Design  Retrospective study.

Setting  University hospital.

Patients  One hundred thirty-five patients undergoing ECF repair between 1989 and 2005.

Main Outcome Measures  Mortality and recurrence of ECF.

Results  Definitive operation for ECF was attempted in 135 patients. Mortality was 8%, recurrence was 17%, and 84% of patients eventually survived with a closed fistula. The primary determinant of mortality was ECF recurrence (odds ratio [OR], 6.7; 95% confidence interval [CI], 1.9-23.4). Factors independently associated with ECF recurrence by multivariate logistic regression included the presence of inflammatory bowel disease (OR, 4.9; 95% CI, 1.5-16.1), interval between diagnosis and operation of 36 weeks or longer (OR, 5.4; 95% CI, 1.8-16.4), location of fistulae in the small intestine (OR, 9.8; 95% CI, 1.7-57.6), and resection with stapled anastomosis (OR, 4.1; 95% CI, 1.3-13.2). Recurrence of ECF was 35% with resection and stapled anastomosis, 22% with simple oversew, and 11% with resection and hand-sewn anastomosis. Recurrence of ECF was 12% when operation was performed prior to 36 weeks from diagnosis, compared with 36% if performed at or beyond 36 weeks.

Conclusions  The primary determinant of mortality after ECF repair is a failed operation leading to recurrence of the fistula. Risk factors for ECF recurrence include inflammatory bowel disease, fistula located in the small intestine, an interval of 36 weeks or longer between diagnosis and operation, and resection with stapled anastomosis.

Design, Setting, and Patients  A 15-year, single-institution, retrospective review and analysis of demographic and outcomes data for 350 patients diagnosed with gastric adenocarcinoma.

Main Outcome Measures  Histologic features, frequency of stage IV disease, frequency of curative gastric resection, postoperative mortality, and long-term survival in very young and older patient groups.

Results  Of 350 total patients, 30 (9%) were aged 35 years or younger. Very young patients (aged ≤35 years) as compared with older patients (aged >35 years) more often had diffuse-type tumor histologic findings (93% vs 69%, respectively; P = .003), adjacent organ invasion (74% vs 29%, respectively; P = .001), nodal metastases (94% vs 70%, respectively; P = .046), distant metastases (81% vs 50%, respectively; P = .003), and stage IV disease (90% vs 64%, respectively; P = .007). Potentially curative gastrectomy was accomplished in 58% of older patients but only 17% of very young patients (P = .001). Nontherapeutic operations were performed in only 6% of older patients but 33% of very young patients (P = .002). Very young patients as compared with older patients had high postoperative mortality (22% vs 2%, respectively; P = .003) related to advanced-stage disease. Mean survival was 33.4 months among older patients compared with only 11.6 months for very young patients (P = .02).

Conclusions  Very young patients (aged ≤35 years) with gastric adenocarcinoma have significantly higher incidences of diffuse-type tumor histologic findings and both locally advanced and metastatic disease at presentation. These findings confirm a more aggressive tumor biology that results in often futile surgical interventions and an unusually grave prognosis. Strategies for earlier diagnosis together with effective new therapies are desperately needed to attenuate the extreme lethality in these uniquely unfortunate patients.

Objective  To evaluate the combined prognostic significance of MSI and LI in a colon cancer population.

Design  Colon cancers were prospectively evaluated for MSI by assessing 11 satellite markers and were classified as MSI+ if 2 or more satellite markers displayed instability. Tumors were classified as LI+ if at least 5 lymphocytes were observed per 10 high-power fields.

Setting  Community hospital system.

Patients  Individuals undergoing definitive surgery for colon cancer.

Main Outcome Measures  Overall and disease-free survival were compared according to combined MSI and LI status.

Results  In 150 patients, tumors were classified as follows: 95 were MSI–/LI–, 9 were MSI–/LI+, 30 were MSI+/LI–, and 16 were MSI+/LI+. Median follow-up was 40.6 months. Five-year disease-free survival was 56.7% for patients with MSI–/LI– tumors and 88.9% for those with MSI+/LI+ tumors (P = .01). Patients with MSI+/LI– and MSI–/LI+ tumors had 5-year survival of 75.4% and 75.0%, respectively.

Conclusions  Patients with colon cancer and MSI–/LI– tumors have worse disease-free survival rate regardless of stage at diagnosis. Patients exhibiting both MSI+ and LI+ tumors have more favorable disease-free survival rates. Both MSI and LI show promise as a combined prognostic marker and with further study may prove to be particularly useful in selecting patients with stage II disease for adjunctive therapy.

Design  Retrospective review comparing neonates with gastroschisis treated before and after the implementation of selective SLS placement.

Setting  Tertiary referral center.

Patients  Of 91 consecutive neonates admitted for initial treatment of gastroschisis between January 1998 and August 2007, 45 were admitted before and 46 were admitted after implementation of the SLS.

Main Outcome Measures  Immediate fascial closure rate, infection rate, time to fascial closure, time to initiation of enteral feeding, time to achievement of full enteral feeds, time of hyperalimentation requirement, and length of hospital stay.

Results  The rate of immediate fascial closure was lower in the postimplementation group (58% before vs 20% after implementation, P < .001). Overall length of stay, time to enteral feeding, and infection rates were not significantly different between the 2 groups.

Conclusions  The use of an SLS placed at the bedside has resulted in lower immediate fascial closure rates for infants with gastroschisis without significant detrimental clinical outcome. The main benefit of using the bedside-placed SLS is the avoidance of urgent surgical intervention. For patients undergoing delayed fascial closure, use of the bedside SLS resulted in shorter times to definitive fascial closure.

Design  Systematic literature review.

Setting  Academic research.

Subjects  We summarized the clinical presentation and outcomes of PVT after laparoscopic surgery other than splenectomy in 18 subjects and reviewed the treatment strategies.

Main Outcome Measures  Systematic review of the literature on PVT after laparoscopic procedures other than splenectomy.

Results  Eighteen cases of PVT following laparoscopic procedures were identified after Roux-en-Y gastric bypass (n = 7), Nissen fundoplication (n = 5), partial colectomy (n = 3), cholecystectomy (n = 2), and appendectomy (n = 1). The mean patient age was 42 years (age range, 20-74 years). Systemic predispositions toward venous thrombosis were identified in 11 patients. Clinical symptoms consisted primarily of abdominal pain manifested, on average, 14 days (range, 3-42 days) after surgery. Thrombus location varied, but 8 patients had a combination of portal and superior mesenteric venous thrombosis. Sixteen patients were treated with anticoagulation therapy. Ten patients underwent major interventions, including exploratory laparotomy in 6 patients and thrombolytic therapy in 4 patients. Six patients had complications, and 2 patients died.

Conclusions  Portomesenteric venous thrombosis following laparoscopic surgery usually manifests as nonspecific abdominal pain. Computed tomography can readily provide the diagnosis and demonstrate the extent of the disease. Treatment should be individualized based on the extent of thrombosis and the presence of bowel ischemia but should include anticoagulation therapy. Venous stasis from increased intra-abdominal pressure, intraoperative manipulation of splanchnic vasculature, and systemic thrombophilic states likely converges to produce this potentially lethal condition.

Design  Case series and literature review.

Setting  University hospital.

Patients  Seven patients with ampullary neuroendocrine tumors.

Main Outcome Measures  Clinical presentation, pathologic findings, and survival.

