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June 2019 - July 1920

Decade

Year

Issue

March 1, 2011, Vol 146, No. 3, Pages 251-370

Original Article

Robotic-Assisted Major Pancreatic Resection and Reconstruction

Abstract Full Text
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Arch Surg. 2011;146(3):256-261. doi:10.1001/archsurg.2010.246
HypothesisRobotic-assisted pancreatic resection and reconstruction are safe and can reproduce perioperative results seen in open surgery.DesignSingle-institution retrospective review.SettingTertiary care center.PatientsPatients undergoing completed robotic-assisted pancreatic resection and reconstruction at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, between October 3, 2008, and February 26, 2010.Main Outcome MeasuresPrimary pathology, operative time, operative blood loss, perioperative blood transfusions, pancreatic fistula, 90-day morbidity and mortality, and readmission rate.ResultsThirty patients with a median age of 70 years (range, 32-85 years) underwent completed robotic-assisted pancreatic resection and reconstruction. Procedures were robotic-assisted non-pylorus-preserving pancreaticoduodenectomy (n = 24), robotic-assisted central pancreatectomy (n = 4), and the robotic-assisted Frey procedure (n = 2). The median operative time was 512 minutes (range, 327-848 minutes). The median blood loss was 320 mL (range, 50-1000 mL), with a median length of hospital stay of 9 days (range, 4-87 days). The final diagnoses included periampullary adenocarcinoma (n = 7), pancreatic ductal adenocarcinoma (n = 6), pancreatic neuroendocrine tumor (n = 5), intraductal papillary mucinous neoplasm (n = 4), mucinous cystic neoplasm (n = 3), serous cystic adenoma (n = 2), chronic pancreatitis (n = 2), and solid pseudopapillary neoplasm (n = 1). There was 1 postoperative death. The overall pancreatic fistula rate was 27% (n = 8). The clinically significant pancreatic fistula rate (International Study Group on Pancreatic Fistula grades B and C) was 10% (n = 3). Clavien grade III and IV complications occurred in 7 patients (23%), while Clavien grade I and II complications occurred in 8 patients (27%).ConclusionsRobotic-assisted complex pancreatic surgery can be performed safely in a high-volume pancreatic tertiary care center with perioperative outcomes comparable to those of open surgery. Advances in robotic technology and increasing experience may improve long operative times.

Evaluating an Evidence-Based Bundle for Preventing Surgical Site Infection: A Randomized Trial

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Arch Surg. 2011;146(3):263-269. doi:10.1001/archsurg.2010.249
ObjectiveTo determine if an evidence-based practice bundle would result in a significantly lower rate of surgical site infections (SSIs) when compared with standard practice.DesignSingle-institution, randomized controlled trial with blinded assessment of main outcome. The trial opened in April 2007 and was closed in January 2010.SettingVeterans Administration teaching hospital.PatientsPatients who required elective transabdominal colorectal surgery were eligible. A total of 241 subjects were approached, 211 subjects were randomly allocated to 1 of 2 interventions, and 197 were included in an intention-to-treat analysis.InterventionsSubjects received either a combination of 5 evidenced-based practices (extended arm) or were treated according to our current practice (standard arm). The interventions in the extended arm included (1) omission of mechanical bowel preparation; (2) preoperative and intraoperative warming; (3) supplemental oxygen during and immediately after surgery; (4) intraoperative intravenous fluid restriction; and (5) use of a surgical wound protector.Main Outcome MeasureOverall SSI rate at 30 days assessed by blinded infection control coordinators using standardized definitions.ResultsThe overall rate of SSI was 45% in the extended arm of the study and 24% in the standard arm (P = .003). Most of the increased number of infections in the extended arm were superficial incisional SSIs (36% extended arm vs 19% standard arm; P = .004). Multivariate analysis suggested that allocation to the extended arm of the trial conferred a 2.49-fold risk (95% confidence interval, 1.36-4.56; P = .003) independent of other factors traditionally associated with SSI.ConclusionsAn evidence-based intervention bundle did not reduce SSIs. The bundling of interventions, even when the constituent interventions have been individually tested, does not have a predictable effect on outcome. Formal testing of bundled approaches should occur prior to implementation.Trial Registrationclinicaltrials.gov Identifier: NCT00953784

