlled trial was performed on patients undergoing liver resection comparing hemihepatic vascular inflow occlusion, main portal vein inflow occlusion, and Pringle maneuver. The primary endpoints were intraoperative blood loss and postoperative liver injury. The secondary outcomes were operating time, morbidity, and mortality.Results: A total of 180 patients were randomized into 3 groups according to the technique used for inflow occlusion during hepatectomy: the hemihepatic vascular inflow occlusion group (n = 60), the main portal vein inflow occlusion group (n = 60), and the Pringle maneuver group (n = 60). Only 1 patient in the hemihepatic vascular occlusion group required conversion to the Pringle maneuver because of technical difficulty. The Pringle maneuver group showed a significantly shorter operating time. There were no significant differences between the 3 groups in intraoperative blood loss and perioperative mortality. The degree of postoperative liver injury and complication rates were significantly higher in the Pringle maneuver group, resulting in a significantly longer hospital stay.Conclusions: All 3 vascular inflow occlusion techniques were safe and efficacious in reducing blood loss. Patients subjected to hemihepatic vascular inflow occlusion, or main portal vein inflow occlusion responded better than those with Pringle maneuver in terms of earlier recovery of postoperative liver function. As hemihepatic vascular inflow occlusion was technically easier than main portal vein inflow occlusion, it is recommended.

Radiofrequency ablation of unresectable liver tumors: factors associated with incomplete ablation or local recurrence - Corrected Proof

2010-04-22

Abstract: Background: Radiofrequency ablation (RFA) of liver tumors is associated with a risk of incomplete ablation or local recurrence.Methods: One hundred sixty-eight patients with 311 unresectable liver tumors were included. Effects of different variables on incomplete ablation and local recurrence were analyzed.Results: There were 132 hepatocellular carcinomas and 179 liver metastases. Tumor size was 24 (±13) mm. Two hundred twenty-six tumors were treated percutaneously, and 85 through open approach (associated with liver resection in 42 cases). There was no mortality. Major morbidity rate was 7%. Incomplete ablation and local recurrence rates were 14% and 18.6%. Follow-up was 29 months. On multivariate analysis, factors associated with incomplete ablation were tumor size (>30 mm vs ≤30 mm, P = .004) and approach (percutaneous vs open, P = .0001). Factors associated with local recurrence were tumor size (>30 mm vs ≤30 mm, P = .02) and patient age (>65 years vs ≤65 years, P = .05).Conclusions: RFA is effective to treat unresectable liver tumors. However, there is a risk of incomplete ablation when percutaneously treating tumors >30 mm. When tumor ablation is completely achieved, the main factor associated with local recurrence is tumor size >30 mm.

Prognostic factors and patterns of recurrence in esophageal cancer assert arguments for extended two-field transthoracic esophagectomy - Corrected Proof

2010-04-22

Abstract: Background: High recurrence rates determine the dismal outcome in esophageal cancer. We reviewed our experiences and defined prognostic factors and patterns of recurrences after curatively intended transthoracic esophagectomy.Methods: Between January 1991 and December 2005, 212 consecutive patients underwent a radical transthoracic esophagectomy with extended 2-field lymphadenectomy. Recurrence rates, survival, and prognostic factors were analyzed (minimal follow-up period, 2 y).Results: Radicality was obtained in 85.6%. The median follow-up period was 26.6 months. The overall recurrence rate at 1, 3, and 5 years was 28%, 44%, and 64%, respectively, and locoregional recurrence rate was 17%, 27%, and 43%, respectively. Overall survival rates, including postoperative deaths, were 45% and 34% at 3 and 5 years, respectively. pT stage and lymph node (LN) ratio greater than .20 were independent prognostic factors for survival and recurrences. Radicality was most prognostic for survival, and for N+ greater than 4 positive LN for recurrences.Conclusions: Radicality and LN ratio are strong prognostic factors. High radicality and adequate nodal assessment are guaranteed by an extended transthoracic approach.

Antibiotic prophylaxis for severe acute pancreatitis - Corrected Proof

Peter B. Imrey, Ryan Law — 2010-04-22

Jafri et al, in a recent meta-analysis of antibiotic prophylaxis for severe acute pancreatitis, concluded that, “The present meta-analysis presents conclusive evidence that antibiotic prophylaxis for SAP is not beneficial in protecting against infected necrosis, surgical intervention, or reducing mortality” (p. 812). This conclusion rests on a basic error in statistical reasoning, with potential consequences that could seriously disadvantage patients. This is despite the evident care with which the authors have executed their literature search and analysis.

