Contemporary Surgical Practice Research Articles

Commentary on “Long-term survival following partial vs. radical nephrectomy among older patients with early-stage kidney cancer.” Tan HJ, Norton, EC, Ye Z, Hafez KS, Gore JL, Miller DC, Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI: JAMA 2012;307(15):1629–35

Although partial nephrectomy is the preferred treatment for many patients with early-stage kidney cancer, recent clinical trial data, which demonstrate better survival for patients treated with radical nephrectomy, have generated new uncertainty regarding the comparative effectiveness of these treatment options. To compare long-term survival after partial vs. radical nephrectomy among a population-based patient cohort whose treatment reflects contemporary surgical practice. We performed a retrospective cohort study of Medicare beneficiaries with clinical stage T1a kidney cancer treated with partial or radical nephrectomy from 1992 to 2007. Using an instrumental variable approach to account for measured and unmeasured differences between treatment groups, we fit a 2-stage residual inclusion model to estimate the treatment effect of partial nephrectomy on long-term survival. Overall survival and kidney cancer-specific survival. Among 7,138 Medicare beneficiaries with early-stage kidney cancer, we identified 1,925 patients (27.0%) treated with partial nephrectomy and 5,213 patients (73.0%) treated with radical nephrectomy. During a median follow-up of 62 months, 487 (25.3%) and 2,164 (41.5%) patients died following partial or radical nephrectomy, respectively. Kidney cancer was the cause of death for 37 patients (1.9%) treated with partial nephrectomy, and 222 patients (4.3%) treated with radical nephrectomy. Patients treated with partial nephrectomy had a significantly lower risk of death (hazard ratio 0.54; 95% CI, 0.34-0.85). This corresponded with a predicted survival increase with partial nephrectomy of 5.6 (95% CI, 1.9-9.3), 11.8 (95% CI, 3.9-19.7), and 15.5 (95% CI, 5.0-26.0) percentage points at 2, 5, and 8 years post treatment (P <0.001). No difference was noted in kidney cancer-specific survival (hazard ratio 0.82; 95% CI, 0.19-3.49). Among Medicare beneficiaries with early-stage kidney cancer who were candidates for either surgery, treatment with partial rather than radical nephrectomy was associated with improved survival.

Blood-Sparing Heart Surgery in Critically Anaemic Patients Refusing Red Blood Cell Transfusions

Objective: The need for allogenic blood, plasma and platelets is an unresolved dilemma in contemporary surgical practice. There is increasing evidence that transfusions worsen the prognosis and should be avoided as far as possible. Patients refusing transfusion for personal reasons but requiring urgent surgery represent a challenge to maximize blood-sparing strategies. Methods: As the referral hospital for heart surgery in Jehova’s Witnesses in Central Italy, the European Hospital of Rome has developed a multimodal strategy for blood-sparing heart surgery. This strategy has been in use since January 2006 and from early 2010 the protocol has consisted of four points: high-dose preoperative erythropoietin administration; screening and optimization of platelet aggregation and serum coagulation; intraoperative and early postoperative reinfusion of blood loss; and strict control of fluid administration. Results: Since January 2006, 202 patients who refused any kind of transfusion have been operated on at our hospital, which represents around 4% of all people undergoing cardiac surgery at our hospital. All types of heart surgery were undertaken, with a prevalence of Coronary Artery Bypass Grafting (CABG), ascending aorta replacement and aortic valve replacement. Not a single unit of blood was transfused to these patients, whereas in a comparison group consisting of 4700 patients with an average of 1.1 units of blood per patient were used. The expected mortality as calculated by EURO score was 8.1%. The overall observed mortality was 3.1%, with mortality directly related to anaemia accounting for 1.6%. Conclusion: A multimodal approach to the problem of anaemia, involving optimization of preoperative haemoglobin level as far as possible in an emergency setting, optimization of coagulation and aggregation, reinfusion of lost blood intra- and perioperatively and minimizing haemodilution, allows heart surgery to be performed with a minimally increased risk in this subset of patients, casting new light on reducing the use of allogenic transfusion in the general population.

