Showing papers in "Annals of Surgery in 2006"

A Prospective Randomized Trial Comparing Percutaneous Local Ablative Therapy and Partial Hepatectomy for Small Hepatocellular Carcinoma

Abstract: Objective:To compare the results of percutaneous local ablative therapy (PLAT) with surgical resection in the treatment of solitary and small hepatocellular carcinoma (HCC).Summary Background Data:PLAT is effective in small HCC. Whether it is as effective as surgical resection in the long-term survi

One thousand consecutive pancreaticoduodenectomies.

Abstract: The first successful local resection of a periampullary tumor was performed by Dr. William Stewart Halsted in 1898.1 The patient was a 58-year-old woman with obstructive jaundice. Halsted resected a segment of the second portion of the duodenum, including the tumor, and anastomosed the duodenum end to end. He then reimplanted the bile and pancreatic ducts. The first successful regional resection for a periampullary tumor was performed by the German surgeon from Berlin, Kausch, in 1909, and reported in 1912.2 The regional operative procedure for periampullary tumors was popularized by Whipple in a paper published in 1935.3 In this paper, 3 patients were reported who underwent regional resection performed in 2 stages. Two of the 3 patients survived. Between 1912 and Whipple’s report in 1935, a small number of patients in Europe underwent a regional resection of a periampullary tumor successfully. Following Whipple’s report, the operative procedure became widely known but was still infrequently performed. By the end of Whipple’s career, he had only performed 37 such procedures.4 During the 1960s and 1970s, few pancreaticoduodenectomies were performed because of a hospital mortality in the range of 25%. However, during the 1980s and 1990s, experience performing pancreaticoduodenectomy increased, and large volume “centers of excellence” developed. These high-volume centers acquired a substantial experience, and mortality decreased to below 5%.5–8 In recent years at the Johns Hopkins Hospital, more than 200 pancreaticoduodenectomies have been performed annually. This has allowed individual surgeons to develop significant experiences. Between 1969 and 2003, 1000 consecutive pancreaticoduodenectomies were performed by a single surgeon (J.L.C.) at the Johns Hopkins Hospital. This report reviews that experience and documents the changes that have occurred with this operative procedure over 5 decades.

Epidemiology and management of liver metastases from colorectal cancer.

Abstract: Objective/Background:Little is known about the epidemiology and the management of liver metastases from colorectal cancer at a population level. The aim of this population-based study was to report on the incidence, treatment, and prognosis of synchronous and metachronous liver metastases.Methods:Da

Gut Hormone Profiles Following Bariatric Surgery Favor an Anorectic State, Facilitate Weight Loss, and Improve Metabolic Parameters

Abstract: The rising prevalence of obesity in developed societies is causing a major health threat in terms of morbidity and mortality.1 The complications of obesity, especially type 2 diabetes mellitus (T2DM), are placing growing demand on healthcare resources.1,2 Existing medical therapeutic strategies to achieve and maintain clinically significant weight loss remain limited.3 Surgical procedures for the treatment of obesity are, however, highly effective in achieving substantial and sustained weight loss,4,5 but they are technically demanding and costly and carry small but significant rates of morbidity and mortality.6 Dramatic improvements in glycemic control have been observed in subjects with T2DM following bariatric surgery, and specifically the Roux-en-Y gastric bypass (RYGB) procedure.7–11 In the early postoperative period following RYGB, many patients with T2DM discontinue all antidiabetic medication, and may achieve normal fasting plasma glucose concentrations even before substantial weight loss has occurred.10,11 It has been postulated that the improvements in glycemic control, reduction in appetite, and subsequent weight loss following bypass surgery may be due to changes in circulating gut hormones.10,12–14 A number of peptides released from the gastrointestinal tract have recently been shown to regulate appetite and food intake, effecting both orexigenic and anorexic outcomes through actions on the hypothalamic arcuate nucleus.15,16 Ghrelin, a hormone produced from the stomach in the preprandial state, increases expression of the orexigenic hypothalamic neuropeptide Y (NPY) and stimulates food intake in rodents and humans.17,18 In contrast, peptide YY (PYY), released postprandially from the distal gastrointestinal tract, acts within the arcuate nucleus to inhibit the release of NPY19. Intravenous PYY3–36 infusions into humans and intraperitoneal injections into rodents induce satiety and reduce food intake.19,20 Glucagon-like peptide 1 (GLP-1) acts mainly as an incretin, promoting postprandial insulin release21 and improving pancreatic β-cell function,22 and has also been reported to inhibit food intake in humans.23 Pancreatic polypeptide (PP) has recently been shown to inhibit appetite and food intake and promotes energy expenditure.24,25 We sought to determine the changes in the entero-hypothalamic endocrine axis in human subjects following bariatric surgery, examining the meal-stimulated release of PYY, GLP-1, and PP. We used a rodent model of jejuno-intestinal bypass (JIB) surgery to further examine gut hormone changes and to investigate the potential role of PYY in mediating the food intake and weight reducing effects of surgery.

The Mechanism of Diabetes Control After Gastrointestinal Bypass Surgery Reveals a Role of the Proximal Small Intestine in the Pathophysiology of Type 2 Diabetes

Abstract: Summary Background Data:Most patients who undergo Roux-en-Y gastric bypass (RYGB) experience rapid resolution of type 2 diabetes. Prior studies indicate that this results from more than gastric restriction and weight loss, implicating the rearranged intestine as a primary mediator. It is unclear, ho

Assessment of complications after pancreatic surgery: A novel grading system applied to 633 patients undergoing pancreaticoduodenectomy.