Results  The patients presented with jaundice (3 patients), anemia (1 patient), gastric outlet obstruction (1 patient), or incidental discovery (2 patients). No patients had neurofibromatosis. Preoperative biopsy was diagnostic in 5 of 6 patients. All of the tumors expressed chromogranin and synaptophysin. Even when the tumor expressed gastrin, vasoactive intestinal peptide, or somatostatin, no patient had a hypersecretion syndrome. Five patients were treated by pancreaticoduodenectomy, 4 for low-grade neuroendocrine tumors and 1 for high-grade neuroendocrine carcinoma. The lesions measured 1.0 to 3.5 cm in diameter. Computed tomographic scans failed to detect nodal metastases that were present in 4 patients. One patient with a high-grade malignant neoplasm died after 15 months. The rest were disease-free after 19 to 48 months. Two patients had transduodenal local resections, one for a 1.1-cm paraganglioma (disease-free, 11 years) and the other for a 0.6-cm carcinoid tumor (disease-free, 7 months).

Conclusions  This is one of the largest series of neuroendocrine tumors of the ampulla. Preoperative biopsy was accurate, but computed tomographic scans were insensitive in detecting nodal metastases. Unlike duodenal carcinoid tumors, hypersecretion syndromes were absent and small tumor size did not preclude locoregional metastases. Tumor grade predicted survival. We recommend pancreaticoduodenectomy for this disease, with local resection reserved for mobile, superficial lesions.

Design  A retrospective analysis was performed using data from the Area Resource File. Multivariate linear regression analysis was performed to identify the variations in access to colorectal surgeons, gastroenterologists, and radiation oncologists.

Setting  All counties in the United States.

Participants  Prevalence rate of African Americans and Asian Americans within a county.

Main Outcome Measure  Rate of colorectal surgeons, gastroenterologists, and radiation oncologists.

Results  Unadjusted analysis revealed that each percentage point increase in the African American population within a county was associated with a decrease in the number of specialists within that county. Multivariate analysis also revealed a statistically significant decrease in the number of gastroenterologists (P < .001) and radiation oncologists (P < .001) with each percentage point increase in the African American population and a trend toward a decrease in colorectal surgeons within that county (P = .28). Each percentage point increase in the Asian American population was associated with a significant increase in the number of gastroenterologists (P < .001) and radiation oncologists (P < .001) with a similar trend toward an increase in the number of colorectal surgeons within that county (P = .13).

Conclusion  Increasing numbers of minority patients in counties is accompanied by a differential access to specialists. This may affect the likelihood of a patient to receive appropriate care.

Design  Retrospective review.

Setting  Academic level I trauma center.

Patients  The study included 35 311 trauma registry patients.

Main Outcome Measures  The cause, effect on outcome, preventability (preventable, potentially preventable, or nonpreventable), and loop closure recommendations for all preventable and potentially preventable complications, and clinical data related to each complication retrieved from the trauma registry and individual medical records.

Results  Over the 8-year study, 35 311 trauma registry patients experienced 2560 complications. Three hundred fifty-one patients (0.99% of all patients) had 403 preventable or potentially preventable complications. The most common preventable or potentially preventable complications were unintended extubation (63 patients [17% of complications]), surgical technical failures (61 patients [15% of complications]), missed injuries (58 patients [14% of complications]), and intravascular catheter–related complications (48 patients [12% of complications]). These complications were clinically relevant; 258 (64% of complications) resulted in a change in management, including 61 laparotomies, 52 reintubations, 41 chest tube insertions, and 19 vascular interventions.

Conclusions  The incidence of preventable or potentially preventable complications at an academic level I trauma center is low. These complications often require a change in management and cluster in 4 major categories (ie, unintended extubation, surgical technical failures, missed injuries, and intravascular catheter–related complications) that must be recognized as critical areas for quality improvement initiatives.

Objectives  To identify thresholds of physical independence achievement associated with improved 6-month survival and to identify and compare other risk factors after removing the influence of the grade achieved.

Design  Data were combined from 8 administrative databases. Grade was measured on the basis of 13 individual self-care and mobility activities measured at inpatient rehabilitation discharge.

Setting  Ninety-nine US Department of Veterans Affairs Medical Centers.

Patients  Retrospective longitudinal cohort study of 2616 veterans who underwent lower extremity amputation and subsequent inpatient rehabilitation between October 1, 2002, and September 30, 2004.

Main Outcome Measure  Cumulative 6-month survival after rehabilitation discharge.

Results  The 6-month survival rate (95% confidence interval [CI]) for those at grade 1 (total assistance) was 73.5% (70.5%-76.2%). The achievement of grade 2 (maximal assistance) led to the largest incremental improvement in prognosis with survival increasing to 91.1% (95% CI, 85.6%-94.5%). In amputees who remained at grade 1, the 30-day hazards ratio for survival compared with grade 6 (independent) was 43.9 (95% CI, 10.8-278.2), sharply decreasing with time. Whereas metastatic cancer and hemodialysis remained significantly associated with reduced survival (both P ≤ .001), anatomical amputation level was not significant when rehabilitation discharge grade and other diagnostic conditions were considered.

Conclusions  Even a small improvement to grade 2 in the most severely impaired amputees resulted in better 6-month survival. Health care systems must plan appropriate interdisciplinary treatment strategies for both medical and functional issues after amputation.

Design  Prospective observational cohort study.

Setting  University Hospital Basel, with an average of 28 000 surgical interventions per year.

Participants  Consecutive series of 4147 surgical procedures performed in the Visceral Surgery, Vascular Surgery, and Traumatology divisions of the Department of General Surgery.

Main Outcome Measures  The outcome of interest was SSI occurrence as assessed pursuant to the Centers of Disease Control and Prevention standards. The primary predictor variable was compromised asepsis due to glove perforation.

Results  The overall SSI rate was 4.5% (188 of 4147 procedures). Univariate logistic regression analysis showed a higher likelihood of SSI in procedures in which gloves were perforated compared with interventions with maintained asepsis (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.4-2.8; P < .001). However, multivariate logistic regression analyses showed that the increase in SSI risk with perforated gloves was different for procedures with vs those without surgical antimicrobial prophylaxis (test for effect modification, P = .005). Without antimicrobial prophylaxis, glove perforation entailed significantly higher odds of SSI compared with the reference group with no breach of asepsis (adjusted OR, 4.2; 95% CI, 1.7-10.8; P = .003). On the contrary, when surgical antimicrobial prophylaxis was applied, the likelihood of SSI was not significantly higher for operations in which gloves were punctured (adjusted OR, 1.3; 95% CI, 0.9-1.9; P = .26).

Conclusion  Without surgical antimicrobial prophylaxis, glove perforation increases the risk of SSI.

Design  Retrospective analysis.

Setting  Department of surgery of a university hospital.

Patients  A total of 197 patients who underwent laparoscopy-assisted gastrectomy for gastric cancer from May 1998 to September 2007 and who were followed up for more than 3 years.

Main Outcome Measures  Feasibility and long-term survival rate with survival analysis by the Kaplan-Meier method.

Results  Subtotal and total gastrectomies were performed in 178 and 19 patients, respectively. The scope of the lymph node dissections were D1 + β (n = 152) and D2 (n = 45). There were 153, 28, 8, 6, 1, and 1 patients in stages Ia, Ib, II, IIIa, IIIb, and IV, respectively. The median follow-up was 45 months (range, 1-113 months), and there were 7 recurrences. Multivariate analysis of disease-specific survival showed that depth of invasion and lymph node metastasis influenced the prognosis independently. The actual 3-year disease-free survival rate for all patients was 96.9%. The 173 patients with early gastric cancer and 24 with advanced gastric cancer showed 98.8% and 79.1% actual 3-year disease-free survival rates, respectively.

Conclusions  Laparoscopy-assisted gastrectomy is acceptable oncologically in early gastric cancer if 3-year disease-free survival represents 5-year overall survival. Laparoscopy-assisted gastrectomy may also play an important role in the treatment of advanced gastric cancer.

