Hypothesis  Laparoscopic distal pancreatectomy (LDP) provides outcome advantages compared with open distal pancreatectomy (ODP).

Design  Single-institutional, retrospective review from January 1, 2004, to May 1, 2009.

Setting  Tertiary referral center.

Patients  Patients undergoing LDP (n = 100) were matched by age, pathologic diagnosis, and pancreatic specimen length to a cohort undergoing ODP (n = 100).

Main Outcome Measures  Perioperative outcomes and overall 30-day morbidity and mortality. Univariate and multivariate analyses were performed using logistic or linear regression as appropriate.

Results  Patients in the LDP group did not differ from those in the ODP group in age (mean, 59.0 vs 58.6 years; P = .85), sex (60% vs 50% female; P = .16), body mass index (calculated as weight in kilograms divided by height in meters squared) (mean, 27.4 vs 27.9; P = .44), or American Society of Anesthesiologists score of 3 or higher (58% vs 52%; P = .39). Tumor size was greater in the ODP group than in the LDP group (mean, 4.0 vs 3.3 cm; P = .02). The LDP group as compared with the ODP group demonstrated decreased blood loss (mean, 171 vs 519 mL; P < .001) and shorter duration of hospital stay (mean, 6.1 vs 8.6 days; P < .001). There were no differences between the LDP and ODP groups in operative time (mean, 214 vs 208 minutes; P = .50), pancreatic leak rate (17% vs 17%; P > .99), overall 30-day morbidity (34% vs 29%; P = .45), and 30-day mortality (3% vs 1%; P = .62).

Conclusions  The laparoscopic approach to distal pancreatectomy appears to provide advantages of reduced blood loss and length of hospital stay in selected patients compared with the open approach. Overall complication rates appear similar. Patient selection bias and limits of a retrospective analysis warrant prospective validation.

Hypothesis  Sentinel lymph node (SLN) biopsy provides valuable prognostic information for patients with thick (T4) melanoma.

Design  Post hoc analysis of data from a prospective, randomized trial.

Setting  Academic and private hospitals.

Patients  Data of 240 patients with melanoma thicker than 4 mm were analyzed. Patients with tumor-positive SLNs underwent completion lymphadenectomy. Disease-free and overall survival were evaluated by Kaplan-Meier analysis. Univariate and multivariate analyses were performed to evaluate factors predictive of tumor-positive SLNs and disease-free and overall survival.

Results  Median thickness of melanoma was 5.6 mm, and patients were followed up for a median of 50 months. The SLNs were tumor positive in 100 patients (41.7%); 18% of these had additional positive nodes on completion lymphadenectomy. Extremity tumor location (risk ratio, 1.66; 95% confidence interval, 1.24-2.24; P = .001), Clark level (1.95; 1.33-2.87; P = .02), and lymphovascular invasion (1.57; 1.13-2.17; P = .01) were associated with a greater risk of tumor-positive SLNs. The patients with tumor-negative SLNs had significantly better median disease-free survival (46.5 vs 31.0 months; P = .04) and overall survival (55.5 vs 43.0 months; P = .004) compared with patients with tumor-positive SLNs. On multivariate analysis, male sex (risk ratio, 1.59; 95% confidence interval, 1.05-2.50; P = .02), increasing Breslow thickness (1.58; 1.10- 2.30; P = .03), ulceration (1.73; 1.18-2.59; P = .02), and tumor-positive SLNs (1.68; 1.17-2.43; P = .009) were associated with worse overall survival.

Conclusion  The SLN biopsy provides useful prognostic information for patients with T4 melanoma.

Hypothesis  Focused parathyroidectomy guided by intraoperative parathyroid hormone monitoring (IPM) may lead to higher failure rates because of missed multiglandular disease.

Design  Retrospective review of prospectively collected data.

Setting  Tertiary referral center.

Patients  From September 8, 1993, through January 30, 2009, a total of 845 consecutive patients with sporadic primary hyperparathyroidism underwent focused parathyroidectomy guided by IPM at a single institution.

Main Outcome Measures  Parathyroid hormone dynamics and perioperative data were analyzed for factors affecting outcome. Operative failure was defined as hypercalcemia with elevated parathyroid hormone levels within 6 months after parathyroidectomy. Detailed intraoperative data from the failed operations were also reviewed.

Results  Of 723 patients followed up for at least 6 months, 702 (97.1%) had successful parathyroidectomy, and 21 (2.9%) had failed parathyroidectomy. The major cause of operative failure was the surgeon's inability to find the abnormal parathyroid gland (16 of 21 patients [76.2%]). In the remaining patients, IPM results were false-positive in 5 of 21 patients (23.8%) or 0.7% overall. Among the cohort, IPM correctly identified missed multiglandular disease in 33 of 38 patients (86.8%). Patients having operative failure were more likely to have a history of thyroidectomy or parathyroidectomy and were less likely to have correct findings on technetium Tc 99m sestamibi or ultrasonographic localizing studies compared with patients having operative success.

