Surgery News

Bilateral subtotal thyroidectomy versus total thyroidectomy for Graves' disease
The extent of thyroid resection in Graves' disease remains controversial. The aim of this study was to evaluate long-term results of bilateral subtotal thyroidectomy (BST) compared with total thyroidectomy (TT) in patients with Graves' disease and mild active ophthalmopathy. Overall it was shown that TT for Graves' disease prevented recurrent hyperthyroidism but did not prevent the progression of ophthalmopathy compared with BST. 

More, Faster Weight Loss Seen With Gastric Bypass Than Banding
Gastric bypass surgery results in faster and longer-lasting weight loss than does gastric banding, according to a new study by Swiss investigators. A gastric bypass operation called Roux-en-Y involves reducing stomach size with staples and connecting the smaller "pouch" directly to the small intestine.

Selection of Prophylactic Antimicrobial Agent May Affect Incidence of Infection in Small Bowel and Colorectal Surgery
Antibiotic prophylaxis guidelines suggest single-dose regimens are adequate, but comparisons of multiple agents are lacking. The authors compared post-operative infection rates retrospectively among six common prophylactic agents given as a single dose to colorectal surgery patients. Overall this article showed the use of Ertapenem was associated with a lower infection rate and that agent selection among prophylactic antibiotics is one of many factors associated with infection development in colorectal surgery patients.

What is the likelihood of requiring contralateral inguinal hernia repair after unilateral repair?
Factors that predispose patients to the development of inguinal hernias will persist after repair. This study aimed to determine the incidence of future contralateral hernia repair. Despite a reported 8% to 22% incidence of clinically unsuspected contralateral inguinal hernia, the likelihood of undergoing contralateral repair within 10 years is low at 3.8%.

Incidence of blunt cerebrovascular injury in low-risk cervical spine fractures
It has been suggested that specific cervical spine fractures (CSfx) (location at upper cervical spine [CS], subluxation, or involvement of the transverse foramen) are predictive of blunt cerebrovascular injury (BCVI). The authors sought to determine the incidence of BCVI with CSfx in the absence of high-risk injury patterns and found that all CS fracture patterns warrant screening for BCVI.

Prophylactic Antibiotics and Chest Tubes
No consensus exists as to whether antibiotic prophylaxis in tube thoracostomy as primary treatment for traumatic chest injuries reduces the incidence of surgical-site and pleural cavity infections. This systematic literature search was performed according to PRISMA guidelines to identify randomized clinical trials on antibiotic prophylaxis in tube thoracostomy for traumatic chest injuries. Overall Infectious complications are less likely to develop when antibiotic prophylaxis is administered to patients with thoracic injuries requiring chest drains after penetrating injury. 

Tigecycline Penetration into Skin and Soft Tissue
 Tigecycline, a derivative of minocycline, has antibacterial activity against common pathogens associated with complicated skin and soft tissue infections (cSSTIs), including methicillin-resistant Staphylococcus aureus. At present, there is a paucity of data concerning its penetration into skin and soft tissue (SST).  This study evaluated the penetration of tigecycline into SST in 25 patients (mean age, 52 years) with cSSTIs requiring surgical intervention. The authors found that there were higher concentrations of tigecycline in SST than in the serum at the same time point.

Pitt, UPMC experts want trauma patients suffering cardiac arrest to chill
Each year about 150,000 Americans die from trauma, chiefly from automobile accidents or gunshot wounds. About 25 percent of these deaths are from cardiac arrest, usually induced by massive bleeding from the injury. Fewer than 10 percent of trauma victims who suffer cardiac arrest survive. But experts at the University of Pittsburgh School of Medicine and UPMC believe they can improve significantly the odds for those who reach the hospital alive by chilling them to nearly 50 degrees below the normal body temperature of 98.6.

