Design  Retrospective cohort study.

Setting  Urban teaching hospital.

Methods  Data were abstracted from the medical records of all patients with acute cholecystitis admitted to the surgical service via the emergency department during 36 months (October 1, 2002, to September 30, 2005). Patients were divided into 5 groups on the basis of treatment received. Length of stay, duration of symptoms, major complications, and conversion rates were analyzed.

Results  Of 173 patients with acute cholecystitis, 71 (41%) underwent early LC. Of 102 patients treated with antibiotic therapy alone (59%), 57 were discharged; antibiotic therapy was unsuccessful in 45 patients. Of the patients in whom antibiotic therapy was unsuccessful, 26 underwent late LC and 19 underwent percutaneous cholecystostomy. Interval LC was eventually performed in 55 patients who did not undergo surgery during the index admission. Length of stay was significantly shorter in the early LC group compared with the interval LC group (P < .001). Conversion rates were not statistically different for the 3 LC groups (early LC, 5.6%; late LC, 11.5%; and interval LC, 9.1%). The only biliary complication occurred in the interval LC group.

Conclusions  Early laparoscopic cholecystectomy resulted in a significantly reduced length of stay, no major complications, and no significant difference in conversion rates when compared with initial antibiotic treatment and interval LC. Despite these advantages, early LC is not the most common treatment for acute cholecystitis in practice.

Design  Retrospective review of a prospectively collected database.

Setting  An academic tertiary care hepatobiliary unit.

Patients  Twenty patients who underwent surgical treatment for stage IVA HCC between July 1998 and October 2004 were identified from the database.

Intervention  Intraoperative ablation of HCC nodules was combined with resection in 6 patients (30%) to increase resectability. Three patients also underwent resection of extrahepatic tumors. Five patients (25%) had macroscopic invasion of the portal vein and 2 patients (10%) underwent thrombectomy of the vena cava.

Main Outcome Measures  Intraoperative data, recurrence, and long-term survival rates were analyzed.

Results  Postoperative mortality and morbidity were 5% and 30%, respectively. The median number of resected tumors per patient was 3, and the median diameter of the largest tumor was 60 mm. With a median follow-up of 23 months, 14 patients (70%) developed recurrence. Treatment of recurrence was possible in 10 patients and included transarterial chemoembolization in 7 patients (35%), of whom 2 (10%) had radiofrequency ablation first, and systemic chemotherapy in 3 patients (15%). Median survival time was 32 months, and the actuarial 1-, 3-, and 5-year survival rates were 73%, 56%, and 45%, respectively.

Conclusions  Long-term survival can be achieved using an aggressive surgical approach in select patients with advanced HCC. Patients with stage IVA HCC should be followed up by a multidisciplinary team because recurrence is common and sequential treatments may prolong survival.

Objective  To determine whether the use of both endovascular and open repair of rAAA leads to improved results.

Design  A single-center, retrospective analysis of 89 patients suffering from rAAA treated either by EVAR or OGR.

Patients  From October 1999 until July 2006, a consecutive series of patients with rAAA were analyzed. Time was divided into 2 periods of 41 months. During the first period, 42 patients were treated by OGR exclusively. Period 2 started with the availability of an EVAR protocol to treat rAAA; 31 patients received open repair while 16 patients underwent EVAR.

Main Outcome Measures  Kaplan-Meier survival estimates were calculated and compared.

Results  Survival estimates showed a statistically significant reduction in overall postoperative mortality following the introduction of EVAR (P < .03). The 90-day overall mortality rate was reduced from 54.8% to 27.7% during the second period (P < .01). Survival of patients older than 75.5 years was especially improved (75% vs 28.6%; P < .01). There was a parallel pattern of significant reduction of the mortality rate after OGR to 29% (P < .03).

Conclusion  Offering both EVAR and OGR to patients with rAAA leads to significant improvements in postoperative survival.

Design  Retrospective cohort study.

Setting  Two thousand nine hundred sixty-five acute care US hospitals.

Patients  Medicare inpatients (N = 35 904) undergoing major surgery (coronary artery bypass and other open-chest cardiac operations; vascular surgery; general abdominal colorectal surgery; or hip or knee total joint arthroplasty) in 2001.

