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Ginwalla, Rashna; Rickard, Jennifer
doi: 10.1001/jamasurg.2014.2262pmid: 25651075
This Viewpoint discusses surgical missions to low- and middle-income countries and suggests changes to improve their effectiveness, relevance, and sustainability.
Li, Bin; Xiang, Jiaqing; Zhang, Yawei; Li, Hecheng; Zhang, Jie; Sun, Yihua; Hu, Hong; Miao, Longsheng; Ma, Longfei; Luo, Xiaoyang; Chen, Sufeng; Ye, Ting; Zhang, Yiliang; Zhang, Yang; Chen, Haiquan
Bischof, Danielle A.; Kim, Yuhree; Dodson, Rebecca; Jimenez, M. Carolina; Behman, Ramy; Cocieru, Andrei; Fisher, Sarah B.; Groeschl, Ryan T.; Squires, Malcolm H.; Maithel, Shishir K.; Blazer, Dan G.; Kooby, David A.; Gamblin, T. Clark; Bauer, Todd W.; Quereshy, Fayez A.;
Cornwell, Lorraine D.; Omer, Shuab; Rosengart, Todd; Holman, William L.; Bakaeen, Faisal G.
doi: 10.1001/jamasurg.2014.1700pmid: 25671647
ImportanceToday’s coronary artery bypass grafting (CABG) population appears to comprise sicker patients than in the past; however, little is known about the change in the risk profile. ObjectiveTo evaluate the change with time in the risk profile of patients who undergo CABG. Design, Setting, and ParticipantsRetrospective review of records from the Veterans Affairs (VA) Surgical Quality Improvement Program (VASQIP); 65 097 patients who underwent isolated primary CABG from October 1, 1997, to April 30, 2011, were evaluated. Main Outcomes and MeasuresTrends in risk profiles, surgical volume, and modern outcomes in the VA system. We determined the significance of changes in age and major comorbidities across time with simple linear regression analysis and evaluated the rates of perioperative mortality (30-day or in-hospital) and VASQIP predicted risk of mortality trends over time. ResultsFrom 1997 to 2011, there were increases in mean (SD) patient age (63.1 [9.4] vs 64.3 [7. 8] years; R2 = 0.34; P = .02) and body mass index (28.3 [5.1] vs 30.1 [5.8]; R2 = 0.95). There were also increases in the prevalence of diabetes mellitus (32.8% vs 41.3%; R2 = 0.82), preoperative New York Heart Association (NYHA) class III or IV heart failure status (14.3% vs 34.2%; R2 = 0.74), and left main coronary artery disease (26.0% vs 32.8%; R2 = 0.82) (all P < .001). There was a decrease in the prevalence of advanced angina severity (Canadian Cardiovascular Society class III or IV) (R2 = 0.95), previous myocardial infarction (R2 = 0.82), and low ejection fraction (≤34%) (R2 = 0.88) (all P < .05). There was no significant change in the prevalence of cerebrovascular and peripheral vascular disease, chronic obstructive pulmonary disease, or 3-vessel coronary artery disease. Perioperative mortality rates and the VASQIP predicted risk of mortality, respectively, decreased with time (3.2% and 3.1% vs 1.7% and 1.6%). From 2004 to 2011, there was a significant increase in the prevalence of previous percutaneous coronary intervention (18.6% to 29.2%; R2 = 0.82; P = .002). Overall CABG volume decreased (5551 in 1998 vs 3857 in 2012; R2 = 0.95; P < .001). Conclusions and RelevanceFrom 1997 to 2011, there was a progressive increase in the prevalence of obesity, diabetes, left main coronary artery disease, and advanced NYHA heart failure class among VA patients undergoing CABG. The prevalence of previous myocardial infarction, low ejection fraction, and advanced angina decreased, perhaps because of earlier surgical referral, improvement in medical management, or a shift in patient selection for CABG. Operative mortality also decreased with time. These trends confirm the general perception of significant, ongoing improvement in the care of patients who undergo CABG in the VA, despite an older, sicker population.
