Archives of Surgery最新文献

{"title":"Preoperative biopsy evaluation of chemotherapy-associated liver injuries: looking for a needle in a haystack? Comment on \"prospective evaluation of accuracy of liver biopsy findings in the identification of chemotherapy-associated liver injury\".","authors":"Timothy M Pawlik, Jean-Nicolas Vauthey","doi":"10.1001/archsurg.2012.1874","DOIUrl":"https://doi.org/10.1001/archsurg.2012.1874","url":null,"abstract":"W e read with great interest the study by Viganò et al regarding the use of preoperative biopsy to evaluate chemotherapyassociated liver injuries (CALIs). With the increasing use of preoperative chemotherapy, concern has grown that CALIs may be more prevalent and, in turn, adversely affect perioperative outcomes. Our group has previously shown that patients who undergo a major hepatic resection in the setting of steatohepatitis are at risk for increased perioperative mortality. Other studies, however, found no association between simple steatosis or sinusoidal dilatation and outcome. The prospective trial by the European Organisation for the Research and Treatment of Cancer examined the use of perioperative chemotherapy and found a small increase in perioperative complications in the treatment arm but no difference in mortality. Despite data to suggest that the risk of CALIs may be overstated for most patients, surgeons continue to use myriad tests in an attempt to assess preoperative liver function after preoperative chemotherapy. In the present report, Viganò et al assess the accuracy of direct pathological assessment of the liver with needle biopsy findings. The authors report that the overall sensitivity and accuracy of biopsy findings for CALIs is very poor. Based on previous studies, the overall incidence of clinically relevant CALIs has been noted to be relatively low. Viganò et al found that only about one-quarter of patients had any evidence of severe steatosis, sinusoidal dilatation, or steatohepatitis. Therefore, not surprisingly, the authors recommend against routine use of needle biopsy. Although diagnostic accuracy traditionally has not been thought to be directly affected by factors such as the prevalence of disease, some investigators have pointed out that clinical variability may cause sensitivity and specificity to vary with prevalence. For example, a patient population with a higher disease prevalence may include patients with more severe disease; therefore, a test may perform better in this population. As such, although Viganò et al provide compelling data against the routine use of needle biopsy, the study does not conclusively answer perhaps the more relevant clinical question: Should needle biopsy be used selectively in a population with a suspected higher prevalence of CALIs (eg, patients who are obese or diabetic, have metabolic syndrome, or underwent 6-8 cycles of chemotherapy)? In contrast to clinical accuracy, the clinical efficacy of a test refers to the practical value or the utility of a test for a particular clinical situation. As noted by Remaley et al, the 2 factors that have a large effect on clinical efficacy, but not on clinical accuracy, are prevalence and the cost of misclassifications. In considering needle biopsy, the surgeon must consider the implications of misclassifying CALIs (eg, a false-positive or a false-negative result). Would misclassification dramatically alter the therapeutic plan, operative ap","PeriodicalId":8298,"journal":{"name":"Archives of Surgery","volume":"147 12","pages":"1092"},"PeriodicalIF":0.0,"publicationDate":"2012-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1001/archsurg.2012.1874","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10648307","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Surgical Approach for Long-term Survival of Patients With Intrahepatic Cholangiocarcinoma: A Multi-institutional Analysis of 434 Patients.","authors":"Dario Ribero,&nbsp;Antonio Daniele Pinna,&nbsp;Alfredo Guglielmi,&nbsp;Antonio Ponti,&nbsp;Gennaro Nuzzo,&nbsp;Stefano Maria Giulini,&nbsp;Luca Aldrighetti,&nbsp;Fulvio Calise,&nbsp;Giorgio Enrico Gerunda,&nbsp;Mariano Tomatis,&nbsp;Marco Amisano,&nbsp;Pasquale Berloco,&nbsp;Guido Torzilli,&nbsp;Lorenzo Capussotti","doi":"10.1001/archsurg.2012.1962","DOIUrl":"https://doi.org/10.1001/archsurg.2012.1962","url":null,"abstract":"<p><p>OBJECTIVES To examine the outcomes of a hepatectomy for intrahepatic cholangiocarcinoma (IHC) and to clarify the prognostic impact of a lymphadenectomy and the surgical margin. Large series of patients who were surgically treated for IHC are scarce. Thus, prognostic factors and long-term survival after resection of IHC remain uncertain. DESIGN Prospective study of patients who were surgically treated for IHC. Clinicopathologic, operative, and long-term survival data were analyzed. SETTING Prospectively