Archives of Surgery最新文献

Hypothesis: When assessing the effect of operative approach on outcomes, it may be less relevant whether a transhiatal or an Ivor Lewis esophagectomy was performed and may be more important to focus on patient selection and the quality of the hospital performing the operation.

Design: Observational study.

Setting: Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program.

Patients: Individuals undergoing esophagectomy were identified from January 1, 2005, to December 31, 2010. The following 4 groups were created based on operative approach: transhiatal, Ivor Lewis, 3-field, and any approach with an intestinal conduit.

Main outcome measures: Risk-adjusted 30-day outcomes and hospital-level variation in performance.

Results: At 164 hospitals, 1738 patients underwent an esophageal resection: 710 (40.9%) were transhiatal, 497 (28.6%) were Ivor Lewis, 361 (20.8%) were 3-field, and 170 (9.8%) were intestinal conduits. Compared with the transhiatal approach, Ivor Lewis esophagectomy was not associated with increased risk for postoperative complications; however, 3-field esophagectomy was associated with increased likelihood of postoperative pneumonia (odds ratio [OR], 1.88; 95% CI, 1.28-2.77) and prolonged ventilation exceeding 48 hours (OR, 1.68; 95% CI, 1.16-2.42). Intestinal conduit use was associated with increased 30-day mortality (OR, 2.65; 95% CI, 1.08-6.47), prolonged ventilation exceeding 48 hours (OR, 1.61; 95% CI, 1.01-2.54), and return to the operating room for any indication (OR, 1.85; 95% CI, 1.16-2.96). Patient characteristics were the strongest predictive factors for 30-day mortality and serious morbidity. After case-mix adjustment, hospital performance varied by 161% for 30-day mortality and by 84% for serious morbidity.

Conclusions: Compared with transhiatal dissection, Ivor Lewis esophagectomy did not result in worse postoperative complications. After controlling for case-mix, hospital performance varied widely for all outcomes assessed, indicating that reductions in short-term outcomes will likely result from expanding other aspects of hospital quality beyond a focus on specific technical maneuvers.

HYPOTHESIS Patients with mild gallstone pancreatitis may undergo an early laparoscopic cholecystectomy (LC) within 48 hours of hospital admission without awaiting the normalization of pancreatic and liver enzyme levels. This may decrease the hospital stay without increasing morbidity or mortality and may minimize the unnecessary use of endoscopic retrograde cholangiopancreatography. DESIGN A retrospective review. SETTING Two university-affiliated urban medical centers. PATIENTS A total of 303 patients with mild gallstone pancreatitis, of whom 117 underwent an early LC and 186 underwent a delayed LC. MAIN OUTCOME MEASURES Hospital length of stay, morbidity and mortality rates, and the use of endoscopic retrograde cholangiopancreatography. RESULTS Similar hospital admission variables were observed in the early and delayed LC groups, although the delayed group was older (P = .006). The median hospital length of stay was significantly less for the early group than for the delayed group (3 vs 6 days; P < .001). There were no patients who died, and the complication rates were similar for both groups. However, the patients who underwent an early LC were less likely than patients who underwent a delayed LC to undergo endoscopic retrograde cholangiopancreatography (P = .02). CONCLUSIONS An early LC may be safely performed for patients with mild gallstone pancreatitis, without concern for increased morbidity and mortality, resulting in shortened hospital stays and a decrease in the use of endoscopic retrograde cholangiopancreatography. The practice of delaying an LC until normalization of laboratory values appears to be unnecessary.

OBJECTIVE To demonstrate that senior surgical residents would benefit from focused training by professionals with management expertise. Although managerial skills are recognized as necessary for the successful establishment of a surgical practice, they are not often emphasized in traditional surgical residency curricula. DESIGN Senior residents from all surgical subspecialties at McGill University were invited to participate in a 1-day management seminar. Precourse questionnaires aimed at evaluating the residents' perceptions of their own managerial knowledge and preparedness were circulated. The seminar was then given in the form of interactive lectures and case-based discussions. The questionnaires were readministered at the end of the course, along with an evaluation form. Precourse and postcourse data were compared using the Freeman-Halton extension of the Fisher exact test to determine statistical significance (P < .05). SETTING McGill University Health Centre in Montreal, Quebec, Canada. PARTICIPANTS A total of 43 senior residents. RESULTS Before the course, the majority of residents (27 of 43 [63%]) thought that management instruction only happened "from time to time" in their respective programs. After the course, 15 residents (35%) felt that management topics were "well addressed," and 19 (44%) felt that management topics have been "very well addressed" (P < .01). Residents noted a significant improvement in their ability to perform the following skills after the course: giving feedback, delegating duties, coping with stress, effective learning, and effective teaching. On the ensemble of all managerial skills combined, 26 residents (60%) rated their performance as "good" or "excellent" after the course vs only 21 (49%) before the course (P = .02). Residents also noted a statistically significant improvement in their ability to perform the managerial duties necessary for the establishment of a surgical practice. CONCLUSIONS Surgical residency programs have the responsibility of preparing their residents for leadership and managerial roles in their future careers. An annual seminar serves as a starting point that could be built on for incorporating formal management training in surgical residency curricula.