Outcome predictors in acute surgical admissions for lower gastrointestinal bleeding
The BLEED criterion is a triaging model for lower gastrointestinal bleeding (LGIB) which was developed and validated in the United States. The authors assessed the BLEED criteria in a UK population and aimed to elucidate factors which can be implemented for early risk stratification.  The commonest aetiologies were diverticular disease, haemorrhoids and malignancy. Four prognosticators of adverse outcome were identified, these being: creatinine >150μmol, age >60years, abnormal haemodynamic parameters on presentation and continued bleeding within first 24-hours.  The BLEED criterion was not shown to have any predictive value in this patient cohort. Our study has determined an independent set of prognostic factors which could be incorporated into initial triaging of patients presenting with LGIB. This may facilitate early identification of patients requiring more aggressive resuscitation, admission to monitored bed and consideration for early radiological or surgical intervention.

Uncovering the truth about covered stents: is there a difference between covered versus uncovered stents with transjugular intrahepatic portosystemic shunts?
Polytetrafluoroethylene (PTFE)-covered transjugular intrahepatic portosystemic shunt (TIPS) stents purportedly provide superior patency. This study was undertaken to determine whether covered stents provide better long-term patency and outcomes after TIPSs. Patients with portal hypertension undergoing TIPS at a large teaching hospital from 2001 to 2010 were studied and it was found that Covered stents may improve patency but do not mitigate postshunt hepatic dysfunction and do not improve survival.

Randomized clinical trial of fluid restriction in colorectal surgery
Perioperative fluid therapy can influence postoperative hospital stay and complications after elective colorectal surgery. This trial was designed to examine whether an extremely restricted perioperative fluid protocol would reduce hospital stay beyond the existing fast-track hospital time of 7 days after surgery. Patients were randomized to restricted or standard perioperative intravenous fluid regimens in a single-centre trial. Randomization was stratified for colonic, rectal, open and laparoscopic surgery. Seventy-nine patients were randomized to restricted and 82 to standard fluid therapy. Patients in the restricted group received a median of 3050 ml fluid on the day of surgery compared with 5775 ml in the standard group. There was no difference between groups in primary hospital stay or stay including readmission. The proportion of patients with complications was significantly lower in the restricted group. Vasopressors were more often required in the restricted group

Contralateral prophylactic mastectomy in breast cancer patients who test negative for BRCA mutations
Determination of BRCA1 and 2 mutation carrier status is important. Although BRCA carriers are offered bilateral mastectomy and oophorectomy, most who test negative decline. Some women choose contralateral prophylactic mastectomy (CPM) at the time of their breast cancer diagnosis despite testing negative. A total of 110 women with breast cancer received genetic testing before surgical treatment. Patient demographics, tumor characteristics, surgical treatment, and magnetic resonance imaging use were recorded. This article found Increased rates of CPM have been observed and that married women were more likely to choose CPM. We recommend genetic genotyping before surgery. These findings warrant further investigation.

Majority of Post Surgical DVT's related to Central Lines
The authors of this article attempted to characterize the location, incidence, and timing of deep venous thrombosis (DVT) after general surgical procedures through a Retrospective data review Of 2189 patients who underwent general surgical operation, 35 (1.6%) developed DVT afterward. Main outcome measures included patient characteristics, location of DVT (lower vs upper), time of DVT diagnosis from the index operation (days), time of diagnosis according to discharge (inpatient vs outpatient), any associated pulmonary embolism, and mortality. They found that In the presence of prophylaxis, the incidence of DVT after general surgical operation is low, with more than 80% of cases diagnosed in the inpatient setting. Since morethan half of the DVTs are catheter induced, efforts for DVT prevention should include more attention to the need for a central catheter, limiting the amount of time of a central catheter, and possibly the use of anticoagulation in the presence of a central catheter.

Effect of type of alcoholic beverage in causing acute pancreatitis
The effect of different alcoholic beverages and drinking behaviour on the risk of acute pancreatitis has rarely been studied. The aim of this study was to investigate the effect of different types of alcoholic beverage in causing acute pancreatitis. A follow-up study was conducted, using the Swedish Mammography Cohort and Cohort of Swedish Men, to study the association between consumption of spirits, wine and beer and the risk of acute pancreatitis. No patient with a history of chronic pancreatitis was included and those who developed pancreatic cancer during follow-up were excluded. Overall The risk of acute pancreatitis was associated with the amount of spirits consumed on a single occasion but not with wine or beer consumption.

