Design  Retrospective medical record review. Outcomes for nonoperative vs operative management were analyzed using Fisher exact and log-rank tests.

Setting  Tertiary care referral center.

Patients  One thousand five hundred sixty-eight consecutive patients admitted from the emergency department with a diagnosis of small bowel obstruction between 2000 and 2005 by CT criteria.

Main Outcome Measures  Recurrence of symptoms and complications.

Results  One hundred forty-five patients (9%) with HGSBO were identified, with 88% follow-up (median, 332 days; range, 4-2067 days). Sixty-six (46%) were successfully managed nonoperatively while 79 (54%) required an operation. Length of stay and complications were significantly increased in the operative group (4.7 days vs 10.8 days and 3% vs 23%; P < .001). Nonoperative management was associated with a higher recurrence rate (24% vs 9%; P < .005) and shorter time to recurrence (39 days vs 105 days; P < .005) compared with operative intervention. Computed tomography signs of ischemia, admission laboratory results, and presence of cancer or inflammatory bowel disease were not predictive of an operation.

Conclusions  Patients with HGSBO by CT can be managed safely with nonoperative therapy; however, they have a significantly higher rate of recurrence requiring readmission or operation within 5 years.

Design  Data were collected from the National Trauma Data Bank from January 1, 2002, through December 31, 2006 (version 7.0). We used multiple logistic regression to compare mortality rates by insurance status.

Setting  The National Trauma Data Bank contains information from 2.7 million patients admitted for traumatic injury to more than 900 US trauma centers, including demographic data, medical history, injury severity, outcomes, and charges.

Patients  Data from patients (age, ≥18 years; n = 687 091) with similar age, race, injury severity, sex, and injury mechanism were evaluated for differences in mortality by payer status.

Main Outcome Measure  In-hospital death after blunt or penetrating traumatic injury.

Results  Crude analysis revealed a higher mortality for uninsured patients (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.36-1.42; P < .001). Controlling for sex, race, age, Injury Severity Score, Revised Trauma Score, and injury mechanism (adjusted for clustering on hospital), uninsured patients had the highest mortality (OR, 1.80; 95% CI, 1.61-2.02; P < .001). Subgroup analysis of young patients unlikely to have comorbidities revealed higher mortality for uninsured patients (OR, 1.89; 95% CI, 1.66-2.15; P < .001), as did subgroup analyses of patients with head injuries (OR, 1.65; 95% CI, 1.42-1.90; P < .001) and patients with 1 or more comorbidities (OR, 1.52; 95% CI, 1.30-1.78; P < .001).

Conclusions  Uninsured Americans have a higher adjusted mortality rate after trauma. Treatment delay, different care (via receipt of fewer diagnostic tests), and decreased health literacy are possible mechanisms.

Design  Retrospective cohort study.

Setting  One hundred twenty-one hospitals participating in American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).

Patients  Using the ACS-NSQIP participant use file (2005-2006), patients undergoing upper gastrointestinal tract (n = 4115), hepatobiliary or pancreatic (n = 3364), and colorectal (n = 17 268) operations at 121 hospitals were examined.

Main Outcome Measures  Risk-adjusted 30-day outcomes were assessed using regression modeling adjusting for patient characteristics, comorbidities, and surgical procedures. The elderly were defined as those older than 75 years.

Results  Between January 1, 2005, and December 31, 2006, a total of 54 747 patients who underwent major GI tract operations were identified from the ACS-NSQIP data file. In the elderly, overall perioperative morbidity was 1.2 to 2 times higher and mortality was 2.9 to 6.7 times higher than in younger patients after adjusting for differences in preoperative comorbidities. Irrespective of procedure type, the elderly were significantly more likely to experience cardiac (acute myocardial infarction and cardiac arrest), pulmonary (pneumonia, pulmonary embolism, and respiratory failure), and urologic (urinary tract infection and renal failure) complications. However, surgical site infections, postoperative bleeding events, deep venous thromboses, and rates of return to the operating room did not differ significantly by age.

Conclusions  Morbidity and mortality are markedly higher in older patients. Quality measures for the elderly currently address only myocardial infarction, surgical site infection, and deep venous thrombosis. If care for the elderly is to be improved, quality improvement initiatives need to be expanded to include postoperative pulmonary and renal complications.

Design  Prospective cohort.

Setting  University-affiliated Veterans Affairs Medical Center.

Patients  All patients who underwent resections of the colon and/or rectum (as the principal operation) at a single hospital whose data are captured in the Veterans Affairs National Surgical Quality Improvement Program (VA-NSQIP) database from January 1, 2000, through December 31, 2006.

Main Outcome Measures  Mortality at 30 days and 90 days.

Results  The VA-NSQIP cohort included 186 patients who underwent CRS, including 148 patients who underwent elective procedures (79.6%) and 38 patients who underwent emergency procedures (20.4%). All but 8 patients were men, with a median age of 67 years (range, 26-92 years). Laparoscopic operations comprised 24.2% and open operations comprised 75.8%. Most (60.8%) were performed for neoplasms. The actual 30-day mortality rates (all, elective, and emergency procedures) were 4.3%, 1.4%, and 15.8%, respectively. These rates closely mirrored the calculated VA-NSQIP risk-adjusted observed-to-expected ratio for 30-day mortality (4.8%, 1.8%, and 18.2%, respectively). However, mortality at 90 days increased substantially to 9.1%, 4.1%, and 28.9%, respectively.

Conclusion  The 30-day mortality significantly underreports the true risk of death after CRS. The 90-day mortality rate should be included as a standard outcome measure after CRS because it serves as a better estimation of risk for counseling patients.

Design  Descriptive study.

Setting  Veterans Health Administration Medical Centers.

Participants  Veterans of the US Armed Forces.

Interventions  The VHA instituted an initial directive, "Ensuring Correct Surgery and Invasive Procedures," in January 2003. The directive was updated in 2004 to include non–operating room (OR) invasive procedures and incorporated requirements of The Joint Commission Universal Protocol for preventing wrong-site operations.

Main Outcome Measures  The categories included 5 incorrect event types (wrong patient, side, site, procedure, or implant), major or minor surgical procedures, location in or out of the OR, therapeutic or diagnostic events, adverse event or close call, inpatient or ambulatory events, specialty department, body segment, and severity and probability of harm.

Results  We reviewed 342 reported events (212 adverse events and 130 close calls). Of these, 108 adverse events (50.9%) occurred in an OR, and 104 (49.1%) occurred elsewhere. When examining adverse events only, ophthalmology and invasive radiology were the specialties associated with the most reports (45 [21.2%] each), whereas orthopedics was second to ophthalmology for number of reported adverse events occurring in the OR. Pulmonary medicine cases (such as wrong-side thoracentesis) and wrong-site cases (such as wrong spinal level) were associated with the most harm. The most common root cause of events was communication (21.0%).

Conclusions  Incorrect ophthalmic and orthopedic surgical procedures appear to be overrepresented among adverse events occurring in ORs. Outside the OR, adverse events by invasive radiology were most frequently reported. Incorrect surgical procedures are not only an OR challenge but also a challenge for events occurring outside of the OR. We support earlier communication based on crew resource management to prevent surgical adverse events.

Design, Patients, and Main Outcome Measures  Retrospective review of 25 patients treated for hepatic EHE (1976-2007). We examined treatment modality, overall survival, complications, and clinicopathologic characteristics.

