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Publisher: Elsevier   (Total: 3031 journals)

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Showing 1 - 200 of 3031 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: 16, SJR: 1.008, h-index: 75)
Accident Analysis & Prevention     Partially Free   (Followers: 79, SJR: 1.109, h-index: 94)
Accounting Forum     Hybrid Journal   (Followers: 22, 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: 302, 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  
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: 195, 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: 21, SJR: 1.365, h-index: 73)
Acta Sociológica     Open Access  
Acta Tropica     Hybrid Journal   (Followers: 5, 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: 3, 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: 4)
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: 7, SJR: 1.039, h-index: 5)
Additives for Polymers     Full-text available via subscription   (Followers: 20)
Advanced Drug Delivery Reviews     Hybrid Journal   (Followers: 119, 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: 8, 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: 24, 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: 21, 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: 26, 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: 8, 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: 39, 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: 38, 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: 41, SJR: 0.674, h-index: 38)
Advances in Fuel Cells     Full-text available via subscription   (Followers: 14)
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: 18, 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: 22)
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: 33, 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: 4)
Advances in Intl. Accounting     Full-text available via subscription   (Followers: 4)
Advances in Life Course Research     Hybrid Journal   (Followers: 7, SJR: 0.764, h-index: 15)
Advances in Lipobiology     Full-text available via subscription   (Followers: 1)
Advances in Magnetic and Optical Resonance     Full-text available via subscription   (Followers: 8)
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: 5, 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: 21)
Advances in Molecular and Cellular Endocrinology     Full-text available via subscription   (Followers: 10)
Advances in Molecular Toxicology     Full-text available via subscription   (Followers: 6, SJR: 0.324, h-index: 8)
Advances in Nanoporous Materials     Full-text available via subscription   (Followers: 3)
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: 20, SJR: 0.4, h-index: 28)
Advances in Pharmaceutical Sciences     Full-text available via subscription   (Followers: 14)
Advances in Pharmacology     Full-text available via subscription   (Followers: 13, 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: 17, SJR: 1.5, h-index: 62)
Advances in Psychology     Full-text available via subscription   (Followers: 56)
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: 1, SJR: 0.1, h-index: 2)
Advances in Space Research     Full-text available via subscription   (Followers: 332, SJR: 0.606, h-index: 65)
Advances in Structural Biology     Full-text available via subscription   (Followers: 7)
Advances in Surgery     Full-text available via subscription   (Followers: 6, SJR: 0.823, h-index: 27)
Advances in the Study of Behavior     Full-text available via subscription   (Followers: 28, SJR: 1.321, h-index: 56)
Advances in Veterinary Medicine     Full-text available via subscription   (Followers: 14)
Advances in Veterinary Science and Comparative Medicine     Full-text available via subscription   (Followers: 12)
Advances in Virus Research     Full-text available via subscription   (Followers: 5, SJR: 1.878, h-index: 68)
Advances in Water Resources     Hybrid Journal   (Followers: 42, 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: 303, 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: 4, SJR: 0.344, h-index: 6)
Ageing Research Reviews     Hybrid Journal   (Followers: 7, SJR: 3.289, h-index: 78)
Aggression and Violent Behavior     Hybrid Journal   (Followers: 389, 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: 29, SJR: 1.275, h-index: 74)
Agricultural Water Management     Hybrid Journal   (Followers: 36, 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: 48, 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: 3, 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: 5)
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: 7, 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: 5, 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: 6, SJR: 0.158, h-index: 9)
Alzheimer's & Dementia     Hybrid Journal   (Followers: 45, 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: 45, SJR: 3.157, h-index: 153)
American J. of Cardiology     Hybrid Journal   (Followers: 47, SJR: 2.063, h-index: 186)
American J. of Emergency Medicine     Hybrid Journal   (Followers: 34, 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: 14, SJR: 1.653, h-index: 93)
American J. of Human Genetics     Hybrid Journal   (Followers: 32, SJR: 8.769, h-index: 256)
American J. of Infection Control     Hybrid Journal   (Followers: 25, SJR: 1.259, h-index: 81)
American J. of Kidney Diseases     Hybrid Journal   (Followers: 31, SJR: 2.313, h-index: 172)
American J. of Medicine     Hybrid Journal   (Followers: 48, 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: 173, SJR: 2.255, h-index: 171)
American J. of Ophthalmology     Hybrid Journal   (Followers: 51, SJR: 2.803, h-index: 148)
American J. of Ophthalmology Case Reports     Open Access   (Followers: 2)
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: 22, SJR: 0.59, h-index: 45)
American J. of Pathology     Hybrid Journal   (Followers: 23, 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: 32, SJR: 1.286, h-index: 125)
American J. of the Medical Sciences     Hybrid Journal   (Followers: 13, 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: 52, SJR: 0.124, h-index: 9)
Anaesthesia Critical Care & Pain Medicine     Full-text available via subscription   (Followers: 3)
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: 152, SJR: 0.725, h-index: 154)
Analytical Chemistry Research     Open Access   (Followers: 7, SJR: 0.18, h-index: 2)
Analytical Spectroscopy Library     Full-text available via subscription   (Followers: 10)
Anesthésie & Réanimation     Full-text available via subscription  
Anesthesiology Clinics     Full-text available via subscription   (Followers: 21, 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: 141, 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   (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]   [32 followers]  Follow
    
   Hybrid Journal Hybrid journal (It can contain Open Access articles)
   ISSN (Print) 0002-9610
   Published by Elsevier Homepage  [3031 journals]
  • SBAS Presidential Address: Change Management, Leadership & the Society
           of Black Academic Surgeons (SBAS)
    • Authors: Orlando C. Kirton
      Pages: 597 - 600
      Abstract: Publication date: April 2017
      Source:The American Journal of Surgery, Volume 213, Issue 4
      Author(s): Orlando C. Kirton


      PubDate: 2017-03-29T09:32:54Z
      DOI: 10.1016/j.amjsurg.2017.02.013
       
  • Impact of minimally invasive vs. open distal pancreatectomy on use of
           adjuvant chemoradiation for pancreatic adenocarcinoma
    • Authors: Kevin L. Anderson; Mohamed A. Adam; Samantha Thomas; Sanziana A. Roman; Julie A. Sosa
      Pages: 601 - 605
      Abstract: Publication date: April 2017
      Source:The American Journal of Surgery, Volume 213, Issue 4
      Author(s): Kevin L. Anderson, Mohamed A. Adam, Samantha Thomas, Sanziana A. Roman, Julie A. Sosa
      Background Published data examining the impact of minimally invasive distal pancreatectomy (MIDP) on survival are generally limited to experiences from high-volume institutions. Our aim was to compare utilization of adjuvant chemoradiation and time from surgery until its initiation following MIDP vs. open surgery (ODP) at a national level. Methods Adult patients undergoing distal pancreatectomy for Stage I and II pancreatic adenocarcinoma were identified from the National Cancer Data Base, 2010–2012. Results A total of 1807 patients underwent distal pancreatectomy for adenocarcinoma at 506 institutions (27.9% MIDP). After adjustment, those who underwent MIDP were more likely to have complete tumor resections and a shorter hospital length of stay. Patients undergoing MIDP vs. ODP were more likely to receive adjuvant chemotherapy; time to initiation of adjuvant chemotherapy or radiation was not different between groups. After adjustment, overall survival for MIDP vs. ODP remained similar (HR 0.85, CI 0.67–1.10, p = 0.21). Conclusion MIDP is associated with increased use of adjuvant chemotherapy; further study is needed to understand the etiology and impact of this association.

      PubDate: 2017-03-29T09:32:54Z
      DOI: 10.1016/j.amjsurg.2017.01.005
       
  • Examining the role of follow-up skeletal surveys in non-accidental trauma
    • Authors: Rebecca D. Powell-Doherty; Nora E. Raynor; Donna A. Goodenow; David G. Jacobs; Anthony Stallion
      Pages: 606 - 610
      Abstract: Publication date: April 2017
      Source:The American Journal of Surgery, Volume 213, Issue 4
      Author(s): Rebecca D. Powell-Doherty, Nora E. Raynor, Donna A. Goodenow, David G. Jacobs, Anthony Stallion
      Background Diagnosing NAT (non-accidental trauma) includes a skeletal survey to identify injuries. A follow-up survey is performed for missed injuries. This study examines the necessity of follow-up surveys. Methods The trauma database identified cases of suspected NAT in <4 years olds (2013–2014). Data were stratified by survey, age, injury, then analyzed for the prevalence of findings. All analyses (relative risk, prevalence and odds ratios) utilized RealStats Resource Pack (Trento, Italy). Results 79% positive initial findings and no new follow up findings. Those with negative initial imaging, had no missed injuries. Initial scans were 27.6X more likely to be positive. Fractured skull (31.3), femur (17.2) and ribs (15.7) were the most prevalent. No pelvic fractures and <1% spinal injuries despite both having the greatest radiation exposure. Repeat scans rarely identify findings for age >12 months. Conclusions Follow-up skeletal surveys maybe unnecessary without clinical evidence. Uncommon pelvic and spinal fractures may warrant exclusion from surveys unless clinically indicated.
      Teaser Summary: Evaluation of the necessity for follow-up surveys in Non-Accidental Trauma. Findings suggest that routine follow-up skeletal surveys are unnecessary in the absence of clinical evidence. Pelvic and spinal injuries are uncommon, the radiation exposure to these areas may warrant their exclusion from initial skeletal surveys unless clinical examination indicates otherwise.