In-hospital Delay Increases the Risk of Perforation in Adults with Appendicitis
The influence of in-hospital delay (time between admission and operation) on outcome after appendectomy is controversial. A total of 1,827 adult patients underwent open or laparoscopic appendectomy for suspected appendicitis in eleven Swiss hospitals between 2003 and 2006. Of these, 1,675 patients with confirmed appendicitis were included in the study. Groups were defined according in-hospital delay (≤12 vs. >12 h). Overall, in-hospital delay negatively influences outcome after appendectomy. In-hospital delay of more than 12 h, age over 65 years, time of admission during regular hours, and the presence of co-morbidity are all independent risk factors for perforation. Perforation was associated with a higher reintervention rate and increased length of hospital stay.

Characteristics of Perforated Appendicitis: Effect of Delay Is Confounded by Age and Gender
The effect of age and gender on time to perforation in acute appendicitis has not been well characterized. This study examined the relationship between duration of disease and appendiceal perforation in different subgroups of age and gender. This study is a retrospective analysis of 380 patients who underwent an appendectomy from January 2000 to June 2005 at a rural teaching hospital. There is an early risk of perforated appendicitis even within the first 36 h of symptoms. This risk appears to be higher in males and patients older than 55 years, a quarter of whom are perforated within the first 36 h of symptom duration. Additionally, perforation in acute appendicitis may be more of a continuous phenomena worsening exponentially with duration of symptoms rather than a threshold phenomenon.

Prospective, Observational Validation of a Multivariate Small-Bowel Obstruction Model to Predict the Need for Operative Intervention
The authors of this article published previously a model predictive of the need for exploration in small-bowel obstruction. They aimed to validate and refine the model, hypothesizing that the model would be predictive, would prevent delayed management of strangulation, and would be successfully improved. Data from 100 consecutive patients with small-bowel obstruction and concurrent CT were collected prospectively. New features evaluated included obstipation and the absence of colonic gas on CT. Overall mortality was 8%. Twenty-nine patients had all 4 clinical features, 22 of whom required operative exploration, confirming the validity of the old model. Intraperitoneal free fluid and vomiting were not predictive of operative exploration; however, mesenteric edema and lack of the small-bowel feces sign were. Obstipation was associated with the need for exploration, but absence of colonic gas was not. A new model was equally predictive of the need for exploration: mesenteric edema, lack of the small-bowel feces sign, and obstipation. The current prospective study validated our original model and was successfully improved. Our new model demonstrated equivalent predictive ability and was simpler to use. When all 3 features of the new model are present, strong consideration for early operative exploration should be entertained and may decrease the rate of missed strangulation obstructions.

Removal of Tonsils, Appendix Linked to Early MI
People who had their tonsils, appendix, or both removed before the age of 20 had a higher risk of acute myocardial infarction before age 40, according to a Swedish population study.
When compared with controls and adjusted for parental occupation and parental history of acute myocardial infarction, these patients had a hazard ratio for MI of 1.33 (95% CI 1.05 to 1.70) with appendectomy and 1.44 (95% CI 1.04 to 2.01) with tonsillectomy, Imre Janszky, MD, from the Karolinska Institute in Stockholm, and colleagues found.