Conclusion  Inability of the surgeon to find the abnormal parathyroid gland—not missed multiglandular disease—is the main cause of operative failure in focused parathyroidectomy guided by IPM.

Objective  To determine the importance of hospital volume, surgeon experience, and surgeon volume in performing pancreaticoduodenectomy (PD).

Design, Setting, and Patients  From 1980 through 2007, 1003 patients underwent PD by 19 surgeons at a university hospital.

Main Outcome Measures  Patient morbidity and mortality, quality of resection, and learning curve were examined according to hospital volume (period 1: 1980-2003 vs period 2: 2004-2007), surgeon experience (total number of PDs), and surgeon volume (number of PDs per year).

Results  Perioperative morbidity and mortality for all 1003 PDs were 41% and 3%, respectively. Differences existed between period 1 and period 2 in percentage of PDs performed in elderly patients (7% vs 17%), mortality (4% vs 2%), estimated blood loss (1817 mL vs 780 mL), length of stay (18 days vs 12 days), and proportion of International Study Group on Pancreatic Fistula grade C pancreatic fistulae (29% vs 12%). Surgeons with less experience (<50 PDs) performed PD with higher morbidity (53% vs 39%), pancreatic fistula rate (20% vs 10%), estimated blood loss (1918 mL vs 1101 mL), and operative time (458 minutes vs 335 minutes) compared with surgeons with more experience (≥50 PDs). Experienced surgeons had comparable outcomes irrespective of annual volume. Mortality, margins, and number of lymph nodes resected were not affected by surgeon experience or surgeon volume. Learning curves projected that less experienced surgeons would achieve morbidity and mortality rates equivalent to those of experienced surgeons when they reached 20 and 60 PDs, respectively.

Conclusions  Improvement in PD outcomes, including mortality, occurred with increased PD volume at a pancreatic center. Surgeon experience remained an important determinant of overall morbidity. Experienced surgeons, however, had comparable outcomes irrespective of annual volume.

Hypothesis  Describe the incidence, type, and detection method of surgical listing errors and implement a system to reduce errors.

Design  All errors/discrepancies between the surgical listing and the performed procedure reported to an institutional event line during 2008 were analyzed.

Setting  Academic tertiary medical center.

Main Outcome Measures  Error characteristics and detection mode were documented. An error causal tree analysis was developed and used to modify the standard listing process to reduce errors.

Results  During 2008, 759 listing errors were reported of 55 197 surgical procedures for an error rate of 1.38%. No wrong-site surgeries occurred. The errors were missing laterality (501; 66%), incorrect side (108; 14%), incorrect listing besides laterality (86; 11%), and other (64; 9%). Identification/correction of the listing error occurred in the following areas: nursing review the evening prior to surgery (517; 68%), preoperative admission unit (132; 17%), operating room (98; 12%), recovery room (6; 0.8%), and other (6; 0.8%). Using a causal tree analysis, error-proofing strategies applied in an electronic standardized case listing system significantly reduced the error rate from 1.50% to 0.54% (P < .05) and 2.06% to 0.49% (P < .05) in gynecologic and colorectal surgery, respectively.

Conclusions  Surgical listings errors occur with a low constant rate across specialties. The majorities of errors were related to laterality and were detected prior to surgery. An electronic listing system using standardized case descriptions with required laterality significantly reduced the error frequency.

Background  Uncomplicated surgical care has highly variable costs. High costs of complications have led payers to deny additional payments even for predictable complications.

Hypothesis  A payment warranty indexed to effective and efficient hospitals can promote quality and economic stewardship in surgical care.

Design  Analysis of hospital costs for elective colon surgery in the Healthcare Cost and Utilization Project's National Inpatient Sample from 2002 through 2005.

Setting  A 20% sample of acute care hospitals in the United States.

Patients and Methods  Data for elective colon resections were used to create predictive models for adverse outcomes (AOs) and costs. Total hospital costs were determined using cost-to-charge ratios. Costs of AOs were computed as total costs minus predicted costs of uncomplicated care. Surgical warranties were computed as the probability of AOs times per-case predicted costs of AOs. Final predictive models were calibrated using data only from effective and efficient hospitals.

Results  We studied 51 602 cases from 632 hospitals. There were 4048 (7.8%) AOs with 505 deaths (1.0%); 19 hospitals had excessive AOs and 95 hospitals had excessive costs. For 518 effective and efficient hospitals, total per-case costs for routine care were $9843 with an average warranty of $1294 and a $276 stop-loss allocation. This cost model would reduce national expenditures for colon surgery by 6%.