Abstract: Mortality associated with pancreaticoduodenectomy (PD) has decreased dramatically to less than 5% over the past 2 decades in high-volume centers,1–6 but persistent high morbidity rates have remained an important concern for patients, healthcare providers, and payers. While mortality is an objective and easily quantifiable outcome parameter, morbidity is only poorly defined, and this shortcoming has severely hampered conclusive comparisons among centers and within the same institution over time.7–9 Similarly, the identification of risk factors related to specific complications has been difficult. Recognizing this deficiency, there has been several recent attempts to define specific complications related to PD such as pancreatic fistula, either by individual groups10–14 or through consensus statements from a few experts.15 Although important, these definitions have focused only on one specific complication (pancreatic fistula), and typically lack a severity grading system. For example, when a pancreatic fistula is defined as the persistent drainage of amylase-rich fluid during the postoperative course or as radiologic evidence of pancreatic anastomotic disruption, no distinction is made between the minimal criteria and more severe manifestation leading to reoperation or even death. An attempt was recently made by a group of experts in pancreas surgery to grade pancreatic fistula by severity,15 but the grading system is complex, includes multiple subjective criteria, and is not applicable to other types of complications. Therefore, there is persistent need for the availability of a reproducible, simple, and widely acceptable system to grade all complications following PD. A previously reported grading system7–9 was recently revisited and validated in a large cohort of patients undergoing general surgery. An international survey confirmed the simplicity and reproducibility of the new grading system.16 This classification was recently adopted by the International Transplantation Society17 to prospectively monitor the outcome of living liver donors. A key feature facilitating the use of the grading system is that it mostly relies on the therapies used to correct negative events. This is crucial to minimize down grading of complications as even nursing notes can be used to secure appropriate grading in retrospective analyses. Another attractive aspect of the new classification is that it considers the patient perspective through a strong emphasis on long lasting disability. Such a grading system can be adapted to any complication as long as the minimal criteria to define each specific complication are well described and widely accepted. We adapted this novel classification of complications by severity16 to a large cohort of patients, who underwent a PD at Johns Hopkins Hospital, a high-volume center with the availability of a comprehensive database. We used the well-established Johns Hopkins definitions for pancreatic fistula and delayed gastric emptying (DGE),18,19 and stratified them according to severity criteria. Of importance, the John Hopkins definition of pancreatic fistula is consistent with a recent consensus statements.15 The primary aims of the study were to evaluate the feasibility of grading each recorded complication in the database according to the novel classification system, to present specific complications by severity, and to identify risk factors. A secondary aim was to test the novel classification system in comparing the incidence and severity of one type of complication, pancreatic fistula, with a previous series of patients in the same institution. Finally, an attempt was made to evaluate the impact of complications on long-term survival.

Early and Late Recurrence After Liver Resection for Hepatocellular Carcinoma: Prognostic and Therapeutic Implications

Abstract: Hepatic resection is a well-accepted therapy for hepatocellular carcinoma (HCC), but many patients develop a cancer recurrence, which is the main cause of death in long-term evaluations.1–3 Prevention and therapy for recurrence could further improve the data of survival and support the value of surgery when compared to non surgical procedures such as percutaneous ethanol injection (PEI) and radiofrequency ablation (RFA), or to liver transplantation (OLT). The identification of the predictive factors of recurrence is the first step of this process. Different from other common gastrointestinal tumors, the pathologic features related to cancer presentation are not always related to the final results, expressed as overall survival (OS) and disease-free survival (DFS).4–7 This is not surprising; the recurrence of HCC includes some entities that are different for pathogenesis and clinical value, such as intrahepatic metastases of primary HCC or metachronous primary lesions. Another factor to be considered is the time of presentation of recurrence; generally, shorter is the free interval time, poorer is the prognosis, but a clear line between early and late recurrences cannot be driven “a priori.”7 The aim of this study is: 1) to identify the factors influencing the risk and the type of recurrence and to verify if the type of presentation of the recurrence, including the morphology and the free interval time can identify groups of patients with a homogeneous behavior; and 2) to foresee the results that can be expected from an aggressive radical treatment of the different type of recurrence.

Influence of preoperative chemotherapy on the risk of major hepatectomy for colorectal liver metastases.

Abstract: Depending on the stage of the primary colorectal cancer, liver metastases occur in 20% to 70% of patients and represent the major cause of death in this disease.1,2 Surgical resection remains the only treatment that can, to date, ensure long-term survival in 25% to 40% of patients.3–8 It should be considered whenever liver metastases can be totally resected with clear margins and when there is no nonresectable extrahepatic disease. However, using the current indications for surgery, only 15% to 20% of patients with colorectal liver metastases are suitable for surgical resection.1,2 When liver metastases are nonresectable, palliative chemotherapy increases survival and enhances quality of life.9 Progresses including more efficient chemotherapy drugs such as oxaliplatin or irinotecan10,11 have opened new perspectives in the treatment of resectable and nonresectable liver metastases. These drugs can render resectable previously unresectable liver metastases.12–16 When liver metastases are resectable, the benefit of neoadjuvant chemotherapy on reducing the risks of recurrence after surgery is not yet demonstrated. However, in case of synchronous metastases, chemotherapy is often prescribed between the resection of the colorectal primary and the liver surgery. The risks of liver resections have been reduced in recent years. Postoperative mortality is less than 5% in most reported series.5–7 Postoperative morbidity, including transient liver failure, hemorrhage, subphrenic abscesses, and biliary fistula, occur in 20% to 40% of patients.3–8 It is not clearly established whether systemic preoperative chemotherapy increases the risks of surgery due to injury of liver parenchyma. Recent data have suggested that prolonged systemic chemotherapy could induce steatosis and microvascular changes such as peliosis or sinusoidal congestion.17 Sclerosing cholangitis, dilatation, and fibrosis of the central veins and moderate hepatocellular necrosis or cholestasis in the centrilobular area have been reported with the intra-arterial use of fluorodeoxyuridine, a 5-fluorouracil (5-FU) metabolite.13,17 These pathologic changes can be responsible for an increased risk of bleeding during surgery as the parenchyma tends to be more congested and friable.13,15 Hepatic arterial chemotherapy prior to liver resection was associated with an increased postoperative morbidity in one series (57% versus 18%).13 The consequences of systemic chemotherapy on liver parenchyma and on postoperative course following resections have not been specifically analyzed in the reports that have studied resectability following preoperative chemotherapy. The populations studied were heterogeneous regarding the duration and the regimens of preoperative chemotherapy, the extent of liver resections performed and the clamping methods used.12,14,16,18–20 The pathologic changes induced by chemotherapy in these patients have not been reported. The present study was designed to analyze the effects of preoperative systemic chemotherapy on remnant liver parenchyma and to assess the consequences on postoperative mortality, morbidity, and liver function tests. Among patients having received liver resection for metastases from colorectal cancer, we selected a homogeneous subgroup of patients who received a major liver resection under total vascular exclusion. In theory, the removal of more than three hepatic segments with continuous occlusion of hepatic inflow and outflow is at higher risk of inducing postoperative mortality and morbidity; therefore, this subgroup offers the better chances of showing an influence of preoperative chemotherapy.

