Design  Matched-pair study in patients with a body mass index (BMI) less than 50.

Setting  University hospital and regional community hospital with a common bariatric surgeon.

Patients  Four hundred forty-two patients were matched according to sex, age, and BMI.

Interventions  Laparoscopic GB or RYGBP.

Main Outcome Measures  Operative morbidity, weight loss, residual BMI, quality of life, food tolerance, lipid profile, and long-term morbidity.

Results  Follow-up was 92.3% at the end of the study period (6 years postoperatively). Early morbidity was higher after RYGBP than after GB (17.2% vs 5.4%; P < .001), but major morbidity was similar. Weight loss was quicker, maximal weight loss was greater, and weight loss remained significantly better after RYGBP until the sixth postoperative year. At 6 years, there were more failures (BMI > 35 or reversal of the procedure/conversion) after GB (48.3% vs 12.3%; P < .001). There were more long-term complications (41.6% vs 19%; P < .001) and more reoperations (26.7% vs 12.7%; P < .001) after GB. Comorbidities improved more after RYGBP.

Conclusions  Roux-en-Y gastric bypass is associated with better weight loss, resulting in a better correction of some comorbidities than GB, at the price of a higher early complication rate. This difference, however, is largely compensated by the much higher long-term complication and reoperation rates seen after GB.

Design  The Nationwide Inpatient Sample (NIS) database from 1998 to 2008.

Participants  Emergent hospitalizations (843 179) with AC as a primary diagnosis.

Interventions  Insurance type was analyzed against cholecystectomy in propensity score–matched cohorts.

Main Outcome Measures  Surgical intervention and surgical outcomes.

Results  Approximately 200 000 patients were in each matched cohort. The median age of the matched patients was 43.9 years, 76% were women, and the mean Charlson Comorbidity Index was 0.5. While 89% of the private insurance cohort underwent cholecystectomy during their hospitalization, only 83% of the Medicaid population received equivalent care (P < .001). The Medicaid cohort also had reduced rates of laparoscopic surgery (78% vs 69%; P < .001) and an increased conversion rate from laparoscopic to open surgery (3.9% vs 3.0%; P < .001). While disparities in the rates of laparoscopic surgery between the 2 groups sequentially narrowed during the 10-year period, overall disparities in surgical treatment remained constant over time.

Conclusions  Medicaid payer status confers inferior access to surgical treatment for AC. While this finding may be due in part to patients' health beliefs and physician preferences, the magnitude of difference suggests that health systems factors may provide a significant contribution toward clinical decision making in this entity.

Objective  To determine the effect of β-blocker continuation on outcomes in patients undergoing elective noncardiac surgery.

Design, Setting, and Patients  The Surgical Care and Outcomes Assessment Program is a Washington quality improvement benchmarking initiative based on clinical data from more than 55 hospitals. Linking Surgical Care and Outcomes Assessment Program data to Washington's hospital admission and vital status registries, we studied patients undergoing elective colorectal and bariatric surgical procedures at 38 hospitals between January 1, 2008, and December 31, 2009.

Main Outcome Measures  Mortality, cardiac events, and the combined adverse event of cardiac events and/or mortality.

Results  Of 8431 patients, 23.5% were taking β-blockers prior to surgery (mean [SD] age, 61.9 [13.7] years; 63.0% were women). Treatment with β-blockers was continued on the day of surgery and during the postoperative period in 66.0% of patients. Continuation of β-blockers both on the day of surgery and postoperatively improved from 57.2% in the first quarter of 2008 to 71.3% in the fourth quarter of 2009 (P value <.001). After adjusting for risk characteristics, failure to continue β-blocker treatment was associated with a nearly 2-fold risk of 90-day combined adverse event (odds ratio, 1.97; 95% CI, 1.19-3.26). The odds were even greater among patients with higher cardiac risk (odds ratio, 5.91; 95% CI, 1.40-25.00). The odds of combined adverse events continued to be elevated 1 year postoperatively (odds ratio, 1.66; 95% CI, 1.08-2.55).

Conclusions  β-Blocker continuation on the day of and after surgery was associated with fewer cardiac events and lower 90-day mortality. A focus on β-blocker continuation is a worthwhile quality improvement target and should improve patient outcomes.

Design  Review of records of patients who participated in the Analysis of Predictive Parameters for Evident Anastomotic Leakage study.

Setting  Eight health centers.

Patients  Two hundred fifty-nine patients who underwent left-sided colorectal anastomoses.

Intervention  Corticosteroids taken as long-term medication for underlying disease or perioperatively for the prevention of postoperative pulmonary complications.

Main Outcome Measures  Prospective evaluations for risk factors for symptomatic AL.

Results  In 23% of patients, a defunctioning stoma was constructed. The incidence of AL was 7.3%. The clinical course of patients with AL showed that in 21% of leaks, the drain indicated leakage; in the remaining patients, computed tomography or laparotomy resulted equally often in the detection of AL. In 50% of patients with AL, a Hartmann operation was needed. The incidence of AL was significantly higher in patients with pulmonary comorbidity (22.6% leakage), patients taking corticosteroids as long-term medication (50% leakage), and patients taking corticosteroids perioperatively (19% leakage). Perioperative corticosteroids were prescribed in 8% of patients for the prevention of postoperative pulmonary complications.

