Design  Prospective study.

Setting  Academic research.

Patients  Using a pentaplex polymerase chain reaction assay, MSI status was determined prospectively for 135 operative patients.

Main Outcome Measures  Mismatch repair defects were investigated by immunohistochemistry on tumors demonstrating MSI.

Results  Among 82 stage I or II colorectal carcinomas, 11 had MSI, and 71 had MSS, with a mean (SD) number of 23.6 (3.1) and 13.7 (1.0) negative lymph nodes, respectively (P = .001). The mean number of lymph nodes for all resected stage I or II colorectal carcinomas analyzed at our hospital was 15. The prevalence of MSI among tumors with more than 15 lymph nodes in the specimen was 25% (9 of 36), and 82% (9 of 11) of MSI tumors belonged to this group.

Conclusions  A high number of isolated lymph nodes in stage I or II colorectal carcinomas was associated with the MSI phenotype. Good prognosis that is usually associated with tumors having a high number of uninvolved lymph nodes might reflect the high prevalence of MSI among these tumors. The number of examined lymph nodes as a quality criterion should be used with caution. For stage I or stage II colorectal carcinomas, restricting MSI phenotyping to tumors with more than the mean number of lymph nodes identifies almost all MSI tumors.

Design  Single-institutional retrospective review.

Setting  Tertiary referral center.

Patients  All consecutive patients undergoing total laparoscopic pancreaticoduodenectomy from July 2007 through July 2009 at a single center (n = 62).

Main Outcome Measures  Blood loss, operative time, postoperative morbidity, length of hospital stay, and 30-day or in-hospital mortality.

Results  Of 65 patients undergoing laparoscopic resection, 62 patients with a mean age of 66 years (SD, 12 years) underwent total laparoscopic pancreaticoduodenectomy. The pancreaticojejunostomy consisted of a duct-to-mucosa anastomosis with interrupted suture. Median operative time was 368 minutes (range, 258-608 minutes) and median blood loss was 240 mL (range, 30-1200 mL). Diagnosis was pancreatic adenocarcinoma (n = 31), intraductal papillary mucinous neoplasm (n = 12), periampullary adenocarcinoma (n = 8), neuroendocrine tumor (n = 4), chronic pancreatitis (n = 3), cholangiocarcinoma (n = 1), metastatic renal cell carcinoma (n = 1), cystadenoma (n = 1), and duodenal adenoma (n = 1). Median tumor size was 3 cm (range, 0.9-10.0 cm) and the median number of lymph nodes harvested was 15 (range, 6-31). Perioperative morbidity occurred in 26 patients and included pancreatic fistula (n = 11), delayed gastric emptying (n = 9), bleeding (n = 5), and deep vein thrombosis (n = 2). There was 1 postoperative mortality. Median length of hospital stay was 7 days (range, 4-69 days).

Conclusions  Laparoscopic pancreaticoduodenectomy is feasible, safe, and effective. Outcomes appear comparable with those via the open approach; however, controlled trials are needed. Despite this series representing experience within the learning curve, laparoscopic pancreaticoduodenectomy holds promise for providing advantages seen with minimally invasive approaches in other procedures.

Design  Our study was a prospective trial conducted following written informed consent, with randomization by the serially numbered, opaque envelope technique.

Setting  Our institution is an academic teaching hospital and the central receiving and trauma center for the City and County of San Francisco, California.

Patients  We randomized 122 patients (American Society of Anesthesiologists grade 1 or 2) meeting entry criteria. Ten of these patients, excluded from outcome analysis, were protocol violators having signed out of the hospital against medical advice before 1 or both procedures were completed.

Interventions  Treatment was preoperative ERCP/S followed by LC, or LC+LCBDE.

Main Outcome Measures  The primary outcome measure was efficacy of stone clearance from the common bile duct. Secondary end points were length of hospital stay, cost of index hospitalization, professional fees, hospital charges, morbidity and mortality, and patient acceptance and quality of life scores.

