Surgery

Cover 1

2012-05-01

The state of performance on the American Board of Surgery Qualifying Examination and Certifying Examination and the effect of residency program size on program pass rates

John L. Falcone, Giselle G. Hamad — 2012-01-13

Examinees must pass both the American Board of Surgery (ABS) Qualifying Examination (QE) and the ABS Certifying Examination (CE) to become board certified. The Residency Review Committee (RRC) expects that residency programs maintain a 65% first-time examinee pass rate on the ABS Examinations. Higher individual performance on the ABS QE and ABS CE has been linked with Alpha Omega Alpha status, medical class rank, the United States Medical Licensing Examination Step 1 score, United States Medical Licensing Examination Step 2 score, and the ABS In-Training Examination performance. Overall residency program pass rates on the ABS QE and the ABS CE from 2006 to 2011 are electronically published. Predictors for residency program performance are unknown.

Capturing the teachable moment: A grounded theory study of verbal teaching interactions in the operating room

2012-01-13

Background: Teaching in the operating room is one of the major cornerstones of surgical education. As time available for intraoperative resident teaching diminishes, such teaching time becomes increasingly precious. We studied how surgeons communicate with residents during an operation, with the goal of enhancing intraoperative teaching opportunities.Methods: Grounded theory methodology was used to investigate intraoperative verbal communication during four videotaped surgical procedures. Utterance-by-utterance analysis was performed to generate codes for each surgeon–resident interaction. Interactions were then analyzed to determine the percentage time spent in verbal teaching, number of topics covered, times each topic was visited, and time per topic.Results: Four main types of teaching surgeon–resident verbal interaction were identified from 1306 interactions. Instrumental interactions were intended solely to move the operation forward. Pure teaching interactions served to educate the trainee, shape judgment, or enhance performance. Instrumental and Teaching interactions were directive but also contained teaching. Banter was discussion unrelated to the operation. Analysis of a subset of the operations demonstrated 13–29 topics covered per procedure, with each topic addressed between 1 and 8 times, and 25–330 seconds spent per topic. Most teaching instances were prompted by errors in resident performance.Conclusion: Instances of verbal teaching were numerous, arose opportunistically in this study, and focused typically on multiple points. To maximize teaching opportunities, the authors propose a structured approach to intraoperative teaching that involves identification of a limited set of specific learning objectives, followed by intraoperative teaching and postoperative debriefing targeted to those objectives.

Variations in surgical outcomes associated with hospital compliance with safety practices

2012-01-19

Background: The Leapfrog Group aims to improve patient safety by promoting hospital compliance with National Quality Forum (NQF) safe practices. It is unknown, however, whether implementation of these safety practices improve outcomes after high-risk operations.Methods: We conducted a cross-sectional analysis of 658 nationwide hospitals that responded to the 2005 Leapfrog Group Hospital Quality & Safety survey. A total of 79,462 patients were identified from Medicare claims data who underwent a pancreatectomy, hepatectomy, esophagectomy, open aortic aneurysm repair, colectomy, or gastrectomy procedure from 2004 through 2006. Random effects logistic regression models were used to estimate the association between hospital compliance with NQF safe practices and risk-adjusted odds of complications, rate of failure to rescue, and mortality after adjusting for patient- and hospital-level confounders.Results: Of the 658 hospitals that responded to surveys, 41% had fully implemented NQF safe practices and 59% reported partial compliance with these standards. Compared with hospitals with partial NQF compliance, we found evidence that hospitals with full compliance had an increased likelihood of diagnosing a complication after any of the 6 high-risk operations (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.03–1.25), but had a decreased likelihood of failure to rescue (OR, 0.82; 95% CI, 0.71–0.96), and a decreased odds of mortality (OR, 0.80; 95% CI, 0.71–0.91).Conclusion: Despite having a greater rate of postoperative complications, hospitals fully complying with safe practices were associated with less failure to rescue and decreased mortality after high-risk operations. These results highlight the importance of having hospital systems in place to promote safety and manage postoperative complications.