Conclusions  We found a significantly increased incidence of AL in patients treated with long-term corticosteroids and perioperative corticosteroids for pulmonary comorbidity. Therefore, we recommend that in this patient category, anastomoses should be protected by a diverting stoma or a Hartmann procedure should be considered to avoid AL.

Trial Registration  trialregister.nl Identifier: NTR1258

Design  Retrospective study.

Setting  Tertiary care hospital.

Patients  Using a prospective database, all HALS colorectal resections from 2003 to 2009 by 2 surgeons (A and B) were reviewed. Over 6 years, surgeons A and B performed 397 and 322 cases.

Interventions  Change-Point Analysis (CUSUM) was used to define the number of cases required to effect improvement in operative time. Cases before and after the change point were considered as being in the "learning period" and "skilled period."

Main Outcome Measures  Operative time; short-term outcomes.

Results  The change point occurred after 108 and 105 cases for surgeons A and B, respectively. The learning period and skilled period were similar with respect to age, sex, body mass index, prior abdominal surgery, medical comorbidities, and American Society of Anesthesiologists class. Mean overall operative time decreased from 263 to 185 minutes (P < .001). The decrease in mean operative duration for specific resections were as follows: right colectomy, 35 minutes (P = .003); left colectomy, 63 minutes (P = .006); sigmoid colectomy, 63 minutes (P < .001); anterior resection, 70 minutes (P < .001); coloanal anastomosis, 52 minutes (P = .003); subtotal colectomy, 75 minutes (P < .001); and total proctocolectomy with ileal reservoir, 80 minutes (P < .001). Intraoperative complications and conversion rate were similar, but overall morbidity, infectious complications, readmissions, and length of stay were all significantly (P < .05) lower during the skilled period.

Conclusions  For HALS colorectal resection, technical proficiency occurred after approximately 105 cases, and increased surgeon experience resulted in improved short-term outcomes. These data suggest that the learning curve for HALS colorectal resection will extend beyond fellowship training for many colorectal surgeons.

Design  Retrospective review of consecutive patients undergoing thyroidectomy. Patients were divided into 2 groups. Group 1 (the "high-risk/calcium-yes" group) included patients who were found to have (1) postoperative symptoms of hypocalcemia (ie, tingling and numbness), (2) any postoperative serum calcium level of less than 7 mg/dL, or (3) a parathyroid hormone level of less than 3 pg/mL on postoperative day 1. Group 2 (the "low-risk/calcium-no" group) included all other patients. Demographic, operative, biochemical, and pathologic data, as well as postoperative calcium supplementation data, were recorded. Trends in serum calcium level and parathyroid hormone level were analyzed during the immediate postoperative period to identify specific factors unique to group 1.

Patients  A total of 156 patients who underwent a thyroidectomy.

Setting  Tertiary care center.

Results  Of the 156 patients reviewed, 78% were female, 70% had a malignant disease, and the median age at operation was 50 years. Thirty-four patients (22%) were in group 1, and 122 patients (78%) were in group 2. Twenty-nine (19%) patients had a parathyroid hormone level of less than 3 pg/mL within 24 hours after a thyroidectomy. Patients who underwent a central neck dissection (P = .001), had malignant disease (P = .01), or had a documented removal of the parathyroid gland (with or without autotransplantation) at operation (P = .013) were most likely to be classified into group 1. Forty-two percent of patients in group 2 had either a parathyroid hormone level of less than 6 pg/mL or a serum calcium level of less than 8 mg/dL on postoperative day 1, but all patients in group 1 who were symptomatic met these parameters.

Conclusion  Limiting supplementation to patients with a parathyroid hormone level of less than 6 pg/mL or a serum calcium level of less than 8 mg/dL on postoperative day 1 may eliminate unnecessary calcium/vitamin D intake, phlebotomy, and follow-up assessments in up to 58% of patients undergoing thyroidectomy. Validation is required in a prospective setting.

Design, Setting, and Patients  We queried the Veterans Affairs Surgical Quality Improvement Program database for liver resections (2005-2008) and grouped the patients into 5 BMI categories: normal weight (BMI 18.5-24.9), overweight (BMI 25.0-29.9), obese class 1 (BMI 30.0-34.9), obese class 2 (BMI 35.0-39.9), and obese class 3 (BMI ≥40.0). Differences in risk factors and perioperative complications across groups were analyzed in univariate and multivariate analyses.

Results  Of 403 patients who underwent hepatectomy, 106 (26%) were normal weight, 161 (40%) were overweight, 94 (23%) were obese class 1, 31 (8%) were obese class 2, and 11 (3%) were obese class 3. Among these groups, higher BMI was associated with increased rates of hypertension (52%, 61%, 77%, 77%, and 73%, respectively; P = .002) and diabetes (18%, 27%, 36%, 39%, and 45%, respectively; P = .04) and lower incidence of smokers (53%, 35%, 30%, 16%, and 9%, respectively; P < .001). The BMI groups were similar in demographic characteristics and metrics correlating with preexisting liver disease. There were no differences across BMI groups in overall and specific morbidity or in length of stay. Compared with the other groups, obese class 3 patients received more blood transfusions (mean [SD], 4.3 [2.7] in obese class 3 patients vs 1.1 [0.2] in normal-weight patients; P = .02) and had a higher 30-day mortality (27% in obese class 3 patients vs 6% in normal-weight patients; P = .05). Multivariate analyses confirmed obese class 3 as an independent predictor of postoperative mortality.

