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Publisher: Elsevier   (Total: 3043 journals)

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Showing 1 - 200 of 3043 Journals sorted alphabetically
AASRI Procedia     Open Access   (Followers: 15)
Academic Pediatrics     Hybrid Journal   (Followers: 20, SJR: 1.402, h-index: 51)
Academic Radiology     Hybrid Journal   (Followers: 18, SJR: 1.008, h-index: 75)
Accident Analysis & Prevention     Partially Free   (Followers: 83, SJR: 1.109, h-index: 94)
Accounting Forum     Hybrid Journal   (Followers: 23, SJR: 0.612, h-index: 27)
Accounting, Organizations and Society     Hybrid Journal   (Followers: 27, SJR: 2.515, h-index: 90)
Achievements in the Life Sciences     Open Access   (Followers: 4)
Acta Anaesthesiologica Taiwanica     Open Access   (Followers: 5, SJR: 0.338, h-index: 19)
Acta Astronautica     Hybrid Journal   (Followers: 331, SJR: 0.726, h-index: 43)
Acta Automatica Sinica     Full-text available via subscription   (Followers: 3)
Acta Biomaterialia     Hybrid Journal   (Followers: 25, SJR: 2.02, h-index: 104)
Acta Colombiana de Cuidado Intensivo     Full-text available via subscription   (Followers: 1)
Acta de Investigación Psicológica     Open Access   (Followers: 2)
Acta Ecologica Sinica     Open Access   (Followers: 8, SJR: 0.172, h-index: 29)
Acta Haematologica Polonica     Free   (SJR: 0.123, h-index: 8)
Acta Histochemica     Hybrid Journal   (Followers: 3, SJR: 0.604, h-index: 38)
Acta Materialia     Hybrid Journal   (Followers: 211, SJR: 3.683, h-index: 202)
Acta Mathematica Scientia     Full-text available via subscription   (Followers: 5, SJR: 0.615, h-index: 21)
Acta Mechanica Solida Sinica     Full-text available via subscription   (Followers: 9, SJR: 0.442, h-index: 21)
Acta Oecologica     Hybrid Journal   (Followers: 9, SJR: 0.915, h-index: 53)
Acta Otorrinolaringologica (English Edition)     Full-text available via subscription   (Followers: 1)
Acta Otorrinolaringológica Española     Full-text available via subscription   (Followers: 3, SJR: 0.311, h-index: 16)
Acta Pharmaceutica Sinica B     Open Access   (Followers: 2)
Acta Poética     Open Access   (Followers: 4)
Acta Psychologica     Hybrid Journal   (Followers: 23, SJR: 1.365, h-index: 73)
Acta Sociológica     Open Access  
Acta Tropica     Hybrid Journal   (Followers: 6, SJR: 1.059, h-index: 77)
Acta Urológica Portuguesa     Open Access  
Actas Dermo-Sifiliograficas     Full-text available via subscription   (Followers: 4)
Actas Dermo-Sifiliográficas (English Edition)     Full-text available via subscription   (Followers: 3)
Actas Urológicas Españolas     Full-text available via subscription   (Followers: 4, SJR: 0.383, h-index: 19)
Actas Urológicas Españolas (English Edition)     Full-text available via subscription   (Followers: 2)
Actualites Pharmaceutiques     Full-text available via subscription   (Followers: 5, SJR: 0.141, h-index: 3)
Actualites Pharmaceutiques Hospitalieres     Full-text available via subscription   (Followers: 4, SJR: 0.112, h-index: 2)
Acupuncture and Related Therapies     Hybrid Journal   (Followers: 3)
Ad Hoc Networks     Hybrid Journal   (Followers: 11, SJR: 0.967, h-index: 57)
Addictive Behaviors     Hybrid Journal   (Followers: 15, SJR: 1.514, h-index: 92)
Addictive Behaviors Reports     Open Access   (Followers: 5)
Additive Manufacturing     Hybrid Journal   (Followers: 8, SJR: 1.039, h-index: 5)
Additives for Polymers     Full-text available via subscription   (Followers: 20)
Advanced Drug Delivery Reviews     Hybrid Journal   (Followers: 128, SJR: 5.2, h-index: 222)
Advanced Engineering Informatics     Hybrid Journal   (Followers: 11, SJR: 1.265, h-index: 53)
Advanced Powder Technology     Hybrid Journal   (Followers: 16, SJR: 0.739, h-index: 33)
Advances in Accounting     Hybrid Journal   (Followers: 9, SJR: 0.299, h-index: 15)
Advances in Agronomy     Full-text available via subscription   (Followers: 15, SJR: 2.071, h-index: 82)
Advances in Anesthesia     Full-text available via subscription   (Followers: 25, SJR: 0.169, h-index: 4)
Advances in Antiviral Drug Design     Full-text available via subscription   (Followers: 3)
Advances in Applied Mathematics     Full-text available via subscription   (Followers: 6, SJR: 1.054, h-index: 35)
Advances in Applied Mechanics     Full-text available via subscription   (Followers: 10, SJR: 0.801, h-index: 26)
Advances in Applied Microbiology     Full-text available via subscription   (Followers: 22, SJR: 1.286, h-index: 49)
Advances In Atomic, Molecular, and Optical Physics     Full-text available via subscription   (Followers: 16, SJR: 3.31, h-index: 42)
Advances in Biological Regulation     Hybrid Journal   (Followers: 4, SJR: 2.277, h-index: 43)
Advances in Botanical Research     Full-text available via subscription   (Followers: 3, SJR: 0.619, h-index: 48)
Advances in Cancer Research     Full-text available via subscription   (Followers: 25, SJR: 2.215, h-index: 78)
Advances in Carbohydrate Chemistry and Biochemistry     Full-text available via subscription   (Followers: 9, SJR: 0.9, h-index: 30)
Advances in Catalysis     Full-text available via subscription   (Followers: 5, SJR: 2.139, h-index: 42)
Advances in Cellular and Molecular Biology of Membranes and Organelles     Full-text available via subscription   (Followers: 12)
Advances in Chemical Engineering     Full-text available via subscription   (Followers: 24, SJR: 0.183, h-index: 23)
Advances in Child Development and Behavior     Full-text available via subscription   (Followers: 10, SJR: 0.665, h-index: 29)
Advances in Chronic Kidney Disease     Full-text available via subscription   (Followers: 10, SJR: 1.268, h-index: 45)
Advances in Clinical Chemistry     Full-text available via subscription   (Followers: 28, SJR: 0.938, h-index: 33)
Advances in Colloid and Interface Science     Full-text available via subscription   (Followers: 18, SJR: 2.314, h-index: 130)
Advances in Computers     Full-text available via subscription   (Followers: 16, SJR: 0.223, h-index: 22)
Advances in Developmental Biology     Full-text available via subscription   (Followers: 11)
Advances in Digestive Medicine     Open Access   (Followers: 4)
Advances in DNA Sequence-Specific Agents     Full-text available via subscription   (Followers: 5)
Advances in Drug Research     Full-text available via subscription   (Followers: 22)
Advances in Ecological Research     Full-text available via subscription   (Followers: 41, SJR: 3.25, h-index: 43)
Advances in Engineering Software     Hybrid Journal   (Followers: 25, SJR: 0.486, h-index: 10)
Advances in Experimental Biology     Full-text available via subscription   (Followers: 7)
Advances in Experimental Social Psychology     Full-text available via subscription   (Followers: 40, SJR: 5.465, h-index: 64)
Advances in Exploration Geophysics     Full-text available via subscription   (Followers: 3)
Advances in Fluorine Science     Full-text available via subscription   (Followers: 8)
Advances in Food and Nutrition Research     Full-text available via subscription   (Followers: 47, SJR: 0.674, h-index: 38)
Advances in Fuel Cells     Full-text available via subscription   (Followers: 15)
Advances in Genetics     Full-text available via subscription   (Followers: 15, SJR: 2.558, h-index: 54)
Advances in Genome Biology     Full-text available via subscription   (Followers: 11)
Advances in Geophysics     Full-text available via subscription   (Followers: 6, SJR: 2.325, h-index: 20)
Advances in Heat Transfer     Full-text available via subscription   (Followers: 21, SJR: 0.906, h-index: 24)
Advances in Heterocyclic Chemistry     Full-text available via subscription   (Followers: 8, SJR: 0.497, h-index: 31)
Advances in Human Factors/Ergonomics     Full-text available via subscription   (Followers: 25)
Advances in Imaging and Electron Physics     Full-text available via subscription   (Followers: 2, SJR: 0.396, h-index: 27)
Advances in Immunology     Full-text available via subscription   (Followers: 35, SJR: 4.152, h-index: 85)
Advances in Inorganic Chemistry     Full-text available via subscription   (Followers: 9, SJR: 1.132, h-index: 42)
Advances in Insect Physiology     Full-text available via subscription   (Followers: 3, SJR: 1.274, h-index: 27)
Advances in Integrative Medicine     Hybrid Journal   (Followers: 5)
Advances in Intl. Accounting     Full-text available via subscription   (Followers: 4)
Advances in Life Course Research     Hybrid Journal   (Followers: 8, SJR: 0.764, h-index: 15)
Advances in Lipobiology     Full-text available via subscription   (Followers: 2)
Advances in Magnetic and Optical Resonance     Full-text available via subscription   (Followers: 9)
Advances in Marine Biology     Full-text available via subscription   (Followers: 16, SJR: 1.645, h-index: 45)
Advances in Mathematics     Full-text available via subscription   (Followers: 10, SJR: 3.261, h-index: 65)
Advances in Medical Sciences     Hybrid Journal   (Followers: 6, SJR: 0.489, h-index: 25)
Advances in Medicinal Chemistry     Full-text available via subscription   (Followers: 5)
Advances in Microbial Physiology     Full-text available via subscription   (Followers: 4, SJR: 1.44, h-index: 51)
Advances in Molecular and Cell Biology     Full-text available via subscription   (Followers: 22)
Advances in Molecular and Cellular Endocrinology     Full-text available via subscription   (Followers: 10)
Advances in Molecular Toxicology     Full-text available via subscription   (Followers: 7, SJR: 0.324, h-index: 8)
Advances in Nanoporous Materials     Full-text available via subscription   (Followers: 4)
Advances in Oncobiology     Full-text available via subscription   (Followers: 3)
Advances in Organometallic Chemistry     Full-text available via subscription   (Followers: 15, SJR: 2.885, h-index: 45)
Advances in Parallel Computing     Full-text available via subscription   (Followers: 7, SJR: 0.148, h-index: 11)
Advances in Parasitology     Full-text available via subscription   (Followers: 7, SJR: 2.37, h-index: 73)
Advances in Pediatrics     Full-text available via subscription   (Followers: 24, SJR: 0.4, h-index: 28)
Advances in Pharmaceutical Sciences     Full-text available via subscription   (Followers: 13)
Advances in Pharmacology     Full-text available via subscription   (Followers: 15, SJR: 1.718, h-index: 58)
Advances in Physical Organic Chemistry     Full-text available via subscription   (Followers: 7, SJR: 0.384, h-index: 26)
Advances in Phytomedicine     Full-text available via subscription  
Advances in Planar Lipid Bilayers and Liposomes     Full-text available via subscription   (Followers: 3, SJR: 0.248, h-index: 11)
Advances in Plant Biochemistry and Molecular Biology     Full-text available via subscription   (Followers: 8)
Advances in Plant Pathology     Full-text available via subscription   (Followers: 5)
Advances in Porous Media     Full-text available via subscription   (Followers: 4)
Advances in Protein Chemistry     Full-text available via subscription   (Followers: 18)
Advances in Protein Chemistry and Structural Biology     Full-text available via subscription   (Followers: 19, SJR: 1.5, h-index: 62)
Advances in Psychology     Full-text available via subscription   (Followers: 60)
Advances in Quantum Chemistry     Full-text available via subscription   (Followers: 5, SJR: 0.478, h-index: 32)
Advances in Radiation Oncology     Open Access  
Advances in Small Animal Medicine and Surgery     Hybrid Journal   (Followers: 2, SJR: 0.1, h-index: 2)
Advances in Space Research     Full-text available via subscription   (Followers: 343, SJR: 0.606, h-index: 65)
Advances in Structural Biology     Full-text available via subscription   (Followers: 8)
Advances in Surgery     Full-text available via subscription   (Followers: 7, SJR: 0.823, h-index: 27)
Advances in the Study of Behavior     Full-text available via subscription   (Followers: 30, SJR: 1.321, h-index: 56)
Advances in Veterinary Medicine     Full-text available via subscription   (Followers: 15)
Advances in Veterinary Science and Comparative Medicine     Full-text available via subscription   (Followers: 13)
Advances in Virus Research     Full-text available via subscription   (Followers: 5, SJR: 1.878, h-index: 68)
Advances in Water Resources     Hybrid Journal   (Followers: 43, SJR: 2.408, h-index: 94)
Aeolian Research     Hybrid Journal   (Followers: 5, SJR: 0.973, h-index: 22)
Aerospace Science and Technology     Hybrid Journal   (Followers: 307, SJR: 0.816, h-index: 49)
AEU - Intl. J. of Electronics and Communications     Hybrid Journal   (Followers: 8, SJR: 0.318, h-index: 36)
African J. of Emergency Medicine     Open Access   (Followers: 5, SJR: 0.344, h-index: 6)
Ageing Research Reviews     Hybrid Journal   (Followers: 8, SJR: 3.289, h-index: 78)
Aggression and Violent Behavior     Hybrid Journal   (Followers: 405, SJR: 1.385, h-index: 72)
Agri Gene     Hybrid Journal  
Agricultural and Forest Meteorology     Hybrid Journal   (Followers: 15, SJR: 2.18, h-index: 116)