Influence of preoperative chemotherapy on the risk of major hepatectomy for colorectal liver metastases. Authors' reply

Abstract: Objective:To assess the effects of preoperative systemic chemotherapy on remnant liver parenchyma, liver function, and morbidity after major liver resection for colorectal liver metastases. Background:Many patients operated upon for colorectal cancer liver metastases receive previous chemotherapy. Whether systemic chemotherapy alters liver parenchyma in such way that it increases the risks of liver resection remains unclear. Patients and Methods:Among 214 patients who received a liver resection for colorectal liver metastases between 1998 and 2002 in a single institution, 67 who underwent a major liver resection under total hepatic vascular exclusion form the basis of this report. Forty-five patients operated upon after systemic chemotherapy were compared with 22 who did not receive any chemotherapy in the 6 months prior to resection. Postoperative mortality, morbidity, liver function tests, and pathology of the resected liver in the two groups were compared. Results:There was no postoperative mortality. Values of liver function tests on days 1, 3, 5, and 10 were similar in both groups. Morbidity rate was higher in the chemotherapy group (38% versus 13.5%, P = 0.03). Postoperative morbidity was correlated with the number of cycles of chemotherapy administered before surgery but not to the type of chemotherapy. Preoperative chemotherapy was significantly associated with sinusoidal dilatation, atrophy of hepatocytes, and/or hepatocytic necrosis (49% versus 25%, P = 0.005). Conclusion:Prolonged neoadjuvant systemic chemotherapy alters liver parenchyma and increases morbidity after major resection under total hepatic vascular exclusion, but it does not increase operative mortality. This should be taken into consideration before deciding a major liver resection in patients who have received preoperative chemotherapy.

A clinical outcome-based prospective study on venous thromboembolism after cancer surgery: the @RISTOS project.

Abstract: Summary Background Data: The epidemiology of venous thromboembolism (VTE) after cancer surgery is based on clinical trials on VTE prophylaxis that used venography to screen deep vein thrombosis (DVT). However, the clinical relevance of asymptomatic venography-detected DVT is unclear, and the population of these clinical trials is not necessarily representative of the overall cancer surgery population. Objective: The aim of this study was to evaluate the incidence of clinically overt VTE in a wide spectrum of consecutive patients undergoing surgery for cancer and to identify risk factors for VTE. Methods: @RISTOS was a prospective observational study in patients undergoing general, urologic, or gynecologic surgery. Patients were assessed for clinically overt VTE occurring up to 30 5 days after surgery or more if the hospital stay was longer than 35 days. All outcome events were evaluated by an independent Adjudication Committee. Results: A total of 2373 patients were included in the study: 1238 (52%) undergoing general, 685 (29%) urologic, and 450 (19%) gynecologic surgery. In-hospital prophylaxis was given in 81.6% and postdischarge prophylaxis in 30.7% of the patients. Fifty patients (2.1%) were adjudicated as affected by clinically overt VTE (DVT, 0.42%; nonfatal pulmonary embolism, 0.88%; death 0.80%). The incidence of VTE was 2.83% in general surgery, 2.0% in gynecologic surgery, and 0.87% in urologic surgery. Forty percent of the events occurred later than 21 days from surgery. The overall death rate was 1.72%; in 46.3% of the cases, death was caused by VTE. In a multivariable analysis, 5 risk factors were identified: age above 60 years (2.63, 95% confidence interval, 1.21‐5.71), previous VTE (5.98, 2.13‐16.80), advanced cancer (2.68, 1.37‐5.24), anesthesia lasting more than 2 hours (4.50, 1.06‐19.04), and bed rest longer than 3 days (4.37, 2.45‐7.78). Conclusions: VTE remains a common complication of cancer surgery, with a remarkable proportion of events occurring late after surgery. In patients undergoing cancer surgery, VTE is the most common cause of death at 30 days after surgery.

Teaching surgical skills: what kind of practice makes perfect?: a randomized, controlled trial.