Results  The baseline characteristics of the 2 randomized groups were similar. Efficacy of stone clearance was likewise equivalent for both groups. The time from first procedure to discharge was significantly shorter for LC+LCBDE (mean [SD], 55 [45] hours vs 98 [83] hours; P < .001). Hospital service and total charges for index hospitalization were likewise lower for LC+LCBDE, but the differences were not statistically significant. The professional fee charges for LC+LCBDE were significantly lower than those for ERCP/S+LC (median [SD], $4820 [1637] vs $6139 [1583]; P < .001). Patient acceptance and quality of life scores were equivalent for both groups.

Conclusions  Both ERCP/S+LC and LC+LCBDE were highly effective in detecting and removing common bile duct stones and were equivalent in overall cost and patient acceptance. However, the overall duration of hospitalization was shorter and physician fees lower for LC+LCBDE.

Trial Registration  clinicaltrials.gov Identifier: NCT00807729

Design  Retrospective study.

Setting  Rikshospitalet University Hospital.

Patients  One hundred thirty-nine patients who underwent 177 laparoscopic liver resections in 149 procedures from August 18, 1998, through October 14, 2008. One hundred thirteen patients had malignant lesions, of whom 96 had colorectal metastases.

Intervention  Laparoscopic liver resection for malignant and benign lesions.

Main Outcome Measures  Perioperative and oncologic outcomes and survival.

Results  Five procedures (3.4%) were converted to laparotomy and 1 (0.7%) to laparoscopic radiofrequency ablation. The remaining 143 procedures were completed laparoscopically, during which 177 liver resections were undertaken, including 131 nonanatomic and 46 anatomic resections. The median operative time and blood loss were 164 (50-488) minutes and 350 (<50-4000) mL, respectively. There were 10 intraoperative (6.7%) and 18 postoperative (12.6%) complications. One patient (0.7%) died. The median postoperative stay and opioid requirement were 3 (1-42) and 1 (0-11) days, respectively. Tumor-free resection margins determined by histopathologic evaluation were achieved in 140 of 149 malignant specimens (94.0%). The 5-year actuarial survival for patients undergoing procedures for colorectal metastases was 46%.

Conclusions  In experienced hands, laparoscopic liver resection is a favorable alternative to open resection. Perioperative morbidity and mortality and long-term survival after laparoscopic resection of colorectal metastases appear to be comparable to those after open resections.

Design  Retrospective record review.

Setting  Tertiary academic medical center.

Patients  All patients who underwent primary laparoscopic ileocolectomy for terminal ileal Crohn disease between April 28, 1994, and August 3, 2006, at the Mayo Clinic, Rochester, Minnesota.

Main Outcome Measures  All patients were reviewed for follow-up, recurrence, risk factors for recurrence, and use of postoperative immunosuppressive prophylaxis.

Results  One hundred nine patients were identified, of whom 89 were followed up postoperatively at Mayo Clinic with a median follow-up of 3.5 years (range, 1.8 months to 11.9 years). Recurrence was discovered in 54 patients (61%) at a median of 13.1 months (range, 1.3 months to 8.7 years). Forty-four patients (49%) received postoperative immunosuppressive prophylaxis (37 [42%] received azathioprine, 8 [9%] received 6-mercaptopurine, and 3 [3%] received infliximab). In a multivariate model of various risk factors for recurrence, presence of granulomas was the only significant predictor of recurrence (P = .01). The 2-year cumulative recurrence rates in the prophylaxis and nonprophylaxis groups were 37.5% and 52.6%, respectively (log-rank test, P = .87).

Conclusions  Recurrence occurred in more than half of the patients with Crohn disease after primary laparoscopic ileocolectomy. In this highly selected patient population, use of immunosuppressive prophylaxis was not associated with a delay in recurrence. Presence of granulomas was the only significant predictor of recurrence. These findings should be further explored in larger and less selected patient populations.