Agricultural Systems     Hybrid Journal   (Followers: 30, SJR: 1.275, h-index: 74)
Agricultural Water Management     Hybrid Journal   (Followers: 38, SJR: 1.546, h-index: 79)
Agriculture and Agricultural Science Procedia     Open Access  
Agriculture and Natural Resources     Open Access   (Followers: 1)
Agriculture, Ecosystems & Environment     Hybrid Journal   (Followers: 53, SJR: 1.879, h-index: 120)
Ain Shams Engineering J.     Open Access   (Followers: 5, SJR: 0.434, h-index: 14)
Air Medical J.     Hybrid Journal   (Followers: 5, SJR: 0.234, h-index: 18)
AKCE Intl. J. of Graphs and Combinatorics     Open Access   (SJR: 0.285, h-index: 3)
Alcohol     Hybrid Journal   (Followers: 9, SJR: 0.922, h-index: 66)
Alcoholism and Drug Addiction     Open Access   (Followers: 6)
Alergologia Polska : Polish J. of Allergology     Full-text available via subscription   (Followers: 1)
Alexandria Engineering J.     Open Access   (Followers: 1, SJR: 0.436, h-index: 12)
Alexandria J. of Medicine     Open Access  
Algal Research     Partially Free   (Followers: 8, SJR: 2.05, h-index: 20)
Alkaloids: Chemical and Biological Perspectives     Full-text available via subscription   (Followers: 3)
Allergologia et Immunopathologia     Full-text available via subscription   (Followers: 1, SJR: 0.46, h-index: 29)
Allergology Intl.     Open Access   (Followers: 4, SJR: 0.776, h-index: 35)
ALTER - European J. of Disability Research / Revue Européenne de Recherche sur le Handicap     Full-text available via subscription   (Followers: 7, SJR: 0.158, h-index: 9)
Alzheimer's & Dementia     Hybrid Journal   (Followers: 48, SJR: 4.289, h-index: 64)
Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring     Open Access   (Followers: 5)
Alzheimer's & Dementia: Translational Research & Clinical Interventions     Open Access   (Followers: 3)
American Heart J.     Hybrid Journal   (Followers: 48, SJR: 3.157, h-index: 153)
American J. of Cardiology     Hybrid Journal   (Followers: 45, SJR: 2.063, h-index: 186)
American J. of Emergency Medicine     Hybrid Journal   (Followers: 38, SJR: 0.574, h-index: 65)
American J. of Geriatric Pharmacotherapy     Full-text available via subscription   (Followers: 6, SJR: 1.091, h-index: 45)
American J. of Geriatric Psychiatry     Hybrid Journal   (Followers: 16, SJR: 1.653, h-index: 93)
American J. of Human Genetics     Hybrid Journal   (Followers: 31, SJR: 8.769, h-index: 256)
American J. of Infection Control     Hybrid Journal   (Followers: 24, SJR: 1.259, h-index: 81)
American J. of Kidney Diseases     Hybrid Journal   (Followers: 33, SJR: 2.313, h-index: 172)
American J. of Medicine     Hybrid Journal   (Followers: 46, SJR: 2.023, h-index: 189)
American J. of Medicine Supplements     Full-text available via subscription   (Followers: 3)
American J. of Obstetrics and Gynecology     Hybrid Journal   (Followers: 191, SJR: 2.255, h-index: 171)
American J. of Ophthalmology     Hybrid Journal   (Followers: 54, SJR: 2.803, h-index: 148)
American J. of Ophthalmology Case Reports     Open Access   (Followers: 3)
American J. of Orthodontics and Dentofacial Orthopedics     Full-text available via subscription   (Followers: 6, SJR: 1.249, h-index: 88)
American J. of Otolaryngology     Hybrid Journal   (Followers: 23, SJR: 0.59, h-index: 45)
American J. of Pathology     Hybrid Journal   (Followers: 26, SJR: 2.653, h-index: 228)
American J. of Preventive Medicine     Hybrid Journal   (Followers: 21, SJR: 2.764, h-index: 154)
American J. of Surgery     Hybrid Journal   (Followers: 34, SJR: 1.286, h-index: 125)
American J. of the Medical Sciences     Hybrid Journal   (Followers: 12, SJR: 0.653, h-index: 70)
Ampersand : An Intl. J. of General and Applied Linguistics     Open Access   (Followers: 5)
Anaerobe     Hybrid Journal   (Followers: 4, SJR: 1.066, h-index: 51)
Anaesthesia & Intensive Care Medicine     Full-text available via subscription   (Followers: 55, SJR: 0.124, h-index: 9)
Anaesthesia Critical Care & Pain Medicine     Full-text available via subscription   (Followers: 10)
Anales de Cirugia Vascular     Full-text available via subscription  
Anales de Pediatría     Full-text available via subscription   (Followers: 2, SJR: 0.209, h-index: 27)
Anales de Pediatría (English Edition)     Full-text available via subscription  
Anales de Pediatría Continuada     Full-text available via subscription   (SJR: 0.104, h-index: 3)
Analytic Methods in Accident Research     Hybrid Journal   (Followers: 2, SJR: 2.577, h-index: 7)
Analytica Chimica Acta     Hybrid Journal   (Followers: 38, SJR: 1.548, h-index: 152)
Analytical Biochemistry     Hybrid Journal   (Followers: 162, SJR: 0.725, h-index: 154)
Analytical Chemistry Research     Open Access   (Followers: 8, SJR: 0.18, h-index: 2)
Analytical Spectroscopy Library     Full-text available via subscription   (Followers: 11)
Anesthésie & Réanimation     Full-text available via subscription   (Followers: 1)
Anesthesiology Clinics     Full-text available via subscription   (Followers: 22, SJR: 0.421, h-index: 40)
Angiología     Full-text available via subscription   (SJR: 0.124, h-index: 9)
Angiologia e Cirurgia Vascular     Open Access  
Animal Behaviour     Hybrid Journal   (Followers: 157, SJR: 1.907, h-index: 126)
Animal Feed Science and Technology     Hybrid Journal   (Followers: 5, SJR: 1.151, h-index: 83)
Animal Reproduction Science     Hybrid Journal   (Followers: 5, SJR: 0.711, h-index: 78)
Annales d'Endocrinologie     Full-text available via subscription   (Followers: 1, SJR: 0.394, h-index: 30)
Annales d'Urologie     Full-text available via subscription  
Annales de Cardiologie et d'Angéiologie     Full-text available via subscription   (SJR: 0.177, h-index: 13)
Annales de Chirurgie de la Main et du Membre Supérieur     Full-text available via subscription  
Annales de Chirurgie Plastique Esthétique     Full-text available via subscription   (Followers: 2, SJR: 0.354, h-index: 22)
Annales de Chirurgie Vasculaire     Full-text available via subscription   (Followers: 1)

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Journal Cover American Journal of Surgery
  [SJR: 1.286]   [H-I: 125]   [34 followers]  Follow
   Hybrid Journal Hybrid journal (It can contain Open Access articles)
   ISSN (Print) 0002-9610
   Published by Elsevier Homepage  [3043 journals]
  • The seven attributes of the academic surgeon: Critical aspects of the
           archetype and contributions to the surgical community
    • Authors: Todd K. Rosengart; Meredith C. Mason; Scott A. LeMaire; Mary L. Brandt; Joseph S. Coselli; Steven A. Curley; Kenneth L. Mattox; Joseph L. Mills; David J. Sugarbaker; David A. Berger
      Pages: 165 - 179
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Todd K. Rosengart, Meredith C. Mason, Scott A. LeMaire, Mary L. Brandt, Joseph S. Coselli, Steven A. Curley, Kenneth L. Mattox, Joseph L. Mills, David J. Sugarbaker, David A. Berger
      Background “Academic surgeon” describes a member of a medical school department of surgery, but this term does not fully define the important role of such physician-scientists in advancing surgical science through translational research and innovation. Methods The curriculum vitae and self-descriptive vignettes of the records of achievement of seven surgeons possessing documented records of academic leadership, innovation, and dissemination of knowledge were reviewed. Results Out analysis yielded seven attributes of the archetypal academic surgeon: 1) identifies complex clinical problems ignored or thought unsolvable by others, 2) becomes an expert, 3) innovates to advance treatment, 4) observes outcomes to further improve and innovate, 5) disseminates knowledge and expertise, 6) asks important questions to further improve care, and 7) trains the next generation of surgeons and scientists. Conclusion Although alternative pathways to innovation and academic contribution also exist, the academic surgeon typically devotes years of careful observation, analysis, and iterative investigation to identify and solve challenging or unexplored clinical problems, ideally leverages resources available in academic medical centers to support these endeavors.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.02.003
  • Perioperative beta blockers and statins for noncardiac surgery patients
           with coronary stents
    • Authors: Joshua S. Richman; Laura A. Graham; Aerin DeRussy; Thomas M. Maddox; Kamal M.F. Itani; Mary T. Hawn
      Pages: 180 - 185
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Joshua S. Richman, Laura A. Graham, Aerin DeRussy, Thomas M. Maddox, Kamal M.F. Itani, Mary T. Hawn
      Importance Recent publications report that perioperative initiation of statin therapy is associated with improved outcomes particularly among patients with increased cardiac risk. However, findings on associations with beta blocker (BB) initiation are mixed. Objective This study examines associations between perioperative statin and BB use in a national sample of patients with cardiac stents. Design Retrospective cohort study. Setting VA Medical Centers nationwide. Participants We identified Veterans Affairs (VA) patients undergoing non-cardiac surgery in the within two years after stent placement between October 2002 and September 2011 with BB and/or statin prescriptions within one year prior to surgery. Using VA inpatient data we identified major adverse cardiac or cerebrovascular events (MACCE) within 30 days of surgery. General usage patterns and percent of days covered by medication were calculated as additional markers of medication use. Adjusted logistic regression was used to examine associations between medication use and 30-day postoperative outcomes. Results 23,537 patients underwent surgery within 2 years following stent placement, of whom 20,566 (88.6%) had prescriptions for beta blockers and statins within 365 days prior to surgery. Of those, 13,501 (65.6%) used both BB and statins prior to surgery, while 2626 (12.8%) used only BB, 2346 (11.4%) used only statins, and 2093 (10.2%) used neither. In fully adjusted models, the only significant association was between perioperative statin use and decreased mortality (OR 0.65, 95% CI 0.48–0.87). Conclusions Our results suggest that maintaining statin therapy perioperatively is associated with reduced 30 day mortality in stented patients undergoing non-cardiac surgery who have previously been prescribed both beta blockers and statins.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.05.001
  • Comparing definitions of outpatient surgery: Implications for quality
    • Authors: Hillary J. Mull; Peter E. Rivard; Aaron Legler; Steven D. Pizer; Mary T. Hawn; Kamal M.F. Itani; Amy K. Rosen
      Pages: 186 - 192
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Hillary J. Mull, Peter E. Rivard, Aaron Legler, Steven D. Pizer, Mary T. Hawn, Kamal M.F. Itani, Amy K. Rosen
      Background Adverse event (AE) rates in outpatient surgery are inconsistently reported, partly because of the lack of a standard definition of outpatient surgery. We compared the types and rates of surgical procedures defined by two national healthcare agencies: Health Care Cost Institute (HCCI) and the Healthcare Cost and Utilization Project (HCUP) and considered implications for quality measurement. Methods We used HCCI and HCUP definitions to identify FY2012-14 VA outpatient surgeries. Results There were six times as many HCCI surgeries as HCUP (6,575,830 versus 1,086,640). Ninety-nine percent of HCUP-defined surgeries were also identified by HCCI. More HCUP surgeries had higher average Medicare Relative Value Units then HCCI surgeries [5.3 (SD = 4.4) versus 1.6 (SD = 2.3) RVUs]. Conclusions Rates and types of procedures vary widely between definitions. Quality measurement using HCCI versus HCUP may produce significantly lower AE rates because many of the surgeries included reflect low complexity and potentially low risk of AEs.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.01.021
  • Implementation of the surgical safety checklist at a tertiary academic
           center: Impact on safety culture and patient outcomes
    • Authors: Areg Zingiryan; Jennifer L. Paruch; Turner M. Osler; Neil H. Hyman
      Pages: 193 - 197
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Areg Zingiryan, Jennifer L. Paruch, Turner M. Osler, Neil H. Hyman
      Background The impact and efficacy of the World Health Organization Surgery Safety Checklist (SSC) is uncertain. We sought to determine if the SSC decreases complications and examined the attitudes of the surgical team members following implementation of the SSC. Methods A 28-question survey was developed to assess perspectives of surgical team members at the University of Vermont Medical Center (UVMC). The University Health System Consortium database was examined to compare the rates of nine complications before and after SSC implementation using Chi square analysis and Fisher's exact test. Results There was no significant decrease in any of the nine complications 2 years after SSC implementation. There was overall agreement that the SSC improved communication, safety, and prevented errors in the operating room. However, there was disagreement between nursing and surgeons over whether all three parts of the SSC were always completed. Conclusions Implementation of the SSC did not result in a significant decrease in perioperative morbidity or mortality. However, it did improve the perception of safety culture by operating room staff.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2016.10.027
