Journal of the American College of Surgeons

Human Polymerized Hemoglobin for the Treatment of Hemorrhagic Shock when Blood Is Unavailable: The USA Multicenter Trial

2009-01-01

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

Peripheral Vascular Surgery Using Targeted Beta Blockade Reduces Perioperative Cardiac Event Rate

2009-01-01

Background: Recent studies suggest that preoperative cardiac stress testing is unnecessary in low to intermediate cardiac risk patients undergoing operations, and that targeted beta blockade is cardiac protective.Study Design: A cohort study of patients undergoing vascular surgery or major amputation, with low to intermediate cardiac risk, but without cardiac stress testing, was performed. Targeted beta blockade was initiated preoperatively. The primary end point was a composite of adverse cardiac outcomes. A comparison was made with historical controls who received selective stress testing and selective nontargeted beta blockade.Results: One hundred consecutive patients were prospectively enrolled, and 80 retrospective controls were identified. There were no differences between groups with respect to median revised cardiac index (RCI; 0 versus 1). In the retrospective group, 14% underwent preoperative cardiac stress testing versus none in the prospective group (p=0.0002). Nontargeted beta blockade was given in 61% of the retrospective group. The median heart rate for the prospective group was significantly lower (66 versus 77 beats/minute; p=0.0007). The composite cardiac complication rate was 2% in the prospective group versus 10% in the retrospective group (p=0.02). There were no deaths. On multivariate analysis, after adjusting for revised cardiac index score, there was a lower cardiac complication rate in the prospective group (odds ratio, 2.46; 95% CI, 1.3 to 4.5; p=0.003).Conclusions: In patients undergoing vascular surgery or major amputation, with low to intermediate cardiac risk, preoperative targeted beta blockade alone is more effective than selective cardiac stress testing and nontargeted beta blockade in preventing cardiac morbidity.

Assessing the Database Needs of Vascular Surgeons

Peter F. Lawrence, Olivia I. Lund, Frederick Eko, Ehsan Sarabi, Joseph Wu — 2009-01-01

Background: Vascular surgery is an ideal specialty for developing a shared database, because outcomes measures are precise, national standards have been established, and vascular surgeons have traditionally collected data.Study Design: A questionnaire of database experience and needs was developed, reviewed by a Western Vascular Society advisory committee, and sent to Western Vascular Society and Rocky Mountain Vascular Surgical Society members. Additionally, we obtained software from existing commercial vascular databases.Results: We had a 57% response from 196 surveys: 36% of vascular surgeons have functional vascular databases, which have been used from 1 to 26 years and contain 71 to 15,000 patients. Databases are used for research, quality control, and billing. Time (38%), expense (19%), and expertise (8%) preclude database use. Of physicians without a database, 17% had used 1 previously, and 89% would like 1. Sixty percent of physicians are unwilling to spend more than 5 minutes on data entry, unless forced to do so for reimbursement or to maintain hospital privileges. Seventy-three percent believe it is more important to control data-entry time than number of variables; 98% are willing to share Health Insurance Portability and Accountability Act-compliant data; 82% have interest in a handheld data-entry system. Thirty-nine percent are willing to spend $1,000 for the initial database, and 88% are willing to spend $500 per year on maintenance.Conclusions: Vascular surgeons have interest and experience with databases, although some have discontinued use. If databases have short entry times, limited costs, permit portable data entry, and allow data sharing, most vascular surgeons are enthusiastic about collecting clinical outcomes data.

Survival Advantage in Trauma Centers: Expeditious Intervention or Experience?

2009-01-01

Background: Trauma patients who receive care at designated trauma centers have a decreased risk of death, but the processes of care that lead to improved outcomes are unknown. We set out to examine the relationship between trauma center care, rapidity of assessment and intervention, and mortality among trauma patients with indications for immediate operative intervention.Study Design: Data were collected from a multicenter prospective cohort study of adult patients cared for in trauma centers (TC) and nondesignated centers (NTC). From this cohort, we identified patients with two patterns of injury: hypotensive penetrating trauma (PT) and blunt traumatic brain injury (TBI) with mass effect. Times from admission to relevant interventions were assessed, as were relative risks of in-hospital death in TC compared with NTC. Relative risks were adjusted for differences in case mix using propensity analysis.Results: Among 1,331 patients who met inclusion criteria, 23.5% died in hospital. Relative risk of death was 0.61 (95% CI, 0.43 to 0.86) among patients managed at TC compared with those admitted to NTC. This survival advantage was greatest among patients in the PT group managed at TC (relative risk: 0.43; 95% CI, 0.19 to 0.94). Relative risk of death at TC among patients in the TBI group was 0.72 (95% CI, 0.50 to 1.0). Within the first 24 hours of admission, however, there was no statistically significant difference between median times to radiographic assessment or operative intervention at TC as compared with other hospitals.Conclusions: Risk of death is considerably lower among patients requiring early operative intervention if they are treated at a designated Level I trauma center. These outcomes are not a result of more rapid assessment and intervention alone, and emphasize the complex factors that contribute to the survival benefit of trauma center care.

