Design  Prospective single-surgeon case series.

Setting  Referral center.

Patients  Forty-two patients with primary hyperparathyroidism, indications for surgery, and both cervical ultrasonographic results and technetium Tc 99m sestamibi nuclear images that were nonlocalizing over a 5- year span.

Main Outcome Measures  Extent of surgery required to produce cure; operative findings.

Results  Of 430 patients undergoing surgery for primary hyperparathyroidism, 351 underwent both ultrasonographic and sestamibi imaging. Among 351 patients, the imaging results of 42 patients did not show an adenoma, and these patients underwent cervical exploratory surgery. Of 42 patients, 41 were cured at a mean follow-up of 90 days; 1 patient underwent surgical reexploration and was cured by removal of a mediastinal adenoma. To achieve initial cure, 12 of 42 patients (28.6%) required partial thyroidectomy, 9 (21.4%) required partial thymectomy, 17 (40.5%) required paratracheal dissection to access or devascularize an obscure adenoma. Pathologic examination disclosed single adenoma in 26 of 42 patients (61.9%), parathyroid hyperplasia in 14 (33.3%), and double adenoma in 2 (4.8%).

Conclusions  Patients whose preoperative localization studies fail to localize solitary adenoma commonly require extensive surgery to cure hyperparathyroidism. Lack of localization may be a reasonable criterion on which to base referral of the patient to a high-volume medical center.

Design  Hospital discharge data from the Nationwide Inpatient Sample from January 1, 1988, through December 31, 2003.

Setting  A 20% random sample of patients admitted to US hospitals.

Patients  All patients who underwent CABG or percutaneous transluminal coronary interventions. Facilities performing CABG were assigned to standard volume cutoffs.

Main Outcome Measures  Rates of cardiac procedures and the proportion of hospitals meeting standard volume cutoffs, as well as the CABG mortality rate.

Results  During our 16-year study period, the rate of CABG increased from 7.2 cases per 1000 discharges in 1988 to 12.2 cases in 1997 but then decreased to 9.1 cases in 2003, while the rate of percutaneous interventions tripled. For CABG, the proportion of high-volume hospitals declined from 32.5% in 1997 to 15.5% in 2003. Despite shifts between high- and low-volume hospitals, the CABG mortality rate steadily declined from 5.4% in 1988 to 3.3% in 2003. Hospitals performing the lowest volume of CABG experienced the largest decrease in the in-hospital mortality rate.

Conclusions  Since 1997, CABG volume has declined in the setting of a decrease in in-hospital mortality. A lower mortality rate in the setting of reduced CABG volume is a counterintuitive finding, suggesting that procedure volume is an insufficient predictor of outcome on which to base regionalization strategies.

Design  Retrospective longitudinal analysis.

Setting  Clinically active general surgeons in the United States.

Participants  The American Medical Association's Physician Masterfiles from 1981, 1991, 2001, and 2005 were used to identify all clinically active general surgeons in the United States.

Main Outcome Measures  Number of general surgeons per 100 000 population and the age, sex, and locale of these surgeons.

Results  General surgeon to population ratios declined steadily across the study period, from 7.68 per 100 000 in 1981 to 5.69 per 100 000 in 2005. The overall urban ratio dropped from 8.04 to 5.85 (–27.24%) across the study period, and the overall rural ratio dropped from 6.36 to 5.02 (–21.07%). The average age of rural surgeons increased compared with their urban counterparts, and women were disproportionately concentrated in urban areas.

Conclusions  The overall number of general surgeons per 100 000 population has declined by 25.91% during the past 25 years. The decline has been most marked in urban areas. However, more remote rural areas continue to have significantly fewer general surgeons per 100 000 population. These findings have implications for training, recruiting, and retaining general surgeons.

Design  Retrospective study.

Setting  University hospital.

Patients  Sixty-five consecutive symptom-free colorectal cancer patients with unresectable synchronous metastases confined to the liver undergoing bowel tumor resection plus systemic chemotherapy (42 patients [resection group]) or chemotherapy first (23 patients [chemotherapy group]).

Main Outcome Measures  Long-term survival and identification of prognostic indicators of outcome.

Results  In the resection group, the mean and median overall survival times were shown to be significantly better than those in the chemotherapy group (P = .03). Performance status, basal serum levels of lactic dehydrogenase and alkaline phosphatase, percentage of liver involvement, potentially curative resection of the bowel tumor, and type of treatment (resection vs chemotherapy) were demonstrated to be the only variables significantly correlated with long-term survival. On multivariate analysis, performance status, extent of liver involvement, and type of treatment were shown to be the only covariates independently associated with survival rate. The rate of liver metastasis downstaging with subsequent curative hepatic resection was clearly associated with good performance status, limited liver involvement, and resection of the bowel tumor.