      PubDate: 2017-03-29T09:32:54Z
      DOI: 10.1016/j.amjsurg.2016.12.004
       
  • Hospital-based, Multidisciplinary, youth mentoring and medical exposure
           program positively influences and reinforces health care career choice:
           “The Reach One Each One Program early Experience”
    • Authors: Omar K. Danner; Carl Lokko; Felicia Mobley; Montreka Dansby; Michael Maze; Brene’ Bradley; Elizabeth Williams; Leslie Ray Matthews; Emma Harrington; Lisa Mack; Clarence Clark; Ken Wilson; Derrick Beech; Sheryl Heron; Ed Childs
      Pages: 611 - 616
      Abstract: Publication date: April 2017
      Source:The American Journal of Surgery, Volume 213, Issue 4
      Author(s): Omar K. Danner, Carl Lokko, Felicia Mobley, Montreka Dansby, Michael Maze, Brene’ Bradley, Elizabeth Williams, Leslie Ray Matthews, Emma Harrington, Lisa Mack, Clarence Clark, Ken Wilson, Derrick Beech, Sheryl Heron, Ed Childs
      Background According to the National Center for Educational Statistics, underrepresented minorities (URMs) are more likely to leave science, technology, engineering and mathematics (STEM) fields at higher rates than their peers during undergraduate studies. Many institutions of higher learning have implemented pipeline programs aimed at preparing and inspiring high school and college aged students in select careers in health sciences with varying levels of success. Research has shown that a health care workforce that mirrors the community they serve is more effective in reducing health disparities and increasing positive health outcomes. We hypothesize that a hospital-based, multidisciplinary youth mentoring and medical exposure program will enhance the decision of URM high school students to choose healthcare careers. Materials and method A retrospective analysis of the Reach One Each One Program (ROEO) was performed. ROEO is a hospital based, 11-week multidisciplinary youth mentoring and medical exposure program for inner-city high school students. The analysis was based on a phone survey of the twenty-six (26) seniors who completed the program and subsequently graduated from high school between May 2013 and May 2015 to assess the following: 1) College enrollment/attendance, 2) Health profession majors, and 3) Pre-med status. The study was approved by the Morehouse School of Medicine Institutional Review Board. Results Of the twenty-six students, 23 were female and 3 were male; 25 (96%) of the students were African American and one student was a Caucasian female. Twenty-four (92.3%) of the students were enrolled in college and 2 (7.7%) were scheduled to begin in the spring semester of 2016. Twenty-one of the 24 attending college at the time of the survey (87.5%) were enrolled in a health science degree program and 16 (66.7%) confirmed that they were enrolled in pre-medical (Pre-med) curriculum. Conclusion Hospital-based, multidisciplinary medical mentoring programs can have a positive impact on the lives and health care career decisions of aspiring URM high school students. Further study will be necessary to validate the most influential components needed for the success of such programs.

      PubDate: 2017-03-29T09:32:54Z
      DOI: 10.1016/j.amjsurg.2016.12.002
       
  • Physiologically-based, predictive analytics using the
           heart-rate-to-Systolic-Ratio significantly improves the timeliness and
           accuracy of sepsis prediction compared to SIRS
    • Authors: Omar K. Danner; Sandra Hendren; Ethel Santiago; Brittany Nye; Prasad Abraham
      Pages: 617 - 621
      Abstract: Publication date: April 2017
      Source:The American Journal of Surgery, Volume 213, Issue 4
      Author(s): Omar K. Danner, Sandra Hendren, Ethel Santiago, Brittany Nye, Prasad Abraham
      Background Enhancing the efficiency of diagnosis and treatment of severe sepsis by using physiologically-based, predictive analytical strategies has not been fully explored. We hypothesize assessment of heart-rate-to-systolic-ratio significantly increases the timeliness and accuracy of sepsis prediction after emergency department (ED) presentation. Methods We evaluated the records of 53,313 ED patients from a large, urban teaching hospital between January and June 2015. The HR-to-systolic ratio was compared to SIRS criteria for sepsis prediction. There were 884 patients with discharge diagnoses of sepsis, severe sepsis, and/or septic shock. Results Variations in three presenting variables, heart rate, systolic BP and temperature were determined to be primary early predictors of sepsis with a 74% (654/884) accuracy compared to 34% (304/884) using SIRS criteria (p < 0.0001)in confirmed septic patients. Conclusion Physiologically-based predictive analytics improved the accuracy and expediency of sepsis identification via detection of variations in HR-to-systolic ratio. This approach may lead to earlier sepsis workup and life-saving interventions.

      PubDate: 2017-03-29T09:32:54Z
      DOI: 10.1016/j.amjsurg.2017.01.006
       
  • A Simulation-based, cognitive assessment of resident decision making
           during complex urinary catheterization scenarios
    • Authors: Jay N. Nathwani; Katherine E. Law; Anna K. Witt; R.D. Ray; S.M. DiMarco; C.M. Pugh
      Pages: 622 - 626
      Abstract: Publication date: April 2017
      Source:The American Journal of Surgery, Volume 213, Issue 4
      Author(s): Jay N. Nathwani, Katherine E. Law, Anna K. Witt, R.D. Ray, S.M. DiMarco, C.M. Pugh
      Background This study explores general surgery residents' decision making skills in uncommon, complex urinary catheter scenarios. Methods 40 residents were presented with two scenarios. Scenario A was a male with traumatic urethral injury and scenario B was a male with complete urinary blockage. Residents verbalized whether they would catheterize the patient and described the workup and management of suspected pathologies. Residents' decision paths were documented and analyzed. Results In scenario A, 45% of participants chose to immediately consult Urology. 47.5% named five diagnostic tests to decide if catheterization was safe. In scenario B, 27% chose to catheterize with a 16 French Coude. When faced with catheterization failure, participants randomly upsized or downsized catheters. Chi-square analysis revealed no measurable consensus amongst participants. Conclusions Residents need more training in complex decision making for urinary catheterization. The decision trees generated in this study provide a useful blueprint of residents' learning needs. Summary Exploration of general surgery residents' decision making skills in uncommon, complex urinary catheter scenarios revealed major deficiencies. The resulting decision trees reveal residents' learning needs.

      PubDate: 2017-03-29T09:32:54Z
      DOI: 10.1016/j.amjsurg.2017.01.007
       
  • Achieving clear margins. Directed shaving using MarginProbe, as compared
           to a full cavity shave approach
    • Authors: Jeffrey Coble; Vincent Reid
      Pages: 627 - 630
      Abstract: Publication date: April 2017
      Source:The American Journal of Surgery, Volume 213, Issue 4
      Author(s): Jeffrey Coble, Vincent Reid
      Background Following lumpectomy, full cavity shaving approach is used to reduce positive margin rates, among other issues previously studied by others, at an expense of increase in tissue volume removed. We present our experience after switching from full cavity shaving to a targeted shaving approach using MarginProbe, an intra-operative margin assessment device. Methods Specimen excision was performed according to standard of care. Additional shavings were taken based on device readings on the lumpectomy specimen. Intra-operative imaging was used, as required. Results We compared 137 MarginProbe cases to 199 full cavity shave cases. The re-excision rate was reduced by 57% (P = 0.026), from 15.1% to 6.6%. The overall tissue volume removed was reduced by 32% (P = 0.0023), from 115 cc to 78 cc. Conclusions MarginProbe enabled a change in the lumpectomy technique from full cavity shavings to directed shavings guided by the device. There was a significant reduction in re-excisions and in the overall tissue volume removed.The lower amount of shavings also contributed to a reduction in pathology work.

      PubDate: 2017-03-29T09:32:54Z
      DOI: 10.1016/j.amjsurg.2016.12.019
       
  • Research Residents' perceptions of skill decay: Effects of repeated skills
           assessments and scenario difficulty
    • Authors: Grace F. Jones; Katherine Forsyth; Caitlin G. Jenewein; Rebecca D. Ray; Shannon DiMarco; Carla M. Pugh
      Pages: 631 - 636
      Abstract: Publication date: April 2017
      Source:The American Journal of Surgery, Volume 213, Issue 4
      Author(s): Grace F. Jones, Katherine Forsyth, Caitlin G. Jenewein, Rebecca D. Ray, Shannon DiMarco, Carla M. Pugh
      Introduction Skills decay is a known risk for surgical residents who have dedicated research time. We hypothesize that simulation-based assessments will reveal significant differences in perceived skill decay when assessing a variety of clinical scenarios in a longitudinal fashion. Methods Residents (N = 46; Returning: n = 16, New: n = 30) completed four simulated procedures: urinary catheterization, central line, bowel anastomosis, and laparoscopic ventral hernia repair. Perception surveys were administered pre- and post-simulation. Results Perceptions of skill decay and task difficulty were similar for both groups across three procedures pre- and post-simulation. Due to a simulation modification, new residents were more confident in urinary catheterization than returning residents (F(1,4) = 11.44, p = 0.002). In addition, when assessing expectations for skill reduction, returning residents perceived greater skill reduction upon reassessment when compared to first time residents (t(35) = 2.37, p = 0.023). Conclusion Research residents may benefit from longitudinal skills assessments and a wider variety of simulation scenarios during their research years. Table of contents summary As part of a longitudinal study, we assessed research residents' confidence, perceptions of task difficulty and surgical skill reduction. Residents completed surveys pre- and post-experience with four simulated procedures: urinary catheterization, subclavian central line insertion, bowel anastomosis, and laparoscopic ventral hernia repair. Returning residents perceived greater skill reduction upon reassessment when compared to residents participating for the first time. In addition, modification of the clinical scenarios affected perceptions of skills decay.

      PubDate: 2017-03-29T09:32:54Z
      DOI: 10.1016/j.amjsurg.2016.12.003
       
  • Diagnostic evaluation of ovarian torsion: An analysis of pediatric
           patients using the Nationwide Emergency Department Sample
    • Authors: Kristy L. Rialon; Steven Wolf; Jonathan C. Routh; Obinna O. Adibe
      Pages: 637 - 639
      Abstract: Publication date: April 2017
      Source:The American Journal of Surgery, Volume 213, Issue 4
      Author(s): Kristy L. Rialon, Steven Wolf, Jonathan C. Routh, Obinna O. Adibe
      Background Ultrasonography (US) is the diagnostic modality of choice during work-up for ovarian torsion, although computed tomography (CT) may be used. We examined the utilization of CT in girls with ovarian torsion, and determined which patients are most likely to undergo this study. Methods The Nationwide Emergency Department Sample dataset was searched for patients <18 years who presented with ovarian torsion from 2006 to 2012. Hospitals were categorized by the volume of pediatric patients seen. Results A total of 1279 patients were identified. Seven hundred twelve (56%) were seen at adult hospitals, 154 (12%) at pediatric privileged, and 413 (32%) at pediatric hospitals. Patients cared for in a pediatric or pediatric privileged hospital had more US alone performed to diagnose ovarian torsion (p < 0.01). Conclusions Girls seen at pediatric hospitals are more likely to undergo US for work-up of ovarian torsion.