Conclusions  Obesity did not increase postoperative complications after liver resection in veterans. After adjusting for other clinical factors, extreme obesity (BMI ≥40.0) was an independent risk factor for increased mortality.

Design  Cross-sectional study.

Setting  Data from the Pennsylvania Trauma Outcome Study.

Patients  We studied data from 210 942 patients admitted to 35 trauma centers in Pennsylvania between 2000 and 2009.

Main Outcome Measures  Regression analyses were performed to examine the association between ACSCOT quality indicators and in-hospital mortality and death or major complications.

Results  Seven of the ACSCOT quality indicators were associated with either increased (1) in-hospital mortality or (2) death or major complications. No head computed tomography scan in patients with a Glasgow Coma Scale score less than 13 was associated with a 4-fold increase in mortality (adjusted odds ratio [AOR], 4.39; 95% confidence interval [CI], 3.18-6.07) and a nearly 3-fold increased risk of death or major complications (AOR, 2.76; 95% CI 2.05-3.72). Gunshot wounds to the abdomen managed nonoperatively were associated with a nearly 5-fold increase in mortality (AOR, 4.80; 95% CI, 2.95-7.81). Femoral fractures treated with nonfixation were also strongly associated with mortality (AOR, 4.08; 95% CI, 2.50-6.66) and death or major complications (AOR, 2.54; 95% CI, 1.96-3.31).

Conclusion  Several current ACSCOT quality indicators have a strong association with clinical outcomes. These findings should be interpreted with caution because some measures may lack face validity for identifying poor-quality care in complex patients with multiple injuries.

Design  Retrospective database analysis.

Setting  The National Inpatient Sample database.

Patients  Patients who underwent a colorectal resection during the period from 2006 to 2008 in the United States.

Main Outcome Measures  Patient characteristics, patient comorbidities, type of pathology, type of resection, surgical technique used, type of admission, and teaching hospital status were evaluated for splenic injury during colorectal surgery.

Results  A total of 975 825 patients underwent colorectal resection during this period. Overall, the rate of splenic injury was 0.96%, of which 84.75% were treated with complete splenectomy (splenorrhaphy, 13.55%; partial splenectomy, 1.70%). The most common procedure associated with splenic injury was transverse colectomy (3.40%). Using multivariate regression analysis, we found that transverse colectomy (adjusted odds ratio [AOR], 5.30), left colectomy (AOR, 5.08), total colectomy (AOR, 2.85), open operation (AOR, 2.68), malignant tumor (AOR, 2.11), diverticulitis (AOR, 1.93), teaching hospital (AOR, 1.73), male sex (AOR 1.20), peripheral vascular disease (AOR, 1.14), and emergent admission (AOR, 1.06) were associated with a higher risk of splenic injury. There was no association between age, race, hypertension, diabetes, chronic lung disease, congestive heart failure, renal failure, liver disease, obesity, sigmoidectomy, proctectomy, ulcerative colitis, or Crohn disease and splenic injury.

Conclusions  Type of resection (transverse, total, or left colectomy), type of pathology (malignancy or diverticulitis), open operation, and teaching hospital are potent independent predictors of splenic injury. Male sex, peripheral vascular disease, and emergent admission are less effective predictors. Surgeons should be aware of these risk factors and inform patients accordingly. In higher-risk circumstances, it may be appropriate to consider prophylactic vaccination.

Design, Setting, and Participants  A 56-item survey was administered to a convenience sample (n = 108) of resident and attending physicians at surgery, emergency medicine, and anesthesiology departmental conferences at a large tertiary care academic hospital.

Main Outcome Measures  Likelihood of seeking support, perceived barriers, awareness of available services, sources of support, and experience with stress.

Results  Among the resident and attending physicians, 79% experienced either a serious adverse patient event and/or a traumatic personal event within the preceding year. Willingness to seek support was reported for legal situations (72%), involvement in medical errors (67%), adverse patient events (63%), substance abuse (67%), physical illness (62%), mental illness (50%), and interpersonal conflict at work (50%). Barriers included lack of time (89%), uncertainty or difficulty with access (69%), concerns about lack of confidentiality (68%), negative impact on career (68%), and stigma (62%). Physician colleagues were the most popular potential sources of support (88%), outnumbering traditional mechanisms such as the employee assistance program (29%) and mental health professionals (48%). Based on these results, a one-on-one peer physician support program was incorporated into support services at our hospital.

Conclusions  Despite the prevalence of stressful experiences and the desire for support among physicians, established services are underused. As colleagues are the most acceptable sources of support, we advocate peer support as the most effective way to address this sensitive but important issue.

