Journal of the American College of Surgeons

Early Platelet Dysfunction: An Unrecognized Role in the Acute Coagulopathy of Trauma

2012-05-01

Background: Our aim was to determine the prevalence of platelet dysfunction using an end point of assembly into a stable thrombus after severe injury. Although the current debate on acute traumatic coagulopathy has focused on the consumption or inhibition of coagulation factors, the question of early platelet dysfunction in this setting remains unclear. Study Design: Prospective platelet function in assembly and stability of the thrombus was determined within 30 minutes of injury using whole blood samples from trauma patients at the point of care using thrombelastography-based platelet functional analysis. Results: There were 51 patients in the study. There were significant differences in the platelet response between trauma patients and healthy volunteers, such that there was impaired aggregation to these agonists. In trauma patients, the median ADP inhibition of platelet function was 86.1% (interquartile range [IQR] 38.6% to 97.7%) compared with 4.2 % (IQR 0 to 18.2%) in healthy volunteers. After trauma, the impairment of platelet function in response to arachidonic acid was 44.9% (IQR 26.6% to 59.3%) compared with 0.5% (IQR 0 to 3.02%) in volunteers (Wilcoxon nonparametric test, p < 0.0001 for both tests). Conclusions: In this study, we show that platelet dysfunction is manifest after major trauma and before substantial fluid or blood administration. These data suggest a potential role for early platelet transfusion in severely injured patients at risk for postinjury coagulopathy.

Infections Caused by Multidrug Resistant Organisms Are Not Associated with Overall, All-Cause Mortality in the Surgical Intensive Care Unit: The 20,000 Foot View

Laura H. Rosenberger, Damien J. LaPar, Robert G. Sawyer — 2012-03-14

Background: Resistant pathogens are increasingly common in the ICU, with controversy regarding their relationship to outcomes. We hypothesized that an increasing number of infections with resistant pathogens in our surgical ICU would not be associated with increased overall mortality. Study Design: All ICU-acquired infections were prospectively identified between January 1, 2000 and December 31, 2009 in a single surgical ICU. Crude in-hospital, all-cause mortality data were obtained using a prospectively collected ICU database. Trends in rates were compared using linear regression. Results: A total of 799 resistant pathogens were identified (257 gram-positive, 542 gram-negative) from a total of 3,024 isolated pathogens associated with 2,439 ICU-acquired infections. The most frequently identified resistant gram-positive and -negative pathogens (defined as resistant to at least 1 major class of antimicrobials) were methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa, respectively. Pathogens were most commonly isolated from the lung, blood, and urine. The crude mortality rate declined steadily from 2000 to 2009 (9.4% to 5.4%; equation for trend y = −0.11x + 8.26). Linear regression analysis of quarterly rates revealed a significant divergence in trends between increasing total resistant infections (equation for trend y = 0.34x + 13.02) and percentage resistant infections (equation for trend y = 0.36x + 18.66) when compared with a decreasing mortality (p = 0.0003, p < 0.0001, respectively). Conclusions: Despite a steady rise in the proportion of resistant bacterial infections in the ICU, crude mortality rates have decreased over time. The rates of resistant infections do not appear to be a significant factor in overall mortality in our surgical ICU patients.

Influence of the National Trauma Data Bank on the Study of Trauma Outcomes: Is It Time to Set Research Best Practices to Further Enhance Its Impact?

2012-02-09

Background: Risk-adjusted analyses are critical in evaluating trauma outcomes. The National Trauma Data Bank (NTDB) is a statistically robust registry that allows such analyses; however, analytical techniques are not yet standardized. In this study, we examined peer-reviewed manuscripts published using NTDB data, with particular attention to characteristics strongly associated with trauma outcomes. Our objective was to determine if there are substantial variations in the methodology and quality of risk-adjusted analyses and therefore, whether development of best practices for risk-adjusted analyses is warranted. Study Design: A database of all studies using NTDB data published through December 2010 was created by searching PubMed and Embase. Studies with multivariate risk-adjusted analyses were examined for their central question, main outcomes measures, analytical techniques, covariates in adjusted analyses, and handling of missing data. Results: Of 286 NTDB publications, 122 performed a multivariable adjusted analysis. These studies focused on clinical outcomes (51 studies), public health policy or injury prevention (30), quality (16), disparities (15), trauma center designation (6), or scoring systems (4). Mortality was the main outcome in 98 of these studies. There were considerable differences in the covariates used for case adjustment. The 3 covariates most frequently controlled for were age (95%), Injury Severity Score (85%), and sex (78%). Up to 43% of studies did not control for the 5 basic covariates necessary to conduct a risk-adjusted analysis of trauma mortality. Less than 10% of studies used clustering to adjust for facility differences or imputation to handle missing data. Conclusions: There is significant variability in how risk-adjusted analyses using data from the NTDB are performed. Best practices are needed to further improve the quality of research from the NTDB.

