Mark L. Shapiro

A comprehensive review of topical hemostatic agents: efficacy and recommendations for use.

Since ancient times we have attempted to facilitate hemostasis by application of topical agents. In the last decade, the number of different effective hemostatic agents has increased drastically. In order for the modern surgeon to successfully choose the right agent at the right time, it is essential to understand the mechanism of action, efficacy and possible adverse events as they relate to each agent. In this article we provide a comprehensive review of the most commonly used hemostatic agents, subcategorized as physical agents, absorbable agents, biologic agents, and synthetic agents. We also evaluate novel hemostatic dressings and their application in the current era. Furthermore, wholesale acquisition prices for hospitals in the United States are provided to aid in cost analysis. We conclude with an expert opinion on which agent to use under different scenarios.

Predictors of Major Morbidity and Mortality After Pneumonectomy Utilizing The Society for Thoracic Surgeons General Thoracic Surgery Database

BACKGROUND Pneumonectomy is associated with a significant incidence of perioperative morbidity and mortality. The purpose of this study is to identify the risk factors responsible for adverse outcomes in patients after pneumonectomy utilizing The Society of Thoracic Surgeons General Thoracic Surgery Database (STS GTDB). METHODS All patients who had undergone pneumonectomy between January 2002 and December 2007 were identified in the STS GTDB. Among 80 participating centers, 1,267 patients were selected. Logistic regression analysis was performed on preoperative variables for major adverse outcomes. RESULTS The rate of major adverse perioperative events was 30.4%, including 71 patients who died (5.6%). Major morbidity was defined as pneumonia, adult respiratory distress syndrome, empyema, sepsis, bronchopleural fistula, pulmonary embolism, ventilatory support beyond 48 hours, reintubation, tracheostomy, atrial or ventricular arrhythmias requiring treatment, myocardial infarct, reoperation for bleeding, and central neurologic event. Patients with major morbidity had a longer mean length of stay compared with patients without major morbidity (13.3 versus 6.1 days, p < 0.001). Independent predictors of major adverse outcomes were age 65 years or older (p < 0.001), male sex (p = 0.026), congestive heart failure (p = 0.04), forced expiratory volume in 1 second less than 60% of predicted (p = 0.01), benign lung disease (p = 0.006), and requiring extrapleural pneumonectomy (p = 0.018). Among patients with lung carcinoma, those receiving neoadjuvant chemoradiotherapy were more at risk for major morbidity than patients without induction therapy (p = 0.049). CONCLUSIONS The mortality rate after pneumonectomy by thoracic surgeons participating in the STS database compares favorably to that in previously published studies. We identified risk factors for major adverse outcomes in patients undergoing pneumonectomy.

Thoracoscopic segmentectomy compares favorably with thoracoscopic lobectomy for patients with small stage I lung cancer

OBJECTIVE As thoracoscopic lobectomy becomes widely applied for treatment of non-small cell lung cancer, thoracoscopic segmentectomy remains controversial for patients with small stage I lung cancers. Questions remain regarding safety, morbidity, mortality, and recurrence rate. This study compared outcomes between thoracoscopic segmentectomy and lobectomy. METHODS Retrospective review was undertaken of patients who underwent thoracoscopic segmentectomy or lobectomy for clinical stage I non-small cell lung cancer between January 2002 and February 2008. Indications for segmentectomy were tumor smaller than 3 cm, limited pulmonary reserve, comorbidities, and peripheral tumor location. RESULTS Thirty-one patients underwent segmentectomy and 113 underwent lobectomy. Patients after segmentectomy had worse mean forced expiratory volume in 1 second than after lobectomy (83% vs 92%, P = .04). There were no differences in mean number of nodes (10) and nodal stations (5) resected. Segmentectomy and lobectomy groups had similar median chest tube durations (2 vs 3 days, P = .18), stays (both 4 days), total complications, recurrence rates, and survivals at mean follow-ups of 22 and 21 months, respectively. Lobectomy group had 1 30-day death; segmentectomy group had none. There were 5 (17.2%) recurrences after segmentectomy and 23 (20.4%) after lobectomy (P = .71), with locoregional recurrence rates of 3.5% and 3.6%, respectively. CONCLUSION Thoracoscopic segmentectomy is a safe option for experienced thoracoscopic surgeons treating patients with small stage I lung cancers. No significant difference in oncologic outcome was seen between thoracoscopic segmentectomy and thoracoscopic lobectomy. Lymph node dissection could be performed as effectively during segmentectomy as lobectomy.