Results  Of the 25 patients treated for hepatic EHE, 17 underwent liver transplantation (LT); 4, transcatheter arterial chemoembolization (TACE); 2, resection; and 2, TACE followed by LT. Twelve patients (48%) were male. The median age at diagnosis was 38 years (range, 9 months to 72 years). Mean overall survival was 167 (95% confidence interval [CI], 123-212) months, with 172 (124-220) months in the LT group and 83 (54-112) months in the TACE group. The 2 patients in the resection group remain alive after 19 and 71 months. The 2 patients treated with TACE followed by LT died after 13 and 113 months. Extrahepatic disease was identified as a predictor of outcome. Patients with extrahepatic disease treated with TACE fared better than those treated with surgical approaches (mean survival, 83.0 [95% CI, 54.2-111.8] vs 38.8 [23.7-53.8] months; P = .12).

Conclusions  Hepatic EHE is a rare tumor that can be treated with surgical or nonsurgical approaches. In our experience, LT is used for patients with advanced local disease, whereas TACE is the primary modality when extrahepatic disease or comorbid conditions prohibiting LT are present. To our knowledge, this is the largest single-institution experience describing the various therapeutic modalities in the treatment of hepatic EHE.

Design  Retrospective review from 1992 to 2007.

Setting  Mayo Clinic in Rochester, Minnesota, a tertiary care center.

Patients  A cohort of patients who sustained splenic injury during colectomy from 1992 to 2007.

Main Outcome Measures  Overall 30-day major morbidity and mortality and overall 5-year survival.

Results  Of 13 897 colectomies, we identified 59 splenic injuries (0.42%). Of these, 33 (56%) were in men; there was a median age of 68 years (range, 30-93 years) and a median body mass index of 25.5 (range, 15-54). Thirty-seven injuries (63%) occurred during elective surgery, 6 (10%) occurred without splenic flexure mobilization, and 5 (8.4%) occurred during minimally invasive surgery. Injury was successfully managed by primary repair in 10 (17%), splenorrhaphy in 4 (7%), and splenectomy in 45 cases (76%). Four injuries (7%) were unrecognized and resulted in reoperation and splenectomy. Multiple attempts at splenic salvage were performed in 30 (51%); of these, 21 (70%) required splenectomy. More than 2 attempts at salvage was associated with splenectomy (P = .03). The 30-day major morbidity and mortality rates were 34% and 17%, respectively. Sepsis was the most common complication, with no confirmed episodes of postsplenectomy sepsis. Median survival after splenic injury was 7.25 years. There was no significant association between the surgical management of splenic injuries and short- or long-term outcomes.

Conclusions  Splenic injury is an infrequent but morbid complication. Splenic salvage is frequently unsuccessful; our data suggest that surgeons should not be reluctant to perform splenectomy when initial repair attempts fail.

Design  Retrospective medical record review.

Setting  Northwestern Memorial Hospital, Chicago, Illinois.

Patients  Two hundred consecutive patients who underwent ventral hernia repair using the components separation technique.

Interventions  Biological and permanent meshes were used in select patients to augment the repair of the midline fascial closure but were not used as "bridging" materials.

Main Outcome Measures  Hernia recurrence rates and major and minor complication rates for the overall series and for the different techniques.

Results  Primary components separation (n = 158) yielded a 22.8% recurrence rate. Closure of the midline tissues with augmentation of the repair using an acellular cadaveric dermis underlay (n = 18) had a 33.3% recurrence rate requiring a second operation, whereas intra-abdominal soft polypropylene mesh (n = 18) had 0% recurrence (P = .04). Elevated body mass index was a significant risk factor predicting hernia recurrence (P = .003). Contamination (P = .04) and enterocutaneous fistula (P = .02) at the time of surgery were associated with increased major complications, whereas body mass index (P = .01) and diabetes mellitus (P = .04) were associated with increased minor complications.

Conclusions  Large complex hernias can be reliably repaired using the components separation technique despite the presence of open wounds, the need for bowel surgery, and numerous comorbidities. The long-term strength of the hernia repair is not augmented by acellular cadaveric dermis but seems to be improved with soft polypropylene mesh.

Design  Prospective randomized controlled trial.

Setting  Surgical department.

Patients  Patients operated on through a midline incision.

Intervention  Wound closure with a short stitch length (ie, placing stitches <10 mm from the wound edge) or a long stitch length.

Main Outcome Measures  Wound dehiscence, surgical site infection, and incisional hernia.

Results  In all, 737 patients were randomized: 381 were allocated to a long stitch length and 356, to a short stitch length. Wound dehiscence occurred in 1 patient whose wound was closed with a long stitch length. Surgical site infection occurred in 35 of 343 patients (10.2%) in the long stitch group and in 17 of 326 (5.2%) in the short stitch group (P = .02). Incisional hernia was present in 49 of 272 patients (18.0%) in the long stitch group and in 14 of 250 (5.6%) in the short stitch group (P < .001). In multivariate analysis, a long stitch length was an independent risk factor for both surgical site infection and incisional hernia.

Conclusion  In midline incisions closed with a running suture and having a suture length to wound length ratio of at least 4, current recommendations of placing stitches at least 10 mm from the wound edge should be changed to avoid patient suffering and costly wound complications.

Trial Registration  clinicaltrials.gov Identifier: NCT00508053

Design  Population-based retrospective cohort analysis.

Setting  Healthcare Cost and Utilization Project Nationwide Inpatient Sample.

Participants  Adults (≥18 years) undergoing adrenalectomy in the United States (1999-2005). Patient demographic and clinical characteristics, surgeon specialty (general vs urologist), surgeon adrenalectomy volume, and hospital factors were assessed.

Main Outcome Measures  The ² test, analysis of variance, and multivariate linear and logistic regression were used to assess in-hospital complications, mean hospital length of stay (LOS), and total inpatient hospital costs.

Results  A total of 3144 adrenalectomies were included. Mean patient age was 53.7 years; 58.8% were women and 77.4% white. A higher proportion of general surgeons were high-volume surgeons compared with urologists (34.1% vs 18.2%, P < .001). Low-volume surgeons had more complications (18.2% vs 11.3%, P < .001) and their patients had longer LOS (5.5 vs 3.9 days, P < .001) than did high-volume surgeons; urologists had more complications (18.4% vs 15.2%, P = .03) and higher costs ($13 168 vs $11 732, P = .02) than did general surgeons. After adjustment for patient and provider characteristics in multivariate analyses, surgeon volume, but not specialty, was an independent predictor of complications (odds ratio = 1.5, P < .002) and LOS (1.0-day difference, P < .001). Hospital volume was associated only with LOS (0.8-day difference, P < .007). Surgeon volume, specialty, and hospital volume were not predictors of costs.

Conclusion  To optimize outcomes, patients with adrenal disease should be referred to surgeons based on adrenal volume and laparoscopic expertise irrespective of specialty practice.

Design  Cross-sectional survey.

Setting  The Breast and Cervical Cancer Treatment Program for the state of California.

Patients  A statewide sample of 789 low-income women who received treatment for breast cancer from February 1, 2003, through September 31, 2005.

Main Outcome Measure  Satisfaction with surgical treatment.

Results  Three of every 4 women reported being extremely satisfied with the treatment they received from their surgeon. African American women and those with arm swelling were less likely to be satisfied, whereas those reporting that the surgeon always spent enough time and explained concepts in a way they could understand were more likely to report greater satisfaction.

Conclusion  Our findings highlight the importance of 2 relatively simple behaviors that surgeons can easily implement to increase patient satisfaction, which can be of potential benefit in the litigious world of today.

Data Sources  A MEDLINE database search from January 1, 1990, to August 31, 2008, was performed to identify relevant articles using the keywords pancreatoduodenectomy, pancreaticojejunostomy, pancreaticogastrostomy, pancreatic anastomotic leakage, and pancreatic fistula. Additional articles were identified by a manual search of the references from the key articles.