  • The salutary effect of an integrated system on the rate of repeat CT
           scanning in transferred trauma patients: Improved costs and efficiencies
    • Authors: Joseph Bledsoe; Amy E. Liepert; Todd L. Allen; Li Dong; Jamon Hemingway; Sarah Majercik; Scott Gardner; Mark H. Stevens
      Pages: 198 - 200
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Joseph Bledsoe, Amy E. Liepert, Todd L. Allen, Li Dong, Jamon Hemingway, Sarah Majercik, Scott Gardner, Mark H. Stevens
      Background Duplication of Computed Tomography (CT) scanning in trauma patients has been a source of quality waste in healthcare and potential harm for patients. Integrated and regional health systems have been shown to promote opportunities for efficiencies, cost savings and increased safety. Methods This study evaluated traumatically injured patients who required transfer to a Level One Trauma Center (TC) from either within a vertically integrated healthcare system (IN) or from an out-of-network (OON) hospital. Results We found the rate of repeat CT scanning, radiology costs and total costs for day one of hospitalization to be significantly lower for trauma patients transferred from an IN hospital as compared to those patients transferred from OON hospitals. Conclusion The inefficiencies and waste often associated with transferred patients can be mitigated and strategies to do so are necessary to reduce costs in the current healthcare environment.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2016.10.020
  • Peak creatinine kinase level is a key adjunct in the evaluation of
           critically ill trauma patients
    • Authors: Saskya Byerly; Elizabeth Benjamin; Subarna Biswas; Jayun Cho; Eugene Wang; Monica D. Wong; Kenji Inaba; Demetrios Demetriades
      Pages: 201 - 206
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Saskya Byerly, Elizabeth Benjamin, Subarna Biswas, Jayun Cho, Eugene Wang, Monica D. Wong, Kenji Inaba, Demetrios Demetriades
      Background Elevated creatinine kinase (CK) can indicate rhabdomyolysis, a risk factor for acute kidney injury (AKI). We investigated risk factors and clinical significance of peak CK levels. Methods Retrospective analysis, adult trauma patients. Logistic regression was used to identify risk factors for elevated CK and AKI. Results 3240 trauma patients were analyzed; median time to peak CK was 17 h and 347 patients had peak CK > 5000. On multivariable analysis, younger males with severe injury were more likely to have peak CK > 5000 and peak CK > 5000 was an independent risk factor for AKI (AOR 3.79). Although peak CK levels were significantly lower in older patients (1,637U/L vs 2,604U/L), older patients were more likely to develop AKI at lower CK levels. Conclusions CK levels commonly peak within 1–2 days after admission. Despite lower peak CK levels, older patients are more likely to develop AKI. These data may support more rigorous CK monitoring and lower intervention threshold in older patients.
      Teaser Retrospective analysis using logistic regression was used to identify risk factors for elevated creatinine kinase (CK) and acute kidney injury (AKI) in adult trauma patients. Although peak CK levels were significantly lower in older patients (1,637U/L vs 2,604U/L), older patients were more likely to develop AKI at lower CK levels.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2016.11.034
  • Conscious status predicts mortality among patients with isolated traumatic
           brain injury in administrative data
    • Authors: Hatim A. Alsulaim; Blair J. Smart; Anthony O. Asemota; R. Sterling Haring; Joseph K. Canner; David T. Efron; Elliott R. Haut; Eric B. Schneider
      Pages: 207 - 210
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Hatim A. Alsulaim, Blair J. Smart, Anthony O. Asemota, R. Sterling Haring, Joseph K. Canner, David T. Efron, Elliott R. Haut, Eric B. Schneider
      Background Outcome studies in trauma using administrative data traditionally employ anatomy-based definitions of injury severity; however, physiologic factors, including consciousness, may correlate with outcomes. We examined whether accounting for conscious status in administrative data improved mortality prediction among patients with moderate to severe TBI. Methods Patients meeting Centers for Disease Control and Prevention (CDC) guidelines for TBI in the 2006 to 2011 Nationwide Emergency Department Sample were identified. Patients were dichotomized as having no/brief loss of consciousness (LOC) vs extended LOC greater than 1 hour using International Classification of Diseases, Ninth Revision (ICD-9) fifth digit modifiers. Receiver operating curves compared the ability of logistic regression to predict mortality in models that included LOC vs models that did not. Results Overall, 98,397 individuals met criteria, of whom 25.8% had extended LOC. In univariate analysis, AIS alone predicted mortality in 69.6% of patients (area under receiver operating characteristic curve .696, 95% CI .689 to .702), extended LOC alone predicted mortality in 76.8% (AUROC .768, 95% CI .764 to .773), and a combination of AIS and extended LOC predicted mortality in 82.6% of cases (AUROC .826, 95% CI .821 to .830). Similar differences were observed in best-fit models. Conclusions Accounting for LOC along with anatomical measures of injury severity improves mortality prediction among patients with moderate/severe TBI in administrative datasets. Further work is warranted to determine whether other physiological measures may also improve prediction across a variety of injury types.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2016.07.012
  • Injuries from all-terrain vehicles: An opportunity for injury prevention
    • Authors: Emily C. Benham; Samuel W. Ross; Mariana Mavilia; Peter E. Fischer; A. Britton Christmas; Ronald F. Sing
      Pages: 211 - 216
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Emily C. Benham, Samuel W. Ross, Mariana Mavilia, Peter E. Fischer, A. Britton Christmas, Ronald F. Sing
      Background Patient demographics, behavior, and injury patterns were assessed to inform preventative efforts for reduced incidence of all-terrain vehicle (ATV) trauma. Methods ATV-related injuries treated at a Level I trauma center from 2008 to 2012 were retrospectively reviewed. Patient outcomes and incidence of traumatic brain injury (TBI) were compared by helmet use and alcohol intoxication. Results Helmet data were available for 304 patients of 404 patients included; of these, 75 (24.7%) wore a helmet. Incidence of TBI was lower in the helmeted (8.0%) versus the unhelmeted subgroup (26.6%) (P < 0.001). Helmeted patients had lower injury severity scores, lower intensive-care unit (ICU) admission rates, and shorter ICU and hospital length of stay (LOS) (P < 0.05). Intoxicated patients had higher rates of TBI and ICU admission as well as prolonged ICU LOS (P < 0.05). Conclusions These data support the requirement for a greater emphasis on injury prevention among ATV users.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2016.11.017
  • Prone positioning reduces perineal infections when performing the miles
    • Authors: Anne M. Dinaux; Ramzi Amri; David L. Berger
      Pages: 217 - 221
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Anne M. Dinaux, Ramzi Amri, David L. Berger
      Background Abdominoperineal resection (APR) remains the cornerstone treatment for rectal cancers less than 5 cm from the anal verge. The perineal portion of an APR can be done with the patient in lithotomy or repositioned to prone jack-knife position, which influences accessibility, visualization and ability to close the wound. This paper analyses the effect of patient positioning on perineal wound dehiscence and infections. Methods A retrospective review of all rectal cancer patients who underwent an APR at Massachusetts General Hospital between 2004 and 2014 (n = 149). Patients were divided into supine (n = 91) or prone (n = 58) positioning as documented in operative reports. Results Twenty-two percent of supine positioned patients developed a perineal wound infection, versus 3.4% of the prone patients (P = 0.002). Perineal wound dehiscence rate was also higher in the supine positioned group (14.3% vs. prone 3.4%; P = 0.032). Multivariable analysis showed OR = 9.2 of developing a perineal wound infection for supine positioned patients, compared to prone, corrected for obesity and smoking history. Conclusion Repositioning patients into prone position for the perineal portion of an APR was associated with significantly lower perineal wound infection and dehiscence rates compared to supine positioned patients.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.05.021
  • Laparoscopic complete mesocolic excision with central vascular ligation in
           600 right total mesocolectomies: Safety, prognostic factors and oncologic
    • Authors: Luca Maria Siani; Andrea Lucchi; Pierluigi Berti; Gianluca Garulli
      Pages: 222 - 227
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Luca Maria Siani, Andrea Lucchi, Pierluigi Berti, Gianluca Garulli
      Background To analyze our experience with laparoscopic right Mesocolectomy in right colonic cancers. Methods 600 consecutive patients were studied. Results Mortality was 0.5%; morbidity was 35.5%. Mean mesocolic area was 15339 ± 1639 mm3, specimen length 24.3 ± 3.3 cm, distance from the tumor to high tie was 103 ± 6 mm and mean lymph nodes harvested was 27 ± 3; mesocolic plane was achieved in 81% of cases. Survival was 83%; stratified survival in patients with stage II, IIIA/B and in the subgroup of stage IIIC patients with negative apical nodes was 88.7%, 72.4%, 71.4% respectively; stage IIIC patients with positive apical nodes showed poor survival (27.7%). Recurrence occurred in 177 patients (29.5%) and was mainly systemic (22.7%). At the multivariate analysis, “non mesocolic” plane of resection, positive N3 apical nodes and CEA levels >5 ng/dL were found to be independent prognostic factors. Conclusions Laparoscopic right Mesocolectomy showed to be safe and yielded surgical specimens of high quality, with impact on survival; positive N3 apical nodes and “non mesocolic” planes were independently associated to poor outcome.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2016.10.005
  • Assessing the national trends in colon cancer among Native Americans: A 12
           year SEER database study
    • Authors: R. Thuraisingam; J. Jandova; V. Pandit; M. Michailidou; V.N. Nfonsam
      Pages: 228 - 231
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): R. Thuraisingam, J. Jandova, V. Pandit, M. Michailidou, V.N. Nfonsam
      Introduction Native Americans (NA) form a unique cohort of colon cancer (CC) patients among whom the variability in demographics and cancer characteristics remains unclear. Methods We abstracted the national estimates for NA with CC using the Surveillance, Epidemiology, and End Result (SEER) database. Trend analysis of incidence, variation in location and patient demographic analysis were performed. Results A total number of 26,674 NA with CC were reported during the 12-year study period. While the overall incidence of CC decreased by 12% during the study period, incidence increased by 38% in NA. Incidence of CC was more prevalent and higher increase (42%) seen in NA females than males (p = 0.02; 34%). Stage III tumors represented 29% of all CC, sigmoid colon the most common site location (38%) with 72% of all tumors being moderately differentiated. 55% tumors were localized in left, 36% in right and 9% in transverse colon. 92% of the NA were insured. Conclusion Incidence of CC continues to rise in NA with majority of CC presented at higher stage and moderate differentiation.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2016.11.033
  • Incidence, recurrence and risk factors of hernias following stoma reversal
    • Authors: Brad S. Oriel; Qi Chen; Kamal M.F. Itani
      Pages: 232 - 238
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Brad S. Oriel, Qi Chen, Kamal M.F. Itani