Novel use of electronic whiteboard in the operating room increases surgical team compliance with pre-incision safety practices

2012-01-13

Background: Despite evidence that use of a checklist during the pre-incision time out improves patient morbidity and mortality, compliance with performing the required elements of the checklist has been low. In an effort to improve compliance, a standardized time out interactive Electronic Checklist System [iECS] was implemented in all hospital operating room (OR) suites at 1 institution. The purpose of this 12-month prospective observational study was to assess whether an iECS in the OR improves and sustains improved surgical team compliance with the pre-incision time out.Methods: Direct observational analyses of preprocedural time outs were performed on 80 cases 1 month before, and 1 and 9 months after implementation of the iECS, for a total of 240 observed cases. Three observers, who achieved high interrater reliability (kappa = 0.83), recorded a compliance score (yes, 1; no, 0) on each element of the time out. An element was scored as compliant if it was clearly verbalized by the surgical team.Results: Pre-intervention observations indicated that surgical staff verbally communicated the core elements of the time out procedure 49.7 ± 12.9% of the time. After implementation of the iECS, direct observation of 80 surgical cases at 1 and 9 months indicated that surgical staff verbally communicated the core elements of the time out procedure 81.6 ± 11.4% and 85.8 ± 6.8% of the time, respectively, resulting in a statistically significant (P < .0001) increase in time out procedural compliance.Conclusion: Implementation of a standardized, iECS can dramatically increase compliance with preprocedural time outs in the OR, an important and necessary step in improving patient outcomes and reducing preventable complications and deaths.

Video-assisted thoracoscopic surgery for esophageal cancer attenuates postoperative systemic responses and pulmonary complications

2012-01-13

Background: Less invasive operations such as laparoscopic surgery have been developed for treating gastrointestinal malignancies. However, the advantages of video-assisted thoracoscopic surgery for esophageal cancer (VATS-e) with regard to postoperative morbidity and mortality remains controversial.Methods: We investigated the postoperative clinical course of patients who underwent esophagectomy for esophageal cancer in terms of systemic inflammatory response syndrome (SIRS) induced by VATS-e (VATS-e group) or conventional open surgery (OS group) combined with laparoscopic gastric tube reconstruction.Results: Compared with the OS group (n = 27), the VATS-e group (n = 22) had a greater thoracic operation time (VATS-e versus OS, 181 ± 56 vs 143 ± 45 minutes, respectively), and lesser duration of stay in the intensive care unit (17 ± 2 vs 32 ± 21 hours, respectively). The VATS-e group also had a lesser SIRS duration (1.5 vs 4.3 days), a lesser incidence of SIRS, a lesser number of positive SIRS criteria, and lesser serum interleukin-6 levels immediately after operation and on postoperative day (POD) 1. The heart rate in the VATS-e group was less than that in the OS group on POD 3. The respiratory rate in the VATS-e group was significantly less than that in the OS group on PODs 3, 5, and 7. Although no difference was observed in the frequencies of postoperative complications between the 2 groups, the VATS-e group had less postoperative pneumonia.Conclusion: VATS-e attenuates postoperative SIRS, and is therefore a potentially less invasive operative procedure.

A controlled clinical trial of the effect of gastric bypass surgery and intensive lifestyle intervention on nocturnal hypertension and the circadian blood pressure rhythm in patients with morbid obesity

