Journal of the American College of Surgeons RSS feed: Current Issue. The Journal of the American College of Surgeons ( JACS ) is a monthly journal publishing peer-reviewed original contributions on all aspects of surgery. These contributions include, but are not limited to, original clinical studies, review articles, and experimental investigations with clear clinical relevance. In general, case reports are not considered for publication. As the official scientific journal of the American College of Surgeons, JACS has the goal of providing its readership the highest quality rapid retrieval of information relevant to surgeons. Visit the Journal of the American College of Surgeons Web site maintained by the American College of Surgeons at http://www.journalacs.org Subscription orders and inquiries should be mailed to: Elsevier Subscription Customer Service 6277 Sea Harbor Dr. Orlando, FL 32887-4800 USA Telephone: Toll free (for customers inside U.S./Canada): 800-654-2452 For customers outside the U.S./Canada: 407-345-4000 Fax: 407-363-9661 E-mail: elspcs@elsevier.com http://www.journalacs.org/?rss=yesElsevier Inc.en Published by Elsevier Inc. Journal of the American College of Surgeons1072-75152113September 2010 Published by Elsevier Inc. healthpermissions@elsevier.comhttp://www.journalacs.org/article/PIIS1072751510008598/abstract?rss=yesBackground: Accurate assessment of cognitive functioning is an important step in understanding how to better evaluate both clinical and cognitive competence in practicing surgeons. As part of the Cognitive Changes and Retirement among Senior Surgeons study, we examined the objective cognitive functioning of senior surgeons in relation to retirement status and age.Study Design: Computerized cognitive tasks measuring visual sustained attention, reaction time, and visual learning and memory were administered to both practicing and retired surgeons at annual meetings of the American College of Surgeons. Data from 168 senior surgeons aged 60 and older were compared with data from 126 younger surgeons aged 45 to 59, with performance below 1.5 standard deviations or more indicating a significant difference between the groups.Results: Sixty-one percent of practicing senior surgeons performed within the range of the younger surgeons on all cognitive tasks. Seventy-eight percent of practicing senior surgeons aged 60 to 64 performed within the range of the younger surgeons on all tasks compared with 38% of practicing senior surgeons aged 70 and older. Forty-five percent of retired senior surgeons performed within the range of the younger surgeons on all tasks. No senior surgeon performed below the younger surgeons on all 3 tasks.Conclusions: The majority of practicing senior surgeons performed at or near the level of their younger peers on all cognitive tasks, as did almost half of the retired senior surgeons. This suggests that older age does not inevitably preclude cognitive proficiency. The variability in cognitive performance across age groups and retirement status suggests the need for formal measures of objective cognitive functioning to help surgeons detect changes in cognitive performance and aid in their decisions to retire.Cognitive Functioning, Retirement Status, and Age: Results from the Cognitive Changes and Retirement among Senior Surgeons StudyLauren L. Drag, Linas A. Bieliauskas, Scott A. Langenecker, Lazar J. Greenfield10.1016/j.jamcollsurg.2010.05.022Journal of the American College of Surgeons 211, 3 (2010)2010-09-01Journal of the American College of Surgeons2010-09-012113S1072-7515(10)X0008-4Original Scientific Articles303307http://www.journalacs.org/article/PIIS1072751510003595/abstract?rss=yesBackground: Electronic synoptic operative reports (E-SORs) have replaced dictated reports at many institutions, but whether E-SORs adequately document the components and findings of an operation has received limited study. This study assessed the reliability and completeness of E-SORs for pancreatic surgery developed at our institution.Study Design: An attending surgeon and surgical fellow prospectively and independently completed an E-SOR after each of 112 major pancreatic resections (78 proximal, 29 distal, and 5 central) over a 10-month period (September 2008 to June 2009). Reliability was assessed by calculating the interobserver agreement between attending physician and fellow reports. Completeness was assessed by comparing E-SORs to a case-matched (surgeon and procedure) historical control of dictated reports, using a 39-item checklist developed through an internal and external query of 13 high-volume pancreatic surgeons.Results: Interobserver agreement between attending and fellow was moderate to very good for individual categorical E-SOR items (kappa = 0.65 to 1.00, p < 0.001 for all items). Compared with dictated reports, E-SORs had significantly higher completeness checklist scores (mean 88.8 ± 5.4 vs 59.6 ± 9.2 [maximum possible score, 100], p < 0.01) and were available in patients' electronic records in a significantly shorter interval of time (median 0.5 vs 5.8 days from case end, p < 0.01). The mean time taken to complete E-SORs was 4.0 ± 1.6 minutes per case.Conclusions: E-SORs for pancreatic surgery are reliable, complete in data collected, and rapidly available, all of which support their clinical implementation. The inherent