Objective  To identify the additional benefit of adjuvant therapy by retrospectively examining a large population-based registry of patients who underwent definitive surgical resection for pancreatic adenocarcinoma.

Design and Setting  The Florida cancer registry and state inpatient and outpatient hospital data records were queried for pancreatic adenocarcinoma diagnosed between 1998 and 2002.

Patients  A total of 2877 patients who underwent surgical resection with curative intent for pancreatic adenocarcinoma were identified.

Main Outcome Measure  Overall survival time.

Results  Overall, 58.7% of patients were older than 65 years. Most patients were white (90.7%), were non-Hispanic (86.7%), and did not consume alcohol abusively (89.2%). Approximately half of the patients (51.9%) did not receive chemotherapy or chemoradiotherapy. Approximately 25.0% of the patients underwent chemoradiotherapy, and 10.0% received chemotherapy alone. Patients were more frequently treated at low-volume centers (57.6%) and nonteaching facilities (72.8%). Multivariate analysis correcting for patient comorbidities demonstrated that postoperative chemoradiotherapy (hazard ratio = 0.69, P = .04) and treatment at high-volume centers (hazard ratio = 0.85, P < .001) and teaching facilities (hazard ratio = 0.84, P < .001) were independent predictors of improved survival.

Conclusions  Adjuvant chemoradiotherapy was found to provide a significant additional survival benefit to surgical resection for patients with pancreatic adenocarcinoma. Furthermore, this benefit is independent of the additional survival advantage when patients are treated at teaching facilities or high-volume centers. Although selection bias may be contributing to the observed differences, these data nonetheless support the use of adjuvant chemoradiotherapy for pancreatic cancer.

Design  Decision analytic Markov state transition model with multiple logistic regression models as inputs. Data from the 2005 National Inpatient Survey were used to calculate in-hospital mortality risk associated with bariatric surgery and then adjusted for 30-day mortality. To calculate excess mortality associated with obesity, we used the 1991-1996 National Health Interview Survey linked to the National Death Index. Bariatric surgery was assumed to influence mortality only through its impact on the excess mortality associated with obesity, and the efficacy of surgery was estimated from a recent large observational trial.

Intervention  Gastric bypass surgery.

Main Outcome Measure  Life expectancy.

Results  Our base case, a 42-year-old woman with a body mass index of 45, gained an additional 2.95 years of life expectancy with bariatric surgery. No surgical treatment was favored in our base case when the 30-day surgical mortality exceeded 9.5% (baseline 30-day mortality, 0.2%) or when the efficacy of bariatric surgery for reducing mortality decreased to 2% or less (baseline efficacy, 53%).

Conclusions  The optimal decision for individual patients varies based on the balance of risk between perioperative mortality, excess annual mortality risk associated with increasing body mass index, and the efficacy of surgery; however, for the average morbidly obese patient, gastric bypass improves life expectancy.

Design  Epidemiologic study.

Setting  The National Hospital Discharge Survey

Patients  Estimated US hospitalized population.

Main Outcome Measures  International Classification of Diseases, Ninth Revision, Clinical Modification discharge diagnosis codes of the National Hospital Discharge Survey were queried from 1970 to 2006 to identify admissions for appendicitis, influenza, rotavirus, and enteric infections. Cointegration analysis of time series data was used to determine if the disease incidence trends for these various disease entities varied over time together.

Results  Rates of influenza and nonperforating appendicitis declined progressively from the late 1970s to 1995 and rose thereafter, but influenza rates exhibited more distinct seasonal variation than appendicitis rates. Rotavirus infection showed no association with the incidence of nonperforating appendicitis. Perforating appendicitis showed a dissimilar trend to both nonperforating appendicitis and viral infection. Hospital admissions for enteric infections substantially increased over the years but were not related to appendicitis cases.

