The American Surgeon™

The complexity of embryological development of the gastrointestinal tract and mesentery provides a platform for the formation of a wide variety of variant veils, folds, and membranes, collectively termed peritoneal bands. These structures, which represent anatomically unabsorbed portions of the omentum and mesentery, although often benign, have the potential to cause clinically significant manifestations in both the neonate and adult. Although these deviant structures may be identified over a broad range of the abdominal cavity, they are most commonly identified in the regions of the duodenum, duodenojejunal flexure, ileocecal junction, and ascending colon. As a result of the diverse location of these variant structures, clinical manifestations are highly variable, ranging from acute presentations of intestinal necrosis as a result of strangulated midgut volvulus to chronic, vague abdominal pain. This article seeks to highlight the importance of a thorough anatomical understanding of the distribution of the various abnormal peritoneal folds, bands, and ligaments, which may result from aberrations in embryonic gastrointestinal development and their respective clinical implications. Moreover, to advance the knowledge of peritoneal bands, this article discusses the appropriate diagnostic studies and treatment interventions required for these variant structures.

Repair of ventral hernias constitutes one of the most common surgical procedures. Although an abundance of data exists on objective outcome measures, very little information exists on subjective measures of surgeon preference and patient satisfaction in surgical management of ventral hernias. Moreover, there are minimal data on indications for elective repair of ventral hernias. Two questionnaires were sent to a population of general and plastic surgeons active in hernia surgery. The first of these aimed at gathering information from surgeons about their indications and contraindications for repair of ventral hernias. The second survey was aimed at determining surgeons’ perception of patient satisfaction with repair of large ventral hernias (greater than 15 cm width). Five hundred sixty-eight surgeons responded to the first survey and 336 responded to the second survey. The most common indications for elective repair of abdominal wall hernias were generalized pain (68.7%) and cosmesis (54.6%), whereas the most common contraindications were morbid obesity (43.3%), American Society of Anesthesiologists Class III or IV (35.4%), and enterocutaneous fistula (33.1%). The majority of surgeons do not routinely repair large abdominal wall hernias in asymptomatic patients, but 31.6 per cent do repair asymptomatic large hernias. Most surgeons reported that the majority of patients had resolution of pain and subjective impression of improved cosmesis after surgery. This study demonstrates uniform indications and contraindications for surgical repair of ventral hernias among surgeons as well as surgeons’ perception of improvements in satisfaction of most patients after surgery. Future studies will focus on comparing surgeon and patient satisfaction.

Flail chest represents a severe injury with mortality historically reported at up to 30 per cent. Although management has changed dramatically over the past several decades, there is a paucity of large recent series. With Institutional Review Board approval, a retrospective review of all patients with flail chest admitted from January 2001 through May 2010 was undertaken. Patient demographics, outcomes, and cause of death were specifically analyzed with univariate and multivariate analysis. There were 164 patients at a median age of 51.4 years. Head injury and pulmonary contusion were present in 67 (40.8%) and 125 (77%), respectively. Pneumonia developed in 72 (43.9%). There were 41 deaths (25%), for which flail chest contributed to 15 (9.1%). Of the patients with flail chest-related death, the majority (n = 10 [66.7%]) died within 48 hours of presentation. There were only five deaths (3.0%) related to flail chest after 48 hours. Multivariate analysis of ventilator dependency revealed requirement for laparotomy (P = 0.019) or tracheostomy (P < 0.0001) and pneumonia (P = 0.0002) as significant. Pneumonia was the most significant independent predictor of overall (P < 0.0001) and intensive care unit length of stay (P < 0.0001). The mortality associated with flail chest has greatly improved; however, the rate of pneumonia remains high. Further efforts at pneumonia prevention are thus warranted.

Safe management of small bowel obstruction (SBO) depends on rapid diagnosis. The objective of this study was to determine factors predictive for operation and resulting in operative delay. A retrospective review was done of 1613 patients over 4 years (2003 to 2007) with International Classification of Diseases, 9th Revision codes for SBO. After excluding patients with incomplete clinical data, incorrectly coded, and age younger than 5 years, 872 patients were reviewed. Analysis was done for factors predictive for operation and factors associated with operative delay. Statistics was done using t test, Wilcoxon-rank-sum, and χ². Four hundred ninety-four patients (56.6%) underwent surgery for SBO. Three hundred seventy-eight patients (43.4%) were managed nonoperatively. Of factors examined, younger patients (P = 0.001), no previous operation (P < 0.001), and absence of adhesive disease (P < 0.001) were more likely to go to operation. Acquiring a computed tomographic scan (P = 0.029) or radiograph (P < 0.001) were the only factors that increased time to the operating room (OR). Increased time to the OR was associated with a higher incidence of bowel resection. With those with time to OR less than 24 hours, 39 of 325 patients(12%) had bowel resection versus time to OR greater than 24 hours, 23 of 80 patients (29%) required bowel resection. Identifying patients who may safely undergo nonoperative management remains difficult. Delay in operation for SBO places patients at higher risk for bowel resection.