strengths of E-SORs offer real promise of a new standard for operative reporting and health communication.Electronic Synoptic Operative Reporting: Assessing the Reliability and Completeness of Synoptic Reports for Pancreatic ResectionJason Park, Venu G. Pillarisetty, Murray F. Brennan, William R. Jarnagin, Michael I. D'Angelica, Ronald P. DeMatteo, Daniel G Coit, Maria Janakos, Peter J. Allen10.1016/j.jamcollsurg.2010.05.008Journal of the American College of Surgeons 211, 3 (2010)2010-07-14Journal of the American College of Surgeons2010-07-142113S1072-7515(10)X0008-4Original Scientific Articles308315http://www.journalacs.org/article/PIIS1072751510002942/abstract?rss=yesBackground: Use of prosthetic grafts for reconstruction after portal vein (PV) resection during pancreaticoduodenectomy is controversial. We examined outcomes in patients who underwent vein reconstruction using polytetrafluoroethylene (PTFE).Study Design: Review of prospectively maintained databases at 3 centers identified all patients who underwent pancreaticoduodenectomy (PD) with vein resection and reconstruction using PTFE grafts between 1994 and 2009. Patient, operative, and outcomes variables were studied. Graft patency and survival were assessed using the Kaplan-Meier technique.Results: Thirty-three patients underwent segmental vein resection with interposition PTFE graft reconstruction. Median age was 67 years; median Eastern Cooperative Oncology Group score was 1. Most operations were performed for pancreatic adenocarcinoma (n = 28, 85%); 96% were T3 lesions or greater. Standard PD was performed in 12 (36%) patients, pylorus-preservation in 17 (52%), and total pancreatectomy in 4 (12%). Combined resection of portal and superior mesenteric veins (SMV) was required in 49%, with resection isolated to PV in 12% and SMV in 39%. Splenic vein ligation was necessary in 30%. Median graft diameter was 12 mm (range 8 to 20 mm), with the majority being ring-enforced (73%). Median operative and vascular clamp times were 463 and 41 minutes, respectively, with median blood loss of 1,500 mL. The negative margin rate was 64%. Overall morbidity rate was 46%, and 30-day mortality was 6%. No patients developed irreversible hepatic necrosis or graft infection. Pancreatic fistulas occurred in 3 (9.1%). With mean follow-up of 14 months, overall graft patency was 76%. Estimated median duration of graft patency was 21 months. Median survival was 12 months for pancreatic adenocarcinoma.Conclusions: With careful patient selection, PTFE graft reconstruction of resected PV/SMV during pancreaticoduodenectomy is possible with minimal risk of hepatic necrosis or graft infection. Comparison studies to primary anastomosis and autologous vein reconstruction are necessary.Prosthetic Graft Reconstruction after Portal Vein Resection in Pancreaticoduodenectomy: A Multicenter AnalysisCarrie K. Chu, Michael B. Farnell, Justin H. Nguyen, John A. Stauffer, David A. Kooby, Guido M. Sclabas, Juan M. Sarmiento10.1016/j.jamcollsurg.2010.04.005Journal of the American College of Surgeons 211, 3 (2010)2010-06-07Journal of the American College of Surgeons2010-06-072113S1072-7515(10)X0008-4Original Scientific Articles316324http://www.journalacs.org/article/PIIS1072751510003443/abstract?rss=yesBackground: Failure to rescue (ie, mortality after a major complication) has recently been demonstrated as a mechanism underlying differences between high and low mortality hospitals. In this study, we sought to better understand the hospital characteristics that may explain failure to rescue.Study Design: Using data from the 2000 to 2006 Nationwide Inpatient Sample and the American Hospital Association annual survey, we evaluated the effect of 5 hospital level characteristics on failure to rescue (FTR) rates. Using multivariate logistic regression models, we determined the relative contribution of each of these factors to the FTR rates at the lowest and highest mortality hospitals.Results: Failure to rescue varied 6-fold across hospitals (6.4% in very low mortality hospitals vs 40.0% in very high mortality hospitals, p < 0.001). Several hospital characteristics were significantly associated with lower FTR: teaching status (odds ratio [OR] 0.66, 95% CI 0.53 to 0.82), hospital size greater than 200 beds (OR 0.65, 95% CI 0.48 to 0.87), average daily census greater than 50% capacity (OR 0.56, 95%CI 0.32 to 0.98), increased nurse-to-patient ratios (OR 0.94, 95% CI 0.89 to 0.99), and high hospital technology (OR 0.65, 95% CI 0.52 to 0.81). Including all hospital characteristics into a multivariate model results in a 36% reduction in the odds of FTR between very high and very low mortality hospitals (OR 6.6, 95% CI 3.7 to 11.9).Conclusions: Several hospital characteristics are associated with FTR from major complications. However, a large portion of what makes some hospitals better than others at rescuing patients remains unexplained. Future research should focus on hospital cultures and attitudes that may contribute to the timely recognition and effective management of major complications.Hospital Characteristics Associated with Failure to Rescue from Complications after PancreatectomyAmir A. Ghaferi, Nicholas H. Osborne, John D. Birkmeyer, Justin B. Dimick10.1016/j.jamcollsurg.2010.04.025Journal of the American College of Surgeons 211, 3 (2010)2010-07-14Journal of the