2012-01-19

Background: Nocturnal hypertension, increased night-to-day systolic blood pressure (BP) ratio and nondipper status (night-to-day systolic BP ratio > 0.9) are associated with an increased risk of cardiovascular disease. Our aim was to compare the 1-year effect of Roux-en-Y gastric bypass (RYGB) versus a program of intensive lifestyle intervention (ILI) only on nocturnal hypertension and circadian BP rhythm.Methods: The study participants were part of a 1-year, controlled clinical trial comparing the effect of RYGB or ILI on obesity-related comorbidities. Ninety participants (49 in the RYGB group) successfully completed 24-hour ambulatory BP monitoring at baseline and follow-up and were eligible subsequently for analysis.Results: A total of 71 subjects (79%) had nocturnal hypertension at baseline. The number of subjects with nocturnal hypertension decreased from 42 to 14 in the RYGB group (P ≤ .001) and from 29 to 27 (P = .791) in the ILI group. Subjects in the RYGB group had a lesser adjusted odds ratio (OR) of nocturnal hypertension at follow-up (OR 0.15; 95% confidence interval, 0.05–0.42; P ≤ .001); however, after further adjustment for weight loss, there was no additional beneficial effect of RYGB (P = .674). No differences between groups regarding improvement in the night-to-day systolic BP ratio were found after adjustment for 24-hour systolic pressure (P = .107). Both interventions showed a decrease in the proportion of subjects classified as nondippers, namely, 44% (P ≤ .001) and 28% (P = .002) in the RYGB and ILI groups, respectively.Conclusion: Only RYGB was associated with a decrease in the prevalence of nocturnal hypertension. Both interventions showed an improvement in dipper status, although RYGB was more effective.

Surgical management for advanced duodenal adenomatosis and duodenal cancer in Dutch patients with familial adenomatous polyposis: A nationwide retrospective cohort study

2012-01-24

Background: Duodenal cancer is a major cause of mortality in patients with familial adenomatous polyposis (FAP). The clinical challenge is to perform duodenectomy before cancer develops; however, procedures are associated with complications. Our aim was to gain insight into the pros and cons of prophylactic duodenectomy.Methods: Patients with FAP from the nationwide Dutch polyposis registry who underwent prophylactic duodenectomy or were diagnosed with duodenal cancer were identified and classified as having benign disease or cancer at preoperative endoscopy. Surveillance, clinical presentation, surgical management, outcome, survival, and recurrence were compared.Results: Of 1,066 patients with FAP in the registry, 52 (5%; 25 males) were included: 36 with benign adenomatosis (median: 48 years old; including two (6%) cancer cases diagnosed after operation), and 16 with cancer (median: 53 years old). Cancer cases had been diagnosed with colorectal cancer more often (6% vs 44%; P < .01). Forty-three patients underwent duodenectomy (35 benign/eight cancer): 30-day mortality was 4.7% (n = 2), and in-hospital morbidity occurred in 21 patients (49%), without differences between patients with benign adenomatosis and cancer. Adenomas recurred in reconstructed proximal small bowel in 14 of 28 patients (50%, median time to recurrence: 75 months), and one patient developed cancer. Median survival of all 18 cancer cases in the registry (1.7%; 12 ampullary/six duodenal) was 11 months.Conclusion: Prognosis of duodenal cancer in patients with FAP is poor, which justifies an aggressive approach to advanced benign adenomatosis. Strict adherence to recommended surveillance intervals is essential for a well-timed intervention. Given the substantial morbidity and mortality of duodenectomy, patients’ individual characteristics are to be critically evaluated preoperatively. As adenomas recur, postoperative endoscopic surveillance is mandatory.

Impact of subcentimeter margin on outcome after hepatic resection for colorectal metastases: A meta-regression approach