Informatics and the American College of Surgeons National Surgical Quality Improvement Program: Automated Processes Could Replace Manual Record Review

David A. Hanauer, Michael J. Englesbe, John A. Cowan, Darrell A. Campbell — 2009-01-01

Background: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) provides reliable, risk-adjusted outcomes data using standardized definitions and end points. Collection of the data is time consuming, and the surgical clinical nurse reviewers (SCNRs) can sample only a subset of all surgical cases. We sought to test the feasibility of using an informatics tool to automatically identify postoperative complications stored as free-text documents in our electronic medical record.Study Design: We used a locally developed electronic medical record search engine (EMERSE) to build sets of terminology that could accurately identify postoperative complications of both myocardial infarction (MI) and pulmonary embolism (PE) as defined by the ACS-NSQIP. All complications had been previously identified by our SCNRs and these were considered the gold standard. We used 5,894 cases from 2001 to 2004 from our institution's ACS-NSQIP dataset for building the terminology and 4,898 cases from 2005 to 2006 for validation. False-positive cases were then further reviewed manually.Results: We achieved sensitivities of 100.0% and 92.8% for identifying postoperative myocardial infarction and pulmonary embolism, respectively, with somewhat lower specificities of 93.0% and 95.9%, respectively. These results compared favorably with results from the SCNRs, especially because our manual review uncovered cases previously missed.Conclusions: Informatics has the potential to improve the efficiency and accuracy of chart abstraction by SCNRs for the ACS-NSQIP. Using such tools may eventually allow all cases at an institution to be reviewed rather than a small subset.

Survival in Stage III Colon Cancer Is Independent of the Total Number of Lymph Nodes Retrieved

2009-01-01

Background: Retrieval of ≥ 12 lymph nodes has been set as a marker of quality for surgical resection for colon cancer. The aim of our study was to determine if increasing the number of lymph nodes recovered in stage III colon cancer results in improved survival and if it does represent a reasonable quality metric.Study Design: Data from patients with stage III colon cancer from 1996 to 2001 were analyzed. Outcomes after operation (cancer-specific survival, disease-free survival, and overall survival) with or without adjuvant therapy were evaluated in 3 categories: the entire cohort, patients with N1, and patients with N2 disease. These categories were then classified into subgroups by the number of nodes (≤ 12 versus >12) retrieved per specimen and whether they had 5-FU−based chemotherapy or not.Results: Three hundred twenty-nine patients, with a median followup of 5 years with stage III colon cancer, were identified. Five-year cancer-specific and disease-free survival was 67.2% and 59.7%, respectively. A positive correlation between number of positive lymph nodes and overall survival was found (p < 0.05). No significant association was observed between the total number (> 12 versus ≤ 12) of lymph nodes removed either in the entire cohort or in patients with N1 (249 patients) and N2 (80 patients) disease.Conclusion: Accurate staging requires an appropriate operation and a concerted pathologic effort to identify lymph nodes in the colon specimen. The total number of lymph nodes analyzed for stage III colon cancer is not a prognostic indicator of cancer-specific and disease-free survival.

Anastomotic Leaks after Bowel Resection: What Does Peer Review Teach Us about the Relationship to Postoperative Mortality?

2009-01-01

Background: Anastomotic leak is a dreaded complication of intestinal surgery and has been associated with a high mortality rate. But it is uncertain exactly which patient populations are at risk of death from the leak. We sought to assess the impact of surgeon volume on leak rate and to better understand the relationship of a leak to postoperative mortality.Study Design: All adult patients having a small or large bowel resection with anastomosis at a university hospital from July 2003 to June 2006 were entered into a prospectively maintained quality database; data were entered by a specially trained nurse practitioner who rounded daily with housestaff. Patients with a postoperative leak based on standardized criteria were identified. Patient characteristics, surgical procedure, and operating surgeon were noted. Overall complication and leak rates by surgeon were compared using Fisher's exact test. Individual case review by a group of peers was performed for all patients with a leak who died, to determine the relationship to mortality.Results: Five hundred fifty-six patients underwent resection with anastomosis during the study period. There were 27 patients with leaks (4.9%), 6 of whom died. Leak rate for the highest-volume surgeons ranged from 1.6% to 9.9% (p <0.01), and overall complication rate varied from 30.5% to 44% (p=0.04). In four of six deaths, leaks occurred in very ill patients undergoing emergency procedures and appeared to be premorbid events. In only one patient did the leak appear to be the primary cause of death.Conclusions: The variability in leak rate by surgeons doing similar operations suggests that many leaks may be preventable. But death after a leak is most often a surrogate for a critically ill patient and was infrequently the actual cause of death.