American College of Surgeons2010-07-142113S1072-7515(10)X0008-4Original Scientific Articles325330http://www.journalacs.org/article/PIIS1072751510003406/abstract?rss=yesBackground: Retention of learning from surgical training is often limited, especially if the knowledge and skills are used infrequently. Using histopathology diagnostic skills as an experimental system, we compared knowledge transfer and retention between bolus Web-based teaching (WBT) modules and online spaced education, a novel email-based method of online education founded on the spacing effect.Study Design: All US urology residents were eligible to participate. Enrollees were randomized to 1 of 2 cohorts. Cohort 1 residents received 3 cycles/repetitions of spaced education on prostate-testis histopathology (weeks 1 to 16) and 3 WBT modules on bladder-kidney (weeks 14 to 16). Cohort 2 residents received 3 cycles of spaced education on bladder-kidney (weeks 1 to 16) and 3 WBT modules on prostate-testis (weeks 14 to 16). Each daily spaced education email presented a clinical scenario with histopathology image and asked for a diagnosis. Participants received immediate feedback after submitting their answers. Each cycle/repetition was 4 weeks long and consisted of 20 questions with unique images. WBT used the identical content and delivery system, with questions aggregated into three 20-question modules. Long-term retention of all 4 topics was assessed during weeks 18 to 45.Results: Seven-hundred and twenty-four urology residents enrolled. Spaced education and WBT were completed by 77% and 66% of residents, respectively. Spaced education and WBT generated mean long-term score increases of 15.2% (SD 15.3%) and 3.4% (SD 16.3%), respectively (p < 0.01). Spaced education increased long-term learning efficiency 4-fold.Conclusions: Online spaced education generates transfer of histopathology diagnostic skills and substantially improves their long-term retention. Additional research is needed to determine how spaced education can optimize learning, transfer, and retention of surgical skills.Online Spaced Education Generates Transfer and Improves Long-Term Retention of Diagnostic Skills: A Randomized Controlled TrialB. Price Kerfoot, Yineng Fu, Harley Baker, Donna Connelly, Michael L. Ritchey, Elizabeth M. Genega10.1016/j.jamcollsurg.2010.04.023Journal of the American College of Surgeons 211, 3 (2010)2010-07-13Journal of the American College of Surgeons2010-07-132113S1072-7515(10)X0008-4Original Scientific Articles331337.e1http://www.journalacs.org/article/PIIS1072751510003017/abstract?rss=yesBackground: The average life expectancy of Japanese individuals is the longest in the world. The mortality rate from injury is increasing among older people. There have been no detailed reports on the relationship between pre-existing medical conditions (PMCs) and mortality from trauma among elderly people in Japan.Study Design: We conducted a retrospective analysis using 20,257 cases recorded in the Japan Trauma Data Bank from 2004 to 2007. The subjects were 11,590 hospital inpatients (57.2%) 16 years of age or older. A logistic regression analysis was conducted for the relation between 23 PMCs and in-hospital mortality.Results: Overall in-hospital mortality was 10.8%, and for people 75 years of age and older, was 17.7%. The incidence of PMC was 4,752 (41.0%). Patients with PMCs of cirrhosis, active cancer, chronic obstructive pulmonary disease, hematologic disorders, anticoagulation drugs, dementia or mental retardation, or other conditions had higher in-hospital mortality. The existence of a single PMC did not increase mortality, but with 2 or more PMCs, mortality significantly increased. The existence of 2 or more PMCs in the 50- to 74-year-old age group and in the minor injury group strongly affected the odds ratio for mortality.Conclusions: The existence of certain PMCs or of 2 or more PMCs increases in-hospital mortality from injury. This effect is particularly conspicuous in middle-aged patients and people with minor injuries, but was not found to be a problem among elderly people. The increased mortality from injury in elderly people in Japan is therefore not affected by the existence of PMCs.Effect of Pre-existing Medical Conditions on In-Hospital Mortality: Analysis of 20,257 Trauma Patients in JapanTomohisa Shoko, Atsushi Shiraishi, Masahito Kaji, Yasuhiro Otomo10.1016/j.jamcollsurg.2010.04.010Journal of the American College of Surgeons 211, 3 (2010)2010-07-13Journal of the American College of Surgeons2010-07-132113S1072-7515(10)X0008-4Original Scientific Articles338346http://www.journalacs.org/article/PIIS1072751510003388/abstract?rss=yesBackground: Patient Safety Indicator (PSI) 11, or postoperative respiratory failure, was developed by the US Agency for Healthcare Research and Quality to detect incident cases of respiratory failure after elective operations through use of ICD-9-CM diagnosis and procedure codes. We sought to determine the positive predictive value (PPV) of this indicator.Study Design: We conducted a retrospective cross-sectional study, sampling consecutive cases that met PSI 11 criteria from 18 geographically diverse academic medical centers on or before June 30, 2007. Trained abstractors from each center reviewed medical records using a standard instrument. We assessed the PPV of the indicator (with 