Journal of the American College of Surgeons

A Community Cancer Center Program: Getting to the Next Level

Nicholas J. Petrelli — 2009-12-24

In an editorial entitled, “A Presidential Blue Print for Success and Change,” Frederick Greene, MD, previous Chair of the Commission on Cancer of the American College of Surgeons stated, “All of us dedicated to cancer care will gain much insight from the Graham Center's blue print.” I hope that some of you in the audience today will be able to use in your own institutions some of the successes that we have had in our Cancer Program at the Helen F Graham Cancer Center at Christiana Care. To put the Cancer Program in context, illustrates the 2008 key metrics for the Christiana Care Health Systems. I would point out that there were 42,362 surgical procedures, 3,239 analytic cancer cases, and there are 229 Christiana Care residents and fellows as part of the independent training programs at Christiana Care approved by the American College of Graduate Medical Education. This includes a general surgery residency program that graduates 5 chief residents each year.

Low Oxygen-Affinity Hemoglobin Solution Increases Oxygenation of Partially Ischemic Tissue During Acute Anemia

Pedro Cabrales — 2010-03-01

Background: Maintenance of postsurgical tissue oxygenation depends on the ability of the specific tissue to recruit perfusion and oxygen (O2) supply. When native O2-carrying capacity is lacking, fluids to improve O2-carrying capacity based in hemoglobin (Hb) could prevent partially ischemic tissue hypoxia by increasing O2 release from the remaining red blood cells.Study Design: Responses to facilitated O2 transport after exchange transfusion with polymerized bovine Hb (PBH) were studied in a chronic partially ischemic tissue model, induced by large feeding arteriole ligation during hamster window chamber model implantation. PBH effects in microvascular perfusion and tissue oxygenation were studied after exchange transfusion of 40% of animal's blood volume. Experimental groups were defined by the concentration of PBH used, ie, PBH at 13 g/dL (PBH13); PBH at 4 g/dL in albumin solution to matching colloidal osmotic pressure (COP) (PBH4); and no PBH, only albumin solution at matching COP (PBH0).Results: Restitution of O2-carrying capacity with PBH13 increased blood pressure and produced vasoconstriction compared with PBH4 and PBH0. On the other hand, PBH4 maintained blood pressure without substantial vasoconstriction, increased tissue partial pressure of O2, arteriolar O2 supply, and extraction to the partially ischemic tissue compared with PBH0 and PBH13.Conclusions: Results suggest the existence of an optimal concentration of low O2-affinity acellular Hb to increase oxygenation of partially ischemic tissue during anemic conditions.

Insurance Coverage Is Associated with Mortality after Gunshot Trauma

2010-03-01

Background: Poor access to adequate health care coverage is associated with poor outcomes for many chronic medical conditions. We hypothesized that insurance coverage is also associated with mortality after gunshot trauma.Study Design: The trauma records for gunshot victims and their insurance status were reviewed at our center from January 1998 to December 2007. Patient demographics (age, gender, race, and insurance coverage), injury severity, hospital care (operations and radiographic studies), and in-hospital mortality were analyzed.Results: There were 2,164 gunshot trauma activations reviewed during the study period. One-quarter (n = 544) of these patients had insurance and three-quarters (n = 1,620) were uninsured. The in-hospital mortality rate was significantly higher for uninsured patients than for insured patients (9% vs 6%, p = 0.02). After controlling for age, gender, race, and injury severity by logistic regression analysis, the odds ratio for death of uninsured patients was 2.2 (95% CI 1.1 to 4.5). Insured patients did not differ from uninsured patients with respect to mean Injury Severity Score ([ISS] 12.2 ± 10.7 vs 12.6 ± 12.4, p = 0.56); similar percentages of patients were severely injured (ISS 16 to 24, 17% vs 15%, p = 0.19) and most severely injured (ISS > 24, 15% vs 16%, p = 0.68). Insured patients did not differ from uninsured patients with respect to use of radiographic imaging (53% vs 50%, p = 0.15) or operative intervention (37% vs 35%, p = 0.35).Conclusions: Despite similar injury severity, uninsured trauma patients were more likely to die after gunshot injury than insured patients. This difference could not be attributed to demographics or hospital resource use. Insurance coverage may reflect the many social determinants of health. Improving the social determinants of health in patients affected by violent trauma may be a step toward improving outcomes after trauma.