Hepatectomy for Noncolorectal Non-Neuroendocrine Metastatic Cancer: A Multi-Institutional Analysis

2012-03-19

Background: Although hepatic metastasectomy is well established for colorectal and neuroendocrine cancer, the approach to hepatic metastases from other sites is not well defined. We sought to examine the management of noncolorectal non-neuroendocrine liver metastases. Study Design: A retrospective review from 4 major liver centers identified patients who underwent liver resection for noncolorectal non-neuroendocrine metastases between 1990 and 2009. The Kaplan-Meier method was used to analyze survival, and Cox regression models were used to examine prognostic variables. Results: There were 420 patients available for analysis. Breast cancer (n = 115; 27%) was the most common primary malignancy, followed by sarcoma (n = 98; 23%), and genitourinary cancers (n = 92; 22%). Crude postoperative morbidity and mortality rates were 20% and 2%, respectively. Overall median survival was 49 months, and 1, 3, and 5-year Kaplan-Meier survival rates were 73%, 50%, and 31%. Survival was not significantly different between the various primary tumor types. Recurrent disease was found after hepatectomy in 66% of patients. In multivariable models, lymphovascular invasion (p = 0.05) and metastases ≥5 cm (p = 0.04) were independent predictors of poorer survival. Median survival was shorter for resections performed between 1990 and 1999 (n = 101, 32 months) when compared with resections between 2000 and 2009 (n = 319, 66 months; p = 0.003). Conclusions: Hepatic metastasectomy for noncolorectal non-neuroendocrine cancers is safe and feasible in selected patients. Lymphovascular invasion and metastases ≥5 cm were found to be associated with poorer survival. Patients undergoing metastasectomy in more recent years appear to be surviving longer, however, the reasons for this are not conclusively determined.

Serum Brain Naturietic Peptide Measurements Reflect Fluid Balance after Pancreatectomy

2012-03-22

Background: Overaggressive fluid resuscitation in elderly patients requiring pancreatectomy can delay recovery and increase morbidity. Despite advancements, no accurate and reproducible methods exist to evaluate effective intravascular volume status in the postoperative setting. We hypothesized that sequential measurement of currently available serum proteins will indicate fluid balance. Study Design: Clinicopathologic (n = 44) and echocardiogram (echo) data (n = 18) were collected on patients receiving pancreatectomy or diagnostic laparoscopy (n = 5). Measured fluid balance, serum BUN, creatinine (CR), and brain natriuretic peptide (BNP) levels were recorded on postoperative days (POD) 1 to 7 (only POD1 for diagnostic laparoscopy). ANOVA and bivariate random effect models examined the correlation between BNP and BUN/CR and fluid balance. Linear mixed-effect models examined the correlation between factors associated with vascular stiffness and BNP, BUN/CR, and fluid balance. Results: On POD1 after diagnostic laparoscopy, the fluid balance was positive by 3,265 mL and was accompanied by a >300-point increase in BNP (p = 0.0083). After pancreatectomy, a similar increase in BNP (250 pg/mL) and fluid balance (4,492 mL) on POD1 was observed. During the return to euvolemia, the change in serum BNP levels correlated with fluid balance changes during POD 1 to 3 (p = 0.039), and BUN/CR levels correlated with fluid balance during POD 4 to 7. Patients with risk factors associated with cardiovascular stiffness or echo evidence of poor compliance experienced higher BNP during the postoperative period. Conclusions: Fluid loading at surgery is accompanied by an increase in serum BNP, and return to a balanced fluid state after pancreatectomy is paralleled by changes in BNP and BUN/CR levels.

Determinants of Adverse Events in Vascular Surgery

2012-03-16

Background: Patient safety is a national priority. Patient Safety Indicators (PSIs) monitor potential adverse events during hospital stays. Surgical specialty PSI benchmarks do not exist, and are needed to account for differences in the range of procedures performed, reasons for the procedure, and differences in patient characteristics. A comprehensive profile of adverse events in vascular surgery was created. Study Design: The Nationwide Inpatient Sample was queried for 8 vascular procedures using ICD-9-CM codes from 2005 to 2009. Factors associated with PSI development were evaluated in univariate and multivariate analyses. Results: A total of 1,412,703 patients underwent a vascular procedure and a PSI developed in 5.2%. PSIs were more frequent in female, nonwhite patients with public payers (p < 0.01). Patients at mid and low-volume hospitals had greater odds of developing a PSI (odds ratio [OR] = 1.17; 95% CI, 1.10–1.23 and OR = 1.69; 95% CI, 1.53–1.87). Amputations had highest PSI risk-adjusted rate and carotid endarterectomy and endovascular abdominal aortic aneurysm repair had lower risk-adjusted rate (p < 0.0001). PSI risk-adjusted rate increased linearly by severity of patient indication: claudicants (OR = 0.40; 95% CI, 0.35–0.46), rest pain patients (OR = 0.78; 95% CI, 0.69–0.90), ulcer (OR = 1.20; 95% CI, 1.07–1.34), and gangrene patients (OR = 1.85; 95% CI, 1.66–2.06). Conclusions: Patient safety events in vascular surgery were high and varied by procedure, with amputations and open abdominal aortic aneurysm repair having considerably more potential adverse events. PSIs were associated with black race, public payer, and procedure indication. It is important to note the overall higher rates of PSIs occurring in vascular patients and to adjust benchmarks for this surgical specialty appropriately.