collected data of all consecutive patients with pathologically confirmed IHC who had undergone liver resection with a curative intent at 1 of 16 tertiary referral centers were entered into a multi-institutional registry. PATIENTS All consecutive patients who underwent a hepatectomy with a curative intent for IHC (1990-2008) were identified from a multi-institutional registry. RESULTS A total of 434 patients were included in the analysis. Most patients underwent a major or extended hepatectomy (70.0%) and a systematic lymphadenectomy (62.2%). The incidence of lymph node metastases (overall, 36.9%) increased with increased tumor size, with 24.4% of patients with a small IHC (diameter ≤3 cm) having N1 disease. Almost one-third of patients required an additional major procedure to obtain a R0 resection in 84.6% of the cases. In these patients, the median time of survival was 39 months, and the 5-year survival rate was 39.8%. Lymph node metastases (hazard ratio, 2.21; P &lt; .001), multiple tumors (hazard ratio, 1.50; P = .009), and an elevated preoperative cancer antigen 19.9 level (hazard ratio, 1.62; P = .006) independently predicted an adverse prognosis. Conversely, survival was not influenced by the width of a negative resection margin (P = .61). The potential survival benefit of a lymphadenectomy was assessed with the therapeutic value index, which was calculated to be 5.9 points. CONCLUSIONS Survival rates after a hepatectomy with a curative intent for IHC at tertiary referral centers exceed the survival rates reported in most study series in single institutions, which strengthens the value of an aggressive approach to radical resection. Lymph node metastases and multiple tumors are associated with decreased survival rates, but they should not be considered selection criteria that prevent other patients from undergoing a potentially curative resection. Lymphadenectomy should be considered for all patients.</p>","PeriodicalId":8298,"journal":{"name":"Archives of Surgery","volume":" ","pages":"1107-13"},"PeriodicalIF":0.0,"publicationDate":"2012-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1001/archsurg.2012.1962","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30848974","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Transanal endoscopic microsurgery in small, large, and giant rectal adenomas.","authors":"Andrea Scala,&nbsp;Gianpiero Gravante,&nbsp;Neville Dastur,&nbsp;Roberto Sorge,&nbsp;Jay N L Simson","doi":"10.1001/archsurg.2012.1954","DOIUrl":"https://doi.org/10.1001/archsurg.2012.1954","url":null,"abstract":"<p><p>OBJECTIVE To assess the outcomes of transanal endoscopic microsurgery in small (&lt;3 cm), large (3-5 cm), and giant (&gt;5 cm) lesions and compare these with reports of alternative techniques. DESIGN Data from January 1998 to February 2010 were prospectively collected. Lesions were divided into 3 groups according to the maximum diameter (group A, &lt;3 cm; group B, 3-5 cm; and group C, &gt;5 cm) and outcomes were analyzed separately. SETTING Colorectal unit in a single-district general hospital. PATIENTS Patients diagnosed as having benign rectal adenomas. INTERVENTION Transanal endoscopic microsurgery excision. MAIN OUTCOME MEASURES Completion of excision (R0), en bloc and full-thickness excisions, complication and local recurrence rates, and disease-free survival. RESULTS A total of 320 lesions were analyzed. Overall en bloc and full-thickness excision rates were 99% and 80.7%, respectively. In the 279 benign lesions, the R0 rate was 90.3%. Outcomes for groups A, B, and C were, respectively: 9.3%, 12.8%, and 14.4% incidence of unexpected malignancy (P = .64); 95.9%, 92.2%, and 85.1% R0 resection for benign lesions (P = .19); and 7.4%, 14.9%, and 24.6% complication rates (P &lt; .05). Overall operative mortality was 1 of 320 (0.3%). In group C, there was a higher estimated recurrence rate, therefore a lower disease-free survival than groups A and B; this difference was significant 40 months after surgery. Recurrences were associated with closeness to dentate line and advanced age (univariate analysis) and R1 resection (Cox regression). CONCLUSIONS Outcomes of transanal endoscopic microsurgery on large rectal lesions compared favorably with literature reports of alternative techniques. Postoperative complications and recurrences increased significantly with lesions larger than 5 cm.