Clostridium difficile infection is associated with substantial morbidity and mortality, increased duration of hospitalization, and a marked economic impact. Several case reports and case series have described C. difficile infection in excluded bowels or immediately after reversal of defunctioning ileostomy. The aim of this prospective study is to detect whether the excluded colon is associated with a higher rate of C. difficile colonization than the normal population, which may increase the risk of C. difficile infection. Patients with defunctioning loop ileostomy, undergoing closure of ileostomy to restore bowel continuity, were prospectively recruited. Two stool samples were collected from the ileostomy effluent before closure of ileostomy and two after the procedure including the first bowel movement. All samples were cultured for C. difficile and analyzed for toxins A and B by a Premier EIA test. Demographic data and possible confounding factors were observed and recorded. Twenty-fine adult patients were recruited to this study; five patients were subsequently excluded. Two patients had positive stool cultures for C. difficile in the postoperative samples and another patient developed clinical pseudomembranous colitis with positive toxin. This indicates a possible colonization rate of 3 to 38 per cent (95% confidence interval). Four observed cases out of the 20 subjects taking part in this study would confidently conclude that C. difficile colonization in the excluded colon is 6 to 44 per cent, i.e., higher than the incidence in the healthy adult population, which is 3 per cent. However, the findings of this study prompt larger and well-powered studies to confirm these findings.

Choledochal cyst, usually recognized as a problem in infants, is increasingly reported in adult patients. The aim of this study was to share our experience in treating adult patients with choledochal cysts. Two hundred twenty-one adult patients with choledochal cysts who were treated in our hospital from January 2002 to December 2010 were enrolled. The clinical data were retrospectively collected and analyzed. There were 168 Type I, three Type II, three Type III, 26 Type IV, and 21 Type V cysts. The presentations were nonspecific with 177 patients having abdominal pain and a few patients having other rare symptoms including back pain, cirrhosis, occupying lesions, or spontaneous rupture. The cysts were completely removed in 169 patients, and 36 patients required liver resection. There was one death resulting from abdominal bleeding. Morbidity was limited to 27 patients, 11 of whom underwent invasive interventions. Choledochal cysts remain an interesting clinical problem. In some adult cases, the diagnosis is very difficult. Treatment is type-dependent, complete removal of the cysts is widely accepted, and lifelong follow-up for these patients is recommended.

The purpose of this study was to determine the poor prognostic factors after repeat hepatectomy (Hx) in patients with recurrent hepatocellular carcinoma (HCC). Overall survival rates and clinicopathological variables in 112 patients with repeat Hx from 1992 to 2010 were compared with those in 531 patients who underwent a primary Hx. To clarify the poor prognosis factors after repeat Hx, survival data among 112 patients were univariately and multivariately analyzed. Overall survival after repeat Hx was similar for that of the patients who underwent a primary Hx. The mean age of repeat Hx group was significantly higher, and a well-preserved liver function was recognized than the primary Hx group. Multivariate analysis revealed that: 1) indocyanine green retention rate at 15 minutes; 2) disease-free interval; 3) tumor size; 4) portal vein invasion at primary Hx; 5) gender; and 6) estimated blood loss to be an independent and significant poor prognostic factors. The overall 3-year postrecurrence overall survival rates were 100, 91.3, 59.6, and 0 per cent at risk number (R) R0, R1/2, R3, R4, respectively (P < 0.05). Repeat Hx provided a good compatible prognosis with primary Hx. In our findings, five risk factors to predict poor outcomes after repeat Hx were useful. Patients with recurrent HCC do not have universally poor outcomes, and our simple scoring system using five poor prognostic factors could serve to advise the prognosis and the potential benefit for patient selection about repeat Hx.

