Journal of the American College of Surgeons - Articles in Press

Patient Readmission and Mortality after Colorectal Surgery for Colon Cancer: Impact of Length of Stay Relative to Other Clinical Factors - Corrected Proof

2012-01-30

Background: Data on readmission as well as the potential impact of length of stay (LOS) after colectomy for colon cancer remain poorly defined. The objective of the current study was to evaluate risk factors associated with readmission among a nationwide cohort of patients after colorectal surgery. Study design: We identified 149,622 unique individuals from the Surveillance, Epidemiology, and End Results–Medicare dataset with a diagnosis of primary colorectal cancer who underwent colectomy between 1986 and 2005. In-hospital morbidity, mortality, LOS, and 30-day readmission were examined using univariate and multivariate logistic regression models. Results: Primary surgical treatment consisted of right (37.4%), transverse (4.9%), left (10.5%), sigmoid (22.8%), abdominoperineal resection (7.3%), low anterior resection (5.6%), total colectomy (1.2%), or other/unspecified (10.3%). Mean patient age was 76.5 years and more patients were female (52.9%). The number of patients with multiple preoperative comorbidities increased over time (Charlson comorbidity score ≥3: 1986 to 1990, 52.5% vs 2001 to 2005, 63.1%; p < 0.001). Mean LOS was 11.7 days and morbidity and mortality were 36.5% and 4.2%, respectively. LOS decreased over time (1986 to 1990, 14.0 days; 1991 to 1995, 12.0 days; 1996 to 2000, 10.4 days; 2001 to 2005, 10.6 days; p < 0.001). In contrast, 30-day readmission rates increased (1986 to 1990, 10.2%; 1991 to 1995, 10.9%; 1996 to 2000, 12.4%; 2001 to 2005, 13.7%; p < 0.001). Factors associated with increased risk of readmission included LOS (odds ratio = 1.02), Charlson comorbidities ≥3 (odds ratio = 1.27), and postoperative complications (odds ratio = 1.17) (all p < 0.01). Conclusions: Readmission rates after colectomies have increased during the past 2 decades and mean LOS after this operation has declined. More research is needed to understand the balance and possible trade off between these hospital performance measures for all surgical procedures.

Blunt Thoracic Aortic Injuries: Crossing the Rubicon - Corrected Proof

Demetrios Demetriades — 2012-01-23

I want to thank the leadership of the American College of Surgeons for the great honor and privilege of delivering the 2011 Scudder Oration. I feel both honored and humbled, having in mind the stature and major contributions of all the previous Scudder Orators.

Abandoning Unilateral Parathyroidectomy: Why We Reversed Our Position after 15,000 Parathyroid Operations - Corrected Proof

James Norman, Jose Lopez, Douglas Politz — 2012-01-23

Background: Our group championed the techniques and benefits of unilateral parathyroidectomy. As our experience has matured, it seems this limited operation might be appropriate only occasionally. Methods: A single surgical group's experience with 15,000 parathyroidectomies examined the ongoing differences between unilateral and bilateral techniques for 10-year failure/recurrence, multigland removal, operative times, and length of stay. Results: With limited experience, 100% of operations were bilateral, decreasing to 32% by the 500th operation (p < 0.001), and long-term failure rates increased to 6%. Failures were 11 times more likely for unilateral explorations (p < 0.001 vs bilateral), causing gradual increases in bilateral explorations to 97% at the 14,000th operation (p < 0.001). Ten-year cure rates are unchanged for bilateral operations, and unilateral operations show continued slow recurrence rates of 5% (p < 0.001). Removal of more than one gland occurred 16 times more frequently when 4 glands were analyzed (p < 0.001), increasing cure rates to the current 99.4% (p < 0.001). Of 1,060 reoperations performed for failure at another institution, intraoperative parathyroid hormone levels fell >50% in 22% of patients, yet a second adenoma was subsequently found. Operative times decreased with experience; bilateral operations taking only 5.9 minutes longer on average (22.3 vs 16.4 minutes; p < 0.001), which is 25 minutes less than unilateral at the 500th operation (p < 0.001). By the 1,000th operation, incision size (2.5 ± 0.2 cm), anesthesia, and hospital stay (1.6 hours) were identical for unilateral and bilateral procedures. Conclusions: Regardless of surgical adjuncts (scanning, intraoperative parathyroid hormone), unilateral parathyroidectomy will carry a 1-year failure rate of 3% to 5% and a 10-year recurrence rate of 4% to 6%. Allowing rapid analysis of all 4 glands through the same 1-inch incision has caused us to all but abandon unilateral parathyroidectomy.