Conclusions  Neither influenza nor rotavirus are likely proximate causes of appendicitis given the lack of a seasonal relationship between these disease entities. However, because of significant cointegration between the annual incidence rates of influenza and nonperforated appendicitis, it is possible that these diseases share common etiologic determinates, pathogenetic mechanisms, or environmental factors that similarly affect their incidence.

Design  Analysis of the University HealthSystem Consortium database from October 1, 2004, through September 31, 2007.

Setting  A total of 102 academic medical centers and approximately 150 of their affiliated hospitals, representing more than 90% of the nation's nonprofit academic medical centers.

Patients  Medicare and Medicaid patients who underwent bariatric surgery to treat morbid obesity.

Main Outcome Measures  Demographics, length of stay, 30-day readmission, morbidity, observed-to-expected mortality ratio, and costs.

Results  A total of 3196 bariatric procedures were performed before and 3068 after the NCD. After the implementation of the NCD, the volume of gastric banding doubled and the proportion of laparoscopic gastric bypass increased from 60.0% to 77.2%. Patients who underwent bariatric surgery after the NCD benefited from a shorter length of stay (3.5 vs 3.1 days, P < .001) and lower overall complication rates (12.2% vs 10.0%, P < .001), with no significant differences in the in-hospital mortality rates (0.28% vs 0.20%). Among Medicare patients, there was a 29.3% reduction in the number of bariatric procedures performed within the first 2 quarters after the NCD. However, the number of procedures returned to baseline volume within 1 year and exceeded baseline volume after 2 years of the NCD.

Conclusion  The bariatric surgery NCD resulted in improved outcomes for Medicare beneficiaries without limiting access to care for individuals with medical disability.

Design  Observational study from January 1, 1993, through December 31, 2006.

Setting  Bellvitge University Hospital, Barcelona, Spain.

Patients  A total of 1046 patients underwent emergency colorectal resection. Patients were classified into 2 groups: those operated on by a colorectal surgeon (CS) and those operated on by a general surgeon (GS).

Main Outcome Measures  Preoperative variables studied were sex, age, American Society of Anesthesiologists grade, associated medical disease, presentation, reason for surgery, and type of operation. Univariate relations between predictors and outcomes were estimated, and multivariate logistic regression analysis was used to assess the prognostic effect of the combination of the variables.

Results  Patients in the CS group underwent a significantly higher percentage of resection and primary anastomosis. The postoperative morbidity rate was 52.2% in the CS group and 60.5% in the GS group (P = .01). The anastomotic dehiscence rate was lower in the CS group (6.2%) than in the GS group (12.1%) (P = .01). Postoperative mortality decreased among patients in the CS group (17.9%) with respect to the patients in the GS group (28.3%) (P < .001). Being operated on by a CS was predictive in both the univariate and multivariate analyses for postoperative complications and mortality, and it was the only variable with predictive value for anastomotic dehiscence.

Conclusions  Specialization in colorectal surgery has a significant influence on morbidity, mortality, and anastomotic dehiscence after emergency operations.

Data Sources  We conducted a review of the medical literature by the use of PubMed and OVID MEDLINE databases.

Study Selection  We identified all published series that describe the use of cricothyrotomy, with the inclusion of the subset of patients who require an emergency airway after trauma, from January 1, 1978, to January 1, 2008.

Data Extraction  Only 20 published series of cricothyrotomy were identified: 17 retrospective reports and 3 prospective, observational series.

Data Synthesis  Considerable variance in methods and follow-up periods were noted between examinations. Published experiences documented the results of 1134 total patients for whom cricothyrotomy was performed, including 368 trauma patients who underwent emergent cricothyrotomy. The rate of chronic subglottic stenosis among survivors after cricothyrotomy was 2.2% (11/511) overall and 1.1% (4/368) among trauma patients for follow-up periods with a range from 2 to 60 months. Only 1 (0.27%) of the 368 trauma patients in whom an emergent cricothyrotomy was performed required surgical treatment for chronic subglottic stenosis. Although the literature that documents complications of surgical airway conversion is scarce, rates of severe complications of up to 43% were reported.

