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October 2016 - July 1920

Decade

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Issue

June 1, 2011, Vol 146, No. 6, Pages 630-765

Original Article

Angiographic Intervention in Patients With a Suspected Visceral Artery Pseudoaneurysm Complicating Pancreatitis and Pancreatic Surgery

Abstract Full Text
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Arch Surg. 2011;146(6):647-652. doi:10.1001/archsurg.2011.11
ObjectiveTo assess the clinical effectiveness of angiography and transcatheter intervention in patients suspected of visceral artery pseudoaneurysm complicating pancreatitis and pancreatic surgery.DesignRetrospective study.SettingUniversity hospital.PatientsA total of 51 patients who underwent mesenteric angiography for a suspected visceral artery pseudoaneurysm following pancreatitis or pancreatic surgery from 1978 to 2010 were included in this study. There were 39 men and 12 women. The mean age was 66 years (range, 21-89 years) at the time of the angiography. Data on patients' demographics, medical history, angiographic findings, treatment, and outcomes were recorded. Of these 51 patients, 27 had acute pancreatitis, 22 had pancreatic cancer, and 2 experienced pancreatic trauma. Embolization was performed for patients with a pseudoaneurysm. One patient was treated with a stent graft.Main Outcome MeasuresThe technical success rate of the intervention, the 24-hour and 30-day rebleeding rates, and the 24-hour and 30-day mortality rates were calculated. A multivariate analysis was performed to determine the factors associated with survival following angiography.ResultsOf the 51 patients studied, 23 had a visceral artery pseudoaneurysm involving the gastroduodenal (7 patients), hepatic (5 patients), splenic (5 patients), and other arteries (7 patients). The technical success rate of the intervention (ie, embolization or exclusion with a Stent graft) was 100%. The 24-hour and 30-day rebleeding rates were 4% and 17%, respectively. The 24-hour and 30-day mortality rates were 0% and 9%, respectively. For the 27 patients who had a negative angiographic finding, the 24-hour and 30-day rebleeding rates were 0% and 11%, respectively, and the 24-hour and 30-day mortality rates were 4% and 21%, respectively. The requirement of a large number of blood products prior to angiography was associated with poor outcome.ConclusionEmbolization was highly effective in treating a pseudoaneurysm complicating pancreatitis and pancreatic surgery. The hemodynamic status at the time of angiography determines overall survival.

The Vulnerable Stage of Dedicated Research Years of General Surgery ResidencyResults of a National Survey

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Arch Surg. 2011;146(6):653-658. doi:10.1001/archsurg.2011.12
ObjectiveTo characterize the demographics and attitudes of US general surgery residents performing full-time research.DesignCross-sectional national survey administered after the 2008 American Board of Surgery In-Service Training Examination.SettingTwo hundred forty-eight residency programs.ParticipantsGeneral surgery residents.InterventionSurvey administration.Main Outcomes MeasuresA third of categorical general surgery residents interrupt residency to pursue full-time research. To our knowledge, there exist no comprehensive reports on the attitudes of such residents.ResultsFour hundred fifty residents performing full-time research and 864 postgraduate year 3 (PGY-3) clinical residents completed the survey. Thirty-eight percent of research residents were female, 53% were married, 30% had children, and their mean age was 31 years. Residency programs that were academic, large, and affiliated with fellowships had proportionally more research residents compared with other programs. Research and PGY-3 residents differed (P < .05) on 10 survey items. Compared with PGY-3 residents, research residents were less likely to feel they fit well in their program (86% vs 79%, respectively), that their program had support structures if they struggled (72% vs 64%), or that they could turn to faculty (71% vs 65%). They were more likely to feel training was too long (21% vs 30%) and that surgeons must be specialty trained (55% vs 63%). In multivariate analyses, research residents believed surgical training was too long (odds ratio, 1.36) and they fit in less well at their programs (odds ratio, 0.71) (P < .05).ConclusionsCompared with PGY-3 residents, research residents report less satisfaction with important aspects of training, suggesting this is a vulnerable stage. Interventions could be targeted to facilitate support and better integration into the mainstream of surgical education.