Using the National Surgical Quality Improvement Program and the Tennessee Surgical Quality Collaborative to Improve Surgical Outcomes - Corrected Proof

2012-01-23

Background: Led by the Tennessee Chapter of the American College of Surgeons, in May 2008 a 10-hospital collaborative was formed between the Tennessee Chapter of ACS, the Tennessee Hospital Association, and the BlueCross BlueShield of Tennessee Health Foundation. We hypothesized that by forming the Tennessee Surgical Quality Collaborative using the National Surgical Quality Improvement Program (NSQIP) system to share surgical process and outcomes data, overall patient surgical outcomes would improve. Study Design: All NSQIP data from the 10-hospital collaborative for the time periods January to December 2009 (period 1) and January to December 2010 (period 2) were collected. Data on 20 categories of postoperative complications and 30-day mortality were compared between periods. Complication comparisons and hospital costs associated with complications were calculated per 10,000 procedures. Statistical analysis was performed by Z-test. Results: There were 14,205 total surgical cases in period 1 and 14,901 surgical cases in period 2. Between periods (per 10,000 cases) there were significant improvements in superficial surgical site infections (−19%, p = 0.0005), on ventilator longer than 48 hours (−15%, p = 0.012), graft/prosthesis/flap failure (−60%, p < 0.0001), acute renal failure (−25%, p = 0.023), and wound disruption (−34%, p = 0.011). Although mortality (per 10,000) was higher in period 2 (237.6 vs 232.3), no statistical difference was noted. Net costs avoided between these periods were calculated as $2,197,543 per 10,000 general and vascular surgery cases. Conclusions: Data organization and scrutiny are the initial steps of process improvement. Participation in our regional surgical quality collaborative resulted in improved outcomes and reduced costs. Although the mechanisms for these changes are likely multifactorial, the collaborative establishes communication, process improvement, and frank discussion among the members as best practices are identified and shared and standardized processes are adopted.

AUDIT-C Alcohol Screening Results and Postoperative Inpatient Health Care Use - Corrected Proof

2012-01-12

Background: Alcohol screening scores ≥5 on the Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) up to a year before surgery have been associated with postoperative complications, but the association with postoperative health care use is unknown. This study evaluated whether AUDIT-C scores in the year before surgery were associated with postoperative hospital length of stay, total ICU days, return to the operating room, and hospital readmission. Study Design: This cohort study included male Veterans Affairs patients who completed the AUDIT-C on mailed surveys (October 2003 through September 2006) and were hospitalized for nonemergent noncardiac major operations in the following year. Postoperative health care use was evaluated across 4 AUDIT-C risk groups (scores 0, 1 to 4, 5 to 8, and 9 to 12) using linear or logistic regression models adjusted for sociodemographics, smoking status, surgical category, relative value unit, and time from AUDIT-C to surgery. Patients with AUDIT-C scores indicating low-risk drinking (scores 1 to 4) were the referent group. Results: Adjusted analyses revealed that among eligible surgical patients (n = 5,171), those with the highest AUDIT-C scores (ie, 9 to 12) had longer postoperative hospital length of stay (5.8 [95% CI, 5.0−6.7] vs 5.0 [95% CI, 4.7−5.3] days), more ICU days (4.5 [95% CI, 3.2−5.8] vs 2.8 [95% CI, 2.6−3.1] days), and increased probability of return to the operating room (10% [95% CI, 6−13%] vs 5% [95% CI, 4−6%]) in the 30 days after surgery, but not increased hospital readmission within 30 days postdischarge, relative to the low-risk group. Conclusions: AUDIT-C screening results could be used to identify patients at risk for increased postoperative health care use who might benefit from preoperative alcohol interventions.