Objectives  To (1) present a succinct synopsis of the rationale and elements of our current surgical management strategy for papillary thyroid carcinoma and, within this context, (2) provide a detailed stepwise description of a compartment-oriented modified radical neck dissection. This description is combined with intraoperative photographs and a medical artist's illustrations to enhance and emphasize the most important points.

Conclusions  With anatomically defined precise dissection, following the steps outlined and illustrated, a thorough lymphadenectomy can be accomplished safely, with reasonable cosmetic results, minimizing disease relapse.

Data Sources  Patient records from our institution over the last 10 years and relevant studies from BioMed Central, CENTRAL, PubMed, and PubMed Central. In addition, references cited in selected works were also used as source data.

Study Selection  Patient records were selected if the CT or radiograph findings matched the term hepatic portal venous gas. Studies were selected based on the search terms hepatic portal venous gas or portal venous gas.

Data Extraction  Quantitative and qualitative data were quoted directly from cited work.

Data Synthesis  Early studies of HPVG were based on plain abdominal radiography and a literature survey in 1978 found an associated mortality rate of 75%, primarily due to ischemic bowel disease. Modern abdominal CT has resulted in the detection of HPVG in more benign conditions, and a second literature survey in 2001 found a total mortality of only 39%. While the pathophysiology of HPVG is, as yet, unclear, changing abdominal imaging technology has altered the significance of this radiologic finding. Hepatic portal venous gas therefore predicts high risk of mortality (>50%) if detected by plain radiography or by CT in a patient with additional evidence of necrotic bowel. If detected by CT in patients after surgical or endoscopic manipulation, the clinician is advised that there is no evidence of increased risk. If HPVG is detected by CT in patients with active peptic ulcer disease, intestinal obstruction and/or dilatation, or mucosal diseases such as Crohn disease or ulcerative colitis, caution is warranted, as risk of death may approach 20% to 30%.

Conclusion  The finding of HPVG alone cannot be an indication for emergency exploration, and we have developed an evidence-based algorithm to guide the clinician in management of patients with HPVG.

Design  Retrospective cross-sectional study.

Setting  Health Care Utilization Project Nationwide Inpatient Sample (HCUP-NIS), a 20% sample of nonfederal US hospitals.

Patients  All pregnant women, compared with age-matched nonpregnant women, who underwent thyroid and parathyroid procedures from 1999 to 2005.

Main Outcome Measures  Fetal, maternal, and surgical complications, in-hospital mortality, median length of stay, and hospital costs.

Results  A total of 201 pregnant women underwent thyroid (n = 165) and parathyroid (n = 36) procedures and were examined together. The mean age was 29 years, 60% were white, 25% were emergent or urgent admissions, and 46% had thyroid cancer. Compared with nonpregnant women (n = 31 155), pregnant patients had a higher rate of endocrine (15.9 vs 8.1%; P < .001) and general complications (11.4 vs 3.6%; P < .001), longer unadjusted lengths of stay (2 days vs 1 day; P < .001), and higher unadjusted hospital costs ($6873 vs $5963; P = .007). The fetal and maternal complication rates were 5.5% and 4.5%, respectively. On multivariate regression analysis, pregnancy was an independent predictor of higher combined surgical complications (odds ratio, 2; P < .001), longer adjusted length of stay (0.3 days longer; P < .001), and higher adjusted hospital costs ($300; P < .001). Other independent predictors of outcome were surgeon volume, patient race or ethnicity, and insurance status.

Conclusions  Pregnant women have worse clinical and economic outcomes following thyroid and parathyroid surgery than nonpregnant women, with disparities in outcomes based on race, insurance, and access to high-volume surgeons.

Design  Cohort analysis.

Setting  Subspecialty practice at a tertiary care facility.

Patients  Consecutive subjects were selected from a prospective colorectal database of 2627 patients treated between January l, 2001, and December 31, 2007.

Intervention  Creation of left-sided colorectal anastomoses and air leak testing per surgeon preference.

Main Outcomes Measures  Anastomosis type, method (handsewn vs stapled), performance of air leak testing, repair method of anastomoses after air leak tests yielding positive results, and development of postoperative clinical leak.

Results  A total of 998 left-sided colorectal anastomoses were performed without proximal diversion; 90.1% were stapled and 9.9% were handsewn. Intraoperative air leaks were noted in 65 of 825 tested anastomoses (7.9%), that is, 7.8% of stapled anastomoses and 9.5% of handsewn anastomoses. A clinical leak developed in 48 patients (4.8%). Clinical leaks were noted in 7.7% of anastomoses with positive air leak test results compared with 3.8% of anastomoses with negative air leak test results and 8.1% of all untested anastomoses (P < .03). If air leak testing yielded positive results, suture repair alone was associated with the highest rate of postoperative clinical leak compared with diversion or reanastomosis, 12.2% vs 0% vs 0%, respectively (P = .19).

Conclusions  Our data indicate a high rate of air leaks at air leak testing of left-sided colorectal anastomoses. In addition, the high rate of clinical leaks in untested anastomoses leads us to recommend air leak testing of all left-sided anastomoses, whether stapled or handsewn.

Design  Retrospective multicenter study.

Setting  Eleven New England trauma centers (7 academic and 4 nonacademic).

Patients  Two hundred thirty patients (>15 years old) with BPDI admitted to the hospital during 11 years. Each BPDI was graded from 1 (lowest) to 5 (highest) according to the American Association for the Surgery of Trauma grading system.

Main Outcome Measures  Success of NOM, sensitivity of CT, BPDI-related complications, length of hospital stay, and mortality.

Results  Ninety-seven patients (42.2%) with mostly grades 1 and 2 BPDI were selected for NOM: NOM failed in 10 (10.3%), 10 (10.3%) developed BPDI-related complications (3 in patients in whom NOM failed), and 7 (7.2%) died (none related to failure of NOM). The remaining 133 patients were operated on urgently: 34 (25.6%) developed BPDI-related complications and 20 (15.0%) died. The initial CT missed BPDI in 30 patients (13.0%); 4 of them (13.3%) died but not because of the BPDI. The mortality rate in patients without a missed diagnosis was 8.8% (P = .50). There was no correlation between time to diagnosis and length of hospital stay (Spearman r = 0.06; P = .43). The sensitivity of CT for BPDI was 75.7% (76% for pancreatic and 70% for duodenal injuries).

Conclusions  The NOM of low-grade BPDI is safe despite occasional failures. Missed diagnosis of BPDI continues to occur despite advances in CT but does not seem to cause adverse outcomes in most patients.

Design, Setting, and Participants  Surveys were administered to faculty at a university teaching hospital before and after allocation of the incentive during the inaugural implementation of an AIP.

Main Outcome Measure  Survey Likert scale.

Results  Preallocation and postallocation survey response rates were 64% and 67%, respectively. Although 92% of respondents submitted the required self-reports of academic activities, only 25% met with their chiefs to assess productivity. Despite the small incentive, more than 50% believed that the AIP encouraged them to increase academic pursuits and rewarded activities important to the department that had not previously been reimbursed. Most did not believe that teaching, clinical research, or citizenship were adequately compensated before or after AIP implementation. However, more thought that citizenship (P=.02) and administration (P=.001) were adequately compensated in the postallocation vs preallocation survey; there were similar trends for clinical research (P=.17) and teaching (P = .06). Among 25 respondents who provided additional comments, 52% mentioned a lack of transparency in the method of incentive distribution as a concern.