What Are the Real Rates of Postoperative Complications: Elucidating Inconsistencies Between Administrative and Clinical Data Sources

2012-03-15

Background: Comparison of quality outcomes generated from administrative and clinical datasets have shown inconsistencies. Understanding this is important because data designed to drive performance improvement are used for public reporting of performance. We examined administrative and clinical data and 2 clinical data sources in 4 surgical morbidity outcomes. Study Design: Patients who underwent operations between January 2009 and May 2010 had outcomes compared for postoperative hemorrhage, respiratory failure, deep vein thrombosis (DVT), and sepsis. Three data sources were examined: administrative (Agency for Healthcare Research and Quality [AHRQ] Patient Safety Indicators [PSIs]), a national clinical registry (National Surgical Quality Improvement Program [NSQIP]), and an institutional clinical registry (Cardiovascular Information Registry [CVIR]). Cohen's Kappa (K) coefficient was used as a measure of agreement between data sources. Results: For 4,583 patients common to AHRQ and NSQIP, concordance was poor for sepsis (K = 0.07) and hemorrhage (K = 0.14), moderate for respiratory failure (K = 0.30), and better concordance for DVT (K = 0.60). For 7,897 patients common to AHRQ and CVIR, concordance was poor for hemorrhage (K = 0.08), respiratory failure (K = 0.02), and sepsis (K = 0.16), and better for DVT (K = 0.55). For 886 patients common to NSQIP and CVIR, concordance was poor for sepsis (K = 0.054), moderate for hemorrhage (K = 0.27) and respiratory failure (K = 0.4), and better for DVT (K = 0.51). Conclusions: We demonstrate considerable discordance between data sources measuring the same postoperative events. The main contributor was difference in definitions, with additional contribution from data collection and management methods. Although any of these sources can be used for their original intent of performance improvement, this study emphasizes the shortcomings of using these sources for grading performance without standardizing definitions, data collection, and management.

Certification by the American Board of Surgery among US Medical School Graduates

Dorothy A. Andriole, Donna B. Jeffe — 2012-03-29

Background: We sought to identify variables associated with American Board of Medical Specialties (ABMS)–member board certification and lack thereof among US medical graduates who planned at medical school graduation to become certified in surgery and entered graduate medical education in general surgery. Study Design: Deidentified, individualized records updated through March 2009 for all 1993−2000 US medical school matriculants who graduated by 2002, intended to become certified in surgery, and entered general surgery training were analyzed using multivariable logistic regression to identify variables associated with graduates' board certification status, including American Board of Surgery (ABS)–board certified (BC), other ABMS-member–BC (other-BC) and non-BC. Results: Of 3,373 graduates included in the study sample, 2,036 (60.4 %) were ABS-BC, 342 (10.1 %) were other-BC, and 995 (29.5 %) were non-BC. Graduates who were women, older than 26 years old at graduation, and initially failed US Medical Licensing Examination Step 2 Clinical Knowledge were more likely, and graduates who rated the quality of their surgery clerkship in medical school more highly were less likely, to be other-BC vs ABS-BC. Graduates who were women, under-represented minority race/ethnicity, Asian/Pacific Islander race/ethnicity, older than 28 years old at graduation, initially failed US Medical Licensing Examination Step l, initially failed or received low passing scores on US Medical Licensing Examination Step 2 Clinical Knowledge, and graduated in more recent years were more likely to be non-BC vs ABS-BC. Conclusions: Demographic and professional development variables were associated with ABMS-member BC status among US medical graduates who had intended at medical school graduation to become certified in surgery.