Abstract: Changes in the surgical training curriculum, precipitated by limitations to resident work hours,1,2 concerns over patient safety,3,4 and budgetary constraints in the operating room5,6 have compelled surgical educators to search for more effective and creative means of teaching surgical skills. Emerging technologies have also created a need for strategies to deliver technical education to surgeons already in practice. Consequently, laboratories dedicated to teaching technical aspects of surgical skill have become increasingly popular worldwide. These laboratories deploy an increasing array of training models, both low and high fidelity, many of which have been validated as effective teaching tools.7,8 Much work has been done on the development of performance metrics of assessment that can chart the progress through training regimens, demonstrate effects of intervention, and differentiate between varying levels of experience.9,10 Recently, there has been an important focus on ensuring that skills taught in laboratory environments can translate to the real world of human operations.11,12 Despite the important work on model development, simulators, and assessment methodologies, there is needed effort in the realm of curricular development.13 The ways in which the training is delivered (how, what, when, and how often) are equally important. For example, in many programs, junior residents learn a particular skill 1 week and return the next week to learn a different skill, with very little opportunity structured within the curriculum to rehearse what has previously been taught. Likewise, many CME programs offer courses that are short and intensive (1-day or weekend), not allowing for rehearsal of skills after a period of rest (and forgetting) has elapsed. Commonly, there is a delay between the time the skill is learned in the laboratory and the time the skill is needed in the operating room. Performance may be adequate immediately following training, but how much is retained is uncertain. The ultimate value of skills courses should be measured not by performance immediately after training, but by performance after a time delay, preferably in a realistic setting. Drawing upon the motor skill learning principle of massed versus distributed practice found in the domains of psychology and athletics, there is good evidence that practice interspersed with periods of rest (distributed practice), leads to better acquisition and retention of skill compared with practice delivered in continuous blocks with little or no rest in between (massed practice).14–16 How these principles transfer to the domain of surgical skill acquisition have yet to be demonstrated. This randomized controlled trial was designed to assess the impact that scheduling of practice (massed versus distributed) has on surgical skill acquisition. The study was designed to have maximal relevance to current residents' surgical skills courses and curricula. Using previously validated outcome measures and microsurgery as the technical skill domain, this study evaluates not only the immediate impact of each training schedule, but more importantly, the durability of skill acquisition (“retention” testing 1 month later) and the clinical transferability of the skill to a more realistic setting (testing on live anesthetized rats).

Surgical simulation: a systematic review.

Abstract: Objective: To evaluate the effectiveness of surgical simulation compared with other methods of surgical training.

Peritoneal Carcinomatosis of Colorectal Origin: Incidence and Current Treatment Strategies

Abstract: OBJECTIVE: To review the literature with regard to the incidence and prognostic significance of peritoneal seeding during surgery for primary colorectal cancer (CRC), the incidence of intraperitoneal recurrence of CRC, and the current treatment strategies of established PC of colorectal origin, with special focus on cytoreductive surgery and intraperitoneal chemotherapy (IPEC). SUMMARY BACKGROUND DATA: Although hematogenous dissemination forms the greatest threat to patients with CRC, peritoneal carcinomatosis (PC), presumably arising from intraperitoneal seeding of cancer cells, is a relatively frequent event in patients with recurrent CRC. METHODS: The PubMed and Medline literature databases were searched for pertinent publications regarding the incidence and prognostic significance of exfoliated tumor cells in the peritoneal cavity during curative surgery for primary CRC, the incidence of intraperitoneal recurrence of CRC, and the therapeutic results of systemic chemotherapy or cytoreductive surgery followed by IPEC. RESULTS: The incidence of peritoneal seeding during potentially curative surgery for primary CRC, as reported in 12 patient series, varied widely, from 3% to 28%, which may be explained by differences in methods to detect tumor cells. PC is encountered in approximately 7% of patients at primary surgery, in approximately 4% to 19% of patients during follow-up after curative surgery, in up to 44% of patients with recurrent CRC who require relaparotomy, and in 40% to 80% of patients who succumb to CRC. The reported median survival after systemic 5-fluorouracil-based chemotherapy for PC varies from 5.2 to 12.6 months. Median survival after aggressive cytoreductive surgery followed by (hyperthermic) IPEC in selected patients, as reported in 16 patient series, tends to be better and varies from 12 to 32 months at the cost of morbidity and mortality rates of 14% to 55% and 0% to 19%, respectively. One randomized controlled trial has been published confirming the superiority of aggressive surgical cytoreduction and intraperitoneal chemotherapy over strictly palliative treatment. CONCLUSIONS: Peritoneal seeding of cancer cells possibly leading to PC is a rather common phenomenon in patients with CRC. Cytoreductive surgery and adjuvant (hyperthermic) IPEC have been shown to be efficacious in selected patients and should therefore be considered in patients with resectable PC of colorectal origin.

Two Hundred Forty Consecutive Portal Vein Embolizations Before Extended Hepatectomy for Biliary Cancer: Surgical Outcome and Long-term Follow-Up

Abstract: Objective:To assess clinical benefit of portal vein embolization (PVE) before extended, complex hepatectomy for biliary cancer.Summary Background Data:Many investigators have addressed clinical utility of PVE before simple hepatectomy for metastatic liver cancer or hepatocellular carcinoma, but few

Postmastectomy Lymphedema: Long-term Results Following Microsurgical Lymph Node Transplantation

Abstract: Lymphedema complicating breast cancer treatment remains a challenging problem. Combined physiotherapy is not performed equally in all centers, and many physicians remain skeptical on the overall efficacy of surgical treatments.1 Furthermore, whatever the treatment proposed, the possibility of cure remains questionable. Over the last 12 years, our team has treated limb lymphedema by transplanting lymph nodes.2 The purpose of this study was to analyze the results obtained with this procedure during a minimal 5-year follow-up.

Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair: a multicenter, prospective, randomized trial.