Morgan, Courtney E.; Prakash, Vivek S.; Vercammen, Janet M.; Pritts, Timothy; Kibbe, Melina R.
doi: 10.1001/jamasurg.2014.1685pmid: 25693160
ImportanceHemorrhage is the leading cause of death in military trauma and second leading cause of death in civilian trauma. Although many well-established animal models of hemorrhage exist in the trauma and anticoagulant literature, few focus on directly quantitating blood loss. ObjectiveTo establish and validate a reproducible rodent model of uncontrolled hemorrhage to serve as the foundation for developing therapies for noncompressible torso trauma. Design, Settings, and SubjectsWe developed and evaluated 4 different hemorrhage models using male Sprague-Dawley rats (6 rats/model), aged 10 to 14 weeks and weighing 330 to 460 g, at the Department of Surgery, Northwestern University. InterventionsWe used tail-cut (4 cm), liver punch biopsy (12 mm), liver laceration (3.0 × 1.5 cm), and spleen transection models. All animals underwent invasive hemodynamic monitoring. Main Outcomes and MeasuresBlood loss, expressed as a percentage of total blood volume (TBV), mean arterial pressure, and heart rate, which were recorded at 2- to 5-minute intervals. ResultsThe tail-cut model resulted in a mean (SD) TBV loss of 15.4% (6.0%) with hemodynamics consistent with class I hemorrhagic shock. The liver punch biopsy model resulted in a mean (SD) TBV loss of 16.7% (3.3%) with hemodynamics consistent with class I hemorrhagic shock. The liver laceration model resulted in a mean (SD) TBV loss of 19.8% (3.0%) with hemodynamics consistent with class II hemorrhagic shock. The spleen transection model resulted in the greatest blood loss (P < .01), with a mean (SD) TBV loss of 27.9% (3.4%) and hemodynamics consistent with class II hemorrhagic shock. The liver laceration and punch biopsy models resulted in most of the blood loss within the first 2 minutes, whereas the spleen transection and tail-cut models resulted in a steady loss during 10 minutes. The liver laceration and spleen transection models resulted in the greatest degree of hemodynamic instability (mean [SD] arterial pressure decreases of 25 [1] and 41 [11] mm Hg, respectively). One-hour survival was 100% in all 4 models. Conclusions and RelevanceWe established and validated the reproducibility of 4 different rat models of uncontrolled hemorrhage. These models provide a foundation to design novel nonsurgical therapies to control hemorrhage, and the different degrees of hemorrhagic shock produced from these models allow for flexibility in experimental design.
Schwarze, Margaret L.; Barnato, Amber E.; Rathouz, Paul J.; Zhao, Qianqian; Neuman, Heather B.; Winslow, Emily R.; Kennedy, Gregory D.; Hu, Yue-Yung; Dodgion, Christopher M.; Kwok, Alvin C.; Greenberg, Caprice C.
Showing 1 to 10 of 24 Articles
doi: 10.1001/jamasurg.2014.2877pmid: 25650816
ImportanceSweet esophagectomy is performed widely in China, while the Ivor-Lewis procedure, with potential benefit of an extended lymphadenectomy, is limitedly conducted owing to concern for a higher risk for morbidity. Thus, the role of the Ivor-Lewis procedure for thoracic esophageal cancer needs further investigation. ObjectiveTo determine whether Ivor-Lewis esophagectomy is associated with increased postoperative complications compared with the Sweet procedure. Design, Setting, and ParticipantsA randomized clinical trial was conducted from May 2010 to July 2012 at Fudan University Shanghai Cancer Center, Shanghai, China, of 300 patients with resectable squamous cell carcinoma in the middle and lower third of the thoracic esophagus. Intent-to-treat analysis was performed. InterventionsPatients were randomly assigned to receive either the Ivor-Lewis (n = 150) or Sweet (n = 150) esophagectomy. Main Outcomes and MeasuresThe primary outcome of this clinical trial was operative morbidity (any surgical or nonsurgical complications). Secondary outcomes included oncologic efficacy (number of lymph nodes resected and positive lymph nodes), postoperative mortality (30-day and in-hospital mortality), and patient discharge. ResultsResection without macroscopical residual (R0/R1) was achieved in 149 of 150 patients in each group. Although there was no significant difference between the 2 groups regarding the incidence of each single complication, a significantly higher morbidity rate was found in the Sweet group (62 of 150 [41.3%]) than in the Ivor-Lewis group (45 of 150 [30%]) (P = .04). More patients in the Sweet group (8 of 150 [5.3%]) received reoperations than in the Ivor-Lewis group (1 of 150 [0.7%]) (P = .04). The median hospital stay was 18 days in the Sweet group vs 16 days in the Ivor-Lewis group (P = .002). Postoperative mortality rates in the Ivor-Lewis (1 of 150) and Sweet (3 of 150) groups were 0.7% and 2.0%, respectively (P = .25). More lymph nodes were removed during Ivor-Lewis esophagectomy than during the Sweet procedure (22 vs 18, P < .001). Conclusions and RelevanceEarly results of this study demonstrate that the Ivor-Lewis procedure can be performed with lower rates of postoperative complications and more lymph node retrieval. Ivor-Lewis and Sweet esophagectomies are both safe procedures with low operative mortalities. Trial Registrationclinicaltrials.gov Identifier:NCT01047111