The Vulnerable Stage of Dedicated Research Years of General Surgery ResidencyResults of a National Survey

Abstract Full Text
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Arch Surg. 2011;146(6):653-658. doi:10.1001/archsurg.2011.12
ObjectiveTo characterize the demographics and attitudes of US general surgery residents performing full-time research.DesignCross-sectional national survey administered after the 2008 American Board of Surgery In-Service Training Examination.SettingTwo hundred forty-eight residency programs.ParticipantsGeneral surgery residents.InterventionSurvey administration.Main Outcomes MeasuresA third of categorical general surgery residents interrupt residency to pursue full-time research. To our knowledge, there exist no comprehensive reports on the attitudes of such residents.ResultsFour hundred fifty residents performing full-time research and 864 postgraduate year 3 (PGY-3) clinical residents completed the survey. Thirty-eight percent of research residents were female, 53% were married, 30% had children, and their mean age was 31 years. Residency programs that were academic, large, and affiliated with fellowships had proportionally more research residents compared with other programs. Research and PGY-3 residents differed (P < .05) on 10 survey items. Compared with PGY-3 residents, research residents were less likely to feel they fit well in their program (86% vs 79%, respectively), that their program had support structures if they struggled (72% vs 64%), or that they could turn to faculty (71% vs 65%). They were more likely to feel training was too long (21% vs 30%) and that surgeons must be specialty trained (55% vs 63%). In multivariate analyses, research residents believed surgical training was too long (odds ratio, 1.36) and they fit in less well at their programs (odds ratio, 0.71) (P < .05).ConclusionsCompared with PGY-3 residents, research residents report less satisfaction with important aspects of training, suggesting this is a vulnerable stage. Interventions could be targeted to facilitate support and better integration into the mainstream of surgical education.

Early vs Interval Appendectomy for Children With Perforated Appendicitis

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Arch Surg. 2011;146(6):660-665. doi:10.1001/archsurg.2011.6
ObjectiveTo compare the effectiveness and adverse event rates of early vs interval appendectomy in children with perforated appendicitis.DesignNonblinded randomized trial.SettingA tertiary-referral urban children's hospital.PatientsA total of 131 patients younger than 18 years with a preoperative diagnosis of perforated appendicitis.InterventionsEarly appendectomy (within 24 hours of admission) vs interval appendectomy (6-8 weeks after diagnosis).Main Outcome MeasuresTime away from normal activities (days). Secondary outcomes included the overall adverse event rates and the rate of predefined specific adverse events (eg, intra-abdominal abscess, surgical site infection, unplanned readmission).ResultsEarly appendectomy, compared with interval appendectomy, significantly reduced the time away from normal activities (mean, 13.8 vs 19.4 days; P < .001). The overall adverse event rate was 30% for early appendectomy vs 55% for interval appendectomy (relative risk with interval appendectomy, 1.86; 95% confidence interval, 1.21-2.87; P = .003). Of the patients randomized to interval appendectomy, 23 (34%) had an appendectomy earlier than planned owing to failure to improve (n = 17), recurrent appendicitis (n = 5), or other reasons (n = 1).ConclusionsEarly appendectomy significantly reduced the time away from normal activities. The overall adverse event rate after early appendectomy was significantly lower compared with interval appendectomy.Trial Registrationclinicaltrials.gov Identifier: NCT00435032

Neuronal Differentiation of Human Adipose Tissue–Derived Stem Cells for Peripheral Nerve Regeneration In Vivo

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Arch Surg. 2011;146(6):666-674. doi:10.1001/archsurg.2011.148
ObjectiveTo evaluate the ability of a tissue-engineered nerve construct composed of a nerve guidance channel and neurally differentiated human adipose tissue–derived stem cells (hASCs) to enhance peripheral nerve regeneration in a rat sciatic nerve model.DesignA 13-mm sciatic nerve gap was bridged with silastic conduits in 64 athymic nude rats, and differentiated hASCs were implanted into the nerve gap. The effect of repetitive renewal of differentiation medium on days 14 and 28 was further tested. Adequate negative controls and isograft controls were used.SettingAcademic research.PatientsThe hASCs were isolated from human adipose tissue of patients undergoing liposuction procedures.Main Outcome MeasuresDirect measurements of nerve function included sciatic functional index score, extensor postural thrust, and sensory evaluation. Indirect measurements included gastrocnemius and soleus muscle atrophy. Histomorphometric evaluation included the number and diameter of axons and fibers, nerve fiber density, myelin thickness, g-ratio (axon diameter–total fiber diameter ratio), and myelin thickness–axon diameter ratio.ResultsThe use of hASCs demonstrated significantly improved functional recovery as measured by the sciatic functional index, extensor postural thrust, sensory evaluation, and gastrocnemius and soleus muscle weight after 14 days and 1, 2, 3, and 4 months. Groups with their medium renewed also demonstrated further enhanced functional recovery compared with their counterparts that did not have their medium renewed.ConclusionThis tissue-engineered nerve construct using hASCs was able to improve functional recovery during the first 4 months, comparable with nerve isografts.