Statins in Abdominal Surgery: A Systematic Review - Corrected Proof

2012-01-12

Statins (3-hydroxy-3-methylglutaryl coenzyme A [HMG-CoA] or HMG-CoA reductase inhibitors) are the most commonly prescribed class of lipid-lowering drugs. In addition to their established role in the medical management of cardiovascular disease, benefits have also been demonstrated in cardiac and vascular surgery, where they have been shown to decrease cardiovascular complications and reduce perioperative mortality. These cardioprotective effects also extend to the wider surgical population, with similar benefits seen in noncardiovascular surgical settings.

A Systematic Review and Meta-Analysis of Diagnostic Screening Criteria for Blunt Cerebrovascular Injuries - Corrected Proof

2012-01-12

Background: Despite progress in diagnosing and managing blunt cerebrovascular injury (BCVI), controversy remains regarding the appropriate population to screen. A systematic review of published literature was conducted to summarize the overall incidence of BCVI and the various screening criteria used to detect BCVI. A meta-analysis was performed to evaluate which screening criteria may be associated with BCVI. Goals were to confirm inclusion of certain criteria in current screening protocols and possibly eliminate criteria not associated with BCVI. Study Design: Studies published between January 1995 and April 2011 using digital subtraction angiography or CT angiography as a diagnostic modality and reporting overall BCVI incidence or prevalence of BCVI for specific screening criteria were examined. Screening criteria were analyzed using a random effects model to determine if an association with BCVI was present. Results: The incidence range of BCVI was between 0.18% and 2.70% among approximately 122,176 blunt trauma admissions. The meta-analysis encompassed 418 BCVI and 22,568 non-BCVI patients. Of the 9 screening criteria analyzed, cervical spine (odds ratio [OR] 5.45; 95% CI 2.24 to 13.27; p < 0.0001) and thoracic (OR 1.98; 95% CI 1.35 to 2.92; p = 0.001) injuries demonstrated a significant association with BCVI. Conclusions: Patients with cervical spine and thoracic injuries had significantly greater likelihoods of BCVI compared with patients without these injuries. All patients with either injury should be screened for BCVI. Multivariate logistic regression analysis is needed to elucidate the possible impact of the combined presence of screening criteria, but it was not possible in our study due to limitations in data presentation. Standardized reporting of BCVI data is not established and is recommended to permit future collaboration.

Total Mesorectal Excision with Intraoperative Assessment of Internal Anal Sphincter Innervation Provides New Insights into Neurogenic Incontinence - Corrected Proof

2012-01-12

Background: The aim of this prospective study was to assess internal anal sphincter (IAS) innervation in patients undergoing total mesorectal excision (TME) by intraoperative neuromonitoring (IONM). Study Design: Fourteen patients underwent TME. IONM was carried out through pelvic splanchnic nerve stimulation under continuous electromyography of the IAS. Anorectal function was assessed with the digital rectal examination scoring system and a standardized questionnaire. Results: Nine of 11 patients who underwent low anterior resection had positive IONM results, with stimulation-induced increased IAS electromyographic amplitudes (median 0.23 μV (interquartile range [IQR] 0.05, 0.56) vs median 0.89 μV (IQR 0.64, 1.88), p < 0.001) after TME. The patients with the positive IONM results were continent after stoma closure. Of 2 patients with negative IONM results, 1 had fecal incontinence after closure of the defunctioning stoma and received a permanent sigmoidostomy. In the other patient the defunctioning stoma was deemed permanent due to decreased anal sphincter function. In 3 patients who underwent abdominoperineal excision, IONM assessed denervation of the IAS after performance of the abdominal part. Conclusions: This study demonstrated that IONM of IAS innervation in rectal cancer patients is feasible and may predict neurogenic fecal incontinence.