Quantitative Weighting of Postoperative Complications Based on the Accordion Severity Grading System: Demonstration of Potential Impact Using the American College of Surgeons National Surgical Quality Improvement Program

Matthew R. Porembka, Bruce Lee Hall, Mitzi Hirbe, Steven M. Strasberg — 2010-03-01

Background: To quantify severity of postoperative complications based on the Accordion Severity Grading System, determine the ability of severity grading to enhance National Surgical Quality Improvement Program (NSQIP) data, and develop an aggregate measure of severity of complications (the postoperative morbidity index).Study Design: Forty-three surgical experts rated case vignettes containing postoperative complications on a severity scale. Vignettes were based on the Accordion Severity Grading System derived from the Toronto Severity Grading System. The system was adjusted using the expert severity scale results and applied to 1 year of NSQIP outcomes (1,857 patients, 704 complications) at a large tertiary care center.Results: Experts initially distinguished the 6 grades of severity in a highly significant manner (t-test probabilities all < 0.005), with 1 exception. They rated reoperation and single-system organ failure without reoperation as similar, rather than distinct, in severity. The Accordion System was adjusted to reflect this. Distinction of grades thereafter was highly significant (t-test probabilities all < 0.005). Application to American College of Surgeons NSQIP data provided important novel insights. For example, complications in 6 American College of Surgeons NSQIP categories spanned 4 or more severity grades. Severity-weighted outcomes revealed that quantitatively the greatest burden of outcomes was due to wound infection, shock, and return to the operating room, which is not revealed by unweighted outcomes. Based on this information, an aggregate measure of severity of complications—the postoperative morbidity index—was proposed.Conclusions: Quantitative severity weighting of complications is feasible. Adjustment of American College of Surgeons NSQIP outcomes using this quantitative severity grading system provides uniquely informative representations of relative burdens of morbidities.

Verified Centers, Nonverified Centers, or Other Facilities: A National Analysis of Burn Patient Treatment Location

David Zonies, Christopher Mack, Bradley Kramer, Frederick Rivara, Matthew Klein — 2010-03-01

Background: Although comprehensive burn care requires significant resources, patients may be treated at verified burn centers, nonverified burn centers, or other facilities due to a variety of factors. The purpose of this study was to evaluate the association between patient and injury characteristics and treatment location using a national database.Study Design: We performed an analysis of all burn patients admitted to United States hospitals participating in the Healthcare Cost and Utilization Project over 2 years. Univariate and multivariate analyses were performed to identify patient and injury factors associated with the likelihood of treatment at designated burn care facilities. Definitive care facilities were categorized as American Burn Association-verified centers, nonverified burn centers, or other facilities.Results: During the 2 years of the study, 29,971 burn patients were treated in 1,376 hospitals located in 19 participating states. A total of 6,712 (22%) patients were treated at verified centers, with 26% and 52% treated at nonverified or other facilities, respectively. Patients treated at verified centers were younger than those treated at nonverified or other facilities (33.1 years versus 33.7 years versus 41.9 years; p < 0.001) and had a higher rate of inhalation injury (3.4% versus 3.2% versus 2.2%; p < 0.001). Independent factors associated with treatment at verified centers include burns to the head or neck (relative risk [RR], 2.4; CI, 2.1 to 2.7), hand (RR, 1.8; CI, 1.6 to 1.9), electrical injury (RR, 1.4; CI, 1.2 to 1.7), and fewer comorbidities (RR, 0.55; CI, 0.5 to 0.6).Conclusions: More than two-thirds of significantly burned patients are treated at nonverified burn centers in the United States. Many patients meeting American Burn Association criteria for transfer to a burn center are being treated at nonburn center facilities.