Design  Retrospective analysis of Hospital Episode Statistics, which is a prospectively maintained national database.

Setting  All patients undergoing colorectal resection in National Health Service trusts in England.

Patients  Adult patients undergoing elective or planned surgery between April 2001 and March 2008.

Intervention  Colorectal resection for benign and malignant diagnoses.

Main Outcome Measures  Mortality and morbidity at 30 days and 1 year following elective colorectal resection.

Results  One hundred thirty-eight thousand seven hundred thirty-five elective colorectal resections were identified between the study dates. Thirty-day in-hospital mortality was 3.4% and 1.7% following conventional and laparoscopic surgery, respectively (P < .001). Overall, the 30-day postoperative medical morbidity rate was 14.6%. Use of the minimal access approach demonstrated a significant reduction in total morbidity risk at 30 days (odds ratio, 0.79; P < .001) and 365 days (odds ratio, 0.81; P < .001) following case-mix adjustment. Multiple regression analyses demonstrated that cardiorespiratory complications and venous thromboembolism occurred less frequently during the index admission and up to 1 year following minimal access surgery when compared with the conventional approach (P < .049).

Conclusions  In this population-based study, patients selected for laparoscopic colorectal resection were associated with lower risk of mortality as well as reduced cardiorespiratory and venous thromboembolic risk than those undergoing open surgery.

Design  Multivariable logistic regression analysis was used to assess the statistical significance of the relationship between BMI and mortality, with adjustments for patient-level differences in overall mortality risk and principal operating procedures. Odds ratios with 95% CIs were calculated to measure the relative difference in mortality by BMI quintile, with reference to the middle quintile of the BMI. The overall significance of the BMI and of the other covariates was measured using the Wald ² test statistic. A separate multivariable logistic regression model was developed to assess the significance of the interaction between BMI and primary procedure.

Setting  A total of 183 sites.

Patients  Patients with major surgical procedures reported in the participant use data file database of the American College of Surgeons National Surgical Quality Improvement Program.

Results  The data included 189 533 cases of general and vascular surgical procedures reported in 2005 and 2006 for patients with known overall probabilities of death. Among these, 3245 patients died within 30 days of their surgery (1.7%). Patients with a BMI of less than 23.1 demonstrated a significant increased risk of death, with 40% higher odds compared with patients in the middle range for BMI (26.3 to <29.7). Important differences in the association between BMI and mortality risk occur by type of primary procedure.

Conclusions  Body mass index is a significant predictor of mortality within 30 days of surgery, even after adjusting for the contribution to mortality risk made by type of surgery and for a specific patient's overall expected risk of death.

Design  Randomized controlled trial.

Setting  Academic tertiary referral center.

Patients  Morbidly obese patients scheduled to undergo laparoscopic bariatric procedures.

Interventions  Patients were randomly assigned to receive intraoperatively high (10 mL/kg/h, n = 55) or low (4 mL/kg/h, n = 52) amounts of Ringer lactate solution.

Main Outcome Measures  The primary end point was urine output. Secondary end points were postoperative creatinine serum concentration and complication rate.

Results  Significantly more fluids were administered intraoperatively to patients in the high-volume group compared with the low-volume group (P < .001). Regardless of the amount of fluids administered intraoperatively, low urine outputs (median [range], 100 [15-1050] mL in the high-volume group vs 107 [25-500] mL in the low-volume group; P = .34) were documented and were not significantly different. The mean creatinine serum concentration was within normal range at all times and was not significantly different between the groups (P = .68). The number of patients with complications was nonsignificantly lower in the low-volume group compared with the high-volume group (7 vs 10 patients, respectively; P = .60).

Conclusions  In patients undergoing laparoscopic bariatric surgery, intraoperative urine output is low regardless of the use of relatively high-volume fluid therapy. The results suggest that we should reconsider the common practice to administer intraoperative fluids in response to low urine output. Further studies are required to evaluate these data in other surgical patient populations.

Trial Registration  clinicaltrials.gov Identifier: NCT00753402

Design  Retrospective cohort study.

Setting  Two hundred eleven hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program.

Patients  All 271 368 patients from the National Surgical Quality Improvement Program 2008 Participant Use Data File were examined, and 2249 patients with IBD were compared with 269 119 patients without IBD.

Main Outcome Measures  Occurrence of DVT, PE, myocardial infarction, or stroke within 30 days of surgery.

Results  Of 268 703 National Surgical Quality Improvement Program patients, 2249 (0.8%) had IBD. There were 2665 cases of DVT or PE (1.0%). Occurrence of DVT or PE was more common in patients with IBD (2.5%) overall (P < .001). Nonintestinal surgical cases had a higher rate of DVT or PE (5.0%; P = .002). Regression analysis, controlling for confounders, confirmed that IBD was associated with increased risk for DVT or PE (odds ratio = 2.03; 95% CI, 1.52-2.70). For nonintestinal surgery, risk of DVT or PE for patients with IBD was increased (odds ratio = 4.45; 95% CI, 1.72-11.49). Inflammatory bowel disease had no effect on risk of postoperative myocardial infarction or stroke.