Outcomes and Perception of Lung Surgery with Implementation of a Patient Video Education Module: A Prospective Cohort Study

2012-03-29

Background: Although surgeons are constantly making efforts to improve efficiency of care, it is important to also optimize the patients' understanding and satisfaction with their surgical experience. We investigated the effect of a preoperative educational video on patient outcomes and perception of surgery. Study Design: An educational video was developed outlining preoperative, operative, and postoperative expectations for patients undergoing pulmonary resection. A prospective study was conducted with 150 patients undergoing surgery with routine preoperative discussion (control group, January 2008 to June 2009) and 150 patients who were provided a supplemental video module (video or study group, September 2009 to October 2010) in addition to routine discussion. Demographics and outcomes data were recorded. Patients completed a pain survey (McGill Questionnaire) and a standardized patient satisfaction survey at discharge and within 1 month of operation. Results: The groups were similar in sex, age, comorbidities, and forced expiratory volume, 1 second, % predicted. Length of hospital stay (5.19 ± 7.4 days vs 4.31 ± 4.3 days; p = 0.2) and hospital readmission rates (12 of 134 [9%] vs 5 of 103 [4.9%]; p = 0.3) were similar for the 2 groups. At discharge, patients in the study group reported less pain at rest (0.98 ± 0.09) vs controls (1.39 ± 0.11) (p = 0.01) with no difference in pain with lifting or coughing. Patients in the study group reported better overall satisfaction with their operation (2.14 ± 0.07 vs 1.85 ± 0.07; p = 0.02), believed they were better prepared (2.01 ± 0.07 vs 1.70 ± 0.06; p = 0.006), and reported less anxiety about the surgical experience (2.79 ± 0.10 vs 2.24 ± 0.09; p = 0.0001). Conclusions: Implementation of a pulmonary resection education module improves patient preparedness, relieves anxiety, and improves pain perception. Additional development and dissemination of a comprehensive education program can improve patients' experience with lung surgery and impact outcomes.

Relevance of the C-Statistic When Evaluating Risk-Adjustment Models in Surgery

2012-03-22

Background: The measurement of hospital quality based on outcomes requires risk adjustment. The c-statistic is a popular tool used to judge model performance, but can be limited, particularly when evaluating specific operations in focused populations. Our objectives were to examine the interpretation and relevance of the c-statistic when used in models with increasingly similar case mix and to consider an alternative perspective on model calibration based on a graphical depiction of model fit. Study Design: From the American College of Surgeons National Surgical Quality Improvement Program (2008−2009), patients were identified who underwent a general surgery procedure, and procedure groups were increasingly restricted: colorectal-all, colorectal-elective cases only, and colorectal-elective cancer cases only. Mortality and serious morbidity outcomes were evaluated using logistic regression-based risk adjustment, and model c-statistics and calibration curves were used to compare model performance. Results: During the study period, 323,427 general, 47,605 colorectal-all, 39,860 colorectal-elective, and 21,680 colorectal cancer patients were studied. Mortality ranged from 1.0% in general surgery to 4.1% in the colorectal-all group, and serious morbidity ranged from 3.9% in general surgery to 12.4% in the colorectal-all procedural group. As case mix was restricted, c-statistics progressively declined from the general to the colorectal cancer surgery cohorts for both mortality and serious morbidity (mortality: 0.949 to 0.866; serious morbidity: 0.861 to 0.668). Calibration was evaluated graphically by examining predicted vs observed number of events over risk deciles. For both mortality and serious morbidity, there was no qualitative difference in calibration identified between the procedure groups. Conclusions: In the present study, we demonstrate how the c-statistic can become less informative and, in certain circumstances, can lead to incorrect model-based conclusions, as case mix is restricted and patients become more homogenous. Although it remains an important tool, caution is advised when the c-statistic is advanced as the sole measure of a model performance.

Predictive Factors of Early Bowel Obstruction in Colon and Rectal Surgery: Data from the Nationwide Inpatient Sample, 2006–2008

2012-03-29

Background: Early postoperative bowel obstruction is associated with considerable morbidity and mortality after colorectal surgery. We evaluated the impact of patient characteristics, patient comorbidities, pathology, resection site, surgical technique, admission type, and teaching hospital status on the incidence of in-hospital bowel obstruction after colorectal surgery. Study Design: Using the Nationwide Inpatient Sample database, we examined the clinical data of patients who underwent colorectal resection from 2006 to 2008. Regression analyses were performed to identify factors predictive of in-hospital bowel obstruction. Results: A total of 975,825 patients underwent colorectal resection during this period. Overall, the rate of postoperative bowel obstruction was 8.65% (elective surgery: 5.32% vs emergent surgery: 13.26%; p < 0.01). Bowel obstruction was less frequent after laparoscopic procedures compared with open procedures (6.61% vs 8.81%; p < 0.01). Using multivariate regression analysis, Crohn disease (adjusted odds ratio [AOR] = 12.32), emergent surgery (AOR = 2.54), malignant tumor (AOR = 1.84), diverticulitis (AOR = 1.45), age older than 65 years (AOR = 1.22), female sex (AOR = 1.14), history of alcohol abuse (AOR = 1.12), transverse colectomy (AOR = 1.11), peripheral vascular disease (AOR = 1.07), left colectomy (AOR = 1.06), chronic lung disease (AOR = 1.05), open procedure (AOR = 1.05), African-American race (AOR = 1.03), and teaching hospital (AOR = 1.02) were associated with a higher risk of in-hospital bowel obstruction. There was no association between hypertension, diabetes, congestive heart failure, chronic renal failure, liver disease, obesity, smoking, proctectomy or total colectomy, and early bowel obstruction. Conclusions: Early bowel obstruction is a relatively common complication after colorectal surgery. Crohn disease patients had a 12-fold higher incidence of early bowel obstruction, and emergent surgery and malignancy were relevant predictors of early bowel obstruction.