Conclusions  Cricothyrotomy after trauma is safe for initial airway access among patients who require the establishment of an emergent airway. The prolonged use of a cricothyrotomy tube, however, remains controversial. Although no study to date has demonstrated any benefit of routine conversion to tracheostomy, considerable deficiencies in existing studies highlight the need for further investigations of this practice.

Design  Retrospective, population-based cohort study.

Setting  Washington State hospital discharge database.

Participants  A total of 101 318 adults 65 years or older who underwent common abdominal procedures such as cholecystectomy, colectomy, and hysterectomy from 1987 through 2004.

Main Outcome Measures  Ninety-day rates of postsurgical morbidity and mortality.

Results  The 90-day cumulative incidence of complications was 17.3%, with a 90-day mortality rate of 5.4%. Advancing age was associated with increasing frequency of complications (65-69 years, 14.6%; 70-74 years, 16.1%; 75-79 years, 18.8%; 80-84 years, 19.9%; 85-89 years, 22.6%; and ≥90 years, 22.7%; trend test, P < .001) and mortality (65-69 years, 2.5%; 70-74 years, 3.8%; 75-79 years, 6.0%; 80-84 years, 8.1%; 85-89 years, 12.6%; and ≥90 years, 16.7%; trend test, P < .001). After adjusting for demographic, patient, and surgical characteristics as well as hospital volume, the odds of early postoperative death increased considerably with each advance in age category. These associations were found among patients with both cancer and noncancer diagnoses and for both elective and nonelective admissions (trend test, P < .001).

Conclusions  Among older adults, the risk of complications and early death after commonly performed abdominal procedures is greater than previously reported. These rates should be considered in ongoing quality improvement initiatives and may be helpful when counseling patients regarding abdominal operations.

Design  Our prospectively accrued cancer registry was analyzed for all colon cancer resections performed in a consecutive 52-month period (January 1, 2003, through April 30, 2007).

Setting  The study was performed at an 851-bed community hospital. Seventeen surgeons performed colon resections, with the number of resections varying from 1 to 154. Ten pathologists and 3 pathology assistants evaluated the specimens.

Patients  A total of 430 patients met the inclusion criteria and underwent surgical resection. Only patients with colon cancer were included in the study; patients with rectal cancers, in situ disease only, T4 tumors, and stage IV disease at the time of diagnosis were excluded to ensure a uniform group of patients, all undergoing resection with curative intent.

Main Outcome Measures  Age of the patient; the surgeon, pathologist, and pathology technician; stage of disease; and year of surgery were analyzed.

Results  No statistical difference was found in the number of lymph nodes retrieved based on the surgeon (P = .21), pathologist (P = .11), or pathology technician (P = .26). Age of the patient, primary site of the tumor, stage, and year of surgery were all significantly associated with number of lymph nodes retrieved (P <.001).

Conclusions  The origin of a low lymph node count appears multifactorial. Inadequate lymph node retrieval for colon cancer resections cannot uniformly be attributed to 1 factor, such as the surgeon.

Design  We customized the Trauma Mortality Probability Model to create separate injury-specific models for patients who sustained blunt trauma, gunshot wounds, pedestrian trauma, or motor vehicle accident trauma.

Setting  This analysis was conducted using the National Trauma Data Bank. We limited the study to hospitals with 250 or more trauma admissions per year, which coded more than 90% of patients.

Patients  The final data set included 54 859 patients admitted to 44 hospitals.

Main Outcome Measures  We performed hospital-level analyses to examine the correlation between hospital risk-adjusted mortality measures based on all trauma patients vs quality measures based on injury-specific measures.