The home remains a very common location for deadly injuries among children younger than 5 years. The aim of this study is to describe the demographic and injury characteristics of domestic injuries in children younger than 5 years. The National Trauma Data Bank's National Sample Program data set was queried for children younger than 5 years with the injury site classified as home. Bivariate analysis was performed to determine unadjusted differences by ethnicity. Appropriate weight was applied to the sample to determine accurate national estimates. A total of 7,364 children, representing 32,033 children, were analyzed. Overall mortality was 1.6 per cent. Among whites, blacks, Hispanics, Asians, and Native Americans, intentional injuries accounted for 6.5, 12.8, 10.2, 5.2, and 19.0 per cent of all injuries by intent, respectively (P < 0.003). Burn injury was disproportionately higher in blacks (24.1%) followed by Native Americans and Asians (15.3 and 11.5%, P = 0.008). On multivariate analysis, black ethnicity was associated with increased length of stay. Intentional injuries were significantly higher in blacks and Native Americans with black patients sustaining a disproportionately higher proportion of burn injury. Therefore, greater attention is needed to provide more effective home safety interventions to children among high-risk ethnic groups.

Giant paraesophageal hernias (PEHs) are associated with progression of symptoms in up to 45 per cent of patients. Recently, many series have reported that laparoscopic repair of PEH is technically feasible, effective, and safe. A retrospective review of the University of Athens tertiary care hospitals patient database and the patient medical records identified 45 patients who underwent elective repair of a giant PEH between 2002 and 2009. Elective laparoscopic repair of a giant PEH was attempted in 45 patients who were treated with Gore-Tex dual mesh with or without Nissen fundoplication. They all had a mesh repair. Intraoperative complications included one pulmonary embolism and one recurrent hernia. The use of a mesh seems to be effective in the treatment of large hernias. It appears to offer the benefit of a shorter hospital stay and a quicker recovery.

Single-incision laparoscopic surgery (SILS) for cholecystectomy is a well-established procedure and represents the next step in developing the concept of fast track surgery. This report describes our experience with SILS cholecystectomy in patients that stay overnight. Between February 2009 and July 2010, patients referred for cholecystectomy to the day surgery unit who agreed to undergo SILS were included in a prospective study. All operations were performed by the same surgical team specially trained in this type of surgery and the same operative technique was used in all cases. Postoperative pain and nausea were assessed using a 10-cm visual analogue scale on a self-completion questionnaire on the night of operation and the morning of discharge. A total of 107 patients (58% women, mean age 56 years) with symptomatic gallstones were included in the study. SILS was successfully performed in all patients and no patient required conversion to an open procedure. There were no significant differences in the median visual analogue scale for postoperative pain and nausea between the night of surgery and the next morning. The mean length of hospital stay was 23 hours, and 98 per cent of patients were satisfied with the results of surgery and would be willing to undergo the same procedure again. SILS cholecystectomy is a valid alternative to standard laparoscopic cholecystectomy as an outpatient surgery or overnight stay procedure. According to these promising results, SILS cholecystectomy could be included in a major ambulatory surgery program.

Paramount to staging and patient management is accurately measuring the size of invasive breast cancers. We assessed the accuracy of mammography (MG), ultrasonography (US), and magnetic resonance imaging (MRI) at our community-based hospital in which multiple radiologists and imaging machines are used in the care of our patients. We performed a retrospective analysis of a prospectively maintained database of 277 patients seen at our breast center from 2009 to 2010. We tabulated MG, US, and MRI-reported tumor sizes in 161 women with pathology-proven invasive breast cancer and compared the preoperative size measurements with final pathologic tumor size. In the 161 patients, 169 lesions were identified. Imaging using all three modalities was available in 47 patients. When compared with final pathology, MRI had a correlation of r = 0.75 to mean tumor size as compared with US (r = 0.67) and MG (r = 0.76). Mean tumor size was 1.90 cm by MG, 1.87 cm by US, 2.40 cm by MRI, and 2.19 cm by pathology. We were able to achieve an excellent correlation of pathologic tumor size to preoperative imaging. The absolute differences in size between the modalities were small. MRI, in select patients, added to the assessment of tumor size based on US and MG.

Since 2010, we have used single-incision laparoscopic surgery (SILS) for patients with a gastric submucosal tumor, as a less invasive alternative to conventional laparoscopy. From September 2010 to January 2011, five patients underwent a local resection for a gastric submucosal tumor using a SILS™ port at Keio University Hospital. We performed partial gastrectomy via the SILS™ port using a 5 mm flexible endoscope, a vessel sealing system, and a stapling device. There were no major intraoperative complications, conversion to laparotomy, or cases of tumor rapture. The average operative time was 89 (range, 72–129) minutes with minimal blood loss. Pathological examination revealed four cases of gastrointestinal stromal tumor and one case of inflammatory fibrosis caused by nonspecific inflammation. Although we examined only a small number of cases in this study, the results suggested that SILS gastrectomy can be performed safely and effectively for gastrointestinal stromal tumor.