Conclusions  Although only a few met with their chiefs for assessment, most faculty believed that even a minimal financial incentive might encourage them to increase their academic activities. We are encouraged to continue the AIP as a positive motivator for academic pursuits, and we plan additional measures to make incentive allocation more transparent.

Design  Single-institution, retrospective medical record review from February 1990 to March 2008.

Setting  Tertiary care hospital.

Patients  Eighty-one nonneonatal patients (mean age, 23 years; age range, 2 months to 61 years) with acute respiratory failure who had failed maximal ventilator support received ECMO therapy between 1990 and 2008. Patients were grouped into 6 categories based on diagnosis: sepsis (n = 8), bacterial or fungal pneumonia (n = 15), viral pneumonia (n = 9), trauma or burn (n = 10), immunocompromise (n = 15), and other (n = 24).

Main Outcome Measure  Survival to hospital discharge.

Results  Overall survival was 53%. Survival was highest in patients with viral pneumonia (78%), followed by bacterial pneumonia (53%), sepsis syndrome (44%), and immunocompromise (40%). Patients treated following trauma or burns had the lowest survival (33%). The average age was 19 years for survivors as compared with 27 years for nonsurvivors. Survival was lower in patients with multiple organ failure as compared with those with single organ failure (33% vs 60%, respectively), in patients who experienced mechanical ventilation for longer than 10 days prior to the initiation of ECMO as compared with those who received ventilatory support for less than 10 days prior to the initiation of ECMO (31% vs 57%, respectively), and in patients requiring more than 400 hours of ECMO support as compared with those requiring less than 400 hours of ECMO support (42% vs 55%, respectively).

Conclusions  Therapy with ECMO may provide a survival benefit in carefully selected patients with nonneonatal acute respiratory failure who have failed maximal ventilator support. Nonneonatal survival with ECMO therapy is strongly dependent on diagnosis, with the highest survival seen in those with viral or bacterial pneumonia. Older age, multiple organ failure, prolonged ventilation prior to ECMO initiation, and long ECMO runs are associated with decreased survival.

Design  Retrospective study.

Setting  Academic tertiary referral center.

Patients  We reviewed the records of 4796 inpatients diagnosed as having C difficile colitis from January 1, 1996, to December 31, 2007, and identified 199 (4.1%) with fulminant C difficile colitis, as defined by the need for colectomy or admission to the intensive care unit for C difficile colitis.

Main Outcome Measures  Risk of inpatient mortality was determined by multivariate analysis according to clinical predictors, colectomy, and medical team.

Results  The inhospital mortality rate for fulminant C difficile colitis was 34.7%. Independent predictors of mortality included the following: (1) age of 70 years or older, (2) severe leukocytosis or leukopenia (white blood cell count, ≥35 000/µL or <4000/µL) or bandemia (neutrophil bands, ≥10%), and (3) cardiorespiratory failure (intubation or vasopressors). When all 3 factors were present, the mortality rate was 57.1%; when all 3 were absent, the mortality rate was 0%. Patients who underwent colectomy had a trend toward decreased mortality rates (odds ratio, 0.49; 95% confidence interval, 0.21-1.1; P = .08). Among patients admitted primarily for fulminant C difficile colitis, care in the surgical department compared with the nonsurgical department resulted in a higher rate of operation (85.1% vs 11.2%; P < .001) and lower mortality rates (12.8% vs 39.3%; P = .001). Patients admitted directly to the surgical department had a shorter mean (SD) interval from admission to operation (0 vs 1.7 [2.8] days; P = .001).

Conclusions  Despite awareness and treatment, fulminant C difficile colitis remains a highly lethal disease. Reliable predictors of mortality exist and should be used to prompt aggressive surgical intervention. Survival rates are higher in patients who were cared for by surgical vs nonsurgical departments, possibly because of more frequent and earlier operations.

Design  Retrospective case series.

Setting  University-affiliated tertiary care center.

Patients  Between January 1, 1962, and March 1, 2008, 402 patients with gallbladder cancer were identified and their clinicopathologic data were analyzed.

Interventions  Surgical treatment, radiotherapy, and chemotherapy.

Main Outcome Measures  Incidentally discovered gallbladder cancer, incidence of residual disease, and differences in presentation, treatment, and survival.

Results  Surgical exploration was performed in 260 patients (64.7%), of whom 151 (58.1%) underwent resection. The median age of the patients was 72 years, and 72.3% were female. Between January 1, 1994, and March 1, 2008, 6881 laparoscopic cholecystectomies were performed, and there were 17 incidentally discovered cases of gallbladder cancer (0.25%). Residual disease on reexploration was identified in 0 of 2 patients with T1 tumor, 3 of 13 patients with T2 tumor, and 8 of 10 patients with T3 tumor (P = .01). Patients with stage IV disease (34 [13.1%] diagnosed from 1962-1979; 34 [13.1%] diagnosed from 1980-1997; and 22 [8.5%] diagnosed from 1998-2008) had a median survival of 4 months (range, 0-37 months). Concomitant liver resections increased in the third study period (11.1%, 10.1%, and 54.3%; P < .001), with an increase in negative margins (33.3%, 42.0%, and 63.0%; P = .01). Cox regression analysis identified T stage and surgical margin status as significant prognostic factors.

Conclusions  Gallbladder cancer is incidentally found during 0.25% of laparoscopic cholecystectomies. As T stage increases, the likelihood of residual disease on reexploration increases. Although many patients with gallbladder cancer present with incurable disease and have very poor survival, the overall prognosis is improving, likely because of more extensive operations.

Design  Retrospective case series.

Setting  University-affiliated tertiary care center.

Patients  Four hundred one patients evaluated in the Department of Surgery between January 2004 and December 2007.

Main Outcome Measures  Clinical management, histological diagnosis, and results of surveillance.

Results  Pancreatic cysts were incidentally discovered in 71% (284 of 401) of patients. There was no statistically significant difference in age (60.4 vs 63.1 years; P = .10), cyst size (31 vs 27 mm; P = .12), or histological diagnosis between symptomatic patients and patients with incidentally discovered cysts. Whereas the majority of symptomatic patients had their cystic neoplasms resected on diagnosis, 50% (142 of 284) of incidentally discovered cysts were initially managed nonoperatively. Of the patients who were managed with surveillance, 13 (8%) subsequently underwent resection after a median of 2.1 years because of an increase in cyst size, development of symptoms, increasing tumor markers, worrisome endoscopic ultrasonography findings, or patient anxiety. The most common diagnosis among resected lesions was either main-duct intraductal papillary mucinous neoplasm (25%) or branch-duct intraductal papillary mucinous neoplasm (23%). Invasive cancer was found in 29 of 256 (11%) resected cystic neoplasms, 9 of which were incidentally discovered, and in 7% (1 of 13) of patients who underwent watchful waiting prior to resection.

Conclusions  Incidentally discovered pancreatic cystic neoplasms composed 71% of our series, of which 50% were immediately resected. Subsequent morphologic changes or development of symptoms prompted an operation in 8% of patients after a period of surveillance. Invasive malignancy was present in 11% of all resected specimens but in 38% of main-duct intraductal papillary mucinous neoplasms.

Design  Descriptive analysis of concurrently collected outcome measures.

Setting  University hospital with a designated breast cancer center.

Patients  Patients with a preoperative diagnosis of invasive breast cancer or ductal carcinoma in situ undergoing their initial cancer surgery from April 1, 2003, to March 30, 2008.

Main Outcome Measures  Eight measures were identified: (1) total mastectomy rate; (2) close (<1 mm) and positive margin rate following initial partial mastectomy; (3) number of operations required in breast conservation; (4) number of nodes obtained from sentinel lymph node biopsy; (5) number of nodes from axillary dissection; (6) proportion of patients with positive sentinel lymph node biopsy undergoing axillary dissection; (7) use of intraoperative lymph node assessment; and (8) time from diagnosis to surgery.