Thoracolaparoscopic Esophagectomy: Is the Prone Position a Safe Alternative to the Decubitus Position?

2012-03-14

Background: During the last few years, prone thoracoscopic esophagectomy has been increasingly adopted for thoracolaparoscopic esophagectomy (TLE). However, evidence for the prone position (PP) over the decubitus position (DP) during TLE is currently not strong enough to reach conclusions. Study Design: From May 2009 to December 2010, we conducted thoracoscopic esophagectomies in the DP and then PP on consecutive patients admitted to our institution. TLE in DP was conducted from May 2009 to February 2010 and in PP from March 2010 to December 2010. Clinical features and operation characteristics of all patients were collected and compared to determine differences between the 2 groups. Results: A total of 93 consecutive esophageal cancer patients were enrolled; Forty-one had their operations in DP and 52 in PP. There was no significant difference found between the 2 groups in age, sex, body mass index, tumor location, histological type, and TNM stage. When compared with DP, thoracoscopic esophagectomy in PP had a shorter operation duration (67 vs 77 minutes; p = 0.013), horter overall hospital stay (17.4 vs 11.4 days; p = 0.011), and yielded a larger number of lymph nodes (11.6 ± 4.0 vs 8.9 ± 4.9 on average; p = 0.005). Complication rates were similar between the 2 groups, with anastomotic leak developing in a significantly smaller number of patients in PP (7.7% vs 22.0%; p = 0.049). Conclusions: TLE in the PP is a feasible and safe alternative to DP and is potentially associated with fewer complications. Additional randomized studies are required to discuss the long-term prognostic value of this procedure.

Younger Boys Have a Higher Risk of Inguinal Hernia after Ventriculo-Peritoneal Shunt: A 13-Year Nationwide Cohort Study

2012-05-01

Background: Few studies associate ventriculo-peritoneal shunt (VPS) in children with higher incidence of inguinal hernia (IH). These institutional-based data have small numbers and provided little information about the effects of age and sex. This study aims to examine the incidences and risk factors of IH in children with hydrocephalus treated with VPS. Study Design: Using a 13-year nationwide database, a cohort of 1,568 children younger than 5 years of age who received VPS were followed up for IH. Of these, 194 received IH repair. Kaplan-Meier analysis and Cox regression were conducted. Results: Overall incidence of IH after VPS in children younger than 5 years old was 22.9 per 1,000 person-years. The average follow-up time was 5.41 years, and the mean time interval between VPS and IH repair was 1.14 years. Age-specific incidences were 45.0, 21.3, 18.5, and 4.1 per 1000 person-years for neonates, infants, toddlers, and preschool children, respectively. Compared with preschool children, neonates, infants, and toddlers, were more likely to have IH (crude hazard ratio = 9.8, 5.3, and 4.4; p < 0.001, p = 0.001, and p = 0.006, respectively). Sex and age were significantly different in children with and without IH (both, p < 0.001). Differences of cumulative incidence rates in the 4 age groups were significant in both male and female patients (p < 0.001 and p = 0.023, respectively). Conclusions: The patient's age on VPS surgery significantly affects the likelihood of subsequent IH development. IH is more likely to develop in neonates after VPS than in infants, toddlers, and preschool-aged children. This age-related effect is more prominent in boys than in girls.

Surgical Site Infection after Colon Surgery: National Healthcare Safety Network Risk Factors and Modeled Rates Compared with Published Risk Factors and Rates

2012-03-22

The Inpatient Prospective Payment System stipulates that hospitals must report rates of colon surgical site infection (SSI) to the National Healthcare Safety Network (NHSN) beginning in 2012, and colon SSI rates will be linked to reimbursement beginning in 2014. For the last decade, the use of pay-for-performance has been promoted in the belief that economic incentives and penalties can accelerate improvements in the quality and outcomes of care. Without an appropriate risk-stratification model, surgeons and hospitals would be penalized for performing operations on patients at higher risk for SSI developing, including those with more severe surgical disease or comorbid conditions. Therefore, pay-for-performance can result in unintended outcomes, such as the exclusion of severely ill patients from care.