95% CI adjusted for clustering within centers) and conducted descriptive analyses of the cases.Results: Of 609 cases that met PSI 11 criteria, 551 (90.5%; 95% CI, 86.5–94.4%) satisfied the technical criteria of the indicator and 507 (83.2%; 95% CI, 77.2–89.3%) represented true cases of postoperative respiratory failure from a clinical standpoint. The most frequent reasons for being falsely positive were nonelective hospitalization, prolonged intubation for airway protection, and insufficient evidence to support a diagnosis of acute respiratory failure. Fifty percent of true-positive cases involved substantial baseline comorbidities, and 23% resulted in death.Conclusions: Although PSI 11 predicts true postoperative respiratory failure with relatively high frequency, the indicator does not limit detection to preventable cases. The PPV of PSI 11 might be increased by excluding cases with a principal diagnosis suggestive of a nonelective hospitalization and those with head or neck procedures. Removing the diagnosis code criterion from the indicator might also increase PPV, but would decrease the number of true positive cases detected by 20%.Detection of Postoperative Respiratory Failure: How Predictive Is the Agency for Healthcare Research and Quality's Patient Safety Indicator?Garth H. Utter, Joanne Cuny, Pradeep Sama, Michael R. Silver, Patricia A. Zrelak, Ruth Baron, Saskia E. Drösler, Patrick S. Romano10.1016/j.jamcollsurg.2010.04.022Journal of the American College of Surgeons 211, 3 (2010)2010-07-13Journal of the American College of Surgeons2010-07-132113S1072-7515(10)X0008-4Original Scientific Articles347354.e29http://www.journalacs.org/article/PIIS1072751510003601/abstract?rss=yesBackground: Little is known about preventative measures to lessen solid organ injury in motor vehicle collisions (MVCs). To evaluate the efficacy of airbags in reducing renal injuries in MVC, we analyzed renal injury rates in vehicles with and without airbags using the Crash Injury Research and Engineering Network (CIREN) database.Study Design: The CIREN database was queried for MVC and renal injury from 1996 to September 2008. CIREN is weighted toward late model vehicles and selects more severely injured patients. Search fields were primary direction of force (PDOF), presence of airbags, and location of airbags (steering wheel, instrument panel, seat back, door panel, and roof-side curtain). Abdominal Abbreviated Injury Score was converted to AAST renal injury grade. Renal injury rates were compared between vehicles with and without frontal and side airbags.Results: We reviewed 2,864 records and identified 139 renal injuries (28.9% AAST grade III to V). In MVCs with renal injuries, frontal impact was 54.7% of total (n = 76) and side impact was 45.3% of total (n = 63). Most occupants in frontal impact MVCs had exposure to a steering wheel airbag (74.9%); 16.6% had an instrument panel (passenger) airbags. In side impact MVCs, 32.2% of occupants had a side airbag. Compared with the non-airbags cohort, frontal airbags and side airbags were associated with a 45.3% and 52.8% reduction in renal injury, respectively.Conclusions: Passengers in automobiles with frontal and side airbags have a reduced rate of renal injury compared with those without airbags. Our data support further study of the role of airbags in reducing renal injury after MVC.Examination of the Impact of Airbags on Renal Injury Using a National DatabaseThomas G. Smith, Hunter B. Wessells, Chris D. Mack, Robert Kaufman, Eileen M. Bulger, Bryan B. Voelzke10.1016/j.jamcollsurg.2010.05.009Journal of the American College of Surgeons 211, 3 (2010)2010-07-14Journal of the American College of Surgeons2010-07-142113S1072-7515(10)X0008-4Original Scientific Articles355360http://www.journalacs.org/article/PIIS1072751510003728/abstract?rss=yesBackground: Extracorporeal shock wave therapy may enhance revascularization and repair of healing soft tissue.Methods: Between January 2006, and September 2007, 28 patients with acute traumatic wounds and burns requiring skin grafting were randomly assigned in a 1:1 fashion to receive standard topical therapy (nonadherent silicone mesh [Mepitel, Mölnlycke Health Care] and antiseptic gel [polyhexanide/octenidine]) to graft donor sites with (n = 13) or without (n = 15) defocused extracorporeal shock wave therapy (ESWT, 100 impulses/cm2 at 0.1 mJ/mm2) applied once to the donor site, immediately after skin harvest. The randomization sequence was computer generated, and the patients were blinded to treatment allocation. The primary endpoint was time to complete donor site epithelialization and was determined by an independent blinded observer.Results: Statistical tests indicated no unbalanced distribution of subject characteristics across the two study groups. Mean times to complete graft donor site epithelialization for patients who did and did not undergo ESWT were 13.9 ± 2.0 days and 16.7 ± 2.0 days, respectively (p = 0.0001).Conclusions: For centers that apply nonadherent gauze dressings and topical antiseptics to skin graft donor sites, application of a single defocused shock wave treatment immediately after skin graft harvest can significantly accelerate donor site epithelialization.Prospective Randomized Trial of Accelerated Re-epithelization of Skin Graft Donor Sites Using Extracorporeal Shock Wave TherapyChristian