Main Outcome Measure  Postoperative urinary tract infection.

Results  Eighty-six percent of patients undergoing major operations had perioperative indwelling urinary catheters. Of these, 50% had catheters for longer than 2 days postoperatively. These patients were twice as likely to develop urinary tract infections than patients with catheterization of 2 days or less. In multivariate analyses, a postoperative catheterization longer than 2 days was associated with an increased likelihood of in-hospital urinary tract infection (hazard ratio, 1.21; 95% confidence interval [CI], 1.04-1.41) and 30-day mortality (parameter estimate, 0.54; 95% CI, 0.37-0.72) as well as a decreased likelihood of discharge to home (parameter estimate, – 0.57; 95% CI, – 0.64 to – 1.51).

Conclusions  Indwelling urinary catheters are routinely in place longer than 2 days postoperatively and may result in excess nosocomial infections. The association with adverse outcomes makes postoperative catheter duration a reasonable target of infection control and surgical quality-improvement initiatives.

Design  Prospective clinical trial.

Setting  A tertiary referral center.

Patients  Three hundred sixty-five patients with a multinodular goiter with coexistent dominant nodules.

Main Outcome Measures  The correlation between thyroid gland volume and tumor size and the detection of suspected malignant thyroid nodules by ultrasonography. The incidence of thyroid carcinoma inside and outside the dominant nodules and thyroid gland volume and tumor size in suspected or unsuspected malignant thyroid nodules by ultrasonography were determined. Receiver operating characteristic analysis was used to identify the cutoffs of the tumor size and thyroid gland volume.

Results  One hundred thyroid carcinomas were found in 69 (18.9%) patients. Forty-one of these carcinomas were inside the dominant nodule, whereas 59 were outside the dominant nodule. Only 9 of the 59 thyroid carcinomas outside the dominant nodules were suspected of being malignant by ultrasonography. Thyroid gland volume less than 38 mL and tumor size larger than 7 mm had 48-fold (odds ratio, 48; P < .001) and 21.5-fold (odds ratio, 21.5; P < .001) increased rates, respectively, of detecting suspected malignant thyroid nodules by ultrasonography.

Conclusions  Thyroid gland volume and tumor size were significantly associated with detection of suspected malignant thyroid nodules by ultrasonography. Small thyroid gland volume was associated with detection of suspected malignant thyroid nodules in multinodular goiters.

Design  Case series comparison.

Setting  Forward Resuscitative Surgical System units in Iraq.

Patients  Three hundred thirty-eight casualties treated during the invasion of Iraq in 2003 (Operation Iraqi Freedom I [OIF I]) and 895 casualties treated between March 2004 and February 2005 (OIF II).

Interventions  Definitive and damage control procedures for acute combat casualties.

Main Outcome Measures  Mechanism of injury, procedures performed, time to presentation, and killed in action (KIA) and died of wounds (DOW) rates.

Results  More major injuries occurred per patient (2.4 vs 1.6) during OIF II. There were more casualties with fragment wounds (61% vs 48%; P = .03) and a trend toward fewer gunshot wounds (33% vs 43%; P = .15) during OIF II. More damage control laparotomies (P = .04) and more soft tissue debridements (P < .001) were performed during OIF II. The median time to presentation for critically injured US casualties during OIF I and OIF II were 30 and 59 minutes, respectively. The KIA rate increased from 13.5% to 20.2% and the DOW rate increased from 0.88% to 5.5% for US personnel in the First Marine Expeditionary Force area of responsibility.

Conclusions  The transition from maneuver to insurgency warfare has changed the type and severity of casualties treated by US Marine Corps forward surgical units in Iraq. Improvised explosive devices, severity and number of injuries per casualty, longer transport times, and higher KIA and DOW rates represent major differences between periods. Further data collection is necessary to determine the association between transport times and mortality rates.

Design  Retrospective study.

Setting  Hepatobiliary unit in a tertiary care hospital.

Patients  The clinical records of 35 patients treated for primary intrahepatic lithiasis between January 1, 1992, and December 31, 2005, were reviewed and clinical data, cholangiograms, operative procedures, and early and late results were examined.