doi: 10.1001/jamasurg.2014.2881pmid: 25671681
ImportanceGastrointestinal stromal tumors (GISTs) are the most commonly diagnosed mesenchymal tumors of the gastrointestinal tract. The risk of recurrence following surgical resection of GISTs is typically reported from the date of surgery. However, disease-free survival (DFS) over time is dynamic and changes based on disease-free time already accumulated following surgery. ObjectivesTo assess the comparative performance of established GIST recurrence risk prognostic scoring systems and to characterize conditional DFS following surgical resection of GISTs. Design, Setting, and ParticipantsA retrospective cohort study of 502 patients who underwent surgery for a primary, nonmetastatic GIST between January 1, 1998, and December 31, 2012, at 7 major academic cancer centers in the United States and Canada. Main Outcomes and MeasuresDisease-free survival of the patients was classified according to 5 prognostic scoring systems, including the National Institutes of Health criteria, modified National Institutes of Health criteria, Memorial Sloan Kettering Cancer Center GIST nomogram, and American Joint Committee on Cancer gastric and nongastric categories. The concordance index (also known as the C statistic or the area under the receiver operating curve) of established GIST recurrence risk prognostic scoring systems. Conditional DFS estimates were calculated. ResultsOverall 1-year, 3-year, and 5-year DFS following resection of GISTs was 95%, 83%, and 74%, respectively. All the prognostic scoring systems had fair prognostic ability. For all tumor sites, the American Joint Committee on Cancer gastric category demonstrated the best discrimination (C = 0.79). Using conditional DFS, the probability of remaining disease free for an additional 3 years given that a patient was disease free at 1 year, 3 years, and 5 years was 82%, 89%, and 92%, respectively. Patients with the highest initial recurrence risk demonstrated the greatest increase in conditional survival as time elapsed. Conclusions and RelevanceConditional DFS improves over time following resection of GISTs. This is valuable information about long-term prognosis to communicate to patients who are disease free after a period following surgery.
ImportanceNo consensus exists regarding the definition of high-risk surgery in older adults. An inclusive and precise definition of high-risk surgery may be useful for surgeons, patients, researchers, and hospitals. ObjectiveTo develop a list of high-risk operations. Design, Setting, and ParticipantsRetrospective cohort study and modified Delphi procedure. The setting included all Pennsylvania acute care hospitals (Pennsylvania Health Care Cost Containment Council [PHC4] April 1, 2001, to December 31, 2007) and a nationally representative sample of US acute care hospitals (Nationwide Inpatient Sample [NIS], Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality January 1, 2001, to December 31, 2006). Patients included were those 65 years and older admitted to PHC4 hospitals and those 18 years and older admitted to NIS hospitals. We identified International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes associated with at least 1% inpatient mortality in the PHC4. We used a modified Delphi procedure with 5 board-certified surgeons to further refine this list by excluding nonoperative procedures and operations that were unlikely to be the proximate cause of mortality and were instead a marker of critical illness (eg, tracheostomy). We then cross-validated this list of ICD-9-CM codes in the NIS. Main Outcomes and MeasuresModified Delphi procedure consensus of at least 4 of 5 panelists and proportion agreement in the NIS. ResultsAmong 4 739 522 admissions of patients 65 years and older in the PHC4, a total of 2 569 589 involved a procedure, encompassing 2853 unique procedures. Of 1130 procedures associated with a crude inpatient mortality of at least 1%, 264 achieved consensus as high-risk operations by the modified Delphi procedure. The observed inpatient mortality in the NIS was at least 1% for 227 of 264 procedures (86%) in patients 65 years and older. The pooled inpatient mortality for these identified high-risk procedures performed on patients 65 years and older was double the pooled inpatient mortality for correspondingly identified high-risk operations for patients younger than 65 years (6% vs 3%). Conclusions and RelevanceWe developed a list of procedure codes to identify high-risk surgical procedures in claims data. This list of high-risk operations can be used to standardize the definition of high-risk surgery in quality and outcomes–based studies and to design targeted clinical interventions.