Ottomann, Bernd Hartmann, Josh Tyler, Heike Maier, Richard Thiele, Wolfgang Schaden, Alexander Stojadinovic10.1016/j.jamcollsurg.2010.05.012Journal of the American College of Surgeons 211, 3 (2010)2010-07-14Journal of the American College of Surgeons2010-07-142113S1072-7515(10)X0008-4Original Scientific Articles361367http://www.journalacs.org/article/PIIS1072751510003418/abstract?rss=yesBackground: Porcine acellular dermal matrices (PADMs) have been used clinically for abdominal wall repair. The newer non-cross-linked PADMs, however, have not been directly compared with cross-linked PADMs. We hypothesized that chemical cross-linking affects the biologic host response to PADMs used to repair ventral hernias.Study Design: Fifty-eight guinea pigs underwent inlay repair of surgically created ventral hernias using cross-linked or non-cross-linked PADM. After animals were sacrificed at 1, 2, or 4 weeks, the tenacity of and surface area involved by adhesions to the repair sites were measured. Sections of the repair sites, including the bioprosthesis-musculofascia interface, underwent histologic analysis of cellular and vascular infiltration plus mechanical testing.Results: Compared with cross-linked PADM repairs, non-cross-linked PADM repairs had a significantly lower mean tenacity grade of adhesions at all timepoints and mean adhesion surface area at week 1. Mean cellular and vascular densities were significantly higher in non-cross-linked PADM at all timepoints. Cells and vessels readily infiltrated into the center of non-cross-linked PADM, but encapsulated cross-linked PADM, with a paucity of penetration into it. Mechanical properties were similar for the two PADMs (in isolation) at all timepoints; however, at the bioprosthesis-musculofascia interface, both elastic modulus and ultimate tensile strength were significantly higher at weeks 1 and 2 for non-cross-linked PADM.Conclusions: Non-cross-linked PADM is rapidly infiltrated with host cells and vessels; cross-linked PADM becomes encapsulated. Non-cross-linked PADM causes weaker adhesions to repair sites while increasing the mechanical strength of the bioprosthesis-musculofascia interface at early timepoints. Non-cross-linked PADM may have early clinical advantages over cross-linked PADM for bioprosthetic abdominal wall reconstruction.Comparison of Cross-Linked and Non-Cross-Linked Porcine Acellular Dermal Matrices for Ventral Hernia RepairCharles E. Butler, Nadja K. Burns, Kristin Turza Campbell, Anshu B. Mathur, Mona V. Jaffari, Carmen N. Rios10.1016/j.jamcollsurg.2010.04.024Journal of the American College of Surgeons 211, 3 (2010)2010-07-14Journal of the American College of Surgeons2010-07-142113S1072-7515(10)X0008-4Original Scientific Articles368376http://www.journalacs.org/article/PIIS1072751510003959/abstract?rss=yesBackground: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice for patients with ulcerative colitis and familial adenomatous. This study examined the impact of the surgical approach (laparoscopic versus open) to IPAA on short-term outcomes and time to ileostomy closure in 2-stage restorative proctocolectomies.Study Design: A retrospective review was performed on a prospectively maintained database at Washington University School of Medicine for patients undergoing elective 2-stage restorative proctocolectomy and IPAA from April of 1999 through July of 2008. Outcomes for patients were analyzed according to laparoscopic versus open technique.Results: A total of 124 patients (55 laparoscopy, 69 open) were included in this study. Laparoscopic IPAA took, on average, 79.2 minutes longer to complete than open IPAA (p < 0.0001) and required significantly more intravenous fluid administration (p = 0.0004). There was no significant difference between laparoscopic and open IPAA with respect to estimated blood loss, blood transfusions, postoperative narcotic usage, return of bowel function, length of stay, and hospital readmission rates. Total complications were not statistically significant between the 2 groups. Patients in the laparoscopic IPAA group underwent ileostomy closure an average of 24.1 days sooner than patients in the open group (p = 0.045). Multivariate analysis revealed that surgical approach (p = 0.018) and length of stay (p = 0.004) were associated with faster time to closure of loop ileostomy.Conclusions: Laparoscopic IPAA is safe, with postoperative morbidity comparable with open IPAA. Laparoscopic IPAA can lead to faster recovery and result in faster progression to restoration of intestinal continuity in patients undergoing 2-stage restorative proctocolectomy.Laparoscopic Versus Open 2-Stage Ileal Pouch: Laparoscopic Approach Allows for Faster Restoration of Intestinal ContinuityAlyssa D. Fajardo, Sekhar Dharmarajan, Virgilio George, Steven R. Hunt, Elisa H. Birnbaum, James W. Fleshman, Matthew G. Mutch10.1016/j.jamcollsurg.2010.05.018Journal of the American College of Surgeons 211, 3 (2010)2010-09-01Journal of the American College of Surgeons2010-09-012113S1072-7515(10)X0008-4Original Scientific Articles377383http://www.journalacs.org/article/PIIS1072751510003431/abstract?rss=yesBackground: In patients with primary hyperaldosteronism, distinguishing between unilateral and bilateral adrenal hypersecretion is critical in assessing treatment options. Adrenal venous sampling (AVS) has been