Patients Benefit While Surgeons Suffer: An Impending Epidemic

Adrian Park, Gyusung Lee, F. Jacob Seagull, Nora Meenaghan, David Dexter — 2009-12-24

Background: The widely held belief that laparoscopy causes greater strain on surgeons' bodies than open surgery is not well documented in scope or magnitude. In the largest North American survey to date, we investigated the association of demographics, ergonomics, and environment and equipment with physical symptoms reported by laparoscopic surgeons.Study Design: There were 317 surgeons identified as involved in laparoscopic practices who completed the online survey. Data collected from this comprehensive 23-question survey were analyzed using chi-square.Results: There were 272 laparoscopic surgeons (86.9%) who reported physical symptoms or discomfort. The strongest predictor of symptoms was high case volume, with the surprising exceptions of eye and back symptoms, which were consistently reported even with low case volumes. High rates of neck, hand, and lower extremity symptoms correlated with fellowship training, which is strongly associated with high case volume. Surprisingly, symptoms were little related to age, height, or practice length. The level of surgeons' awareness of ergonomic guidelines proved to be somewhere between slightly and somewhat aware. A substantial number of respondents requested improvements in regard to both the positioning and resolution of the monitor.Conclusions: Far beyond previous reports of 20% to 30% incidence of occupational injury, we present evidence that 87% of surgeons who regularly perform minimally invasive surgery suffer such symptoms or injuries, primarily high case load-associated. Additional data accrual and analysis are necessary, as laparoscopic procedures become more prevalent, for improvement of surgeon-patient and surgeon-technology interfaces to reverse this trend and halt the epidemic before it is upon us.

Palpable Presentation of Breast Cancer Persists in the Era of Screening Mammography

2010-03-01

Background: The aim was to describe cancer detection method and frequency of screening mammography in women undergoing breast cancer surgery in 2000.Study Design: Patients undergoing breast cancer surgery were identified through an institutional database. Charts were reviewed to determine presentation at time of diagnosis. Presentation was coded “palpable” if the woman presented with a breast complaint or if a new mass was detected on examination versus “screening” if detected on screening mammogram.Results: Five hundred ninety-two breast cancers were identified: 57% presenting by screening and 43% palpable. Cancer was more likely to present as palpable in patients with no previous screening mammography compared with those with previous mammography (67% versus 39%; p = 0.0002). Patients with palpable presentation were younger than those with screen-detected cancer (mean age 57 versus 62 years; p < 0.0001).Conclusions: Despite the frequent use of screening mammography, 43% of breast cancers presented as a palpable mass or otherwise symptomatic presentation.

Factors Dominating Choice of Surgical Specialty

2010-03-01

Background: There has been much focus on factors influencing medical students' career choice, prompted by such concerns as a sufficient future surgical workforce, declining applicant pool, changing gender composition, and a cultural shift in values and priorities. Once in a surgical residency, there are little data on factors influencing general surgery (GS) residents' final specialty choice.Study Design: A survey instrument was developed and content validated in conjunction with the Association of American Medical Colleges Center for Workforce Studies. The final instrument was distributed electronically between March 24 and May 2, 2008, through 251 GS program directors to all ACGME-accredited GS residents (n = 7,508).Results: Response rate was 29% (2,153 residents; 89% programs). Half of GS residents remained undecided about specialty choice through the 2nd year, declining to 2% by year 5. Of the two-thirds who decided on a specialty, 16.5% chose to remain in GS, 14.6% chose plastics, 9.3% cardiothoracic, and 8.5% vascular. The specialty choice factors most likely to be very important were type of procedures and techniques, exposure to positive role model, and ability to balance work and personal life. Relative importance of factors in specialty choice varied by gender and chosen specialty. Mentors play a key role in specialty choice (66% decided had mentors versus 47% undecided). Work schedule was the most frequently selected shortcoming in every specialty except plastics. Cardiothoracic surgery followed by GS had the highest shortcomings.Conclusions: The majority of GS residents plan to subspecialize. Three factors dominate specialty choice. Faculty need to understand their impact potential to modify or change perceptions of their specialty.