Results  The analysis of the intraclass correlation coefficients suggests fair-to-substantial agreement (0.39-0.68) between the hospital-adjusted odds ratios based on all patients vs odds ratios based on specific injuries. Analysis demonstrated poor-to-fair agreement between hospital categorical quality measures (high, intermediate, and low quality) when hospital quality was based on outcomes for all trauma patients vs specific subgroups of patients (0.0-0.38). However, none of the hospitals classified as high quality, based on data from all trauma patients, was found to be low quality for any specific injury populations.

Conclusion  A single composite measure based on all injured patients may not capture all the differences in hospital quality across different populations of injured patients.

Design  A randomized controlled trial.

Setting  An acute care hospital.

Patients  Adult patients with an obstructing tumor between the splenic flexure and rectosigmoid junction.

Main Outcome Measures  Successful 1-stage operation, cumulative operative time, blood loss, hospital stay, pain score, and postoperative complications.

Results  Forty-eight patients were analyzed. Twenty-four underwent endoluminal stenting followed by laparoscopic resection and 24 underwent emergency open surgery. The 2 groups were matched for age, sex, body mass index, and disease staging. Patients in the endolaparoscopic group had significantly less cumulative blood loss and lower pain, incidence of anastomotic leak, and wound infection. Significantly more patients in the endolaparoscopic group had a successful 1-stage operation performed (16 vs 9, P = .04). None of the patients in the endolaparoscopic group had a permanent stoma compared with 6 patients in the emergency open surgery group (P = .03).

Conclusions  Self-expanding metal stents serve as a safe and effective bridge to subsequent laparoscopic surgery in patients with obstructing left-sided colon cancer. This endolaparoscopic approach makes a 1-stage operation more feasible, is associated with reduced incidence of stoma creation, and allows patients with malignant large-bowel obstruction to enjoy the full benefit of minimally invasive surgery.

Trial Registration  clinicaltrials.gov Identifier: NCT00654212

Design  Prospective study of checklist use, error self-reporting, and a 10-point safety empowerment survey after participation in a crew resource management training intervention.

Setting  Seven hundred twenty-two–bed university hospital; 247-bed affiliated community hospital.

Participants  There were 857 participants, the majority of whom were nurses (50%), followed by ancillary personnel (28%) and physicians (22%).

Main Outcome Measures  Preoperative checklist use over time; number and type of entries on a Web-based incident reporting system; and measurement of degree of empowerment (1-5 scale) on a 10-point survey of safety attitudes and actions given prior to, immediately after, and a minimum of 2 months after training.

Results  Since 2003, 10 courses trained 857 participants in multiple disciplines. Preoperative checklist use rose (75% in 2003, 86% in 2004, 94% in 2005, 98% in 2006, and 100% in 2007). Self-initiated reports increased from 709 per quarter in 2002 to 1481 per quarter in 2008. The percentage of reports related to environment as opposed to actual events increased from 15.9% prior to training to 20.3% subsequently (P < .01). Perceived self-empowerment, creating a culture of safety, rose by an average of 0.5 point in all 10 realms immediately posttraining (mean [SD] rating, 3.0 [0.07] vs 3.5 [0.05]; P < .05). This was maintained after a minimum of 2 months. There was a trend toward a hierarchical effect with participants less comfortable confronting incompetence in a physician (mean [SD] rating, 3.1 [0.8]) than in nurses or technicians (mean [SD] rating, 3.4 [0.7] for both) (P>.05).

Conclusions  Crew resource management programs can influence personal behaviors and empowerment. Effects may take years to be ingrained into the culture.

Design  Review of findings from a prospectively acquired institutional database.

Setting  University hospital.

Patients  Fifty-five consecutive patients operated on by the same surgeon between October 1997 and March 2008.

Main Outcome Measures  Blood loss, complication rate, and survival.

Results  All operations were accomplished without conversion to open laparotomy. The median operative time was 406 minutes. The median blood loss was 102 mL. A median of 46 lymph nodes were harvested. The TNM stages of the tumor were I in 17 patients (31%), II in 12 (22%), III in 16 (29%), and IV in 10 (18%). A total of 21 complications occurred in 18 patients (33%) with no postoperative mortality. At last follow-up, 44 of the 55 patients were alive without tumor recurrence and 3 with recurrence at a median follow-up of 16 months, whereas 8 had died of recurrence or another cause.

