The American Surgeon™

It is well known that liver disease has an adverse effect on postoperative outcomes. However, what is still unknown is how to appropriately risk stratify this patient population based on the degree of liver failure. Because data are limited, specifically in general surgery practice, we analyzed the model of end-stage liver disease (MELD) in terms of predicting postoperative complications after one of three general surgery operations: inguinal hernia repair (IHR), umbilical hernia repair (UHR), and colon resection (CRXN). National Surgical Quality Improvement Program data on 17,812 total patients undergoing one of three general surgery operations from 2008 to 2012 were analyzed retrospectively. There were 7402 patients undergoing IHR; 5014 patients undergoing UHR; 5396 patients undergoing CRXN. MELD score was calculated using international normalized ratio, total bilirubin, and creatinine. The primary end point was any postoperative complication. The statistical method used was logistic regression. For IHR, UHR, and CRXN, the overall complication rates were 3.4, 6.4, and 45.9 per cent, respectively. The mean MELD scores were 8.6, 8.5, and 8.5, respectively. For every 1-point increase greater than the mean MELD score, there was a 7.8, 13.8, and 11.6 per cent increase in any postoperative complication. The overall 30-day mortality rate was 0.9 per cent. In conclusion, the MELD score continuum adequately predicts patients’ increased risk of postoperative complications after IHR, UHR, and CRXN. Therefore, MELD could be used for preoperative risk stratification and guide clinical decision making for general surgery in the cirrhotic patient.

Prolonged air leaks are the most common postoperative complication following pulmonary resection, leading to increased hospital length of stay (LOS) and cost. This study assesses the safety of discharging patients home with a chest tube (CT) after pulmonary resection. A retrospective review was performed of a single surgeon's experience with pulmonary resections from January 2010 to January 2015. All patients discharged home with a CT were included. Discharge criteria included a persistent air leak controlled by water seal, resolution of medical conditions requiring hospitalization, and pain managed by oral analgesics. Patient demographics, type of resection, LOS, and 30-day morbidity and mortality data were analyzed. Comparisons were made with the Society of Thoracic Surgery database January 2011 to December 2013. Four hundred ninety-six patients underwent pulmonary resection. Sixty-five patients (13%) were discharged home postoperatively with a CT. Fifty-eight patients underwent a lobectomy, two patients a bilobectomy, and five patients had a wedge excision. Two patients were readmitted: One with a lower extremity deep venous thrombosis and the other with a nonlife threatening pulmonary embolus. Four patients developed superficial CT site infections that resolved after oral antibiotics. Patients discharged home with a CT following lobectomy had a shorter mean LOS compared to lobectomy patients (3.65 vs 6.2 days). Mean time to CT removal after discharge was 4.7 days (range 1–22 days) potentially saving 305 inpatient hospital days. Select patients can be discharged home with a CT with reduced postoperative LOS and without increase in major morbidity or mortality.

Horizontal panniculectomy (PAN) offers the advantage of wide exposure for hernia repair with elimination of excess skin and adiposity, at the expense of massive subcutaneous flap creation and its attendant risks. We report our experience with ventral hernia repair (VHR) with PAN compared with patients with hernia repair alone. A prospective database was reviewed retrospectively for all patients undergoing open VHR + PAN. A matched cohort of patients without PAN was used for comparison, resulting in 43 study and 43 control patients. Incidence of surgical site occurrences (SSO), surgical site infection (SSI), and recurrence were analyzed. A total of 43 patients underwent PAN + VHR with mesh. Mean body mass index was 34.3 kg/m², with 35 per cent having undergone prior bariatric surgery. Repair techniques included retromuscular (74.4%), preperitoneal (11.6%), intraperitoneal (6.9%), onlay (4.6%), and suture (2.3%). Mesh used was polypropylene (76.7%), polyester (18.6%), bioabsorbable (2.3%), and polytetrafluoroethylene (ePTFE) (2.3%). Component separation was performed in 44.2 per cent of patients. There was a significant difference in total SSO between PAN + VHR and VHR alone (46.5% vs 27.9%; P < 0.001), though the difference for individual SSOs was not significant. There was no difference in SSI between groups (16.3% vs 20.9%; P = 0.776). Mean follow-up was 11.4 months, with recurrence rate of 11.6 per cent in the PAN group and 9.3 per cent in the control group (P = 0.725). Panniculectomy at the time of VHR does not increase the incidence of SSI, though higher rates of skin necrosis and cellulitis were seen. There is no difference in recurrence. This approach is a valid option for patients with excessive abdominal panniculus requiring VHR.