The role of routine preoperative magnetic resonance imaging (MRI) in newly diagnosed breast cancer patients planned for breast conserving surgery is presently being debated. In our medical center we practice selective use of preoperative MRI; we sought to examine the yield of MRI in this highly selected group of patients. A retrospective study of all newly diagnosed breast cancer patients presenting between January 2007 and July 2010 to the Tel Aviv Sourasky Medical Center (Tel Aviv, Israel) was completed. Patients planned for breast conserving surgery who underwent preoperative MRI were included in this study. Patients and tumor characteristics, indication for MRI, findings on MRI, consequent workup, and impact on surgical treatment were recorded. Association between preoperative characteristics and yield of MRI was examined. During the study period, 105 patients that were candidates for breast conserving surgery underwent pre-operative evaluation with MRI. Use of breast MRI increased over time. Rates of mastectomy were stable throughout the study years. Dense mammogram was the most frequent (51, 68%) indication for MRI. Additional suspicious findings were found in 41 (39%) patients, prompting further workup including 36 biopsies in 25 patients, of which 22 (61%) were with cancer. These additional findings prompted a change in the surgical plan in a third of the patients. In most patients (92; 88%) clear margins were achieved. Limiting the use of MRI in the preoperative workup of breast cancer patients to a selected group of patients can increase the yield of MRI.

Liver resection is considered the therapeutic gold standard for primary and metastatic liver neoplasms. The reduction of postoperative complications and mortality has resulted in a more aggressive approach to hepatic malignancies. For the most part, results of liver surgery have been published by highly experienced institutions, but the observations of highly specialized units results may not reflect the current status of hepatic surgery, underestimating mortality and complications. The objective of this study is to evaluate morbidity and mortality as a result of liver resection for primary and metastatic lesions, analyzing a large number of studies with a meta-analytic process taking into account the overdispersion of data. An extensive literature search has been conducted, and 148 papers published between January 2000 and April 2008, including a total of 36,629 patients from both high-volume and low volume institutions, were included in the meta-analysis. A beta binomial model was used to provide a robust estimate of the summary event rate by pooling overdispersion binomial data from different studies. Overall morbidity and mortality after liver surgery were 29.32 per cent and 3.15 per cent, respectively. Significantly higher postoperative mortality was observed after liver resection for hepatocellular carcinomas and primary hepatic tumors. The application of a beta binomial model to correct for overdispersion of liver surgery data showed significantly higher postoperative mortality rates in patients with hepatocellular carcinomas or primary hepatic tumors after liver resection.

Inferior vena cava (IVC) diameter change on limited transthoracic echocardiogram (LTTE) can provide a useful guide of fluid status evaluation in critically ill patients. Institutional review board approval was obtained. Prospective evaluation of hemodynamic status was performed in hypotensive patients via LTTE. Images were obtained using an ultrasound machine without M-mode capability. Qualitative assessment of the IVC was obtained via subxyphoid window. FLAT IVC was defined as diameter less than 2 cm and FAT IVC when the vein was equal or larger than 2 cm. Collapsibility was assessed by observing respiratory variation of the vessel. Lactate was measured before and after therapy was initiated. A follow-up LTTE was obtained after fluid challenge. A total of 108 LTTE were performed. Patients’ age ranged from 18 to 89 years with an average of 53. Admission diagnosis was blunt trauma in 66 patients, penetrating trauma in 17, whereas 25 had nontraumatic intra-abdominal emergency. Sixty-nine patients were receiving mechanical ventilation at time of LTTE. Seventy-three patients had a FLAT IVC, and received fluid challenge as therapy. All patients had a change in IVC volume from “FLAT” to “FAT” after the fluid challenge. Seventy-one patients (97%) had resolution of hypotension after the first fluid challenge. Two patients had persistent hypotension and received a second fluid challenge. Follow-up LTTE demonstrated a FAT IVC and lack of collapsibility. Lactate decreased in all 73 patients after therapy guided by LTTE (P < 0.00001) Evaluation of the IVC diameter via LTTE offers a rapid, non invasive way to evaluate fluid status in critically ill patients.