Conclusions  The mortality rate of zero and acceptable morbidity of our series indicate that laparoscopic total gastrectomy with D2 lymphadenectomy is technically feasible and safe in the hands of experienced surgeons. Long-term follow-up is mandatory to validate oncologic outcome.

Design  Genetic functional and association study.

Setting  Daping Hospital and Chongqing Emergency Medical Center, Chongqing, China.

Patients  A total of 132 patients with major trauma were prospectively recruited.

Main Outcome Measures  The TLR4 11367 polymorphism was genotyped using single-tube, bidirectional, allele-specific amplification method. Whole peripheral blood samples obtained within 24 hours after admission were stimulated with lipopolysaccharide and then tested for production of tumor necrosis factor and interleukin 6. Sepsis morbidity rate and multiple organ dysfunction scores were assessed.

Results  The 11367 polymorphism was shown to be strongly associated with less capacity of peripheral leukocytes to produce tumor necrosis factor and interleukin 6 in response to ex vivo lipopolysaccharide stimulation in patients with trauma at admission. Results from association study indicated that patients with trauma who carry the 11367C allele were less likely to have sepsis and multiple organ dysfunction.

Conclusions  Combined with our previous in vitro functional study, the results suggest that the TLR4 11367 polymorphism might be a good predictor of who is more likely to develop complications such as sepsis or multiple organ dysfunction syndrome, depending on genotype.

Design  Review of records of patients undergoing open or laparoscopic gastric bypass.

Setting  A comprehensive, multidisciplinary obesity treatment center at a tertiary referral center that serves central Pennsylvania.

Patients  A total of 881 patients undergoing open or laparoscopic gastric bypass from May 31, 2002, through February 24, 2006.

Intervention  All preoperative patients completed a 6-month multidisciplinary program that encouraged a 10% preoperative weight loss.

Main Outcome Measures  Loss of excess body weight (EBW) and total and major complication rates.

Results  Of the 881 patients, 592 (67.2%) lost 5% or more EBW and 423 (48.0%) lost more than 10% EBW. Patients referred for open gastric bypass (n = 466) were generally older (P < .001), had a higher body mass index (P < .001), and were more often men (P < .001) than those undergoing laparoscopic gastric bypass (n = 415). Total and major complication rates were higher in patients undergoing open gastric bypass (P < .001 and P = .03, respectively). Univariate analysis revealed that increasing preoperative weight loss is associated with reduced complication frequencies for the entire group for total complications (P =.004) and most likely for major complications (P = .06). Controlling for age, sex, baseline body mass index, and type of surgery in a multiple logistic regression model, increased preoperative weight loss was a predictor of reduced complications for any (P =.004) and major (P = .03) complications.

Conclusion  Preoperative weight loss is associated with fewer complications after gastric bypass surgery.

Design  Retrospective review. Patients were identified on the basis of Current Procedural Terminology codes and admission through the emergency department. Medical records were reviewed and data were abstracted for comorbidities, procedural details, and in-hospital morbidity and mortality.

Setting  University tertiary referral center.

Patients  Two hundred ninety-two patients 65 years or older undergoing emergency colorectal procedures from January 1, 2000, through December 31, 2006.

Main Outcome Measures  Postoperative morbidity (intensive care unit days, ventilator days, pneumonia, deep venous thrombosis, pulmonary embolus, myocardial infarction, and cerebrovascular accident) and mortality.