Permissive hypotension is a component of damage control resuscitation that aims to provide a directed, controlled resuscitation, while countering the “lethal triad.” This principle has not been specifically studied in elderly (ELD) trauma patients (≥55 years). Given the ELD population's lack of physiologic reserve and risk of inadequate perfusion with “normal” blood pressures, we hypothesized that utilized a permissive hypotension strategy in ELD trauma patients would result in worse outcomes compared with younger patients (18–54 years). A retrospective review of National Trauma Data Bank reports from 2009 and 2010, identifying critically ill patients undergoing a “damage control laparotomy,” was performed to determine the effect of age and systolic blood pressure on outcome. Logistic regression analysis, including evaluation of an interaction between age and admission blood pressure, was performed on mortality using admission demographics, physiology, injury severity, mechanism of injury, and in-hospital complications. Although there was a higher likelihood of death with greater age, lower admission systolic blood pressure, lower Glasgow Coma Score, increased injury severity score, and acute renal failure, a synergistic effect of age and blood pressure on mortality was not identified. Permissive hypotension appears to be a possible management strategy in ELD trauma patients.

Modern adjuncts to complex, open ventral hernia repair often include component separation (CS) and/or panniculectomy (PAN). This study examines nationwide data to determine how these techniques impact postoperative complications. The National Surgical Quality Improvement Program database was queried from 2005 to 2013 for inpatient, elective open ventral hernia repairs (OVHR). Cases were grouped by the need for and type of concomitant advancement flaps: OVHR alone (OVHRA), OVHR with CS, OVHR with panniculectomy (PAN), or both CS and PAN (BOTH). Multivariate regression to control for confounding factors was conducted. There were 58,845 OVHR: 51,494 OVHRA, 5,357 CS, 1,617 PAN, and 377 BOTH. Wound complications (OVHRA 8.2%, CS 12.8%, PAN 14.4%, BOTH 17.5%), general complications (15.2%, 24.9%, 25.2%, 31.6%), and major complications (6.9%, 11.4%, 7.2%, 13.5%) were different between groups (P < 0.0001). There was no difference in mortality. Multivariate regression showed CS had higher odds of wound [odds ratio (OR) 1.7, 95% confidence interval (CI) 1.5–2.0], general (OR 1.5, 95% CI: 1.3–1.8), and major complications (OR 2.1, 95%, CI: 1.8–2.4), and longer length of stay by 2.3 days. PAN had higher odds of wound (OR 1.5, 95%, CI: 1.3–1.8) and general complications (OR 1.7, 95% CI: 1.5–2.0). Both CS and PAN had higher odds of wound (OR 2.2,95%, CI: 1.5–3.2), general (OR 2.5, 95%, CI: 1.8–3.4), and major complications (OR 2.2, 95%CI: 1.4–3.4), and two days longer length of stay. In conclusion, patients undergoing OVHR that require CS or PAN have a higher independent risk of complications, which increases when the procedures are combined.