Conclusions  Patients with IBD are at increased risk for developing postoperative DVT or PE. This risk persists when potential confounding variables are controlled for. Risk of DVT or PE appears to be even higher for patients with IBD who are having nonintestinal surgery. Cardiac and stroke risks do not appear to be increased by IBD. Perhaps standards for DVT and PE prophylaxis in these cases should be reconsidered.

Design  Cross-sectional nationwide sample.

Setting  Nationwide Inpatient Sample from 2002 to 2007.

Patients  Adult patients (≥18 years) hospitalized with a primary or secondary procedure of gastric, hepatic, or pancreatic resection between 2002 and 2007.

Main Outcome Measures  Predicting in-hospital mortality using the 4 comorbidity algorithms. Logistic regression analyses were used and C statistics were calculated to assess the performance of the indexes. Risk adjustment methods were then compared.

Results  In our study, we identified 46 395 gastric resections, 18 234 hepatic resections, and 15 443 pancreatic resections. Predicted in-hospital mortality rates according to the adjustment methods agreed for 43.8% to 74.6% of patients. In all types of resections, the APR-DRGs and Disease Staging algorithms predicted in-hospital mortality better than the Charlson/Deyo and Elixhauser indexes (P < .001). Compared with the Charlson/Deyo algorithm, the Elixhauser index was of higher accuracy in gastric resections (0.847 vs 0.792), hepatic resections (0.810 vs 0.757), and pancreatic resections (0.811 vs 0.741) (P < .001 for all comparisons). Higher accuracy of the Elixhauser algorithm compared with the Charlson/Deyo algorithm was not affected by diagnosis rank, multiple surgeries, or exclusion of transplant patients.

Conclusions  Different comorbidity algorithms were validated in the surgical setting. The Disease Staging and APR-DRGs algorithms were highly accurate. For commonly used algorithms such as Charlson/Deyo and Elixhauser, the latter showed higher accuracy.

Design  Retrospective review.

Setting  A tertiary medical center.

Patients  We enrolled 1074 consecutive patients with HCC who were undergoing a partial hepatectomy. Patients who were 55 years of age or younger were defined as the younger group (n = 374), and patients who were older than 55 years of age were defined as the older group (n = 700).

Main Outcome Measures  The postoperative prognoses of the younger and older groups using multivariate analysis and propensity score matching analysis.

Results  The younger patients had better liver functional reserve but more aggressive tumor factors than did the older patients. After a median follow-up of 41.0 months, 543 patients died. The cumulative 10-year survival rates were 41.3% in younger patients and 28.8% in the older patients (P = .02). However, using both multivariate analysis and propensity score matching analysis, we failed to demonstrate that age was an independent risk factor associated with overall survival. Besides, there were 643 patients with tumor recurrence after surgery. Using both multivariate analysis and propensity score matching analysis, we found that the incidence of tumor recurrence in younger patients was comparable to that in the older patients.

Conclusions  Age is not a risk factor to determine the prognosis of patients with HCC who underwent resection. Older patients with HCC who have good liver functional reserve are encouraged to receive resection surgery.

Design  Retrospective observational study comparing TXA administration with no TXA in patients receiving at least 1 unit of packed red blood cells. A subgroup of patients receiving massive transfusion (≥10 units of packed red blood cells) was also examined. Univariate and multivariate regression analyses were used to identify parameters associated with survival. Kaplan-Meier life tables were used to report survival.

Setting  A Role 3 Echelon surgical hospital in southern Afghanistan.

Patients  A total of 896 consecutive admissions with combat injury, of which 293 received TXA, were identified from prospectively collected UK and US trauma registries.

Main Outcome Measures  Mortality at 24 hours, 48 hours, and 30 days as well as the influence of TXA administration on postoperative coagulopathy and the rate of thromboembolic complications.

Results  The TXA group had lower unadjusted mortality than the no-TXA group (17.4% vs 23.9%, respectively; P = .03) despite being more severely injured (mean [SD] Injury Severity Score, 25.2 [16.6] vs 22.5 [18.5], respectively; P < .001). This benefit was greatest in the group of patients who received massive transfusion (14.4% vs 28.1%, respectively; P = .004), where TXA was also independently associated with survival (odds ratio = 7.228; 95% CI, 3.016-17.322) and less coagulopathy (P = .003).

Conclusions  The use of TXA with blood component–based resuscitation following combat injury results in improved measures of coagulopathy and survival, a benefit that is most prominent in patients requiring massive transfusion. Treatment with TXA should be implemented into clinical practice as part of a resuscitation strategy following severe wartime injury and hemorrhage.

Design  Observational analysis of hospital discharge information.

Setting  The Healthcare Cost and Utilization Project database.

Participants  Appendicitis perforation rates determined from the Healthcare Cost and Utilization Project database of hospital discharges from 2001 to 2008.

Main Outcome Measures  The proportion of the gap between perforation rates explained by various patient- and hospital-level variables.