Background: Until 2004, we treated peritoneal carcinomatosis with cytoreductive surgery accompanied by perioperative systemic chemotherapy. From October 2004, we decided to initiate a hyperthermic intraperitoneal chemotherapy (HIPEC) program for this condition.

Objective: To determine the effect of HIPEC on postoperative outcomes at a single institution performing a high volume of cancer operations.

Method: Sixty consecutive patients underwent cytoreductive surgery plus HIPEC (oxaliplatin; 460 mg/m2 in 2 L/m2) from October 1, 2004, through December 31, 2010. Usual perioperative factors were studied for 3 groups of patients who underwent HIPEC: 0 to 20 HIPEC procedures (period 1), 21 to 40 HIPEC procedures (period 2), and 41 to 60 HIPEC procedures (period 3).

Results: The mean peritoneal carcinomatosis index was 9.6, the mean duration of surgery was 410.7 minutes, and the mean blood loss was 450.2 mL/L. Mortality and morbidity were 0% and 33%, respectively. Grade III/IV morbidity (P = .02), transfusion (P < .01), and reintervention rate (P = .04) significantly decreased during the 3 periods. No difference was seen between the 3 periods with regard to mean peritoneal carcinomatosis index, operative duration, blood loss, mortality, overall morbidity, length of hospital stay, and readmission. The overall 1-, 3-, and 5-year survival rates of 26 patients with peritoneal carcinomatosis originating from colorectal cancer were 100%, 51%, and 37%, respectively. The overall median survival was 39 months.

Conclusions: We observed a significant reduction of grade III/IV morbidity, perioperative transfusion, and reintervention rate after 20 procedures. The introduction of the HIPEC program was successful because of the surgical team's prior experience in cytoreductive and cancer operations.

Background: The Surgical Care Improvement Project (SCIP) Inf-9 guideline promotes removal of indwelling urinary catheters (IUCs) within 48 hours of surgery.

Objectives: To determine whether a correlation exists between SCIP Inf-9 compliance and postoperative urinary tract infection (UTI) rates and whether an association exists between UTI rates and SCIP Inf-9 exemption status. DESIGN Retrospective case control study.

Setting: Southeastern academic medical center.

Patients: American College of Surgeons National Surgical Quality Improvement Program (NSQIP) and SCIP Inf-9 compliance data were collected prospectively on randomly selected general and vascular surgery inpatients. Monthly UTI rates and SCIP Inf-9 compliance scores were tested for correlation. Complete NSQIP data for all the inpatients with postoperative UTIs were compared with a group of 100 random controls to determine whether an association exists between UTI rates and SCIP Inf-9 exemption status.

Main outcome measure: Postoperative UTI.

Results: In 2459 patients reviewed, SCIP Inf-9 compliance increased over time, but this was not correlated with improved monthly UTI rates. Sixty-one of the 69 UTIs (88.4%) were compliant with SCIP Inf-9; however, 49 (71.0%) of these were considered exempt from the guideline and, therefore, the IUC was not removed within 48 hours of surgery. Retrospective review of 100 random controls showed a similar compliance rate (84.0%, P = .43) but a lower rate of exemption (23.5%, P < .001). The odds of developing a postoperative UTI were 8 times higher in patients deemed exempt from SCIP Inf-9 (odds ratio [OR], 7.99; 95% CI, 3.85-16.61). After controlling for differences between the 2 groups, the adjusted ORs slightly increased (OR, 8.34; 95% CI, 3.70-18.76).

Conclusions: Most UTIs occurred in patients deemed exempt from SCIP Inf-9. Although compliance rates remain high, practices are not actually improving. Surgical Care Improvement Project Inf-9 guidelines should be modified with fewer exemptions to facilitate earlier removal of IUCs.