The role of repeat angiography in the management of pelvic fractures

BACKGROUND Angiographic embolization has emerged as the treatment modality of choice for bleeding pelvic fractures. The purpose of this study is to identify potential indicators for ongoing pelvic hemorrhage despite initial therapeutic or non-diagnostic angiography. METHODS The trauma registry of a Level I trauma center was used to identify patients with pelvic fractures between January 2000 and June 2002. Records were reviewed for demographics, severity of injury, hemodynamic status, initial and subsequent base deficit, blood and fluid requirements, length of stay, and mortality. Statistical analysis was performed using Students t test, and univariate and multivariate analysis, significance was assigned to p < or = 0.05. RESULTS During the study period, 678 patients had pelvic fractures. Angiography was performed in 31 (4.6%) of these patients. Arterial hemorrhage was diagnosed initially on 16 (51.6%) patients requiring embolization. Three (18.8%) of these embolized patients required repeat angiography and embolization due to ongoing pelvic hemorrhage. Of the initial 15 patients with negative angiograms, five (33.3%) had repeat angiograms due to continued hypotension and acidosis. Four (80.0%) of these five patients were found to have arterial hemorrhage requiring embolization. Of the seven (22.6%) patients requiring repeat angiography for control of ongoing pelvic hemorrhage, three independent factors were predictive: continued or recurrent hypotension (SBP < 90), absence of intra-abdominal injury, and persistent base deficit of 10 for greater than 6 hours. The presence of all three independent predictors was associated with a 97% probability of pelvic bleeding (p = 0.001). CONCLUSION Angiographic embolization is highly effective in controlling arterial bleeding associated with pelvic fractures. However, repeat angiography should be performed in patients with pelvic fractures with ongoing evidence of hemorrhage demonstrated by persistent base deficit and hypotension once other potential sources of bleeding have been excluded.

No need to wait: an analysis of the timing of cholecystectomy during admission for acute cholecystitis using the American College of Surgeons National Surgical Quality Improvement Program database.

BACKGROUND The objective of our analysis was to determine the optimal timing of cholecystectomy during admission for acute cholecystitis. METHODS All patients from the American College of Surgeons National Surgical Quality Improvement Program Participant User Files from 2005 through 2010 who underwent emergency cholecystectomy within 7 days of hospital admission for acute cholecystitis were included for analysis. The association between timing of cholecystectomy and postoperative outcomes was determined using multivariate logistic regression analyses after adjustment for patient demographics, acute and chronic comorbid medical conditions, preoperative sepsis classification, American Society of Anesthesiologists physical status classification, and preoperative liver function tests. RESULTS A total of 5,268 patients were included for analysis. The timing of operation was day of admission for 49.7% of these patients, 1 day after admission for 33.4%, 2 days after admission for 9.5%, 3 days after admission for 3.9%, and 4 days to 7 days after admission for 3.6%. Multivariate logistic regression analyses revealed no significant association between timing of operation and 30-day postoperative mortality or overall morbidity. Patients who underwent operation later in the course of admission were more likely to require an open procedure and sustained significantly longer postoperative and overall lengths of hospitalization. Similar findings were demonstrated for a subgroup of patients who exhibited characteristics that placed them at higher risk for surgical intervention. CONCLUSION Immediate cholecystectomy is preferred for patients who require hospitalization for acute cholecystitis. LEVEL OF EVIDENCE Economic/decision analysis, level III.

Surgical Management and Outcomes of Patients with Duodenal Crohn's Disease

BACKGROUND Duodenal Crohns disease (DCD) has been reported to occur in 0.5% to 4% of patients with Crohns disease. When patients fail to respond to conservative therapy or severe narrowing of the duodenum develops, operation is required. The recent literature is limited in description of surgical treatment of such patients. We reviewed our experience with surgical management and outcomes in patients with DCD, including outcomes of laparoscopic bypass procedures. STUDY DESIGN A retrospective review was undertaken of all patients who underwent surgical intervention for DCD between 1995 and 2006. Data collected included demographics, clinical presentation, operative and hospital course, and postoperative followup. RESULTS Thirty patients had surgical intervention for DCD during the selected period. Four patients had duodenoenteric fistulas, resulting from complications of their disease in the distal gastrointestinal tract. Operations done for intrinsic DCD were: open bypass (n = 11), laparoscopic bypass (n = 13), and stricturoplasty (n = 2). Only one vagotomy was done. Mean followup was 58 months (range 6 to 144 months). Patients resumed oral diet 3.0 days after laparoscopic bypass, with mean discharge of 6.9 days, as compared with 4.4 days and 12.2 days after open bypass, respectively. In the early postoperative period (0 to 30 days), six major complications (n=5, 19%): persistent obstruction, anastomotic leak, small bowel obstruction, anastomotic bleeding (two patients), and respiratory failure, developed in four patients in the open (36%) and one patient in the laparoscopic (8%) bypass group. There were two more complications during longterm followup, for an overall major morbidity rate of 27%. Two patients experienced recurrence requiring revision (one in the open group and one in the laparoscopic group). Gastroduodenal ulcers requiring operation did not develop in any of the patients. CONCLUSIONS Surgery is a viable and safe option for patients with intractable duodenal Crohns disease. The laparoscopic approach during a bypass procedure, as opposed to an open bypass, may result in faster recovery, less morbidity, and comparable recurrence rate. There is no role for vagotomy in bypass procedures.