Results  There were no disparities observed in adult appendicitis perforation rates. The perforation rate for white children was 26.7%; black children, 35.5%; and Latino children, 36.5%. Gap analysis showed that only 12.0% of the difference in perforation rates between black and white children was explained by insurance status and only 12.7% of the difference between Latino and white children was explained. Income level only accounted for 7.2% of the gap for black children and 6.1% for Latino children. Age explained one-third of the gap for Latino children and one-third was not accounted for by measurable variables. Two-thirds of the difference between appendicitis perforation rates between black and white children was not explained by measurable factors.

Conclusions  A very small amount of the gap between minority and white children's appendicitis rates is explained by the proxy factors for health insurance and poverty status that might relate to health care access. Appendicitis perforation rates are not an appropriate indicator of health care access.

Design  Pilot study.

Setting  University hospital.

Patients  Thirty-six consecutive patients with CRC.

CD133 and CD44 expression (alone or combined) was determined in nontumor cells and in tumor cells by flow cytometry, which identified viable cells only.

Main Outcome Measures  Correlation of CD133 and CD44 expression with each other, with other prognostic indicators, and with disease-free survival.

Results  CD133 and CD44 expression was significantly higher in tumor cells than in nontumor cells, and expression of one did not necessarily correlate with expression of the other. CD133 or CD44 expression alone was variable, while combined CD133/CD44 expression identified a small subset of cells positive for CRC. CD133 or CD44 overexpression was not associated with CRC recurrence; only high frequencies of CD133⁺/CD44⁺ cells were a strong indicator of worse disease-free survival and an independent risk factor for CRC recurrence.

Conclusion  Evaluation of combined CD133/CD44 expression could be useful to identify putative colorectal CSCs and tumors with a poor prognosis.

Design  Retrospective multicenter study including 17 Italian hepatobiliary surgery units.

Patients  A total of 440 patients who underwent resection for hilar cholangiocarcinoma from January 1, 1992, through December 31, 2007.

Main Outcome Measures  Postoperative mortality, morbidity, overall survival, and disease-free survival.

Results  Postoperative mortality and morbidity after liver resection were 10.1% and 47.6%, respectively. At multivariate logistic regression, extent of resection (right or right extended hepatectomy) and intraoperative blood transfusion were independent predictors of postoperative mortality (P = .03 and P = .006, respectively); in patients with jaundice, mortality was also higher without preoperative biliary drainage than with biliary drainage (14.3% vs 10.7%). During the study period, there was an increasingly aggressive approach, with more frequent caudate lobectomies, vascular resections, and resections for advanced tumors (T stage of 3 or greater and tumors with poor differentiation). Despite the aggressive approach, the blood transfusion rate decreased from 81.0% to 53.2%, and mortality slightly decreased from 13.6% to 10.8%. Median overall survival significantly increased from 16 to 30 months (P = .05). At multivariate analysis, R1 resection, lymph node metastases, and T stage of 3 or greater independently predicted overall and disease-free survival.

Conclusions  Surgery for hilar cholangiocarcinoma has improved with decreased operative risk despite a more aggressive surgical policy. Long-term survival after liver resection has also increased, despite the inclusion of cases with more advanced hilar cholangiocarcinoma. Preoperative biliary drainage was a safe strategy before right or right extended hepatectomy in patients with jaundice. Pathologic factors independently predicted overall and disease-free survival at multivariate analysis.

Design  Retrospective study.

Setting  Mayo Clinic.

Patients  Between January 1, 1999, and September 30, 2010, 553 patients underwent pancreaticoduodenectomy by a single surgeon.

Main Outcome Measures  Rates of POPF, morbidity, and mortality between stent and no-stent groups.

Results  The clinically relevant POPF (International Study Group on Pancreatic Fistula definition grade B or C) rates in the stent and no-stent groups were similar (9.6% [43 of 449 patients] and 12.5% [13 of 104 patients], respectively; P = .38). Postoperative outcomes and morbidity were also similar between the 2 groups. Mortality was 0.7% (3 of 449 patients) for the stent group and 1.0% (1 of 104 patients) for the no-stent group. Four patients (0.9%) required endoscopic retrieval of the anastomotic stent. In subset analysis, the clinically relevant POPF rates in patients with a small pancreatic duct (≤3 mm; n = 167) were similar in the stent and no-stent groups (17.7% [23 of 130 patients] and 24.3% [9 of 37 patients], respectively; P = .38). In patients with a soft pancreatic gland (n = 64), rates of clinically relevant pancreatic fistulae were also similar in the stent and no-stent groups (31.7% [13 of 41 patients] and 17.4% [4 of 23 patients], respectively; P = .20).

Conclusions  Internal transanastomotic pancreatic duct stenting does not decrease the frequency or severity of POPF. The effect of stenting on long-term anastomotic patency warrants further investigation.

Design  Retrospective single-center study.

Setting  Tertiary university hospital.

Patients  One hundred twenty-eight patients undergoing 133 laparoscopic liver resections for malignant diseases.

Main Outcome Measures  Perioperative results and midterm overall and disease-free survival.