Influence of Double-Gloving on Manual Dexterity and Tactile Sensation of Surgeons

Donald E. Fry, W. Edwin Harris, Elizabeth N. Kohnke, Carolyn L. Twomey — 2009-12-24

Background: Double-gloving in the performance of surgical procedures has been demonstrated to reduce the frequency of blood contact with the hands of members of the surgical team. Concerns persist that double-gloving can compromise the dexterity and tactile sensitivity of the surgeon.Study Design: Fifty-three surgeons and surgeons-in-training volunteered at the Clinical Congress of the American College of Surgeons and were studied using the Purdue Pegboard test and a standard 2-point discrimination test to compare no gloves, a single pair of gloves, and double-gloving on manual dexterity and tactile sensitivity. Categorical and continuous variables were identified, general linear prediction models were computed, and the influence of glove status was analyzed as an independent variable. Monte Carlo simulation was employed to validate conclusions.Results: Gender, specialty, and handedness did not affect prediction models. Glove status did not affect dexterity performance scores (p = 0.57) after accounting for the influence of age on score variation (p < 0.001). Comparing ulnar and radial surfaces of the index finger for 2-point discrimination, no difference was detected between trials (p < 0.66), nor was an interaction effect detected with glove status (p = 0.40). Monte Carlo simulations validated the apparent absence of differences.Conclusions: Double-gloving does not have a substantial impact on manual dexterity or tactile sensitivity when compared with no gloves or single-gloving in this study.

High Incidence of Technical Errors Involving the EEA Circular Stapler: A Single Institution Experience

2010-01-29

Background: The use of stapling devices is now widespread in colorectal resections. However, the incidence and clinical consequence of technical error involving the circular stapler are still poorly characterized.Study Design: We reviewed the operative reports and Web-based charts for all colon and rectal resections performed at our institution that used a circular stapler. Technical error was defined as any deviation from the normal technical performance of the circular stapler, including, but not limited to, surgeon misfiring, incomplete anastomosis (inadequate donuts or staple line defects), and primary device failure. The unpaired t- and chi-square tests were used for statistical analysis; p < 0.05.Results: There were 349 colorectal resections performed and 67 (19%) featured a technical error. Thirty-two resections (9%) included an anastomotic error. The control group (n = 282) and the error group (n = 67) were comparable with regard to leaks, reoperation, suture line strictures, and hospital stay. The malfunction group had higher incidences of proximal diversions (34% versus 16%; p = 0.0003), ileus (24% versus 8%; p = 0.002), gastrointestinal bleeding (4% versus 0.4%; p = 0.023), and transfusion requirements (13% versus 4%; p = 0.004). Although proximal diversions in the error cohorts were also less likely to be planned (p < 0.001), reversal rates were similar in both groups (p = 0.28).Conclusions: The incidence of technical error involving the circular stapler is considerable. Technical error was found to be associated with a significantly higher risk of gastrointestinal bleeding, transfusions, and unplanned proximal diversions.

Pre-transplant Overweight and Obesity Do Not Affect Physical Quality of Life after Kidney Transplantation

2010-02-01

Background: Recent studies demonstrate that obesity does not affect survival after kidney transplantation. However, overweight and obesity impair health-related quality of life (HRQOL) in patients with chronic illnesses. We wished to examine the effects of pre-transplant overweight and obesity on post-transplant physical HRQOL in kidney transplant recipients.Study Design: Patient-reported HRQOL data were systematically collected in kidney transplant recipients receiving post-transplant follow-up at Vanderbilt Transplant Center. Patients who received kidney transplants between 1998 and 2008, had at least 1 post-transplant physical component summary (PCS) measurement, and did not receive other solid organ transplants were included in this retrospective cohort study. Pre-transplant body mass index was stratified as normal, overweight, obese class I, and obese class II/extremely obese. HRQOL was measured primarily with the PCS scale of the Medical Outcomes Study Short Form 36 Health Survey. Multivariate linear and logistic regression models were used to test the effects of body mass index and demographic and clinical covariates on post-transplant HRQOL.Results: The study cohort included 464 adults (mean body mass index 27.5 ± 5.1; range 18.5 to 47.4). After controlling for gender (p = 0.148), pre-transplant dialysis (p = 0.003), previous kidney transplantation (p = 0.255), donor type (p = 0.455), steroid avoidance immunosuppression (p = 0.070), and follow-up time (p = 0.352), there was no effect of pre-transplant overweight or obesity on post-transplant PCS (all p ≥ 0.112). Kidney transplant recipients who did not require dialysis pre-transplant and those who were managed with steroid avoidance after transplantation were more likely to achieve post-transplant PCS scores at or above the general population average (both p ≤ 0.011).Conclusions: Pre-transplant overweight and obesity do not affect physical quality of life after kidney transplantation.