Study Selection  Case reports were excluded from this study.

Data Extraction  Of the identified studies, only those published in English describing meta-analyses or randomized controlled trials were considered first. In those aspects with limited or no randomized controlled trials, nonrandomized comparative studies and case series were included also.

Data Synthesis  The prophylactic use of perioperative somatostatin and its analogues to prevent pancreas-related complications after pancreatic surgery remains controversial and does not result in a reduction of operative mortality. There is no clear evidence for or against a particular type of pancreaticoenteric anastomosis. Pancreaticoenterostomy cannot be replaced by pancreatic ductal obliteration. Pancreaticogastrostomy is equivalent to pancreaticojejunostomy in perioperative morbidity and mortality.

Conclusion  More large-scale comparative studies and randomized controlled trials are required to determine the optimum pharmacologic interventions and technique of pancreaticoenteric anastomosis after pancreatoduodenectomy.

Design, Setting, and Participants  A retrospective study examined 85 consecutive patients undergoing distal pancreatectomy at an academic institution from September 5, 1997, to September 30, 2007.

Main Outcome Measures  Pancreatic fistula and overall mortality and morbidity.

Results  In February 2004, the use of Seamguard in distal pancreas resections was introduced at our institution. Indications for resection included trauma (11 patients), neoplasms (62 patients), and chronic pancreatitis (12 patients). Pancreatic leak was defined as drain output of 25 mL/d or more 7 days postoperatively with a drain amylase level of 1000 U/L or more. Pancreatic leak occurred in 10 of 38 patients (26%) undergoing conventional resection with suture ligation of the pancreatic duct or nonreinforced stapled resection vs 2 of 47 patients (4%) undergoing staple resection using Seamguard reinforcement. Multivariate analysis showed that use of Seamguard with the stapler independently decreased the risk for pancreatic fistula after distal pancreatectomy (odds ratio, 0.07; 95% confidence interval, 0.01-0.43; P = .01).

Conclusions  The use of Seamguard is quickly becoming a common adjunct in distal pancreas resections. Our study shows a lower incidence of pancreatic leak after distal pancreatectomy with the use of this staple line–reinforcing product.

Design  Medical record review.

Setting  University teaching hospital.

Patients  Eight hundred nine patients treated during 10 years were included in the study. Preoperative data regarding the size of the aneurysm, hypogastric coil embolization, and inferior mesenteric artery patency were evaluated by means of computed tomographic scans and aortograms. Ischemic colitis was diagnosed by lower endoscopy or pathology reports.

Main Outcome Measures  Ischemic colitis after EVAR.

Results  Eleven patients (1.4%) developed ischemic colitis. Seven patients' episode occurred less than 30 days from repair (early), whereas 4 occurred 30 days or more from repair (late). Ten of 11 patients had preoperative inferior mesenteric artery occlusion. Microembolization was seen histologically in 2 patients in the early group, both of whom died. A significant increase in ischemic colitis was seen in patients undergoing preoperative unilateral hypogastric coil embolization (P = .02). Three of the patients with late ischemic colitis had comorbidities other than the EVAR to explain the ischemia.

Conclusions  The incidence of ischemic colitis is decreased in patients undergoing EVAR vs open repair. The cause of the ischemia is multifactorial and seems to differ between patients in the early and late groups. Microembolization tends to produce severe ischemic colitis and is usually fatal. There should be a low threshold for performing endoscopy in any patient thought to have ischemic colitis after EVAR.

Design  Retrospective study based on multicenter prospectively updated databases.

Setting  Two tertiary referral centers specializing in hepatobiliary surgery.

Patients  Two hundred four consecutive patients with cirrhosis undergoing hepatectomy for single nodules of HCC of 5 cm or smaller from January 1, 1997, through September 30, 2006.

Interventions  Patients were divided into the following groups according to their preoperative viral status: HBV positive and hepatitis C virus (HCV) negative (group 1); HBV negative and HCV positive (group 2); HBV negative and HCV negative (group 3); and HBV positive and HCV positive (group 4).

Main Outcome Measures  A multivariate analysis was performed to determine factors associated with recurrence-free survival (RFS) among demographic, clinical, pathological, and surgical variables.

Results  The 2 centers had comparable RFS and early and late recurrence rates. Five-year RFS was significantly higher in groups 2 and 3 compared with group 1 (38%, 34%, and 9%, respectively; P = .007 and P = .05). Factors independently associated with RFS were HBV infection (P = .009; odds ratio, 1.79; 95% confidence interval, 1.15-2.78) and poor tumor differentiation (P < .001; odds ratio, 2.01; 95% confidence interval, 1.36-2.96). The concomitance of 0, 1, or 2 risk factors led to 5-year RFS rates of 49%, 20%, and 8%, respectively (P < .001).

Conclusions  Infection with HBV is a strong predictive factor for lower RFS after hepatectomy for a single nodule of HCC of 5 cm or smaller in patients with cirrhosis, providing a further basis for adjuvant antiviral treatment. Patients who are seropositive for HBV with poorly differentiated HCC should also be considered to be at a high risk of recurrence and possibly included in a policy of salvage liver transplantation.

Design  Prospective study that uses data from the Veterans Affairs (VA) National Surgical Quality Improvement Program.

Setting  Group Health Center for Health Studies, the VA North Texas Health Care System, the Denver VA Medical Center, and the Durham VA Medical Center.

Patients  We identified 856 veterans who had undergone bariatric surgery in 1 of 12 VA bariatric centers from January 1, 2000, through December 31, 2006.

Main Outcome Measures  The risk of death was estimated via Cox proportional hazards.

Results  The 856 veterans had a mean body mass index (BMI) of 48.7, a mean age of 54 years, and a mean DCG score of 0.76; 73.0% were men, 83.9% were white, and 7.0% had an ASA class equal to 4. Fifty-four veterans (6.3%) had died by the end of 2006. In our Cox models, patients with a BMI greater than 50 (superobesity; hazard ratio [HR], 1.8; P = .04) or a DCG score greater than or equal to 2 (HR, 3.4; P < .001) had an increased risk of death.

Conclusion  Superobese veterans and those with a greater burden of chronic disease had a greater risk of death after bariatric surgery from 2000 through 2006.

Design  Prospective, nonrandomized study starting on March 1, 1987, and ending on December 31, 2005.

Setting  A prospective, descriptive study of a group of patients.

Patients  A total of 125 patients with short-segment BE underwent 3 operations in different periods: duodenal switch plus highly selective vagotomy and antireflux technique in 31 patients, vagotomy plus partial gastrectomy and Roux-en-Y loop with antireflux surgery in 58 patients, and laparoscopic Nissen fundoplication in 36 patients.

Main Outcome Measures  Late subjective and objective outcomes of the 3 different surgical procedures.

Results  No operative mortality and only 2 postoperative complications (1.6%) occurred. The regression from intestinal metaplasia to cardiac or oxyntocardiac mucosa occurred in 60.8% to 65.4% of the patients, at a mean time of 39 to 56 months after surgery. Visick grading showed Visick grade I or II in 86.3% to 100.0% of the patients. No progression to low- or high-grade dysplasia or adenocarcinoma occurred.

Conclusions  On the basis of these results, laparoscopic Nissen fundoplication seems to be the surgical option for patients with short-segment BE because it is less invasive, has fewer side effects, and produces good results in the long-term follow-up.

Design  Retrospective review of medical records.

Setting  Academic level I trauma center.