Effect of Body Mass Index on Short-Term Outcomes after Colectomy for Cancer

Ryan P. Merkow, Karl Y. Bilimoria, Martin D. McCarter, David J. Bentrem — 2009-01-01

Background: Obesity is associated with an increased risk of postoperative complications after colectomy for cancer, but it is unclear which specific complications occur more frequently in obese patients. Our objective was to assess the association of body mass index (BMI) on short-term outcomes after colectomy for cancer.Study Design: Using the American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) dataset, we identified patients who underwent colectomy for malignancy at 121 hospitals. Logistic regression models were developed to assess risk-adjusted 30-day outcomes by BMI while adjusting for preoperative risk factors.Results: There were 3,202 patients identified: 33.4% normal weight (BMI 18.5 to 24 kg/m2), 35.1% overweight (BMI 25 to 29 kg/m2), 19.0% obese (BMI 30 to 34 kg/m2), and 12.4% morbidly obese (BMI≥35 kg/m2). Compared with normal weight patients, complications occurred more frequently in the morbidly obese (31.8% versus 20.5%, odds ratio [OR] 1.75, 95% CI 1.33 to 2.31). Specifically, the morbidly obese had a higher risk of surgical site infection (20.7% versus 9.0%; OR 2.66, 95% CI 1.91 to 3.73), dehiscence (3.3% versus 1.1%; OR 3.51, 95% CI 1.55 to 7.95), pulmonary embolism (1.3% versus 0.3%; OR 6.98, 95% CI 1.62 to 30.06), and renal failure (3.0% versus 1.5%; OR 2.75, 95% CI 1.21 to 6.26). Pneumonia, urinary tract infection, stroke, cardiac arrest, myocardial infarction, deep venous thrombosis, length of stay, sepsis, and 30-day mortality did not differ significantly by BMI.Conclusions: Compared with normal weight patients, morbidly obese patients had a higher risk of surgical site infection, dehiscence, pulmonary embolism, and renal failure, but not other complications or mortality. Quality initiatives should include these specific complications.

Longterm Complications of Hand-Assisted Versus Laparoscopic Colectomy

Toyooki Sonoda, Sushil Pandey, Koiana Trencheva, Sang Lee, Jeffrey Milsom — 2009-01-01

Background: Hand-assisted laparoscopic surgery (HALS) requires a larger incision compared with standard laparoscopic surgery (SLS). Whether this leads to more longterm complications, such as incisional hernia (IH) and small bowel obstruction (SBO), has not been studied to date. This study compares the rates of SBO and IH after HALS and SLS in patients undergoing operations for colon and rectal diseases.Study Design: From a colorectal database, 536 consecutive patients were identified who underwent bowel resection using HALS (n = 266) and SLS (n = 270) between 2001 to 2006. All medical records were reviewed, and all subjects were contacted by telephone for accurate followup. Statistical analysis was performed using chi-square, Fisher's exact, and Mann-Whitney U tests, where appropriate.Results: Median followup was 27 months (range 1 to 72 months). Overall conversion rate was 2.2% (SLS, n = 4; HALS, n = 8). Median incision size in HALS (75 mm; range 60 to 140 mm) was larger than SLS (45 mm; range 30 to 130 mm; p < 0.01). Despite the larger wound, the incidence of IH was similar between both approaches (HALS, n = 16 [6.0%] versus SLS, n = 13 [4.8%]; p < 0.54). Rate of SBO was also comparable (HALS, n = 11 [4.1%] versus SLS, n = 20 [7.4%]; p = 0.11). Wound infections occurred similarly between both groups (HALS, n = 18 [6.8%]; SLS, n = 13 [4.8%]; p = 0.33). Converted patients had a higher rate of IH compared with nonconverted ones (25% versus 5%; p = 0.02), although the rate of SBO was similar (8.3% versus 5.7%; p = 0.51).Conclusions: HALS does not lead to more longterm complications of IH and SBO when compared with SLS for resections of the colon and rectum.

Increased Lymph Node Positivity in Multifocal and Multicentric Breast Cancer

2009-01-01

Background: Multifocal and multicentric (MF/MC) breast cancers have been reported to be associated with increased lymph node metastases. The limited data on this issue prompted us to investigate the pathologic and clinical differences between unifocal and MF/MC breast cancer.Study Design: Between 1990 and 2002, 1,322 patients with operable invasive breast cancer underwent a definitive operation at our Breast Clinic. Patients with MF/MC breast cancer (n=147, 11%) were compared with patients with unifocal breast cancer (n=1,175; 89%) in terms of pathologic and clinical characteristics.Results: Patients with MF/MC were found to have a higher frequency of lymph node metastases when the largest diameter was used as a tumor size estimate for MF/MC cancer (unifocal T1 and T2, 35% and 49%, respectively, versus MF/MC T1 and T2, 48% and 67%, respectively; p=0.05 and p=0.003, respectively). When the combined diameter assessment was used, the frequency of lymph node positivity was similarly higher in MF/MC patients versus unifocal patients (unifocal T1 and T2, 35% and 49%, respectively, versus MF/MC T1 and T2, 49% and 61%, respectively; p=0.08 and p=0.046, respectively). At a median followup of 55 months (range 12 to 153 months), 5-year disease-free survival (DFS; unifocal, 88% versus MF/MC, 82%, p=0.14) and overall survival (OS) rates (unifocal, 92% versus MF/MC, 93%, p=0.43) did not show any significant difference between two groups.Conclusions: Our data suggest that breast tumors with multiple foci have a different biology, with an increased metastatic potential to axillary lymph nodes, regardless of tumor size, that reflects an advanced stage. The clinical relevance of the currently used TNM classification system, which uses the diameter of the largest nodule, is supported by our findings.