2012-01-19

Background: The optimal margin width and its influence on outcomes after hepatic resection for colorectal liver metastases is still controversial: a meta-analysis was conducted to analyze the impact of subcentimeter margin width on patient and disease-free survival after resection.Methods: A systematic search was performed, covering the last decade, following the Meta-analysis Of Observational Studies in Epidemiology guidelines. Relative risks (RRs) for patient and disease-free survival (DFS) were calculated after resection in relationship to a margin width >1 cm (R0 > 1 cm) and between 1 mm and 1 cm (R0 < 1 cm) using the DerSimonian and Laird random-effects model. Meta-regression was applied for covariate adjustment.Results: Eleven observational studies were identified involving 2823 patients. Overall, 59.1% of patients were R0 < 1 cm and 40.9% were R0 > 1 cm. Meta-analysis showed that compared with patients with margins R0 > 1 cm, a R0 < 1 cm margin lead to decreased 1-, 3-, and 5-year DFS with a RR of 1.17 (95% confidence interval [CI] 1.07–1.27), 1.38 (95% CI 1.16–1.65), and 1.55 (95% CI 1.25–1.91), respectively, but patient survival was obviously affected (P > .05 in all cases). Patients with margins of R0 < 1 cm differ from those with R0 > 1 cm for greater proportions of multiple metastases (RR 1.43; 95% CI 0.25–1.61) and synchronous bowel disease (RR 1.42; 95% CI 0.8–1.92). Meta-regression showed that these two covariates had a significant impact on DFS but not on patient survival.Conclusion: A resection margin width >1 cm is desirable even if patient survival is at best only slightly affected by subcentimeter margin as a consequence of a decreased DFS. The presence of multiple metastases and synchronous bowel neoplasm represent potential study selection biases that significantly decrease DFS; well-conducted, matched analyses consequently are essential to clarify the issue.

Survival in patients with recurrent hepatocellular carcinoma after primary hepatectomy: Comparative effectiveness of treatment modalities

Cheng-Maw Ho, Po-Huang Lee, Wen-Yi Shau, Ming-Chih Ho, Yao-Ming Wu, Rey-Heng Hu — 2012-01-30

Background: Insufficient data are available on the survival of recurrent hepatocellular carcinoma after primary hepatectomy in patients receiving different treatments. We evaluated retrospectively the effects of treatment modalities on long-term survival.Methods: Between 2001 and 2007, 435 posthepatectomy hepatocellular carcinoma patients who developed recurrence were grouped by treatment modality into re-resection, radiofrequency ablation, transarterial chemoembolization, and supportive treatment groups. Treatment strategies for both primary hepatocellular carcinoma and its recurrence were selected using the same criteria. Postrecurrence survival was estimated using the Kaplan–Meier method and compared using the Cox proportional hazard model with adjusted independent prognostic factors. Survival rates after primary resection without recurrence were also compared.Results: In re-resection, radiofrequency ablation, transarterial chemoembolization, and supportive treatment groups, the 2-year postrecurrence survival rates were 90%, 96%, 75%, and 20%, respectively, and the 5-year survival rates were 72%, 83%, 56%, and 0%, respectively. The adjusted hazard of death was less for the re-resection and radiofrequency ablation groups than for the transarterial chemoembolization group, and the adjusted hazard ratios for the re-resection and radiofrequency ablation groups were 0.45 (95% confidence interval, 0.20–0.98) and 0.25 (0.08–0.81), respectively. The adjusted hazard ratio (95% confidence interval) of death for the radiofrequency ablation group compared to the re-resection group was 0.64 (0.19–2.19). Survival in the single resection group did not differ from that in the re-resection and radiofrequency ablation groups.Conclusion: Postrecurrence survival in the re-resection and radiofrequency ablation groups was significantly better than that in the transarterial chemoembolization group and similar to that of patients in the primary resection without recurrence group.

Resection of liver metastases from breast cancer: Estrogen receptor status and response to chemotherapy before metastasectomy define outcome