      PubDate: 2017-03-29T09:32:54Z
      DOI: 10.1016/j.amjsurg.2016.11.021
       
  • Routine post-operative esophagram Is not necessary after repair of
           esophageal atresia
    • Authors: Jamie Golden; Natalie E. Demeter; Joanna C. Lim; Henri R. Ford; Jeffrey S. Upperman; Christopher P. Gayer
      Pages: 640 - 644
      Abstract: Publication date: April 2017
      Source:The American Journal of Surgery, Volume 213, Issue 4
      Author(s): Jamie Golden, Natalie E. Demeter, Joanna C. Lim, Henri R. Ford, Jeffrey S. Upperman, Christopher P. Gayer
      Introduction Esophagrams are routinely performed following repair of esophageal atresia (EA) with or without tracheoesophageal fistula (TEF); however, its utility has not been validated. Methods EA/TEF repair performed from 2003 to 2014 at a single pediatric hospital and from 2004 to 2014 in the Pediatric Health Information System (PHIS) database were retrospectively reviewed to determine utility of esophagrams. Results Esophagram was performed in 99% of patients at our institution (N = 105). Clinical signs were seen prior to esophagram in patients whose leak changed clinical management. Esophagram on post-operative day ≤15 was performed in 66% of PHIS database patients (N = 3255). Esophagram did not change the incidence of chest tube placement, reoperation, or dilation. Patients who required a reoperation were less likely to have an esophagram than patients who did not require a reoperation (40.7% versus 65.7%, p < 0.001). Conclusion Our data suggest that routine esophagram is not necessary in asymptomatic patients.

      PubDate: 2017-03-29T09:32:54Z
      DOI: 10.1016/j.amjsurg.2016.12.020
       
  • Suberoylanilide hydroxamic Acid, a histone deacetylase inhibitor, alters
           multiple signaling pathways in hepatocellular carcinoma cell lines
    • Authors: Selvi Kunnimalaiyaan; Kevin Sokolowski; T. Clark Gamblin; Muthusamy Kunnimalaiyaan
      Pages: 645 - 651
      Abstract: Publication date: April 2017
      Source:The American Journal of Surgery, Volume 213, Issue 4
      Author(s): Selvi Kunnimalaiyaan, Kevin Sokolowski, T. Clark Gamblin, Muthusamy Kunnimalaiyaan
      Introduction Suberoylanilide hydroxamic acid (SAHA), a histone deacetylase inhibitor, has preclinical efficacy in hepatocellular carcinoma (HCC), despite an unclear molecular mechanism. We sought to further investigate the effects of SAHA on HCC. We hypothesize SAHA will inhibit HCC cellular proliferation through apoptosis and aid in further profiling SAHA's effect on HCC oncogenic pathways. Methods HCC cell lines were treated with various concentrations of SAHA. Cell proliferation was determined by MTT and colonogenic assays. Cell lysates were analyzed via Western blotting for apoptotic and oncogenic pathway markers. Caspase glo-3/7 was used to assess apoptosis. Results SAHA treatment demonstrated significant (<0.05) reduction in cell growth and colony formation through apoptosis and cell cycle arrest. Western analysis showed reduction in Notch, pAKT and pERK1/2 proteins. Interestingly, phosphorylated STAT3 was increased in all cell lines. Conclusions SAHA inhibits Notch, AKT, and Raf-1 pathways but not the STAT3 pathway. We believe that STAT3 may lead to cancer cell progression, reducing SAHA efficacy in HCC. Therefore, combination of SAHA and STAT or Notch inhibition may be a strategy for HCC treatment.

      PubDate: 2017-03-29T09:32:54Z
      DOI: 10.1016/j.amjsurg.2016.12.001
       
  • Do errors and critical events relate to hernia repair outcomes?
    • Authors: Katherine Law Forsyth; Shannon M. DiMarco; Caitlin G. Jenewein; Rebecca D. Ray; Anne-Lise D. D'Angelo; Elaine R. Cohen; Douglas A. Wiegmann; Carla M. Pugh
      Pages: 652 - 655
      Abstract: Publication date: April 2017
      Source:The American Journal of Surgery, Volume 213, Issue 4
      Author(s): Katherine Law Forsyth, Shannon M. DiMarco, Caitlin G. Jenewein, Rebecca D. Ray, Anne-Lise D. D'Angelo, Elaine R. Cohen, Douglas A. Wiegmann, Carla M. Pugh
      Background The study aimed to validate an error checklist for simulated laparoscopic ventral hernia (LVH) repair procedures. We hypothesize that residents' errors can be assessed with a structured checklist and the results will correlate significantly with procedural outcomes. Methods Senior residents' (N = 7) performance on a LVH simulator were video-recorded and analyzed using a human error checklist. Junior residents (N = 38) performed two steps of the same simulated LVH procedure. Performance was evaluated using the error checklist and repair quality scores. Results There were no significant differences between senior and junior residents' checklist errors (p > 0.1). Junior residents' errors correlated with hernia repair quality (p = 0.05). Conclusions The newly developed assessment tool showed significant correlations between performance errors, critical events, and hernia repair quality. These results provide validity evidence for the use of errors in performance assessments. Summary This study validated an error checklist for simulated laparoscopic ventral hernia (LVH) repair procedures. The checklist was designed based on errors committed by chief surgery residents during LVH repairs. In a separate data collection, junior residents were evaluated using the checklist. Hernia repair quality was also assessed. Errors significantly correlated with hernia repair quality (p = 0.05).

      PubDate: 2017-03-29T09:32:54Z
      DOI: 10.1016/j.amjsurg.2016.11.020
       
  • Disparities in kidney transplantation across the United States: Does
           residential segregation play a role?
    • Authors: Olubode A. Olufajo; Joel T. Adler; Heidi Yeh; Steven B. Zeliadt; Roland A. Hernandez; Stefan G. Tullius; Leah Backhus; Ali Salim
      Pages: 656 - 661
      Abstract: Publication date: April 2017
      Source:The American Journal of Surgery, Volume 213, Issue 4
      Author(s): Olubode A. Olufajo, Joel T. Adler, Heidi Yeh, Steven B. Zeliadt, Roland A. Hernandez, Stefan G. Tullius, Leah Backhus, Ali Salim
      Background Although residential segregation has been implicated in various negative health outcomes, its association with kidney transplantation has not been examined. Methods Age- and sex-standardized kidney transplantation rates were calculated from the Scientific Registry of Transplant Recipients, 2000–2013. Population characteristics including segregation indices were derived from the 2010 U.S. Census data and the U.S. Renal Data System. Separate multivariable Poisson regression models were constructed to identify factors independently associated with kidney transplantation among Blacks and Whites. Results Median age- and sex-standardized kidney transplantation rates were 114 per 100,000 for Blacks and 38 per 100,000 for Whites. 16.1% of the U.S. population lived in counties with high segregation. There was no difference in the kidney transplantation rates across the levels of segregation among Blacks and Whites. Conclusion Factors other than residential segregation may play roles in kidney transplantation disparities. Continued efforts to identify these factors may be beneficial in reducing transplantation disparities across the U.S. Summary Using the Scientific Registry of Transplant Recipients and U.S. census data, we aimed to determine whether residential segregation was associated with kidney transplantation rates. We found that there was no association between residential segregation and kidney transplantation rates.

      PubDate: 2017-03-29T09:32:54Z
      DOI: 10.1016/j.amjsurg.2016.10.034
       
  • Pipeline program recruits and retains women and underrepresented
           minorities in procedure based specialties: A brief report
    • Authors: Bonnie S. Mason; William Ross; Monique C. Chambers; Richard Grant; Michael Parks
      Pages: 662 - 665
      Abstract: Publication date: April 2017
      Source:The American Journal of Surgery, Volume 213, Issue 4
      Author(s): Bonnie S. Mason, William Ross, Monique C. Chambers, Richard Grant, Michael Parks
      As the US population continues to grow in racial and ethnic diversity, we also continue to see healthcare disparities across racial lines. Considerable attention has been given to creating a physician workforce that better reflects the population served by healthcare professionals. To address the low numbers of women and underrepresented minorities in procedural based specialties, Nth Dimensions has sought to address and eliminate healthcare disparities through strategic pipeline initiatives. This is a retrospective observational cohort study of 118 medical students from 29 accredited US medical schools, who were awarded a position in the Nth Dimensions Summer Internship program between 2005 and 2012. Overall, 84 NDSI scholars applied and 81 matched into procedure-based specialties; therefore the overall retention rate was 75% and the overall match rate across the eight cohorts was 72.3%. Through intervention-based change, the authors hypothesize that greater numbers in the residency training cohorts can lead to a greater number of physicians with diverse backgrounds and perspectives. Ultimately, this will enhance quality of care for all patients and improve decision making process that influence healthcare systems. Summary Strategic pipeline programs increase successful recruit women and underrepresented minorities to apply and matriculate into procedure based residency programs. This is a retrospective observational cohort study of 118 medical students who completed the Nth Dimensions Summer Internship program between 2005 and 2012. Overall, 84 NDSI scholars applied and 81 matched into procedure-based specialties; therefore the overall retention rate was 75% and the overall match rate across the eight cohorts was 72.3%.

      PubDate: 2017-03-29T09:32:54Z
      DOI: 10.1016/j.amjsurg.2016.11.022
       
  • Outcome disparities between African Americans and Caucasians in
           contemporary kidney transplant recipients
    • Authors: David J. Taber; Leonard E. Egede; Prabhakar K. Baliga
      Pages: 666 - 672
      Abstract: Publication date: April 2017
      Source:The American Journal of Surgery, Volume 213, Issue 4
      Author(s): David J. Taber, Leonard E. Egede, Prabhakar K. Baliga
      Background Racial disparities in African-American (AA) kidney transplant have persisted for nearly 40 years, with limited data available on the scope of this issue in the contemporary era of transplantation. Methods Descriptive retrospective cohort study of US registry data including adult solitary kidney transplants between Jan 1, 2005 to Dec 31, 2009. Results 60,695 recipients were included; 41,426 Caucasians (68%) and 19,269 AAs (32%). At baseline, AAs were younger, had lower college graduation rates, were more likely to be receiving public health insurance and have diabetes. At one-year post-transplant, AAs had 62% higher risk of graft loss (RR 1.62, 95% CI 1.50–1.75) which increased to 93% at five years (RR 1.93, 95% CI 1.85–2.01). Adjusted risk of graft loss, accounting for baseline characteristics, was 60% higher in AAs (HR 1.61 [1.52–1.69]). AAs had significantly higher risk of acute rejection and delayed graft function. Conclusion AAs continue to experience disproportionately high rates of graft loss within the contemporary era of transplant, which are related to a convergence of an array of socioeconomic and biologic risk factors.