Patients  Trauma patients who underwent computed tomographic pulmonary angiography (CTPA) with computed tomographic venography (CTV) of the pelvic and proximal lower extremity veins over a 3-year period (January 1, 2004, to December 31, 2006) were reviewed. Data on demographics, injury type and severity, imaging findings, hospital length of stay, and mortality were collected.

Main Outcome Measures  Pulmonary embolism and DVT.

Results  Among 247 trauma patients undergoing CTPA/CTV, PE was diagnosed in 46 (19%) and DVT in 18 (7%). Eighteen PEs were central (main or lobar pulmonary arteries), and 28 PEs were peripheral (segmental or subsegmental branches). Pulmonary embolism occurred within the first week of injury in two-thirds of patients. Seven patients with PE (4 femoral, 2 popliteal, and 1 iliac) had DVT. Pulmonary embolism was central in 5 patients and peripheral in 2 patients. No significant differences were noted in any of the examined variables between patients with PE having DVT and those not having DVT.

Conclusions  Few patients with PE have DVT of the pelvic or proximal lower extremity veins. Pulmonary embolism may not originate from these veins, as commonly believed, but instead may occur de novo in the lungs. These findings have implications for thromboprophylaxis and, particularly, the value of vena cava filters.

Design  Prospective, randomized clinical trial.

Patients  Thirty patients who had pancreatic resection for pancreatic neoplasm.

Interventions  Patients were prospectively randomized. Perioperative blood glucose levels were continuously monitored using an artificial endocrine pancreas (STG-22). Glucose levels were controlled using either the sliding scale method (sliding scale group, n = 13) or the artificial pancreas (artificial pancreas group, n = 17).

Main Outcome Measures  Incidence of severe hypoglycemia (<40 mg/dL) during the intensive care period following pancreatic resection in patients monitored with the artificial pancreas. The secondary outcome measure was the total amount of insulin required for glycemic control in the first 18 hours after pancreatic resection in each patient group.

Results  In the sliding scale group, postoperative blood glucose levels rose initially before reaching a plateau of approximately 200 mg/dL between 4 and 6 hours after pancreatectomy. The levels remained high for 18 hours postoperatively. In the artificial pancreas group, blood glucose levels reduced steadily, reaching the target zone (80-110 mg/dL) by 6 hours after surgery. The total insulin dose administered per patient during the first postoperative 18 hours was significantly higher in the artificial pancreas group (mean [SD], 107 [109] IU) than the sliding scale group (8 [6] IU; P < .01). Neither group showed hypoglycemia.

Conclusions  Perioperative use of an artificial endocrine pancreas to control pancreatogenic diabetes after pancreatic resection is an easy and effective way to maintain near-normal blood glucose levels. The artificial pancreas shows promise for use as insulin treatment for patients with pancreatogenic diabetes after pancreatic resection.

Design, Setting, and Patients  Population-based retrospective cohort study of all elderly patients undergoing elective surgery in Ontario from April 1, 1992, through March 31, 2006. Preoperative statin use was identified using provincewide pharmacy records. Procedure and patient characteristics were derived from hospital and physician claims databases within Canada's single-payer universal health care system.

Main Outcome Measure  The 30-day risk of surgical site infection was derived from the initial admission, outpatient consultations, and hospital readmissions.

Results  The cohort included 469 349 distinct elderly patients undergoing elective surgery, of whom 68 387 (14.6%) were statin users. The primary analysis included 53 565 statin users matched to 53 565 statin nonusers undergoing the same procedure in the same hospital by the same surgeon. Unadjusted analysis revealed a slight increase in the risk of surgical site infection among statin users compared with nonusers (8.9% vs 8.7%; P < .001), which disappeared after adjustment for demographics, health care utilization variables, comorbidities, and concurrent medication therapy (odds ratio, 1.00; 95% confidence interval, 0.95-1.04; P = .85). A similar lack of association was seen when matching was extended to include propensity scores (odds ratio, 0.99; 95% confidence interval, 0.94-1.05; P = .82). The lack of association persisted across pharmacologic, patient, and procedure subgroups.

Conclusions  Statin use is not associated with an altered risk of surgical site infection. Prevention efforts should be directed toward other evidence-based strategies.

Design  Retrospective case series.

Setting  Academic center.

Patients  Sixty-one consecutive patients diagnosed as having IPA at the Mount Sinai Medical Center, New York, New York, from August 1, 2000, to December 30, 2007.

Main Outcome Measures  Development and cause of IPA, the need for additional interventions, morbidity, and mortality.

Results  The mean age of the patients was 53 years. Most patients were initially seen with pain (95% [58 of 61]), gastrointestinal tract complaints (43% [26 of 61]), and lower extremity pain (30% [18 of 61]). Primary and secondary abscesses occurred in 11% (7 of 61) and 89% (54 of 61), respectively. The most frequent underlying cause of secondary abscesses was inflammatory bowel disease. Broad-spectrum antibiotics were prescribed in all patients. Computed tomography was the most common diagnostic modality used. Abscesses were larger than 6 cm in 39% of patients (24 of 61), bilateral in 13% (8 of 61), and multiple in 25% (15 of 61). Nine patients were treated using antibiotics alone, with a success rate of 78% (7 of 9). Forty-eight patients initially underwent percutaneous drainage, which was successful in 40% (19 of 48). Among those with unresolved IPAs, 71% of patients ultimately required surgery, and the IPAs were typically associated with underlying gastrointestinal tract causes. Seven percent (4 of 61) of patients directly underwent exploratory surgery and drainage, and all of these interventions were successful. The overall mortality was 5% (3 of 61).

Conclusions  Iliopsoas abscess remains a therapeutic challenge. Gastrointestinal tract disease is the most common cause, with computed tomography as the diagnostic modality of choice. Percutaneous drainage remains the initial treatment modality but is rarely the sole therapy required. Patients with inflammatory bowel disease are likely to require ultimate operative management.

Design  Retrospective case series.

Setting  University tertiary care referral center.

Patients  Four hundred twelve consecutive patients who underwent pancreatic resection from October 1, 2001, through March 31, 2008, for benign and malignant periampullary conditions.

Main Outcome Measures  Clinical outcomes were compared for elderly (≥75 years) and nonelderly patient cohorts. Quality assessment analyses were performed to show the differential impact of complications and resource utilization between the groups.

Results  The elderly cohort constituted one-fifth of all patients. Benchmark standards of quality were achieved in this group, including low operative mortality (1%). Despite higher patient acuity, clinical outcomes were comparable to those of nonelderly patients at a marginal cost increase (median, $2202 per case). Cost modeling analysis showed further that minor and moderate complications were more frequent but no more debilitating for elderly patients. Major complications, however, were far more threatening to older patients. In these cases, duration of hospital stay doubled, and invasive interventions were more commonly deployed.

Conclusions  Quality standards for pancreatic resection in the elderly can—and should—mirror those for younger patients. Age-related care, including geriatric consultation, supplemental enteral nutrition, and early rehabilitation placement planning, can be designed to mitigate the impact of complications in the elderly and guarantee quality.

Design  Retrospective review.

Setting  Community teaching hospital.

Patients  Twelve patients having uncomplicated laparoscopic cholecystectomy.

Main Outcome Measures  Number and appearance of postoperative scars.

Results  Twelve attempts to perform the procedure with our new technique were completed successfully. None of the patients required conversion to the standard technique, which requires additional ports. All of the patients were pleased with their results. No identifiable mark was visible in the right upper quadrant of any of the patients; at the 2-week follow-up, the umbilical incisions were nearly invisible, even to the patients.