2012-01-30

Background: The oncologic benefit of resecting liver metastases in patients with breast cancer is unclear. This study was performed to identify predictors of survival after hepatectomy.Methods: Between 1997 and 2010, 86 patients underwent resection of breast cancer liver metastases. Clinicopathologic characteristics of the primary breast neoplasm, timing of metastasis development, and treatment were recorded. Response to prehepatectomy chemotherapy was evaluated according to Response Criteria in Solid Tumors criteria, and the best response to chemotherapy during treatment and the response immediately before hepatectomy were noted. Univariate and multivariate analyses were performed to identify predictors of disease-free survival and overall survival.Results: Fifty-nine patients (69%) had estrogen receptor– or progesterone receptor– positive primary breast neoplasms. Fifty-three patients (62%) had a solitary breast cancer liver metastasis, and 73 (85%) had breast cancer liver metastases ≤5 cm. Sixty-five patients (76%) received prehepatectomy hormonal and/or chemotherapy. Four patients (6%) had progressive disease as the best response, and 19 patients (30%) had progressive disease before hepatectomy (P < .001). Seventy percent of patients who received preoperative chemotherapy or hormonal therapy had either response or stable disease immediately before hepatectomy. No postoperative deaths were observed. At a 62-month median follow-up, the disease-free survival and overall survival were 14 and 57 months, respectively. On univariate analysis, estrogen receptor/progesterone receptor status of the primary breast neoplasm, best radiographic response, and preoperative radiographic response were associated with overall survival. On multivariate analysis, estrogen receptor–negative primary breast disease (P = .009; hazard ratio, 3.3; 95% confidence interval, 1.4–8.2) and preoperative progressive disease (P = .003; hazard ratio, 3.8; 95% confidence interval, 1.6–9.2) were associated with decreased overall survival.Conclusion: Resection of breast cancer liver metastases in patients with estrogen receptor–positive disease that is responding to chemotherapy is associated with improved survival. The timing of operative intervention may be critical; resection before progression is associated with a better outcome.

Laparoscopic resection of exocrine carcinoma in central and distal pancreas results in a high rate of radical resections and long postoperative survival

2012-01-30

Background: The role of laparoscopic resection in patients with pancreatic cancer remains to be clarified, because previous reports have not clearly defined oncologic outcomes. The objective of the present study was to investigate this question with the rate of R0 resection and long-term survival as endpoints.Methods: This retrospective observational study included prospectively collected data from 40 patients operated laparoscopically with curative intent for exocrine pancreatic malignancies identified among 250 consecutive patients undergoing laparoscopic pancreatic operations since 1997. All 40 patients had histologically verified exocrine pancreatic carcinoma.Results: Ten patients (25%) with typical ductal adenocarcinoma of the pancreas were deemed nonresectable by laparoscopic staging. Laparoscopic distal pancreatectomy was performed in 29 patients; 8 resections were combined with resections of adjacent organs and 1 removal of a malignant intraductal papillary mucinous neoplasm what appeared to be ectopic pancreatic tissue. In 1 patient, the resection was completed by hand-assisted technique, and 1 procedure was converted to open resection. Postoperative morbidity was 23% (n = 7). The median hospital stay was 5 days (range, 1–30). The rate of R0 resections was 93%. Postoperative 3-year survivals rates were 36% for the entire cohort (n = 30) and 30% in typical ductal adenocarcinoma (n = 21).Conclusion: Laparoscopic distal pancreatectomy for exocrine pancreatic carcinoma is comparable with outcomes after open surgery and supports the concept that laparoscopic distal pancreatectomy is a safe, oncologic procedure.

Early surgical outcomes comparison between robotic and conventional open thyroid surgery for papillary thyroid microcarcinoma

2012-01-30

Background: Robotic operations have enabled a safer and more meticulous approach to thyroidectomy with the notable benefit of improved cosmesis and decreases in postoperative pain and swallowing discomfort. The aim of this study was to document the early surgical outcomes of robotic thyroidectomy in patients with papillary thyroid carcinoma (PTC) by comparing it with conventional open thyroidectomy.Methods: From October 2007 to September 2008, 458 patients with PTC underwent thyroidectomy at the Yonsei University Health System. Of these patients, 266 patients were in the conventional open group and 192 patients were in the robotic group. These 2 groups were compared retrospectively with respect to clinicopathologic characteristics and surgical outcomes.Results: The mean follow-up period was 29.1 months. Mean tumor size, incidence of capsular invasion, multiplicity, and central nodal metastasis showed no significant difference between the 2 groups. Total thyroidectomy was performed more frequently in the open group. In terms of operation times, the robotic group had a significantly greater length of time for total thyroidectomy and subtotal thyroidectomy. The total number of retrieved central lymph nodes was greater in the open group (5.7 vs 4.6, P = .004). The 2 groups showed no differences in intraoperative and postoperative complications. The postoperative serum thyroglobulin levels were similar in both groups (0.25 vs 0.22 ng/mL, P = .648) and 2-year follow-up sonography of 433 patients revealed no recurrences. No abnormal I131 uptake was observed in whole-body scans in either group.Conclusion: Robotic thyroidectomy was similar to conventional open thyroidectomy in terms of early surgical outcomes but offers advantages. We conclude that robotic thyroidectomy offers a safe, feasible alternative to conventional open thyroidectomy in patients with PTC.