Results  Surgical indications were colorectal carcinoma liver metastasis (n = 83), hepatocellular carcinoma (n = 18), neuroendocrine tumor metastasis (n = 17), non–colorectal carcinoma liver metastasis (n = 11), lymphoma (n = 2), and intrahepatic cholangiocarcinoma (n = 2). Two patients had 2-stage laparoscopic resections for bilobar colorectal carcinoma liver metastasis. Three patients had repeated liver resection for recurrent colorectal carcinoma liver metastasis. Forty-two major hepatectomies (32%) were performed. The median operative time was 210 minutes (range, 30-480 minutes). The median postoperative length of stay was 4 days (range, 1-15 days). Seven patients required conversion to formal open surgery and 4 patients required conversion to a laparoscopic-assisted procedure. Sixteen patients (13%) developed significant postoperative complications. One patient (0.8%) died in the hospital. In the 17 patients with neuroendocrine tumor metastasis, 6 (35%) had microscopic positive resection margins. Most of these patients underwent debulking and cytoreductive surgery. A microscopic negative resection margin was obtained in the remaining 112 of 116 resections (97%). We recorded 2-year overall survivals of 80%, 77%, and 91% in the groups with colorectal carcinoma liver metastasis, hepatocellular carcinoma, and neuroendocrine tumor metastasis, respectively.

Conclusions  Our data support the safety and oncological efficiency of laparoscopic resection for liver malignant neoplasms. Adequate patient selection and extensive experience in hepatic and laparoscopic surgery are essential prerequisites to optimize outcomes.

Design  Longitudinal, uncontrolled observational study evaluating results of intraoperative transfusion in patients entered into the American College of Surgeons National Surgical Quality Improvement Program database. We made propensity-matched comparisons between patients who received and did not receive intraoperative transfusion to minimize confounding when estimating the effect of intraoperative transfusion on postoperative outcomes.

Setting  We queried the American College of Surgeons National Surgical Quality Improvement Program database for patients undergoing operations between January 1, 2005, and December 31, 2009.

Patients  A large sample of surgical patients from 173 hospitals throughout the United States.

Main Outcome Measures  Operative mortality and serious perioperative morbidity (≥1 of 20 complications).

Results  After exclusions, 941 496 operations were analyzed in patients from 173 hospitals. Most patients (893 205 patients [94.9%]) did not receive intraoperative transfusions. Patients who received intraoperative infusion of 1 unit of packed red blood cells (15 186 patients [1.6%]) had higher unadjusted rates of mortality and more serious morbidity. These rates further increased with intraoperative transfusion of more than 1 unit of packed red blood cells in a dose-dependent manner. After propensity matching to adjust for multiple preoperative risks, transfusion of a single unit of packed red blood cells increased the multivariate risk of mortality, wound problems, pulmonary complications, postoperative renal dysfunction, systemic sepsis, composite morbidity, and postoperative length of stay compared with propensity-matched patients who did not receive intraoperative transfusion.

Conclusions  There is a dose-dependent adverse effect of intraoperative blood transfusion. It is likely that a small, possibly discretionary amount of intraoperative transfusion leads to increased mortality, morbidity, and resource use, suggesting that caution should be used with intraoperative transfusions for mildly hypovolemic or anemic patients.

Design  Anonymous questionnaire designed to capture demographics, overall opinions of teaching programs, and willingness to consent to various scenarios of trainee participation. Descriptive and univariate analyses were performed.

Setting  Tertiary-level referral center.

Patients  Three hundred sixteen individuals scheduled for elective surgery.

Main Outcome Measures  Consent rates for various scenarios.

Results  Of the 316 patients who completed the questionnaire, most expressed overall support of resident training: 91.2% opined that their care would be equivalent to or better than that of a private hospital, 68.3% believed they derived benefit from participation, and most consented to having an intern (85.0%) or a resident (94.0%) participate in their surgical procedure. However, when given specific, realistic scenarios involving trainee participation, major variations in the consent rate were observed. Affirmative consent rates decreased from 94.0% to 18.2% as the level of resident participation increased. Patients also were more willing to consent to the participation of a senior resident (83.1%) vs a junior resident (57.6%) or an intern (54.5%). Patients overwhelmingly opined that they should be informed of the level of resident participation and that this information could change their decision of whether to consent.

Conclusions  Most patients expressed approval of teaching facilities and resident education. However, consent rates were significantly altered when more detailed information was provided and they declined with increasing levels of resident participation. Providing detailed informed consent is preferred by patients but it could adversely affect resident participation and training.

Design  Hospitals were categorized on the basis of the percentage of minority patients admitted with trauma. The adjusted odds of in-hospital mortality were compared between hospitals with less than 25% of patients who were minorities (the reference group) and hospitals with 25% to 50% of patients who were minorities and hospitals with more than 50% of patients who were minorities. Multivariate logistic regression (with generalized linear modeling and a cluster-correlated robust estimate of variance) was used to control for multiple patient and injury severity characteristics.

Setting  A total of 434 hospitals in the National Trauma Data Bank.

Participants  Patients aged 18 to 64 years whose medical records were included in the National Trauma Data Bank for the years 2007 and 2008 with an Injury Severity Score of 9 or greater and who were white, black, or Hispanic.

Main Outcome Measures  Crude mortality and adjusted odds of in-hospital mortality.