The use of topical phenytoin for healing of chronic venous ulcerations
Many topical agents have been used for promotion of healing of chronic venous ulcers. One such agent that has been tried is phenytoin. The effect of phenytoin on cutaneous healing has been suggested. This study was designed to evaluate the efficacy of topical phenytoin in healing of venous ulcerations. One hundred and four patients with chronic venous ulcers were recruited in this study. They were divided into study group and control group. The study group was 54 patients while control group was 50 patients. Patients in the study group were subjected to dressing of their ulcers with topical phenytoin once daily while patients in the control group were subjected to dressing with normal saline. All patients were followed up for eight weeks and assessed for their ulcer status and recorded as: complete healing, partial healing, no improvement or worsening of the condition. By the end of the eight weeks, complete healing was evident in 35/54 of the patients (64.8%) in the study group and 26/50 of the patients (52%) in the control group. It was statistically significant (p=.04). The rate of reduction in the mean surface area of the ulcers was faster in the study group than control group. Minor side effects were reported among 4 patients (7.4%) of the study group in the form of burning sensation. By the end of the eight weeks, complete healing was evident in 35/54 of the patients (64.8%) in the study group and 26/50 of the patients (52%) in the control group. This article showed that Topical phenytoin can be used to enhance healing of chronic venous ulcers in conjunction with the established treatment. It has favorable results and tolerable local side effects.

Determining the Need for Radical Surgery in Patients With T1 Rectal Cancer
In the era of modern preoperative staging of patients with rectal cancer, lymph node metastases can be reliably predicted by the histological features of the tumor and preoperative imaging. Local resection can then be safely offered to the patients who are at low risk of having malignant lymph nodes. The authors reviewed the records of 109 consecutive patients with preoperative imaging results suggestive of T1N0 or T2N0 disease who underwent total mesorectal excision. All patients underwent preoperative endorectal ultrasonography or magnetic resonance imaging and computed tomography, with or without positron emission tomography. Final pathologic investigation identified T3 disease in 27 patients. History, physical examination results, and radiologic and pathologic data were evaluated for predictors of positive nodes in the remaining 82 patients. In all, 89% of patients with T1 disease (31 of 35) and 72% of those with T2 disease (34 of 47) underwent unnecessary radical resection. Endorectal ultrasonography ormagnetic resonance imaging and computed tomography, with or without positron emission tomography, for preoperative staging could not identify these patients reliably. In addition, histologic markers of aggressive disease were not helpful. Thus, local resection for T2 rectal cancer is not justified. Local resection should be offered only to patients with superficial T1 tumors who will adhere to aggressive postoperative surveillance.

Trends in Diverticulitis Management in the United States From 2002 to 2007
The authors in this articlesought to demonstrate the recent trends of admission and surgical management for diverticulitis in the United States using a retrospective database analysis. It was found that the emergent admission rate increased by 9.5% over the study period. For emergent patients, 12.2% underwent urgent surgical resection and 87.8% were treated with nonoperative methods (percutaneous abscess drainage: 1.88% and medical treatment: 85.92%). There was only a 4.3% increase in urgent surgical resections, while elective surgical resections increased by 38.7.%. The overall rate of elective laparoscopic colon resection was 10.5%. Elective laparoscopic surgery nearly doubled from 6.9% in 2002 to 13.5% in 2007 (P < .001). Primary anastomosis rates increased for elective resections over time (92.1% in 2002 to 94.5% in 2007; P < .001). For urgent open operation, use of colostomy decreased significantly from 61.2% in 2002 to 54.0% in 2007 (P < .001). In-hospital mortality significantly decreased in both elective and urgent surgery (elective: 0.53% in 2002 to 0.44% in 2007; P = .001; urgent: 4.5% in 2002 to 2.5% in 2007; P < .001).

Smoking and the risk of diverticular disease in women
The relationship between smoking and the risk of diverticular disease is unclear. An observational cohort study was undertaken to investigate the association between smoking and diverticular disease. Women in the Swedish Mammography Cohort born between 1914 and 1948 were followed from 1997 to 2008. Information on smoking and other lifestyle factors was collected through questionnaires. Patients with symptomatic diverticular disease were identified from Swedish national registers. Relative risks (RRs) of symptomatic diverticular disease (resulting in hospital admission or death) according to smoking status were estimated using Cox proportional hazards models. It was found that Past smokers had an increased risk (RR 1·26, 1·02 to 1·56) while current Smokers had a higher risk of developing a diverticular perforation/abscess than non-smokers (RR 1·89, 1·15 to 3·10).