Selection algorithm for posterior versus lateral approach in laparoscopic adrenalectomy

Orhan Agcaoglu, Dursun Ali Sahin, Allan Siperstein, Eren Berber — 2012-01-19

Background: There are no objective selection criteria described in the literature for the laparoscopic posterior retroperitoneal (PR) versus lateral transabdominal (LT) approach in a given patient. The aim of this study is to quantify the algorithm we have been using in our practice.Methods: Within 11 years, 219 patients underwent laparoscopic adrenalectomy at one institution. The laparoscopic LT technique was used in patients with unilateral tumors >6 cm. In those patients with unilateral tumors <6 cm, anthropometric parameters were used to select between laparoscopic PR and LT approaches. These parameters were quantified for 82 patients from computed tomography scans and their effects on operative time were calculated. Statistical analyses were performed by use of the t test and logistic regression analysis.Results: Fifty-two patients underwent laparoscopic LT and 30 patients underwent PR adrenalectomy. Patients were selected for the PR approach if the distance from Gerota’s fascia to the skin was less than 5 cm and the 12th rib was at or rostral to the level of renal hilum. On multivariate analysis, total operative time correlated with body mass index in the LT approach and thickness of the perinephric fat and the distance between the adrenal tumor and the upper pole of kidney in the PR approach.Conclusion: In this study, we have described an objective algorithm that can be used to select patients with unilateral adrenal tumors <6 cm for a laparoscopic PR or LT approach with favorable perioperative outcomes.

Liposome-encapsulated curcumin suppresses neuroblastoma growth through nuclear factor-kappa B inhibition

2012-01-30

Background: Nuclear factor-κB (NF-κB) has been implicated in tumor cell proliferation and survival and in tumor angiogenesis. We sought to evaluate the effects of curcumin, an inhibitor of NF-κB, on a xenograft model of disseminated neuroblastoma.Methods: For in vitro studies, neuroblastoma cell lines NB1691, CHLA-20, and SK-N-AS were treated with various doses of liposomal curcumin. Disseminated neuroblastoma was established in vivo by tail vein injection of NB1691-luc cells into SCID mice, which were then treated with 50 mg/kg/day of liposomal curcumin 5 days/week intraperitoneally.Results: Curcumin suppressed NF-κB activation and proliferation of all neuroblastoma cell lines in vitro. In vivo, curcumin treatment resulted in a significant decrease in disseminated tumor burden. Curcumin-treated tumors had decreased NF-κB activity and an associated significant decrease in tumor cell proliferation and an increase in tumor cell apoptosis, as well as a decrease in tumor vascular endothelial growth factor levels and microvessel density.Conclusion: Liposomal curcumin suppressed neuroblastoma growth, with treated tumors showing a decrease in NF-κB activity. Our results suggest that liposomal curcumin may be a viable option for the treatment of neuroblastoma that works via inhibiting the NF-κB pathway.