Results  Nine hundred ten operations (218 for ductal carcinoma in situ, 692 for invasive breast cancer) were performed by 6 surgeons. Variation existed among surgeons in the combined close and positive margin rate, number of nodes obtained from sentinel lymph node biopsy, and use of intraoperative lymph node assessment. No significant variation was seen for the overall mastectomy rate, mean number of operations, positive margin rate alone, and number of lymph nodes from axillary dissection.

Conclusions  Quality indicators for breast cancer surgery can be identified and readily monitored. Outcome variation exists at a high-volume breast center. Further study into the causes and effects of this variation on short- and long-term patient outcomes as well as health care costs is needed.

Design  Retrospective review.

Setting  Tertiary referral center.

Patients  All adult patients undergoing image-guided adrenal biopsy from 1997 to 2007.

Main Outcome Measure  Biopsy sensitivity for malignancy.

Results  There were 163 biopsies performed on 154 patients. Mean (SD) age was 66 (12.5) years. Eighty-eight biopsies (53.4%) were performed in patients with a prior diagnosis of cancer. Forty-five (26.4%) were performed when imaging study results suggested previously undiagnosed cancer with a simultaneous adrenal metastasis. Thirty (20.2%) were performed for isolated adrenal incidentalomas. Rates of positive biopsy results in these 3 groups were 70.6%, 69.0%, and 16.7%, respectively. Prebiopsy evaluation for pheochromocytoma was performed in less than 5% of patients with established or suspected nonadrenal malignancies and 32% of patients with incidentalomas. In patients with isolated adrenal incidentaloma, a radiology report recommended biopsy 33% of the time for characteristics inconsistent with benign adenoma. Benign incidentalomas measured mean (SD) 4.2 (2.1) cm (range, 1.4-10.7 cm), and malignancies measured mean (SD) 9.3 (3.3) cm (range, 5.3-14 cm) (P < .05). All incidentalomas 5 cm or less (n = 18) were benign. There were 4 false-negative biopsy results: 3 adrenocortical carcinomas and 1 pheochromocytoma.

Conclusions  Biopsy is unhelpful in patients with isolated adrenal incidentaloma. Despite atypical radiographic findings, all nonfunctioning nodules 5 cm or less were benign. The negative predictive value is unacceptably low and cannot be relied on to rule out malignancy. The value of biopsy remains the diagnosis of metastatic carcinoma in patients with a nonadrenal primary malignancy, proven by the more than 70% positive rate in this group.

Design  Retrospective analysis.

Setting  Tertiary center.

Patients  Three hundred fifty patients who underwent living donor kidney transplantation from January 2000 to March 2007.

Interventions  Living donor kidney transplantation.

Main Outcome Measures  Surgical complications and allograft survival.

Results  Three hundred nineteen allografts (91.1%) had a single artery (group 1) and 31 (8.9%) had multiple arteries (group 2), including 2 arteries in 21 grafts (67.8%), 3 arteries in 6 (19.3%), and 4 arteries in 4 grafts (12.9%). The operative time was shorter in group 1 compared with group 2 (mean [SD], 173 [35] vs 259 [48] minutes; P < .001). The overall surgical complication rate in groups 1 and 2 was comparable (9.6% vs 9.7%; vascular, 2.8% vs 3.2%; urological, 1.6% vs 3.2%; symptomatic lymphocele, 2.8% vs 3.2%; and wound infections, 2.8% vs 3.2%). The actuarial 1- and 5-year allograft survival rates were comparable in both groups (98.4% and 91.5% in group 1 and 96.8% and 87.1% in group 2). A significant increased use of allografts with multiple arteries has been observed in recent years: 7.8% (n = 10) in grafts that were procured by open technique (n = 127), 4.1% (n = 5) during our initial experience with laparoscopic nephrectomy (n = 123), and 16% (n = 16) in the most recent 100 cases (P < .01).

Conclusions  Living donor kidney transplantation in the presence of multiple renal arteries is feasible and safe. Additionally, graft survival and graft function are not adversely affected by the presence of multiple renal arteries in grafts procured laparoscopically. Recently, there has been an increased use of kidneys with multiple arteries with excellent results.

Design  A Web-based system was designed to collect physician-reported adverse events including weekly Morbidity and Mortality (M&M) entries and anonymous adverse/near-miss events. An automated system was set up to help identify event patterns. Adverse event frequency was compared with hospital databases to assess reporting completeness.

Setting  A metropolitan tertiary care center.

Main Outcome Measures  Identification of adverse event patterns and completeness of reporting.

Results  From September 2005 to August 2007, 15 524 surgical patients were reported including 957 (6.2%) adverse events and 34 (0.2%) anonymous reports. The automated pattern recognition system helped identify 4 event patterns from M&M reports and 3 patterns from anonymous/near-miss reporting. After multidisciplinary meetings and expert reviews, the patterns were addressed with educational initiatives, correction of systems issues, and/or intensive quality monitoring. Only 25% of complications and 42% of inpatient deaths were reported. A total of 75.2% of adverse events resulting in permanent disability or death were attributed to the nature of the disease. Interventions to improve reporting were largely unsuccessful.

Conclusions  We have developed a user-friendly Web-based system to track complications and identify patterns of adverse events. Underreporting of adverse events and attributing the complication to the nature of the disease represent a problem in reporting culture among surgeons at our institution. Similar systems should be used by surgery departments, particularly those affiliated with teaching hospitals, to identify quality improvement opportunities.

Design  Prospective cohort study comparing results of primary laparoscopic gastric bypass in MO and SO patients.

Setting  University hospital and community hospital with common bariatric programs.

Patients  A total of 492 MO and 133 SO patients treated consecutively between January 1, 1999, and June 30, 2006.

Intervention  Primary laparoscopic Roux-en-Y gastric bypass.

Main Outcome Measures  Operative morbidity, weight loss, residual body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared), evolution of comorbidities, quality of life, and Bariatric Analysis and Reporting Outcome System score.

Results  Surgery was longer in SO patients, but operative morbidity was similar. The MO patients lost a maximum of 15 BMI units and maintained an average loss of 13 BMI units after 6 years, compared with 21 and 17 in SO patients, which corresponds to a 30.1% and 30.7% total body weight loss, respectively. After 6 years, the BMI was less than 35 in more than 90% of MO patients but in less than 50% of SO patients. Despite these differences, improvements in quality of life and comorbidities were impressive and similar in both groups.

Conclusion  Although many SO patients remain in the severely obese or MO category, equivalent improvements in quality of life and obesity-related comorbidities indicate that weight loss is not all that matters after bariatric surgery.

Design  The 2005 National Inpatient Survey was used to compare outcomes at designated vs nondesignated hospitals. In addition to conventional null-hypothesis statistical testing to assess differences, effect sizes were calculated to estimate the clinical significance for observed differences.

Results  Centers of excellence performed substantially more operations than nondesignated centers. Despite this, outcomes were equivalent at centers of excellence and hospitals without this designation. Volume-outcome modeling attempting to identify the optimal number for a minimum volume threshold for bariatric operations revealed that annual procedure volume has a weak effect on outcomes. Similarly, many variables that were statistically significantly different between centers and noncenters proved to be clinically unimportant by effect size analysis. Risk adjustment was effectively achieved by using the Agency for Healthcare Research and Quality–supplied variables all-payer severity-adjusted diagnostic related group expected charges and deaths.

Conclusions  Designation as a bariatric surgery center of excellence does not ensure better outcomes. Neither does high annual procedure volume. Extra expenses associated with center of excellence designation may not be warranted.