Impact of Antiviral Therapy on the Survival of Patients After Major Hepatectomy for Hepatitis B Virus–Related Hepatocellular Carcinoma

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Arch Surg. 2011;146(6):675-681. doi:10.1001/archsurg.2011.125

Comparative Analysis of Resection and Liver Transplantation for Intrahepatic and Hilar CholangiocarcinomaA 24-Year Experience in a Single Center

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Arch Surg. 2011;146(6):683-689. doi:10.1001/archsurg.2011.116

Endoscopic Excision of Large Colorectal Polyps as a Viable Alternative to Surgical Resection

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Arch Surg. 2011;146(6):690-696. doi:10.1001/archsurg.2011.126

Endoscopic Excision of Large Colorectal Polyps as a Viable Alternative to Surgical Resection

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Arch Surg. 2011;146(6):690-696. doi:10.1001/archsurg.2011.126
ObjectiveTo determine the outcome of endoscopic excision of large colorectal polyps.DesignRetrospective medical record review.SettingKaiser Permanente, a large health care maintenance organization.PatientsOne hundred four consecutive patients with large colorectal lesions deemed not amenable to endoscopic resection at initial colonoscopy and referred for surgical resection.InterventionEndoscopic excision under intravenous sedation by 2 interventional endoscopists.Main Outcomes MeasuresEndoscopic success (the ability to completely eradicate the original or recurrent lesion endoscopically at the index procedure or at reintervention), procedure-related complications, disease recurrence, endoscopic reintervention, and surgical intervention.ResultsWe included 48 men (46%) and 56 women (54%) with a mean age of 67 (range, 29-92) years for analysis. Anatomic distribution of the lesions included the colon (68%) and rectum (32%). Thirty-nine patients (37%) had carcinoma. The median size of the lesions was 3.0 (range, 1-9) cm. The endoscopic success rate was 83% and was highest in patients with noncarcinoma histologic findings compared with carcinoma (P < .001). The morbidity rate was 7%, and all complications occurred in the ascending colon (P = .06). Endoscopic reintervention occurred in 25 of 92 patients (27%). Surgical intervention was undertaken in 14% of all patients. During a mean follow-up of 14 (median, 12) months, recurrent disease was noted in 10 of 86 patients (12%) and occurred more frequently in rectal lesions (P = .002). All recurrences were eradicated endoscopically.ConclusionsEndoscopic excision of large colorectal polyps is a viable alternative to surgical resection in a select group of patients and can be performed safely with a good success rate.

Hilar CholangiocarcinomaTumor Depth as a Predictor of Outcome

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Arch Surg. 2011;146(6):697-703. doi:10.1001/archsurg.2011.122

Effect of Incomplete Parathyroidectomy Preserving Entire Parathyroid Glands on Renal Graft Function

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Arch Surg. 2011;146(6):704-710. doi:10.1001/archsurg.2011.138

Minimally Invasive Esophagectomy Provides Equivalent Oncologic Outcomes to Open Esophagectomy for Locally Advanced (Stage II or III) Esophageal Carcinoma

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Arch Surg. 2011;146(6):711-714. doi:10.1001/archsurg.2011.146