Quality Assurance Initiative at One Institution for Minimally Invasive Breast Biopsy as the Initial Diagnostic Technique

2009-01-01

Background: In 2005, the American College of Surgeons Consensus Conference issued a statement about the diagnostic workup of image-detected breast abnormalities. Guidelines include use of image-guided percutaneous needle biopsy as the gold standard for diagnosing image-detected breast abnormalities. In this study, we evaluate a method to audit use of excisional biopsy among different breast surgeons at our institution.Study Design: From March to September 2007, 465 patients undergoing breast operation for benign or malignant lesions at our institution were interviewed by a surgical resident or physician's assistant. If an excisional biopsy was scheduled for initial diagnosis, the patient and surgeon were asked whose preference it was to perform the operation. Three attending groups were designated: academic breast surgeons, private practice breast surgeons on clinical faculty, and general surgeons who perform breast operations in addition to other procedures. Use of excisional biopsy was compared between these groups.Results: Compliance for preoperative interview completion was 79%, differing substantially between surgeon groups with rates of 91%, 74%, and 58% for the academic breast, private practice, and general surgeons, respectively. Excisional biopsy for diagnosis made up 10%, 35%, and 37% of the case load for academic breast, private practice, and general surgeons, respectively. Patient and surgeon agreed 85% of the time for preference of performing diagnostic excisional biopsies.Conclusions: Excisional biopsies continue to be performed as the initial diagnostic procedure for 40% of patients. Tracking biopsy practices by surgeon can improve adherence with current recommendations.

Where's the Outrage?

Melvin Silverstein — 2009-01-01

In the mid 1970s, the Women's Movement was in full force. Outraged women demanded that surgeons abandon the Halsted radical mastectomy and we did. They demanded that the one-stage procedure, with its biopsy, frozen section, and immediate mastectomy if positive, be replaced with a two-stage procedure, with the biopsy done as a single operation before any treatment decision-making. We made the change. They demanded informed consent, with the patient playing a major role in the treatment decision-making process. We complied.

Laparoscopic Management and Longterm Outcomes of Gastrointestinal Stromal Tumors

Parissa Tabrizian, Scott Q. Nguyen, Celia M. Divino — 2009-01-01

Background: Surgery remains the standard for nonmetastatic gastrointestinal stromal tumors (GISTs). Laparoscopic surgery should be considered for these tumors, because their biologic behavior lends them to curative resection without requiring large margins or extensive lymph-adenectomies.Study Design: A retrospective review was performed of patients who underwent laparoscopic treatment of GISTs at Mount Sinai Medical Center from 2000 to 2007. Kaplan-Meier method was used for survival analysis. Chi-square analysis was used to identify factors associated with poor outcomes.Results: Laparoscopic surgery was attempted in 76 patients. The average age was 66 years, and 39 were men. Forty-two percent of patients presented with gastrointestinal bleeding. Tumors were located in the stomach (72%) and in the small bowel (28%). Mean tumor sizes were 4.2 and 3.9 cm, respectively. Operations included laparoscopic wedge resection (26%), partial gastrectomy (25%), sleeve (9%) gastrectomy, and small bowel resection (22%). Reasons for conversions (14%) were invasion of tumor into adjacent organs, adhesions, proximity to the gastroesophageal junction, large tumor size, or coincidental pathology. There was 1 mortality and a 10% morbidity rate, including an evisceration, obstruction, and pelvic hematoma requiring reoperation. Mean followup was 41 months (range, 3 to 102 months). The overall survival rate was 89%. Gastric and small bowel survival rates were the same (89%). The recurrence rate was 6%. The overall disease-free survival was 78% (77% gastric versus 82% small bowel). Three percent of patients died of metastatic disease. Adjuvant therapy was used on patients initially diagnosed with metastatic disease (n=5) and recurrent disease (n=4).Conclusions: Laparoscopic resection of GISTs is considered safe and effective. The longterm disease-free survival of 78% establishes this minimally invasive approach as comparable to open techniques.

Evolving Preoperative Evaluation of Patients with Pancreatic Cancer: Does Laparoscopy Have a Role in the Current Era?