Abstract: Objective: Laparoscopic paraesophageal hernia repair (LPEHR) is associated with a high recurrence rate. Repair with synthetic mesh lowers recurrence but can cause dysphagia and visceral erosions. This trial was designed to study the value of a biologic prosthesis, small intestinal submucosa (SIS), in LPEHR. Methods: Patients undergoing LPEHR (n = 108) at 4 institutions were randomized to primary repair -1°(n = 57) or primary repair buttressed with SIS (n = 51) using a standardized technique. The primary outcome measure was evidence of recurrent hernia (≥2 cm) on UGI, read by a study radiologist blinded to the randomization status, 6 months after operation. Results: At 6 months, 99 (93%) patients completed clinical symptomatic follow-up and 95 (90%) patients had an UGI. The groups had similar clinical presentations (symptom profile, quality of life, type and size of hernia, esophageal length, and BMI). Operative times (SIS 202 minutes vs. 1° 183 minutes, P = 0.15) and perioperative complications did not differ. There were no operations for recurrent hernia nor mesh-related complications. At 6 months, 4 patients (9%) developed a recurrent hernia >2 cm in the SIS group and 12 patients (24%) in the 1° group (P = 0.04). Both groups experienced a significant reduction in all measured symptoms (heartburn, regurgitation, dysphagia, chest pain, early satiety, and postprandial pain) and improved QOL (SF-36) after operation. There was no difference between groups in either pre or postoperative symptom severity. Patients with a recurrent hernia had more chest pain (2.7 vs. 1.0, P = 0.03) and early satiety (2.8 vs. 1.3, P = 0.02) and worse physical functioning (63 vs. 72, P = 0.03 per SF-36). Conclusions: Adding a biologic prosthesis during LPEHR reduces the likelihood of recurrence at 6 months, without mesh-related complications or side effects.

Patterns of Errors Contributing to Trauma Mortality: Lessons Learned From 2594 Deaths

Abstract: Trauma care creates a “perfect storm” for medical errors: unstable patients, incomplete histories, time-critical decisions, concurrent tasks, involvement of many disciplines, and often junior personnel working after-hours in busy emergency departments. Studies in several countries have identified adverse events, including death, that occur in trauma and emergency care.1–4 In 1955, Robert M. Zollinger wrote in the Archives of Surgery about the “preventability” of deaths following motor vehicle crashes.5 In the Journal of the American Medical Association, 30 years later, Donald Trunkey reviewed 29 studies of preventable trauma deaths,6 and more have been published since.7–11 These studies supported the development of regionalized trauma care. They also provided insights into the nature of preventable deaths, including the significance of failure to evaluate the abdomen, delays to treatment, and critical care errors. However, estimates of preventable death rates were wide in Trunkey's review, ranging from 2% to 50%, indicating the variability in care provided and the need for standardized approaches to its analysis that minimized potential variability due to definitions, the methods used to detect events, and the type of reviewers making the final determination.12,13 These studies also showed that trauma surgeons were pioneers in error reduction and quality improvement long before interest in medical errors and patient safety became widespread. More recently, much interest and interdisciplinary expertise have been brought to standardizing error detection and classification,14–16 to understanding of predisposing structural and systemic factors17 and the defective information processing18,19 associated with error, and to the development of effective patient safety and error mitigating strategies.20,21 In trauma, as in all fields, it is likely that recognizable clinical situations create predictable vulnerability to human error, and the erroneous decision-making that occurs in response to these situations can be forecast to some degree.22 To reduce errors, institutions need effective means of identifying errors and error-associated deaths. This is all the more difficult in trauma given high baseline mortality rates, often complicated in-hospital care, and the relative paucity of widely applicable management protocols, especially beyond the “Golden Hour” of initial resuscitation, to which Advanced Trauma Life Support (ATLS) protocols apply. Furthermore, errors that result in death may be relatively infrequent; therefore, opportunities to learn from them may be limited by infrequent attention and lack of “institutional memory.” In this study, we aimed to identify errors that had contributed to the death of trauma patients at a specific high-volume regional trauma center over a 9-year period and determine any apparent patterns of occurrence. We also aimed to examine the effect of introduction of local institutional policies on reducing error incidence.

Hepatic Resection for Noncolorectal Nonendocrine Liver Metastases: Analysis of 1452 Patients and Development of a Prognostic Model

Abstract: Although the liver is a frequent site for tumor metastases, the mechanisms for the development of liver metastases differ based on the location of the primary tumor site. In patients with primary tumors of the gastrointestinal tract (colorectal adenocarcinoma and gut-associated endocrine tumors), the most likely mode of spread to the liver is through portal venous drainage or via direct intraabdominal lymphatic channels. The rationale for liver resection in these cases is that the majority of the patient's tumor burden may be confined to the abdomen. Therefore, adequate treatment of the primary tumor combined with liver resection may provide a chance for cure. This rationale has proven to be correct for colorectal liver metastases, where 5-year survivals are routinely reported to be 40% and 10-year survivals as high as 25% have been documented.1–5 In contrast, most other liver metastases originate from tumors outside of the intraabdominal cavity. Most commonly, metastases from these tumors reach the liver via the systemic circulation, implying that extrahepatic sites may have an equal probability of being involved. Based on this rationale, hepatic resection of noncolorectal liver metastases has been approached with caution. Many of the first reports to examine outcomes for patients with noncolorectal liver metastases treated with hepatic resection included patients with both endocrine and nonendocrine metastases6–15 (Table 1). These analyses demonstrated that patients with endocrine metastases were a unique group with a better prognosis than patients with noncolorectal nonendocrine metastases. Several subsequent studies on this topic have accounted for these survival differences and have excluded patients with endocrine metastases.16–23 TABLE 1. Review of Reports Describing Patients With Noncolorectal Liver Metastases Treated With Hepatic Resection These studies have suggested that hepatic resection is safe and approximately as effective as hepatic resection for colorectal liver metastases, with reported 5-year survivals between 30% and 40% (Table 1). Although these data have contributed to our understanding of the natural history of these diseases and their responses to surgical therapy, the efficacy of liver surgery for patients with noncolorectal nonendocrine metastases has remained unclear because of the heterogeneity of primary tumor types, the frequent inclusion of patients with endocrine tumor metastases, and the limited numbers of patients reported. To minimize the limitations of previous studies, our study was designed to analyze the outcomes for a large number of patients with noncolorectal nonendocrine metastases treated with hepatic resection at multiple centers. Overall survivals in this cohort were determined and analysis of prognostic factors was robust enough to create a risk-model for prognosis that may be helpful in selecting patients for resection.