Conclusions  Complications and costs of care can be indexed to quality performing hospitals. Warranties for surgical care can reward effective and efficient care and preclude the need for additional payments for complications.

Objective  To determine if the use of steatotic grafts adversely affects outcomes in liver transplantation.

Design  A retrospective review of a prospectively maintained database.

Setting  A single center.

Patients  Four hundred ninety adults who underwent liver transplantation from January 1, 2002, to December 31, 2008, at a single center. Graft biopsies were available in 310 (63.3%) cases. Grafts were classified based on amount of macrovesicular steatosis: 5% or less (n = 222), more than 5% to less than 35% (n = 66), and 35% or more (n = 22).

Main Outcome Measures  Recipient demographics, Model for End-Stage Liver Disease (MELD) score, patient/graft survival, complications, transfusion rates, and liver function test results.

Results  One-, 3-, and 5-year patient and graft survivals, respectively, were similar (90.38%, 84.7%, and 74.4%, respectively, P = .3; and 88.7%, 82.5%, and 73.3%, respectively, P = .15). Median follow-up was 25 months. Recipient age, sex, body mass index, laboratory MELD score, and ischemia times were similar among all groups. Packed red blood cell (3 vs 8 U, P < .001), fresh frozen plasma (2 vs 4 U, P = .007), and cryoprecipitate transfusion rates were significantly increased in grafts with 35% or more steatosis. Intensive care unit (5 vs 11 days, P = .02) and hospital (11 vs 21 days, P < .001) stay was also increased in those with grafts with 35% or more steatosis compared with those with 5% or less steatosis. The grafts with 35% or more steatosis had higher transaminase peaks and longer times for bilirubin to normalize (P < .001).

Conclusions  Use of carefully selected steatotic grafts was not associated with higher rates of primary nonfunction or poorer outcomes. However, the use of steatotic grafts is associated with increased resource use in the perioperative period.

Objective  To investigate the association of relative tumor echogenicity and hepatic steatosis in patients undergoing resection of colorectal liver metastases (CRLM).

Design  Prospective study.

Setting  The Johns Hopkins Hospital.

Patients  A total of 126 patients undergoing liver surgery for CRLM from January 1, 1998, through December 31, 2008, in whom 191 lesions had complete intraoperative ultrasonography images for review and adequate linked pathological data available.

Main Outcome Measures  The intraoperative ultrasonography images were reviewed and scored for echogenicity (hypoechoic, isoechoic, or hyperechoic). In addition, a histopathologic review of the nontumorous liver tissue was performed, and the extent of steatosis was scored and correlated with tumor echogenicity.

Results  Of the patients undergoing surgery, 49 (38.8%) were found to have mild to severe steatosis. Of the 191 total CRLM visualized by intraoperative ultrasonography, 91 (47.6%) were found to be hypoechoic, 65 (34.0%) were isoechoic, and 35 (18.3%) were hyperechoic. In patients with steatosis, lesions were significantly more likely to be hypoechoic when compared with patients without steatosis (odds ratio, 4.17; 95% confidence interval, 1.87-8.47; P = .001). Echogenicity was independent of the cause of steatosis or response to chemotherapy.

Conclusions  The echogenicity of CRLM was significantly affected by the presence of liver steatosis, with decreased echogenicity and increased conspicuity of lesions despite overall poorer image quality. These findings might reinforce the usefulness of intraoperative ultrasonography in identifying additional CRLM in patients undergoing surgical therapy, even in those with fatty liver tissue.

Objective  To determine the importance of factors in decision making by general surgery chief residents to pursue fellowships and to relate factor importance to gender and residency characteristics.

Design  Prospective, voluntary, national survey conducted April through May, 2008, in which finishing chief residents rated the importance of 12 factors in their decision making to pursue fellowships.

Setting  General surgery chief residents who applied for admission to the American Board of Surgery Qualifying Examination process.

Participants  All 1034 first-time applicants.

Main Outcome Measures ² tests and 1-way analyses of variance were used to correlate gender and residency type, size, and location with summed values and scaled mean scores for ratings of the importance of 12 potential factors in fellowship decision making.

Results  The fellowship rate was 77% and correlated with residency size and location. Women were dispersed asymmetrically across residencies overall but future female fellows were distributed similarly to male ones. Survey item response rates for future fellows were 96% to 98%. Clinical mastery and specialty activities were valued most highly by more than 90% of men and women. Men placed more value on income potential and spousal influence. Lifestyle factors reached only midrange importance for both genders. Program size had more significant relationships to decision-making factors than did gender.

Conclusions  The ability to master an area of clinical practice and the clinical activities of a specialty are the most important factors for chief residents in fellowship decision making, regardless of gender. Lifestyle factors are of midrange importance. Program size is as influential as is gender.