Repeat imaging in trauma transfers: a retrospective analysis of computed tomography scans repeated upon arrival to a Level I trauma center.

BACKGROUND: The repetition of computed tomography (CT) imaging in caring for injured patients transferred between institutions is common, but it is not well studied. Our objective is to quantify and describe the characteristics associated with repeating chest and abdominal CT images for patients transferred to trauma centers and to determine whether repeat imaging leads to delays in definitive care or disparate outcomes. METHODS: This is a retrospective review of adult, blunt trauma patients transferred to two Level I trauma centers between January 2004 and May 2008 who underwent CT imaging of the chest, abdomen, or both. RESULTS: 60% of patients had at least one study repeated upon arrival to the trauma center. Variables associated with repeat imaging include Injury Severity Scores between 24 and 33 versus <15 (odds radio [OR], 1.6; 95% confidence interval [CI], 1.05–2.4), transfer to University of North Carolina (OR, 1.5; 95% CI, 1.01–2.2), transport by helicopter (OR, 1.6; 95% CI, 1.2–2.2), transfer in any year before 2008 (OR, 2.4; 95% CI, 1.6–3.6 for 2007; OR, 3.4; 95% CI, 2.2–5.3 for 2006; OR, 3.0; 95% CI, 1.8–5.0 for 2005; OR, 2.8; 95% CI, 1.7–4.7 for 2004), and triage alert level higher than the least severe level III (OR, 1.6; 95% CI, 1.01–2.7 for level II; OR, 2.2; 95% CI, 1.2–4.1 for level I). In adjusted models, there was no evidence that repeat imaging neither shortened the total time to definitive care nor altered patient outcomes. CONCLUSIONS: Injured patients often undergo imaging that gets repeated, adding cost and radiation exposure while not significantly altering outcomes. The current policy push to digitize medical records must include provisions for the interoperability and use of imaging software. LEVEL OF EVIDENCE: III, therapeutic study.

Wnt pathway activation predicts increased risk of tumor recurrence in patients with stage I nonsmall cell lung cancer.

Objective: To determine the incidence of Wnt pathway activation in patients with stage I NSCLC and its influence on lung cancer recurrence. Background: Despite resection, the 5-year recurrence with localized stage I nonsmall cell lung cancer (NSCLC) is 18.4%–24%. Aberrant Wnt signaling activation plays an important role in a wide variety of tumor types. However, there is not much known about the role the Wnt pathway plays in patients with stage I lung cancer. Methods: Tumor and normal lung tissues from 55 patients following resection for stage I NSCLC were subjected to glutathione S-transferase (GST) E-cadherin pulldown and immunoblot analysis to assess levels of uncomplexed &bgr;-catenin, a reliable measure of Wnt signaling activation. The &bgr;-catenin gene was also screened for oncogenic mutations in tumors with activated Wnt signaling. Cancer recurrence rates were correlated in a blinded manner in patients with Wnt pathway-positive and -negative tumors. Results: Tumors in 20 patients (36.4%) scored as Wnt positive, with only 1 exhibiting a &bgr;-catenin oncogenic mutation. Patients with Wnt-positive tumors experienced a significantly higher rate of overall cancer recurrence than those with Wnt-negative tumors (30.0% vs. 5.7%, P = 0.02), with 25.0% exhibiting distal tumor recurrence compared with 2.9% in the Wnt-negative group (P = 0.02). Conclusions: Wnt pathway activation occurred in a substantial fraction of Stage I NSCLCs, which was rarely due to mutations. Moreover, Wnt pathway activation was associated with a significantly higher rate of tumor recurrence. These findings suggest that Wnt pathway activation reflects a more aggressive tumor phenotype and identifies patients who may benefit from more aggressive therapy in addition to resection.

Impact of specific postoperative complications on the outcomes of emergency general surgery patients.