      PubDate: 2017-03-29T09:32:54Z
      DOI: 10.1016/j.amjsurg.2016.11.024
       
  • Racial disparities in the use of laparoscopic surgery to treat colonic
           diverticulitis Are not fully explained by socioeconomics or disease
           complexity
    • Authors: Randi L. Lassiter; Asif Talukder; Meryl M. Abrams; Bao-Ling Adam; Daniel Albo; Cassandra Q. White
      Pages: 673 - 677
      Abstract: Publication date: April 2017
      Source:The American Journal of Surgery, Volume 213, Issue 4
      Author(s): Randi L. Lassiter, Asif Talukder, Meryl M. Abrams, Bao-Ling Adam, Daniel Albo, Cassandra Q. White
      Background Several studies have demonstrated favorable outcomes for laparoscopic surgery over open surgery for the treatment of diverticular disease. This study was designed to analyze the relationship between race, socioeconomic status and the use of laparoscopy to address diverticulitis. Methods A retrospective analysis of 53,054 diverticulitis admissions was performed using data from the 2009–2013 National Inpatient Sample (NIS). The primary outcome was the use of laparoscopic versus open colectomy. Bivariate analysis and multivariable logistic regression were used to determine the raw and adjusted odds by race, insurance status, and median household income. Results Overall, 41.6% of colectomies involved the use of laparoscopy. Black patients were 19% less likely than White patients to undergo laparoscopic surgery. Hispanic patients were no more or less likely to undergo laparoscopic colectomy. Lacking private insurance was a strong predictor of undergoing open surgery. Lower income patients were 33% less likely to receive minimally invasive colectomies. Conclusions These results demonstrate disparities in surgical treatment. Further research is warranted to understand and ameliorate treatment differences which can contribute to outcome disparities.

      PubDate: 2017-03-29T09:32:54Z
      DOI: 10.1016/j.amjsurg.2016.11.019
       
  • Surgical skills curricula in American College of Surgeons Accredited
           Education Institutes: An international survey
    • Authors: Iman Ghaderi; Shimae Fitzgibbons; Yusuke Watanabe; Alexander Lachapelle; John Paige
      Pages: 678 - 686
      Abstract: Publication date: April 2017
      Source:The American Journal of Surgery, Volume 213, Issue 4
      Author(s): Iman Ghaderi, Shimae Fitzgibbons, Yusuke Watanabe, Alexander Lachapelle, John Paige
      Background A clear understanding of simulation-based curricula in use at American College of Surgeons Accredited Education Institutes (ACS-AEIs) is lacking. Methods A 25-question online survey was sent to ACS-AEIs. Results The response rate approached 60%. The most frequent specialties to use the ACS-AEIs are general surgery and obstetrics/gynecology (94%). Residents are the main target population for programming/training (96%). Elements of the ACS/Association of Program Directors in Surgery Surgical Skills Curriculum are used by 77% of responding ACS-AEIs. Only 49% of ACS-AEIs implement the entire curriculum and 96% have independently developed their own surgical skills curricula. “Home-grown” simulators have been designed at 71% of ACS-AEIs. Feasibility (80%), evidence of effectiveness (67%), and cost (60%) were reasons for curriculum adoption. All programs use operative assessment tools for resident performance, and 53% use Messick's unitary framework of validity. Most programs (88%) have financial support from their academic institute. Majority of ACS-AEIs had trainees evaluate their faculty instructors (90%), and the main form of such faculty evaluation was postcourse surveys (97%). Conclusion This study provides specific information regarding simulation-based curricula at ACS-AEIs.

      PubDate: 2017-03-29T09:32:54Z
      DOI: 10.1016/j.amjsurg.2016.08.011
       
  • We've come a long way: Let the work begin
    • Authors: Mark A. Malangoni
      First page: 687
      Abstract: Publication date: April 2017
      Source:The American Journal of Surgery, Volume 213, Issue 4
      Author(s): Mark A. Malangoni


      PubDate: 2017-03-29T09:32:54Z
      DOI: 10.1016/j.amjsurg.2016.11.012
       
  • Sorafenib use for recurrent hepatocellular cancer after resection or
           transplantation: Observations from a US regional analysis of the GIDEON
           registry
    • Authors: Robert C.G. Martin; Elizabeth Bruenderman; Allen Cohn; Bilal Piperdi; Rebecca Miksad; Jean-Francois Geschwind; Alec Goldenberg; Arun Sanyal; Ellen Zigmont; Svetlana Babajanyan; Pamela Foreman; Parvez Mantry; Brendan McGuire; Pierre Gholam
      Pages: 688 - 695
      Abstract: Publication date: April 2017
      Source:The American Journal of Surgery, Volume 213, Issue 4
      Author(s): Robert C.G. Martin, Elizabeth Bruenderman, Allen Cohn, Bilal Piperdi, Rebecca Miksad, Jean-Francois Geschwind, Alec Goldenberg, Arun Sanyal, Ellen Zigmont, Svetlana Babajanyan, Pamela Foreman, Parvez Mantry, Brendan McGuire, Pierre Gholam
      Treatment of unresectable recurrent hepatocellular carcinoma (HCC) in patients who recur after resection or orthotopic liver transplantation (OLT) remains a clinical challenge. One option is sorafenib, although little is known about its safety and tolerance in this unique patient population; therefore, we analyzed patients who underwent prior surgical resection and/or OLT and were treated with sorafenib in US cohort of GIDEON registry. In US, 645 patients were enrolled; 553 for intent to treat and 563 for safety. Data were analyzed in the safety population of 479 patients no surgery and 56 for resection or OLT. Forty-one patients underwent resection prior to the initiation of sorafenib, 15 patients had previously received an OLT, and 6 patients had both resection and OLT. Initial low starting doses (400 mg/day) were observed for more patients with prior OLT (71%) than prior resection (36%), resection and OLT (50%), concomitant OLT (25%), and no surgery (36%). Most AEs occurred in the first 4 weeks of treatment. Drug-related AEs were higher in patients with prior resection (87%), prior OLT (100%), or both (100%) than in patients with concomitant OLT (63%) or no surgery (70%). However, incidence of AEs resulting in permanent discontinuation were similar in all groups (19–38%).

      PubDate: 2017-03-29T09:32:54Z
      DOI: 10.1016/j.amjsurg.2016.10.006
       
  • Use of the surgical Apgar score to enhance Veterans Affairs Surgical
           Quality Improvement Program surgical risk assessment in veterans
           undergoing major intra-abdominal surgery
    • Authors: Antonio Masi; Salvatore Amodeo; Ioannis Hatzaras; Antonio Pinna; Alan S. Rosman; Steven Cohen; John K. Saunders; Russell Berman; Elliot Newman; Garth H. Ballantyne; Leon H. Pachter; Marcovalerio Melis
      Pages: 696 - 705
      Abstract: Publication date: April 2017
      Source:The American Journal of Surgery, Volume 213, Issue 4
      Author(s): Antonio Masi, Salvatore Amodeo, Ioannis Hatzaras, Antonio Pinna, Alan S. Rosman, Steven Cohen, John K. Saunders, Russell Berman, Elliot Newman, Garth H. Ballantyne, Leon H. Pachter, Marcovalerio Melis
      Background We investigated whether the surgical Apgar score (SAS) may enhance the Veterans Affairs Surgical Quality Improvement Program (VASQIP) risk assessment for prediction of early postoperative outcomes. Methods We retrospectively evaluated demographics, medical history, procedure, SAS, VASQIP assessment, and postoperative data for patients undergoing major/extensive intra-abdominal surgery at the Manhattan Veterans Affairs between October 2006 and September 2011. End points were overall morbidity and 30-, 60- , and 90-day mortality. Pearson's chi-square, ANOVA, and multivariate regression modeling were employed. Results Six hundred twenty-nine patients were included. Apgar groups did not differ in age, sex, and race. Low SASs were associated with worse functional status, increased postoperative morbidity, and 30-, 60- , and 90-day mortality rates. SAS did not significantly enhance VASQIP prediction of postoperative outcomes, although a trend was detected. Multivariate analysis confirmed SAS as an independent predictor of morbidity and mortality. Conclusions SAS effectively identifies veterans at high risk for poor postoperative outcome. Additional studies are necessary to evaluate the role of SAS in enhancing VASQIP risk prediction.

      PubDate: 2017-03-29T09:32:54Z
      DOI: 10.1016/j.amjsurg.2016.05.017
       
  • Venous thromboembolic events: How low can you go?
    • Authors: Caroline E. Jones; Robert H. Hollis; Allison A. Gullick; Tyler Wahl; Joshua S. Richman; Laura A. Graham; Adam T. Lucy; Daniel I. Chu; Melanie S. Morris
      Pages: 706 - 710
      Abstract: Publication date: April 2017
      Source:The American Journal of Surgery, Volume 213, Issue 4
      Author(s): Caroline E. Jones, Robert H. Hollis, Allison A. Gullick, Tyler Wahl, Joshua S. Richman, Laura A. Graham, Adam T. Lucy, Daniel I. Chu, Melanie S. Morris
      Background We evaluated postoperative venous thromboembolism (VTE) chemical prophylaxis adherence to assess the preventability of VTEs. Methods A case-control study was performed using the 2011–2015 ACS-NSQIP single institution database. Cases were identified as patients who experienced postoperative VTE within 30 days following surgery. Controls were matched 2:1 on procedure, age, and BMI. Association between inpatient chemical prophylaxis adherence and postoperative VTE was evaluated with conditional logistic regression. Results Seventy-three cases were matched to 145 controls. Complete inpatient VTE chemical prophylaxis adherence did not differ between cases and controls (45.2% vs. 46.2%, p = 1.00). Odds of postoperative VTE increased if a patient's prophylaxis was interrupted (OR 6.34, 95% CI 1.82–22.13). However, 53.7% of instances of interrupted prophylaxis were medically justified by concern for bleeding, spine operation, or for additional upcoming procedure. Conclusions Nearly half of patients who experienced postoperative VTEs received appropriate guideline-driven care. Most interruptions in chemical prophylaxis were justified medically. This further questions the preventability of postoperative VTEs and the utility of this outcome as a valid measure of hospital quality.