Argon Beam Coagulator: An Effective Adjunct to Stapled Pulmonary Tractotomy to Control Hemorrhage in Penetrating Pulmonary Injuries - Corrected Proof

Juan A. Asensio, Federico N. Mazzini, Rubén Gonzalo, Eva Iglesias, Thai Vu — 2012-01-12

Stapled pulmonary tractotomy with selective vascular ligation is a rapid technique used to control hemorrhage in penetrating pulmonary injuries and has assumed an important role in the trauma surgical armamentarium for the management of these injuries. This technique was designed as tissue sparing to avoid complications well known to occur with extensive pulmonary resections. Multiple studies have validated and reported this technique to be both safe and effective.

Bacterial Sepsis after Living Donor Liver Transplantation: The Impact of Early Enteral Nutrition - Corrected Proof

2012-01-12

Background: Bacterial sepsis is a significant problem that must be addressed after living donor liver transplantation (LDLT). Study Design: A retrospective analysis of 346 adult-to-adult LDLT patients was performed. Results: Forty-six patients (13.3%) experienced bacterial sepsis, with primary and secondary origins in 23.9% and 76.1%, respectively. Gram-negative bacteria accounted for 71.7% of the bacteria isolated. The 2-year cumulative graft survival rate in patients with bacterial sepsis was 45.7%. Patients with bacterial sepsis secondary to pneumonia (n = 12) had poorer 2-year graft survival rates (16.7%) than did those with primary or other types of secondary sepsis (p = 0.004). Multivariate analysis showed that intraoperative massive blood loss >10L (p < 0.001) and no enteral feeding started within 48 hours after transplantation (p = 0.005) were significant risk factors for bacterial sepsis. Among patients who received enteral nutrition, the incidences of bacterial sepsis in patients who received enteral nutrition within 48 hours (n = 135) or later than 48 hours (n = 57) were 5.9% and 21.0%, respectively (p = 0.002). The incidence of early graft loss was 8-fold higher in recipients with massive intraoperative blood loss without early enteral nutrition (p < 0.001). Conclusions: Early enteral nutrition was associated with significantly reduced risk of developing bacterial sepsis after LDLT.

Management of Papillary Breast Lesions Diagnosed on Core-Needle Biopsy: Clinical Pathologic and Radiologic Analysis of 276 Cases with Surgical Follow-Up - Corrected Proof

2012-01-12

Background: Clinical management of papillary breast lesions (PBLs) remains controversial. The objective of this study was to identify pathologic and radiologic predictors of malignancy from a large cohort of PBLs diagnosed on core-needle biopsy (CNB). Study Design: Retrospective review of the institutional pathology database identified all PBLs diagnosed from 2001 to 2009 and surgically excised within 6 months of diagnosis. PBLs were divided into intraductal papilloma (IDP) and IDP associated with atypical ductal or lobular hyperplasia (ADH/ALH). Surgical pathology of all lesions was reviewed and upgrade was defined as a change to a lesion of greater clinical significance, including ALH, ADH, lobular, or ductal carcinoma in situ (LCIS or DCIS), and invasive ducal carcinoma (IDC). Results: We identified 276 patients (mean age 56 years; range 23 to 88 years) with PBLs on CNB. Seventy-nine patients (28.6%) upgraded to a lesion of greater clinical significance. Of the 234 (84.7%) had IDP only, 42 (17.9%) upgraded to ADH, and 21 (8.9%) to DCIS or IDC. Of the 42 (15.3%) patients with associated ADH or ALH on CNB, 16 (38.0%) upgraded to DCIS or IDC. The majority of patients (n = 173, 62.6%) had no breast symptoms. All patients had an abnormal mammogram and/or ultrasound that prompted the CNB. Among all clinical and radiographic variables analyzed, older age alone was predictive of upgrade. Conclusions: Frequent upgrade to a high-risk lesion or cancer is observed with IDPs diagnosed on CNB without adequate identifiable clinical and radiographic risk factors. Surgical excision should be performed for all IDPs to delineate subsequent clinical management.