      Background To determine the incidence and risk factors for stoma site (SSH) and incisional (IH) hernias following stoma reversal as well as their recurrence following repair. Methods A cohort of VA Surgical Quality Improvement Program patients undergoing stoma reversal from 2002 to 2014 were evaluated at a single institution. Variables were selected a priori and evaluated by univariate analyses. Results Of 114 stoma reversals, 63 utilized a midline approach. The incidence of SSH and IH was 9.6% and 31.7% over a median follow-up of 5.7 (0.5–14) and 4.0 (0.1–14) years, respectively. Five SSH and 10 IH were repaired with no recurrences. Myofascial release and superficial surgical site infections (SSI) were associated with SSH while body mass index, preoperative radiotherapy, American Society of Anesthesiologists classification ≥3, operative duration ≥2.5 h and deep SSIs were associated with IH. Conclusions Incisional hernia incidence after stoma reversal is high for both the stoma site and midline. Risk factors differ for each hernia type. A low recurrence rate exists in short term follow-up following repair of a hernia occurrence.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.04.014
  • Spinal versus general anesthesia for transabdominal preperitoneal (TAPP)
           repair of inguinal hernia: Interim analysis of a controlled randomized
    • Authors: Chamaidi Sarakatsianou; Stavroula Georgopoulou; Ioannis Baloyiannis; Maria Chatzimichail; George Vretzakis; Dimitris Zacharoulis; George Tzovaras
      Pages: 239 - 245
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Chamaidi Sarakatsianou, Stavroula Georgopoulou, Ioannis Baloyiannis, Maria Chatzimichail, George Vretzakis, Dimitris Zacharoulis, George Tzovaras
      Background General anesthesia has been used as standard for laparoscopic hernia repair by the transabdominal preperitoneal (TAPP) approach. Regional anesthesia has been occasionally applied in high risk patients where general anesthesia is contraindicated. This randomized clinical trial compares spinal anesthesia with general anesthesia for TAPP inguinal hernia repair in non-high risk patients. Methods Seventy adult American Society of Anesthesiologists I, II and III patients undergoing elective TAPP inguinal hernia repair were randomized to either general or spinal anesthesia. Results Postoperative morphine consumption was significantly less immediately postoperatively (p < 0.001) in the spinal anesthesia group. Postoperative pain was also significantly decreased within the first 8 h postoperatively (p < 0.05) in the spinal anesthesia group. Conclusions Spinal anesthesia offers some advantages in patient analgesia during the early postoperative period after TAPP inguinal hernia repair and can be proposed as an effective alternative method of anesthesia for TAPP repair.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.01.032
  • Acute kidney injury in pancreatic surgery; association with urine output
           and intraoperative fluid administration
    • Authors: Or Goren; Amalia Levy; Anat Cattan; Guy Lahat; Idit Matot
      Pages: 246 - 250
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Or Goren, Amalia Levy, Anat Cattan, Guy Lahat, Idit Matot
      Background Acute kidney injury (AKI) is a devastating postoperative complication. Intraoperative urine output is assumed to reflect patient's intravascular volume and kidney function. We thus evaluated the incidence of postoperative AKI and its association with intraoperative urine output and the volume of fluid administered. Methods A retrospective study on 153 consecutive patients admitted to Tel Aviv Medical Center for pancreatic surgery. Results The incidence of AKI in patients undergoing pancreatic surgery was 9.8%. Oliguria was not a predictor of AKI. There was no association between the amount of fluids administered and AKI. Pulmonary disease is an independent predictor of AKI. AKI is an independent predictor of mortality. Conclusions AKI is common in patients undergoing pancreas surgeries and is associated with high mortality. Neither urine output, nor the volume of fluids administered correlate with postoperative AKI. Low diuresis is therefore not a sole marker for fluid administration.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.01.040
  • Utility of MRCP in clinical decision making of suspected
           choledocholithiasis: An institutional analysis and literature review
    • Authors: Wesley R. Badger; Andrew J. Borgert; Kara J. Kallies; Shanu N. Kothari
      Pages: 251 - 255
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Wesley R. Badger, Andrew J. Borgert, Kara J. Kallies, Shanu N. Kothari
      Background The ideal treatment algorithm for suspected choledocholithiasis is not yet well defined. Imaging options include magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and intraoperative cholangiogram (IOC). MRCP is diagnostic, while the other two modalities can also be therapeutic. Each of these modalities for diagnosis and treatment carries its own set of risks, benefits, and institutional costs. We hypothesized that there would be a significant difference between the biochemical profiles and characteristics of patients who undergo ERCP vs. MRCP vs. operative intervention as the initial choice of treatment/imaging modality. Methods We performed a retrospective review of the electronic medical records for all patients with a coded diagnosis of choledocholithiasis from 2011 to 2014. The initial diagnostic modality was assessed for each hospital encounter. The statistical characteristics of MRCP as compared to fluoroscopic imaging of the biliary tree (ERCP, IOC) were analyzed. Results Overall, 527 hospital encounters were identified. Initial intervention included ERCP in 63%, MRCP in 12%, and cholecystectomy in 25% of patients. Patients undergoing cholecystectomy first, compared to MRCP or ERCP, tended to have lower values for alkaline phosphatase (P < 0.001) and AST (P = 0.002) as well as be of younger age (P < 0.0001). Of the patients that underwent MRCP as their initial procedure, 82% subsequently underwent either ERCP or laparoscopic cholecystectomy. In patients who underwent an initial MRCP followed by either ERCP or IOC, the predictive performance of MRCP was as follows: sensitivity = 0.90, specificity = 0.86, positive predictive value = 0.97, negative predictive value = 0.60, agreement (Cohen's Kappa) = 0.64. Conclusions There is a significant difference in the laboratory evaluation and demographics of patients undergoing ERCP, MRCP, and laparoscopic cholecystectomy. MRCP was followed with a more invasive test a majority of the time. Since MRCP did not change the management of patients with suspected choledocholithiasis, its utility in this patient population should be questioned. Further research is needed to better define the pretest characteristics which would predict which patients do not need further intervention after MRCP as well as defining the most cost-effective strategy.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2016.10.025
  • Prognostic impact of type of preoperative biliary drainage in patients
           with distal cholangiocarcinoma
    • Authors: Fumihiko Miura; Keiji Sano; Keita Wada; Makoto Shibuya; Yutaka Ikeda; Kunihiko Takahashi; Masahiko Kainuma; Sachiyo Kawamura; Koichi Hayano; Tadahiro Takada
      Pages: 256 - 261
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Fumihiko Miura, Keiji Sano, Keita Wada, Makoto Shibuya, Yutaka Ikeda, Kunihiko Takahashi, Masahiko Kainuma, Sachiyo Kawamura, Koichi Hayano, Tadahiro Takada
      Background Surgical results of patients with resected distal cholangiocarcinoma (DCC) were evaluated to elucidate prognostic impact of the type of preoperative biliary drainage (PBD). Methods Eighty-eight patients with resected DCC were stratified into two groups according to the type of PBD: the percutaneous transhepatic biliary drainage (PTBD) group (n = 25) and the endoscopic biliary drainage (EBD) group (n = 63). Results Overall 5-year survival rate of the patients in the PTBD group was poorer than in the EBD group (24% vs. 52%, P = 0.020). On univariate analysis, PTBD, pancreatic invasion, perineural invasion, and lymph node involvement were significant prognostic factors for poor overall survival. On multivariate analysis, PTBD was the only significantly independent prognostic factor for poor overall survival. The incidence of liver metastasis was significantly higher in the PTBD group than in the EBD group (32.0% vs. 13.3%, P = 0.034). Conclusions PTBD should be avoided as much as possible in patients with DCC since the patients who underwent PTBD had poorer overall survival and higher incidence of liver metastasis than those who underwent EBD.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.01.010
  • Propensity score-matching analysis of the efficacy of late cholecystectomy
           for acute cholecystitis
    • Authors: Yu-ki Takemoto; Tomoyuki Abe; Hironobu Amano; Keiji Hanada; Nobuaki Fujikuni; Makoto Yoshida; Tsuyoshi Kobayashi; Hideki Ohdan; Toshio Noriyuki; Masahiro Nakahara
      Pages: 262 - 266
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Yu-ki Takemoto, Tomoyuki Abe, Hironobu Amano, Keiji Hanada, Nobuaki Fujikuni, Makoto Yoshida, Tsuyoshi Kobayashi, Hideki Ohdan, Toshio Noriyuki, Masahiro Nakahara
      Background Urgent cholecystectomy within 72 h from symptom onset is recommended. We assessed the feasibility of performing late cholecystectomy (4–7 days from symptom onset) for acute cholecystitis. Methods One hundred sixty-four patients with grades 1 and 2 cholecystitis, who underwent urgent cholecystectomy within 7 days from symptom onset between June 2011 and June 2015 were enrolled. One hundred thirteen patients underwent operation within 72 h from symptom onset (early operation group), and 51 underwent operation between 4 and 7 days (late operation group). Surgical outcomes and postoperative complications were analyzed using propensity score-matching analysis. Results The rate of conversion, intraoperative bleeding, and complications were comparable between the groups. After a one-to-two propensity score-matched analysis was performed, outcomes of the late operation group were not inferior to those of the early operation group. Conclusion Late cholecystectomy was acceptable for treating grades 1 and 2 acute cholecystitis.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.01.015
  • Clinical significance of circumportal pancreas, a rare congenital anomaly,
           in pancreatectomy
    • Authors: Takao Ohtsuka; Yasuhisa Mori; Kousei Ishigami; Takaaki Fujimoto; Yoshihiro Miyasaka; Kohei Nakata; Kenoki Ohuchida; Eishi Nagai; Yoshinao Oda; Shuji Shimizu; Masafumi Nakamura
      Pages: 267 - 272
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Takao Ohtsuka, Yasuhisa Mori, Kousei Ishigami, Takaaki Fujimoto, Yoshihiro Miyasaka, Kohei Nakata, Kenoki Ohuchida, Eishi Nagai, Yoshinao Oda, Shuji Shimizu, Masafumi Nakamura
      Background Circumportal pancreas is a rare congenital pancreatic anomaly. The aim of this study was to clarify the clinical characteristics of patients with circumportal pancreases undergoing pancreatectomy. Methods The medical records of 508 patients who underwent pancreatectomy were retrospectively reviewed. The prevalence of circumportal pancreas and related anatomical variations were assessed. Surgical procedures and postoperative outcomes were compared in patients with and without circumportal pancreas. Results Circumportal pancreas was observed in 9 of the 508 patients (1.7%). In all nine patients, the portal vein was completely encircled by the pancreatic parenchyma above the level of the splenoportal junction, and the main pancreatic duct ran dorsal to the portal vein. The rate of variant hepatic artery did not differ significantly in patients with and without circumportal pancreas. Pancreatic fistula developed more frequently in patients with than without circumportal pancreas (44% vs. 14%, p = 0.03), but other clinical parameters did not differ significantly in these two groups. Conclusions Despite being rare, circumportal pancreas may increase the risk of postoperative pancreatic fistula in patients undergoing pancreatectomy. However, a prospective, large-cohort study is necessary to determine the real incidence of relevant anatomical variations and the definitive clinical significance of this rare anomaly.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2016.11.018
  • Wide versus narrow margins after partial hepatectomy for hepatocellular
           carcinoma: Balancing recurrence risk and liver function
    • Authors: Wesley B.S. Field; Jack W. Rostas; Prejesh Philps; Charles R. Scoggins; Kelly M. McMasters; Robert C.G. Martin
      Pages: 273 - 277
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Wesley B.S. Field, Jack W. Rostas, Prejesh Philps, Charles R. Scoggins, Kelly M. McMasters, Robert C.G. Martin