Interventions  Thirty-four patients underwent liver resection; left hepatectomy (18 patients) and left lateral segmentectomy (10 patients) were the most frequently performed procedures. A cholangiocarcinoma was found in 3 patients (8.6%): 2 underwent liver resection and 1, who was found unresectable at surgery, underwent only explorative laparotomy.

Main Outcome Measures  Survival, quality of life, laboratory data, and need for further treatments.

Results  There was no postoperative mortality. Morbidity was 20.0% with a prevalence of infectious complications related to bile leakage. Long-term results, assessed in 26 patients with follow-up longer than 12 months (range, 12-170 months; mean, 63 months), were good or fair in 24 patients (92.3%), including 3 patients who needed subsequent endoscopic removal of biliary stones.

Conclusions  Primary intrahepatic lithiasis more commonly involves 1 single liver segment or lobe. Partial hepatectomy is a safe and effective procedure, allowing definitive treatment of the disease and prevention of cancer.

Design  Prospective study.

Setting  University surgical department.

Patients  Between January 1, 2003, and December 31, 2003, 60 patients with locally advanced breast cancer (T2 or T3) admitted for modified radical mastectomy with axillary dissection were included in this study. The entire procedure was performed by the same surgical team using the electrothermal bipolar vessel sealing system.

Main Outcome Measures  Final outcome, operative time, hospitalization stay duration, intraoperative blood loss, postoperative mastectomy and axillary drainage volume and duration, and postoperative complications (seroma, bleeding, skin burn, hematoma, lymphedema, pneumothorax, and wound infection or necrosis).

Results  The mean (SD) intraoperative blood loss was 45 (12) mL, and the mean (SD) operative time was 105 (7) minutes. No postoperative bleeding, seroma, hematoma, lymphedema, or other complications occurred. The mean (SD) mastectomy and axillary drainage volumes were 20 (8) and 155 (35) mL, respectively, and the mean (SD) drainage durations were 1.3 (0.2) and 2.7 (0.5) days, respectively. The mean (SD) hospital stay was 3.7 (0.6) days.

Conclusions  In this first report (to our knowledge) of modified radical mastectomy with axillary dissection using the electrothermal bipolar vessel sealing system, the technique was feasible, safe, and effective. The device simplified the surgical procedure, while achieving efficient lymph vessel sealing and hemostasis. Compared with historical data regarding the conventional or harmonic scalpel, this technique seems to result in reduced operative time, perioperative blood loss, drainage volume and duration, and incidence of seroma or lymphedema. Prospective randomized controlled studies are necessary to evaluate the effect of this technique on perioperative complications.

Design  Retrospective review of patients undergoing IHR between January 1998 and December 2002.

Setting  Sixteen tertiary care Veterans Affairs medical centers.

Patients  A total of 1124 elective incisional hernia repairs identified in the National Surgical Quality Improvement Program data set.

Intervention  Elective IHR.

Main Outcome Measures  Thirty-day postoperative complication rate, return to operating room, length of stay, and operative time.

Results  Of the 1124 elective procedures, 74.1% were primary IHR, 13.3% were recurrent prior mesh IHR, and 12.6% were recurrent prior suture. Overall, 7.3% had an EBR. The incidence of EBR was increased in patients with prior repair: 5.3% for primary repair, 5.7% for recurrent prior suture, and 20.3% for prior mesh repair (P < .001). The occurrence of EBR was associated with increased postoperative complications (31.7% vs 9.5%; P < .001), rate of reoperation within 30 days (14.6% vs 3.6%; P < .001), and development of enterocutaneous fistula (7.3% vs 0.7%; P < .001). After adjusting for procedure type, age, and American Society of Anesthesiologists class, EBR was associated with an increase in median operative time (1.7 to 3.5 hours; P < .001) and mean length of stay (4.0 to 6.0 days; P < .001).

Conclusions  Enterotomy or unplanned bowel resection is more likely to complicate recurrent IHR with prior mesh. The occurrence of EBR is associated with increased postoperative complications, return to the operating room, risk of enterocutaneous fistula, length of hospitalization, and operative time.

Design  Retrospective medical record review.

Setting  Tertiary referral center.

Patients  Patients undergoing laparoscopic resection of gastric GISTs from April 1, 2000, to April 1, 2006.