Nanoparticle Migration and Delivery of Paclitaxel to Regional Lymph Nodes in a Large Animal Model - Corrected Proof

2012-01-06

Background: The aim of this study was to demonstrate feasibility of migration and in situ chemotherapy delivery to regional lymph nodes (LN) in a large animal model using an expansile polymer nanoparticle (eNP) delivery system. Study Design: Dual-labeled 50-nm and 100-nm eNP were prepared by encapsulating an IR-813 near-infrared (NIR) fluorescent dye within coumarin-conjugated expansile polymer nanoparticles (NIR-C-eNP). NIR imaging and fluorescent microscopy were used to identify intralymphatic migration of NIR-nanoparticles to draining inguinal or mesenteric LN after injection in swine hind legs or intestine. Nanoparticle-mediated intranodal delivery of chemotherapy was subsequently assessed with Oregon Green paclitaxel-loaded NIR-eNP (NIR-OGpax-eNP). Results: NIR imaging demonstrated direct lymphatic migration of 50-nm, but not 100-nm, NIR-C-eNP and NIR-OGpax-eNP to the draining regional LNs after intradermal injection in the hind leg or subserosal injection in intestine. Fluorescent microscopy demonstrated that IR-813 used for NIR real-time trafficking colocalized with both the coumarin-labeled polymer and paclitaxel chemotherapy and was identified within the subcapsular spaces of the draining LNs. These studies verify nodal migration of both nanoparticle and encapsulated payload, and confirm the feasibility of focusing chemotherapy delivery directly to regional nodes. Conclusions: Regionally-targeted intranodal chemotherapy can be delivered to draining LNs for both skin and solid organs using 50-nm paclitaxel-loaded eNP.

An Online Spaced-Education Game to Teach and Assess Residents: A Multi-Institutional Prospective Trial - Corrected Proof

B. Price Kerfoot, Harley Baker — 2012-01-06

Background: While games are frequently used in resident education, there is little evidence supporting their efficacy. We investigated whether a spaced-education (SE) game can be both a reliable and valid method of assessing residents' knowledge and an effective means of teaching core content. Study Design: The SE game consisted of 100 validated multiple-choice questions and explanations on core urology content. Residents were sent 2 questions each day via email. Adaptive game mechanics re-sent the questions in 2 or 6 weeks if answered incorrectly and correctly, respectively. Questions expired if not answered on time (appointment dynamic). Residents retired questions by answering each correctly twice in a row (progression dynamic). Competition was fostered by posting relative performance among residents. Main outcomes measures were baseline scores (percentage of questions answered correctly on initial presentation) and completion scores (percentage of questions retired). Results: Nine hundred thirty-one US and Canadian residents enrolled in the 45-week trial. Cronbach alpha reliability for the SE baseline scores was 0.87. Baseline scores (median 62%, interquartile range [IQR] 17%) correlated with scores on the 2008 American Urological Association in-service examination (ISE08), 2009 American Board of Urology qualifying examination (QE09), and ISE09 (r = 0.76, 0.46, and 0.64, respectively; all p < 0.001). Baseline scores varied by sex, country, medical degree, and year of training (all p ≤ 0.001). Completion scores (median 100%, IQR 2%) correlated with ISE08 and ISE09 scores (r = 0.35, p < 0.001 for both). Seventy-two percent of enrollees (667 of 931) requested to participate in future SE games. Conclusions: An SE game is a reliable and valid means to assess residents' knowledge and is a well-accepted method by which residents can master core content.

Lymph Node Staging in Colorectal Cancer: Revisiting the Benchmark of at Least 12 Lymph Nodes in R0 Resection - Corrected Proof

Jinru Shia, Hangjun Wang, Garrett M. Nash, David S. Klimstra — 2012-01-06

Since the development of Dukes' classification system for colorectal carcinoma in the 1930s by English pathologist Cuthbert Dukes, which emphasized the importance of lymph node involvement, the status of lymph nodes in a colorectal cancer resection specimen has remained the most powerful indicator for prognostication and management. The most important components in lymph node staging include the presence or absence of metastasis in lymph nodes and the total number of lymph nodes examined. The assessment of both components, however, can be influenced by many factors, and how best to carry out the assessment has been an evolving topic. This review aims at analyzing the various factors that can potentially influence lymph node assessment, and how such influences can impact the clinical application of the current benchmark requirement of at least 12 lymph nodes for a colonic or rectal cancer resection.