Conclusion  This novel technique can be performed safely and effectively while minimizing the number and extent of incisions.

Data Sources  For every item of the perioperative treatment pathway, available English-language literature has been examined.

Study Selection  Particular attention was paid to meta-analyses, randomized controlled trials, and systematic reviews.

Data Extraction  A consensus recommendation for each protocol item was reached after critical appraisal of the literature by the group.

Data Synthesis  For most protocol items, recommendations are based on good-quality trials or meta-analyses of such trials.

Conclusions  The Enhanced Recovery After Surgery (ERAS) Group presents a comprehensive evidence-based consensus review of perioperative care for colorectal surgery. It is based on the evidence available for each element of the multimodal perioperative care pathway.

Design  Retrospective case review.

Setting  An urban Veterans Affairs Medical Center.

Patients  Forty-four consecutive cases of patients with AAA who received EVAR.

Main Outcome Measures  Electronic medical records were accessed for 11 high-risk conditions that would have excluded patients from the open surgery trials, and 30-day interventional morbidity and mortality data were collected.

Results  The mean (SD) age of patients who underwent EVAR was 73.2 (10.3) years, with a mean (SD) AAA diameter of 5.8 (1.6) cm. Of 44 patients, 19 (43%) met at least 1 exclusion criterion that would have prevented randomization in the small AAA trials. Significant perioperative complications occurred in 14 patients (32%) and 1 death occurred at home within 30 days of the procedure.

Conclusions  Patients receiving EVAR at an urban Veterans Affairs Medical Center had a greater prevalence of high-risk conditions than patients included in the ADAM and UK Small Aneurysm trials, and overall perioperative morbidity and mortality were lower. Endovascular aneurysm repair has extended aneurysm repair to a higher-risk population with greater safety.

Methods  A prospectively maintained database including consecutive nonruptured open aneurysm repairs from March 1, 2000, through July 31, 2007, was reviewed. Patient demographic characteristics and perioperative outcomes were evaluated and stratified based on proximal aortic cross-clamp placement.

Results  A total of 185 patients with AAA underwent 103 infrarenal and 82 suprarenal cross-clamp repairs. Overall, the complication rate was 37.0% with infrarenal and 61.0% with suprarenal cross-clamps (P = .001). The 30-day mortality was 2.9% with infrarenal and 6.1% with suprarenal cross-clamps (P = .18). Postoperative renal insufficiency (29.3% vs 7.8%; P < .001) and pulmonary complications (25.6% vs 12.6%; P = .03) were more frequent with suprarenal cross-clamps. Suprarenal cross-clamps were associated with greater intraoperative blood loss (2586 mL vs 1638 mL; P = .006), operative duration (391 min vs 355 min; P = .005), use of adjunctive renal and/or visceral grafts (43.9% vs 1.9%; P < .001), duration of intensive care unit stay (4.5 days vs 3.0 days; P = .006), and hospital length of stay (9 days vs 7 days; P = .04). Of patients who received a suprarenal cross-clamp, 25.6% required temporary nursing home placement vs 17.5% with an infrarenal cross-clamp (P = .14).

Conclusions  Until fenestrated and branched endografts are available, open AAA repairs will become increasingly complex. Suprarenal cross-clamping is associated with increased rates of complications but similar mortality rates and need for nursing home placement. With the disappearance of straightforward open aneurysm repair, trainees in vascular surgery will have to learn AAA repair almost exclusively by operating on patients with complex AAAs. Fewer surgeons will perform these repairs, and fewer fellows will be able to complete the operation independently immediately after training.

Design  Retrospective review.

Setting  Tertiary academic medical center.

Patients  Fourteen patients (10 female) with retroperitoneal or extremity sarcomas and major blood vessel involvement who underwent surgery to remove the tumor and had blood vessel reconstruction between 2003 and 2008. Each patient underwent computed tomography angiography.

Main Outcome Measures  Early (<30 days) and late (>30 days) operative morbidity and mortality, freedom from disease, and graft patency.

Results  Seven patients had retroperitoneal sarcomas and 7, extremity sarcomas. Thirteen tumors were malignant (7 high grade and 6 low grade) and 1, benign (leiomyoma). Seven patients had replacement of artery and vein; 5, artery only; and 2, vein only. In all, 16 arteries were reconstructed (2 common femoral; 5 iliac; 2 superficial femoral; 1 brachial; 1 popliteal; and 2 aorta, one with implantation of both iliac arteries and the other with implantation of the left renal, superior mesenteric, and hepatic arteries). Eight patients (57%) had 9 veins reconstructed (3 external iliac, 3 superficial femoral, 2 vena cava, and 1 popliteal). Primary arterial patency was 58% and primary-assisted patency was 83%. Venous patency was 78%. Local recurrence occurred in 3 patients (21%). Five-year disease-free and overall survival were 52% and 68%, respectively. Limb salvage was achieved in 93%.

Conclusion  Involvement of vascular structures is not a contraindication for resection of sarcomas, but appropriate planning is necessary to optimize outcome.

Design  Retrospective analysis of prospectively collected data.

Setting  Tertiary care teaching hospital.

Patients  A total of 141 consecutive patients considered for Nissen fundoplication who also had suspected DGE based on symptoms.

Interventions  Of 141 patients, 63 had a time to 50% emptying (T1/2) greater than 90 minutes; 47 of the 63 of these had severe DGE (T1/2 > 150 minutes) and had Nissen fundoplication and pyloroplasty. Sixteen of the 141 with T1/2 greater than 90 but less than 150 minutes and 78 with normal gastric emptying findings (n = 78) had Nissen fundoplication only.

Main Outcome Measures  Postoperatively, patients with symptom scores greater than 2 and/or abnormal 24-hour pH values (DeMeester score >14.7) were considered to have had unsuccessful treatment. Gastroesophageal reflux disease outcomes were compared between groups 1 and 2. Finally, the outcomes of both groups were compared with a control cohort of 418 patients with Nissen fundoplication and no DGE symptoms (group 3).

Results  At the mean follow-up of 21 months, there were no differences between the 2 groups regarding relief of reflux symptoms (DGE group, 54 of 63 [85.7%] vs NGE group, 71 of 78 [91%]; P = .47) or objective control of acid reflux (DGE group, 33 of 39 [84.6%] vs NGE group, 41 of 51 [80.3%]; P = .78). Dyspeptic symptoms were improved in the DGE group (P < .001); however, the overall incidence remained higher than the NGE group (P = .01). Postoperatively, T1/2 normalized in 88.23% (15 of 17) of patients. Postoperative objective outcomes were also no different between these groups and patients with Nissen fundoplication who did not have DGE symptoms (n = 418).

Conclusions  Delayed gastric emptying does not affect outcomes of gastroesophageal reflux disease following Nissen fundoplication, but patients with DGE have more postoperative gas and bloat and/or nausea compared with patients with normal gastric emptying; this is mostly corrected by addition of a pyloroplasty.

Design  Multicenter animal study.

Setting  Animal laboratories, 2 level I trauma centers.

Participants  Thirty-two Yorkshire crossbred swine.

Interventions  Lyophilized plasma was analyzed for factor levels and clotting activity before lyophilization and after reconstitution. Swine were subjected to complex multiple trauma including extremity fracture, hemorrhage, severe liver injury, acidosis, and hypothermia. They were then resuscitated with FFP, LP, FFP and packed red blood cells (PRBCs) in a ratio of 1:1, or 1:1 LP and PRBCs.

Main Outcome Measures  Residual clotting activity of LP after reconstitution, swine mortality, hemodynamic measures, total blood loss, coagulation profiles, and inflammatory measures.