BACKGROUND The relative contribution of specific postoperative complications on mortality after emergency operations has not been previously described. Identifying specific contributors to postoperative mortality following acute care surgery will allow for significant improvement in the care of these patients. METHODS Patients from the 2005 to 2011 American College of Surgeons’ National Surgical Quality Improvement Program database who underwent emergency operation by a general surgeon for one of seven diagnoses (gallbladder disease, gastroduodenal ulcer disease, intestinal ischemia, intestinal obstruction, intestinal perforation, diverticulitis, and abdominal wall hernia) were analyzed. Postoperative complications (pneumonia, myocardial infarction, incisional surgical site infection, organ/space surgical site infection, thromboembolic process, urinary tract infection, stroke, or major bleeding) were chosen based on surgical outcome measures monitored by national quality improvement initiatives and regulatory bodies. Regression techniques were used to determine the independent association between these complications and 30-day mortality, after adjustment for an array of patient- and procedure-related variables. RESULTS Emergency operations accounted for 14.6% of the approximately 1.2 million general surgery procedures that are included in American College of Surgeons’ National Surgical Quality Improvement Program but for 53.5% of the 19,094 postoperative deaths. A total of 43,429 emergency general surgery patients were analyzed. Incisional surgical site infection had the highest incidence (6.7%). The second most common complication was pneumonia (5.7%). Stroke, major bleeding, myocardial infarction, and pneumonia exhibited the strongest associations with postoperative death. CONCLUSION Given its disproportionate contribution to surgical mortality, emergency surgery represents an ideal focus for quality improvement. Of the potential postoperative targets for quality improvement, pneumonia, myocardial infarction, stroke, and major bleeding have the strongest associations with subsequent mortality. Since pneumonia is both relatively common after emergency surgery and strongly associated with postoperative death, it should receive priority as a target for surgical quality improvement initiatives. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.

Small bowel obStruction: the eternal dilemma of when to intervene

obstruction is the most common disorder afflicting the small bowel. the days of not letting the sun set on a small bowel obstruction (SBo) perhaps allowed for less complex surgical decision-making algorithms than to watchfully wait and wonder about the state of the bowel. this old surgical adage seems to have lost its reverence with time. the caveat is that the current diagnostic armamentarium in predicting nonoperative failures remains far from foolproof. the fundamental clinical shortcoming is the clinicians’ inability to definitively predict cases of small bowel obstruction destined to evolve into strangulated bowel if left to nonoperative measures. Prospective, randomized studies addressing operative timing for small bowel obstruction do not exist. As such, the definitive answer to the dilemma in this article’s title will not be unraveled in the immediate future. the majority (75%) of small bowel obstructions are attributed to intraabdominal adhesions from prior operations. the rate of adhesive SBo development is highest in the first few postoperative years following the index operation, particularly after colorectal surgery, but the risk remains life-long (4). At 10 years, recurrent obstruction from adhesions is estimated to occur 15 to 50% of the time. Amongst patients with adhesive obstruction, anywhere from 25 to 66% are reported to require an operation (3, 12, 13, 17, 20). SBo cases attributed to hernias have been on the decline over the past few decades, from 40% in the 1960s to 15%, presumably due to an increased rate of elective hernia repair (4, 11). With this declining trend, inflammatory bowel disease is now considered one of the leading causes of SBo in the Western world (15, 18). In patients without previous operations or hernias, cancer accounts for half of small bowel obstructions. otherwise, it comprises 5–10% of cases (4). In the first three or so decades of the 20th century, mortality from small bowel obstruction was as high as 60% (19). In more contemporary series, the reported mortality rate is 3–7% in uncomplicated cases, rising to above 15% in the presence of strangulation (7, 11, 13). Factors shown to potentiate mortality risk include older age and presence of comorbidities (7, 17). A prospective study of Veterans Affairs Medical Center patients identified dirty or infected wounds, ASA class ≥ 4, age > 80 years, and dyspnea at rest to increase odds of death (17). Fevang et al. identified old age, comorbidities, nonviable strangulation, and treatment delay > 24 hours to increase mortality rate (11). Similarly, Duron et. al. reported age > 75 years and ASA class III as independent risk factors for increased early mortality (7). In a longitudinal, population-based review of more than 32,000 patients treated for SBo, 24% of whom required surgery on initial admission, length of stay was longer for those undergoing operations, but mortality was lower, readmissions for SBo fewer, and time to obstructive readmission longer (13). others have found increased morbidity with factors such as small bowel resection (compared to adhesiolysis alone), old age, comorbidities, treatment delay > 24 hours, and need for repeat surgery (11, 17, 20).