Robotic system for cervical spine surgery

In contemporary surgical clinical practice, spinal instability is often treated with mechanical stabilization techniques in order to protect the spinal cord and nerve roots. These techniques involve placing screws in defined regions of the vertebrae, typically the pedicle, where the strongest bone is found. The challenge for the surgeon is the accurate placement of screws for good mechanical purchase and to avoid damage to surrounding vital anatomical structures. This is especially critical in the cervical region, where the target bone mass is smaller and the spinal cord, nerve roots and vertebral arteries are all at risk. A robotic system enabling the surgeon to precisely place implants into the vertebrae should enhance safety and may potentially improve surgical results. We describe such a system, which consists of a compact robot positioned using a passive structure, an optical tracking system, a surgical input device and planning and navigational software. The implant trajectory in each vertebra is planned preoperatively, using fine-cut computerized tomography (CT) scans. During surgery, registration matching between the CT scan and the patient's anatomy is achieved using point to point registration, refined with a surface merge technique. Approximate robot positioning is done passively by the surgeon. Final precise instrument positioning is performed by the robot according to the planned trajectory through the target vertebra. Implants (screws) are then placed through the robot-guided working channel. Six cadaver experiments, consisting of placing transarticular (i.e. crossing the joints between the vertebrae) screws in the upper two vertebrae of the human cervical spine, were performed. Implant placement accuracy was comparable with that achieved using freehand image-guided techniques by an experienced surgeon. These results confirm the utility and applicability of the system. It is currently in redesign to improve accuracy and to render it compatible with on-line planning.

Papers that have Changed the Face of Modern Surgery

The last hundred years have resulted in more surgical innovation than in the preceding two millennia. Many surgeons probably believe that the scientific basis for contemporary surgical practice goes back to the pioneering physiologists and pathologists of the 18th and 19th centuries and while there are plenty of examples that support this notion, much of today's surgery is actually based on relatively recent scientific discovery.

Lewisy antigen (blood group 8, BG8) is a useful marker in the histopathological differential diagnosis of flat urothelial lesions of the urinary bladder

Background and aimsThe cell-surface carbohydrate Lewisy antigen (blood group 8, BG8) has recently been investigated in bladder cancer, but its role in the differential diagnosis of flat urothelial lesions of...

Venous Thromboembolism in Oral and Maxillofacial Surgery: A Review of the Literature

p d a Venous thromboembolism (VTE), defined as deep vein thrombosis (DVT), pulmonary embolism, or a combination of both, is among the most common complication in hospitalized patients, with an estimated 900,000 cases occurring annually. Pulmonary embolism resulting from DVT is the leading cause of preventable hospital deaths. In over 7 million paients discharged from acute care hospitals in the nited States, VTE was the second most common edical complication, the second most common ause of increased length of hospital stay, the third ost common cause of mortality and a significant ncrease in financial cost. Although disagreement xists regarding risk classification of thromboemboism in hospitalized individuals, most of these paients have at least 1 risk factor for VTE and almost ne half have 3 or more risk factors. With the continually expanding surgical scope and treatment of medically complex patients in the contemporary oral maxillofacial surgical practice, it is imperative to be aware of the risk factors for VTE and implement evidence-based thromboprophylaxis strategies. This article reviews classic and current literature regarding the pathophysiology, risk factors, and prophylaxis of venous thromboembolism in an effort to increase awareness of this potentially devastating complication.

The evolution of advanced techniques for the management of symptomatic aortic stenosis in the elderly population: conventional surgical management vs transcatheter valve implantation

The shifting age demographic of the adult population has affected every area of contemporary medical and surgical practice. Many more people are living well, not just into their 70s but into their 80s and beyond. Their expectations of treatment for every illness have shifted markedly upwards at the same time. Despite the decline in cases of rheumatic fever in Westernised populations in recent times, the ageing population has led to no decline in the prevalence of valvular aortic stenosis. This is now realised to be an active pro-inflammatory disease, rather than a degenerative process. Thus the condition has remained in the mainstream and continues to be responsible for considerable morbidity, hospitalisation and mortality among the elderly and very elderly. Management has always been based on the triage of cases for direct intervention to the valve by surgery. Just as expectations have risen from patients, the techniques, application and monitoring of cardiac surgery have also made huge strides forward to meet this aspiration. More and more, surgeons are routinely asked to consider procedures in frailer, more elderly patients with more severe disease and co-morbidity. Managing the stenosis is rarely the only issue confronting the operating surgeon. Attempts to provide alternatives to open valve replacement surgery on cardiopulmonary bypass have now emerged. These are based around the transcutaneous placement of a valve prosthesis. While these technologies were initially highly selective in their application, they have now reached a stage to be compared with contemporary standards of cardiac surgical practice.