Results  The most frequent presenting diagnoses were obstructing or perforated colorectal carcinoma (30%) and perforated diverticulitis (25%). Average age at presentation was 78.1 years, and in-hospital mortality was 15%. One hundred one patients (35%) experienced a total of 195 complications. Pneumonia (25%), persistent or recurrent respiratory failure (15%), and myocardial infarction (12%) were the most frequent complications. Operative time, shock, renal insufficiency, and significant intra-abdominal contamination or frank peritonitis were associated with morbidity. Age, septic shock at presentation, large estimated intraoperative blood loss, delay to operation, and development of a complication were associated with in-hospital mortality.

Conclusions  Emergent colorectal procedures in the elderly are associated with significant morbidity and mortality. Minimizing the delay to definitive operative care may improve outcomes. These procedures frequently involve locally advanced colorectal cancer, emphasizing the need for improved colorectal cancer screening.

Design  Retrospective review from September 2005 to August 2008.

Setting  Methodist Dallas Medical Center, Dallas, Texas, a referral, high-volume, nonuniversity tertiary care center.

Patients  All patients who underwent surgery for anastomotic pancreaticojejunal stricture.

Main Outcome Measures  Perioperative outcomes.

Results  All the patients were women and aged 62, 78, and 45 years. Comorbidities were documented in 2 patients. Two patients presented with severe acute abdominal pain and hyperamylasemia while 1 was asymptomatic. Two patients underwent magnetic resonance cholangiopancreatography with secretin stimulation. Endoscopic retrograde cholangiopancreatography was attempted in 1 patient. Operating time was 99 minutes, 158 minutes, and 154 minutes. Estimated blood loss was 250 mL, 400 mL, and 500 mL. A single-layer, side-to-side pancreaticogastrostomy was performed as the drainage procedure in all patients. There was no mortality associated with any of the patients within 30 days. Morbidity was seen only in 1 patient. None of the patients needed a reoperation. The mean length of hospital stay was 9 days. All patients were asymptomatic for pain.

Conclusion  We propose a durable technique for treating pancreatic ductal strictures post-PD that appears to result in superior postoperative outcome.

Data Sources  The MEDLINE, EMBASE, Elsevier, SpringerLink, Ovid, and Cochrane Library electronic databases as well as the LigaSure manufacturer's Web site were searched for studies published between 1996 and 2008. No language restrictions were applied.

Study Selection  Prospective, controlled clinical trials, both randomized and nonrandomized, comparing the hemostatic effects and safety of thyroidectomy using LigaSure and conventional vessel ligation were selected.

Data Extraction  Data regarding operative parameters, duration of the operation, amount of intraoperative blood loss, length of hospital stay, and any postoperative complications were entered and analyzed using dedicated software from the Cochrane Collaboration.

Data Synthesis  Four randomized and 5 nonrandomized trials that met selection criteria reported data from 927 patients, of whom 467 (50.4%) underwent LigaSure and 460 (49.6%) underwent conventional thyroidectomy. Operative duration (weighted mean difference [WMD], –11.97 minutes; 95% confidence interval [CI], –16.42 to –7.53 minutes) was significantly reduced with LigaSure thyroidectomy (P < .001). When LigaSure was used, operative time reductions of 20.32 minutes (95% CI, –33.86 to –6.79 minutes) for total thyroidectomy (P = .003) and 21.74 minutes (–38.32 to –5.16 minutes) for subtotal thyroidectomy (P = .01) were also confirmed with subgroup analysis. However, differences in the amount of intraoperative blood loss (WMD, –25.13 mL; 95% CI, –68.45 to 18.18 mL; P = .26), length of hospital stay (WMD, –0.08 days; 95% CI, –0.23 to 0.08 days; P = .31), and postoperative complication rates (odds ratio, 0.91; 95% CI, 0.61-1.04; P = .65) were not statistically significant for LigaSure vs conventional thyroidectomy.

Conclusions  The LigaSure technique may provide a safe, effective, and fast alternative to conventional vessel ligation in thyroidectomy and may result in a significant reduction in operative duration. However, it may not confer any advantage over conventional thyroidectomy in terms of the amount of intraoperative blood loss, length of hospital stay, and postoperative complication rates.

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.