As surgery residents graduate and begin their careers as junior attending surgeons, the question of whether a surgeon can complete a case alone still lingers. Allowing autonomy during residency answers this question. The purpose of this study was to gather input from general surgery residency program directors on how they achieve autonomy for residents in their programs. An online survey of 18 questions was sent to all general surgery residency program directors in the United States between April and June of 2013 via e-mail. Questions were asked regarding classification of autonomy, percentage of case completed by the resident independently, and in what area a resident worked with minimal supervision. Of the 202 delivered, 85 program directors were responded (42%). Seventy-eight per cent of programs classified a resident as surgeon junior whether the resident completed more than 50 per cent of the case. Most classified autonomy as either the resident completing >75 per cent of a case (41%) or completing the critical steps of a surgery (41%). Eighty-eight per cent stated that chief residents completed the majority of cases under supervision, whereas only 12 per cent stated the chief had autonomy in the operating room and also acted as teaching assistant. While, 60 per cent stated their chief residents did not work in any area of the hospital independently. Despite differences in how autonomy is defined among programs, most program directors feel that their chief residents do not achieve complete autonomy. Programs should allow their residents to work in a progressive responsibility as they progress into their fourth and fifth years of residency to achieve autonomy.

Although anti-reflux surgery has been used liberally over the past decades for the treatment of gastroesophageal reflux disease (GERD), few studies report follow-up after 10 years. This study was undertaken to report follow-up on 100 consecutive GERD patients up to 22 years after utilizing a laparoscopic fundoplication. Hundred consecutive patients undergoing laparoscopic fundoplication for GERD were prospectively followed beginning in 1992. The frequency and severity of symptoms before and after laparoscopic fundoplication were scored on a Likert scale (1 = never/none to 10 = always/very bothersome). Median data are reported. Of the 100 patients who underwent laparoscopic fundoplication for their GERD, nine were reoperations. Twenty-six patients are deceased on average 11 years after their fundoplications. Seventy-four patients are alive, with 27 patients, actively followed for 19 years after their fundoplications. At most recent follow-up, patients experienced long-term amelioration of symptom frequency and severity after fundoplication (e.g., heartburn frequency = 8–2, severity = 8–1; P < 0.01 for each). Eighty-four per cent of patients rated their symptom frequency as less than once per month. Eighty-eight per cent of patients were satisfied with their postoperative results, and 95 per cent of patients confirmed they would have the operation again knowing what they know now. Long-term follow-up documents high patient satisfaction and durable symptomatic relief up to two decades after laparoscopic fundoplication for GERD. Patients should seek this operation not only for symptomatic relief, but to mitigate the deleterious effects of long-term acid exposure and anti-acid therapy.

Reliance on CT imaging in the evaluation of low-impact blunt trauma is a major source of radiation exposure, cost, and resource utilization. This study sought to determine if torso (chest and abdomen) CT could be avoided in patients with ground level falls. This was a retrospective chart review of patients admitted to the trauma service between January 2013 and April 2014. The mechanism of injury was ground level fall or fall from sitting. Patient demographics, physical examination (PE) findings, imaging results, length of stay, and complications were reviewed. History and physical data were based on chief resident or attending documentation. A significant thoracic injury was defined as a hemothorax, a pneumothorax, greater than three rib fractures, or aortic injury. A significant abdominal injury was defined as a solid organ injury, an intra-abdominal hematoma, a hollow viscus injury, aortic injury, or a urologic injury. The trauma service evaluated 156 patients. Nine patients were excluded for intubation or Glasgow Coma Scale (GCS) < 13. Of the 147 remaining, mean age was 69 years, mean GCS was 14.8. A chest CT was obtained in 111 (76%). Eight (7%) had a significant thoracic injury. All patients with significant thoracic injury had positive examination findings. No patient with a normal PE was found to have a significant thoracic injury (negative predictive value of 100%). An abdominal CT was obtained in 86 (59%). Five (6%) were found to have a significant abdominal injury. All patients who had a significant radiographic injury had an abnormal PE (negative predictive value of 100%). In conclusion, thorough history and physical in the trauma bay allow the clinician to obtain selective torso CT imaging. Routine torso CT warrants re-evaluation in low-impact injury mechanisms as there appears to be little benefit compared with the resource utilization and expense.