Single-Access Laparoscopic Sigmoidectomy as Definitive Surgical Management of Prior Diverticulitis in a Human Patient

Single-access laparoscopic surgery should offer minimal scarring without compromising surgical outcome. It is enhanced by both innovative port technology and technical expertise learned by developing natural orifice transluminal endoscopic surgery (NOTES). Sigmoidectomy in a human via a single laparoscopic port. University hospital. Patient A 40-year-old woman with previously documented diverticular abscess. The multichannel single port (Triport; Advanced Surgical Concepts, Wicklow, Ireland) was placed at the umbilicus. The sigmoid was retracted by both intraluminal sigmoidoscopy and magnetic anchoring. Mesenteric dissection between the mid-descending colon and the colorectal junction was carried out close to the colon using a Ligasure Advance (Covidien, Valley lab, Norwalk Connecticut). The stapler anvil was passed retrogradely per ano to lie within the descending colon. A linear stapler effected proximal and distal sigmoidal transection. Magnetic attraction then delivered the in situ anvil pike into a colotomy placed adjacent to the proximal staple line. After its position was secured with an endoloop, the pike was mated with its stapler head positioned in the rectal stump. This allowed creation of a double-stapled colorectal anastomosis 10 cm from the anal verge. Specimen retrieval was performed via the umbilical port site. Extent of scarring, occurrence of surgical complications, technical adequacy, and clinical outcome. No intraoperative complications occurred during the 90-minute procedure. A total of 40 cm of sigmoid was resected. The patient convalesced without complication and went home 4 days after surgery. At the 1-month review, she was fully recovered and her single umbilical scar was well healed. With advancing surgical technology and technique, truly minimally invasive surgical procedures are feasible. Understanding of NOTES can therefore extend beyond its experimental application into contemporary surgical practice.

Does Regional Anesthesia Improve Outcome After Total Knee Arthroplasty?

Total knee arthroplasty (TKA) is amenable to various regional anesthesia techniques that may improve patient outcome. We sought to answer whether regional anesthesia decreased mortality, cardiovascular morbidity, deep venous thrombosis and pulmonary embolism, blood loss, duration of surgery, pain, opioid-related adverse effects, cognitive defects, and length of stay. We also questioned whether regional anesthesia improved rehabilitation. To do so, we performed a systematic review of the contemporary literature comparing general anesthesia and/or systemic analgesia with regional anesthesia and/or regional analgesia for TKA. To reflect contemporary surgical and anesthetic practice, only randomized, controlled trials from 1990 onward were included. We identified 28 studies involving 1538 patients. There was insufficient evidence from randomized, controlled trials alone to conclude if anesthetic technique influenced mortality, cardiovascular morbidity other than postoperative hypotension, or the incidence of deep venous thrombosis and pulmonary embolism when using thromboprophylaxis. Our review suggests there was no difference in perioperative blood loss or duration of surgery in patients who received general anesthesia versus regional anesthesia. Compared with general anesthesia and/or systemic analgesia, regional anesthesia and/or analgesia reduced postoperative pain, morphine consumption, and opioid-related adverse effects. Length of stay may be reduced and rehabilitation facilitated for patients undergoing regional anesthesia and analgesia for TKA.

Branding of Vascular Surgery

The Society for Vascular Surgery surveyed primary care physicians (PCPs) to understand how PCPs make referral decisions for their patients with peripheral vascular disease. Responses were received from 250 PCPs in 44 states. More than 80% of the respondents characterized their experiences with vascular surgeons as positive or very positive. PCPs perceive that vascular surgeons perform "invasive" procedures and refer patients with the most severe vascular disease to vascular surgeons but were more than twice as likely to refer patients to cardiologists, believing they are better able to perform minimally invasive procedures. Nevertheless, PCPs are receptive to the notion of increasing referrals to vascular surgeons. A successful branding campaign will require considerable education of referring physicians about the totality of traditional vascular and endovascular care increasingly provided by the contemporary vascular surgical practice and will be most effective at the local grassroots level.

Acquisition of laparoscopic surgical skills in a district general hospital

SummaryMinimal access surgery (MAS) has become an essential skill in contemporary gynaecological surgical practice. This survey was carried out to assess the current state of basic laparoscopic surgical training in a District Hospital setting. Potential areas of improvement were identified for increasing trainees' experience. It is hoped that this survey, albeit in a single unit, may reflect experiences in other units and thus encourage further discussion and analysis in this important component of training.