Design, Setting, and Patients  Retrospective cohort study based on 66 214 patients in 68 hospitals. Four risk-adjustment models based on either ISS or T-MPM were constructed, with or without physiologic information.

Main Outcome Measures  Hospital quality was measured using the ratio of the observed-to-expected mortality rates. Pairwise comparisons of hospital quality based on ISS_augmented vs T-MPM_augmented were performed using the intraclass correlation coefficient and the statistic.

Results  There was almost perfect agreement for the ratios of the observed to expected mortality rates based on the T-MPM vs the ISS when physiologic information was included in the model (intraclass correlation coefficient, 0.93). There was substantial agreement on which hospitals were identified as high-, intermediate-, and low-quality hospitals ( = 0.79). Excluding physiologic information decreased the level of agreement between the T-MPM and the ISS (intraclass correlation coefficient, 0.88 and  = 0.58).

Conclusions  The choice of expert-based or empirical Abbreviated Injury Score severity scores for individual injuries does not seem to have a significant effect on hospital quality measurement when physiologic information is included in the prediction model. This finding should help to convince all stakeholders that the quality of trauma care can be accurately measured and has face validity.

Design  Retrospective medical record review.

Setting  Academic medical center.

Patients  Patients who underwent colectomy with primary anastomosis (N = 4019) between January 1, 1992, and December 13, 2004, were eligible for participation in the study. Fifty-eight patients (1.5%) with an anastomotic leak demonstrated by communication between the collection and the gastrointestinal tract were identified. Twenty-eight of the patients had free leaks and 30 had contained leaks.

Main Outcome Measures  Time to presentation, symptoms at presentation, rates of reexploration, and in-hospital mortality.

Results  Baseline characteristics, presenting symptoms, physical examination findings, and laboratory values were similar between patients with contained and free leaks. Almost all patients with free leaks were taken directly to the operating room, whereas those with contained leaks were initially more likely to be treated nonoperatively. However, 24 of the 28 patients with contained leaks (86%) ultimately required surgical intervention. In-hospital mortality was the same in both groups (18% in the contained leak group and 17% in the free leak group).

Conclusions  In patients with contained leaks who have documented communication between the abscess cavity and the bowel, there is no difference in the rate of operative management or morbidity and mortality when compared with those with free leaks. This finding suggests that the categorization of leaks as free or contained may not be justified and argues for early operative intervention even in patients with contained leaks.

Design  Retrospective and prospective cohort study.

Setting  University hospitals of Hamburg-Eppendorf and Düsseldorf, Germany.

Patients  Between 1985 and 2006, 22 patients (8 men and 14 women; median age at initial diagnosis, 54 years [range, 19-80 years]) were surgically treated for primary hepatic sarcomas.

Intervention  Tumor resection with curative intent ranging from nonanatomical resection to liver transplant.

Main Outcome Measures  Effects on overall survival were analyzed using the log-rank test.

Results  The majority of tumors were more than 5 cm (n = 19), with a median tumor size of 7 cm (range, 4-14 cm); of intermediate differentiation (G2; n = 15); and classified as leiomyosarcoma (n = 7). Ten patients received a hemihepatectomy. In 4 patients, a bisegmentectomy was performed and in 2 patients, a segmentectomy, while 4 patients received a nonanatomical resection. Liver transplant was performed in 2 patients. In 18 patients, complete tumor resection (R0) was achieved. Perioperative mortality was 0%. Median follow-up was 88 months (range, 6-246 months). Local recurrence occurred in 6 patients. Distant metastases were diagnosed in 10 patients, predominantly in the lung (n = 6). The 5-year survival after surgery was 65%, with 41% of the patients living more than 10 years without disease. Patients with angiosarcoma had a poor prognosis (P = .03).

Conclusions  Although primary hepatic sarcoma is a rare malignant tumor, no standard treatment is established. A long-term survival is possible after complete tumor resection in a preselected population with early-stage disease.

Design  Retrospective study (1999-2006).

Setting  Wakayama Medical University Hospital, Wakayama, Japan.

Patients  Fifty-four patients with IPMN who underwent surgery; histologic examination showed benign adenomas in 29, carcinoma in situ in 14, and invasive carcinoma in 11 patients.

Main Outcome Measures  Clinical data, preoperative imaging findings, cytologic findings, tumor markers in serum and pancreatic juice, and overall survival.

Results  Age of 70 years or older, presence of mural nodules, mural nodule size of 5 mm or larger, and carcinoembryonic antigen (CEA) level in pancreatic juice of 110 ng/mL or higher (as obtained by preoperative endoscopic retrograde pancreatography) were predictive of a malignant IPMN by univariate analysis, and a CEA level of 110 ng/mL or higher in pancreatic juice was identified as the only independent predictive factor for the malignant entity. The presence of jaundice or body weight loss, main pancreatic duct type, presence of mural nodules, mural nodule size of 5 mm or larger, and CEA level in the pancreatic juice of 110 ng/mL or higher were all predictive of invasive IPMCs by univariate analysis.

Conclusion  Measurement of the CEA level in pancreatic juice should be considered in the diagnosis of IPMC.

Design  Retrospective study from January 1, 1992, through December 31, 2002.

Setting  Wakayama Medical University Hospital.

Patients  This study included 689 patients who underwent curative gastrectomy (R0). Patients who underwent laparoscopic gastrectomy, gastrectomy with pancreaticoduodenectomy, gastrectomy with another organ resection (liver, colon, or ovary), or gastrectomy with thoracotomy were not included.

Main Outcome Measures  Duration of operation, amount of blood loss, incidence of postoperative complications, and survival analysis.

Results  The mean (SD) duration of the operation was longer in the overweight group (315 [75] minutes) than in the normal-weight group (277 [85] minutes) (P < .001). The mean (SD) intraoperative blood loss was larger in the overweight group (882 [764] mL) than in the normal-weight group (536 [410] mL) (P < .001). The rates of postoperative complications (anastomotic leakage, pancreatic fistula, and intra-abdominal abscess) were significantly higher in the overweight group (P < .05). Multivariate logistic regression analysis identified that postoperative complications were significantly associated with being overweight (P = .01) and with undergoing pancreatectomy (P = .03). Disease-specific and overall survival did not show any significant difference between the 2 groups.

Conclusions  Being overweight is not a poor risk factor for survival in patients with gastric cancer, although it is independently predictive of postoperative complications.

Data Sources  A systematic literature search was conducted using the MEDLINE, EMBASE, and Cochrane databases and included a manual search of references of original articles, poster presentations, and abstracts from major meetings ("gray" literature).

Study Selection  Twenty-one of 2167 articles met the inclusion criteria. Of these, 5 randomized controlled trials (3001 patients) assessed the effect of perioperative supplemental oxygen use on the SSI rate. Studies used a treatment-inspired oxygen concentration of 80%. Maximum follow-up was 30 days.

Data Extraction  Data were abstracted by 3 independent reviewers using a standardized data collection form. Relative risks were reported using a fixed-effects model. Results were subjected to publication bias testing and sensitivity analyses.

Data Synthesis  Infection rates were 12.0% in the control group and 9.0% in the hyperoxic group, with relative risk reduction of 25.3% (95% confidence interval [CI], 8.1%-40.1%) and absolute risk reduction of 3.0% (1.1%-5.3%). The overall risk ratio was 0.742 (95% CI, 0.599-0.919; P = .006). The benefit from increasing oxygen concentration was greater in colorectal-specific procedures, with a risk ratio of 0.556 (95% CI, 0.383-0.808; P = .002).

