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In This Issue of JAMA Surgery
August 2013


JAMA Surg. 2013;148(8):697-699. doi:10.1001/jamasurg.2013.2200


Furman and colleagues hypothesized that there is an increased rate of neoplasms in adult patients undergoing an interval appendectomy. Through a retrospective review of 376 patients undergoing an appendectomy, they identified a 29.4% incidence of mucinous neoplasms in patients who had an interval appendectomy for complex appendicitis. The authors recommend interval appendectomy for all patients older than 40 years of age with complex appendicitis owing to the increased risk of neoplasms.

Dingeman and colleagues compare the efficacy of ultrasonography-guided bilateral rectus sheath block (BRSB) and local anesthetic infiltration (LAI) in providing postoperative analgesia after pediatric umbilical hernia repair. They conducted a prospective, observer-blinded, randomized clinical trial of children 3 to 12 years of age between 2009 and 2011, with 27 in the BRSB group and 25 in the LAI group. In the postanesthesia care unit, ultrasonography-guided BRSB is associated with lower median FACES Pain Rating Scale scores and decreased consumption of opioid and nonopioid medications compared with LAI. In a commentary, Warner discusses the cost differences between LAI and BRSB and the risks unique to BRSB.

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Winner and colleagues used the Surveillance, Epidemiology, and End Results and Medicare claims linked database to investigate the risk factors associated with the incidence of bowel obstruction in patients with stage IV colon cancer. They found that 8% of subjects developed bowel obstruction after cancer diagnosis. Increased risk was associated with proximal tumor site, high tumor grade, high nodal stage, and mucinous histology of the primary tumor. In a commentary, Krouse describes the limitations in understanding malignant bowel obstruction.

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This study was designed to evaluate the outcomes of laparoscopic vs open ventral hernia repair (VHR) in the era of laparoscopy and obesity. Lee and colleagues analyzed obese patients undergoing VHR from 2008 to 2009 from the Nationwide Inpatient Sample database. Outcome measures included intraoperative and postoperative complications, length of stay, and total hospital charges. The overall use of laparoscopic VHR for obese patients has increased significantly, which appears to be safe with a lower cost of care.

This report describes the 2-month internship boot camp curriculum based on knowledge and procedural skills for interns in a university-based general surgery residency. Krajewski and colleagues evaluate teaching faculty and nursing staff perceptions of intern performance. The clinical skills assessment scores for the study cohort after the 2-month boot camp parallel the scores seen at the conclusion of the 2 previous intern years.

The use of a thoracic approach for esophagectomy is not required and may increase pulmonary morbidity. Bhayani and colleagues used a prospective, nationwide outcomes database to compare perioperative outcomes for esophagectomies with (the Ivor Lewis and McKeown techniques) and without (transhiatal) thoracic incisions. Esophagectomies with a thoracic incision were associated with higher rates of ventilator dependence, pneumonia, and septic shock. A subgroup analysis of the Ivor Lewis and McKeown techniques did not reveal morbidity attributable to the location of the anastomosis. In a commentary, Chang asks if the surgical approach is all that matters.

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Postoperative pulmonary complications may be highly morbid and costly. With the goal of preventing adverse pulmonary events and improving clinical quality, Cassidy and colleagues designed and implemented a multidisciplinary postoperative patient care program emphasizing early mobilization, lung expansion exercises, patient and family education, and standardized nursing practice. In a before-after analysis of National Surgical Quality Improvement Program data, they found that these interventions reduced the incidence of postoperative pneumonia and unplanned intubation in their urban hospital. In a commentary, Leavitt emphasizes how simple measures can improve outcome and lower costs.

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Continuing Medical Education

Screening colonoscopy decreased colorectal cancer rates in the United States, but its influence on the outcomes of patients with colon cancer is unclear. Amri and colleagues included 1071 successive patients with colon cancer who were treated surgically at Massachusetts General Hospital to find out whether a diagnosis through screening provided any prognostic benefits. In this series, patients with screening diagnoses had significantly less invasive node-positive or metastatic tumors and better outcomes, including lower death and recurrence rates, independent of their staging.

Continuing Medical Education

Knowledge of the effects of smoking on postoperative outcomes in patients undergoing major surgery is limited. In a cohort study using data from 607 558 adult patients undergoing major surgery, Musallam and colleagues demonstrate that smoking increases the risks of 30-day mortality and 30-day arterial and respiratory events. Patients who discontinued smoking at least 1 year prior to surgery had no increased risk of mortality and a lower risk of morbidity.

Sorensen and colleagues describe the burden of unnecessary interfacility transfer of minimally injured patients to a rural level I trauma center. They report that one-quarter of transferred trauma patients meet criteria for secondary overtriage (ie, they do not require an operation, they have an Injury Severity Score of <15, and they are discharged alive within 48 hours of admission).