Proximal Esophageal pH Monitoring: Improved Definition of Normal Values and Determination of a Composite pH Score

2010-03-01

Background: Patients with respiratory and laryngeal symptoms are commonly referred for evaluation of reflux disease as a potential cause. Dual-probe pH monitoring is often performed, although data on normal acid exposure in the proximal esophagus are limited because of the small number of normal subjects and inconsistent placement of the proximal pH sensor in relation to the upper esophageal sphincter. We measured proximal esophageal acid exposure using dual-probe pH and calculated a composite pH score in a large number of asymptomatic volunteers to better define normal values.Study Design: Eighty-one normal subjects free of reflux, laryngeal, or respiratory symptoms were recruited. All had video esophagraphy to exclude hiatal hernia. Esophageal pH monitoring was performed using 1 of 3 different dual-probe catheters with sensors spaced 10, 15, or 18 cm apart. The standard components of esophageal acid exposure were measured, excluding meal periods. A composite pH score for the proximal esophagus was calculated using these components.Results: The final study population consisted of 59 (49% male) subjects, with a median age of 27 years. All had normal distal esophageal acid exposure and no hiatal hernia. The 95th percentile values for the percent time the pH was < 4 for the total, upright, and supine periods were 0.9%, 1.2%, and 0.4%, respectively. The 95th percentile for the number of reflux episodes was 24 and for the calculated proximal esophageal composite pH score was 16.4.Conclusions: In a large population of normal subjects, we have defined the normal values and calculated a composite pH score for proximal esophageal acid exposure. The total percent time pH < 4 was similar to previously published normal values, but the number of reflux episodes was greater.

Treatment Options for Squamous Cell Cancer of the Esophagus: A Systematic Review of the Literature

Michael Kranzfelder, Peter Büchler, Konstanze Lange, Helmut Friess — 2010-03-01

The prognosis of patients with esophageal squamous cell cancer (ESCC) is still not satisfying, with long-term survival rates between 5% and 20%. The key prognostic factor is curative resection with proper lymphadenectomy; however, considerable postoperative morbidity hampers this therapeutic approach. Several clinical trials analyzed multimodal treatment concepts, but the combination with the best outcomes has yet to be defined. The introduction of neoadjuvant chemoradiotherapy followed by operation yielded promising results for a subgroup of patients, particularly those who respond well to neoadjuvant therapy. Two meta-analyses showed a significant advantage for the combined treatment regarding local tumor control and disease-free survival for patients with locally advanced resectable esophageal cancer. For patients with unresectable disease, combined chemoradiotherapy is the treatment of choice. However, there is an ongoing discussion about a substantial increase in treatment-related morbidity and mortality. The recent implication of response monitoring (positron emission tomography [PET]-CT) may further tailor neoadjuvant therapy to patients who profit most depending on whether they are responders or nonresponders to multimodal therapy. We reviewed the literature to summarize the results of recently published data in order to estimate the survival probability for patients with ESCC with different treatment modalities.

Primary Chest Wall Tumors

Asad A. Shah, Thomas A. D'Amico — 2009-12-21

Primary chest wall tumors are a heterogenous group of neoplasms arising from bone, soft tissue, or cartilage of the chest wall. They are rare tumors, with an incidence of <2% of the population, and represent approximately 5% of all thoracic neoplasms. They frequently present with pain, a chest wall mass, or both. They can be classified based on their tissue of origin and their benign or malignant nature (). The most common benign tumors include osteochondromas, chondromas, fibrous dysplasia, and desmoids tumors. The most common malignant tumors include soft-tissue sarcomas, chondrosarcomas, and the Ewing sarcoma family of tumors. Approximately 50% to 80% of chest wall tumors are malignant. Of these malignant tumors, approximately 55% arise from bone or cartilage and 45% from soft tissue. Overall 5-year survival after resection of primary chest wall neoplasms is approximately 60%. Recurrence can occur in up to 50% of patients, with a resultant 5-year survival of 17%.