Results  A total of 311 568 patients were examined. Hospitals in which the percentage of minority patients was more than 50% also had younger patients, fewer female patients, more patients with penetrating trauma, and the highest crude mortality. After adjustment for potential confounders, patients treated at hospitals in which the percentage of minority patients was 25% to 50% and at hospitals in which the percentage of minority patients was more than 50% demonstrated increased odds of death (adjusted odds ratio, 1.16 [95% confidence interval, 1.01-1.34] and adjusted odds ratio, 1.37 [95% confidence interval, 1.16-1.61], respectively), compared with the reference group. This disparity increased further on subset analysis of patients with a blunt injury. Uninsured patients had significantly increased odds of mortality within all 3 hospital groups.

Conclusions  Patients treated at hospitals with higher proportions of minority trauma patients have increased odds of dying, even after adjusting for potential confounders. Differences in outcomes between trauma hospitals may partly explain racial disparities.

Design  A prospective study over a 10-month period.

Setting  A 636-bed community teaching hospital.

Patients  A total of 57 consecutive patients and 60 operative procedures for breast cancer.

Main Outcome Measures  A total of 60 consecutive breast cancer narrative operative reports, dictated by the attending surgeon, were compared with synoptic computerized operative reports filled by an operating resident. It included a total of 36 items containing data on demographics, preoperative history, diagnostic evaluation, and precise intraoperative findings. The 2 types of reports were compared for overall completeness and for the completeness of individual items.

Results  Comparison of the narrative and synoptic reports showed that there was significant improvement in data completeness with the use of the synoptic report. The overall analysis showed that the synoptic operating report contained 94.7% of the preoperative and operative data, whereas the dictated operative report was able to capture only 66% of the data (P < .001). Eleven of 15 items in the general and preoperative sections of the dictated report and 6 of 21 items in the intraoperative section of the dictated report were underreported compared with those same items in the synoptic report (P = .004-.001).

Conclusion  The computerized synoptic operative report is superior to the dictated report in the documentation of important preoperative and intraoperative data. Although checklists and templates are not new in medicine, the use of a synoptic operative report as a surgical educational tool is a novel concept. Each resident who participated in our study had to develop a better understanding of the operative procedure in order to complete a more accurate synoptic report.

Design  Retrospective analysis of the Nationwide Inpatient Sample (NIS) database over 10 years.

Patients  Patients admitted for trauma (primary International Classification of Diseases, Ninth Revision [ICD-9 ] diagnosis codes 800-959) who had a vagotomy (ICD-9 procedure codes 44.00, 44.01, and 44.03) were included. A second cohort of injured patients without vagotomy was extracted and matched 3 to 1 on the following criteria: age, race, sex, concurrent splenectomy, survival risk ratio, payer status, comorbidities, and calendar year.

Main Outcome Measures  The primary outcome measured was in-hospital mortality. Secondary outcomes included septicemia, systemic inflammatory response syndrome, acute respiratory distress syndrome, ulcer disease, length of stay, and total charges.

Results  A total of 56 and 115 patients were included in the vagotomy and control groups, respectively, and were similar in demographic characteristics, comorbidities, and injury severity. We found that the vagotomy group had elevated mortality (27.27% vs 9.57% for controls; P = .003). Patients who received vagotomy also had more septicemia (26.79% vs 3.48%; P < .001) and ulcer disease (71.43% vs 2.61%; P < .001) but not systemic inflammatory response syndrome or acute respiratory distress syndrome. Patients who received vagotomy also had an increased length of hospital stay (36.4 vs 9.6 mean days; P < .001) and total cost ($211 899.90 vs $59 321.64; P < .001).

Conclusions  Vagotomy after traumatic injury is associated with an increase in ulcer disease, septicemia, and mortality. This may reflect a loss of control over the systemic response to injury and warrants further study.

Data Sources  We searched PubMed for relevant studies published from January 1, 1989, through August 1, 2011. In addition, we identified and reviewed 4 cases at our institution.

Study Selection  Search phrases were perforated duodenal diverticulum and duodenal diverticulitis.

Data Extraction  Patient demographics, clinical characteristics, radiologic findings, treatment, and outcomes were obtained.

Results  We reviewed 39 studies producing 57 cases, which were combined with the 4 at our institution for a total of 61 patients. The addition of 2 previous series revealed a total of 162 patients in the world literature. Perforations were most commonly located in the second or third portion of the duodenum (60 of 61 cases [98%]), and the most frequent cause was diverticulitis (42 of 61 [69%]). There has been a dramatic improvement in the preoperative diagnosis of perforated diverticula. Only 13 of 101 reported cases (13%) were correctly diagnosed before 1989, and 29 of 61 (48%) in the present series were identified with radiologic examinations. Most patients in the current series (47 of 61) underwent operative treatment for their perforation, although 14 underwent successful nonoperative management. Complications were reported in 17 of 47 patients in the surgical group (36%), whereas only 1 complication was seen in patients undergoing nonoperative management. Mortality in the surgical group was 6% (3 of 47), and no deaths were reported in the nonoperative group.

Conclusions  Perforation of a duodenal diverticulum is rare, with only 162 cases reported in the world literature. Nonoperative management has emerged as a safe, practical alternative to surgery in selected patents.