Results  Lyophilization decreased clotting factor activity by an average of 14%. Survival and heart rate were similar between all groups. Swine resuscitated with LP had equivalent or higher mean arterial pressures. Swine treated with LP had similar coagulation profiles, plasma lactate levels, and postinjury blood loss compared with those treated with FFP. Swine treated with 1:1 FFP-PRBCs were similar to those treated with 1:1 LP-PRBCs. Resuscitation with LP resulted in a reduction in postresuscitation interleukin 6 expression compared with resuscitation with FFP.

Conclusions  The process of lyophilization and reconstitution of plasma reduces coagulation factor activity by 14%, without acute differences in blood loss. Lyophilized plasma can be used for resuscitation in a severe multiple trauma and hemorrhagic shock swine model with efficacy equal to that of FFP and with decreased interleukin 6 production.

Objective  To evaluate the outcomes of patients with colon cancer treated with and without adjuvant chemotherapy on the basis of stage, MSI, and LI.

Design  Prospective evaluation of MSI and LI status with retrospective analysis of chemotherapy regimen.

Setting  Community hospital system.

Patients  A total of 167 patients with colon cancer.

Intervention  Definitive resection of colorectal cancer with or without chemotherapy.

Main Outcome Measure  Disease-free survival (DFS) with and without chemotherapy according to combined MSI and LI status.

Results  Data on MSI and LI status and chemotherapeutic regimens were available for 140 patients. The 5-year DFS was 50% for patients with stage II disease who underwent chemotherapy vs 76% for those who did not (P = .02). In the group negative for MSI and LI, 5-year DFS was 29% for those undergoing chemotherapy and 91% for those who did not (P = .001).

Conclusions  Forgoing adjuvant chemotherapy should be considered in patients with stage II colon cancer who are negative for MSI and LI. The MSI and LI status shows promise as a combined prognostic marker and may prove particularly useful in selecting patients with stage II disease for adjunctive therapy.

Design  Retrospective analysis of single-institution tumor registry database.

Setting  University medical center.

Patients  From October 1, 2003, to May 31, 2008, 90 patients underwent pancreaticoduodenectomy for periampullary mass lesions.

Main Outcome Measures  Clinicopathologic data were reviewed and analyzed among patients who did and did not receive BD for their association with perioperative outcomes. ² Analysis, independent-samples t tests, and Mann-Whitney U tests were used as appropriate.

Results  Fifty-six patients (62%) underwent BD, and 34 (38%) did not. Intraoperative bile cultures were positive for 1 or more species of microorganisms in 88% of stented patients (35 of 40). There were no significant differences in fluid requirements, transfusion requirements, or surgery duration between patients who did and did not undergo BD. Estimated blood loss was increased in patients who received BD (625 mL vs 525 mL in patients who did not undergo BD; P = .03), while reoperation was significantly more common in nonstented patients (4% vs 15% in patients who did not undergo BD; P = .02). Intensive care unit stay, overall length of stay, pancreatic leak/abscess/fistula, infectious complications, postoperative percutaneous drainage, hospital readmission, and 30- and 90-day mortality were not significantly different between the 2 groups.

Conclusions  Although preoperative biliary stents may complicate the intraoperative management and lessen the postoperative complications of patients undergoing pancreaticoduodenectomy, only estimated blood loss and reoperation were significantly different in this cohort. Further study may reveal patient subgroups who may specifically benefit or suffer from preoperative biliary stenting. Currently, selective preoperative BD appears appropriate in the multidisciplinary management of patients with periampullary lesions.

Design  Retrospective medical record review of an accumulated database.

Setting  University tertiary care medical center.

Patients  All patients who underwent open incisional ventral hernia repair from March 1, 2003, through February 28, 2008.

Intervention  Open incisional ventral hernia repair.

Main Outcome Measures  Postoperative complications, including hernia recurrences.

Results  A total of 507 cases (465 patients; female to male ratio, 1.1:1) met our criteria; median follow-up was 40 months. In 23.5% of the cases, repair had been attempted previously, and 16.4% had previously undergone organ transplant. The postoperative complication rate was 38.1%. Hernias recurred in 18.9% of cases. Perioperative mortality was 1.0%. Patients undergoing transplant were more likely than those not undergoing transplant to have a hernia recurrence (16.3% vs 32.5%; P < .001) and were equally likely to have a postoperative complication (36.9% vs 44.6%; P = .19). Patients who underwent repair of a recurrent incisional hernia were as likely to have a hernia recurrence as those who underwent initial repair (21.0% vs 18.3%; P = .52) but more likely to have an overall complication (47.9% vs 35.1%; P = .01).

Conclusions  In this series of incisional hernia repairs at a tertiary care center, the overall recurrence rate of 18.9% is comparable to that of other published series. Ours is the largest published series of recurrent hernias that shows a recurrence rate comparable to that for initial repairs. This outcome may be the result of greater use of more complex repair techniques.

Objective  To prospectively evaluate the performance of our institution's current triage system compared with a simplified system using only 4 highly predictive variables.

Design, Setting, and Patients  A prospective observational study of trauma patients in a 9-month period at an academic level II trauma center was undertaken. All trauma admissions were analyzed for the need for immediate emergency interventions or operative procedures. The accuracy and safety of the current triage system was compared with a simplified triage protocol using only 4 variables (hypotension, mental status, altered respirations, and penetrating truncal wound). Overtriage and undertriage rates were compared, and detailed analysis of all undertriaged patients was performed.

Main Outcome Measures  Rates of overtriage, undertriage, morbidity, and mortality.

Results  There were 244 trauma team activations, with 21% requiring urgent intervention. Existing criteria produced an overtriage rate of 79%, an undertriage rate of 1%, and mistriage in 14%. Using the simplified criteria, the overtriage rate was reduced to 12% and the undertriage rate was increased to 4% (both P < .05). Undertriaged patients were all hemodynamically stable, with 4 requiring tube thoracostomy only and 4 undergoing nonemergent laparotomy (2 nontherapeutic laparotomies, 1 bladder repair, and 1 bowel mesenteric injury). There were no deaths among undertriaged patients with either system.

Conclusions  Using a simplified triage system can safely reduce the rate of overtriage. This could conserve resources, reduce mistriage from misunderstood guidelines, and improve specificity by including only those variables with high predictive value.

Design  Prospective analysis of hospital operations for 1-week periods beginning 2 weeks (baseline) and 1 week (transition) prior to move day; analysis of regional hospital and emergency department capacity.

Setting  Large metropolitan university teaching hospital.

Main Outcome Measures  Hospital census figures and patient outcomes.

Results  Census was reduced by 36% from 537 at baseline to 345 on move day, a rate of 18 patients/d (P < .005). Census reduction was greater for surgical services than nonsurgical services (46% vs 30%; P = .02). Daily volume of elective operations also decreased significantly, while the number of emergency operations was unchanged. Hospital admissions were decreased by 42%, and the adjusted discharges per occupied bed were increased by 8% (both P < .05). Inpatient mortality was not affected. Regional capacity to absorb new patients was limited. During a period in which southern California population grew by 8.5%, acute care beds fell by 3.3%, while Los Angeles County emergency departments experienced a 13% diversion rate due to overcrowding.

Conclusions  Local or regional disasters of any size can overwhelm the system's ability to respond. Our strategy produced a surge capacity of 36% without interruption of emergency department and trauma services but required 3 to 4 days for implementation, making it applicable to disasters and mass casualty events with longer lead times. These principles may aid in disaster preparedness and planning.

Design  Retrospective database review.

Setting  Trauma centers contributing to the National Trauma Data Bank (NTDB).