Conclusions  Achieving complete cure in asymptomatic colorectal cancer patients with unresectable synchronous liver-only metastases appears to be mostly the result of shrinkage and resection of hepatic metastases. In patients with good performance status and limited liver involvement, bowel tumor resection appears to be the best treatment option for this purpose.

Design  Comparison of the rate of serious complications between open and laparoscopic fundoplication in Finland at the national level.

Setting  University teaching hospital.

Patients  From January 1, 1992, to December 31, 2001, 10 846 fundoplications were performed in Finland. Of these, 3987 (37%) were open and 6859 (63%) were laparoscopic.

Main Outcome Measures  Administrative databases provided the number of fundoplications, the rate of severe complications, and the mortality. Medical records allowed for evaluation of the nature and cause of severe complications of laparoscopic and open fundoplications.

Results  From January 1, 1992, to December 31, 2001, hospital mortality was significantly lower after laparoscopy (P = .01). In comparable groups, surgical mortality or the overall rate of serious complications did not differ. The rate of serious complications decreased after both open surgery (P = .01) and laparoscopic surgery (P = .03). After laparoscopy, patients made claims for injuries more often (P = .003) and had a higher rate of dysphagia (P < .001). In all of the patients with severe dysphagia or fundic perforations after laparoscopy, the short gastric vessels were not divided. Furthermore, 1 open fundoplication and 22 laparoscopic fundoplications had to have reoperations performed owing to dysphagia, mostly involving technical failure.

Conclusions  At the national level, the first 10-year experience of laparoscopic fundoplication reduced the rate of serious complications. The complications largely were technical failures related to the lack of a standardized surgical technique.

Data Sources  An evaluation of current literature concerning religious beliefs among persons of Jewish, Muslim, and Hindu faiths was undertaken to determine if animal-derived surgical implants are permitted for use in these religions.

Study Selection  Because of the limited published literature about this topic, the opinions of religious leaders in Australia were sought.

Data Extraction  Religious and cultural beliefs can conflict with and limit treatment options, especially in surgery. Approximately 81 porcine and bovine surgical implants are regularly used in Australia.

Data Synthesis  It is deemed acceptable for members of the Jewish faith to undergo surgery using porcine products. In dire situations and only after all other options have been exhausted, followers of the Muslim faith are permitted to use porcine surgical products. Hindu religious leaders did not accept the use of bovine surgical implants.

Conclusions  Australia comprises a multicultural society; therefore, it is necessary to consider religious beliefs of all patients. As part of a surgeon's duty of care, the informed consent process should include a discussion about animal-derived surgical implants to avoid religious distress and possible litigation. A greater understanding of religious views would enhance the medical care of persons of Jewish, Muslim, and Hindu faiths.

Design  Blinded randomized single-center trial emphasizing methodologic quality and generalizability.

Setting  General teaching hospital in the Netherlands.

Patients  A total of 257 patients undergoing cholecystectomy for symptomatic cholecystolithiasis.

Interventions  Laparoscopic cholecystectomy and small-incision cholecystectomy, performed mainly by surgical residents.

Main Outcome Measures  Complications and symptom relief were primary outcome measures; conversion rate, operative time, and hospital stay were secondary outcome measures. Feasibility of performing both procedures by residents was evaluated as well.

Results  In the 257 patients, surgical residents performed 105 laparoscopic and 118 small-incision cholecystectomies. There were no significant differences in complications, conversion rates, and hospital stay. Operative time was significantly shorter with the small-incision technique.

Conclusions  No differences in primary clinical outcome measures were found between laparoscopic and small-incision cholecystectomy in this randomized trial with emphasis on methodologic quality and generalizability. The gold standard status of laparoscopic cholecystectomy is questionable.

Trial Registration  isrctn.org Identifier: ISRCTN67485658

Design  Retrospective review.

Setting  Academic research institute.

Patients  Patients who underwent 1260 consecutive liver resections, 338 of them (26.8%) in patients with cirrhosis.

Main Outcome Measures  Postoperative complications and mortality were analyzed relative to liver disease, blood transfusion, vascular clamping, and type of liver resection.

Results  Vascular clamping was applied in 594 patients (47.1%). Operative mortality was 4.4% in the vascular clamping group and 2.9% in the nonclamped group, a statistically nonsignificant difference. On multivariate analysis, blood transfusion, major hepatectomies, and the presence of cirrhosis were statistically significantly associated with postoperative complications. Among the overall cohort and among patients with cirrhosis, there was statistically significantly reduced use of vascular clamping and of blood transfusion during the past 20 years. The lowest incidences of severe complications occurred among cases of continuous or hemihepatic clamping. Among 338 patients with cirrhosis, 155 (45.9%) received some type of vascular control; morbidity and mortality rates were similar in the groups with vs those without vascular control. On multivariate analysis, only blood transfusion was statistically significantly associated with postoperative morbidity. Postoperative complications were statistically significantly reduced among patients receiving intermittent compared with continuous clamping.