advocated by some to be the gold standard for localization of the responsible lesion, but there remains a lack of consensus for the criteria and the standardization of technique.Study Design: We performed a retrospective study of 114 patients with a biochemical diagnosis of primary hyperaldosteronism who all underwent CT scan and AVS before and after corticotropin (ACTH) stimulation. Univariate and multivariate analyses were performed to determine what factors were associated with AVS lateralization, and which AVS values were the most accurate criteria for lateralization.Results: Eighty-five patients underwent surgery at our institution for unilateral hyperaldosteronism. Of the 57 patients who demonstrated unilateral abnormalities on CT, AVS localized to the contralateral side in 5 patients and revealed bilateral hyperplasia in 6 patients. Of the 52 patients who showed bilateral disease on CT scan, 43 lateralized with AVS. The most accurate criterion on AVS for lateralization was the post-ACTH stimulation value. Factors associated with AVS lateralization included a low renin value, high plasma aldosterone-to plasma-renin ratio, and adrenal mass ≥ 3 cm on CT scan.Conclusions: Because 50% of patients would have been inappropriately managed based on CT scan findings, patients with biochemical evidence of primary hyperaldosteronism and considering adrenalectomy should have AVS. The most accurate measurement for AVS lateralization was the post-ACTH stimulation value. Although several factors predict successful AVS lateralization, none are accurate enough to perform AVS selectively.Consequences of Adrenal Venous Sampling in Primary Hyperaldosteronism and Predictors of Unilateral Adrenal DiseaseAarti Mathur, Clinton D. Kemp, Utpal Dutta, Smita Baid, Alejandro Ayala, Richard E. Chang, Seth M. Steinberg, Vasilios Papademetriou, Eileen Lange, Steven K. Libutti, James F. Pingpank, H. Richard Alexander, Giao Q. Phan, Marybeth Hughes, W. Marston Linehan, Peter A. Pinto, Constantine A. Stratakis, Electron Kebebew10.1016/j.jamcollsurg.2010.05.006Journal of the American College of Surgeons 211, 3 (2010)2010-07-14Journal of the American College of Surgeons2010-07-142113S1072-7515(10)X0008-4Original Scientific Articles384390http://www.journalacs.org/article/PIIS1072751510002528/abstract?rss=yesBackground: Significantly higher mortality has been demonstrated in patients who suffer severe burns complicated by Klebsiella pneumoniae bacteremia. The specific virulence mechanisms associated with this organism in this population are unclear.Study Design: Our study assessed the impact of the mechanism of antibiotic resistance, strain clonality, and other host factors on morbidity and mortality. All patients with thermal burns infected with K pneumoniae between January 1, 2004 and July 1, 2008 were included in the analysis.Results: Ninety-one patients had 111 episodes of K pneumoniae infections, with 59 isolates among the 91 patients producing extended spectrum beta-lactamase (ESBL). Patients with ESBL-producing strains were slightly younger, had higher Injury Severity Scores (ISS), and higher percent full thickness burns. Those who survived to discharge were younger (p < 0.001), had less burned surface area (p = 0.013), had fewer ventilator days (p = 0.016), and fewer infections with ESBL-producing isolates (p = 0.042). Logistic regression revealed that an infection with ESBL-producing K pneumoniae during the hospital stay was the factor most predictive of death, with a nearly 4-fold increased odds of dying. However, survival duration analysis of the population with and without ESBL-producing K pneumoniae using Kaplan-Meier technique showed no significant difference in the populations. Cox regression proportional hazards model revealed that only age (p = 0.01) and ventilator days (p ≤ 0.01) were associated with time to death. No specific clonality of the strains tested or ESBL production resistance genes were associated with mortality or ESBL production.Conclusions: These results suggest that infections caused by ESBL-producing K pneumoniae are predictive of death when occurring in an older, more badly burned population.Impact of Extended Spectrum Beta-Lactamase Producing Klebsiella pneumoniae Infections in Severely Burned PatientsJason W. Bennett, Janelle L. Robertson, Duane R. Hospenthal, Steven E. Wolf, Kevin K. Chung, Katrin Mende, Clinton K. Murray10.1016/j.jamcollsurg.2010.03.030Journal of the American College of Surgeons 211, 3 (2010)2010-06-07Journal of the American College of Surgeons2010-06-072113S1072-7515(10)X0008-4Original Scientific Articles391399http://www.journalacs.org/article/PIIS1072751510003741/abstract?rss=yesBackground: Certain clinical environments, including military field hospitals or rural medical centers, lack readily available surgical subspecialists. We hypothesized that telementoring by a surgical subspecialist using a robotic platform is feasible and can convey subspecialty knowledge and skill to a remotely located general surgeon.Study Design: Eight general surgery residents evaluated the effect of remote surgical telementoring by performing 3 operative procedures, first unproctored and then again when teleproctored by a surgical subspecialist. The clinical scenarios consisted of a penetrating right ventricular injury requiring suture repair, an open tibial fracture requiring