Archives of Surgery最新文献

Objective: To compare the distance to be traversed during needle thoracostomy decompression performed at the second intercostal space (ICS) in the midclavicular line (MCL) with the fifth ICS in the anterior axillary line (AAL).

Design: Patients were separated into body mass index (BMI) quartiles, with BMI calculated as weight in kilograms divided by height in meters squared. From each BMI quartile, 30 patients were randomly chosen for inclusion in the study on the basis of a priori power analysis (n = 120). Chest wall thickness on computed tomography at the second ICS in the MCL was compared with the fifth ICS in the AAL on both the right and left sides through all BMI quartiles.

Setting: Level I trauma center.

Patients: Injured patients aged 16 years or older evaluated from January 1, 2009, to January 1, 2010, undergoing computed tomography of the chest.

Results: A total of 680 patients met the study inclusion criteria (81.5% were male and mean age was 41 years [range, 16-97 years]). Of the injuries sustained, 13.2% were penetrating, mean (SD) Injury Severity Score was 15.5 (10.3), and mean BMI was 27.9 (5.9) (range, 15.4-60.7). The mean difference in chest wall thickness between the second ICS at the MCL and the fifth ICS at the AAL was 12.9 mm (95% CI, 11.0-14.8; P < .001) on the right and 13.4 mm (95% CI, 11.4-15.3; P < .001) on the left. There was a stepwise increase in chest wall thickness across all BMI quartiles at each location of measurement. There was a significant difference in chest wall thickness between the second ICS at the MCL and the fifth ICS at the AAL in all quartiles on both the right and the left. The percentage of patients with chest wall thickness greater than the standard 5-cm decompression needle was 42.5% at the second ICS in the MCL and only 16.7% at the fifth ICS in the AAL.

Conclusions: In this computed tomography-based analysis of chest wall thickness, needle thoracostomy decompression would be expected to fail in 42.5% of cases at the second ICS in the MCL compared with 16.7% at the fifth ICS in the AAL. The chest wall thickness at the fifth ICS AAL was 1.3 cm thinner on average and may be a preferred location for needle thoracostomy decompression.

Objectives: To develop and validate a risk-adjusted tool with fewer than 10 variables to measure surgical outcomes in resource-limited hospitals.

Design: All National Surgical Quality Improvement Program (NSQIP) preoperative variables were used to develop models to predict inpatient mortality. The models were built by sequential addition of variables selected based on their area under the receiver operator characteristic curve (AUROC) and externally validated using data based on medical record reviews at 1 hospital outside the data set. SETTING Model development was based on data from the NSQIP from 2005 to 2009. Validation was based on data from 1 nonurban hospital in the United States from 2009 to 2010.

Patients: A total of 631 449 patients in NSQIP and 239 patients from the validation hospital.

Main outcome measures: The AUROC value for each model.

Results: The AUROC values reached higher than 90% after only 3 variables (American Society of Anesthesiologists class, functional status at time of surgery, and age). The AUROC values increased to 91% with 4 variables but did not increase significantly with additional variables. On validation, the model with the highest AUROC was the same 3-variable model (0.9398).

Conclusions: Fewer than 6 variables may be necessary to develop a risk-adjusted tool to predict inpatient mortality, reducing the cost of collecting variables by 95%. These variables should be easily collectable in resource-poor settings, including low- and middle-income countries, thus creating the first standardized tool to measure surgical outcomes globally. Research is needed to determine which of these limited-variable models is most appropriate in a variety of clinical settings.

Hypothesis: Lymph node metastases decrease survival in patients with pancreatic neuroendocrine tumors (pNETs).

Design: Prospective database searches.

Setting: National Institutes of Health (NIH) and Stanford University Hospital (SUH).

Patients: A total of 326 patients underwent surgical exploration for pNETs at the NIH (n = 216) and SUH (n = 110).

Main outcome measures: Overall survival, disease-related survival, and time to development of liver metastases.