Merkel cell carcinoma is a cutaneous neuroendocrine neoplasm that has been poorly studied in contemporary cohorts. Patients with Merkel cell carcinoma from 1986 to 2011 were identified in the Surveillance Epidemiology and End Results registry. A total of 5211 patients met the inclusion criteria. The mean age was 74.9 years; majority were male (61.4%) and white (94.9%). Patients were divided into two cohorts: Group 1 (1986 and 1999) and Group 2 (1999–2010). Group 2 was more likely to have Stage III disease (14.6 vs 23.3%, P < 0.001) and less likely to have Stage I/II disease (71.8 vs 65.1%, P < 0.0001). The increase in Stage III was likely secondary to increased use of sentinel lymph node biopsy. Disease-specific five-year survival for Stages I/II was 78.1 per cent and Stage III was 54 per cent. Disease-specific five-year survival was unchanged between Groups 1 and 2, 69.9 versus 66.6 per cent, respectively (P = 0.44). Both incidence and mortality significantly increased over the study period with P value for both trends <0.0001. In 1986, incidence and mortality rates per 100,000 were 0.22 and 0.03, respectively, and increased to 0.79 and 0.43 in 2011, respectively. There has been a greater than 333 per cent increase in mortality from Merkel cell carcinoma.

There has been considerable debate on the cost-effectiveness of bariatric surgery within larger population groups. Despite the recognition that morbid obesity and its comorbidities are best treated surgically, insurance coverage is not universally available. One of the more costly comorbidities of obesity is Type II diabetes mellitus (T2DM). We propose a model that demonstrates the cost-effectiveness of increasing the number of bariatric surgical operations performed on patients with T2DM in the United States. We applied published population cost estimates (2012) for medical care of T2DM to a retrospective cohort of morbidly obese patients in South Carolina. We compared differences in 10-year medical costs between those having bariatric surgery and controls. Resolution of T2DM in the bariatric cohort was assumed to be 40 per cent. Considering only the direct medical costs of T2DM, the 10-year aggregate cost savings compared with a control group is $2.7 million/1000 patients; the total (direct and indirect) cost savings is $5.4 million/1000 patients. When considering resolution of T2DM alone, increasing the number of bariatric operations for a given population leads to a substantial cost savings over a 10-year period. This study adds to the growing body of evidence suggesting that bariatric surgery is a cost-effective means of caring for the obese patient.

The Roux-en-Y gastric bypass (RYGB) has been shown to cause significant weight loss. However, fat-free mass (FFM) is often lost with this rapid weight change. It is suggested that the loss of FFM is minimized with restrictive-only procedures, such as the vertical sleeve gastrectomy (VSG), when compared with malabsorptive surgery. The purpose of the study was to determine the difference in the postoperative loss of FFM between RYBG and VSG patients. We reviewed all patients who underwent RYGB or VSG between May 2012 and January 2013. Patients were evaluated one month before their procedure and 12 months after for comparison of results. Preoperative and postoperative body analysis data were procured using a body composition analysis device. Within the study period, 33 patients underwent a RYGB procedure and 20 patients a VSG. After 12 months, RYGB patients had an average increase of 38.15 per cent in their proportion of FFM, whereas VSG patients had an average FFM increase of 22.09 per cent, a statically significant difference (P = 0.004). The RYGB helps preserve overall FFM as compared with the VSG. These findings are unexpected because malabsorptive procedures require increased protein intake, resulting in a stronger likelihood of inadequate protein intake, which may lead to protein malnutrition.

The purpose of this study was to review central line-associated blood stream infection (CLABSI) data from a surgical trauma intensive care unit to better understand patient risk factors, pathogens, and treatment interventions. We performed a retrospective review of all surgical ICU patients who met the Centers for Disease Control definition for Gram-negative CLABSI from 2006 through 2013. Demographics, pathogens, interventions, and outcomes were evaluated. A total of 40 patients were included with an average age of 49.9 ± 19 years and 72.5 per cent male. The average length of central venous line (CVL) was 11 ± 5.9 days with average time from line placement to positive culture 9.4 ± 6.8 days. Most common organisms were Enterobacter species (37.5%) with 17.8 per cent of all cultured organisms considered multidrug resistant. Piperacillin–tazobactam (67.5%) was the most commonly used antibiotic. Overall mortality rate was 22.5 per cent. A total of 11 patients who developed a recurrence did so at 10.7 ± 8 days and were similar to those without recurrence. Predominant pathogens associated with surgical trauma intensive care unit CLABSI in this study are different from those Gram-negative bacteria associated with published studies in the general hospital population. Further investigation into risk factors for infection and relapse is important to minimize such consequences. Understanding appropriate line placement and use as well as clarifying optimal duration of therapy is integral in improving outcomes.