      PubDate: 2017-03-29T09:32:54Z
      DOI: 10.1016/j.amjsurg.2016.10.037
       
  • MicroRNA-21 as a Prognostic Biomarker in Patients with Pancreatic Cancer
           – A Systematic Review and Meta-Analysis
    • Abstract: Publication date: Available online 26 April 2017
      Source:The American Journal of Surgery
      Author(s): Ionut Negoi, Sorin Hostiuc, Massimo Sartelli, Ruxandra Irina Negoi, Mircea Beuran
      Objectives The aim of this systematic review and meta-analysis is to summarize the current knowledge regarding microRNA-21 and to evaluate its prognostic impact in patients with pancreatic cancer. Methods We conducted an electronic literature search to identify all published studies in PubMed/MEDLINE, Scopus and Google Scholar databases from 2000 until August 2016. Results A total of 17 studies involving 1471 patients met the inclusion criteria for the quantitative synthesis. The microRNA-21 upregulation was significantly associated with poorer overall survival, disease-free survival, and progression-free survival. The subgroup analysis revealed that microRNA-21 overexpression has a significant higher prognostic value for patients who receive adjuvant chemotherapy. Increased microRNA-21 was associated with a statistically significant higher rate of metastatic lymph nodes and poorly differentiated tumors. Conclusions MicroRNA-21 upregulation in pancreatic cancer is associated with a significantly poorer overall survival, disease-free survival, and progression-free survival. MicroRNA-21 may be a useful prognostic biomarker, allowing stratification for chemotherapy administration, and being a component of precision medicine in patients with pancreatic cancer.

      PubDate: 2017-04-26T09:54:05Z
       
  • Detection and Potential Consequences of Intraoperative Adverse Events: A
           Pilot Study in the Veterans Health Administration
    • Abstract: Publication date: Available online 25 April 2017
      Source:The American Journal of Surgery
      Author(s): Qi Chen, Brad S. Oriel, Amy K. Rosen, Mary A. Greenan, Houman Amirfarzan, Hillary J. Mull, Mia Shapiro, Piero M. Fisichella, Kamal M.F. Itani
      Surgical quality improvement efforts have focused on tracking and reducing postoperative mortality and morbidity. However, the prevalence of intraoperative adverse events (IAEs) and their association with postoperative surgical outcomes has been poorly studied. In this study, we detected IAEs using both retrospective chart review and prospective provider reporting. We then examined the association of IAEs with postoperative outcomes. The overall IAE detection rate per case was 0.7 and 0.07 (P<0.0001) based on chart review and provider reporting, respectively. Types of IAEs varied between detection methods. Provider-reported IAEs were more serious, i.e., had a stronger association with 30-day postoperative complications than chart-identified IAEs (risk-adjusted odds ratios were 1.52 vs 1.02, respectively, both p<0.0001). Our findings suggest that IAEs can be detected using either retrospective chart review or prospective provider reporting. However, provider reporting appears more likely to detect serious (albeit infrequent) IAEs compared to chart review.

      PubDate: 2017-04-26T09:54:05Z
       
  • Management of hepatocellular carcinoma recurrence after liver transplant
           is far from perfect
    • Abstract: Publication date: Available online 25 April 2017
      Source:The American Journal of Surgery
      Author(s): Andrea Mancuso, Alberto Maringhini


      PubDate: 2017-04-26T09:54:05Z
       
  • Patient-centered surgical prehabilitation
    • Abstract: Publication date: Available online 25 April 2017
      Source:The American Journal of Surgery
      Author(s): Gabrielle Shaughness, Ryan Howard, Michael Englesbe


      PubDate: 2017-04-26T09:54:05Z
       
  • Clinical burden of preoperative albumin-globulin ratio in esophageal
           cancer patients
    • Abstract: Publication date: Available online 25 April 2017
      Source:The American Journal of Surgery
      Author(s): Satoshi Oki, Yuji Toiyama, Yoshinaga Okugawa, Tadanobu Shimura, Masato Okigami, Hiromi Yasuda, Hiroyuki Fujikawa, Yoshiki Okita, Shigeyuki Yoshiyama, Junichiro Hiro, Minako Kobayashi, Masaki Ohi, Toshimitsu Araki, Yasuhiro Inoue, Yasuhiko Mohri, Masato Kusunoki
      Background Lower albumin-globulin ratio (AGR) is associated with increased mortality in several cancers. However, no studies have evaluated the relationship between the AGR and prognostic outcome in esophageal cancer (EC) patients. Methods To identify indicators of early recurrence and poor prognosis, we assessed the clinicopathological findings and preoperative laboratory data (carcinoembryonic antigen [CEA], squamous cell carcinoma antigen, total protein, and albumin) of 112 EC patients who underwent surgery. The AGR was calculated as albumin/(total protein–albumin). Results A lower AGR was significantly associated with tumor progression. The CEA level was an independent predictor for overall survival (OS) and disease-free survival (DFS). The AGR and CEA combination was identified as a feasible indicator of poor prognosis and early recurrence. Among EC patients without lymph node metastasis, those with lower AGR had poorer DFS and OS than those with higher AGR. Conclusion AGR was identified as a significant predictor of OS and DFS in EC patients. Among EC patients without lymph node metastasis, AGR may help identify candidates who might benefit from more intensive adjuvant therapy. Summary This report revealed clinical significance of AGR as a predictive biomarker for prognosis and recurrence in esophageal cancer patients. The preoperative AGR could be potentially useful decision-making biomarker for the evaluation of EC patients without lymph node metastases.

      PubDate: 2017-04-26T09:54:05Z
       
  • Failure of efforts to contain costs of care after colorectal procedures:
           Nationwide trends in length of stay, costs and post-acute care utilization
           
    • Abstract: Publication date: Available online 25 April 2017
      Source:The American Journal of Surgery
      Author(s): Ahmed M. Al-Mazrou, Baser Onur, Ravi P. Kiran
      Background This study aims to report trends in healthcare resource utilization and costs after colorectal surgery in the US. Methods From all-payer inpatient data, patients who were discharged after elective colorectal procedures (2002–2011) were identified. Trends in postoperative hospital stay, costs and post-acute care were evaluated. Results Of 251,583 included patients, median length of stay was 6 days. Trends over time suggested a progressive reduction in hospital stay after surgery until 2008 after which there was an increase (6.6 days in 2002, 5.9 days in 2008 and 6.1 days in 2010). Costs (peak:2011, $51,731) and post-acute care (peak:2011, 19.4%) continued to increase throughout. Conclusions While length of stay over the last decade reduced, a further reduction may not be feasible. Meanwhile, inpatient costs as well as the use of post-acute care programs have continued to rise. Healthcare planning needs to focus on patients who cannot be discharged early, and more comprehensively evaluate the interplay between length of stay, readmissions, inpatient and post-acute care utilization if we are to contain overall healthcare costs.

      PubDate: 2017-04-26T09:54:05Z
       
  • How can we be more “deliberate” in training surgeons?
    • Abstract: Publication date: Available online 25 April 2017
      Source:The American Journal of Surgery
      Author(s): Jason J. Han, Ari D. Brooks


      PubDate: 2017-04-26T09:54:05Z
       
  • In Search of a Resident-Centered Handoff Tool: Discovering the Complexity
           of Transitions of Care
    • Abstract: Publication date: Available online 25 April 2017
      Source:The American Journal of Surgery
      Author(s): Meredith Barrett, David Turer, Hadley Stoll, David T. Hughes, Gurjit Sandhu
      Introduction Transfer of a patient’s care between providers is a significant potential for medical errors. Given the potential for patient safety breeches we sought to investigate residents’ perceptions of handoffs at our institution. Methods Residents completed an online survey assessing the effectiveness of handoffs and what they thought was necessary for safe and informative transition communication. Thematic analysis was used to identify critical themes. Results 78% of residents reported formal training in handoff delivery. 90% stated they were effective in delivering handoffs; however they scored 41% of handoffs they received as less than effective. 11 themes emerged, the most commonly described requirement was “important events” from the previous shift. Only 16% of residents used an established formal handoff tool. Conclusions In a survey of surgical residents they view themselves as very effective at delivering handoffs, but judge nearly half of handoffs they receive as ineffective. Multiple handoff tools exist but residents rarely use them. In an era of increasing transitions of care, efforts targeting improvement of handoff effectiveness will require education beyond checklists and mnemonics.

      PubDate: 2017-04-26T09:54:05Z
       
  • Revision of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass: a Canadian
           Experience
    • Authors: Ekua Yorke; Caroline Sheppard; Noah J. Switzer; David Kim; Christopher de Gara; Shahzeer Karmali; Aliyah Kanji; Daniel Birch
      Abstract: Publication date: Available online 8 April 2017
      Source:The American Journal of Surgery
      Author(s): Ekua Yorke, Caroline Sheppard, Noah J. Switzer, David Kim, Christopher de Gara, Shahzeer Karmali, Aliyah Kanji, Daniel Birch
      Introduction Sleeve gastrectomy (SG) can be associated with inadequate weight loss, insufficient resolution of co-morbidities and severe reflux. Conversion to Roux-en-Y Gastric Bypass (RYGB) is a potential solution. The aim of this study was to determine the common indications for conversion from SG to RYGB at our centre, and evaluate patient outcomes with respect to weight loss and co-morbidity resolution. Methods A retrospective review of patients who underwent conversion from SG to RYGB between 2008 and 2015. Results 273 SGs were performed of which 6.6% (n=18) were converted to RYGB most commonly due to inadequate weight loss (65.3%) and severe reflux (26.1%). Two patients were converted as a planned two-stage approach to RYGB. Patients went from a mean preoperative BMI of 50.5 to a mean BMI of 40.5 post-SG on average by 20.9 months. The mean time to conversion was 41.8 months. There was a positive correlation between pre-SG BMI and time to conversion (p=0.040). The mean BMI after conversion was 36.4, but this additional weight loss was not significant (p = 0.057). After conversion, four of the five diabetic patients are now medication free and 75% of patients no longer have reflux symptoms. All patients had complete resolution of their hypertension and obstructive sleep apnea. Revision perioperative complication rates were comparable to primary RYGB. Two patients developed new onset iron deficiency anemia. Conclusion Revision to RYGB is a safe option for SG failure and resulted in significant benefits from co-morbidity resolution.