Conclusions  Perioperative supplemental oxygen therapy exerts a significant beneficial effect in the prevention of SSIs. We recommend its use along with maintenance of normothermia, meticulous glycemic control, and preservation of intravascular volume perioperatively in the prevention of SSIs.

Hypothesis  Human acellular dermal matrix is a suitable implant for CVHR in a compromised surgical field.

Design  Multi-institutional, 5-year retrospective review.

Setting  Four academic medical centers.

Patients and Methods  Each center obtained institutional review board approval. Patients included in the review had undergone CVHR with human acellular dermal matrix. Data collected included age, body mass index (calculated as weight in kilograms divided by height in meters squared), comorbidities, size of fascial defect, wound classification, hospital length of stay, length of follow-up, and mortality. Primary outcomes were surgical site infection, fistula recurrence, and hernia recurrence. Both ² and logistic regression analyses were performed.

Results  Two hundred forty patients met the study criteria. Their mean (SD) age was 52.2 (15.0) years, and 132 (55.0%) were men. The most common comorbidity was hypertension (115 patients [47.9%]), and the mean defect size was 201 cm². The mean hospital length of stay was 17.2 days, and the mean follow-up was 317 days. The overall mortality was 2.9%. The hernia recurrence rate was 17.1% (41 patients). Repair of a fistula or stoma was associated with hernia recurrence (P = .03) and with fistula recurrence (P < .001). Logistic regression analysis demonstrated surgical site infection and body mass index of greater than 30 to be independent risks of hernia recurrence.

Conclusions  Human acellular dermal matrix is a suitable alternative for CVHR in a compromised surgical field. The hernia recurrence rate with human acellular dermal matrix in a compromised surgical field is less than that seen with primary repair, offering additional and improved surgical options for CVHR in this group of patients. Stoma or fistula takedown at the time of CVHR continues to be associated with significant complications.

Design  Retrospective review and statistical analysis using prospectively collected data.

Setting  Referral center with a dedicated multidisciplinary pancreas cancer program.

Patients  Two hundred eighty-five consecutive patients with data available for BMI calculation who underwent potentially curative pancreas resection to treat adenocarcinoma from January 1, 1999, to October 31, 2006.

Main Outcome Measure  Influence of BMI and other known prognostic variables on the incidence of lymph node metastasis and disease-free and overall survival.

Results  We identified a subset of obese patients (BMI >35) who were at 12-fold risk of lymph node metastasis compared with nonobese patients (BMI ≤35). The estimated disease-free and overall survival rates were decreased in the obese patients, and the risk of cancer recurrence and death after pancreatectomy was nearly twice that in nonobese patients.

Conclusions  Obese patients with a BMI of more than 35 are more likely to have node-positive pancreatic cancer and decreased survival after surgical resection. Data suggest that the negative influence of BMI of more than 35 on cancer-related end points is unrelated to the potential complexity of performing major oncologic surgery in obese patients.

Design  Retrospective cohort.

Setting  University hospital.

Patients  Thirty patients with thoracoabdominal aneurysms were evaluated between November 1, 2005, and December 31, 2006.

Interventions  There were 18 HRs and 12 ORs. Aortic abnormalities included the arch, visceral aorta, and arch/visceral aorta combined. Aortic debranching with TEVAR (HR) was performed at a single setting. Dacron grafts were used for OR, and branch vessels were bypassed. Hospital costs and reimbursements were obtained from the finance department.

Main Outcome Measures  Perioperative morbidity, mortality, and cost.

Results  Patients were significantly older in the HR group (mean [SD], 72 [8.9] vs 58 [17.4] years, P = .2). The HR group had significantly less blood loss (mean [SD], 1.7 [2.3] vs 4.8 [3.1] L, P = .004), transfusions (5.1 [5.9] vs 14.7 [7.8] units, P = .001), renal failure (0% vs 42.0%, P = .002), and pulmonary morbidity (17% vs 67%, P < .001); shorter intensive care unit stays (5.2 [4.8] vs 16.4 [12.9] days, P = .005); and shorter hospital length of stay (mean [SD], 11.6 [6.2] vs 20.8 [10.8] days, P = .01). There were no differences in mortality or spinal cord ischemia. There was no difference in mean direct hospital costs (HR: $59 435.70 vs OR: $49 341; P = .35). However, the mean cost margin per case was –34% for HR and +6.2% for OR (P = .04).

Conclusions  Improved clinical outcomes are seen after HR despite treatment of an older, sicker patient population. However, HR ultimately comes at a significant cost to the hospital, with a 34% loss in revenue per case.

Design  Retrospective review.

Setting  University hospital.

Patients  Thirty-one transplant recipients who underwent LIHR between July 9, 2004, and October 27, 2005.

Main Outcome Measures  Operative complications and incisional hernia recurrence.

Results  The mean (SD) mesh size required for LIHR was 611 (307) cm². Median (range) hospital stay was 4 (1-28) days, with follow-up of 589 (22-953) days. Eighteen patients developed a postoperative complication, most frequently seroma formation, which occurred in 13 patients (72%). The mesh size required for LIHR was significantly larger in patients with a postoperative complication (n = 18; 706 [319] cm² vs n = 13; 480 [244] cm²; P = .04). Seroma formation was not associated with previous open hernia repair, diabetes mellitus, or corticosteroid use. No statistically significant relationship was noted between the transplanted organ and seroma development. There were no post-LIHR wound infections. In 7 patients (23%), hernia recurred.

Conclusions  Laparoscopic incisional hernia repair in solid-organ transplant recipients is associated with a high rate of seroma formation but minimal long-term morbidity. The recurrence rate after LIHR is equivalent to that after open hernia repair. These results suggest that LIHR is a safe and effective alternative to open repair in this patient population.

Design and Patients  This study included 357 consecutive patients who underwent colorectal resection. We evaluated intraoperative and postoperative complications, symptom outcomes, and long-term follow-up.

Main Outcome Measure  Three hundred forty-three patients (96.1%) underwent laparoscopic colorectal resection, and radical endometriosis ablation was in 334 patients (93.6%).

Results  Fourteen (3.9%) required laparoconversion. Median operating time was 300 (range, 85-720) minutes, with a median estimated blood loss of 250 (range, 50-550) mL. Radical endometriosis ablation was achieved in 334 patients (93.6%). Median ileus was 4 (range, 1-8) days, with a median postoperative hospitalization of 8 (range, 3-36) days. Early and late complications were observed in 44 patients (12.3%) and, in 35 of these (79.5%), surgical management was necessary. Median follow-up after colorectal resection was 19.6 (range, 6-48) months. The median preoperative and postoperative dyspareunia scores were 8 (range, 4-10) and 3 (range, 0-10), respectively (P < .04), and the median preoperative and postoperative gastrointestinal tract symptom scores were 7 (range, 2-10) and 2 (range, 0-10), respectively (P < .05). During follow-up, 24 of 286 recurrences (8.4%) were registered. Patients who previously underwent surgery for endometriosis showed a higher risk of recurrence compared with patients undergoing primary surgery (13.2% vs 3.4%; P < .048).

Conclusions  Laparoscopic colorectal resection for severe endometriosis is feasible and markedly improved endometriosis-related symptoms. Despite the risk of major postoperative complications, the procedure shows good results in terms of recurrence rate and could be adopted as the primary approach for patients with symptomatic colorectal infiltrating endometriosis.

Design  Time-to-event analysis.

Setting  Academic research.

Patients  The United Network for Organ Sharing provided deidentified patient-level data. Analysis included 19 373 heart transplant recipients from January 1, 1995, to December 31, 2005.