A Systematic Review of the Effect of Institution and Surgeon Factors on Surgical Outcomes for Gastric Cancer

Alyson L. Mahar, Robin S. McLeod, Alex Kiss, Lawrence Paszat, Natalie G. Coburn — 2012-03-28

A potential relationship between institution volume and surgical outcomes has been explored for many complex surgical procedures performed for a variety of benign and malignant medical conditions. Institution volume and surgeon experience are potentially modifiable factors; where an association of increased institution volume and improved outcomes has been observed, arguments have been brought forth to centralize services and for the requirement of minimum case-load requirements for certain procedures, affecting the provision of health care at both the system and physician level. Unfortunately, increasing volume alone may not improve outcomes, as institution volume might represent a proxy measure for the technology, amenities, and increased infrastructure available to physicians treating patients at higher-volume hospitals. Surgeon volume, subspecialty training, and age are also believed to be factors that affect a surgeons' ability to perform a procedure to the best advantage of the patient.

Laparoscopic Liver Resection

T. Peter Kingham, Michael I. D'Angelica, William R. Jarnagin — 2012-05-01

We read with interest Dr Cannon's article “Laparoscopic Liver Resection: An Examination of Our First 300 Patients.” As laparoscopic techniques are increasingly being used for hepatic resections, outcomes from series such as this are particularly relevant. We have several questions. Similar to the results reported in a previous article by the authors, the percentage of patients with benign pathology was high. As was concluded at the 2008 Louisville consensus conference, “indications for surgery for benign hepatic lesions should not be widened.” It is difficult to determine from the article why the number of patients undergoing liver resection for benign tumors was so high. To understand this better, it would be helpful to know the histology of tumors resected at open hepatic resection and the proportion of all liver resections performed laparoscopically and for benign disease. These numbers will help the readers place this series into context. For example, are the authors selecting the majority of their benign cases for laparoscopic resection and, in reality, the benign cases are only a small percentage of all of the liver resection performed (combining open and laparoscopic procedures)? It is concerning that in both articles by the authors the rate of malignancy is only 40% to 47% during a 10-year period. This means that 53% to 60% of all laparoscopic liver resections were performed for benign disease, which is inconsistent with reports that describe open liver resections. In a report from our institution describing 1,803 liver resections, only 9% were for benign diagnoses. As a cancer center, our referral bias might alter what is seen in general hospitals, but Belghiti and colleagues published the results of liver resection in 747 patients in the 1990s, with only 35% of patients having benign causes. Keep in mind that this series reflects patients managed before upgraded MRI and CT scanning made it consistently easier to diagnose benign liver pathology without even a biopsy. The authors must clarify the indications for surgery in the 53% to 60% of patients with benign tumors who underwent resection, particularly in a contemporary time frame with better diagnostic modalities at their disposal. As laparoscopic liver surgery expands, it is vital that the indications for resection remain in line with what is considered appropriate for open resections.

Reply

Joseph F. Buell, Robert Cannon, Michael R. Marvin, Guy Brock, Ibrahim Dagher — 2012-05-01

We thank Dr Kingham and colleagues for their interest in our study and for their comments. As the authors noted, during the Louisville Consensus Meeting on Laparoscopic Liver Surgery, the conclusion was reached that the ability to perform laparoscopic liver surgery should not alter the indications for liver resection. This same sentiment was echoed in a published discussion with Dr Henri Bismuth and Dr Ronald Bussutil during the 2008 American Surgical Association presentation of our 500 minimally invasive hepatic procedures.

Appropriate Use of Emergency Department Thoracotomy

Nathan M. Mollberg, Stephen R. Wise — 2012-05-01

We read the article by Passos and colleagues, “Societal costs of inappropriate emergency department thoracotomy” with great interest because it mirrored our own previously published results. Passos and colleagues confirm that the use of emergency department thoracotomy (EDT) outside current guidelines results in the use of scarce health care resources without the benefit of neurologically intact survivors. The authors report that 51.2% (63 of 123) of EDTs were performed inappropriately, a rate that was slightly higher than the 41.7% (50 of 120) seen at our own institution. The authors' results, and our own, illustrate that the inappropriate use of EDT is a widespread problem and we commend the authors for taking a “societal” perspective in their focus. In addition to patient outcomes, the authors focused on the risk to health care personnel in the form of needle stick injury. We were unable to obtain this information in our own study and it lends even more impetus to the need to reform current EDT practice.