Results: Forty patients (12.3%) underwent enucleation and 305 (93.6%) underwent resection. Of the patients who underwent resection, 117 (35.9%) had partial pancreatectomy and 30 (9.2%) had a Whipple procedure. Forty-one patients also had liver resections, 21 had wedge resections, and 20 had lobectomies. Mean follow-up was 8.1 years (range, 0.3-28.6 years). The 10-year overall survival for patients with no metastases or lymph node metastases only was similar at 80%. As expected, patients with liver metastases had a significantly decreased 10-year survival of 30% (P < .001). The time to development of liver metastases was significantly reduced for patients with lymph node metastases alone compared with those with none (P < .001). For the NIH cohort with longer follow-up, disease-related survival was significantly different for those patients with no metastases, lymph node metastases alone, and liver metastases (P < .001). Extent of lymph node involvement in this subgroup showed that disease-related survival decreased as a function of the number of lymph nodes involved (P = .004).

Conclusions: As expected, liver metastases decrease survival of patients with pNETs. Patients with lymph node metastases alone have a shorter time to the development of liver metastases that is dependent on the number of lymph nodes involved. With sufficient long-term follow-up, lymph node metastases decrease disease-related survival. Careful evaluation of number and extent of lymph node involvement is warranted in all surgical procedures for pNETs.

Objective: To compare the outcomes of a large cohort undergoing biliopancreatic diversion/duodenal switch (DS) vs gastric bypass (GB).

Design: Retrospective review of the Bariatric Outcomes Longitudinal Database from 2007 to 2010. All inpatient and outpatient follow-up data were analyzed.

Setting: Multicenter database.

Patients: Patients undergoing primary DS were compared with a concurrent cohort undergoing GB.

Main outcome measures: The main outcome measures were (1) weight loss; (2) control of comorbidities including diabetes mellitus, hypertension, and sleep apnea; and (3) failure to achieve at least 50% excess body weight loss.

Results: One thousand five hundred forty-five patients underwent DS and 77 406 underwent GB, with a mean preoperative body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 52 and 48, respectively (P < .01). The DS was associated with longer operative times, greater blood loss, and longer lengths of hospital stay (all P < .05). Early reoperation rates were higher in the DS group (3.3% vs 1.5%). Percentage of change in BMI was significantly greater in the DS group at all follow-up intervals (P < .05). Subgroup analysis of the superobese population (BMI >50) revealed significantly greater percentage of excess body weight loss in the DS group at 2 years (79% vs 67%; P < .01). Comorbidity control of diabetes, hypertension, and sleep apnea were all superior with the DS (all P < .05). The risk of weight loss failure was significantly reduced with DS vs GB for all patients, with a greater reduction in the BMI more than 50 subgroup.

Conclusions: The DS is a less commonly used bariatric operation, with higher early risks compared with GB. However, the DS achieved better weight and comorbidity control, with even more pronounced benefits among the superobese.

Objective: To determine the rates and predictors of remediation and attrition among general surgery residents.

Design, setting, and participants: Eleven-year retrospective analysis of 348 categorical general surgery residents at 6 West Coast programs.

Main outcome measures: Rates and predictors of remediation and attrition.

Results: Three hundred forty-eight categorical general surgery residents were included. One hundred seven residents (31%) required remediation, of which 27 were remediated more than once. Fifty-five residents (15.8%) left their programs, although only 2 were owing to failed remediation. Remediation was not a predictor of attrition (20% attrition for those remediated vs 15% who were not [P = .40]). Remediation was most frequently initiated owing to a deficiency in medical knowledge (74%). Remediation consisted of monthly meetings with faculty (79%), reading assignments (72%), required conferences (27%), therapy (12%), and repeating a clinical year (6.5%). On univariate analysis, predictors of remediation included receiving honors in the third-year surgery clerkship, United States Medical Licensing Examination (USMLE) step 1 and/or step 2, and American Board of Surgery In-Training Examination scores at postgraduate years 1 through 4. On multivariable regression analysis, remediation was associated with receiving honors in surgery (odds ratio, 1.9; P = .01) and USMLE step 1 score (odds ratio, 0.9; P = .02). On univariate analysis, the only predictor of attrition was the American Board of Surgery In-Training Examination score at the postgraduate year 3 level (P = .04).

Conclusions: Almost one third of categorical general surgery residents required remediation during residency, which was most often owing to medical knowledge deficits. Lower USMLE step 1 scores were predictors of the need for remediation. Most remediated residents successfully completed the program. Given the high rates of remediation and the increased educational burden on clinical faculty, medical schools need to focus on better preparing students to enter surgical residency.