Improving Access to Care: Breast Surgeons, the Gatekeepers to Breast Reconstruction - Corrected Proof

2012-01-06

Background: Fewer than half of patients undergo reconstruction after breast cancer treatment, despite its quality of life benefits. Earlier studies demonstrated that most general surgeons do not discuss reconstructive options with patients. The aim of this study was to examine the likelihood of reconstruction within a cohort of mastectomy patients and compare rates of reconstruction between those referred and not referred for plastic surgery evaluation. Study design: Retrospective review of the records of 471 consecutive patients between the ages of 19 and 94 years who underwent mastectomy between 2003 and 2007. Variables evaluated were age, body mass index, diabetes, laterality (unilateral vs bilateral), TNM staging, history of radiation, smoking history, insurance type, and race. Results: Of 471 patients, 313 were referred for consultation with a plastic surgeon and 158 were not; 91.7% of those referred were reconstructed and 100% of those not referred were not reconstructed. The 2 groups differed considerably in terms of age (mean age 61.84 years in the nonreferred group vs 51.83 years in the referred group), body mass index (25.9 in referred group, 27 in nonreferred group), diabetes (15% in nonreferred group vs 3.5% in referred group), and laterality (14% of nonreferred group underwent bilateral mastectomies vs 26% of those referred). The groups did not differ significantly in terms of race or tobacco use. Those with private insurance were more likely to be reconstructed, but no independent effect of insurance type was seen on multivariate analysis. Conclusions: The breast surgeon's decision to refer a patient for reconstruction significantly affects whether the patient will receive breast reconstruction. Factors that appear to influence the referral decision are age, diabetes, body mass index, and laterality of mastectomy (bilateral more than unilateral).

Application of Subcutaneous Talc after Axillary Dissection in a Porcine Model Safely Reduces Drain Duration and Prevents Seromas - Corrected Proof

2011-12-22

Background: Talc, the most common pleurodesis agent, has recently been shown to prevent seromas and decrease drain duration when placed subcutaneously after large subcutaneous dissection accompanying open ventral hernia repair. We hypothesized that talc would decrease drain duration and prevent seromas after axillary dissection without local or systemic side effects. Study Design: Six pigs underwent full, bilateral axillary dissection (n 12 dissections). Three animals each had aerosolized small particle (SP) talc and large particle (LP) talc sprayed unilaterally (TALC) before closure, with the contralateral axillary dissection serving as the control (NOTALC). Functional status, wound complications, and drain duration were recorded. Local neurovascular structures and systemic organs were harvested at 28 days, processed with hematoxylin and eosin, and examined under normal and polarized light microscopy by blinded physicians. Results: All pigs were back to baseline functional status by 72 hours. Two seromas (33%) were noted in the NOTALC dissections vs 0 in the TALC group (0%). Drain duration was significantly decreased in TALC vs NOTALC dissections (8.3 ± 2.7 vs 12.0 ± 3.2 days, p = 0.03), as was total drain volume (222.5 ± 127.1 mL vs 334.2 ± 137.9 mL, p = 0.02). Gross and histologic evaluation revealed neurovascular structures to be intact. Minimal splenic deposition of talc within macrophages without evidence of injury was identified in all specimens, with fewer deposits in the large particle talc group. Serum laboratory examination at time of harvest revealed all animals to have normal values. Conclusions: Direct application of talc throughout the wound after axillary dissection in pigs decreased drain duration and drain volume and prevented seroma formation. Gross, histologic, and serum laboratory evaluation demonstrated no talc-related local or systemic complications. Aerosolized talc is an effective and safe pretreatment to prevent seromas and hasten drain removal after axillary dissection.