Reply

Edward M. Passos, Homer Tien — 2012-05-01

We thank Drs Mollberg and Wise for their interest in our recent study, “Societal costs of inappropriate emergency department thoracotomy.” In their letter, the authors reported analogies between our study and their excellent paper published recently. Interestingly, besides relating the success with the presence of a thoracic surgeon in the procedure, they also focused on appropriate use of emergency department thoracotomy (EDT). They wonder “who initiates, and incidentally performs EDT [at our institution]?” They also wonder if there might be any benefit in involving cardiothoracic surgeons, based on their own experience. At our institution, the attending trauma team leader or the trauma surgery fellow usually initiates the EDT in the trauma room, and the staff trauma surgeon is the attending surgeon for the case. The trauma team leader can be an anesthesiologist, emergency medicine physician, or a general surgeon. Cardiothoracic surgeons are involved on a case-by-case basis, and this practice relates more to their immediate availability for critically injured trauma patients in the emergency department. Our practice does not, in any way, minimize the importance or the need for involving cardiothoracic surgeons for appropriate cases. In fact, in our study, cardiothoracic surgeons were involved in the operative care of two of the survivors.

Ultrasound-Guided Core Needle Biopsy of Axillary Lymph Nodes in Breast Cancer

S. David Nathanson — 2012-05-01

Solon and colleagues' report of ultrasound-guided core needle biopsy (AxUS-CB) of morphologically suspicious ipsilateral axillary lymph nodes (LNs) in breast cancer confirms our findings that the technique is relatively accurate in the preoperative determination of LN metastasis. By showing that the sentinel lymph node (SLN) found intraoperatively contained a microclip placed at the time of AxUS-CB, our study proved that it was possible to identify the SLN in 78.3% of patients. We also showed a false-negative core needle biopsy rate of 13.6%, an unexpectedly high rate of positive LNs of 45.5%, and a smaller metastasis size in nodes falsely negative than in those truly positive.

End-of-Life Care Decisions

Leon Morgenstern — 2012-05-01

In regard to the article “Patient characteristics associated with end-of-life decision making in critically ill surgical patients,” if, as the authors quote, more than 20% of the deaths in the US occur in the ICUs, then ICUs are indeed in the “eye” of the current health care “storm.” Analysis of ICU deaths is therefore a commendable and necessary effort. I have the following comments to make on the authors' depiction of patient characteristics in end-of-life care decisions.

Reply

Matthew Lissauer — 2012-05-01

We thank Dr Morgenstern for his thoughtful comments regarding our article, “Patient characteristics associated with end-of-life decision making in critically ill surgical patients.” Dr Morgenstern has concerns that the field of bioethics was not given more consideration in regard to palliative care and decision making. We certainly agree bioethics has been a formative influence on palliative care, but we did not include this in our discussion because our institution's active palliative care service is offered to all critically ill patients whose nurse, family, or physician believes it will improve care. Palliative care services are offered to patients who wish all life-sustaining treatment to continue. In these instances, palliative care is an ongoing process that involves alleviation of pain and suffering, whatever the medical decision making may be. Because all patients, families, and physicians had access to the same service, it wasn't considered a difference between groups.

JACS CME Featured Articles, Volume 214, May 2012

2012-05-01

Masoomi H, Kang CY, Chaudhry O, et al J Am Coll Surg 2012;214:831–837

A New Single-Port Approach to Perform a Transperitoneal Step and an Extraperitoneal Para-Aortic Lymphadenectomy with a Single Incision

2012-05-01

Chemoradiation therapy (CRT), a combination of external beam irradiation and brachytherapy with concurrent chemotherapy, is considered the standard treatment for bulky cervical cancer (> stage IB2 according to the International Federation of Gynecology and Obstetrics [FIGO] classification) by many North American and Western European teams. The incidence of para-aortic (PA) nodal metastasis in these tumors ranges from 10% to 25%. Positron emission tomography (PET) with or without CT imaging is the most accurate imaging modality for evaluating extrapelvic disease in locally advanced cervical cancer (LACC), When PA nodes are known to be metastatic, the radiation field is extended from the pelvis to include the PA area. However, the rate of false negatives at PET-CT assessment of PA metastasis in LACC is 12%, increasing to 22% if PET-CT reveals pelvic lymph nodes with suspicious metastases. The concept of surgical staging has gained momentum with the development of laparoscopy, which reduces surgical complications. Since January 2011, this surgical staging procedure has been performed more often in our institution using a single-port extraperitoneal approach, which was previously described by our team. We have refined this procedure and developed a “real” single-port approach avoiding a second transumbilical port (to explore the peritoneum), which was used in the first procedure. We report in this series a new procedure for performing these two steps via a single access with only one incision.