Conclusions  Vascular clamping can be applied without additional risk during partial hepatectomy. Intermittent or hemihepatic clamping is preferable in patients with cirrhosis.

Design  Preferences were determined using the Prospective Measure of Preference.

Setting  Royal Prince Alfred and St Vincent's hospitals in Sydney, Australia.

Participants  Patients with colorectal cancer were interviewed during their postoperative hospital stay, and physicians were asked to complete a mailed survey.

Main Outcome Measures  The Prospective Measure of Preference method produces 2 outcome measures of preference: willingness to trade and prospective measure of preference time trade-off.

Results  Patients' strongest preference was to avoid a stoma: more than 60% would give up a mean of 34% of their life expectancy to avoid this surgical option. This was followed by treatment options involving chemoradiotherapy, where more than 50% would give up a mean of almost 25% of their life to avoid treatment. Surgeons held stronger preferences against all adjuvant options compared with oncologists (P ≤ .01).

Conclusions  Patients had strong preferences against all treatment options, and these preferences frequently differed from those of physicians. These results highlight the importance of determining patients' own preferences in the clinical encounter. Furthermore, the diversity of preferences of clinical subspecialists emphasizes the need for multidisciplinary treatment planning to ensure a balanced approach to treatment decision making for patients with rectal cancer.

Design  Prospective study.

Setting  Tertiary referral unit.

Patients  Sixty-two patients requiring liver resection between November 1, 2004, and February 28, 2006, primarily for metastatic cancer.

Intervention  Liver resection with the radiofrequency device.

Main Outcome Measures  Intraoperative blood loss, liver parenchyma transection time, and complications.

Results  There were 51 minor and 11 major hepatectomies. Mean (SD) transection time was 39 (27) seconds per square centimeter. Mean (SD) blood loss was 4.8 (5.6) mL per square centimeter. No patient required hepatic inflow occlusion. One patient required blood transfusion. There were no deaths, and the morbidity rate was 18%. Mean (SD) hospital stay was 8 (3) days.

Conclusions  This new bipolar radiofrequency device allows minor and major hepatectomies to be performed with minimal blood loss, low blood transfusion requirement, and reduced mortality and morbidity rates.

Methods  At the end of the major hepatic resection, 10 to 30 mL of sterile fat emulsion, 5%, is injected via an olive-tip cannula through the cystic duct while manually occluding the distal common bile duct. As the biliary tree fills with fat emulsion solution, leakage of the white fluid is visualized on the raw surface of the liver resection margin. The detected leakages are closed by means of single stitches. Afterwards, the residual fat emulsion on the resection surface is washed off with saline and the White test is repeated to detect and/or exclude additional bile leakages. At the end, residual fat emulsion is washed out from the biliary tract by a low-pressure infusion of saline solution.

Results  Intraoperatively, additional potential bile leakages (not seen using a conventional saline bile leakage test) were identified in 74% of our patients. Postoperative bile leakages (within 30 days) occurred in only 5.1% of patients when the White test was used. No adverse effects related to this technique were observed.

Conclusions  The White test has clear advantages in comparison with other bile leakage tests: it precisely detects bile leakages, regardless of size; it does not stain the resection surface, allowing it to be washed off and repeated ad infinitum; and it is safe, quick, and inexpensive.

Data Sources  The literature was searched by means of MEDLINE, Embase, Ovid, and Cochrane databases for all studies published from 1978 through July 15, 2005.

Study Selection  Comparative (randomized and nonrandomized) studies evaluating outcomes after restorative proctocolectomy with or without ileostomy were included.

Data Extraction  Three authors independently extracted data by using operative variables, early and late adverse events, and functional outcomes between the 2 groups. Trials were assessed by means of the modified Newcastle-Ottawa Score. Random-effects meta-analytical techniques were used for analysis.

Data Synthesis  The review included 17 studies comprising 1486 patients (765 without ileostomy and 721 with ileostomy). There were no significant differences in functional outcomes between the 2 groups. The development of pouch-related leak was significantly higher in the no-ileostomy group (odds ratio, 2.37; P = .002). Small-bowel obstruction was more common in the stoma group but was not statistically significant (odds ratio, 0.65). The development of anastomotic stricture favored the no-stoma group (odds ratio, 0.31; P = .045). On sensitivity analysis, pelvic sepsis was significantly less common in patients whose ileostomies were defunctioned; however, this finding was not mirrored by a significant difference in ileal pouch failure in this subgroup.

Conclusions  Restorative proctocolectomy without a diverting ileostomy resulted in functional outcomes similar to those of surgery with proximal diversion but was associated with an increased risk of anastomotic leak. Diverting ileostomy should be omitted in carefully selected patients only.