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In This Issue of JAMA Surgery
November 2013


JAMA Surg. 2013;148(11):993-995. doi:10.1001/jamasurg.2013.2206

Presentations From the Association of VA Surgeons Annual Meeting April 21-23, 2013, Milwaukee, Wisconsin


In 2007, the VHA prioritized expansion of screening mammography services. In this context, Kvasnovsky and coauthors performed a retrospective evaluation of breast cancer cases treated at the Baltimore Veterans Affairs (VA) Medical Center from 2000 to 2012, comparing process-of-care metrics before and after the expansion. Mammography and breast cancer volumes increased significantly (1200% and 61%, respectively). Most patients required non-VA referral for specialized services not available on-site. The time from diagnosis to definitive treatment also increased significantly (from 33 days to 51 days; P = .03), suggesting that the VHA might benefit from acquiring fully on-site breast cancer services.

Up to 25% of patients with normal lungs develop acute lung injury (ALI) secondary to mechanical ventilation with 60% to 80% progressing to acute respiratory distress syndrome (ARDS). Emr and coauthors compared rats ventilated with conventional tidal volume (n = 6) to rats ventilated with airway pressure release ventilation (APRV [n = 5]) and spontaneously breathing rats (n = 5) as controls. Rats ventilated with APRV did not develop ALI compared with rats ventilated with conventional tidal volume, as evidenced by Pao2/Fio2 ratio, histopathology, and bronchoalveolar lavage protein and surfactant data. The data suggest that APRV applied early could reduce the incidence of ARDS for patients at risk.

Continuing Medical Education

This study compares pain at the harvest site and functional changes associated with harvesting the radial artery vs the saphenous vein for coronary bypass grafting. Eleven hospitals screened 6148 patients, 751 of whom were included in the trial. Holman and colleagues made comparisons for pain at the harvest site (radial artery vs saphenous vein) and hand performance (radial artery only). The radial artery group reported significantly more pain than the saphenous vein group 3 months after operation; however, similar levels of pain were observed in the radial artery and saphenous vein groups at 12 months after operation. Group strength and manual dexterity were not changed by radial artery harvesting at 3 and 12 months after surgery.

For veterans with lung cancer, the usefulness of an endobronchial ultrasonography-guided transbronchial needle aspiration (EBUS-TBNA) biopsy for preoperative nodal staging is unclear. Cornwell et al reviewed data from 166 lung resections performed for clinical early stage lung cancer at a Veterans Affairs center. Compared with noninvasive nodal staging, EBUS-TBNA was associated with improved accuracy (93.5% vs 74.0%) and a comparable rate of nontherapeutic resection in patients with occult N2 disease (8.1% vs 12.5%).

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It is unclear how the relative use and associated perioperative mortality of on-pump and off-pump coronary artery bypass grafting (CABG) have changed with time. Bakaeen and coauthors retrospectively analyzed data from 65 097 patients who underwent isolated primary on-pump or off-pump CABG at 42 Veterans Affairs cardiac surgery centers from 1997 to 2011. The relative use of off-pump CABG peaked at 24% in 2003; for both on-pump and off-pump CABG, perioperative mortality rates decreased over time to less than 2% in 2006.

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Maximizing small intestinal mucosal function in short bowel syndrome requires not only more cells but mature functional cells. Chaturvedi and colleagues evaluated the effects of the GLP-2 analogue teduglutide on Caco-2 cell proliferation and differentiation. Although teduglutide was mitogenic, the expression of differentiation markers was inhibited by teduglutide.

The role of laparoscopy in the repair of primary ventral hernias (PVH) is unclear. Liang and colleagues performed a risk-adjusted retrospective study 532 consecutive patients who underwent an elective PVH repair at a single institution from 2000 to 2010 in order to compare the outcomes of patients who underwent laparoscopic ventral hernia repair (LVHR) with the outcomes of patients who underwent open ventral hernia repair (OVHR) using 2 separate statistical methods: case-matching and propensity score–matched multivariate analysis with internal resampling. Compared with OVHR, LVHR was significantly associated with fewer surgical site infections but more clinical cases of bulging and port-site hernia. No differences in recurrence at the site of the hernia repair were observed.

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Continuing Medical Education

Gayed and coauthors determine the effectiveness Lean Six Sigma process improvement methods applied to perioperative processes in a Veterans Affairs hospital. A retrospective review of prospectively collected data examines the cumulative impact of small process changes on length of stay and outsourcing costs for patients receiving total hip or total knee arthroplasty during the study period (n = 638). The data demonstrate a sustained reduction in length of stay associated with increased operative volume and a significant return on investment when comparing preproject and postproject data.

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