Achieving an R0 resection can be difficult for hilar cholangiocarcinoma (HC) because of the anatomic structures of the hepatic hilum and frequent tumor infiltration. The aim of this study was to evaluate the margin status of bile duct resected in HC and prognostic impact of R1 resection. Between 2000 and 2009, 245 patients underwent operation for HC at Asan Medical Center. We retrospectively analyzed the clinicopathologic features and surgical outcomes, focusing on the proximal margin status, of 162 cases of patients with curative intention. Curative resections were achieved in 125 (52.1%) patients, and R1 resections were performed in 43 (26.5%). Proximal ductal margin states were classified as free margin (73.5%), carcinoma in situ (3.7%), and invasive carcinoma (22.8%). The 3- and 5-year survival rates of the R1 group (39.5% and 34.9%) were not significantly different from the rates of the R0 group (55.5% and 44.5%, respectively). Multivariate analysis showed lymph node metastasis (P = 0.001) and histologic differentiation (P = 0.001) were independent predictors of patient survival. The aggressive surgical approach based on liver resection including caudate lobe may increase the number of patients eligible for a curative chance and improve long-term survival even if the microscopically positive margin is still achieved.

The factors contributing to the development of pneumothorax after removal of chest tube thoracostomy are not fully understood. We hypothesized that development of post pull pneumothorax (PPP) after chest tube removal would be significantly lower in those patients with thicker chest walls, due to the “protective” layer of adipose tissue. All patients on our trauma service who underwent chest tube thoracostomy from July 2010 to February 2011 were retrospectively reviewed. Patient age, mechanism of trauma, and chest Abbreviated Injury Scale score were analyzed. Thoracic CTs were reviewed to ascertain chest wall thickness (CW). Thickness was measured at the level of the nipple at the midaxillary line, as perpendicular distance between skin and pleural cavity. Chest X-ray reports from immediately prior and after chest tube removal were reviewed for interval development of PPP. Data are presented as average ± standard deviation. Ninety-one chest tubes were inserted into 81 patients. Patients who died before chest tube removal (n = 11), or those without thoracic CT scans (n = 13) were excluded. PPP occurred in 29.9 per cent of chest tube removals (20/67). When PPP was encountered, repeat chest tube was necessary in 20 per cent of cases (4/20). After univariate analysis, younger age, penetrating mechanism, and thin chest wall were found to be significant risk factors for development of PPP. Chest Abbreviated Injury Scale score was similar in both groups. Logistic regression showed only chest wall thickness to be an independent risk factor for development of PPP.

Surgical-site infections (SSIs) remain a major source of morbidity after colectomy for fulminant ulcerative colitis (UC). Identifying UC patients at elevated risk of developing SSIs might improve postoperative outcomes. Our goal was to identify preoperative factors, which could predict SSI development in the postoperative UC population. The records of 59 patients treated by colectomy for fulminant UC from 2004 to 2009 were retrospectively reviewed and statistically analyzed. Few differences were observed between patients who developed postoperative complications and those who did not. Twenty patients sustained a total of 27 complications, with superficial SSIs being the single most common event. Multivariate analysis identified diabetes, white blood cell count > 15 cells/mm³, intraoperative blood loss >200 cc, and intraoperative blood transfusion to all be independent predictors for the development of postoperative SSIs. These four factors were all able to independently predict SSIs. Postoperative UC patients with these risk factors might benefit from heightened wound surveillance or closer follow-up.

The levels of interleukin-6 (IL-6) are proportionate to injury; it is the most commonly used quantitative marker in surgical studies. Cytokines and the acute-phase response play an important role in controlling the human immune system. The objective of this study was to compare the systemic acute cytokine response and clinical outcomes of conventional laparoscopic and single port laparoscopic cholecystectomy. We compared patients who underwent single port laparoscopic cholecystectomy (the single port group) with patients who underwent conventional laparoscopic cholecystectomy (the conventional group) according to the clinical variables, IL-6, leukocyte subpopulations, and visual analog scale (VAS) pain score. The mean age in the single port group was significantly younger (P = 0.010) and the mean operation time in the conventional group was significantly shorter (P = 0.002). Postoperative 4-hour VAS pain score was slightly worse in the single port laparoscopic cholecystectomy group, but was not significantly different. We found no difference in clinical outcomes, the level of serum IL-6, C-reactive protein, leukocyte subpopulations, and complications between the two groups. Stress response in single port laparoscopic cholecystectomy is equal to conventional surgery. Postoperative 4-hour VAS pain score was slightly worse and the operation time is significantly longer in the single port laparoscopic cholecystectomy group.