      PubDate: 2017-04-12T09:43:32Z
      DOI: 10.1016/j.amjsurg.2017.04.003
       
  • The Affordable Care Act and its association with length of stay and payer
           status for trauma patients at a level I trauma center
    • Authors: Vicente Undurraga Perl; Chris Dodgion; Kyle Hart; Bruce Ham; Martin Schreiber; David Zonies
      Abstract: Publication date: Available online 8 April 2017
      Source:The American Journal of Surgery
      Author(s): Vicente Undurraga Perl, Chris Dodgion, Kyle Hart, Bruce Ham, Martin Schreiber, David Zonies
      Background We hypothesized that the ACA would shorten length of stay and increase numbers of insured patients without changing trauma patient outcomes. Methods A retrospective review of adult trauma patients admitted to a level I trauma center between 2012 and 2014 was performed. Demographics, length of stay, payer status, discharge disposition, and complications before and after the ACA implementation were analyzed. Results 4448 trauma patients were admitted during the study period. Patients treated after ACA implementation were older (53 vs 51, p = 0.05) with shorter ICU stays (1.7 vs 1.5 days, p = 0.04), but longer overall hospital stays (3.7 vs 4.1 days, p < 0.01). The proportion of self-pay patients decreased 11%–3% (p=<0.001). A higher proportion of patients were discharged to skilled nursing facilities (SNF, 17.1% vs 19.9%, p = 0.02). There was no change in rates of death, readmission, infection, pneumonia or decubiti. Conclusion Among trauma patients, there was a decrease in self-pay status and increase in public insurance without change in private insurance after implementation of the ACA. More patients were discharged to SNF without changes in reported outcomes.

      PubDate: 2017-04-12T09:43:32Z
      DOI: 10.1016/j.amjsurg.2017.03.036
       
  • Splenectomy is associated with higher infection and pneumonia rates among
           trauma laparotomy patients
    • Authors: Kelly A. Fair; Christopher R. Connelly; Kyle D. Hart; Martin A. Schreiber; Jennifer M. Watters
      Abstract: Publication date: Available online 8 April 2017
      Source:The American Journal of Surgery
      Author(s): Kelly A. Fair, Christopher R. Connelly, Kyle D. Hart, Martin A. Schreiber, Jennifer M. Watters
      Splenectomy increases lifetime risk of thromboembolism (VTE) and is associated with long-term infectious complications, primarily, overwhelming post-splenectomy infection (OPSI). Our objective was to evaluate risk of VTE and infection at index hospitalization post-splenectomy. Retrospective review of all patients who received a laparotomy in the NTDB. Propensity score matching for splenectomy was performed, based on ISS, abdominal abbreviated injury score >3, GCS, sex and mechanism. Major complications, VTE, and infection rates were compared. Multiple logistic regression models were utilized to evaluate splenectomy-associated complications. 93,221 laparotomies were performed and 17% underwent splenectomy. Multiple logistic regression models did not demonstrate an association between splenectomy and major complications (OR 0.96, 95% CI 0.91-1.03, p=0.25) or VTE (OR 1.05, 95% CI 0.96-1.14, p=0.33). Splenectomy was independently associated with infection (OR 1.07, 95% CI 1.00-1.14, p=0.045). Subgroup analysis of patients with infection demonstrated that splenectomy was most strongly associated with pneumonia (OR 1.41, 95% CI 1.26-1.57, p<0.001). Splenectomy is not associated with higher overall complication or VTE rates during index hospitalization. However, splenectomy is associated with a higher rate of pneumonia.

      PubDate: 2017-04-12T09:43:32Z
      DOI: 10.1016/j.amjsurg.2017.04.001
       
  • A three-step method for modular lymphadenectomy in gastric cancer surgery:
           The ability to retrieve sufficient lymph nodes and improve survival
    • Authors: Maolan Li; Xu-an Wang; Lei Wang; Xiangsong Wu; Wenguang Wu; Xiaoling Song; Shuai Zhao; Fei Zhang; Qiang Ma; Haibin Liang; Shanshan Xiang; Zheng Wang; Wei Gong; Ping Dong; Yingbin Liu
      Abstract: Publication date: Available online 7 April 2017
      Source:The American Journal of Surgery
      Author(s): Maolan Li, Xu-an Wang, Lei Wang, Xiangsong Wu, Wenguang Wu, Xiaoling Song, Shuai Zhao, Fei Zhang, Qiang Ma, Haibin Liang, Shanshan Xiang, Zheng Wang, Wei Gong, Ping Dong, Yingbin Liu
      Background Systematic lymphadenectomy for the resection of sufficient lymph nodes is the most important part of curative resection in gastric cancer surgery. Here, we explore the outcomes of the three-step method for modular lymphadenectomy (TSMML) and determine its safety and efficacy, compared with the conventional method for lymphadenectomy (CML). Methods From 2008 to 2011, 270 patients with gastric cancer were divided into 2 subgroups: the TSMML group and the CML group. Results Patients in the TSMML group had a significantly higher median number of retrieved lymph nodes (rLNs), lower median metastatic lymph node ratios (MLRs), and superior 5-year relapse-free survival (RFS) than the CML group. Moreover, the use of the TSMML procedure was an independent protective factor for RFS. No significant intergroup differences were found in morbidity or mortality in these two groups. Conclusion The TSMML procedure is safe and effective and is easy to learn.

      PubDate: 2017-04-12T09:43:32Z
      DOI: 10.1016/j.amjsurg.2017.01.042
       
  • Global surgical electives in residency: The impact on training and future
           practice
    • Authors: Melike Harfouche; Leandra Krowsoski; Amy Goldberg; Zoe Maher
      Abstract: Publication date: Available online 7 April 2017
      Source:The American Journal of Surgery
      Author(s): Melike Harfouche, Leandra Krowsoski, Amy Goldberg, Zoe Maher
      Background The purpose of this study was to evaluate perceptions regarding the value of global surgical electives (GSEs) and pursuit of a career in global surgery amongst residents and surgeons. Methods We sent an anonymous questionnaire to all current and former surgical residents of our tertiary-care, university-based institution from the years 2000–2013. Questions addressed the experience and value of practicing surgery in low or middle income countries (LMIC) in residency and as a career. Results Twenty-three (40%) graduates (G) and 36 (84%) surgical residents (R) completed the survey. Thirteen residents (36%) and 13 (52%) graduates had delivered surgical care in a LMIC. Respondents stated that their experience positively impacted patient care (G = 80% vs R = 75%) and learning (G = 75% vs R = 90%). Of the 4 graduates still working in a LMIC, the majority (75%) were providing less than 2 months of care. Logistical reasons and family obligations were the most common barriers (n = 13). Conclusion Few graduates are able to incorporate global surgery into their practice despite interest. For enduring participation, logistical and family support is needed.

      PubDate: 2017-04-12T09:43:32Z
      DOI: 10.1016/j.amjsurg.2017.03.040
       
  • Comparison of inflammatory cytokines in peritoneal fluid at source control
           surgery for abdominal sepsis
    • Authors: Michael S. Bleszynski; Tiffany Chan; Andrzej K. Buczkowski
      Abstract: Publication date: Available online 6 April 2017
      Source:The American Journal of Surgery
      Author(s): Michael S. Bleszynski, Tiffany Chan, Andrzej K. Buczkowski
      Background Open abdomen with vacuum assisted closure (VAC) is an alternate method to primary abdominal closure (PAC) in select situations for the management of severe surgical abdominal sepsis or septic shock. Peritoneal cytokines may potentially correlate with deranged physiology and help stratify severity of sepsis. The primary objective of the study was to identify if cytokines can differentiate between patients who underwent PAC or VAC at primary source control laparotomy (SCL). Methods Prospective case series including patients with severe abdominal sepsis/septic shock requiring urgent SCL. Peritoneal fluid (PF) was collected intra-operatively and blood samples were collected pre- and post SCL. Samples were analyzed with a Cytokine 30-plex Panel. APACHE-IV was used as a measure of disease severity between groups. Results 4 PAC and 8 VAC patients were included. PF concentrations of IL 6, IL-17, IL-5 and HGF were significantly elevated in VAC compared to PAC. Serum RANTES was increased in survivors compared to non-survivors. Conclusions Patients who received VAC management had a more severe degree of local abdominal sepsis based on significantly elevated peritoneal cytokines.

      PubDate: 2017-04-12T09:43:32Z
      DOI: 10.1016/j.amjsurg.2017.03.037
       
  • The remarkable life of Dr Robert Schaller
    • Authors: Preston L. Carter
      Abstract: Publication date: Available online 6 April 2017
      Source:The American Journal of Surgery
      Author(s): Preston L. Carter


      PubDate: 2017-04-12T09:43:32Z
      DOI: 10.1016/j.amjsurg.2017.03.008
       
  • Outcome comparisons between high-volume robotic and laparoscopic surgeons
           in a large healthcare system
    • Authors: Laila Rashidi; Chris Neighorn; Amir Bastawrous
      Abstract: Publication date: Available online 6 April 2017
      Source:The American Journal of Surgery
      Author(s): Laila Rashidi, Chris Neighorn, Amir Bastawrous
      Robotic colorectal surgery has been performed for nearly a decade, but has been criticized for high cost. We sought to assess outcomes of colorectal operations performed by surgeons with higher experience in robotics and laparoscopy across a large health system. We performed a retrospective review of colon or rectal resections performed between January 2013 and May 2016 within the Providence Health and Services. Surgeons were only included if they performed 30 or more procedures with an approach per year. We assessed outcomes including operative time, hospital length of stay, complications, readmission, conversion to open rates and total direct costs. When comparing the two groups, robotics surgery had a decreased length of hospital stay, lower conversion rate, and longer operative time. There was no statistical difference between complications and rate of readmission. There was no statistically significant difference in total direct cost. These data do suggest that high volume robotic surgery can carry the benefit of a lower length of stay and lower conversion rate, while not incurring an increase in total cost, complication or readmissions.