Malpractice Risk and Cost Are Significantly Reduced after Tort Reform
Rising medical malpractice premiums have reached a crisis point in many areas of the United States. In 2003 the Texas legislature passed a comprehensive package of tort reform laws that included a cap at $250,000 on noneconomic damages in most medical malpractice cases. We hypothesized that tort reform laws significantly reduce the risk of malpractice lawsuit in an academic medical center. We compared malpractice prevalence, incidence, and liability costs before and after comprehensive state tort reform measures were implemented. Two prospectively maintained institutional databases were used to calculate and characterize malpractice risk: a surgical operation database and a risk management and malpractice database. Risk groups were divided into pretort reform (1992 to 2004) and post-tort reform groups (2004 to the present). During the study period, 98,513 general surgical procedures were performed. A total of 28 lawsuits (25 pre-reform, 3 postreform) were filed, naming general surgery faculty or residents. The prevalence of lawsuits filed/100,000 procedures performed is as follows: before reform, 40 lawsuits/100,000 procedures, and after reform, 8 lawsuits/100,000 procedures (p < 0.01, relative risk 0.21 [95% CI 0.063 to 0.62]). Virtually all of the liability and defense cost was in the pretort reform period: $595,000/year versus $515/year in the postreform group (p < 0.01).

Cyclical Increase in Diverticulitis During the Summer Months
This authors of this article hypothesized that the rate of nonelective hospital admissions for diverticulitis conforms to seasonal variation. Using a retrospective cohort analysis the authors identified patients with a nonelective admission or discharge for diverticulitis from January 1, 1997, through December 31, 2005, and determined the proportion of diverticulitis admissions (standardized to all inpatient admissions) for a particular admission month or discharge quarter. Next, we analyzed the potential effects of region, age, sex, and race on excess seasonal admissions for diverticulitis. Overall hospitalization for diverticulitis adheres to a sinusoidal pattern, with more nonelective admissions occurring during the summer months. The excess summer burden of diverticulitis is noted across US census regions, age, sex, and race. A more thorough understanding of these trends may provide a mechanism to identify a potential trigger for diverticulitis.

Hydrocortisone Therapy for Patients With Multiple Trauma
In patients with multiple trauma, treatment with hydrocortisone is associated with a 49% reduced risk of hospital-acquired pneumonia, researchers reported. The use of the corticosteroid was also associated with a reduction in the number of days patients needed mechanical ventilation, compared with those given a placebo, according to Karim Asehnoune, MD, PhD, of the University Hospital of Nantes in Nantes, France, and colleagues. But there was no significant difference in mortality between the hydrocortisone and placebo arms of the randomized, blinded trial, Asehnoune and colleagues reported in the March 23/30 issue of the Journal of the American Medical Association.

Do pregnant women have improved outcomes after traumatic brain injury?
Pregnant women, who have significantly elevated levels of estrogen and progesterone, might benefit from the neuroprotective effect of steroid hormones. In this article Pregnant patients were identified and compared with their nonpregnant counterparts with respect to demographics and outcome. Overall it was found that Pregnant patients with moderate to severe TBI show no statistically significant difference in mortality compared with their nonpregnant counterparts.

Incidence of small bowel obstruction after laparoscopic and open colon resection
Small bowel obstruction (SBO) is responsible for more than 1 billion dollars in health care costs yearly in the United States. The authors sought to evaluate whether laparoscopic colorectal surgery resulted in a decreased incidence of SBO within the first year of surgical resection compared with open surgery. From January 2003 to December 2008, 339 patients underwent open (open colorectal resection [OPEN]) colorectal resection and 448 patients underwent laparoscopic (laparoscopic colorectal resection [LAP]) colorectal resection. During the 1st year after surgery, 6 patients in the OPEN group developed SBO, and 5 patients in the LAP group developed SBO. The overall frequency of SBO for the OPEN group was 1.8% and 1.1% for the LAP group (P < .5461). Although advantages such as quicker postoperative recovery and decreased hospital stay have been attributed to laparoscopic surgery, no difference in the incidence of SBO within the 1st year of surgery was found compared with open colorectal surgery.

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