      Background The goal of this study was to compare the outcome after partial hepatectomy for hepatocellular carcinoma (HCC) in which a margin less than or equal to 5 mm or greater than 5 mm was achieved. Methods A review of our 3300-patient prospective HPB database was performed from 12/2002 to 4/2015. Patients were stratified into two groups: resection margins ≤5 (“narrow”) and >5 mm (“wide”) as measured on final pathologic assessment. Results One-hundred thirty patients were included in the analysis (margin ≤5 mm, n = 41 and margin >5 mm, n = 89). At the time of analysis 54 patients had developed 56 recurrences, 15 (37%) in the narrow margin group and 41 (46%) in the wide margin group, p = 0.45. The pattern of recurrence was similar in the two groups: intrahepatic 11 (79%) versus 30 (75%), p = 1, and extra-hepatic 6 (43%) versus 17 (43%), p = 1. Median disease-free survival was similar in both groups, 18.1 versus 19.5 months (p = 0.85). Conclusions A narrow resection margin (5 mm or less) does not detract from oncologic outcomes after partial hepatectomy for HCC. Tailoring resection margins may lead to greater preservation of hepatic parenchyma. Factors other than margin status represent the driving forces for local and systemic recurrence.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.06.002
  • Predictors of curative resection and long term survival of gallbladder
           cancer – A retrospective analysis
    • Authors: Pramod Kumar Mishra; Sundeep Singh Saluja; Nabi Prithiviraj; Vaibhav Varshney; Neeraj Goel; Nilesh Patil
      Pages: 278 - 286
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Pramod Kumar Mishra, Sundeep Singh Saluja, Nabi Prithiviraj, Vaibhav Varshney, Neeraj Goel, Nilesh Patil
      Background Gallbladder cancer (GBC) is an aggressive malignancy. We analysed factors predicting resectability and survival of patients with GBC and the impact of surgical obstructive jaundice (SOJ). Methods Four hundred and thirty-seven patients with suspected GBC were analysed (52 excluded: benign pathology n = 35, missed GBC n = 17). The remaining 385 patients were divided into non-SOJ (n = 234) and SOJ (n = 151) groups. Predictors of resectability and long term survival were analysed and compared with their subgroups. Results Patients with gastric outlet obstruction, abdominal lump, weight loss and SOJ were more likely to be unresectable (p:0.04, 0.024, 0.003 and 0.003, respectively). TNM stage, node positivity and adjacent organ involvement were predictors of survival (p < 0.001, 0.008 and <0.001). Metastatic (36.7% vs 47.7%), inoperable (1.7% vs 12.6%) and unresectable disease (9.8% vs 24.5%) were more in the SOJ group and had lower curative resection rates (51.7% vs 15.2%; p < 0.0001). The 1,2 and 5-year survival rates were higher in patients in the non-SOJ than SOJ group (79.6%, 65% and 52.9% vs 48.6, 32.4% and 0%; p < 0.001). Conclusion GBC with SOJ is more likely to be unresectable. SOJ, nodal involvement, adjacent organ infiltration and higher TNM stage predict poor survival.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.02.006
  • Trends in open abdominal surgery in the United States—Observations from
           9,950,759 discharges using the 2009–2013 National Inpatient Sample (NIS)
    • Authors: Martin J. Carney; Jason M. Weissler; Justin P. Fox; Michael G. Tecce; Jesse Y. Hsu; John P. Fischer
      Pages: 287 - 292
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Martin J. Carney, Jason M. Weissler, Justin P. Fox, Michael G. Tecce, Jesse Y. Hsu, John P. Fischer
      Introduction Incisional hernia (IH) represents a complex and costly surgical complication. We aim to address trends in open surgery to better understand potential drivers of hernia risk. Material and methods Using the 2009–2013 NIS, a cross-sectional review of hospital discharges associated with an open abdominal surgery was performed. Results Between 2009 and 2013, there were nearly 10 million discharges associated with an open abdominal surgery. Overall, there were 2,140,616 patients receiving open surgery in 2009, decreasing to 1,760,549 in 2013 (18% decrease, p < 0.001). Open hernia procedures increased from 37,325 patients in 2009 to 41,845 in 2013 (12% increase, p = 0.001). The most prevalent comorbidities within this population included uncomplicated hypertension (25.26%), chronic pulmonary diseases (13.52%), obesity (10.24%), uncomplicated diabetes (11.06%), and depression (10.72%). Conclusions Our analysis allowed for a unique view of surgical trends, health care population dynamics, and an opportunity to use evidence-driven analytics in the understanding of IH.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.01.001
  • Perioperative blood transfusions increases the risk of anastomotic leakage
           after surgery for GEJ-cancer
    • Authors: Kaare Terp Fjederholt; Lars Bo Svendsen; Frank Viborg Mortensen
      Pages: 293 - 298
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Kaare Terp Fjederholt, Lars Bo Svendsen, Frank Viborg Mortensen
      Objective To investigate the effect of blood transfusions on the risk of anastomotic leakage (AL) in patients with gastro-esophageal-junction (GEJ) cancer. Background The incidence of GEJ cancer is increasing in the western world. Surgery is the curative treatment of choice. AL increases mortality and morbidity, and increases the risk cancer reoccurrence. In colo-rectal surgery a relation between AL and blood transfusions have been demonstrated. Method The risk of AL in relation to blood transfusions was investigated in a cohort study. 253 consecutive patients undergoing surgery for GEJ cancer was included. Data was based on a prospective maintained database and analyzed using logistic regressions models adjusting for multiple confounders. Results We found an increased risk of AL when blood was transfused OR: 3.47, (1.51; 7.99). This relation was consistent after adjustment for multiple confounders OR: 4.60, (1.29; 16.4). Increasing number of blood units did not increase risk of AL further. Conclusion We present data demonstrating a strong correlation between receiving blood transfusions and the risk of AL after surgery in GEJ cancers patients.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.01.022
  • Twenty-year trends in the utilization of Heller myotomy for achalasia in
           the United States
    • Authors: Kelly R. Haisley; Jennifer F. Preston; James P. Dolan; Brian S. Diggs; John G. Hunter
      Pages: 299 - 302
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Kelly R. Haisley, Jennifer F. Preston, James P. Dolan, Brian S. Diggs, John G. Hunter
      Introduction Trends in the utilization of Heller myotomy for achalasia in the U.S. over time have not been previously described. Materials and methods Using the Nationwide Inpatient Sample (NIS) database, we analyzed patients undergoing Heller myotomy for achalasia over a 20-year period (1992–2011) to estimate rates of Heller myotomy, locations where the procedures were performed (rural, urban or teaching) and changes in technique (laparoscopic vs open) as well as outcomes of length of stay and in-hospital mortality. Results Over the last 20 years, the total number of Heller myotomies performed in the U.S. has increased (1576 cases in 1992 to 5046 cases in 2011, p = 0.001). These procedures are now being performed laparoscopically (0.9%–67.0%, p < 0.001) and at urban teaching hospitals (45.4%–77.1%, p < 0.001). In-hospital mortality has decreased (0.9%–0.3%, p = 0.006). Hospital length of stay has decreased from 7 days to 2 days (p < 0.001). Discussion These data show a trend of increasing utilization of laparoscopic Heller myotomy at teaching institutions with decreased in-hospital mortality and shorter LOS.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.03.003
  • Overseas organ donation during wartime operations: Benchmarking military
           performance against civilian practice
    • Authors: John S. Oh; Darren Malinoski; Kathleen D. Martin; J. Salvador De La Cruz; David Zonies
      Pages: 303 - 306
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): John S. Oh, Darren Malinoski, Kathleen D. Martin, J. Salvador De La Cruz, David Zonies
      Background Over the past 15 years of war, eligible U.S. military members donated organs overseas in Germany. Our hypothesis was that outcomes at a military treatment facility were comparable to a civilian cohort. Methods Military donors were matched 1:3 with a donor cohort from the U.S. United Network for Organ Sharing. Data were compared using univariate and multivariate analysis. Significance set at p < 0.05. Results Forty military organ donors were compared with 116 civilian matched donors. The military cohort conversion rate was 75.5% and recovered more organs per donor (4.6 vs. 4.0, p = 0.02) with more transplants (4.2 vs 3.5, p = 0.01). Multivariate analysis controlling for sex, age, and type of organ donation showed no difference in odds of total organs donated in the military versus civilian cohort (odds ratio 2.1, 95% CI 0.87–5.24, p = 0.10). Conclusions Organ donation at a military treatment facility overseas can be accomplished successfully.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.01.024
  • Complication profile, failure to rescue, and mortality following elective
           endovascular aortic aneurysm repair
    • Authors: David S. Kauvar; Eric D. Martin; Todd E. Simon; Matthew D. Givens
      Pages: 307 - 311
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): David S. Kauvar, Eric D. Martin, Todd E. Simon, Matthew D. Givens
      Introduction Understanding the relationship between patient risk factors, postoperative complications, and morbidity and mortality is important when considering elective endovascular aortic aneurysm repair (E-EVAR) performed to prevent aneurysm rupture mortality. We aimed to stratify complications in E-EVAR and explore their relationship with postoperative death. Methods E-EVAR cases from 2012 NSQIP were identified. 30-day complications were categorized as major (MAJCX) or minor (MINCX) using the Clavien-Dindo classification. Failure to rescue (FTR) was defined as death following a complication. Univariate and multivariate analyses were performed to identify associations between patient risk factors, complications, and mortality. Significance set at P < 0.05. Results 3344 E-EVAR's were analyzed, with 155 (4.6%) MINCX, 106 (3.2%) MAJCX, and 39 (1.2%) mortality. Significant univariate risk factors differed between MINCX (preoperative dyspnea 27% vs 19%, COPD 32% vs19%, HTN 87% vs 79%, functional dependence 9% vs 3%) and MAJCX (female sex 33% vs 18%, preoperative diabetes 30% vs 17%, dyspnea 40% vs 19%, COPD 46% vs 20%, anticoagulant use 20% vs 11%, and functional dependence 13% vs 3%). 24 of 39 (62%) of deaths were preceded by a complication. FTR was more frequent following MAJCX than MINCX (16% vs 4.5%, P = 0.002), and occurred most commonly after renal failure with dialysis (33% mortality with complication), cardiac arrest (33%), septic shock (22%), and reintubation (22%). Independent predictors of MAJCX included female sex (OR 2, P = 0.001), COPD (OR 2, P = 0.009), and anticoagulant use (OR 2, P = 0.001). Mortality was independently predicted by MAJCX (OR 29, P < 0.001), MINCX (OR 8, P < 0.001), and preoperative renal failure (OR 11.6, P < 0.001). Conclusion The majority of deaths within 30 days following E-EVAR are preceded by a complication; both MAJCX and MINCX predict mortality. FTR is more common after MAJCX; prevention efforts should take this into account. Identified risk factors should be taken into consideration when considering E-EVAR.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.02.007
  • Racial and ethnic variations in one-year clinical and patient-reported
           outcomes following breast reconstruction
    • Authors: Nicholas L. Berlin; Adeyiza O. Momoh; Ji Qi; Jennifer B. Hamill; Hyungjin M. Kim; Andrea L. Pusic; Edwin G. Wilkins
      Pages: 312 - 317
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Nicholas L. Berlin, Adeyiza O. Momoh, Ji Qi, Jennifer B. Hamill, Hyungjin M. Kim, Andrea L. Pusic, Edwin G. Wilkins
      Background Existing studies evaluating racial and ethnic disparities focus on describing differences in procedure type and the proportion of women who undergo reconstruction following mastectomy. This study seeks to examine racial and ethnic variations in clinical and patient-reported outcomes (PROs) following breast reconstruction. Methods The Mastectomy Reconstruction Outcomes Consortium is an 11 center, prospective cohort study collecting clinical and PROs following autologous and implant-based breast reconstruction. Mixed-effects regression models, weighted to adjust for non-response, were performed to evaluate outcomes at one-year postoperatively. Results The cohort included 2703 women who underwent breast reconstruction. In multivariable models, Hispanic or Latina patients were less likely to experience any complications and major complications. Black or African-American women reported greater improvements in psychosocial and sexual well-being. Conclusions Despite differences in pertinent clinical and socioeconomic variables, racial and ethnic minorities experienced equivalent or better outcomes. These findings provide reassurance in the context of numerous racial and ethnic health disparities and build upon our understanding of the delivery of surgical care to women with or at risk for developing breast cancer.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.02.009