Main Outcome Measures  Multivariate Cox proportional hazards regression analysis was performed to identify pretransplantation recipient characteristics associated with improved long-term survival following HKT. Kaplan-Meier survival functions and Cox proportional hazards regression were used for time-to-event analysis. Using the relative risks calculated in regression analysis, weights were assigned for each risk factor, allowing for the construction of a risk score.

Results  Among heart transplant recipients, 264 (1.4%) underwent HKT. Factors associated with diminished survival included peripheral vascular disease, recipient age older than 65 years, nonischemic etiology of heart failure, dialysis dependence at the time of transplantation, and bridge to transplantation using a ventricular assist device. After stratification by risk score, 1-year survival was 93.2% and 61.9% in the lowest- and highest-risk HKT groups, respectively. Further stratification by estimated glomerular filtration rate (eGFR) was performed based on a previous study showing decreased survival of patients undergoing orthotopic heart transplantation with a preoperative eGFR of less than 33 mL/min. Low-risk patients with an eGFR of less than 33 mL/min undergoing HKT constituted the only group that had significantly better survival compared with isolated patients undergoing orthotopic heart transplantation with eGFRs and risk scores in the same range (P = .006).

Conclusions  When patients were stratified by risk score and by diminished eGFR (<33 mL/min), low-risk HKT recipients with a diminished eGFR had improved survival following HKT over isolated heart transplant recipients. Only low-risk patients with combined kidney failure (eGFR, <33 mL/min) and heart failure seem to gain a survival benefit from HKT.

Design and Setting  Retrospective cohort study in a university tertiary referral center.

Patients and Methods  Patients with cancer of the thoracic esophagus or esophagogastric junction seen from 1980 through 2004 were included (N = 3493). Three time periods were defined: 1980-1987, 1988-1995, and 1996-2004.

Main Outcome Measures  Clinical presentation, tumor characteristics, and morbidity, mortality, and survival rates among patients with esophageal cancer undergoing esophagectomy.

Results  The ratio of squamous cell carcinoma to adenocarcinoma decreased from 3.3 to 1.7 (P <.001) during the study period, in parallel with an increase in the number of patients with tumors in the lower esophagus/esophagogastric junction. An increasing proportion of patients who underwent resection received neoadjuvant treatment (chemotherapy/chemoradiotherapy), and 1978 patients underwent esophagectomy. The R0 resection rate increased from 74.5% to 90.1% (P <.001). In addition, an increasing proportion of patients had early-stage tumor in the resected specimen. In-hospital postoperative mortality decreased from 8.2% to 2.6% (P <.001), and the 5-year survival rate significantly improved from 18.8% to 42.3% (P <.001) for all patients who underwent resection. Pathological tumor stage, completeness of the resection, time period, sex, tumor histological type, and tumor location influenced the prognosis of patients with esophageal cancer undergoing esophagectomy.

Conclusions  A change in location and histological type of esophageal cancer has occurred during the past 25 years. Earlier diagnosis, a multidisciplinary approach, and refinements in surgical technique and perioperative care have led to a significant reduction in postoperative mortality rate and improved long-term survival among patients with cancer of the thoracic esophagus or esophagogastric junction.

Design  Retrospective cohort study of patients operated on for primary adrenal disease between September 1, 1987, and August 17, 2007.

Setting  Academic hospital.

Patients  Sixty-six patients treated before (group 1) and 203 treated after (group 2) introduction of laparoscopic adrenalectomy.

Main Outcome Measures  Patient characteristics, comorbidity, tumor size, indication, and time between diagnosis and surgery.

Results  Group 2 had more patients in American Society of Anesthesiologists class III with gastrointestinal and metabolic-endocrine comorbidities. Tumor size did not change, and, despite an increase in the number of adrenalectomies, indications for surgery remained consistent over time.

Conclusion  Despite an increased volume of procedures, the introduction of laparoscopic adrenalectomy in our hospital did not change the indications for surgical intervention.

Design  Retrospective analysis.

Setting  Tertiary care referral center.

Patients  A total of 689 consecutive patients treated for acute pancreatitis between 2001 and 2005, of whom 64 (9.3%) had pancreatic necrosis documented on contrast-enhanced computed tomography.

Main Outcome Measures  Mortality and organ failure.

Results  In the 64 patients with documented NP, overall mortality was 16%. Thirty-six patients (56%) had organ failure according to the Atlanta classification. Compared with patients with sterile necrosis, those with infected necrosis did not have an increased prevalence of organ failure or increased need for intubation, pressors, or dialysis but had an increased mortality. Mortality in patients treated conservatively was 1 of 29 (3%); in those with PCD alone, 6 of 11 (55%); in those with PCD and surgery, 2 of 17 (12%); and in those with surgery alone, 1 of 7 (14%). All patients treated with PCD alone had organ failure, whereas 10 (59%) of those with PCD and surgery had organ failure.

Conclusion  The use of PCD did not improve the mortality of NP among patients with organ failure.

Data Sources  Published randomized controlled trials of CH vs SH with a minimum clinical follow-up of 12 months were searched and selected in the MEDLINE, EMBASE, and Cochrane Library databases using the keywords hemorrhoid, stapl, and anopexy, without language restrictions.

Study Selection  Potentially relevant studies were identified by the title and the abstract, and full articles were obtained and assessed in detail.

Data Extraction  Studies were scored according to the presence of 3 key methodologic features of randomization, blinding, and accountability of all patients, including withdrawals, and the scores ranged from 0 to 5. Studies that received a score from 3 to 5 were considered high-quality studies, whereas those with a score of 2 or less were considered of low quality. A specifically designed data form was used to collect all relevant data, including details of the experimental design, patient demographics, technical aspects, outcome measures, and complications.

Data Synthesis  Fifteen articles met the inclusion criteria for a total of 1201 patients. Outcomes at a minimum of 1 year showed a significantly higher rate of prolapse recurrences in the SH group (14 studies, 1063 patients; odds ratio, 5.5; P < .001) and patients were more likely to undergo further treatment to correct recurrent prolapses compared with the CH group (10 studies, 824 patients; odds ratio, 1.9; P = .02).

Conclusion  Stapled hemorrhoidopexy is a safe technique for the treatment of hemorrhoids but carries a significantly higher incidence of recurrences and additional operations compared with CH. It is the patient's choice whether to accept a higher recurrence rate to take advantage of the short-term benefits of SH.

Data Sources  A structured Medline search for published studies.

Study Selection  The available literature from 1975 until June 2007 was searched using the Medical Subject Headings of the National Library of Medicine term fundoplication and the free-text terms fundoplication, surgery, and reflux. Data were analyzed using Review Manager software (Cochrane Collaboration, Oxford, England).

Data Extraction  Eleven trials were identified comparing TF with PF in 991 patients.

Data Synthesis  Total fundoplication resulted in a significantly higher incidence of postoperative dysphagia (odds ratio [OR], 1.82-3.93; P < .001), bloating (OR, 1.07-2.56; P = .02), and flatulence (OR, 1.66-3.96; P < .001). No significant differences were noted in the incidence of esophagitis (OR, 0.72-2.7; P = .33), heartburn (OR, 0.48-1.52; P = .58), or persisting acid reflux (OR, 0.77-1.79; P = .45). The reoperation rate was significantly higher after TF compared with PF (OR, 1.13-3.95; P = .02). No significant differences were present in the proportion of patients experiencing a good or excellent long-term outcome (OR, 0.54-1.38; P = .53) or in the proportion of patients with a Visick I or II score (OR, 0.62-1.59; P = .99).

Conclusions  Partial fundoplication is a safe and effective alternative to TF, resulting in significantly fewer reoperations and a better functional outcome. The poor quality of the included trials warrants caution in the interpretation of the results of this meta-analysis.