2009-01-01

Background: Recent years have brought important developments in preoperative imaging and use of laparoscopic staging of patients with pancreatic adenocarcinoma (PAC). There are few data about the optimal combination of preoperative studies to accurately identify resectable patients.Study Design: We conducted a statewide review of all patients with surgically managed PAC from 1996 to 2003 using data from the Oregon State Cancer Registry, augmented with clinical information from primary medical record review. We documented the use of all staging modalities, including CT, endoscopic ultrasonography, and laparoscopy. Primary outcomes included resection with curative intent. The association between staging modalities, clinical features, and resection was measured using a multivariate logistic regression model.Results: There were 298 patients from 24 hospitals who met the eligibility criteria. Patients were staged using a combination of CT (98%), laparoscopy (29%), and endoscopic ultrasonography (32%). The overall proportion of patients who went to surgical exploration and were resected was 87%. Of patients undergoing diagnostic laparoscopy, metastatic disease that precluded resection was discovered in 24 (27.6%). For patients who underwent diagnostic laparoscopy and were not resected, vascular invasion was the most common determinant of unresectability (56.6%). In multivariate analysis, preoperative weight loss and surgeon decision to use laparoscopy predicted unresectability at laparotomy.Conclusions: This population-based study demonstrates that surgeons appear to use laparoscopy in a subset of patients at high risk for metastatic disease. The combination of current staging techniques is associated with a high proportion of resectability for patients taken to surgical exploration. With current imaging modalities, selective application of laparoscopy with a dual-phase CT scan as the cornerstone of staging is a sound clinical approach to evaluate pancreatic cancer patients for potential resectability.

Nationwide Volume and Mortality after Elective Surgery in Cirrhotic Patients

Nicholas G. Csikesz, Louis N. Nguyen, Jennifer F. Tseng, Shimul A. Shah — 2009-01-01

Background: The outcomes after elective surgery in patients with cirrhosis have not been well studied.Study Design: We used the Nationwide Inpatient Sample (NIS) to identify all patients undergoing elective surgery for four index operations (cholecystectomy, colectomy, abdominal aortic aneurysm repair, and coronary artery bypass grafting) from 1998 to 2005. Elixhauser comorbidity measures were used to characterize patients' disease burden. Three distinct groups were created based on severity of liver disease: patients without cirrhosis (NON-CIRR), those with cirrhosis (CIRR), and patients with cirrhosis complicated by portal hypertension (PHTN). In-hospital mortality was the primary endpoint.Results: There were 22,569 patients with cirrhosis (of whom 4,214 had PHTN) who underwent 1 of the 4 index operations compared with approximately 2.8 million patients without cirrhosis having these operations. Patients with CIRR or PHTN were more likely to be women (49.5% versus 44.0%, p < 0.0001) and were less likely to be treated in a large hospital (62.8% versus 67.6%, p < 0.0001) than NON-CIRR patients. Length of hospital stay and total charges per hospitalization increased with severity of liver disease for all operations (p < 0.001, respectively). Adjusted mortality rates increased with increasing liver disease for each operation (cholecystectomy: CIRR hazard ratio [HR] 3.4, 95% CI 2.3 to 5.0; PHTN HR 12.3, 95% CI 7.6 to 19.9; colectomy: CIRR HR 3.7, 95% CI 2.6 to 5.2; PHTN HR 14.3, 95% CI 9.7 to 21.0; coronary artery bypass grafting: CIRR HR 8.0, 95% CI 5.0 to 13.0, PHTN HR 22.7, 95% CI 10.0 to 53.8; abdominal aortic aneurysm: CIRR HR 5.0, 95% CI 2.6 to 9.8, PHTN HR 7.8, 95% CI 2.3 to 26.5).Conclusions: In-hospital mortality, length of stay, and total hospital charges are significantly higher after elective surgery in cirrhotic patients, even in the absence of portal hypertension. Careful decision-making about surgery in these patients is critical as the nationwide increase in hepatitis C and cirrhosis continues.

Avoiding Common Technical Errors in Subclavian Central Venous Catheter Placement

Michael J. Kilbourne, Grant V. Bochicchio, Thomas Scalea, Yan Xiao — 2009-01-01

Background: Proficiency in placing infraclavicular subclavian venous catheters can be achieved through practice and repetition. But few data specifically document insertion technical errors, which mentors could teach novice operators to avoid.Study Design: Surgical, medical, and anesthesia textbooks and procedural handbooks were reviewed. Subclavian catheter placement technical errors described were identified and consolidated. Video captures from 86 consecutive patients receiving subclavian central venous catheterizations at an urban trauma center were evaluated. In each video segment, the number of attempts at insertion, the number of failures at insertion, and the technical error observed during failed attempts were recorded and tabulated.Results: Of the 86 subclavian line placements attempted, 77 were successful (89.5%), with a total of 357 subclavian venipuncture attempts and 279 failures (78% attempt failure rate). There was a mean of 3.2 failed attempts per line (left side, 2.1 attempts; right side, 5.5 attempts). Junior residents (PGY 1 to 2) had more failures per line than senior residents (PGY 3 to 5): 4.1 versus 3.6. The most common technical errors observed were improper site for needle insertion relative to the clavicle; insertion of the needle through the clavicular periosteum; too shallow of a trajectory for the needle; improper or inadequate anatomic landmark identification; aiming the needle too cephalad; and inadvertent movement of the needle out of the vein before or during wire placement.Conclusions: In subclavian central venous access attempts, there are six common technical errors. Mentors can improve novice operators' proficiency by teaching them to avoid these errors.