  • Fibroepithelial breast lesions diagnosed by core needle biopsy demonstrate
           a moderate rate of upstaging to phyllodes tumors
    • Authors: Gabriel Marcil; Stephanie Wong; Nora Trabulsi; Alexandra Allard-Coutu; Armen Parsyan; Atilla Omeroglu; Gulbeyaz Atinel; Benoit Mesurolle; Sarkis Meterissian
      Pages: 318 - 322
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Gabriel Marcil, Stephanie Wong, Nora Trabulsi, Alexandra Allard-Coutu, Armen Parsyan, Atilla Omeroglu, Gulbeyaz Atinel, Benoit Mesurolle, Sarkis Meterissian
      Background Fibroepithelial lesions of the breast (FEL) are atypical lesions diagnosed on core-needle biopsy. The purpose of this study was to determine the rate at which FELs are upstaged to phyllodes tumor on excision, and to examine the clinical and radiological factors that may be predictive of upstaging. Methods A retrospective review from the medical records of patients diagnosed with FEL on CNB at a single institution between 2010 and 2015 was performed. Patients diagnosed with benign or borderline phyllodes tumors were compared to those diagnosed with fibroadenoma. Results Of 74 patients diagnosed with FEL, 48 underwent excision (64.9%). Of the 48 lesions excised, pathology revealed 30 fibroadenomas (62.5%), 14 benign phyllodes tumors (29.2%), and 4 borderline phyllodes tumor (8.3%). No malignant phyllodes tumors were identified. On preoperative ultrasound, heterogeneous echotexture (p = 0.03) and lack of internal vascularity (p = 0.03) were significantly associated with upstaging to phyllodes tumor. Conclusions Surgical excision of FELs yield a pathological diagnosis of benign and borderline phyllodes tumor in 37.5% of cases. A high BIRADs score (≥4b), heterogeneous echotexture and lack of internal vascularity on ultrasound may help predict upstaging to phyllodes tumor.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2016.12.017
  • Incidence, characteristics, and management of recently diagnosed,
           microscopically invasive breast cancer by receptor status: Iowa SEER 2000
           to 2013
    • Authors: Alexandra Thomas; Ronald J. Weigel; Charles F. Lynch; Philip M. Spanheimer; Elizabeth K. Breitbach; Mary C. Schroeder
      Pages: 323 - 328
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Alexandra Thomas, Ronald J. Weigel, Charles F. Lynch, Philip M. Spanheimer, Elizabeth K. Breitbach, Mary C. Schroeder
      Background Recent incidence, treatment patterns, and outcomes for node negative microscopically invasive breast cancer (MIBC) have not been reported. Methods State Health Registry of Iowa data identified women with ductal carcinoma in situ (DCIS), MIBC, and stage I breast cancer excluding MIBC (stage 1BC). Results From 2000 to 2013, 1,706, 193, and 4,514 women were diagnosed with DCIS, MIBC, and stage 1BC, respectively. MIBC increased at an annual percentage change of 2.1 (P = .041). MIBC was more frequently human epidermal growth factor receptor 2 positive than stage 1BC (39.7% vs 9.6%, P < .001). Mastectomy was performed more frequently in MIBC than DCIS (40.9% vs 30.6%, P = .014) or stage 1BC (40.9% vs 33.8%, P = .119). Chemotherapy was given to 4.1% of women with MIBC. Survival for women with MIBC was intermediate between DCIS and stage 1BC. Conclusions Management of MIBC is an increasingly frequent clinical scenario. Women with MIBC receive more aggressive local and systemic therapy than women with DCIS.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2016.08.008
  • Health disparities in infants with hypertrophic pyloric stenosis
    • Authors: Alexander Feliz; Janette L. Holub; Nima Azarakhsh; Marielena Bachier-Rodriguez; Kate B. Savoie
      Pages: 329 - 335
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Alexander Feliz, Janette L. Holub, Nima Azarakhsh, Marielena Bachier-Rodriguez, Kate B. Savoie
      Background This study investigates whether health disparities exist in infants with hypertrophic pyloric stenosis (HPS), to identify factors affecting definitive treatment, and if more morbidity occurs. Methods A 6-year retrospective analysis was performed on infants with HPS. Analysis of variance was used to evaluate the impact of socioeconomic factors on disease severity and hospitalization. General linear models were used to assess the impact of risk factors on the outcomes. Results There were a total of 584 infants. African-American's had lower serum chloride (P < .001), higher bicarbonate (P = .001), and sodium levels (P = .006), adding to longer hospitalization than whites (P = .03). Uninsured infants had lower sodium and chloride (P < .001) and higher bicarbonate (P < .001), resulting in a longer time to operation (P = .05) than privately insured infants. In multivariable analyses, African-American's were associated with chloride (P = .002) and higher bicarbonate (P = .009), and uninsured status remained significantly associated with all electrolyte abnormalities. Conclusions African-American and poorly insured infants with HPS had greater risk of metabolic derangements. This required more time to correct dehydration and electrolytes, adding to longer hospitalizations.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2016.07.009
  • Pediatric vascular injuries: Are we preparing trainees appropriately to
           meet our needs'
    • Authors: Lori A. Gurien; Robert T. Maxson; Melvin S. Dassinger; Steven C. Mehl; Marie E. Saylors; Samuel D. Smith
      Pages: 336 - 340
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Lori A. Gurien, Robert T. Maxson, Melvin S. Dassinger, Steven C. Mehl, Marie E. Saylors, Samuel D. Smith
      Background There is no required competency for pediatric vascular injury in surgical training. We sought to describe changes over time for surgical specialists operating on pediatric vascular trauma injuries at a pediatric trauma center. Methods Charts were retrospectively reviewed for vascular trauma injuries at a freestanding children's hospital between 1993 and 2015. Data were collected on mechanism, injured vessel(s), operation(s) performed, and specialists performing operation. Surgical specialists were compared over time. Results Ninety-four patients (median age = 12) underwent 101 pediatric vascular trauma operations. There were significant differences in frequency of types of operations (primary repairs, graft repairs, and ligations) performed by pediatric, vascular, and orthopedic surgeons (P < .001). The proportion of operations performed by vascular surgeons increased and those performed by pediatric surgeons decreased significantly over time. Conclusions Various surgical specialists manage pediatric vascular trauma. With expansion of integrated residency programs, surgical specialists managing these patients in the future should be trained in both pediatric and vascular surgery.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2016.09.032
  • Has survival improved following resection for pancreatic
    • Authors: Kenneth Luberice; Darrell Downs; Benjamin Sadowitz; Sharona Ross; Alexander Rosemurgy
      Pages: 341 - 346
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Kenneth Luberice, Darrell Downs, Benjamin Sadowitz, Sharona Ross, Alexander Rosemurgy
      Introduction This study was undertaken to determine if survival after resection of pancreatic adenocarcinoma has improved over the past two decades. Methods The SEER database was queried for patients who underwent pancreatectomy for pancreatic adenocarcinoma from 1992 to 2010. AJCC Stage and survival were determined for patients. Data were analyzed using Mantel-Cox test and linear regression. Results 15,604 patients underwent pancreatectomy from 1992 to 2010. Survival improved from 1992 to 2010 (p < 0.0001); specifically, median survival increased 1992–2010 (p < 0.0001). However, 5-year survival rates did not change 1992–2010. More patients (p = 0.007) underwent resections of Stage I and relatively more patients (p = 0.004) underwent resections of Stage II cancers 2004–2010 with commensurately smaller tumors (p = 0.01). Conclusions From 1992 to 2010, progressively more patients underwent pancreatectomy for pancreatic adenocarcinoma with progressively smaller tumors and earlier stages. These patients lived more years (e.g., improved survival curves and median survival) but without improved 5-year survival, denoting better early and intermediate survival. Early detection, better perioperative care, more efficacious noncurative chemotherapy undoubtedly play a role, but better solutions for long-term survival must be sought.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.05.007
  • Operative management of chronic pancreatitis: A review
    • Authors: John D. Tillou; Jacob A. Tatum; Joshua S. Jolissaint; Daniel S. Strand; Andrew Y. Wang; Victor Zaydfudim; Reid B. Adams; Kenneth L. Brayman
      Pages: 347 - 357
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): John D. Tillou, Jacob A. Tatum, Joshua S. Jolissaint, Daniel S. Strand, Andrew Y. Wang, Victor Zaydfudim, Reid B. Adams, Kenneth L. Brayman
      Background Pain secondary to chronic pancreatitis is a difficult clinical problem to manage. Many patients are treated medically or undergo endoscopic therapy and surgical intervention is often reserved for those who have failed to gain adequate pain relief from a more conservative approach. Results There have been a number of advances in the operative management of chronic pancreatitis over the last few decades and current therapies include drainage procedures (pancreaticojejunostomy, etc.), resection (pancreticoduodenectomy, etc.) and combined drainage/resection procedures (Frey procedure, etc.). Additionally, many centers currently perform total pancreatectomy with islet autotransplantation, in addition to minimally invasive options that are intended to tailor therapy to individual patients. Discussion Operative management of chronic pancreatitis often improves quality of life, and is associated with low rates of morbidity and mortality. The decision as to which procedure is optimal for each patient should be based on a combination of pathologic changes, prior interventions, and individual surgeon and center experience.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.03.004
  • A pilot study examining experiential learning vs didactic education of
           abdominal compartment syndrome
    • Authors: Anju Saraswat; John Bach; William D. Watson; John O. Elliott; Edward P. Dominguez
      Pages: 358 - 364
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Anju Saraswat, John Bach, William D. Watson, John O. Elliott, Edward P. Dominguez
      Background Current surgical education relies on simulated educational experiences or didactic sessions to teach low-frequency clinical events such as abdominal compartment syndrome (ACS). The purpose of this pilot study was to evaluate if simulation would improve performance and knowledge retention of ACS better than a didactic lecture. Methods Nineteen general surgery residents were block randomized by postgraduate year level to a didactic or a simulation session. After 3 months, all residents completed a knowledge assessment before participating in an additional simulation. Two independent reviewers assessed resident performance via audio-video recordings. Results No baseline differences in ACS experience were noted between groups. The observational evaluation demonstrated a significant difference in performance between the didactic and simulation groups: 9.9 vs 12.5, P = .037 (effect size = 1.15). Knowledge retention was equivalent between groups. Conclusions This pilot study suggests that simulation-based education may be more effective for teaching the basic concepts of ACS.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2016.07.011
  • Strategies for increasing the feasibility of performance assessments
           during competency-based education: Subjective and objective evaluations
           correlate in the operating room
    • Authors: Peter Szasz; Marisa Louridas; Kenneth A. Harris; Teodor P. Grantcharov
      Pages: 365 - 372
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Peter Szasz, Marisa Louridas, Kenneth A. Harris, Teodor P. Grantcharov