Surgeons' Stress From Surgery and Night Duty: A Multi-institutional Study

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Arch Surg. 2011;146(3):271-278. doi:10.1001/archsurg.2010.250
ObjectiveTo examine the stress experienced by surgeons in response to surgery and night duty.DesignAnalyses were done by subjective questionnaires and an objective urine analysis.SettingOne university hospital and 15 community/public hospitals in Kitakyushu City, Japan.ParticipantsSixty-six Japanese surgeons.Main Outcome MeasuresScores on the NASA Task Load Index and Stress Arousal Checklist and urine biopyrin levels.ResultsThe Task Load Index score significantly increased in association with the duration of surgery and the amount of surgical blood loss. Urine biopyrin levels significantly increased with the duration of surgery. Night duty significantly decreased sleep time and significantly increased urine biopyrin levels. Stress Arousal Checklist Arousal Scale scores significantly decreased the morning after night duty and the evening after the end of the following day shift.ConclusionSurgery was associated with stress on surgeons and night duty influenced the arousal of the surgeons during the day shift following night duty.

An Optimal Algorithm for Intraoperative Parathyroid Hormone Monitoring

Abstract Full Text
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Arch Surg. 2011;146(3):280-285. doi:10.1001/archsurg.2011.5

Racial Disparities in Survival After Lung Transplantation

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Arch Surg. 2011;146(3):286-293. doi:10.1001/archsurg.2011.4

Motor Subtypes of Postoperative Delirium in Older Adults

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Arch Surg. 2011;146(3):295-300. doi:10.1001/archsurg.2011.14

Trends in Central Line–Associated Bloodstream Infections in a Trauma-Surgical Intensive Care Unit

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Arch Surg. 2011;146(3):302-307. doi:10.1001/archsurg.2011.9

Epidemiological Similarities Between Appendicitis and Diverticulitis Suggesting a Common Underlying Pathogenesis

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Arch Surg. 2011;146(3):308-314. doi:10.1001/archsurg.2011.2

Cyclical Increase in Diverticulitis During the Summer Months

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Arch Surg. 2011;146(3):319-323. doi:10.1001/archsurg.2011.27

Airway Pressure Release Ventilation and Successful Lung Donation

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Arch Surg. 2011;146(3):325-328. doi:10.1001/archsurg.2011.35

Endoscopic Retrograde Cholangiopancreatography Prior to Laparoscopic Cholecystectomy: A Common and Potentially Hazardous Technique That Can Be Avoided

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Arch Surg. 2011;146(3):329-333. doi:10.1001/archsurg.2011.30

Cessation of Clopidogrel Before Major Abdominal Procedures

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Arch Surg. 2011;146(3):334-339. doi:10.1001/archsurg.2011.23

Impact of Surgeon Experience on 5-Year Outcome of Laparoscopic Nissen Fundoplication

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Arch Surg. 2011;146(3):340-346. doi:10.1001/archsurg.2011.32
Invited Critique

The Advent of Laparoscopic Pancreatic Surgery Using the Robot: Comment on “Robotic-Assisted Major Pancreatic Resection and Reconstruction”

Abstract Full Text
Arch Surg. 2011;146(3):261-262. doi:10.1001/archsurg.2010.247

Too Much of a Good Thing? Multi-tasking and Distraction in Quality Improvement: Comment on: “Evaluating an Evidence-Based Bundle for Preventing Surgical Site Infection”

Abstract Full Text
Arch Surg. 2011;146(3):270. doi:10.1001/archsurg.2011.7

Peaceful Rest vs Rest in Peace: Comment on “Surgeons' Stress From Surgery and Night Duty”

Abstract Full Text
Arch Surg. 2011;146(3):278-279. doi:10.1001/archsurg.2011.26a

Is Time on the Side of Diversity in Lung Transplantation?Comment on “Racial Disparities in Survival After Lung Transplantation”

Abstract Full Text
Arch Surg. 2011;146(3):293-294. doi:10.1001/archsurg.2010.338

Improving Outcomes: The Importance of Data Monitoring and Ongoing Educational Interventions: Comment on “Trends in Central Line–Associated Bloodstream Infections in a Trauma-Surgical Intensive Care Unit”

Abstract Full Text
Arch Surg. 2011;146(3):307. doi:10.1001/archsurg.2011.10

Appendicitis Equals Diverticulitis: A Challenge to Traditional Dogma: Comment on “Epidemiological Similarities Between Appendicitis and Diverticulitis Suggesting a Common Underlying Pathogenesis”

Abstract Full Text
Arch Surg. 2011;146(3):315. doi:10.1001/archsurg.2011.1

Diverticulitis: Something New Under the Sun?Comment on “Cyclical Increase in Diverticulitis During the Summer Months”

Abstract Full Text
Arch Surg. 2011;146(3):324. doi:10.1001/archsurg.2011.26

Is Timing Really Everything in Patients Receiving Antiplatelet Therapy?Comment on “Cessation of Clopidogrel Before Major Abdominal Procedures”