Management of Biliary Tract Disease During Pregnancy

2010-03-01

The 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.

Treating Recurrent Inguinal Hernia

Tetsuji Fujita — 2010-03-01

Although solid evidence is lacking for conducting the best management plan for recurrent inguinal hernia, reading the article by Dr Itani and colleagues would help choose the optimal operative procedure or watchful waiting for the disease. Based on a subset analysis of middle-aged male patients who were recruited for a landmark study showing the feasibility of watchful waiting for minimally symptomatic inguinal hernia, the authors conclude that watchful waiting is also an acceptable alternative to early surgery for a recurrent inguinal hernia. To offer early repair or watchful waiting to individual hernia patient, in addition to accurate risk calculation of incarceration and strangulation, outcomes surveys of emergency hernia surgery are necessary. A recent national survey of 138,309 patients with inguinal hernia shows that the proportions of emergency operations for inguinal hernia are about 4.8% in men and about 10.9% in women. Rates for emergency surgery continue to exponentially increase with advancing age, and emergency admission rates in a group aged older than 80 years are as high as those in infants and young children. The mortality rate after emergency surgery for incarcerated inguinal hernia is lower than previously expected or might be acceptable in young and middle-aged adults. However, an emergency operation for patients aged 70 years or older is associated with high morbidities and mortalities. Overall, a large database suggests that inguinal hernia surgery in the emergency setting is associated with 5- to 6-fold increases in operative mortality compared with elective surgery. An audit of emergency admissions for complicated inguinal hernias indicates that asymptomatic hernias are not less likely to become incarcerated when compared with symptomatic hernias. Although a recent review states that there is no merit in trying to differentiate between lateral and medial hernias, it has been widely accepted that medial hernias, especially those presenting as broad direct bulges, are 10 times less prone to be strangulated than lateral hernia. In a prospective randomized trial comparing Lichtenstein hernioplasty with laparoscopic totally extraperitoneal (TEP) hernioplasty, the proportion of lateral hernia was increased from 55% in initial repairs to 60% in re-repairs. Therefore, I think that recurrent suspected lateral inguinal hernia should be repaired, especially for elderly medically fitted patients, even if the hernia is minimally symptomatic. For recurrent inguinal hernias in women, the discussion in the article seems insufficient. As prolonged wait times for surgery to repair hernias are not accepted among infants and young children because of a high incarceration rate, surgical repair should be performed without delay for women with a recurrent groin bulge because femoral hernia is more prevalent in women, and is commonly misdiagnosed as inguinal hernia and becomes frequently and suddenly incarcerated and strangulated. The additional reason to offer early surgery is the higher proportion of emergency repair for inguinal hernia in women compared with men, as described here.

Reply

Kamal M.F. Itani — 2010-03-01

We thank Dr Fujita for his insightful comments. With regard to “watchful waiting” of an incarcerated recurrent inguinal hernia, we agree with Dr Fujita that caution should be exercised when observing these patients, especially elderly patients with multiple comorbid conditions. The high overall complication rate of 36.2% reported in inguinal hernia repair, and the low rate of hernia strangulation or incarceration reported at 0.0018 events/year still needs to be presented to the patient and placed within the context of their lifestyle and symptoms; an informed decision can then be reached by the patient about surgery. It needs to be stressed that a strategy of observation should not translate into abandonment. The recommendation demands careful follow-up of nonoperated patients. It is for this reason that the term watchful waiting was coined by Fitzgibbons and colleagues and that none of the 35% of patients with recurrent inguinal hernias who were initially watched were denied surgery when they became more symptomatic or uncomfortable.

Management of Recurrent Inguinal Hernias

Arthur I. Gilbert, Michael F. Graham, Jerrold Young — 2010-03-01

Although Itani and colleagues claim there is absence of “best evidence in the field,” they state that after failed open or laparoscopic posterior repairs the anterior approach to the preperitoneal space (PPS) is technically difficult. Based on our first 3-year experience using a bilayer mesh device through an anterior approach, and contrary to an inherited vacuous presumption, we were impressed with the ease of dissecting the PPS in most of the 48 operations we did for failed posterior mesh repairs. When doing recurrent hernias previously done with a posterior approach (laparosopic, Kugel, and Prolene [Ethicon] Hernia System), we observed that, through an anterior approach, the site of the recurrent herniation in the canal's posterior wall was an obvious and convenient entry point; and actualizing the PPS was not technically difficult. We also noticed that in many of those patients we could not locate the old mesh. We speculate the original mesh either had been too small or it had migrated. In those patients, insertion of a new mesh and deploying it to repair a recurrent hernia was done as easily as for a primary hernia. Our impression of the technical challenge has not changed.