Stored Red Blood Cell Transfusion Induces Regulatory T Cells

2009-01-01

Background: Allogeneic blood transfusion mediates immunosuppression in transfused recipients by an unknown mechanism. Regulatory T cells (Tregs) are suppressive CD4+CD25+Foxp3+ cells with a central role in immunosuppression in trauma victims, cancer patients, and transplant recipients. We hypothesized that transfusion-related immunosuppression is, in part, mediated by induction of Tregs, and this induction is attenuated with prestorage leukoreduction and accentuated with prolonged storage.Study Design: Packed red blood cell (PRBC) units were obtained and 50% of PRBCs were leukoreduced (LR) before routine storage for 1 day or 42 days and the supernatant was collected. Normal human peripheral blood mononuclear cells (PBMCs) were exposed to 1-day NLR, 42-day NLR, 1-day LR, or 42-day LR PRBC supernatants or to PRBC storage solution or washed PRBC supernatant ± anti-CD3 stimulation, and analyzed by flow cytometry for Foxp3+ Tregs or CD25+-activated T cells. PRBC supernatants and cell culture supernatants were analyzed by immunoassay for interleukin (IL)-1β, IL-2, IL-4, IL-10, interferon-γ, tumor necrosis factor−α, and transforming growth factor−β. Treg activity was evaluated by suppression assay.Results: All PRBC groups induced Tregs compared with control media in anti−CD3-stimulated PBMCs, without alteration by LR or prolonged storage. PRBC supernatant did not alter nonspecific T-cell activation from control media. PRBC-induced Tregs were suppressive, inhibiting proliferation of T-responder cells. All cytokines measured decreased with storage in LR PRBC units and no cytokines were substantially elevated in cell supernatants exposed to PRBC supernatant. PRBC storage solution did not reproduce the effects of PRBC supernatant, and washed PRBC supernatant attenuated Treg induction.Conclusions: PRBC supernatant induces Tregs, but this induction is not altered by LR or prolonged storage. This induction appears to be independent of cytokines and is attenuated with washed PRBCs, implicating the plasma fraction.

Use of Recombinant Factor VIIa to Facilitate Organ Donation in Trauma Patients with Devastating Neurologic Injury

2009-01-01

Background: Organ donation serves a public health function but is also an important part of end-of-life care. Nearly 40% of organ donors are the victims of traumatic brain injury (TBI). We report on a series of patients with nonsurvivable TBI and severe coagulopathy or active hemorrhage who went on to successful organ donation with the use of recombinant factor VIIa (rFVIIa).Study Design: Organ donors from a 6-year period were identified from the local Organ Procurement Organization (OPO). Medical records were reviewed, and demographics, injury-specific data, coagulation profiles, and medications administered were abstracted. Outcomes data on early graft function after transplantation were obtained.Results: One hundred forty-eight patients had organ recovery after either brain death or withdrawal of care. Twenty-nine patients received rFVIIa and 119 patients did not. rFVIIa was administered before determination of nonsurvivability or brain death in 21 patients. In eight patients, rFVIIa was administered as a specific salvage therapy to allow donation. Mean Injury Severity Score in the rFVIIa group was 43.4 (±14.8) versus 34.0 (±13.3) in the group that did not receive rFVIIa (p = 0.001). Organs transplanted per donor were no different in the 2 groups (3.5 versus 3.6; p = 0.7). There were nearly twice as many successfully recovered lungs from the donors who received rFVIIa (44.1% versus 26.2%; p = 0.04). There was no difference in early graft function in the two groups when recipient outcomes were compared.Conclusions: Use of rFVIIa facilitated donation in patients with multisystem injuries who otherwise might have been ineligible for organ donation. Use of rFVIIa did not affect early graft function, although longterm outcomes are unknown. Recombinant factor VIIa is expensive, but its use is justified if the donor organ supply can be increased.

Immediate Reconstruction after Mastectomy for Breast Cancer: Which Factors Affect Its Course and Final Outcome?

2009-01-01

Surgery is one of the main pillars in the multidisciplinary treatment of breast cancer. Advances in diagnosis and adjuvant treatment have made less aggressive operations possible without affecting survival or tumor recurrence, and nowadays, conservative surgery is the technique of choice in women with breast cancer. But mastectomy is still necessary in a significant percentage of patients (women at high risk because of a family or personal history of breast cancer, contraindication to adjuvant radiotherapy, large tumors relative to breast size, diffuse disease, or patient preference) in whom breast reconstruction should be one of the several therapeutic options available.

Evidence-Based Approach to Cholangiocarcinoma: A Systematic Review of the Current Literature

2009-01-01

Cholangiocarcinomas (CC) are relatively rare tumors, although their incidence is increasing worldwide. Several advances in the diagnosis, therapy, and palliation for patients affected by CC have occurred during the last decades. The aim of this article is to provide a systematic review of the most recent literature on CC.

Incidence of Clinically Significant Seroma after Breast and Axillary Surgery

2009-01-01

Seroma is a collection of serous fluid that occurs at rates ranging from 3% to 85% after breast or axillary surgery. Varying methods of defining seroma likely account for the wide variation in rates of incidence reported in the literature. Seromas can interfere with healing, require prolonged treatment, cause patient discomfort, and delay adjuvant treatment. We hypothesized that seromas occur more frequently in extensive surgical procedures or in those that require a drainage tube. In addition, we theorized that seroma and surgical site infection (SSI) were directly correlated. The aims of this study were to evaluate the frequency of seromas that require intervention, to assess variation based on the extent of the breast or axillary surgical procedure, and to evaluate the incidence of SSI in relation to seroma occurrence.