Early Removal of Prophylactic Drains Reduces the Risk of Intra-abdominal Infections in Patients With Pancreatic Head Resection: Prospective Study for 104 Consecutive Patients

Abstract: Objective The aim of this study was designed to determine whether the period of drain insertion influences the incidence of postoperative complications. Background data The significance of prophylactic drains after pancreatic head resection is still controversial. No report discusses the association of the period of drain insertion and postoperative complications. Methods A total of 104 consecutive patients who underwent pancreatic head resection were enrolled in this study. To assess the value of prophylactic drains, we prospectively assigned the patients into 2 groups: group I underwent resection from January 2000 to January 2002 (n = 52, drain to be removed on postoperative day 8); group II underwent resection from February 2002 to December 2004 (n = 52, drain to be removed on postoperative day 4). Postoperative complications in the 2 groups were compared. Results The rate of pancreatic fistula was significantly lower in group II (3.6%) than in group I (23%) (P = 0.0038). The rate of intra-abdominal infections, including intra-abdominal abscess and infected intra-abdominal collections, was significantly reduced in group II (7.7%) compared with group I (38%) (P = 0.0003). Eighteen of 52 (34.6%) patients in group I had an inserted drain beyond 8 days, whereas only 2 of 52 (3.7%) patients in group II had an inserted drain beyond 4 days (P = 0.0002). Cultures of drainage fluid were positive in 16 of 52 (30.8%) patients in group I, and in 2 of 52 (3.7%) patients in group II (P = 0.0002). Intraoperative bleeding (> 1500 mL), operative time (> 420 minutes, and the period of drain insertion were significant risk factors for intra-abdominal infections (P = 0.043, 0.025, 0.0003, respectively). The period of drain insertion was the only independent risk factor for intra-abdominal infections by multivariate analysis (odds ratio, 6.7). Conclusion Drain removal on postoperative day 4 was shown to be an independent factor in reducing the incidence of complications with pancreatic head resection, including intra-abdominal infections.

More extensive nodal dissection improves survival for stages I to III of colon cancer: a population-based study.

Abstract: Objective: To determine whether analyzing more lymph nodes in colon cancer specimens improves survival. Background Data: Increasing the number of lymph nodes analyzed has been reported to correlate with improved survival in patients with node-negative colon cancer. Methods: The Surveillance, Epidemiology, and End Results database was queried for all patients undergoing resection for histologically confirmed colon cancer between the years 1988 and 2000. Patients were excluded for distant metastases or if an unknown number of nodes was sampled. The number of nodes sampled was categorized into 0, 1 to 7, 8 to 14, and ≥15 nodes. Survival curves constructed using the Kaplan-Meier method were compared using log rank testing. A Cox proportional hazard model was created to adjust for year of diagnosis, age, race, gender, tumor grade, tumor size, TNM stage, and percent of nodes positive for tumor. Results: The median number of lymph nodes sampled for all 82,896 patients was 9. For all stages examined, increasing nodal sampling was associated with improved survival. Multivariate regression demonstrated that patients who had at least 15 nodes sampled as compared with 1 to 7 nodes experienced a 20.6% reduction in mortality independent of other patient and tumor characteristics. Conclusions: Adequate lymphadenectomy, as measured by analysis of at least 15 lymph nodes, correlates with improved survival, independent of stage, patient demographics, and tumor characteristics. Currently, most procedures do not meet this guideline. Future trials of adjuvant therapy should include extent of lymphadenectomy as a stratification factor.

The impact of the 80-hour resident workweek on surgical residents and attending surgeons.

Abstract: Objective: To assess the impact of the 80-hour resident workweek restrictions on surgical residents and attending surgeons. Background Data: The ACGME mandated resident duty hour restrictions have required a major workforce restructuring. The impact of these changes needs to be critically evaluated for both the resident and attending surgeons, specifically with regards to the impact on motivation, job satisfaction, the quality of surgeon training, the quality of the surgeon's life, and the quality of patient care. Methods: Four prospective studies were performed at a single academic surgical program with data collected both before the necessary workforce restructuring and 1 year after, including: 1) time cards to assess changes in components of daily activity; 2) Web-based surveys using validated instruments to assess burnout and motivation to work; 3) structured, taped, one-on-one interviews with an external PhD investigator; and 4) statistical analyses of objective, quantitative data. Results: After the work-hour changes, surgical residents have decreased "burnout" scores, with significantly less "emotional exhaustion" (Maslach Burnout Inventory: 29.1 "high" vs. 23.1 "medium," P = 0.02). Residents have better quality of life both in and out of the hospital. They felt they got more sleep, have a lighter workload, and have increased motivation to work (Herzberg Motivation Dimensions). We found no measurable, statistically significant difference in the quality of patient care (NSQIP data). Resident training and education objectively were not statistically diminished (ACGME case logs, ABSITE scores). Attending surgeons perceived that their quality of their life inside and outside of the hospital was "somewhat worse" because of the work-hour changes, as they had anticipated. Many concerns were identified with regards to the professional development of future surgeons, including a change toward a shift-worker mentality that is not patient-focused, less continuity of care with a loss of critical information with each handoff, and a decrease in the patient/doctor relationship. Conclusion: Although the mandated restriction of resident duty hours has had no measurable impact on the quality of patient care and has led to improvements for the current quality of life of residents, there are many concerns with regards to the training of professional, responsible surgeons for the future.

Long-term outcomes of laparoscopic resection of gastric gastrointestinal stromal tumors.