Reply

Kamal M.F. Itani — 2010-03-01

We very much appreciate Dr Gilbert's comments about our article. His expertise and experience with the Prolene (Ethicon) hernia system are well-recognized. In our review, we provided the practicing surgeon with a balanced, evidence-based, best approach to recurrent inguinal hernia. In cases where best evidence is lacking, we have added our collective experience as surgeons with a particular interest in hernia surgery.

Image-Guided Treatment of Breast Cancer

Mohammed Badruddoja — 2010-03-01

The article by Dr Silverstein and colleagues was published at a very important time, when key issues of disagreement remain in the management of breast carcinoma. The authors have discussed very eloquently various issues, such as the role of MRI, minimally invasive breast biopsy, sentinel node biopsy, clinical significance of micrometastasis, brachytherapy, and management of ductal carcinoma of situ and future research to improve the survival and overall survival in breast cancer.

Reply

Melvin J. Silverstein, Gary M. Levine, Michael D. Lagios, Abram Recht — 2010-03-01

We wish to thank Dr Badruddoja for his thoughtful response to our article, “Consensus Conference on Image-Detected Breast Cancer III.” The differences between the 3 Consensus Statements reflect the evolution of our thinking about nonpalpable image-detected breast cancer and how such lesions should be diagnosed and treated as new information has become available. The statements cover far too many topics for them all to be discussed in letter format, but a few items are worth pointing out.

JACS Category 1 CME Credit Featured Articles, Volume 210, March 2010

2010-03-01

Correction

2010-03-01

A Population-Based Study of Outcomes from Thyroidectomy in Aging Americans: At What Cost? Sosa JA, Mehta PJ, Wang TS, et al. J Am Coll Surg 2008;206:1097–1105. In the article by Sosa et al, the authors utilized the Nationwide Inpatient Sample Database, which is maintained by the Agency for Healthcare Research and Quality (AHRQ). It has come to the authors' attention that two tables in their article contained cells with fewer than 10 patients, which is out of compliance with AHRQ regulations. The corrected are:

2010-03-01

Journal of the American College of Surgeons

A Community Cancer Center Program: Getting to the Next Level

Low Oxygen-Affinity Hemoglobin Solution Increases Oxygenation of Partially Ischemic Tissue During Acute Anemia

Insurance Coverage Is Associated with Mortality after Gunshot Trauma

Quantitative Weighting of Postoperative Complications Based on the Accordion Severity Grading System: Demonstration of Potential Impact Using the American College of Surgeons National Surgical Quality Improvement Program

Verified Centers, Nonverified Centers, or Other Facilities: A National Analysis of Burn Patient Treatment Location

Patients Benefit While Surgeons Suffer: An Impending Epidemic

Palpable Presentation of Breast Cancer Persists in the Era of Screening Mammography

Factors Dominating Choice of Surgical Specialty

Influence of Double-Gloving on Manual Dexterity and Tactile Sensation of Surgeons

High Incidence of Technical Errors Involving the EEA Circular Stapler: A Single Institution Experience

Pre-transplant Overweight and Obesity Do Not Affect Physical Quality of Life after Kidney Transplantation

Proximal Esophageal pH Monitoring: Improved Definition of Normal Values and Determination of a Composite pH Score

Treatment Options for Squamous Cell Cancer of the Esophagus: A Systematic Review of the Literature

Primary Chest Wall Tumors

Management of Biliary Tract Disease During Pregnancy

Treating Recurrent Inguinal Hernia

Reply

Management of Recurrent Inguinal Hernias

Reply

Image-Guided Treatment of Breast Cancer

Reply

JACS Category 1 CME Credit Featured Articles, Volume 210, March 2010

Correction

Contents