Achalasia of the Esophagus: A Surgical Disease

Valerie A. Williams, Jeffrey H. Peters — 2009-01-01

Achalasia is a primary esophageal motility disorder of unclear etiology. As treatment has evolved during the past 10 to 15 years, it has become primarily a surgical disease. It is uncommon, but not rare, affecting approximately 1 in 100,000 individuals per year. Occurring equally in men and women, it is an acquired condition usually diagnosed between 20 and 50 years of age, but can occur at any age. In 1672, Sir Thomas William first described the disease as “cardiospasm” and treated the problem with dilation using a whale sponge attached to a whale bone. It was not until 1927, when A F Hurst determined that the problem was the result of an inability of the lower esophageal sphincter (LES) to relax, and named the disease achalasia, a Greek term meaning failure to relax. Normal individuals have a lower esophageal high-pressure zone, which completely relaxes with initiation of a swallow. In achalasia, residual pressures in the LES remain well above normal after swallowing, resulting in a functional outflow obstruction at the gastroesophageal junction. In addition, the LES can be hypertensive, resulting in higher than normal resting pressures, and the esophageal body is aperistaltic, all leading to failure of bolus transport. When untreated, intraesophageal pressures rise and the esophagus slowly dilates, often to the point of gross deformity.

Benign Symmetrical Lipomatosis (Madelung's Disease)

Seock Yeol Lee, Cheol Woo Jeon, Seung Jin Lee — 2009-01-01

A 64-year-old man had a palpable large mass of the neck ( & , white arrows), which started as a single mass about 10 years ago and led to increasing discomfort. Chest CT findings showed abnormally proliferating fat deposited in the supraclavicular area (, white arrows). The deep and superficial fatty masses of the neck were excised with good results ().

Scapulothoracic Dislocation after Transthoracic Esophagectomy

2009-01-01

A 64-year-old man presented with an acute onset of severe pain of the right shoulder and inability to move it. Three months earlier he had undergone a right-sided posterolateral thoracotomy for an esophageal carcinoma that appeared irresectable because of ingrowth into the trachea.

Three-Dimensional Digital Evaluation of Breast Symmetry after Breast Conservation Therapy

Giuseppe Catanuto, Andrea Spano, A. Pennati, M. Nava — 2009-01-01

We would like to congratulate Dr Moyer and colleagues for their interesting article on three-dimensional imaging of the breast. They provided accurate data on quantitative evaluation of volume and symmetry in patients who received breast conservative surgery for cancer treatment. Some aspects, in our opinion, are still not clear.

Reply

Hunter R. Moyer — 2009-01-01

We appreciate Dr Catanuto's interest in outcomes measurements for breast surgery. As stated, the 3dMD (3Q Corporation) camera is composed of 12 lenses focused on the midpoint of the chest. Three of the lenses are positioned inferiorly and capture the inframammary fold when the patient's arms are raised, but this does become more difficult in women with significant ptosis. Patients are asked to stand in a marked spot to place the chest wall at the focal point and to ensure reproducibility of results. They are also instructed to exhale and hold their breath while the picture is captured. When superimposing breasts, we select the midline of the chest using the umbilicus and sternal notch as landmarks. Dr Catanuto is correct that calculating breast volume requires estimating the posterior chest wall, but the beauty of the root mean square value is that it represents the volume of the difference between breast surfaces, so determining the posterior wall of the chest is unnecessary. If the 3dMD patient software were to compare a square and a circle of equal volumes, the root mean square value would not be zero, but rather a calculation of the nonoverlapping volume. We realize that breast size and shape evaluation will always be somewhat subjective and that this system is an attempt to improve the objective nature of breast measurements.

JACS CME-1 Featured Articles, Volume 208, January 2009

2009-01-01

Williams VA, Peters JH J Am Coll Surg 2009;208:151–162

Correction

2009-01-01

In the Original Scientific Article, “Effects of Two Different Meshes Used in Hernia Repair on Nerve Transport,” by Ozkan N, Kayaoglu HA, Ersoy OF, et al, which appeared in the November 2008 issue of the Journal of the American College of Surgeons, volume 207, number 5, pages 670–675, there was an author misstatement. On page 670 the authors' degrees should all be MD, not PhD.

Intraoperative Fluorescent Cholangiography Using Indocyanine Green: A Biliary Road Map for Safe Surgery

2009-01-01

Unlike blood vessels, the biliary tract lies in the Glissonian sheath and is buried in the perivascular connective tissue, so it is difficult to clearly visualize and isolate it during hepatobiliary surgery. Intraoperative cholangiography (IOC), which was originally introduced by Mirizzi in 1937, has been widely used to delineate the biliary tract anatomy in this setting. For example, routine IOC was recently recommended during cholecystectomy to prevent bile duct injury. IOC is also considered an essential procedure during donor hepatectomy because it enables the bile duct to be divided at the appropriate level to ensure wider and fewer residual orifices. But conventional radiographic IOC is disadvantageous in that it exposes the patient and the medical staff to radiation and usually requires a large and expensive C-arm fluoroscopy machine and the additional human resources involved.