      PubDate: 2017-04-12T09:43:32Z
      DOI: 10.1016/j.amjsurg.2017.03.034
       
  • Comparison of three caval reconstruction techniques in orthotopic liver
           transplantation: A retrospective review
    • Authors: Tiffany Chan; Kristin DeGirolamo; Stephanie Chartier-Plante; Andrzej K. Buczkowski
      Abstract: Publication date: Available online 6 April 2017
      Source:The American Journal of Surgery
      Author(s): Tiffany Chan, Kristin DeGirolamo, Stephanie Chartier-Plante, Andrzej K. Buczkowski
      Background Classic caval reconstruction during liver transplantation involves complete cross-clamping and resection of the recipient inferior vena cava (IVC) followed by donor IVC interposition. Other techniques preserve the IVC, with piggyback (PB) to the hepatic veins or side-to-side (SS) caval anastomosis. Avoidance of cross-clamping may be beneficial for minimizing hemodynamic instability and transfusion requirements. Methods Retrospective review of a provincial transplant database (2007–2011). MELD score was used to measure disease severity. Intraoperative blood loss and volume resuscitation were compared between three caval reconstruction techniques using ANOVA. Results 200 deceased-donor transplants (Classic:58, PB:72, SS:70) were included. Baseline disease severity was equal. Mean case duration was shorter in the PB technique (Classic:366, PB:306, SS:385 min, p < 0.001). Despite similar blood loss, there was significantly less cell saver return, FFP, platelets, and overall resuscitation volume (Classic:12.8, PB:9.5, SS:13.2 L, p = 0.001) utilized in the piggyback technique. Conclusions The PB technique was faster and used less cell saver return, FFP and platelets, despite similar blood loss. Availability of different caval reconstruction techniques allows for a breadth of options in difficult cases.

      PubDate: 2017-04-12T09:43:32Z
      DOI: 10.1016/j.amjsurg.2017.03.045
       
  • Optimizing physician skill development for medical students: The four-part
           assessment
    • Authors: Justin J.J. Watson; Phillip M. Kemp Bohan; Katrina Ramsey; John D. Yonge; Christopher R. Connelly; Richard J. Mullins; Jennifer M. Watters; Martin A. Schreiber; Laszlo N. Kiraly
      Abstract: Publication date: Available online 5 April 2017
      Source:The American Journal of Surgery
      Author(s): Justin J.J. Watson, Phillip M. Kemp Bohan, Katrina Ramsey, John D. Yonge, Christopher R. Connelly, Richard J. Mullins, Jennifer M. Watters, Martin A. Schreiber, Laszlo N. Kiraly
      Background Medical student performance has been poorly correlated with residency performance and warrants further investigation. We propose a novel surgical assessment tool to determine correlations with clinical aptitude. Methods Retrospective review of medical student assessments from 2013 to 2015. Faculty rating of student performance was evaluated by: 1) case presentation, 2) problem definition, 3) question response and 4) use of literature and correlated to final exam assessment. A Likert scale interrater reliability was evaluated. Results Sixty student presentations were scored (4.8 assessors/presentation). A student's case presentation, problem definition, and question response was correlated with performance (r = 0.49 to 0.61, p ≤ 0.003). Moderate correlations for either question response or use of literature was demonstrated (0.3 and 0.26, p < 0.05). Conclusion Our four-part assessment tool identified correlations with course and examination grades for medical students. As surgical education evolves, validated performance and reliable testing measures are required.

      PubDate: 2017-04-12T09:43:32Z
      DOI: 10.1016/j.amjsurg.2017.03.026
       
  • Dissatisfaction after laparoscopic Heller myotomy: The truth is easy to
           swallow
    • Authors: Alexander Rosemurgy; Darrell Downs; Gianvanna Jadick; Forat Swaid; Kenneth Luberice; Carrie Ryan; Sharona Ross
      Abstract: Publication date: Available online 5 April 2017
      Source:The American Journal of Surgery
      Author(s): Alexander Rosemurgy, Darrell Downs, Gianvanna Jadick, Forat Swaid, Kenneth Luberice, Carrie Ryan, Sharona Ross
      Background Although laparoscopic Heller myotomy has been shown to well palliate symptoms of achalasia, we have observed a small subset of patients who are “Dissatisfied”. This study was undertaken to identify the causes of their dissatisfaction. Study design Patients undergoing laparoscopic Heller myotomy from 1992 to 2015 were prospectively followed. Using a Likert scale, patients rated their symptom frequency/severity before and after the procedure. Patients graded their experience from “Very Satisfying” to “Very Unsatisfying.” Results 647 patients underwent laparoscopic Heller myotomy. Fifty (8%) patients, median age 57 years and BMI 24 kg/m2 reported dissatisfaction at follow-up subsequent to myotomy. “Dissatisfied” patients were more likely to have undergone prior abdominal operations (p = 0.01) or previous myotomies (p = 0.02). “Dissatisfied” patients had a greater incidence of diverticulectomy (p = 0.03) and had longer postoperative LOS (p = 0.01). Symptom frequency/severity persisted after myotomy for dissatisfied patients (p > 0.05). Conclusion Dissatisfaction after laparoscopic Heller myotomy is directly related to persistent/recurrent symptoms. Previous abdominal operations/myotomies, diverticulectomies, and longer LOS are predictors of dissatisfaction. With this understanding, we can identify patients who might be more prone to dissatisfaction.

      PubDate: 2017-04-12T09:43:32Z
      DOI: 10.1016/j.amjsurg.2017.03.043
       
  • Near-perfect compliance with SCIP Inf-9 had no effect on catheter
           utilization or urinary tract infections at an academic medical center
    • Authors: Jennifer A. Kaplan; Jonathan T. Carter
      Abstract: Publication date: Available online 5 April 2017
      Source:The American Journal of Surgery
      Author(s): Jennifer A. Kaplan, Jonathan T. Carter
      Background The Joint Commission's SCIP Inf-9 mandated early removal of indwelling urinary catheters (IUCs), but the impact of compliance on catheter-associated urinary tract infection (CAUTI) and postoperative urinary retention (POUR) are unknown. Methods Retrospective pre- and post-intervention study at a single tertiary academic medical center of all patients undergoing general surgery procedures with an IUC placed at the time of surgery who were admitted for at least two days before and after a Best Practice Advisory was put in place to improve compliance with SCIP Inf-9. Results A total of 1036 patients were included (468 pre-intervention; 568 post-intervention). POUR occurred in 13% of patients and CAUTI in 0.8%. There was no change in POUR, CAUTI, or catheter utilization after the Best Practice Advisory was initiated. Both POUR and CAUTI predicted longer lengths of stay. Conclusions Near-perfect SCIP Inf-9 compliance had no effect on the CAUTI rate at our institution. Summary Implementation of a Best Practice Advisory that ensured near-perfect compliance with a SCIP process measure designed for early indwelling urinary catheter removal had no measurable effect on catheter associated urinary tract infections, catheter utilization, or urinary retention. Early catheter removal was associated with double the odds of urinary retention.

      PubDate: 2017-04-12T09:43:32Z
      DOI: 10.1016/j.amjsurg.2017.03.039
       
  • Increased risk of ventral hernia recurrence after pregnancy: a nationwide
           register-based study
    • Authors: Erling Oma; Kristian K. Jensen; Lars N. Jorgensen
      Abstract: Publication date: Available online 5 April 2017
      Source:The American Journal of Surgery
      Author(s): Erling Oma, Kristian K. Jensen, Lars N. Jorgensen
      Background Female patients of reproductive age constitute a substantial portion of patients undergoing ventral hernia repair, however the impact of pregnancy on the risk of recurrence is scarcely documented. The aim of the study was to evaluate if pregnancy following ventral hernia repair was associated with an increased risk of recurrence. Methods This nationwide cohort study included all female patients of reproductive age registered in the Danish Ventral Hernia Database with ventral hernia repair between 2007 and 2013. The primary outcome was ventral hernia recurrence. Multivariable extended Cox regression analysis was performed. Results A total of 3,578 patients were included in the study, 267 (7.5%) of whom subsequently became pregnant during follow-up. The median follow-up was 3.1 years (range 0-8.4 years). Pregnancy was independently associated with recurrence (hazard ratio 1.56, 95% confidence interval 1.09-2.25, P = 0.016). Conclusions Pregnancy after ventral hernia repair was independently associated with ventral hernia recurrence. Summary Female patients of reproductive age constitute a substantial portion of patients undergoing ventral hernia repair, however the impact of pregnancy on the risk of recurrence is scarcely documented. In this cohort study based on nationwide Danish registries, we found that pregnancy after ventral hernia repair was independently associated with an increased risk of ventral hernia recurrence.

      PubDate: 2017-04-12T09:43:32Z
      DOI: 10.1016/j.amjsurg.2017.03.044
       
  • Laparoscopic surgery versus open resection in patients with
           gastrointestinal stromal tumors: An updated systematic review and
           meta-analysis
    • Authors: Hanchu Xiong; Ji Wang; Yunlu Jia; Chenyang Ye; Yi Lu; Cong Chen; Jianguo Shen; Yongxia Chen; Wenhe Zhao; Linbo Wang; Jichun Zhou
      Abstract: Publication date: Available online 5 April 2017
      Source:The American Journal of Surgery
      Author(s): Hanchu Xiong, Ji Wang, Yunlu Jia, Chenyang Ye, Yi Lu, Cong Chen, Jianguo Shen, Yongxia Chen, Wenhe Zhao, Linbo Wang, Jichun Zhou
      Purposes The contemporary surgery has reported the safety of laparoscopic surgery (LAP) for patients with gastrointestinal stromal tumors (GISTs). However, its use is still debated due to suspicion of the oncologic equivalence to open surgery (OPEN). We conducted a systematic review and meta-analysis of updated original articles to investigate the short- and long-term clinical outcomes of LAP compared with OPEN for GISTs. Methods A systematic search was performed in PubMed, Embase, Web of Science, Cochrane Library and CNKI. Comparative studies of laparoscopic and open surgery for GISTs were published before November 2016. The Newcastle-Ottawa scale was utilized to conduct quality assessment. The Review Manager (RevMan) software version 5.0 was used for meta-analysis. Results Twenty-four studies involving 2140 patients were included for the meta-analysis. The meta-analysis results showed that, compared with OPEN, LAP indicated potentially favorable outcomes in terms of operative time (WMD, −30.71; 95% CI, −58.48 to −2.95; P = 0.03); intraoperative blood loss (WMD, −60.90; 95% CI, −91.53 to −30.28; P < 0.0001); time to flatus (WMD, −1.10; 95% CI, −1.41 to −0.79; P < 0.00001); time to oral intake (WMD, −1.25; 95% CI, −1.64 to −0.86; P < 0.00001); length of hospital stay (WMD, −3.42; 95% CI, −4.37 to −2.46; P < 0.00001); overall complications (OR, 0.38; 95% CI, 0.27 to 0.54; P < 0.00001); and recurrence (OR, 0.45; 95% CI, 0.30 to 0.66; P < 0.0001). Conclusions Laparoscopic surgery is safe and feasible for the treatment of GISTs including less operative time and intraoperative blood loss, earlier postoperative recovery, shorter hospital stay, and lower rate of overall complications and recurrence.