Postoperative unplanned intubation (PUI) is a significant complication and is associated with severe adverse events and mortality. By participating in the National Surgical Quality Improvement Program (NSQIP), we learned that PUI occurred more frequently than expected at our institution. The aim of this study was to identify risk factors that are predictors of PUI at our institution. We reviewed the NSQIP data from our institution and the NSQIP national database for surgery patients from 2010 through 2013. The rate of PUI at our institution was 1.54 per cent compared with the national rate of 1.03 per cent. Perioperative risk factors were analyzed by multivariate logistic regression. Analysis of the national NSQIP database identified 14 independent risk factors for PUI. Analysis of the NSQIP data at our institution demonstrated that emergent cases, preoperative ventilator status, smoking, chronic obstructive pulmonary disease, and older age were independent risk factors. In conclusion, patients at our institution with these five risk factors were at higher risk of requiring PUI. These risk factors could be used to help identify patients at high risk and possibly help prevent postoperative respiratory failure and unplanned intubation.

Inadequate pain control after ambulatory surgery can lead to unexpected return visits to the hospital. The purpose of this study was to compare patients based on which medications they were prescribed and to see whether this affected the rate of return to the hospital. A retrospective chart review of patients who underwent ambulatory laparoscopic cholecystectomy between January 2009 and December 2013 was performed. Patients were divided into two groups based on the pain medication prescribed after surgery: Opioids and nonopioids. Patients returning to the Emergency room (ER) within seven days were evaluated. If no complication or other diagnosis was identified, the patient was considered to have returned for inadequate pain control. The two groups were statistically compared with each other using Fisher's exact chi-squared test. A total of 749 patients underwent laparoscopic cholecystectomy during the study period: 180 (25.2%) were prescribed opioids, whereas, 560 (74.8%) were prescribed nonopioids. In the nonopioid group, 14 (1.9%) returned to the ER for pain, whereas no patient in the opioid group returned for pain. This difference was statistically significant (P = 0.027). In conclusion, patients who were given opioid pain medications after ambulatory laparoscopic cholecystectomy were less likely to return to the ER for pain. This implied that opioids were better at pain control and helped avoid the costs of unnecessary ER visits. Future research should be aimed at more direct measures of pain control, as well as the role of opioids after inpatient surgery.

Acute care surgery services continue expanding to provide emergency general surgery (EGS) care. The aim of this study is to define the characteristics of the EGS population in Maryland. Retrospective review of the Health Services Cost Review Commission database from 2009 to 2013 was performed. American Association for the Surgery of Trauma-defined EGS ICD-9 codes were used to define the EGS population. Data collected included patient demographics, admission origin [emergency department (ED) versus non-ED], length of stay (LOS), mortality, and disposition. There were 3,157,646 encounters. In all, 817,942 (26%) were EGS encounters, with 76 per cent admitted via an ED. The median age of ED patients that died was 74 years versus 61 years for those that lived (P < 0.001). Twenty one per cent of ED admitted patients had a LOS > 7 days. Of 78,065 non-ED admitted patients, the median age of those that died was 68 years versus 59 years for those that lived (P < 0.001). Twenty eight per cent of non-ED admits had LOS > 7 days. In both ED and non-ED patients, there was a bimodal distribution of death, with most patients dying at LOS ≤ 2 or LOS > 7 days. In this study, EGS diagnoses are present in 26 per cent of inpatient encounters in Maryland. The EGS population is elderly with prolonged LOS and a bimodal distribution of death.