Main Outcome Measures  Demographic data, diagnostic workup, operative technique, tumor characteristics, morbidity, mortality, and follow-up.

Results  Thirty-three patients underwent attempted laparoscopic resection of gastric GISTs, with 31 operations completed laparoscopically. The mean patient age was 68 years (age range, 35-86 years). The female to male ratio was 18:15. Sixteen patients (49%) were asymptomatic, and their tumors were found incidentally. Of 24 patients (73%) who underwent preoperative endoscopic ultrasonography, the results of fine-needle aspiration verified the diagnosis in 13 patients (54%). The mean operative time was 124 minutes (range, 30-253 minutes). A combined endoscopic-laparoscopic approach was used in 11 patients (33%). The mean tumor size was 3.9 cm (range, 0.5-10.5 cm). Two patients (6%) underwent conversion to an open procedure. The median hospital stay duration was 3 days. The mean follow-up was 13 months (range, 3-64 months). There were no local recurrences. Three patients (9%) experienced complications, including 1 wound infection and 2 episodes of upper gastrointestinal tract bleeding. There were no mortalities.

Conclusion  Although technically demanding, the laparoscopic approach to gastric GISTs is safe and effective, resulting in a short hospital stay duration and low morbidity.

Data Sources  Electronic searches of MEDLINE, Current Contents, and the Cochrane Library were performed for the period of 1990 to June 1, 2005, using relevant search terms. A manual check of all references in accepted studies was also performed.

Study Selection  Only comparative studies (including randomized and nonrandomized control trials) of ultrasonic surgical instrumentation with nonultrasonic instrumentation were accepted. Procedures of interest included the following: colorectal surgery, gynecologic surgery, head and neck surgery, solid organ surgery, vessel harvesting, cholecystectomy, hemorrhoidectomy, mastectomy, and Nissen fundoplication.

Data Extraction  Two investigators reviewed each study: the first investigator extracted all relevant data, and consensus of each extraction was performed by a second investigator to verify the data. Data were then entered into a database and quality checked for accuracy.

Data Synthesis  Fifty-one primary studies that examined 4902 patients were included in this systematic review, of which 24 were randomized trials and 27 were nonrandomized studies. Comparative meta-analyses for blood loss, surgery time, and hospital length of stay were performed using a random-effects model and stratified by surgery type. Heterogeneity was tested using Q statistics. Statistical significance was defined as P < .05.

Conclusion  Meta-analysis of outcomes comparing ultrasonic with conventional nonultrasonic surgical instrumentation demonstrates significant improvement of several perioperative outcomes in procedure-specific settings when ultrasonic instrumentation is used.

Design  A retrospective cohort analysis comparing the rate of DSWI before and after implementing a multidisciplinary TGC initiative.

Setting  A cardiac surgical program in a tertiary care community hospital in New England.

Patients  A total of 3065 consecutive adult patients undergoing cardiac surgery who were operated on between January 1, 2004, and December 31, 2006.

Interventions  Evidence demonstrating the relationship between hyperglycemia and DSWI was presented to the multidisciplinary group caring for patients undergoing cardiac surgery. In addition, special emphasis was placed on nursing feedback and in-service training. A cumbersome glycemic management text protocol was replaced with a novel color-coded bedside tool (nomogram) to guide the bedside management of hyperglycemia. Subsequently, an algorithm for the transition to a home regimen was developed, which further improved standardization of care and ease of management.

Main Outcome Measures  Hourly blood glucose level monitoring and the incidence of DSWI.

Results  Eighteen months after the new program was initiated, the DSWI rate decreased by more than 60% from 2.6% to 1.0%, when compared with the preceding 18 months (P < .001).

Conclusion  A TGC program using a novel tool in a multidisciplinary setting was successfully and safely established, resulting in sustained improvement in the DSWI rate.

Design  Retrospective record review.

Setting  University-affiliated tertiary care center.

Patients  All of the patients were referred after endoscopic treatment failure. Surgery was not immediately considered because of poor surgical risk, refusal to consent, or endoscopist's decision. Patients with coagulopathy, hemobilia, and variceal or traumatic upper gastrointestinal tract bleeding were excluded from review.

Interventions  Between January 1, 1996, and December 31, 2006, 70 embolization procedures were performed in 57 patients.