      PubDate: 2017-04-12T09:43:32Z
      DOI: 10.1016/j.amjsurg.2017.03.042
       
  • Improving transitions of care across the spectrum of healthcare delivery:
           A multidisciplinary approach to understanding variability in outcomes
           across hospitals and skilled nursing facilities
    • Authors: Giana H. Davidson; Elizabeth Austin; Lucas Thornblade; Louise Simpson; Thuan D. Ong; Hanh Pan; David R. Flum
      Abstract: Publication date: Available online 5 April 2017
      Source:The American Journal of Surgery
      Author(s): Giana H. Davidson, Elizabeth Austin, Lucas Thornblade, Louise Simpson, Thuan D. Ong, Hanh Pan, David R. Flum
      INTRODUCTION Improving coordination during transitions of care from the hospital to Skilled Nursing Facilities (SNF)s is critical for improving healthcare quality. In 2014, we formed (Improving Nursing Facility Outcomes using Real-Time Metrics, INFORM) to improve transitions of care by identifying structural and process factors that lead to poor clinical outcomes and hospital readmission. METHODS Stakeholders from 10 SNFs and 4 hospitals collaborated to assess the current hospital and system-level challenges to safe transitions of care and identify targets for interventions. RESULTS The INFORM collaborative identified areas for improvement including improving accuracy and timeliness of discharge information, facilitating congruent medication reconciliation, and developing care plans to support functional improvement. DISCUSSION Hospital and SNF stakeholder engagement prioritized the challenges in patient transitions from inpatient to skilled nursing facility settings. Innovative solutions that address barriers to safe and effective transitions of care are critical to improving clinical outcomes, decreasing adverse events and avoiding readmission.

      PubDate: 2017-04-12T09:43:32Z
      DOI: 10.1016/j.amjsurg.2017.04.002
       
  • Surgical outcomes in women ≥70 years undergoing mastectomy with and
           without reconstruction for breast cancer
    • Authors: Simone Mays; Hanan Alabdulkareem; Paul Christos; Rache Simmons; Tracy-Ann Moo
      Abstract: Publication date: Available online 5 April 2017
      Source:The American Journal of Surgery
      Author(s): Simone Mays, Hanan Alabdulkareem, Paul Christos, Rache Simmons, Tracy-Ann Moo
      Background Approximately 4% of women age 70 will develop breast cancer during the next ten years. Reconstruction has become a standard option for young women undergoing mastectomy for breast cancer, however may not be offered to older women due to the presence of co-morbidities. There is limited data on the outcomes of mastectomy with reconstruction in patient's ≥ 70. This study examines comorbidities and 30-day complication rates in patients ≥70 undergoing mastectomy for breast cancer. Methods The American College of Surgeons National Surgery Quality Improvement Program database was used to examine co-morbidities and 30-day complication rates in breast cancer patients undergoing mastectomy from 2007 to 2012. Patients were grouped based on age and procedure. Complication rates were characterized using descriptive statistics and Wilcoxon rank sum-test. Variable frequencies were compared using Chi-square or Fisher's exact test. Results 54,821 patients underwent mastectomy. Among patients ≥70, 11,927 did not have reconstruction, 109 had reconstruction. Among patients <70, 40,755 did not have reconstruction and 2040 had reconstruction. Patients without reconstruction had a significantly higher number of co-morbidities compared to those having reconstruction (P = 0.001). The 30-day complication rate for patients without reconstruction was 4.2% in patients ≥70 compared to 4.4% for those <70 (p = 0.4). In patients with reconstruction, the 30-day complication rate was 6.4% in patients ≥70 compared to 5.6% for those <70 (p = 0.7). Conclusion There was no difference in 30-day complication rate between patients ≥70 and < 70 having mastectomy with and without reconstruction. Similar outcomes among women ≥70 years and younger patients undergoing reconstruction may reflect patient selection based on co-morbidities. With appropriate risk stratification, breast reconstruction may be a safe surgical option for women ≥70 year patients undergoing treatment for breast cancer.

      PubDate: 2017-04-12T09:43:32Z
      DOI: 10.1016/j.amjsurg.2017.03.041
       
  • Tumor size as a prognostic factor in patients with stage IIa colon cancer
    • Authors: Francesco Santullo; Alberto Biondi; Ferdinando C.M. Cananzi; Valeria Fico; Flavio Tirelli; Riccardo Ricci; Gianluca Rizzo; Claudio Coco; Claudio Mattana; Domenico D'Ugo; Roberto Persiani
      Abstract: Publication date: Available online 5 April 2017
      Source:The American Journal of Surgery
      Author(s): Francesco Santullo, Alberto Biondi, Ferdinando C.M. Cananzi, Valeria Fico, Flavio Tirelli, Riccardo Ricci, Gianluca Rizzo, Claudio Coco, Claudio Mattana, Domenico D'Ugo, Roberto Persiani
      Background The aim of this study was to identify stage II colon cancer patients with a high risk of recurrence. Methods All patients who underwent surgery for stage II colon cancer (CC) were retrospectively enrolled and sub-grouped according to TNM staging (IIa-b-c) and stage IIa in high (IIaHR) and low risk (IIaLR) according to pathologic features. The primary outcomes measured were the 5-year overall survival (OS) and disease-free survival (DFS). Results A total of 214 patients were reviewed. Only a maximum tumor diameter<4 cm in the IIaLR group was associated with a higher recurrence rate than a large tumor size (5-year DFS 71.7%vs.87.6%, p = 0.028). The DFS in the large IIaLR CC group was better than that in the IIaHR and IIb-c groups (5-year DFS: 92.7%vs.79.3%, p = 0.023). In contrast, the recurrence rate in the small IIaLR CC group was similar to that in the IIaHR, IIb-c stage CC group. Conclusions In stage IIa CC evaluation of the tumor size as a prognostic factor may help identify patients who could benefit from additional postoperative therapy.

      PubDate: 2017-04-12T09:43:32Z
      DOI: 10.1016/j.amjsurg.2017.03.038
       
  • Circumferential pedicled omental flap for protection of portomesenteric
           venous reconstruction and gastroduodenal artery stump following
           pancreatoduodenectomy
    • Authors: Angelena Crown; Adnan Alseidi; Thomas Biehl; Scott Helton; Flavio G. Rocha
      Abstract: Publication date: Available online 5 April 2017
      Source:The American Journal of Surgery
      Author(s): Angelena Crown, Adnan Alseidi, Thomas Biehl, Scott Helton, Flavio G. Rocha
      This video demonstrates a technique for creation of an omental tissue barrier to protect a portomesenteric vein reconstruction or gastroduodenal artery (GDA) stump. Following routine pancreatoduodenectomy reconstruction, a generous tongue of omentum is mobilized off the transverse colon ensuring to preserve the feeding branches from the left gastroepiploic artery. The omentum is then passed behind the pancreatojejunostomy above the vein repair site. It is grasped superiorly and passed anterior to the pancreatojejunostomy to exclude the GDA stump. The flap is then secured to the blind end of the jejunum with suture thereby completing the circumferential wrap. Care must be taken in obese patients to trim the flap so it can fit behind the pancreas without devascularizing it or causing tension on the pancreatojejunostomy. If a closed suction drain is desired, it can be passed from the patient’s right either in front of or behind the hepaticojejunostomy and placed around the flap. This technique is most applicable to patients with moderate to high risk of pancreatic fistula (small pancreatic duct and/or soft gland) after undergoing PD with an intact omentum. This circumferential, pedicled omental flap is an easy, reproducible, and durable method to protect vascular structures and repairs from pancreatic fistulas.

      PubDate: 2017-04-05T09:37:15Z
      DOI: 10.1016/j.amjsurg.2017.03.033
       
  • CHIVA – A prospective study of a vein sparing technique for the
           management of varicose vein disease
    • Authors: Marta Zmudzinski; Pierre Malo; Christine Hall; Allen Hayashi
      Abstract: Publication date: Available online 4 April 2017
      Source:The American Journal of Surgery
      Author(s): Marta Zmudzinski, Pierre Malo, Christine Hall, Allen Hayashi
      Background Varicose vein disease (VVD) affects approximately one third of adults. Cure Conservatrice et Hémodynamique de l’Insuffisance Veineuse en Ambulatoire (CHIVA) is a minimally invasive, vein sparing technique that is emerging as an alternative to ablative techniques for treating VVD. Methods This prospective study assessed the rate of recurrence of venous reflux with CHIVA. We evaluated 150 primary procedures with clinical and duplex ultrasound examinations pre and post operatively. Patients were followed at <3 months and >1-year post-op. Recurrence was defined as reflux in the diseased vessel at the saphenofemoral junction on duplex examination. Results There was no documented recurrence at the early follow up. To date, 58 legs have completed the late follow up and reflux was found in 5 legs resulting in a recurrence rate of 8.6%; 95% CI (2.4%, 19%). Conclusion Our results indicate that CHIVA appears to offer a promising alternative for the treatment of VVD.

      PubDate: 2017-04-05T09:37:15Z
      DOI: 10.1016/j.amjsurg.2017.03.025
       
  • Table of Contents (4 pgs)
    • Abstract: Publication date: April 2017
      Source:The American Journal of Surgery, Volume 213, Issue 4


      PubDate: 2017-03-29T09:32:54Z
       
 
 
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