Early Postoperative Outcomes After Pancreaticoduodenectomy in the Elderly

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Arch Surg. 2011;146(6):715-723. doi:10.1001/archsurg.2011.115
BackgroundSingle-institution case series suggest that elderly patients do as well as younger patients after pancreaticoduodenectomy.ObjectivesTo compare morbidity and mortality after pancreaticoduodenectomy in patients older than 70 years vs younger patients.HypothesisElderly patients have worse 30-day outcomes.DesignRetrospective cohort study.SettingAmerican College of Surgeons–National Surgical Quality Improvement Program hospitals.PatientsAll patients who had a pancreaticoduodenectomy from January 1, 2005, to December 31, 2007, were identified.MethodsMultiple logistic regression models were developed to assess the association between age and 30-day outcomes.Main Outcome MeasuresThirty-day postoperative morbidity and mortality.ResultsOf the 2610 patients identified, 977 (37.4%) were elderly and 1633 (62.6%) were younger. Overall morbidity was 36.5%. Elderly patients had a higher likelihood of developing at least 1 morbidity (surgical site infection, wound disruption, outpatient pneumonia, unplanned intubation, pulmonary embolism, prolonged ventilation, acute renal failure, urinary tract infection, stroke, cardiac arrest, deep venous thrombosis, sepsis, or return to the operating room) compared with that of younger patients (40.7% vs 34.0%; odds ratio, 1.27; 95% confidence interval, 1.06-1.51; P = .01). Overall mortality was 2.7%. Elderly patients had a higher likelihood of mortality compared with that of younger patients (4.3% vs 1.7%; adjusted odds ratio, 2.01; 95% confidence interval, 1.18-3.43; P = .01). In patients who had at least 1 morbidity, mortality was 10.1% in the elderly compared with 4.1% in the younger patients (P = .002).ConclusionsAdvanced age is independently associated with morbidity and death following pancreaticoduodenectomy. In addition, the elderly have a higher mortality after a complication compared with that of younger patients, suggesting that advanced age may have a role in “failure to rescue.”

Pancreatic Endocrine Tumors With Major Vascular Abutment, Involvement, or Encasement and Indication for Resection

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Arch Surg. 2011;146(6):724-732. doi:10.1001/archsurg.2011.129

Early-Stage Gallbladder Cancer in the Surveillance, Epidemiology, and End Results DatabaseEffect of Extended Surgical Resection

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Arch Surg. 2011;146(6):734-738. doi:10.1001/archsurg.2011.128

Incidence and Risk Factors of Venous Thromboembolism in Colorectal SurgeryDoes Laparoscopy Impart an Advantage?

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Arch Surg. 2011;146(6):739-743. doi:10.1001/archsurg.2011.127
Commentary

PPE, OPPE, and FPPEComplying With the New Alphabet Soup of Credentialing

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Arch Surg. 2011;146(6):642-644. doi:10.1001/archsurg.2011.136
Review

Bariatric Surgery as a Novel Treatment for Type 2 Diabetes MellitusA Systematic Review

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Arch Surg. 2011;146(6):744-750. doi:10.1001/archsurg.2011.134
Special Feature

Image of the Month—Quiz Case

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Arch Surg. 2011;146(6):755-755. doi:10.1001/archsurg.2011.124-a

Image of the Month—Diagnosis

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Arch Surg. 2011;146(6):756-756. doi:10.1001/archsurg.2011.124-b

Image of the Month—Quiz Case

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Arch Surg. 2011;146(6):757-757. doi:10.1001/archsurg.2011.137-a

Image of the Month—Diagnosis

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Arch Surg. 2011;146(6):758-758. doi:10.1001/archsurg.2011.137-b

Image of the Month—Quiz Case

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Arch Surg. 2011;146(6):759-759. doi:10.1001/archsurg.2011.140-a

Image of the Month—Diagnosis

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Arch Surg. 2011;146(6):760-760. doi:10.1001/archsurg.2011.140-b
Research Letters

Dynamic Parietal Closure: Initial Experience of an Original Parietal Closure Procedure for Treatment of Abdominal Wound Dehiscence

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Arch Surg. 2011;146(6):762-764. doi:10.1001/archsurg.2011.112
Correspondence

“Unnecessary” Postmastectomy Radiation Therapy

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Arch Surg. 2011;146(6):764-765. doi:10.1001/archsurg.2011.131

“Unnecessary” Postmastectomy Radiation Therapy—Reply

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Arch Surg. 2011;146(6):765-765. doi:10.1001/archsurg.2011.132
From JAMA

Better Than the Lungs We Are Taking Out

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Arch Surg. 2011;146(6):645-646. doi:10.1001/archsurg.2011.123
Resident's Forum

An Alternative Pancreatic Anastomosis Following Pancreaticoduodenectomy

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Arch Surg. 2011;146(6):752-754. doi:10.1001/archsurg.2011.133
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