Main Outcome Measures  Technical success rate (target vessel devascularization), clinical success rate (in-hospital cessation of bleeding without further endoscopic, radiologic, or surgical intervention), and complications.

Results  The technical success rate was 94% (66 of 70 angiographies). The primary clinical success rate was 51% (29 of 57 patients), and the clinical success rate after repeat embolization was 56% (32 of 57 patients). Two factors were found to be independent predictors of poor outcome by multivariate analysis: recent duodenal ulcer suture ligation (P = .03) and blood transfusion of more than 6 units prior to the procedure (P = .04). There was no predictive value for angiographic failure based on age, sex, prior coagulopathy, renal failure at presentation, immunocompromised status, multiple organ system failure, empirical (blind) embolization, and use of permanent vs temporary embolic agents. Repeat embolizations were helpful for postsphincterotomy bleeding. Major ischemic complications (4 patients [7%]) were associated with previous foregut surgery.

Conclusions  Angiographic embolization for gastroduodenal hemorrhage was associated with in-hospital rebleeding in almost half of the patients. Angiographic failure can be predicted if embolization is performed late, following blood transfusion of more than 6 units, or for rehemorrhage from a previously suture-ligated duodenal ulcer.

Design, Setting, and Participants  In animal studies, diabetes was induced in 8 Yucatan miniswine via single alloxan injection at age 8 months, followed by skeletal muscle harvest 15 weeks later. Eight nondiabetic Yucatan miniswine served as controls. In patient studies, skeletal muscle was harvested from 11 nondiabetic patients and 10 patients with type 2 diabetes mellitus undergoing initial elective coronary artery bypass graft surgery. Skeletal muscle samples were analyzed via Western blotting and zymography for protein expression and enzyme activity. The study was performed in an academic medical center.

Main Outcome Measures  Skeletal muscle expression of plasminogen, collagen XVIII, angiostatin, endostatin, matrix metalloproteinases 2 and 9, and tissue inhibitor of metalloproteinase 2.

Results  Skeletal muscle expression of plasminogen and collagen XVIII (precursors of angiostatin and endostatin, respectively) remained similar between nondiabetic and diabetic swine and patients. Expression of angiostatin and endostatin was increased 1.70-fold and 1.84-fold, respectively, in diabetic swine relative to control swine. Endostatin expression was increased 1.69-fold in diabetic patients relative to nondiabetic patients. Matrix metalloproteinase 2 expression and activity were significantly increased in the skeletal muscle of diabetic swine and patients.

Conclusions  Antiangiogenic protein levels are increased in the skeletal muscle in the setting of diabetes. Angiostatin, endostatin, and matrix metalloproteinases may offer novel therapeutic targets to improve collateral formation in patients with diabetes.

Design  Retrospective cohort study.

Setting  Tertiary care academic medical center.

Patients  All patients diagnosed as having a neuroendocrine tumor or carcinoid tumor of the rectum who were evaluated at our institution between January 1, 1990, and December 31, 2006.

Main Outcome Measure  Margin status of tumor resection.

Results  Eighty-five patients were identified (median age at diagnosis, 55 years). Thirty-three tumors (39%) were asymptomatic and diagnosed during screening colonoscopy. Eleven tumors (13%) were metastatic at presentation. Of the 85 tumors, 48 (56%) were smaller than 1.0 cm. Endoscopic therapy was performed in 46 patients (54%). Of these, 38 patients (83%) had tumors with positive or indeterminate margins on histologic examination; of whom 6 (16%) had residual tumor on subsequent endoscopy and 1 (3%) had recurrence as metastatic disease. One patient who had a negative margin had residual tumor on follow-up. Thirty-one patients (36%) underwent surgical resection; of these, 23 (74%) underwent transanal excision or transanal endoscopic microsurgery, 6 (19%) underwent low anterior resection, and 2 (6%) underwent abdominoperineal resection. Eight patients who did not receive local clearance of tumor had metastases on presentation, had another active malignant neoplasm, or refused further surgical treatment. Among the 85 patients, 4 metastases occurred during follow-up, including 2 from tumors smaller than 1.0 cm at presentation.