Patients  Version 6.2 of the NTDB (2000-2005) was queried for all patients with moderate to severe traumatic brain injury (head Abbreviated Injury Score ≥3) and ethanol levels measured on admission. Demographics and outcomes were compared between patients with traumatic brain injuries with and without ethanol in their blood. Logistic regression analysis was used to investigate the relationship between mortality and ethanol.

Main Outcome Measures  Mortality and complications.

Results  A total of 38 019 patients with severe traumatic brain injuries were evaluated. Thirty-eight percent tested positive for ethanol. Ethanol-positive patients were younger (mean [SD], 37.7 [15.1] vs 44.1 [22.0] years, P < .001), had a lower Injury Severity Score (22.3 [10.0] vs 23.0 [10.3], P < .001), and a lower Glasgow Coma Scale score (10.0 [5.1] vs 11.0 [4.9], P < .001) compared with their ethanol-negative counterparts. After logistic regression analysis, ethanol was associated with reduced mortality (adjusted odds ratio, 0.88; 95% confidence interval, 0.80-0.96; P = .005) and higher complications (adjusted odds ratio, 1.24; 95% confidence interval, 1.15-1.33; P < .001).

Conclusions  Serum ethanol is independently associated with decreased mortality in patients with moderate to severe head injuries. Additional research is warranted to investigate the potential therapeutic implications of this association.

Design  A randomized prospective trial.

Setting  A community hospital.

Patients  One hundred nine patients undergoing open appendectomy.

Intervention  Randomly assigned conventional retraction or retraction with the wound-protection system. Patients were blinded to the study arm in which they were enrolled. All patients were given standardized preoperative antibiotics. Demographics including age, sex, body mass index, history of diabetes, and tobacco use were recorded. The severity of appendicitis as determined by the attending surgeon at the time of operation was also noted.

Main Outcome Measures  Incidence of wound infection at 21 days postoperatively.

Results  Of the 48 patients enrolled in the traditional retraction arm, there were 7 (14.6%) documented wound infections. Of the 61 patients enrolled in the wound-protection device arm, there was 1 (1.6%) wound infection. The severity of appendicitis between the 2 groups was matched. The decrease in incidence of wound infection observed with the wound-protection system was significant (P = .02).

Conclusion  Use of a wound-protection system reduces the incidence of surgical wound infection in open appendectomy.

Trial Registration  clinicaltrials.gov Identifier: NCT00323453

Design  Retrospective cohort study.

Setting  Academic research.

Patients  Patient data from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project from January 1988 to January 2003.

Main Outcome Measures  In-hospital mortality, perioperative complications, and mortality following a major complication.

Results  A total of 103 222 patients underwent major pancreatic surgery. The annual number of pancreatic resections increased 15.0% during the 16-year study period. Resection for benign pancreatic disease increased 26.8%. Overall in-hospital mortality, perioperative complications, and mortality following a major complication were 6.5%, 35.6%, and 15.6%, respectively. Multivariate analysis demonstrated that significant independent predictors for these 3 perioperative outcomes were advancing age, male sex, medical comorbidity, and hospital volume for each type of pancreatic resection. The in-hospital mortality for pancreatoduodenectomy increases with age and ranges from 1.7% to 13.8% (P < .001). After adjusting for other confounders, the odds of in-hospital mortality for pancreatoduodenectomy, distal pancreatectomy, and total pancreatectomy in those 65 years or older were 4.78-fold, 3.84-fold, and 2.60-fold, respectively, lower in the high-volume hospitals compared with those in the lower-volume hospitals.

Conclusions  Perioperative complications derived from this population-based study were higher than those reported in many case series. A significant disparity was noted in perioperative outcomes among surgical centers across the United States. An outcome-based referral guideline may have an immediate effect on improving the quality of care in patients who undergo pancreatic resection for benign and malignant disease.

Design  Analysis of prospectively collected data and biologic material.

Setting  Tertiary University Hospital, Policlinico "Le Scotte," Siena, Italy.

Patients  Two hundred fifty patients with gastric carcinoma.

Main Outcome Measures  Five mononucleotide repeats (BAT-26, BAT-25, NR-24, NR-21, and NR-27) were analyzed in these patients.

Results  An MSI phenotype was identified in 63 patients (25.2%) and correlated with specific clinicopathologic characteristics. Favorable prognosis was confirmed for patients with an MSI phenotype in univariate (P < .001) and multivariate (P = .05) analyses. Significant differences in clinicopathologic characteristics and long-term prognoses were observed among patients with microsatellite-stable tumors, tumors having instability at 2 to 4 markers, and tumors having instability at all 5 markers (MSI/5). The MSI/5 phenotype was associated with older age (P < .001), female sex (P = .001), antral tumor location (P = .04), intestinal histotype (P = .003), and less infiltration of the serosa (P = .006); lymph node involvement was rare (P < .001) and was limited to few (median, 3) metastatic lymph nodes (P = .001). Long-term survival of patients with the MSI/5 phenotype is favorable and was confirmed in multivariate analysis (relative risk vs patients with stable tumors, 0.32; 95% confidence interval, 0.16-0.63; P = .002).

Conclusions  Compared with stable tumors, MSI tumors have distinct clinicopathologic features and are associated with a better prognosis. Patients with the MSI/5 phenotype have a very good prognosis.

Objective  To examine whether type D personality predicts all-cause mortality in PAD.

Design  Pilot follow-up study.

Setting  Vascular surgery department of a teaching hospital.

Patients  A total of 184 patients with symptomatic PAD (mean [SD] age, 64.8 [9.8] years) were followed up for 4 years (interquartile range, 3.5-4.5 years).

Main Outcome Measures  Patients completed the type D Scale-14 measure of type D personality at baseline. Information about all-cause mortality was obtained from patient medical files.

Results  During 4-year follow-up, 16 patients (8.7%) died. Adjusting for age and sex, type D personality was predictive of mortality (P = .03). Ankle-brachial index (P = .05), age (P = .009), diabetes mellitus (P = .02), pulmonary disease (P = .09), and renal disease (P = .02) were also predictive of mortality. Multivariable logistic regression revealed that age, diabetes, and renal disease were independent predictors of all-cause mortality (odds ratios, 1.1-2.3). After adjustment for these clinical predictors, patients with type D personality still had a more than 3-fold increased risk of death (odds ratio, 3.5; 95% confidence interval, 1.1-11.1; P = .04).

Conclusions  Type D personality predicts an increased risk of all-cause mortality in PAD, above and beyond traditional risk factors. Further research is needed to confirm these findings, but this pilot study suggests that the assessment of type D personality may be useful for detecting high-risk patients with PAD.

Design  Prospective observational case series.

Patients  Eleven patients with symptomatic cholelithiasis were selected based on age, clinical presentation, body habitus, and history of previous abdominal surgery. Patients with acute or chronic cholecystitis were excluded.

Results  All procedures were completed laparoscopically via the single umbilical incision without the need to convert to an open operation and without introduction of any additional laparoscopic instruments or trocars. The mean operative time was 149.5 minutes (range, 99-240 minutes). The mean length of hospital stay was 0.36 days. There were no associated intraoperative or postoperative complications.

Conclusions  In our experience, SILC performed with a flexible endoscope is feasible and safe. Further studies are needed to determine its advantages in reference to postoperative pain and complication rate in juxtaposition with the current standard laparoscopic cholecystectomy.

Design  Retrospective study of prospective data collection.

Setting  University and Veterans Affairs hospitals.

