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This Month in
May 2003

This Month in Archives of Surgery

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Arch Surg. 2003;138(5):469. doi:10.1001/archsurg.138.5.469

If you need confirmation of the effectiveness of sentinel node biopsy in avoiding a full axillary dissection and its consequences, I suggest you read about the low recurrence rate (1 axillary recurrence in 685 node-negative women staged by sentinel node biopsy) noted in this study by Blanchard et al. The use of immunohistochemical analysis if micrometastasis is found in the sentinel node remains a controversial topic; more information and studies with longer follow-up are needed.

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Several articles address problem areas of bariatric surgery, a current hot topic. The first of theseArticle relates to the rate of leakage complicating Roux-en-Y gastric bypass. Of 400 consecutive patients undergoing this operation, 21 (5.25%) developed leaks. Thirteen of these leaks were at the gastrojejunal anastomosis (mean time to diagnosis, 7.0 days), and 5 required reexploration. Four patients developed leaks at the jejunojejunal anastomosis (mean time to diagnosis, 2.0 days), and all required reoperation. Four additional patients were noted to have leaks in various other areas (mean time to diagnosis, 3.5 days), and half required reoperation. Thus, enteric leakage is a very significant complication of this operation, whether it is done openly or laparoscopically. The second of these articles, by Perugini et al,Article relates to the identification of factors predictive of complication and suboptimal weight loss in a series of patients undergoing laparoscopic Roux-en-Y gastric bypass. Of 188 consecutive individuals with morbid obesity who underwent this operation, 50 (27%) developed complications that required an invasive therapeutic intervention. Multivariate analysis revealed that surgeon experience (learning curve of at least 100 cases), sleep apnea, and hypertension were most likely to be associated with complications. Diabetes mellitus was negatively correlated with the percentage of excess body weight lost at 1 year.

Papers of the Western Surgical Association

Two articles on trauma deserve your attention.

Assessment of Volume of Hemorrhage and Outcome From Pelvic Fractures

Blackmore et al from the Harborview Injury Prevention and Research Center, Seattle, Wash, reviewed the records of 759 consecutive nonreferral blunt trauma patients who sustained pelvic fracture. Overall mortality was 13%. Blood transfusion was given to 55% of patients, and 34% received 6 or more units in the first 72 hours. In general, a computed tomographic scan was performed within 48 hours of presentation and was reviewed by a single board-certified radiologist who measured the volume of extraperitoneal blood in the pelvis. Angiography was performed, and 15% of patients had arterial injury. The volume of extraperitoneal pelvic hemorrhage was an important marker for the presence of pelvic arterial injury. Subjects with low pelvic hemorrhage volumes (<200 mL) had only a 5% probability of arterial injury, whereas those with high volumes (>500 mL) had a 45% probability of injury to arterial vasculature—a guide for trauma surgeons.

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High Success With Nonoperative Management of Blunt Hepatic Trauma: The Liver Is a Sturdy Organ

Over a 26-month period, 78 consecutive unselected patients with liver injury were followed up prospectively by Velmahos et al from the University of Southern California, Los Angeles. Except in patients who were unstable or had signs of hollow visceral trauma requiring operation, nonoperative management was offered irrespective of the magnitude of liver injury. In total, 85% of liver injuries did not bleed significantly. The authors conclude that nonoperative management of liver injury is very safe and effective.

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Symptoms Are a Poor Indicator of Reflux Status After Fundoplication for Gastroesophageal Reflux Disease: Role of Esophageal Function Tests

As a result of surveying 124 patients who developed foregut symptoms after laparoscopic fundoplication by esophageal manometry and pH monitoring, Galvani et al found that, with the exception of regurgitation, symptoms were an unreliable index of the need for medication or reoperation.

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