external fixation, and a traumatic subdural hematoma requiring craniectomy. A robotic platform consisting of a pan-and-tilt camera with laser pointer attached to an overhead surgical light with integrated audio allowed surgical subspecialists the ability to remotely teleproctor residents. Performance was evaluated using an Operative Performance Scale. Satisfaction surveys were given after performing the scenario unproctored and again after proctoring.Results: Overall mean performance scores were superior in all scenarios when residents were proctored than when they were not (4.30 ± 0.25 versus 2.43 ± 0.20; p < 0.001). Mean performance scores for individual metrics, including tissue handling, instrument handling, speed of completion, and knowledge of anatomy, were all superior when residents were proctored (p < 0.001). Satisfaction surveys showed greater satisfaction and comfort among residents when proctored. Proctored residents believed the robotic platform facilitated learning and would be feasible if used clinically.Conclusions: This study supports the use of surgical teleproctoring in guiding remote general surgeons by a surgical subspecialist in the care of a wounded patient in need of an emergency subspecialty operation.Live Transference of Surgical Subspecialty Skills Using Telerobotic Proctoring to Remote General SurgeonsAlexander Q. Ereso, Pablo Garcia, Elaine Tseng, Grant Gauger, Hubert Kim, Monica M. Dua, Gregory P. Victorino, T. Sloane Guy10.1016/j.jamcollsurg.2010.05.014Journal of the American College of Surgeons 211, 3 (2010)2010-09-01Journal of the American College of Surgeons2010-09-012113S1072-7515(10)X0008-4Original Scientific Articles400411http://www.journalacs.org/article/PIIS1072751510003960/abstract?rss=yesAlthough laparoscopic approaches are used for many abdominal procedures and allow for faster recovery of bowel function, better immunologic response, and overall accelerated recovery for the patient, use of laparoscopy for cancer surgery is still a matter of debate. For patients with cancer, questions remain about the immunologic implications of laparoscopic surgery, the adequacy and standardization of laparoscopic techniques, risk for disease recurrence, and impact on survival. The safety and efficacy of laparoscopic surgery for colorectal cancer has certainly been established, but the same rigorous approach to other cancers has yet to be reported. In this article, we review the current data and state of the art for laparoscopic approaches in abdominal cancer surgery.Laparoscopic Surgery for Cancer: A Systematic Review and a Way ForwardEliane Angst, Jonathan R. Hiatt, Beat Gloor, Howard A. Reber, O. Joe Hines10.1016/j.jamcollsurg.2010.05.019Journal of the American College of Surgeons 211, 3 (2010)2010-07-14Journal of the American College of Surgeons2010-07-142113S1072-7515(10)X0008-4Collective Review412423http://www.journalacs.org/article/PIIS1072751510002462/abstract?rss=yesThe presentation of Thomas Eakins' massive (96 × 78 inch) oil painting The Gross Clinic (hereafter referred to as Clinic) in 1875 created immediate controversy because of its subject matter. Clinic depicts the 70-year-old Dr Samuel David Gross (1805−1884) of Jefferson Medical College (JMC) in Philadelphia directing an operation on the left leg of a young man and teaching both his assistants and on-looking students packed into an amphitheater. It is a realistic, heroic, action portrait of a great man at his work.Dr Gross's Assistants in The Gross ClinicRobert W. Ikard10.1016/j.jamcollsurg.2010.03.024Journal of the American College of Surgeons 211, 3 (2010)2010-06-07Journal of the American College of Surgeons2010-06-072113S1072-7515(10)X0008-4History424430http://www.journalacs.org/article/PIIS1072751510004291/abstract?rss=yesThe term “evidence-based medicine” was first coined by Sackett and colleagues as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” The key to practicing evidence-based medicine is applying the best current knowledge to decisions in individual patients. Medical knowledge is continually and rapidly expanding and it is impossible for an individual clinician to read all the medical literature. For clinicians to practice evidence-based medicine, they must have the skills to read and interpret the medical literature so that they can determine the validity, reliability, credibility and utility of individual articles. These skills are known as critical appraisal skills. Generally, critical appraisal requires that the clinician have some knowledge of biostatistics, clinical epidemiology, decision analysis and economics as well as clinical knowledge.Meta-analysis comparing healing by primary closure and open healing after surgery for pilonidal sinusKaren J. Brasel, Lester Gottesman, Carol-Ann Vasilevsky, Members of the Evidence-Based Reviews in Surgery Group*10.1016/j.jamcollsurg.2010.06.014Journal of the American College of Surgeons 211, 3 (2010)2010-09-01Journal of the American College of Surgeons2010-09-012113S1072-7515(10)X0008-4Canadian Association of General Surgeons and ACS, Evidence-Based Reviews in Surgery431434http://www.journalacs.org/article/PIIS1072751510003947/abstract?rss=yesThe presence of missing data in clinical studies is a frequent problem and an active area of statistical research. Hamilton and colleagues investigated the implications of missing