Abstract: Gastrointestinal stromal tumors (GISTs) represent a rare but distinct histopathologic group of intestinal neoplasms of mesenchymal origin.1 Historically, most of these tumors were classified as leiomyomas, leiomyoblastomas, and leiomyosarcomas due to the mistaken belief that they were of smooth muscle origin.1–3 However, with the advent of electron microscopy and immunohistochemistry, a pleuropotential intestinal pacemaker cell, the interstitial cell of Cajal, was identified as the origin of GISTs.4 These cells have myogenic and neurogenic architecture and are found within the myenteric plexus, submucosa, and muscularis propria of the gastrointestinal (GI) tract.4,5 The recent discovery and identification of the CD117 antigen, a c-kit proto-oncogene product, and CD34, a human progenitor cell antigen, in the majority of GIST have led to further delineation of the cellular characteristics of these neoplasms.6–8 Although GIST tumors are found throughout the GI tract, the stomach is the site of occurrence in more than half of patients.2,3,9–11 The most common symptoms of gastric GISTs are GI bleeding and abdominal pain. However, most patients are asymptomatic and the lesions are discovered incidentally during an upper endoscopy performed for other reasons.12 Their metastatic potential is difficult to predict due to the lack of clear clinical or pathologic signs of malignancy other than obvious metastasis at surgery. In addition, local recurrence or distant metastasis may not present until years after the initial diagnosis.9 Surgical resection is required for cure of gastric GISTs. In the past, a 1- to 2-cm margin was thought to be necessary for an adequate resection.12,13 Recently, DeMatteo et al demonstrated that tumor size and not negative microscopic surgical margins determined survival.2 These findings support the local resection of GIST lesions, including both wedge and submucosal resections. Although the feasibility of minimally invasive resections of gastric GISTs has been established,11,12,14–18 it has been proposed that this approach be limited to lesions 2 cm, is unclear. We hypothesized that complete resection of gastric GISTs using a combination of laparoscopic or laparoendoscopic techniques results in low perioperative morbidity and effective long-term control of the disease.

Thoracoscopic Lobectomy Is a Safe and Versatile Procedure: Experience With 500 Consecutive Patients

Abstract: Thoracoscopic, also termed video-assisted thoracoscopic, lobectomy has become accepted as a safe and effective procedure to treat early-stage non-small cell lung cancer (NSCLC).1–10 We have previously reported a pilot series of thoracoscopic lobectomy in 110 early stage lung cancer patients, demonstrating low complication rate and effective short-term oncologic results.1 With increasing experience, the indications for thoracoscopic lobectomy have been expanded. The purpose of this study was to examine the longer-term results of thoracoscopic lobectomy across the spectrum of indications to determine safety, efficacy, and versatility.

Subtype specific prognostic nomogram for patients with primary liposarcoma of the retroperitoneum, extremity, or trunk.

Abstract: Objective:To determine the prognostic significance of histologic subtype in a large series of patients with primary liposarcoma (LS) and to construct a LS-specific postoperative nomogram for disease-specific survival (DSS).Summary Background Data:Nomograms, used to define and predict outcome followi

A Comparison of Hand-Sewn Versus Stapled Ileal Pouch Anal Anastomosis (IPAA) Following Proctocolectomy: A Meta-Analysis of 4183 Patients

Abstract: Objective:Using meta-analytical techniques, the study compared postoperative adverse events and functional outcomes of stapled versus hand-sewn ileal pouch-anal anastomosis (IPAA) following restorative proctocolectomy.Background:The choice of mucosectomy and hand-sewn versus stapled pouch-anal anast

Body composition, dietary intake, and energy expenditure after laparoscopic Roux-en-Y gastric bypass and laparoscopic vertical banded gastroplasty: a randomized clinical trial.

Abstract: There are as yet no indications of decrease in the global obesity epidemic.1 The etiology is probably multifactorial, to which a genetic disposition together with unlimited access to high calorie foods and a lifestyle promoting physical inactivity contribute. Morbidity and mortality are strongly correlated to the level of obesity,2–4 and the list of diseases with a causal factor in obesity continues to expand. Obesity surgery is the only option that has been demonstrated to result in efficient, sustained long-term weight loss in the treatment of severe obesity.5 Most authors use the amount of weight loss (or percent excess weight loss [%EWL]) as the only tool to evaluate the efficacy of bariatric surgical procedures. Generally, there is a strong correlation between the level of weight loss and improvements in metabolic risk factors and quality of life (QoL).6,7 However, there is limited knowledge about the differences between the surgical options (restrictive, malabsorptive, and combined) in the crucial task of reducing the metabolic risk and thereby contribute to curing morbidity and preventing mortality. Previous studies of the difference between Roux-en-Y Gastric bypass (GBP) and the restrictive bariatric procedures, such as vertical banded gastroplasty (VBG), have reported a superior outcome in terms of weight loss and a better dietary pattern after GBP.8–12 Studies of body composition have demonstrated a reduction of body fat as well as a decrease in lean tissue mass (LTM) following bariatric surgery.13–16 The question of whether or not higher energy expenditure than expected could be a contributing factor to weight loss after obesity surgery has been disputed in previous studies.17–20 No study has to our knowledge prospectively compared changes in body composition and/or energy expenditure related to dietary intake in a randomized clinical trial between different bariatric surgical techniques. Based on a prospective randomized trial, we have recently reported that laparoscopic GBP (LGBP) resulted in a weight reduction that was clearly superior to the effect of laparoscopic vertical banded gastroplasty (LVBG). Furthermore, remedial surgical interventions were more frequent following LVBG.21 The patients enrolled in the above mentioned clinical trial21 were also examined with regard to other outcome variables not directly related to the operative procedures. In this paper, we report the results concerning effects on body composition, energy expenditure and dietary intake.

Evidence-based treatment of acute pancreatitis: a look at established paradigms.