</p>","PeriodicalId":8298,"journal":{"name":"Archives of Surgery","volume":" ","pages":"1093-100"},"PeriodicalIF":0.0,"publicationDate":"2012-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1001/archsurg.2012.1954","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30849265","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Image of the month. Pseudoaneurysm.","authors":"Kensuke Adachi,&nbsp;Tomohito Minami","doi":"10.1001/archsurg.2011.2032b","DOIUrl":"https://doi.org/10.1001/archsurg.2011.2032b","url":null,"abstract":"","PeriodicalId":8298,"journal":{"name":"Archives of Surgery","volume":" ","pages":"1147-8"},"PeriodicalIF":0.0,"publicationDate":"2012-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1001/archsurg.2011.2032b","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"31126437","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Image of the month. Mucinous adenocarcinoma of an ileostomy.","authors":"Nsikak J Umoh,&nbsp;Robert E H Khoo","doi":"10.1001/archsurg.2011.2230b","DOIUrl":"https://doi.org/10.1001/archsurg.2011.2230b","url":null,"abstract":"","PeriodicalId":8298,"journal":{"name":"Archives of Surgery","volume":" ","pages":"1149-50"},"PeriodicalIF":0.0,"publicationDate":"2012-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1001/archsurg.2011.2230b","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"31126438","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"History and heritage of the Department of Surgery, Georgetown University.","authors":"Richard W Holt,&nbsp;Stephen R T Evans","doi":"10.1001/archsurg.2012.2281","DOIUrl":"https://doi.org/10.1001/archsurg.2012.2281","url":null,"abstract":"","PeriodicalId":8298,"journal":{"name":"Archives of Surgery","volume":" ","pages":"1074-6"},"PeriodicalIF":0.0,"publicationDate":"2012-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1001/archsurg.2012.2281","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"31129137","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Effects of prior abdominal surgery, obesity, and lumbar spine level on anterior retroperitoneal exposure of the lumbar spine.","authors":"Abid Mogannam,&nbsp;Christian Bianchi,&nbsp;Jason Chiriano,&nbsp;Sheela Patel,&nbsp;Theodore H Teruya,&nbsp;Sharon S Lum,&nbsp;Ahmed M Abou-Zamzam","doi":"10.1001/archsurg.2012.1148","DOIUrl":"https://doi.org/10.1001/archsurg.2012.1148","url":null,"abstract":"<p><strong>Objective: </strong>To evaluate the effects of prior abdominal surgery and obesity and the level of spine exposure on the technical aspects and complications of anterior retroperitoneal exposure of the lumbar spine (ARES).</p><p><strong>Design: </strong>Retrospective review of prospective database.</p><p><strong>Setting: </strong>Academic vascular surgery practice.</p><p><strong>Patients: </strong>Patients undergoing ARES from 2001 to 2011.</p><p><strong>Main outcome measures: </strong>Influence of prior abdominal surgery, obesity, and level of exposure on time to spine exposure and incidence of vascular and perioperative complications.</p><p><strong>Results: </strong>Four hundred seventy-six patients underwent ARES. Mean (SD) age was 47.7 (12.6) years; 46.6% had undergone prior abdominal surgery. Mean (SD) body mass index (BMI) was 28.3 (5.5); 61.6% of procedures included the L4-5 disk. Mean (SD) time to exposure was 70.0 (25.5) minutes. Vascular injury occurred in 23.3% (3.8% major). Perioperative complications occurred in 16.4% of cases. Prior abdominal surgery had no effect on time to exposure, vascular injury, and perioperative complications. A BMI of 30 or more had no effect on time to exposure compared with a lower BMI. A BMI of 30 or more led to higher rates of vascular injury (30.8% vs 19.7%; P = .007) and overall complications (21.4% vs 14.0%; P = .04). Exposures involving L4-5 led to increased time to exposure (77.0 vs 56.2 minutes; P < .001) and higher rates of vascular injury (29.7% vs 13.1%; P < .001) but had no effect on overall complications compared with exposures for other levels.</p><p><strong>Conclusion: </strong>Prior abdominal surgery should not be considered a contraindication to ARES. Caution is warranted in obese patients and exposures involving L4-5.</p>","PeriodicalId":8298,"journal":{"name":"Archives of Surgery","volume":" ","pages":"1130-4"},"PeriodicalIF":0.0,"publicationDate":"2012-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1001/archsurg.2012.1148","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"31129141","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"TEMS for Rectal Adenomas: Comment on \"Transanal Endoscopic Microsurgery in Small, Large, and Giant Rectal Adenomas\".","authors":"Susan L Gearhart","doi":"10.1001/archsurg.2012.1969","DOIUrl":"https://doi.org/10.1001/archsurg.2012.1969","url":null,"abstract":"","PeriodicalId":8298,"journal":{"name":"Archives of Surgery","volume":" ","pages":"1101"},"PeriodicalIF":0.0,"publicationDate":"2012-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1001/archsurg.2012.1969","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30850092","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Risk and Cost-effectiveness of Surveillance Followed by Cholecystectomy for Gallbladder Polyps.","authors":"Vaux Cairns,&nbsp;Christopher P Neal,&nbsp;Ashely R Dennison,&nbsp;Giuseppe