The effect of adding fish oil to parenteral nutrition on hepatic mononuclear cell function and survival after intraportal bacterial challenge in mice

2012-01-13

Background: Parenteral nutrition (PN) is indispensable for meeting caloric and substrate needs of patients who cannot receive adequate amounts of enteral nutrition; however, PN impairs hepatic immunity. We examined the effects of ω-3 and -6 polyunsaturated fatty acids, added individually to fat-free PN, on hepatic immunity in a murine model. We focused on serum liver enzymes, cytokine production, histopathology, and the outcomes after intraportal bacterial challenge.Methods: Male Institute of Cancer Research mice were randomized into 4 groups; ad libitum chow (CHOW), fat-free PN (FF-PN), PN + fish oil (FO-PN), or PN + safflower oil (SO-PN). After the mice had been fed for 5 days, hepatic mononuclear cells (MNCs) were isolated. The number of MNCs was counted and cytokine production (tumor necrosis factor [TNF]-α and interleukin [IL]-10) by hepatic MNCs in response to lipopolysaccharide (LPS) was measured. Blood samples were analyzed for hepatobiliary biochemical parameters. Moreover, 1.0 × 107 pseudomonas aeruginosa were delivered by intraportal injection. Survival and histology were examined.Results: Hepatic MNC numbers were significantly less in the FO-PN and FF-PN than in the CHOW group, whereas the SO-PN group showed moderate recovery of hepatic MNC numbers. The CHOW, FO-PN, and SO-PN groups showed LPS dose-dependent increases in TNF-α levels. These increases were blunted in the FF-PN group. IL-10 levels were increased LPS dose-dependently in the CHOW and FO-PN groups, but no marked changes were observed with LPS stimulation in the SO-PN and FF-PN groups. Plasma levels of aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase were significantly greater in the FF-PN than in the FO- and SO-PN and CHOW groups. The FO-PN group showed significantly improved survival compared with the SO-PN and FF-PN groups, showing essentially no morphologic hepatic abnormalities.Conclusion: Addition of fish oil to PN was advantageous in terms of reversing PN-induced deterioration of hepatic immunity, as reflected by altered cytokine production. Fish oil administration was also useful for preventing PN-induced hepatobiliary dysfunction. These changes seem to result in better survival and to protect against severe tissue damage after intraportal bacterial challenge. This therapy may have the potential to ameliorate PN-induced impairment of host immunity and thereby decrease morbidity and mortality.

Robot-assisted laparoscopic ultrasonography for hepatic surgery

2011-10-10

Introduction: This study describes and evaluates a novel, robot-assisted laparoscopic ultrasonographic device for hepatic surgery. Laparoscopic liver surgery is being performed with increasing frequency. One major drawback of this approach is the limited capability of intraoperative ultrasonography (IOUS) using standard laparoscopic devices. Robotic surgery systems offer the opportunity to develop new tools to improve techniques in minimally invasive surgery. This study evaluates a new integrated ultrasonography (US) device with the da Vinci Surgical System for laparoscopic visualization, comparing it with conventional handheld laparoscopic IOUS for performing key tasks in hepatic surgery.Methods: A prototype laparoscopic IOUS instrument was developed for the da Vinci Surgical System and compared with a conventional laparoscopic US device in simulation tasks: (1) In vivo porcine hepatic visualization and probe manipulation, (2) lesion detection accuracy, and (3) biopsy precision. Usability was queried by poststudy questionnaire.Results: The robotic US proved better than conventional laparoscopic US in liver surface exploration (85% success vs 73%; P = .030) and tool manipulation (79% vs 57%; P = .028), whereas no difference was detected in lesion identification (63 vs 58; P = .41) and needle biopsy tasks (57 vs 48; P = .11). Subjects found the robotic US to facilitate better probe positioning (80%), decrease fatigue (90%), and be more useful overall (90%) on the post-task questionnaire.Conclusion: We found this robot-assisted IOUS system to be practical and useful in the performance of important tasks required for hepatic surgery, outperforming free-hand laparoscopic IOUS for certain tasks, and was more subjectively usable to the surgeon. Systems such as this may expand the use of robotic surgery for complex operative procedures requiring IOUS.