      Background Competency-based education necessitates assessments that determine whether trainees have acquired specific competencies. The evidence on the ability of internal raters (staff surgeons) to provide accurate assessments is mixed; however, this has not yet been directly explored in the operating room. This study's objective is to compare the ratings given by internal raters vs an expert external rater (independent to the training process) in the operating room. Methods Raters assessed general surgery residents during a laparoscopic cholecystectomy for their technical and nontechnical performance. Results Fifteen cases were observed. There was a moderately positive correlation (rs = .618, P = .014) for technical performance and a strong positive correlation (rs = .731, P = .002) for nontechnical performance. The internal raters were less stringent for technical (mean rank 3.33 vs 8.64, P = .007) and nontechnical (mean rank 3.83 vs 8.50, P = .01) performances. Conclusions This study provides evidence to help operationalize competency-based assessments.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2016.07.017
  • The effect of a simple intraprocedural checklist on the task performance
           of laparoscopic novices
    • Authors: Michael El Boghdady; Benjie Tang; Iain Tait; Afshin Alijani
      Pages: 373 - 377
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Michael El Boghdady, Benjie Tang, Iain Tait, Afshin Alijani
      Background Surgical checklists are used for error reduction. Checklists are infrequently applied during procedures and have been limited to lists of procedural steps as aid memoires. We aimed to study the effect of a self-administered checklist on the laparoscopic task performance of novices during a standardized task. Methods Twenty novices were randomized into 2 equal groups, those receiving paper feedback (control group) and those receiving paper feedback and the checklist (checklist group). Subjects performed laparoscopic double knots, repeated over 5 separate stages. Human reliability assessment technique was used for error analysis. Results 2,341 errors were detected during the 5 stages. During the first stage, the errors were not significantly different between the 2 groups. The checklist group committed significantly fewer errors as compared with the control group during all the later 4 stages (P < .01). Conclusions The simple intraprocedural checklist significantly improved the laparoscopic task performance and the learning curve of laparoscopic novices.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2016.07.019
  • Prospective evaluation of surgical palliative care immersion training for
           general surgery residents
    • Authors: Mustafa Raoof; Lisa O'Neill; Leigh Neumayer; Mindy Fain; Robert Krouse
      Pages: 378 - 383
      Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2
      Author(s): Mustafa Raoof, Lisa O'Neill, Leigh Neumayer, Mindy Fain, Robert Krouse
      Background Palliative care competencies in surgical training are recognized to improve the care of surgical patients with advanced or life-threatening illnesses. Formal programs to teach these competencies are lacking. The study aims to assess the feasibility and utility of a unique surgical palliative care immersion training program. Study design A half-day Surgical Palliative Care Immersion Training (SPCIT) was developed using the American College of Surgeon's manual titled “Surgical Palliative Care: A Resident's Guide” as a framework. The training format was modeled after the highly successful University of Arizona Center on Aging's Interprofessional Chief Resident Immersion Training (IP-CRIT) Program to teach palliative care competencies to general surgery residents. Objective and self-assessments were performed at baseline, immediately post training and 5-months after training. For all pre-test, post-test comparisons on Likert scale, Wilcoxon Signed Rank Test was used. For aggregate scores a repeated-measures analysis of variance was used. Results Forty of the forty-eight residents (83%) completed the learner's needs assessment survey. Thirty-four (71%) of the forty-eight residents in the residency program participated in the SPCIT. Significant improvement was noted in objective assessment of post-test aggregate scores (Mean difference 2.15, 95% CI 0.52–3.77, p = 0.0083). There was a significant increase in proportion of residents who felt confident in discussing palliative care options (96.5% vs. 27.5%, p < 0.0001); end-of-life care (86.2% vs. 52.5%, p < 0.0065); code status (86% vs. 15%, p < 0.0001); prognosis (96% vs. 35%, p < 0.001); or withholding or withdrawing life support (79.2% vs. 45%, p = 0.0059) with patient/families after the SPCIT. Conclusion The newly developed SPCIT program drastically improves knowledge, attitudes and perceived skills of general surgery residents. Similar training can be implemented in other surgical residency programs.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2016.11.032
  • Colorectal cancer screening in rural and poor-resourced communities
    • Authors: Michael A. Preston; Katherine Glover-Collins; Levi Ross; Austin Porter; Zoran Bursac; Delores Woods; Jacqueline Burton; Karen Crowell; Jonathan Laryea; Ronda S. Henry-Tillman
      Abstract: Publication date: Available online 12 August 2017
      Source:The American Journal of Surgery
      Author(s): Michael A. Preston, Katherine Glover-Collins, Levi Ross, Austin Porter, Zoran Bursac, Delores Woods, Jacqueline Burton, Karen Crowell, Jonathan Laryea, Ronda S. Henry-Tillman
      To test the efficacy of a community-based intervention, Empowering Communities for Life (EC4L), designed to increase colorectal cancer (CRC) screening through fecal occult blood test (FOBT) in rural underserved communities in a randomized controlled trial. Participants were randomized into 3 groups (2 interventions and 1 control). Interventions were delivered by community lay health workers or by academic health professionals. The main outcome of interest was return rate of FOBT screening kit within 60 days. Participants (n=1050) included 330 screening-eligible adults. The return rate of FOBT kits within 60 days was 32%. The professional group (Arm 2) had the highest proportion of returned FOBTs within 60 days at 42% (n=46/110), a significantly higher return rate than the lay group (Arm 1) [28%(n=29/103);P=0.0422] or control group (Arm 3) [25%(n=29/117);P=0.0099]. Thus, one arm (Arm 2) of our intervention produced significantly higher CRC screening through FOBT. Community-based participation partnered with academic health professionals enhanced CRC screening among rural and poor-resourced communities.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.08.004
  • Component separation technique for giant incisional hernia: A systematic
    • Authors: Bram Cornette; Dirk De Bacquer; Frederik Berrevoet
      Abstract: Publication date: Available online 10 August 2017
      Source:The American Journal of Surgery
      Author(s): Bram Cornette, Dirk De Bacquer, Frederik Berrevoet
      The component separation technique (CST) has gained popularity among general surgeons in the management of giant abdominal hernia. A systematic review of the MedLine and EMBASE databases was performed. 36 observational cohort studies were included for data-analysis and divided in 4 main groups: Open Anterior Approach (OAA), Transversus Abdominis Release (TAR), Laparoscopic Anterior Approach (LAA) and Perforator Preserving Approach (PPA). Surgical Site Occurrences (SSO) occurred in 21.4%, 23.7%, 20.3% and 16.0% respectively. Incidence of recurrence was 11.9% (OAA), 5.25% (TAR), 7.02% (LAA) and 6.47% (PPA) with a significant difference in the advantage of TAR over OAA (p < 0.001). Limitations in this systematic review were a lack of randomized trials, a heterogenous population and non-standardized methods for measuring outcomes, all making it difficult to postulate conclusions about CST and its modifications. Based on pooled results of 36 studies, the prevalence of SSO is comparable between the techniques with an average of one in five and the prevalence of recurrences is highest when using the Open Anterior Approach at 11.9%.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.07.032
  • Rothman Index variability predicts clinical deterioration and rapid
           response activation
    • Authors: Brian C. Wengerter; Kevin Y. Pei; David Asuzu; Kimberly A. Davis
      Abstract: Publication date: Available online 10 August 2017
      Source:The American Journal of Surgery
      Author(s): Brian C. Wengerter, Kevin Y. Pei, David Asuzu, Kimberly A. Davis
      Background The overall utility of the Rothman Index (RI), a global measure of inpatient acuity, for surgical patients is unclear. We evaluate whether RI variability can predict rapid response team (RRT) activation in surgical patients. Methods Surgical patients who underwent RRT activation from 2013 to 2015 were matched to four control cases. RI variability was gauged by maximum minus minimum RI (MMRI) and RI standard deviation (RISD) within a 24-h period before RRT. The primary outcome measured was RRT activation, and our secondary outcome was in-hospital mortality. Results Two hundred seventeen (217) patients underwent RRT. RISD (odds ratio, OR, 1.31, 95% confidence interval, CI, 1.23–1.38, P < 0.001; area under receiver operating characteristic, AUROC, curve 0.74, 95% CI 0.70–0.77) and MMRI (OR 1.10, 95% CI 1.08–1.12, P < 0.001; AUROC 0.76, 95% CI 0.72–0.79) predicted increased likelihood of RRT. Conclusions RISD is predictive of RRT.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.07.031
  • Cancer-promoting mechanisms of tumor-associated neutrophils
    • Authors: Brian Hurt; Richard Schulick; Barish Edil; Karim C. El Kasmi; Carlton Barnett
      Abstract: Publication date: Available online 10 August 2017
      Source:The American Journal of Surgery
      Author(s): Brian Hurt, Richard Schulick, Barish Edil, Karim C. El Kasmi, Carlton Barnett
      Importance Neutrophils have classically been considered to mount a defensive response against tumor cells, yet recent evidence suggests tumors modulate neutrophil function to support tumor growth and progression. Observations Tumor-associated neutrophils (TANs) are phenotypically distinct from circulating neutrophils in terms of their surface protein composition and cyto/chemokine activity and response. Although TANs have been shown to both promote and inhibit tumor advancement, the preponderant activity augments tumor progression. This review discusses these cancer-promoting molecular pathways, relevant diagnostic studies in patients, and subsequent treatment modalities. The tumor promoting mechanisms of TANs include dampening of CD8+ response via Arginase-1; a neutrophil-secreted neutrophil elastase (NE) upregulation of tumor cellular proliferation pathways; degradation of basement membrane and ECM via NE and MMP-9; upregulation of angiogenesis by VEGF, Bv8, and HGF; and ICAM-1 dependent tumor intravasation, immune protection in circulation, and extravasation into distant, metastatic tissue beds. Clinicians are constrained in treating TANs systemically as it may induce neutropenia, therefore targeting TANs-mediated tumor progression pathways surgically on a loco-regional level is a viable adjuvant treatment modality. Conclusion and Relevance TANs modulate the tumor microenvironment promoting tumor progression. Mechanistic understanding of TANs role in tumor progression will provide unique therapeutic alternatives.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.08.003
  • A model for a career in a specialty of general surgery: One surgeon's
    • Authors: Bona Ko; Christopher R. McHenry
      Abstract: Publication date: Available online 10 August 2017
      Source:The American Journal of Surgery
      Author(s): Bona Ko, Christopher R. McHenry
      Background The integration of general and endocrine surgery was studied as a potential career model for fellowship trained general surgeons. Methods Case logs collected from 1991–2016 and academic milestones were examined for a single general surgeon with a focused interest in endocrine surgery. Operations were categorized using CPT codes and the 2017 ACGME “Major Case Categories” and there frequencies were determined. Results 10,324 operations were performed on 8209 patients. 412.9 ± 84.9 operations were performed yearly including 279.3 ± 42.7 general and 133.7 ± 65.5 endocrine operations. A high-volume endocrine surgery practice and a rank of tenured professor were achieved by years 11 and 13, respectively. At year 25, the frequency of endocrine operations exceeded general surgery operations. Conclusion Maintaining a foundation in broad-based general surgery with a specialty focus is a sustainable career model. Residents and fellows can use the model to help plan their careers with realistic expectations.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.08.006
  • Quality of life, functional status and adhesiolysis during elective
           abdominal surgery
    • Authors: Chema Strik; Martijn W.J. Stommel; Jeroen C. Hol; Harry van Goor; Richard P.G. ten Broek
      Abstract: Publication date: Available online 10 August 2017
      Source:The American Journal of Surgery
      Author(s): Chema Strik, Martijn W.J. Stommel, Jeroen C. Hol, Harry van Goor, Richard P.G. ten Broek