Garcea","doi":"10.1001/archsurg.2012.1948","DOIUrl":"https://doi.org/10.1001/archsurg.2012.1948","url":null,"abstract":"<p><p>OBJECTIVE To ascertain the best management options for patients presenting with gallbladder polyps. DESIGN Retrospective case-note analysis. SETTING Tertiary referral teaching hospital practice. PATIENTS Patients with ultrasonography-detected gallbladder polyps. INTERVENTIONS Ultrasonography surveillance or surgery. MAIN OUTCOME MEASURES Demographic data and size and number of polyps were recorded as well as size increase and histological findings. Detection rates for potentially neoplastic and frankly neoplastic polyps were recorded and compared with complication rates from cholecystectomy. Cost-effectiveness of ultrasonography surveillance was examined. RESULTS Nine hundred eighty-six patients were identified and 467 patients underwent further follow-up. Only 6.6% of polyps exhibited an increase in size over the surveillance period. Polyps that subsequently progressed in size on surveillance had a significantly greater diameter at first presentation than those polyps that remained static (7 mm vs 5 mm, respectively) (P &lt; .05). Only 3.7% of resected polyps had malignant or potentially malignant histology. Size greater than 10 mm and increase in size during surveillance predicted neoplastic potential. CONCLUSIONS A surveillance with or without selective surgery policy could potentially detect and prevent 5.4 gallbladder cancers per 1000 individuals per year with a cost saving of more than £130 000 (US $201 676) per year. Cancer prevention benefits would exceed the risk ratios from cholecystectomy complications. Polyps greater than 10 mm should be resected; those between 5 and 10 mm should be under ultrasonography surveillance.</p>","PeriodicalId":8298,"journal":{"name":"Archives of Surgery","volume":" ","pages":"1078-83"},"PeriodicalIF":0.0,"publicationDate":"2012-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1001/archsurg.2012.1948","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30849828","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Integrating human factors research and surgery: a review.","authors":"Daniel Shouhed,&nbsp;Bruce Gewertz,&nbsp;Doug Wiegmann,&nbsp;Ken Catchpole","doi":"10.1001/jamasurg.2013.596","DOIUrl":"https://doi.org/10.1001/jamasurg.2013.596","url":null,"abstract":"<p><strong>Objective: </strong>To provide a review of human factors research within the context of surgery.</p><p><strong>Data sources: </strong>We searched PubMed for relevant studies published from the earliest available date through February 29, 2012.</p><p><strong>Study selection: </strong>The search was performed using the following keywords: human factors, surgery, errors, teamwork, communication, stress, disruptions, interventions, checklists, briefings, and training. Additional articles were identified by a manual search of the references from the key articles. As 2 human factors specialists, a senior clinician, and a junior clinician, we carefully selected the most appropriate exemplars of research findings with specific relevance to surgical error and safety.</p><p><strong>Data extraction: </strong>Seventy-seven articles of relevance were selected and reviewed in detail. Opinion pieces and editorials were disregarded; the focus was solely on articles based on empirical evidence, with a particular emphasis on prospectively designed studies.</p><p><strong>Data synthesis: </strong>The themes that emerged related to the development of human factors theories, the application of those theories within surgery, a specific interest in the concept of flow, and the theoretical basis and value of human-related interventions for improving safety and flow in surgery.</p><p><strong>Conclusions: </strong>Despite increased awareness of safety, errors routinely continue to occur in surgical care. Disruptions in the flow of an operation, such as teamwork and communication failures, contribute significantly to such adverse events. While it is apparent that some incidence of human error is unavoidable, there is much evidence in medicine and other fields that systems can be better designed to prevent or detect errors before a patient is harmed. The complexity of factors leading to surgical errors requires collaborations between surgeons and human factors experts to carry out the proper prospective and observational studies. Only when we are guided by this valid and real-world data can useful interventions be identified and implemented.</p>","PeriodicalId":8298,"journal":{"name":"Archives of Surgery","volume":" ","pages":"1141-6"},"PeriodicalIF":0.0,"publicationDate":"2012-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1001/jamasurg.2013.596","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"31126436","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}