Abstract Full Text
Arch Surg. 2011;146(3):339. doi:10.1001/archsurg.2011.26b

Doctor, How Many Have You Done?Comment on “Impact of Surgeon Experience on 5-Year Outcome of Laparoscopic Nissen Fundoplication”

Abstract Full Text
Arch Surg. 2011;146(3):347. doi:10.1001/archsurg.2011.33
Review

Comparative Benefits of Laparoscopic vs Open Hepatic Resection: A Critical Appraisal

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Arch Surg. 2011;146(3):348-356. doi:10.1001/archsurg.2010.248
ObjectivesTo perform a literature review examining the comparative benefits of laparoscopic vs open hepatic resection and to define the benefits and outcomes of laparoscopic liver resection in our own series of 314 patients.Data SourcesCited English-language publications from PubMed. In addition, between 2001 to 2010, hepatic resections were performed in our institution in 1294 patients, of whom 314 patients (24.3%) underwent laparoscopic liver resection for benign or malignant liver lesions.Study SelectionSearch phrases were “laparoscopic liver resection,” “open liver resection,” “versus,” “compared with,” and “advantages.”Data ExtractionThirty-one studies were reviewed that directly compared laparoscopic with open hepatic resection in 2473 patients.Data SynthesisIn case-cohort matched studies, and our institutional series, laparoscopic liver resection was associated with less blood loss, quicker resumption of oral diet, less pain medication requirement, and shorter length of stay, with no difference in complication rates. In those patients undergoing laparoscopic hepatic resection for malignancy, there was no difference in 3- or 5-year overall survival when compared with well-matched open hepatic resection cases. Financially, the total hospital costs of laparoscopic liver resection were either offset or improved because of a shorter length of stay.ConclusionsBased on review of the literature and our institutional series, minimally invasive hepatic resection for benign and malignant liver lesions is safe and feasible with significant benefits for patients consisting of less blood loss, less narcotic requirements, and shorter length of hospital stay. There are no economic disadvantages to the laparoscopic approach, and case-cohort matched studies show no difference in oncologic outcomes between the laparoscopic and open groups.
Special Feature

Image of the Month—Quiz Case

Abstract Full Text
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Arch Surg. 2011;146(3):361. doi:10.1001/archsurg.2011.24-a

Image of the Month—Diagnosis

Abstract Full Text
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Arch Surg. 2011;146(3):362. doi:10.1001/archsurg.2011.24-b

Image of the Month—Quiz Case

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Arch Surg. 2011;146(3):363. doi:10.1001/archsurg.2011.25-a

Image of the Month—Diagnosis

Abstract Full Text
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Arch Surg. 2011;146(3):364. doi:10.1001/archsurg.2011.25-b

Image of the Month—Quiz Case

Abstract Full Text
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Arch Surg. 2011;146(3):365. doi:10.1001/archsurg.2011.15-a

Image of the Month—Diagnosis

Abstract Full Text
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Arch Surg. 2011;146(3):366-367. doi:10.1001/archsurg.2011.15-b
Correspondence

What Should the Targeted Range of Blood Glucose Levels Be to Reduce the Incidence of Surgical Site Infection Following General Surgery?

Abstract Full Text
Arch Surg. 2011;146(3):368-369. doi:10.1001/archsurg.2011.16

Stratification of Patients Who Underwent Colorectal Surgery: Determining the Risk of Surgical Site Infection Related to Postoperative Hyperglycemia

Abstract Full Text
Arch Surg. 2011;146(3):369. doi:10.1001/archsurg.2011.17

Hyperglycemia and Surgical Site Infection: Not Ready for Prime Time

Abstract Full Text
Arch Surg. 2011;146(3):369-370. doi:10.1001/archsurg.2011.18

Hyperglycemia and Surgical Site Infection: Not Ready for Prime Time—Reply

Abstract Full Text
Arch Surg. 2011;146(3):370. doi:10.1001/archsurg.2011.19
From JAMA

Hospital Complication Rates With Bariatric Surgery in Michigan Centers of Excellence: The Emperor's New Clothes

Abstract Full Text
Arch Surg. 2011;146(3):254-255. doi:10.1001/archsurg.2011.22

The Yin and Yang of Blood Transfusions in Cardiac Surgery

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Arch Surg. 2011;146(3):357-358. doi:10.1001/archsurg.2011.31

Local Antibiotics to Prevent Surgical Site Infections: Another Zeno's Paradox?

Abstract Full Text
Arch Surg. 2011;146(3):359-360. doi:10.1001/archsurg.2011.21
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