Abstract: Acute pancreatitis (AP) is predominantly caused by symptomatic gallstone disease and excessive alcohol intake.1,2 Because of improvements in the management including better diagnostics and treatment modalities, disease-related mortality has declined during the past 2 decades despite an increase in the overall incidence of AP in many countries.3–5 Most AP episodes do not require a particular intervention, since they are mild and self-limiting. In contrast, about one fifth of patients develop a severe form of AP, which is still associated with a mortality rate exceeding 30%.1,6,7 This type of AP is usually accompanied by necrosis of the pancreas and the surrounding tissue (necrotizing AP). Such necrosis formation is best assessed by contrast-enhanced computed tomography (ceCT),8,9 and the Balthazar score is most commonly used to define the extent of necrosis.7,10,11 Alternatively, magnetic resonance imaging (MRI) can be used, eg, in case of contraindications for intravenous CT contrast.12 According to the Atlanta classification, AP is predicted severe if it is accompanied by single or multiorgan failure (MOF), local complications, 3 or more Ranson criteria,13 or an APACHE II score of ≥8 points.14 Over decades, the management of AP has been biased by unproven paradigms, which were generated by theories on the pathophysiology of AP. These paradigms have been increasingly questioned over the past 2 decades, resulting in treatment changes that were again based on personal experience and opinions of experts rather than convincing scientific evaluations. As a result, the management of AP still differs from center to center, and many physicians declare their management the standard of care. The aim of this study was to assess the clinical value of different newer treatment modalities by reviewing the current literature on the treatment of AP. To secure the highest level of objectivity, we used the evidence-based approach of Sackett to analyze the literature of the last decade.15

Risk Factors for Long-term Pain After Hernia Surgery

Abstract: Until recently, research on the results of hernia surgery has focused mainly on recurrences. However, with the introduction of mesh techniques and presumably an increased awareness of the importance of systematic quality control, the recurrence rate has decreased dramatically.1 Hence, now that recurrences are no longer a pressing clinical problem, there has been a recent upsurge in interest in chronic pain as an adverse outcome. But the level of quantification of pain has often been limited in studies addressing the risk of long-term pain, and pain has sometimes been treated merely as a dichotomous (yes/no) phenomenon.2 As a result, the clinical and public health significance of reported prevalence rates of residual pain (ranging between 0% and 37%) remains uncertain.3 With the main purpose of evaluating long-term pain as an alternative endpoint in research on the outcome of hernia surgery, we used a validated pain questionnaire to investigate pain behavior rather than imaginary descriptors of pain intensity in an essentially population-based series of patients operated on 59 hospitals.

An evidence-based virtual reality training program for novice laparoscopic surgeons.

Abstract: The implementation of a competency-based surgical skills curriculum necessitates the development of tools to enable structured training, with in-built objective measures of assessment.1 Simulation in the form of virtual reality and synthetic models has been proposed for technical skills training at the early part of the learning curve.2–4 To be efficacious, these tools must convey a sense of realism and a degree of standardization to enable graded acquisition of technical skills. Progression along the curriculum is charted by passing predefined expert benchmark criteria, which lead to more technically demanding tasks. In the laparoscopic era, training on inanimate video trainers, and more recently on virtual reality simulators, has been shown to improve skills performance in the operating room.5,6 Nevertheless, structured training programs utilizing these tools do not exist and have not been validated in terms of which tasks should be performed, at which level, for how long, how often, and to which set of benchmark criteria The aim of this paper was to develop an evidence-based virtual reality training program for the initial acquisition of technical skill, leading to a basic level of proficiency prior to entering the operating theater. Basic and procedural tasks can be simulated in a high-fidelity virtual environment that closely resembles the operative field. Virtual tissues can be manipulated, clipped and cut, and incorporated into a recognizable simulation of Calot triangle dissection, which bleeds and can respond to diathermy (Figs. 1, 2). At the end of each task, performance can be measured using parameters such as time taken, number of errors made, and path length for each hand. This makes it possible to chart the performance of a trainee surgeon along the curriculum and define the attainment of proficiency. FIGURE 1. The “Cutting” task on the LapSim virtual reality simulator. FIGURE 2. The “Dissection” task on the LapSim virtual reality laparoscopic simulator. The structured curriculum can enable trainees to be confident in their skills prior to assisting in and performing the initial laparoscopic procedures, safe in the knowledge that they have achieved preset expert criteria. The ultimate aim is to reduce their learning curve on real patients, leading to acquisition of proficiency at an earlier stage than training on patients alone. Airline pilots become proficient at flying an aeroplane before even leaving the ground, acquiring skills on a high-fidelity flight simulator. The analogous situation should now be possible for the early part of the learning curve in laparoscopic surgery. This may lead to a reduction in the number of unnecessary complications occurring due to a failure of technical skills,7 and the time and expense spent acquiring basic laparoscopic skills in the operating room.8

Race and Surgical Mortality in the United States

Abstract: Objective: This study describes racial differences in postoperative mortality following 8 cardiovascular and cancer procedures and assesses possible explanations for these differences. Summary Background Data: Although racial disparities in the use of surgical procedures are well established, relationships between race and operative mortality have not been assessed systematically. Methods: We used national Medicare data to identify all patients undergoing one of 8 cardiovascular and cancer procedures between 1994 and 1999. We used multiple logistic regression to assess differences in operative mortality (death within 30 days or before discharge) between black patients and white patients, controlling for patient characteristics. Adding hospital indicators to these models, we then assessed the extent to which racial differences in operative mortality could be accounted for by the hospital in which patients were cared for. Results: Black patients had higher crude mortality rates than white patients for 7 of the 8 operations, including coronary artery bypass, aortic valve replacement, abdominal aortic aneurysm repair, carotid endarterectomy, radical cystectomy, pancreatic resection, and esophagectomy. Among these 7 procedures, odds ratios of mortality (black versus white) ranged from 1.23 (95% confidence interval, 1.18–1.29) for CABG to 1.61 (95% confidence interval, 1.28–2.03) for esophagectomy. Adjusting for patient characteristics had modest or no effect on odds ratios of mortality by race. However, there remained few clinically or statistically significant differences in mortality by race after we accounted for hospital. Hospitals that treated a large proportion of black patients had higher mortality rates for all 8 procedures, for white as well as black patients. Conclusions: Black patients have higher operative mortality risks across a wide range of surgical procedures, in large part because of higher mortality rates at the hospitals they attend.