Patients  One hundred twenty-five patients treated between February 1988 and September 2001. Ninety-four patients were male. The mean patient age was 56 years (age range, 29-80 years). Fifty percent of patients were smokers, and 32.0% were obese; comorbidities were similar in the 2 cohorts studied.

Interventions  Open surgical extraperitoneal prosthetic mesh reinforcement of the incisional closure among 75 patients (onlay repair [cohort OR]) or in the retrorectus position among 50 patients (retrorectus repair [cohort RR]).

Main Outcome Measures  Recurrent hernia, wound infection, and intestinal fistulas.

Results  Nine patients in cohort OR and 2 patients in cohort RR (8.8%) had wound infections; no fistulas occurred. Complications were similar in the 2 cohorts. One mortality occurred. All hernias recurred at the cranial or caudal edge of the mesh. The median recurrence rates were 20.0% at 15 months in the OR cohort and 4.0% at 9 months in cohort RR (P < .02). Follow-up periods averaged 64 months. Three other patients in cohort OR developed subsequent hernia adjacent to their mesh reinforcement at 72, 73, and 86 months.

Conclusions  Extraperitoneal mesh reinforcement avoids intestinal complications and subsequent operations to remove mesh. Recurrence is more frequent after onlay mesh reinforcement and usually occurs at the cranial or caudal edge of the mesh within the first 2 years after hernia repair. Retrorectus repair is the preferred open surgical treatment of incisional hernia, but it has not been universally applicable. Hernias developing 6 to 7 years after surgery are not the result of failed earlier repairs.

Design, Setting, and Participants  Telephone survey conducted from November 14, 2006, through March 16, 2007, of the privileging personnel among a random sample of 235 nonchildren's hospitals stratified by teaching status, bed size, metropolitan statistical area, system affiliation, and tax status.

Main Outcome Measures  Proportion of hospitals that require specialty board certification to gain privileges and hospital requirements for recertification.

Results  Of 235 hospitals, 11 were ineligible and 183 completed the telephone interview, resulting in an overall response rate of 82%. Approximately one-third of hospitals did not require surgeons and nonsurgical subspecialists ever to be board certified to receive hospital privileges. Among the 109 hospitals that required certification at some point, only 5 (5%) required surgeons and 3 (3%) required nonsurgical subspecialists to be board certified at the point of initial privileging. More than three-fourths of hospitals had exceptions to their certification policies for surgeons and 84 (77%) had them for nonsurgical subspecialists. Eighty-two percent of all hospitals and two-thirds of hospitals whose policies required recertification allowed surgeons and nonsurgical subspecialists to retain privileges when their board certification expired.

Conclusion  Most hospitals do not consistently use board certification to ensure physician competence at their institutions.

Design  Telephone survey conducted from October 27, 2006, through March 30, 2007.

Setting  Health plans across the United States.

Participants  Health plan credentialing personnel from a random sample of 223 health plans stratified by enrollment size, plan type, Medicaid enrollment, and tax status.

Main Outcome Measures  Proportion of health plans that require specialty board certification at initial contract or at some point during association with the plan and health plan requirements for recertification.

Results  Of 223 health plans, 9 were ineligible, and credentialing personnel completed the telephone survey in 176, which resulted in an overall response rate of 82%. More than 60% of the health plans in this study did not require surgical specialists, general surgeons, or nonsurgical subspecialists ever to be board certified to contract with the plan. Approximately two-thirds of respondents reported that they did not require surgeons (65%) or nonsurgical subspecialists (63%) with time-limited board certification to recertify in their specialty. More than half of the health plans reported that they made exceptions to their board certification policies based on geographic or network need.

Conclusions  Most health plans did not use specialty board certification to assess surgeon and nonsurgical subspecialist competence.

Design  Retrospective cohort study.

Setting  Academic level I trauma center.

Patients  Individuals who had experienced trauma.

Main Outcome Measures  We concurrently compared mortality in trauma patients treated by an experienced trauma surgeon with those admitted by novice surgeons during 51/2 years. We also compared mortality in patients treated by novice surgeons before vs after implementation of a more structured trauma program. The ² test and multiple logistic regression analysis were used to compare the groups. Odds ratios (95% confidence intervals) for death were examined.

Results  Concurrent comparison of patients treated by novice surgeons vs experienced trauma surgeons demonstrated no difference in mortality (odds ratio, 1.33; 95% confidence interval, 0.82-2.15). At unadjusted univariate analysis, mortality in patients treated by novice surgeons significantly improved over time in the blunt trauma group and all emergency department survivor subgroups. Multivariate analysis demonstrated significantly improved mortality over time in patients treated by novice surgeons (odds ratio, 0.56; 95% confidence interval, 0.37-0.85).

Conclusions  In a structured trauma program, there is no mortality difference between novice surgeons and their experienced trauma director. The organized trauma program and senior surgical mentoring overpower any influence of individual surgeon inexperience.

Design  Retrospective analysis.

Setting  Texas Tech University Health Sciences Center, Lubbock.

Patients  A series of 100 patients who had undergone LAGB between August 1, 2006, and February 28, 2007, were evaluated by medical record review and a blinded examination of the upper gastrointestinal tract.

Main Outcome Measures  Laboratory test results and patient vital signs.

Results  The mean age of the patients was 42 years. The mean initial body mass index (calculated as weight in kilograms divided by height in meters squared) was 50.0. Median excess weight loss was 49.0% after 12 months. Three patients did not undergo gastrographin studies because of a history of allergic reactions to the dye. No differences between the opinion of the surgeon and that of the original radiologist were uncovered. The 97 patients who underwent gastrographin studies lacked leaks; the only radiologic abnormalities were slow passage and reflux in 23 patients. No alteration in patient care resulted. The total cost for the 97 patients was $49 470. The 95% confidence interval for 0 useful results for 97 studies is 0.00 to 0.03; at best, 3.2% of patients undergoing this expensive study would have garnered some benefit.

Conclusion  Routine postoperative upper gastrointestinal tract studies are expensive and of limited value. Instead of relying on them to detect leaks, which are extremely rare after LAGB, reliance should be given to the presence or absence of tachypnea and tachycardia, as is currently done for Roux-en-Y gastric bypass. In this way there will be a cost savings and the potential to make LAGB a same-day procedure.

Data Sources  MEDLINE and EMBASE databases.

Study Selection  Articles that reported data on mortality after endovascular repair of RAAAs were identified. Only patients with true ruptures were included. Additionally, information on mortality after concurrent open repair was sought.

Data Extraction  One of the authors reviewed all of the studies and extracted appropriate data. A total of 43 articles were identified, 14 of which were excluded.

Data Synthesis  Twenty-nine articles with 897 patients who underwent endovascular repair met the inclusion criteria. Of the patients with available information, 86% were men; 29% had been operated on under local anesthesia; 28% were hemodynamically unstable; 17% required intra-aortic balloon occlusion; 48% received bifurcated stent grafts; 6% had endovascular procedures converted to open repair intraoperatively; and 5.5% developed abdominal compartment syndrome. In-hospital and/or 30-day mortality ranged between 0% and 54% in different series, whereas the pooled mortality after endovascular repair was 24.5% (95% confidence interval [CI], 19.8%-29.4%). In 19 studies reporting results of both endovascular and concurrent open repair from the same unit, the pooled mortality after open repair was 44.4% (95% CI, 40.0%-48.8%), and the pooled overall mortality for RAAA undergoing endovascular or open repair was 35% (95% CI, 30%-41%).

Conclusions  Endovascular repair of RAAAs is associated with acceptable mortality rates. Additional studies will be required to verify these promising results and precisely define the role of endovascular treatment as an additional therapeutic option for RAAAs.