Use of tumescent mastectomy technique as a risk factor for native breast skin flap necrosis following immediate breast reconstruction - Corrected Proof

2010-04-22

Abstract: Background: Native breast skin flap necrosis is a complication that can result from ischemic injury following mastectomy and can compromise immediate breast reconstruction. The tumescent mastectomy technique has been advocated as a method of allowing sharp dissection with decreased blood loss and perioperative analgesia. This study was performed to determine whether the technique increases the risk for skin flap necrosis in an immediate breast reconstruction setting.Methods: Three hundred eighty consecutive mastectomies with immediate reconstruction over a 6-year period were reviewed and divided into 2 cohorts for comparison: 100 tumescent and 280 nontumescent mastectomy cases. The incidence of minor and major skin flap necrosis was evaluated.Results: The use of tumescent mastectomy (odds ratio [OR], 3.93; P < .001), prior radiation (OR, 3.19; P = .011), patient age (OR, 1.59; P = .006), and body mass index (OR, 1.11; P = .004) were significant risk factors for developing postoperative major native skin flap necrosis.Conclusions: The use of the tumescent mastectomy technique appears to be associated with a substantial increase in the risk for postoperative major skin flap necrosis in an immediate breast reconstruction setting.

Littoral cell angioma in main and accessory intrapancreatic spleen presenting as splenic rupture - Corrected Proof

2010-04-21

Abstract: We report the incidental finding of a nodular mass in the pancreatic tail on a contrast-enhanced computed tomography scan preinterventional to emergency laparotomy for splenic rupture. Because of the past surgical history and radiologic appearance, differential diagnosis included atypical lymphoma in the spleen and regional lymph node, pancreatic adenocarcinoma with splenic metastasis, and intrapancreatic metastase of malignant melanoma; the patient underwent both splenectomy and pancreatic tail resection. A diagnosis of littoral cell angioma in main and accessory intrapancreatic spleen was made. To our knowledge, this is the first description of littoral cell angioma of the spleen involving both main and accessory organ presenting as splenic rupture.

Commentary on “Compliance with guidelines to prevent surgical site infections: as simple as 1-2-3?” - Corrected Proof

Hiram C. Polk — 2010-04-21

The brief period of study and the relatively small number of cases from 2 very large teaching hospitals could make Meeks et al's paper an easy one to ignore. In fact, it makes several critical points about the still very imperfect surgical quality process.

The anatomic basis of total mesorectal excision - Corrected Proof

Moubin Lin, Weiguo Chen, Liang Huang, Jindi Ni, Wenlong Ding, Lu Yin — 2010-04-13

Abstract: Background: Total mesorectal excision is considered the gold standard for rectal cancer surgery, but the anatomic descriptions and nomenclatures that are used are hardly clear and sometimes are contradictory. The aim of this study was to clarify the delimitation of the mesorectum and anatomic landmarks of the correct surgical plane for total mesorectal excision.Methods: Cadaveric dissections were performed on 32 pelvises.Results: The pelvic fasciae around the rectum can be divided into visceral fascia, vesicohypogastric fascia, and parietal fascia. The lateral ligament is the dense connective tissue between the rectum and visceral fascia instead of the pelvic sidewall. There are 2 different fascial envelopes around the rectum. The diffusion type of pelvic plexus is difficult to separate from the visceral fascia.Conclusions: The autonomic nerves and lateral rectal ligament can be distinguished as the landmark to judge the different planes. The correct surgical plane of posterior dissection is conducted between the visceral fascia and parietal fascia, and anterolateral dissection is conducted between the vesicohypogastric fascia and parietal fascia.

Optimal timing of elective laparoscopic cholecystectomy after acute cholangitis and subsequent clearance of choledocholithiasis - Corrected Proof

Vicky Ka Ming Li, Jonathan Lau Kai Yum, Yuk Pang Yeung — 2010-04-12

Abstract: Background: Elective laparoscopic cholecystectomy is recommended after endoscopic clearance of choledocholithiasis for patients with acute cholangitis, according to Toyko guidelines. However, the optimal timing remains uncertain.Methods: Perioperative outcomes were retrospectively reviewed and compared between patients with early (< 6 weeks) and late (> 6 weeks) surgeries, while risk factors for postoperative complications were assessed using multivariate analysis.Results: One hundred twelve patients (mean age, 64 years; range, 30–85 years) were analyzed. Rate of conversion and intraoperative and postoperative complications (classified per Dindo et al) were 21.4% (24 of 112), 23.2% (26 of 112), and 34.8% (39 of 112), respectively. The late surgery group had significantly more intraoperative (28.8% vs 9.4%, P = .029) and postoperative (42.5% vs 15.6%, P = .007) complications compared with the early surgery group. Multivariate analysis showed both late surgery (95% confidence interval, 1.47–12.5; P = .008) and a history of endoscopic sphincterotomy (95% confidence interval, 1.06–8.26; P = .038) to be independent risk factors for postoperative complications.Conclusions: Patients with endoscopic clearance of choledocholithiasis, especially after endoscopic sphincterotomy, should receive elective laparoscopic cholecystectomy within 6 weeks after a cholangitic attack.