Pediatric vascular injuries: patterns of injury, morbidity, and mortality

Purpose The purpose of this study was to identify the patterns of injury and associated morbidity/mortality related to pediatric vascular trauma. Methods A retrospective review of children and adolescents treated between 1993 and 2005 was performed. Patients were identified by International Classification of Diseases, Ninth Revision codes within an institutional pediatric trauma registry. Results One hundred seventy-six patients with vascular injury were identified. Those with injuries isolated to the digits and unspecified vessels were excluded (n = 73). The remaining 103 patients were evaluable and are the basis for subsequent comparisons. Seventy-four percent of injuries occurred in male patients. The average age of the male patients was 11.3 years and that of the female patients was 9.1 years (range, 1-18 years; overall, 10.7 years). Penetrating wounds caused 68% of the injuries, followed by blunt trauma (31%) and burns (0.97%). Anatomical locations of injury included the head/neck (19.4%), torso (13.5%), and extremities (67%). Amputation was required in 11 (10.7%) patients. The average hospital length of stay of the patients was 12.1 days (range, 1-155 days). The overall mortality was 9.7%. Nonoperative management was given to 9.7% of the patients; one death caused by carotid injury occurred. Overall, 24 patients underwent arteriography, with 1 patient receiving definitive treatment in interventional radiology. Of the 103 patients, 29.1% were managed by pediatric surgeons, 38.8% were managed by extremity specialists, 17% were managed by vascular surgeons, 5.8% were managed by neurosurgeons, and 9.3% were managed by others. Conclusions Despite the available multidisciplinary diagnostic and treatment modalities at tertiary care pediatric trauma centers, traumatic vascular injuries in children and adolescents are associated with significant morbidity and mortality in contemporary surgical practice.

Improving physician awareness for blood glucose control in contemporary surgical practice

Improving physician awareness for blood glucose control in contemporary surgical practice

Update on the Gleason Grading System for Prostate Cancer

The Gleason system for prostate cancer was based on a study of 270 patients from the Minneapolis Veterans Administration Hospital in 1966-1967. In 1974, Gleason and the Veterans Administrative Cooperative Urological Research Group expanded this study to 1032 men. These studies formed the basis of the Gleason grading system, which is now endorsed as the primary grading system for prostate cancer by the World Health Organization, the Armed Forces Institute of Pathology Fascicle on prostate cancer, the Association of Directors of Anatomic and Surgical Pathology, and the College of American Pathologists. In the nearly 40 years since its inception, several aspects about prostate cancer and its management have changed, most notably serum prostate-specific antigen, transrectal ultrasonography, 18-gauge needle biopsy sampling, immunohistochemistry for the diagnosis of cancer, and radical prostatectomy and radiation therapy as primary treatment modalities. Several aspects of the disease, and consequently the reporting needs, have changed such as reporting cancer on multiple cases in needle biopsies, multiple nodules in prostatectomy, tertiary patterns, variants and variations in prostate cancer. The application of the Gleason system, therefore, has varied considerably in contemporary surgical pathology practice. An International Consensus Conference attended by 80 urologic pathologists from 20 countries was convened to discuss clarifications and modifications to the Gleason system. This article serves as a brief overview and summary of the proceedings that have been published in detail in recent literature.

The principles and technique of resection of soft parts for sarcoma. 1958.

The principles and technique of resection of soft parts for sarcoma. 1958.

A multicenter prospective analysis of 14,000 carotid endarterectomies

Abstract Introduction: The National Surgical Quality Improvement Program (NSQIP) is a prospectively gathered risk-adjusted database which randomly samples data from the Veterans Affairs (VA) health system, and 14 participating private hospitals. Utilizing the NSQIP database, this study was undertaken to identify the incidence of morbidity and mortality in the contemporary surgical practice of carotid endarterectomy (CEA). Methods: NSQIP data were examined for all patients under going CEA as a primary operation during the 2000–2003 period. This database captures over 150 variables utilizing trained nurse reviewers. Multivariate analysis was undertaken to identify variables associated with a composite of 30-day mortality, stroke or cardiac event. Results: 13,811 patients comprised the study population, 95% were male and 91% were from the VA sector. The average age was 68.5 ± 0.1 years, and 57.9% of the patients were symptomatic. The overall mortality, stroke and cardiac event rates were 2.1%, 1.7% and 1.1% respectively, giving a composite outcome of 4.0%. The combined stroke and death rate was 3.4%. The following variables impacted the composite outcome: age, pack-years of smoking, renal insufficiency, diabetes, previous stroke, history of TIA, hypoalbuminemia and ASA class. Conclusions: The NSQIP database provides a powerful tool to examine the outcome of CEA in current surgical practice. Identification of variables portending a poor outcome may be helpful in selecting patients for non-surgical interventional therapies. Given that the majority of the patients in this study were symptomatic, the results compare favorably to the randomized CEA trials.

Ruptured thoracoabdominal aortic aneurysm treatment in the United States: 1988 to 1998.