Book Reviews January 2009

2009-01-01

Skin Disease in Organ Transplantation, 1st Edition

Renata H. Mullen — 2009-01-01

Otley, Clark C, MD; Stasko, Thomas, MD; Griffin, Matthew D, MB; Murphy, Gillian M, MD; Hirose, Ryutaro, MD; Chong, Alvin H, FACD, MMed, MBBS Cambridge University Press, 2008, $185.00

The Burden of Musculoskeletal Diseases in the United States: Prevalance, Societal and Economic Cost, 1st Edition

Mark R. Hutchinson — 2009-01-01

AAOS American Academy of Orthopaedic Surgeons, 2008, $50.00 ISBN: 978-0-89203-533-5, 247 pages, hard cover. ISBN-10: 0892035331

Cervical Spine Surgery Challenges: Diagnosis and Management, 1st Edition

Mark R. Hutchinson — 2009-01-01

Albert, Todd J, MD; Lee, Joon Yung, MD; Lim, Moe R, MD Thieme Medical Publishers, Inc., 2008, $139.95

Events: Meetings and Courses

2009-01-01

January 2009–September 2009 TO SUBMIT A MEETING NOTICE send the following information by email only to whusser@facs.org: name of meeting group; dates of meeting; place of meeting; telephone number and name of person to be called for full information. The Journal reserves the right to decline notices at discretion of editorial office.

2009-01-01

Message from the Editor: Gratitude for 2008

2009-01-01

The reputation of the Journal is dependent on the contributions of authors But the standard of the Journal, the level of excellence, is also a consequence of the efforts of expert reviewers who evaluate submitted manuscripts and determine their appropriateness for the Journal of the American College of Surgeons The Editorial Board members are recognized on the Journal's masthead each month But many others who deserve credit are unsung heroes who serve on an ad hoc basis, responding to our requests for their expert analyses In addition to expressing gratitude to our Editorial Board members, we are indebted to our ad hoc reviewers throughout the world for the thoughtful comments that are integral to the eventual end product

Journal of the American College of Surgeons

Human Polymerized Hemoglobin for the Treatment of Hemorrhagic Shock when Blood Is Unavailable: The USA Multicenter Trial

Peripheral Vascular Surgery Using Targeted Beta Blockade Reduces Perioperative Cardiac Event Rate

Assessing the Database Needs of Vascular Surgeons

Survival Advantage in Trauma Centers: Expeditious Intervention or Experience?

Informatics and the American College of Surgeons National Surgical Quality Improvement Program: Automated Processes Could Replace Manual Record Review

Survival in Stage III Colon Cancer Is Independent of the Total Number of Lymph Nodes Retrieved

Anastomotic Leaks after Bowel Resection: What Does Peer Review Teach Us about the Relationship to Postoperative Mortality?

Effect of Body Mass Index on Short-Term Outcomes after Colectomy for Cancer

Longterm Complications of Hand-Assisted Versus Laparoscopic Colectomy

Increased Lymph Node Positivity in Multifocal and Multicentric Breast Cancer

Quality Assurance Initiative at One Institution for Minimally Invasive Breast Biopsy as the Initial Diagnostic Technique

Where's the Outrage?

Laparoscopic Management and Longterm Outcomes of Gastrointestinal Stromal Tumors

Evolving Preoperative Evaluation of Patients with Pancreatic Cancer: Does Laparoscopy Have a Role in the Current Era?

Nationwide Volume and Mortality after Elective Surgery in Cirrhotic Patients

Avoiding Common Technical Errors in Subclavian Central Venous Catheter Placement

Stored Red Blood Cell Transfusion Induces Regulatory T Cells

Use of Recombinant Factor VIIa to Facilitate Organ Donation in Trauma Patients with Devastating Neurologic Injury

Immediate Reconstruction after Mastectomy for Breast Cancer: Which Factors Affect Its Course and Final Outcome?

Evidence-Based Approach to Cholangiocarcinoma: A Systematic Review of the Current Literature

Incidence of Clinically Significant Seroma after Breast and Axillary Surgery

Achalasia of the Esophagus: A Surgical Disease

Benign Symmetrical Lipomatosis (Madelung's Disease)

Scapulothoracic Dislocation after Transthoracic Esophagectomy

Three-Dimensional Digital Evaluation of Breast Symmetry after Breast Conservation Therapy

Reply

JACS CME-1 Featured Articles, Volume 208, January 2009

Correction

Intraoperative Fluorescent Cholangiography Using Indocyanine Green: A Biliary Road Map for Safe Surgery

Book Reviews January 2009

Skin Disease in Organ Transplantation, 1st Edition

The Burden of Musculoskeletal Diseases in the United States: Prevalance, Societal and Economic Cost, 1st Edition

Cervical Spine Surgery Challenges: Diagnosis and Management, 1st Edition

Events: Meetings and Courses

Contents

Message from the Editor: Gratitude for 2008