Conclusions  Endoscopic treatment is sufficient for tumors that are small, for tumors limited to the mucosa, and when a margin is negative for tumor. Transanal excision should be considered when margins of endoscopic resection are positive. We recommend rectal resection for tumors that are 1.0 to 1.9 cm and have high-risk features.

Design  Retrospective case series.

Setting  Tertiary academic center.

Patients  Five hundred eighty-one consecutive patients who underwent pancreaticoduodenectomy from January 2001 through June 2006.

Main Outcome Measures  Development of a pancreatic fistula (defined as > 30 mL of amylase-rich fluid from drains on or after postoperative day 7, or discharge with surgical drains in place, regardless of amount); the need for additional interventions or total parenteral nutrition; other morbidity; and mortality.

Results  Seventy-five patients (12.9%) developed a pancreatic fistula. Fistulas were managed with gradual withdrawal of surgical drains. This allowed for patient discharge and eventual closure at a mean of 18 days in 38.7% of cases; these were classified as low-impact fistulas. The remaining 46 patients (61.3%) had an associated abscess, required percutaneous drainage or total parenteral nutrition, or developed bleeding; these were classified as high-impact fistulas and closed a mean of 35 days after surgery. Standard 30-day in-hospital mortality was 1.9% for all pancreaticoduodenectomies and 6.7% for those who developed a pancreatic fistula. The overall fistula-related mortality was 9.3% (7 patients), all but 1 of which was related to major hemorrhage.

Conclusions  More than one-third of pancreatic fistulas are clinically insignificant (low impact). The remaining 60% of fistulas have a high clinical impact and nearly an 8-fold increase in overall mortality.

Design  A validated survey instrument, the Gastroesophageal Reflux Disease–Health-Related Quality-of-Life Scale (GERD-HRQL) was mailed to all patients who underwent laparoscopic fundoplications (LFs) from 1997 to 2006. Additional information was obtained regarding reintervention, satisfaction, and medication use.

Setting  Tertiary care referral center.

Patients  Four hundred five consecutive patients who underwent primary or redo LF from 1997 to 2006.

Main Outcome Measures  GERD-HRQL score, reoperation rate, and antireflux medication use.

Results  A 54% response rate was obtained. Median follow-up was 60 months (range, 4-75 months). In patients who underwent primary LF, the mean (SD) GERD-HRQL score was 5.71 (7.99) (range, 0-45, with 0 representing no symptoms). Seventy-one percent of patients were satisfied with long-term results. Forty-three percent of patients took antireflux medications at some point following surgery; half of these patients had no diagnostic testing to document GERD recurrence. Only 3 patients (1.2%) required reoperation. Patients undergoing redo LF had higher GERD-HRQL scores (mean [SD], 14.25 [10.33]), lower satisfaction (35%), and greater probability of requiring antireflux medication (78%). Patients with body mass indexes (BMIs) (calculated as weight in kilograms divided by height in meters squared) between 25 and 35 had lower GERD-HRQL scores than thin (BMI < 25) and morbidly obese (BMI ≥ 35) patients.

Conclusions  Contrary to the medical literature, our results demonstrate that patients undergoing primary LF by an experienced surgical team have near-normal GERD-HRQL scores at long-term follow-up and low reoperation rates and are satisfied with their decision to undergo surgery. Results following redo LF are not as good, highlighting the importance of proper patient selection and surgical technique when performing primary LF.

Design  Human aortic smooth muscle cells and endothelial cells were statically seeded on porous biodegradable polymeric scaffolds for vascular tissue engineering. These 2-cell tissue-engineered vascular conduits were implanted into immunodeficient female mice as aortic interposition grafts. Grafts were evaluated over a 30-week course to investigate their patency and structure.

Setting  In vivo animal study.

Patients  Thirteen female C.B-17 SCID/bg mice.

Intervention  The TEACs implanted as infrarenal abdominal aortic interposition grafts.

Main Outcome Measures  Selective microcomputed tomography with intra-arterial contrast revealed graft patency and structure. Histological and immunohistochemical evaluations revealed cellularity and extracellular matrix composition. Species-specific immunohistochemical evaluation determined the source of cells within TEACs.