Thoracoabdominal aortic aneurysm (TAAA) rupture usually results in death. The outcome remains poor for patients who reach the operating room. The objective of this investigation was to define contemporary surgical experience with ruptured TAAA in the United States. Patients and methods Clinical data derived from the Nationwide Inpatient Sample on patients who underwent repair of a ruptured TAAA from 1988 to 1998 were analyzed. Age, sex, race, nature of admission, comorbid conditions, and provider volume were abstracted from the database. In-hospital mortality, postoperative complications, and length of stay were the principal outcome measures. Three hundred twenty-one patients were identified for the study. Mean age was 71.5 years; men outnumbered women (63% vs 37%). Crude overall surgical mortality was 53.8% and did not improve over time. Operative mortality was most likely (51%) to occur within the first 24 hours postoperatively. Median length of stay for surviving patients was 16 days. Renal failure (28%) and cardiac complications (18%) were the most common complications. In a logistic regression model, age greater than 77 years was predictive of death (odds ratio [OR], 2.5; P =.005), and nonwhite race appeared protective (OR, 0.53; P =.013). Mortality after surgical treatment of ruptured TAAA is high. Surviving patients experience many postoperative complications and have lengthy hospital stays. Given the lack of significant improvement in contemporary surgical practice, new techniques of repair deserve the attention of clinicians.

Does type of surgeon matter in rectal cancer surgery? Evidence, guideline consensus and surgeons' views.

One of the most obvious but controversial trends in contemporary surgical practice is that of subspecialization. There is a lack of definitive evidence that subspecialization improves cancer outcomes largely because previous research is compromised by confounding variables of referral practice, lack of standardized definitions of surgical skills and selection bias. Randomized controlled trials of generalized versus subspecialist surgical care are unlikely ever to be performed. The present study of surgeons' views about the role of subspecialization in the care of colorectal cancer patients demonstrates partisan reactions among surgeons themselves (89% response rate). Results of national audits will contribute to wider debate about surgical subspecialization in colorectal cancer.

Single coronary artery and complete transposition of the great arteries: a technical challenge resolved?

Background. The origin of the coronary arteries from a single aortic sinus remains a rare congenital anomaly, once regarded as having little clinical significance. Contemporary surgical practice, however, frequently demands precise coronary reimplantation. In this article we emphasize a prophylactic surgical technique found especially helpful in the repair of d-transposition of the great arteries (d-TGA)/single coronary artery.Methods. We reviewed the institutional cardiac registry.Results. Since 1985, 398 neonates with d-TGA were repaired with the arterial switch procedure. A mortality rate of 38% was encountered in “simple” d-TGA (n = 174)/single coronary (2.9% left facing sinus (IRLCx), 7.5% right facing sinus (IIRLCx)) and 41% in neonates with d-TGA (n = 224)/single coronary (3.6% IRLCx, 12% IIRLCx). During the past 3.5 years the surgical mortality rate of neonates (n = 6) treated with origin of the coronary arteries from a single aortic sinus has dropped to 0%.Conclusions. The surgical repair of d-TGA/single coronary artery continues to trouble surgeons. The implantation of a well-mobilized coronary “button” into a previously anastomosed neoaorta remains a key prophylactic technique in the achievement of good technical results.

Tetralogy of Fallot: Late outcome after repair and surgical implications.

Cardiac surgery has transformed the outcome for patients with tetralogy of Fallot. Repair has conveyed excellent long-term results with most patients remaining well and leading normal lives. However, there are problems with late morbidity and mortality primarily due to right ventricular dysfunction, exercise intolerance, arrythmia, and sudden cardiac death. There has been a dynamic shift in our surgical approach to managing patients with tetralogy over the past 5 decades. This in part accounts for persisting difficulties in predicting late outcome for evry single patient with repaired tetralogy of Fallot. There are, however, several confounding variables, influencing long-term outcome for these patients, namely the underlying anatomical substrate, age at repair, surgical approach to repair, and residual hemodynamic abnormalities. It is gratifying to see that recent knowledge accumulated from long-term follow-up studies is influencing contemporary surgical practice. Individualized strategies aiming to minimize the potential for free pulmonary regurgitation, and the long-term detrimental effects associated with it, need to continue to develop. Preservation of right ventricular and pulmonary valve function combined with early restoration of normal pulmonary blood flow are likely to convey an even better long-term outlook for these patients. Further follow-up studies with assessment of bi-venticular function, however, are needed in both our older and contemporary cohorts with repaired tetralogy of Fallot. Copyright 2000 by W.B. Saunders Company