data on a large surgical quality improvement database, comparing methods to impute missing values. This article presents a very real problem of great importance to the American College of Surgeons National Surgical Quality Improvement Program and the hospitals that participate. However, the terminology, results, and assumptions presented necessitate additional clarification.Missing Data AnalysesBrandie Wagner, Tracy Schifftner Smith10.1016/j.jamcollsurg.2010.05.017Journal of the American College of Surgeons 211, 3 (2010)2010-09-01Journal of the American College of Surgeons2010-09-012113S1072-7515(10)X0008-4Letters435435http://www.journalacs.org/article/PIIS1072751510003935/abstract?rss=yesThe authors thank Dr Wagner and Dr Schifftner-Smith for their commentary on our examination of missing data within the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). We acknowledge Dr Wagner's and Dr Schifftner-Smith's expertise and appreciate their contributions to the understanding of this topic as well as to the broader evaluation of quality within health care. We also agree that further discussion of these topics is warranted and will be valuable, and regret that there are many additional issues around the topic of missing data, including additional investigations such as those noted by Dr Wagner and Dr Schifftner-Smith, which were beyond the scope of our brief article.ReplyBruce L. Hall, Barton H. Hamilton, Clifford Ko, Karen Richards10.1016/j.jamcollsurg.2010.05.016Journal of the American College of Surgeons 211, 3 (2010)2010-09-01Journal of the American College of Surgeons2010-09-012113S1072-7515(10)X0008-4Letters435436http://www.journalacs.org/article/PIIS1072751510004321/abstract?rss=yesWe read the article by Goasguen and colleagues and discussed it with interest in our journal club. We congratulate the authors for rejuvenating the concept of parathyroid microadenomas. However, there were certain queries raised during our discussion and it would be fruitful if we get a timely reply. Primary Hyperparathyroidism from Parathyroid MicroadenomaRitesh Agrawal, Sudhi Agarwal, Anjali Mishra, Gaurav Agarwal, Amit Agarwal, Ashok K. Verma, Saroj K. Mishra, Gyan Chand10.1016/j.jamcollsurg.2010.06.017Journal of the American College of Surgeons 211, 3 (2010)2010-09-01Journal of the American College of Surgeons2010-09-012113S1072-7515(10)X0008-4Letters436437http://www.journalacs.org/article/PIIS1072751510004308/abstract?rss=yesWe thank Chand and colleagues for their thoughtful comments on our article “Primary Hyperparathyroidism Due to Parathyroid Microadenoma: Specific Features and Implications for a Surgical Strategy in the Era of Minimally Invasive Parathyroidectomy.” We provide a point-by-point answer to the queries raised. ReplyMircea Chirica, Nicolas Goasguen, Nicolas Munoz-Bongrand, Pierre Cattan, Emile Sarfati10.1016/j.jamcollsurg.2010.06.015Journal of the American College of Surgeons 211, 3 (2010)2010-09-01Journal of the American College of Surgeons2010-09-012113S1072-7515(10)X0008-4Letters437438http://www.journalacs.org/article/PIIS1072751510004059/abstract?rss=yesChu CK, Farnell MB, Nguyen JH, et al J Am Coll Surg 2010;211:316–324JACS Category 1 CME Credit Featured Articles, Volume 211, September 201010.1016/j.jamcollsurg.2010.06.007Journal of the American College of Surgeons 211, 3 (2010)2010-09-01Journal of the American College of Surgeons2010-09-012113S1072-7515(10)X0008-4Continuing Medical Education Program439441http://www.journalacs.org/article/PIIS1072751510004035/abstract?rss=yesIn the late 20th century, surgeons became concerned about patient satisfaction factors, eg, incision scars, pain, and time to return to work after surgery. Consequently, minimally invasive techniques, such as endoscopy and laparoscopic surgery, were developed. These trends also influenced thyroid surgery and the development of new techniques, such as minimally invasive open thyroidectomy and endoscopic thyroidectomy. Since endoscopic subtotal parathyroidectomy was first introduced by Ganger in 1996 and endoscopic thyroidectomy by Hüscher in 1997, various types of endoscopic thyroid operations have been devised using axillary, breast, anterior chest, and cervical approaches. In addition, development of robotic surgical systems has encouraged many surgeons to incorporate more dexterous surgical instruments into thyroid operations. Previously, my colleagues and I described a novel method of robot-assisted endoscopic thyroidectomy for thyroid cancer using a gasless transaxillary approach. Here, we introduce a less invasive robotic procedure that we refer to as transaxillary single-incision robotic thyroidectomy.Feasibility and Safety of a New Robotic Thyroidectomy through a Gasless, Transaxillary Single-Incision ApproachHaeng Rang Ryu, Sang-Wook Kang, So Hee Lee, Kang Young Rhee, Jong Ju Jeong, Kee-Hyun Nam, Woong Youn Chung, Chung Soo Park10.1016/j.jamcollsurg.2010.05.021Journal of the American College of Surgeons 211, 3 (2010)2010-09-01Journal of the American College of Surgeons2010-09-012113S1072-7515(10)X0008-4Surgeon at Worke13e19http://www.journalacs.org/article/PIIS1072751510008707/abstract?rss=yesContents10.1016/S1072-7515(10)00870-7Journal of the American College of Surgeons 211, 3 (2010)2010-09-01Journal of the American College of Surgeons2010-09-012113S1072-7515(10)X0008-4FrontmatterA7A7