Results  All TEACs were patent without evidence of thrombosis or rupture over the 30-week course. Histological and immunohistochemical evaluation revealed a von Willebrand factor–positive luminal monolayer surrounded by concentric collagen-rich layers of -smooth muscle actin–positive cells.

Conclusions  The SCID/bg mouse is a useful model for investigating vascular neotissue formation in human TEACs. We see evidence that these grafts remain patent while developing into vascular neotissue histologically similar to native aorta. This chimeric animal model also enables determination of seeded cell retention, providing insight into cellular mechanisms underlying neotissue formation.

Design  Controlled randomized trial.

Setting  University hospital.

Patients  One hundred patients with symptomatic gallstone disease and American Society of Anesthesiologists status I or II were randomized to have laparoscopic cholecystectomy under spinal (n = 50) or general (n = 50) anesthesia.

Methods  Intraoperative parameters, postoperative pain, complications, recovery, and patient satisfaction at follow-up were compared between the 2 groups.

Results  All the procedures were completed by the allocated method of anesthesia, as there were no conversions from spinal to general anesthesia. Pain was significantly less at 4 hours (P < .001), 8 hours (P < .001), 12 hours (P < .001), and 24 hours (P = .02) after the procedure for the spinal anesthesia group compared with those who received general anesthesia. There was no difference between the 2 groups regarding complications, hospital stay, recovery, or degree of satisfaction at follow-up.

Conclusions  Spinal anesthesia is adequate and safe for laparoscopic cholecystectomy in otherwise healthy patients and offers better postoperative pain control than general anesthesia without limiting recovery.

Trial Registration  clinicaltrials.gov Identifier: NCT00492453

Design  Case series.

Setting  This study was conducted in the General Surgery Department, Faculty of Medicine, Zagazig University, Zagazig City, Egypt, from January 2003 to November 2004.

Patients  This study included 57 patients with chronic pilonidal sinus disease with a mean age of 29 years.

Intervention  Limited and good excision of all diseased tissues was achieved, followed by a zigzag incision to produce triangular flaps on both sides of the wound. Multiple crossed triangular flaps were used to close the wound with a drain. The follow-up period ranged from 18 to 36 months (mean, 30 months).

Main Outcome Measures  Length of hospital stay and return to normal activities, early wound complications, and recurrence.

Results  The hospital stay for all patients was 24 hours and the mean time to return to work was 9 days (range, 7-12 days). Three cases (5.3%) had early wound complications and 1 case (1.75%) had recurrence.

Conclusion  The crossed triangular flaps technique for pilonidal disease is simple and easy and has favorable results regarding time to return to work, rate of recurrence, and cosmetically acceptable postoperative appearance.

Design  We used Medicare data from January 2001 to December 2003 to identify men 65 years and older undergoing elective or urgent AAA repair. We calculated the age-adjusted RR of repair in black men vs white men. We then used findings from the Aneurysm Detection and Management Veterans Affairs Cooperative Study to determine the ratio of screen-detected AAA prevalence among black men vs white men. Finally, we calculated prevalence-adjusted RRs of repair.

Setting  Medicare data study.

Participants  Men 65 years and older undergoing elective or urgent AAA repair.

Main Outcome Measure  Prevalence-adjusted RR of AAA repair in black men vs white men.

Results  The annual rate of elective AAA repair in black men was less than one-third that in white men (42.5 vs 147.8 per 100 000; RR, 0.29; 95% confidence interval [CI], 0.27-0.31). The disparity in urgent AAA repair was smaller, with black men undergoing repair at roughly half the rate of white men (26.1 vs 50.5 per 100 000; RR, 0.52; 95% CI, 0.48-0.56). The screen-detected disease prevalence of AAA among black men was less than half that among white men. Adjusting for this difference in prevalence diminished but did not erase the disparity in elective AAA repair (RR, 0.73; 95% CI, 0.68-0.77) and suggested that black men face a higher rate of urgent AAA repair (RR, 1.30; 95% CI, 1.21-1.41).

Conclusions  Black men undergo elective AAA repair at a lower rate than white men even after accounting for their decreased disease burden. However, the prevalence-adjusted rate of urgent repair is higher among black men. Whether the lower frequency of elective procedures is responsible for the higher frequency of urgent procedures warrants further investigation.

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