Professor Carl Alfred Moyer (1908–1970)

Joshua B. Grossman — 2012-03-05

No man is big enough to be independent of others!—W. W. Mayo One of the saving graces of the general surgery attachment was being able to work with the chairman of the department (Dr. Carl Moyer), a tall, lean, graying man who brought a rare wit and enthusiasm to his dealings with students. At the same time, he was a tireless questioner, always ready to lambast a student who showed evidence of lack of preparation. No matter how early in the morning it was, we were always wide awake when on rounds with this professor.

An unusual cause of unilateral urinary tract obstruction

Tao Li, Bao-Zhu Sun, Xu-Ting Zhi, Si-Feng Qu, Zhao-Ru Dong, San-Yuan Hu — 2011-03-14

A 69-year-old woman was admitted to the emergency department of our hospital with a 6-h history of intermittent abdominal pain that had developed suddenly. She had no history of abdominal surgery, but she suffered from cholecystolithiasis for about 2 years, and there had been 2 similar episodes in the past year. Physical examination revealed tenderness of the right upper and middle abdomen. Laboratory tests, including blood and urine analysis, were within normal limits, except that blood neutrophil counts increased to 8.73 × 109/L. A computed tomography (CT) scan demonstrated that the gallbladder was filled with stones and lying anterior to the ureteropelvic junction, with the right renal pelvis and ureter dilated (). An upright abdominal x-ray showed that the gallbladder descended into the pelvis, lying beside the vertebral column, where the right ureter enters the pelvis (, arrow). Because both CT scans and an abdominal x-ray did not show the presence of urinary stone or tumor, the unilateral dilation of right renal pelvis and ureter was supposed to be caused by the compression of a gallbladder stone. At that time, cholecystectomy was suggested, but the patient refused because of the regression of the symptoms and was discharged several days later. One year later, the patient was admitted to our hospital again for similar symptoms. This time the gallbladder was still full of stones (black arrow), and the dilation of right renal pelvis (white arrow) and ureter (arrowhead) were more obvious (), but urine analysis was still within normal range. Cholecystectomy was performed successfully. The patient was followed up 12 months later without any symptoms, and the dilation of the right renal pelvis and ureter was decreased.

2012-05-01

Information for authors

2012-05-01

Information for readers

2012-05-01

Surgery

Cover 1

The state of performance on the American Board of Surgery Qualifying Examination and Certifying Examination and the effect of residency program size on program pass rates

Capturing the teachable moment: A grounded theory study of verbal teaching interactions in the operating room

Variations in surgical outcomes associated with hospital compliance with safety practices

Novel use of electronic whiteboard in the operating room increases surgical team compliance with pre-incision safety practices

Video-assisted thoracoscopic surgery for esophageal cancer attenuates postoperative systemic responses and pulmonary complications

A controlled clinical trial of the effect of gastric bypass surgery and intensive lifestyle intervention on nocturnal hypertension and the circadian blood pressure rhythm in patients with morbid obesity

Surgical management for advanced duodenal adenomatosis and duodenal cancer in Dutch patients with familial adenomatous polyposis: A nationwide retrospective cohort study

Impact of subcentimeter margin on outcome after hepatic resection for colorectal metastases: A meta-regression approach

Survival in patients with recurrent hepatocellular carcinoma after primary hepatectomy: Comparative effectiveness of treatment modalities

Resection of liver metastases from breast cancer: Estrogen receptor status and response to chemotherapy before metastasectomy define outcome

Laparoscopic resection of exocrine carcinoma in central and distal pancreas results in a high rate of radical resections and long postoperative survival

Early surgical outcomes comparison between robotic and conventional open thyroid surgery for papillary thyroid microcarcinoma

Selection algorithm for posterior versus lateral approach in laparoscopic adrenalectomy

Liposome-encapsulated curcumin suppresses neuroblastoma growth through nuclear factor-kappa B inhibition

The effect of adding fish oil to parenteral nutrition on hepatic mononuclear cell function and survival after intraportal bacterial challenge in mice

Robot-assisted laparoscopic ultrasonography for hepatic surgery

Professor Carl Alfred Moyer (1908–1970)

An unusual cause of unilateral urinary tract obstruction

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