      Background Adhesiolysis during abdominal surgery can cause iatrogenic organ injury, increased operative time and a more complicated convalescence. We assessed the impact of adhesiolysis and adhesiolysis-related complications on quality of life and functional status following elective abdominal surgery. Methods Prospective cohort study, comparing patients requiring and not requiring adhesiolysis during an elective laparotomy or laparoscopy using the SF-36 and DASI questionnaire scores. Results 518 patients were included. Pre- and postoperative quality of life did not significantly differ between both groups. Patients with adhesiolysis had a significantly lower pre- and postoperative functional status (p < 0.01). Higher age, concomitant pulmonary disease, postoperative complications, readmissions and chronic abdominal pain 6 months after surgery were all associated with a significant and independent decline in quality of life and functional status six months after surgery. Conclusion and relevance: Adhesiolysis in itself does not affect functional status and quality of life six months after surgery. Postoperative complications, readmissions and chronic abdominal pain are associated with a lower health status.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.08.001
  • Implementation of a standardized handoff protocol for post-operative
           admissions to the surgical intensive care unit
    • Authors: Dhriti Mukhopadhyay; Katie C. Wiggins-Dohlvik; Mary M. MrDutt; Jeffrey S. Hamaker; Graham L. Machen; Matthew L. Davis; Justin L. Regner; Randall W. Smith; David P. Ciceri; Jay G. Shake
      Abstract: Publication date: Available online 10 August 2017
      Source:The American Journal of Surgery
      Author(s): Dhriti Mukhopadhyay, Katie C. Wiggins-Dohlvik, Mary M. MrDutt, Jeffrey S. Hamaker, Graham L. Machen, Matthew L. Davis, Justin L. Regner, Randall W. Smith, David P. Ciceri, Jay G. Shake
      Background The transfer of critically ill patients from the operating room (OR) to the surgical intensive care unit (SICU) involves handoffs between multiple providers. Incomplete handoffs lead to poor communication, a major contributor to sentinel events. Our aim was to determine whether handoff standardization led to improvements in caregiver involvement and communication. Methods A prospective intervention study was designed to observe thirty one patient handoffs from OR to SICU for 49 critical parameters including caregiver presence, peri-operative details, and time required to complete key steps. Following a six month implementation period, thirty one handoffs were observed to determine improvement. Results A significant improvement in presence of physician providers including intensivists and surgeons was observed (p = 0.0004 and p < 0.0001, respectively). Critical details were communicated more consistently, including procedure performed (p = 0.0048), complications (p < 0.0001), difficult airways (p < 0.0001), ventilator settings (p < 0.0001) and pressor requirements (p = 0.0134). Conversely, handoff duration did not increase significantly (p = 0.22). Conclusions Implementation of a standardized protocol for handoffs between OR and SICU significantly improved caregiver involvement and reduced information omission without affecting provider time commitment.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.08.005
  • Local parastomal hernia repair with biological mesh is safe and effective
    • Authors: Theadore Hufford; Jean-Francois Tremblay; Mohammad Taha Mustafa Sheikh; Slawomir Marecik; John Park; Ina Zamfirova; Kunal Kochar
      Abstract: Publication date: Available online 5 August 2017
      Source:The American Journal of Surgery
      Author(s): Theadore Hufford, Jean-Francois Tremblay, Mohammad Taha Mustafa Sheikh, Slawomir Marecik, John Park, Ina Zamfirova, Kunal Kochar
      PURPOSE The goal of this study was to evaluate the efficacy, morbidity and safety of local parastomal hernia repair using biological mesh. PATIENTS AND METHODS A retrospective analysis of a prospectively maintained database was performed for parastomal hernia repairs. All patients who underwent local parastomal hernia repair with biological mesh between July 2006 and July 2015 were included in the study. Non-local (laparoscopic or midline incision) procedures were excluded. The type of repair, incision used, mesh placement and morbidity were analyzed. Time to recurrence was measured as an independent variable. RESULTS 58 procedures with a median follow up of 3.8 years were analyzed. The majority (91%) of repairs were performed on an elective basis. Underlay technique was used in 24 patients (39%), overlay in 4 (7%) and both overlay and underlay (sandwich technique) in 33 (54%) of the cases. Overall, 11 patients (18.1%) experienced recurrence. Recurrence occurred in 8 patients in the underlay group (33%), 1 in the overlay group (25%), with 2 recurrences identified in the sandwich technique group (6%; p=.02). There was one occurrence of 30-day morbidity in our study population (.016%). No difference was observed for recurrence or morbidity according to the type of biologic mesh used (human, bovine, or porcine). CONCLUSION Our results demonstrate that local parastomal hernia repairs are associated with moderate recurrence rates, very low morbidity and consistent with the current literature. The sandwich technique was found to have a significantly lower recurrence rate compared to underlay or overlay techniques. Keyhole incisions were associated with less recurrence than traditional circular incisions. Our findings further reveal biologic mesh type was not associated with any difference in outcomes. Local parastomal hernia repair with biologic mesh is a safe procedure with very low morbidity and acceptable recurrence rate, especially using the sandwich repair technique.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.05.005
  • TOC
    • Abstract: Publication date: August 2017
      Source:The American Journal of Surgery, Volume 214, Issue 2

      PubDate: 2017-08-16T03:07:58Z
  • Groin hernia repair in women – A nationwide register study
    • Authors: Hanna Nilsson; Henrik Holmberg; Pär Nordin
      Abstract: Publication date: Available online 25 July 2017
      Source:The American Journal of Surgery
      Author(s): Hanna Nilsson, Henrik Holmberg, Pär Nordin
      Introduction The aim of this study was to investigate reoperation for recurrence in men and women with respect to method of repair, hernia anatomy and year of operation. Method Since 1992, groin hernia repairs performed in Sweden are prospectively registered in the Swedish Hernia Register, (SHR). Reoperations are noted, regardless of where the reoperation is performed. Risk of reoperation for recurrence is calculated for men and women with respect of method of repair, hernia anatomy and year of operation. Results Out of 221 108 eligible operations registered between 1992-2013, 17 545 (8%) were performed on women. The risk of being operated for recurrence after laparoscopic surgery was lowered in women, RR 0,4(95%CI 0.3–0.7) and increased in men, RR 2.3(95% CI 2.0–2.7), compared to the Lichtenstein technique. Discussion The reoperation for recurrence rate differed significantly between men and women. As regards the technique used for primary repair, laparoscopic groin hernia repair lowered the risk of reoperation for recurrence in women whereas it doubled the risk in men.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.07.027
  • Should classification as an ACS-NSQIP high outlier be used to direct
           hospital quality improvement efforts'
    • Authors: Elise H. Lawson; Patricia L. Roberts; Todd D. Francone; Peter W. Marcello; Thomas E. Read; Rocco Ricciardi
      Abstract: Publication date: Available online 21 July 2017
      Source:The American Journal of Surgery
      Author(s): Elise H. Lawson, Patricia L. Roberts, Todd D. Francone, Peter W. Marcello, Thomas E. Read, Rocco Ricciardi
      Background ACS-NSQIP classifies hospitals as “high outliers” if their performance is significantly worse than expected. We determined how often hospitals return to as-expected performance after being newly identified as outliers. Methods Outlier status was identified in ACS-NSQIP semi-annual reports (SARs) 2008–2011 for 13 postoperative adverse events. Pearson correlation and R2 measured the relationship between frequency of changes in outlier status, frequency of outlier identification, and adverse event rate. Results Among 284 hospitals, 75% were classified as high outliers for an adverse event at least once. New high outliers frequently did not remain outliers in the next SAR. Of new outliers, mortality had the highest percentage return to as-expected performance (62.7%), while surgical site infection had the lowest (20.5%). The likelihood of an outlier hospital returning to as-expected performance was inversely related to the percentage of hospitals classified as outliers. The percentage of hospitals classified as outliers for an event explained 60% of variation in outlier hospitals returning to as-expected performance. Conclusions Outlier status may be less meaningful for adverse events with relatively few outlier hospitals.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.07.026
  • Decreasing readmissions by focusing on complications and underlying
    • Authors: Cigdem Benlice; Dilara Seyidova-Khoshknabi; Luca Stocchi; Tracy Hull; Scott Steele; Emre Gorgun
      Abstract: Publication date: Available online 21 July 2017
      Source:The American Journal of Surgery
      Author(s): Cigdem Benlice, Dilara Seyidova-Khoshknabi, Luca Stocchi, Tracy Hull, Scott Steele, Emre Gorgun
      Background To analyze demographics and outcomes of patients focusing on 30-day readmission status and identify procedure-specific risk factors. Methods Patients undergoing abdominal colorectal surgery (2011–2013) were identified Demographics and outcomes including in-hospital complications were compared based on readmission status. Results A total of 6637 patients were identified with a mean age of 51.2(±17.1) years. Seven hundred and seventy five(11.7%) patients were readmitted at least once within 30-day. The most common index procedures related to readmission were stoma closure (n = 127/775, 16.4%) and total colectomy (n = 105/775, 13.6%). Readmitted patients had longer length of index hospital stay (LOS)(8.2 ± 5.9 vs 7.9 ± 6.9 days,p < 0.001) and operative time(167 ± 104 vs 144 ± 95 min, p < 0.001), higher intraoperative(2% vs 1%,p = 0.04) and in-hospital complication rates(36% vs 28%,p < 0.001). Main reasons for readmissions were gastrointestinal-related causes(n = 222, 29%), small bowel obstruction (n = 133,17%), wound-related complications(n = 108,14%), and dehydration(n = 93,12%). Median readmission LOS was 4(1–71)days and 54%(n = 407) of readmissions occurred within 7 days of discharge. Conclusion Increased postoperative complications may be the main preventable underlying reason for increased risk of hospital readmission after colorectal surgery. Preventive measures to decrease complications and actions to identify high risk patients for complications would help to reduce readmissions.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.07.024
  • Unplanned readmission and outpatient examination 90-days after acute
           appendectomy in adults
    • Authors: Bo Bendvold; Arne Refsum; Line Schjøth-Iversen; Kjersti Bringedal; Anders Husby; Kristoffer Watten Brudvik
      Abstract: Publication date: Available online 21 July 2017
      Source:The American Journal of Surgery
      Author(s): Bo Bendvold, Arne Refsum, Line Schjøth-Iversen, Kjersti Bringedal, Anders Husby, Kristoffer Watten Brudvik
      Background The aim of this study was to determine the frequency and indications for unplanned readmission and outpatient examination after acute appendectomy. Methods Adults who underwent acute appendectomy from 2008–2013 were included in the study and events occurring within 90-days from discharge recorded. Results A total of 710 patients underwent surgery. The appendix was removed in 622 patients and post-discharge contact occurred in 99 (15.9%): readmission in 60 (9.6%), outpatient examination in 39 (6.3%). The main reasons for post-discharge contact were infection (n = 25; intraabdominal, n = 16; superficial) and abdominal pain of uncertain cause (n = 25). Use of prophylactic antibiotics was associated with lower rates of contact, 8.5% versus 20.9% (p = 0.006), respectively. Removal of non-inflamed appendix was borderline associated with higher rates of contact, 21.7% versus 8.0% (if left in-situ; p = 0.058), respectively. Conclusions A substantial number of patients underwent readmission or outpatient examination within 90-days after appendectomy in the current study. The procedure is common and attempts to prevent readmissions are important. Correct use of antibiotics and not removing a non-inflamed appendix may be key points.

      PubDate: 2017-08-16T03:07:58Z
      DOI: 10.1016/j.amjsurg.2017.07.020
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