Pedunculated Gastric Conduit Interposition with Duodenal Transection after Salvage Esophagectomy: An Option for Increasing the Flexibility of the Gastric Conduit

2012-03-26

A gastric conduit is the first choice for esophageal reconstruction because of its robust blood supply and the need for only a single anastomosis to re-establish continuity with good results. In cases where the stomach is unavailable, a colon conduit is preferentially selected as an esophageal substitute. However, a colon reconstruction is more highly invasive compared with a gastric conduit reconstruction. Salvage esophagectomy after definitive chemoradiotherapy is associated with high morbidity and mortality rates. Gastric conduit necrosis is one of the most critical complications after salvage esophagectomy, potentially leading to in-hospital death. Gastric conduit necrosis can occur when the upper part of the stomach is included in the radiation area of definitive radiotherapy; a damaged stomach with edematous changes and/or redness should be resected (). In such cases, we have previously performed free-jejunal graft interposition or used a colon conduit to avoid anastomosis of the damaged stomach to the cervical esophagus. Here, we present our experience with duodenal transection, which preserves the right gastroepiploic vessels, enabling safe anastomosis at the lower level of the gastric conduit, where the effect of definitive radiation therapy is absent. Given the non-necessity for microvascular anastomosis, this method might represent a suitable minimally invasive technique that minimizes organ sacrifice in this surgical setting.

Difficulties and Countermeasures of Transumbilical Single Incision Laparoscopic Cholecystectomy

Chengyu Luo, Qi Yang, Baoyin Liu, Xiaoxin Ji — 2012-05-01

With the development of minimally invasive surgical techniques, achieving cosmetic results and reducing surgical trauma to the greatest extent become the pursuit of the surgeon. Natural orifice transluminal endoscopic surgery (NOTES) was developed with “no scar,” was less invasive, and had a more esthetic effect. But NOTES is still difficult for broad clinical application because of the limitation of instruments and greater technical difficulty, with the risks of abdominal infection and organ perforation. Transumbilical single incision laparoscopic surgery (TUSILC) hides abdominal operative scars by means of the umbilicus, a natural skin fold. The procedure achieves “no scar” in the abdominal wall and better cosmetic results and technical difficulty and operative risk are greatly reduced. We find that TUSILC has obvious advantages and is the most feasible NOTES operation. From February 2009 to October 2011, 254 patients with gallbladder disease were selected to undergo TUSILC.

2012-05-01

Journal of the American College of Surgeons

Early Platelet Dysfunction: An Unrecognized Role in the Acute Coagulopathy of Trauma

Infections Caused by Multidrug Resistant Organisms Are Not Associated with Overall, All-Cause Mortality in the Surgical Intensive Care Unit: The 20,000 Foot View

Influence of the National Trauma Data Bank on the Study of Trauma Outcomes: Is It Time to Set Research Best Practices to Further Enhance Its Impact?

Hepatectomy for Noncolorectal Non-Neuroendocrine Metastatic Cancer: A Multi-Institutional Analysis

Serum Brain Naturietic Peptide Measurements Reflect Fluid Balance after Pancreatectomy

Determinants of Adverse Events in Vascular Surgery

What Are the Real Rates of Postoperative Complications: Elucidating Inconsistencies Between Administrative and Clinical Data Sources

Certification by the American Board of Surgery among US Medical School Graduates

Outcomes and Perception of Lung Surgery with Implementation of a Patient Video Education Module: A Prospective Cohort Study

Relevance of the C-Statistic When Evaluating Risk-Adjustment Models in Surgery

Predictive Factors of Early Bowel Obstruction in Colon and Rectal Surgery: Data from the Nationwide Inpatient Sample, 2006–2008

Thoracolaparoscopic Esophagectomy: Is the Prone Position a Safe Alternative to the Decubitus Position?

Younger Boys Have a Higher Risk of Inguinal Hernia after Ventriculo-Peritoneal Shunt: A 13-Year Nationwide Cohort Study

Surgical Site Infection after Colon Surgery: National Healthcare Safety Network Risk Factors and Modeled Rates Compared with Published Risk Factors and Rates

A Systematic Review of the Effect of Institution and Surgeon Factors on Surgical Outcomes for Gastric Cancer

Laparoscopic Liver Resection

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Appropriate Use of Emergency Department Thoracotomy

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Ultrasound-Guided Core Needle Biopsy of Axillary Lymph Nodes in Breast Cancer

End-of-Life Care Decisions

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JACS CME Featured Articles, Volume 214, May 2012

A New Single-Port Approach to Perform a Transperitoneal Step and an Extraperitoneal Para-Aortic Lymphadenectomy with a Single Incision

Pedunculated Gastric Conduit Interposition with Duodenal Transection after Salvage Esophagectomy: An Option for Increasing the Flexibility of the Gastric Conduit

Difficulties and Countermeasures of Transumbilical Single Incision Laparoscopic Cholecystectomy

Contents