Predictors of early versus late timing of pulmonary embolus after traumatic injury - Corrected Proof

2010-04-12

Abstract: Objective: To identify risk factors predictive of pulmonary embolus (PE) timing after a traumatic injury.Methods: One hundred eight traumatic injury patients with a confirmed diagnosis of PE were classified as early PE (≤4 days, n = 54) or late PE (>4 days, n = 54). Independent predictors of early versus late PE were identified using multivariate logistic regression.Results: Half the PEs were diagnosed ≤4 days of injury. Only long bone fractures independently predicted early PE (odds ratio 2.8; 95% confidence interval, 1.1–7.1). Severe head injuries were associated with late PE (odds ratio 11.1; 95% confidence interval, 3.9–31). Established risk factors such as age did not affect timing.Conclusions: Half the PEs were diagnosed ≤4 days after injury. The risk of early PE appeared highest in patients with long bone fractures, and the benefits of immediate prophylaxis may outweigh risks. Patients with severe head injuries appear to have later PE events. Prospective interventional trials in these injury populations are needed.

Sealants after axillary lymph node dissection - Corrected Proof

Samir Hidar, Sassi Bouguizane, Lassad Ben Regaya, Mohamed Bibi, Hédi Khairi — 2010-03-04

We read with great interest the recently published paper by Taflampas et al. They reported in a prospective, well-designed, and well-conducted randomized trial the effect of sealants on postoperative drainage duration and volume after axillary lymph node dissection. The authors must be congratulated for this study.

Intrahepatic cholangiocarcinoma: analysis of 44 consecutive resected cases including 5 cases with repeat resections - Corrected Proof

2009-05-12

Abstract: Background: Prognosis after resection for intrahepatic cholangiocarcinoma (ICC) remains unsatisfactory. There remains no effective therapy after recurrent ICC.Objective: The current study sought to evaluate risk factors associated with recurrent ICC and possible therapies after resection.Method: A review of data from patients who underwent potentially curative resection for ICC was performed.Results: A total of 44 potentially curative resections were performed from 1995 to 2008. Mortality was 0% and morbidity was 35%. The 5-year overall and recurrence-free survival rates were 43% and 39%, respectively. Multivariate analysis identified the presence of multiple nodules and poor histologic grade as independent negative prognostic factors for overall and recurrent-free survival. Postoperative recurrence occurred in 25 patients (57%). Solitary recurrence occurred in 5 patients (liver, n = 4; lung, n = 1), all of who had undergone surgical resection. Three of the 5 patients survived for more than 5 years after 2 resections.Conclusion: Prognosis after curative resection of solitary ICC appears favorable. In selected patients with sequential single hepatic or pulmonary recurrence, repeat resection may prolong survival.

How international electives could save general surgery - Corrected Proof

Andrew A. Gumbs, Milton A. Gumbs, Zachary Gleit, Mary Ann Hopkins — 2009-01-30

One of the driving forces for many American surgeons to become a surgeon is to one day work with a humanitarian organization, such as Doctors Without Borders, 3 of the authors for which have volunteered. However, there are many barriers to participating in such organizations. The rising cost of medical school and subsequent loans and the diminishing economic returns of being a surgeon in the United States mean that few American surgeons have the opportunity to work with such organizations until after retirement, if ever. Despite these barriers and others, interest at all levels of training remains high. A recent publication in the Journal of the American College of Surgeons explored the level of interest of general surgery residents at a large American academic center in taking an international elective. By analysis of questionnaires, 98% of residents were found to be interested in an international elective. Although these same residents were concerned about financial constraints and limitations imposed by the Residency Review Commission on elective time, almost half of all residents were willing to use their own vacation time and financial resources to be able to take such an elective.

Inguinodynia and ilioinguinal neurectomy - Corrected Proof

Lawrence A. Danto — 2008-09-15

Abstract: The value of open inguinal herniorraphy without mesh is being lost. Mesh herniorraphy is being inappropriately used as the standard of care. The complication of inguinodynia is occurring at inappropriately high rates. Ilioinguinal neurectomy is not a simple solution.

Complications of endoscopic retrograde cholangiopancreatography: when to operate? An algorithmic approach - Corrected Proof

Siamak Milanchi, Alexander Allins, Andrew Klein, Simon Lo — 2008-08-26

Endoscopic retrograde cholangiopancreatography (ERCP) is a well established and commonly used procedure with the nationwide annual frequency ranging between 40,000 and 50,000 cases. The overwhelming majority of the procedures are performed by qualified gastroenterologists who, over the last several decades, have accumulated a vast fund of knowledge dealing with the indications, technique variations, and complications of ERCP. By comparison, few surgeons are proficient in ERCP. However, surgeons are called upon to evaluate occasional patients who develop complications following this procedure. Thus, we feel that surgeons should be aware of the most frequently encountered types of ERCP complications, the diagnostic modalities available, and the potential treatment options.