Surgery RSS : Gourt

Lucrative MIS - Advanced Laps / Bariatric Surgery Opportunity in a Progressive Historic City :: Iowa :: CompHealth Inc

Job 6511897 Must be Board Certified or Board Eligible General Surgery Will consider new grads or experiences - Prefer MIS Fellowship trained candidates Practice in a 200 bed, modern facility Call 1-4

Bread & Butter General Surgery Opportunity in a Beautiful Coastal Beach Area :: Maryland :: CompHealth Inc

Job 6512465 Ideal candidate is available now with 1-3 years out of training with modern surgical techniques and skills Bread & Butter General Surgery with advanced laps, endoscopic and breast work -

General Surgery Position a Stones Throw Away From Morgantown, West Virginia :: West Virginia :: CompHealth Inc

Job 6512057 Bread & Butter General Surgery - Must be Board Certified or Board Eligible Hospital employed practice opportunity Must be able to do Colonoscopies and Endoscopies Very competitive compensation

Come Grow With This Established General Surgeon Close to Gainesville :: Florida :: CompHealth Inc

Job 6512108 Practice needs to add another Board eligible / Board Certified General Surgeon Outstanding earnings potential being busy from the start and growing community demand Small town southern charm

Hospital Employed Position In Resort Area With White Sand Beaches :: Florida :: CompHealth Inc

Job 6512109 Enjoy Living in "top ten family vacation" area Great beaches, golf, tennis and fishing on Gulf of Mexico Competitive compensation package Malpractice Paid Relocation allowance Full Health

Beautiful Coastal Georgia Community Looking for General Surgeon :: Georgia :: CompHealth Inc

Job 6512426 Join a thriving practice Call 1:4 Must be able to do Vascular access for Dialysis ports One year to full partnership - no buy in Beautiful, culturally rich community Fine dining, great shopping

General / Vascular Surgeon Needed to Practice in Great Location :: West Virginia :: CompHealth Inc

Job 6512223 Fantastic Hospital employed practice opportunity awaits in this West Virginia city for an Experienced General / Vascular Surgeon Must be Board Certified or Board Eligible in General Surgery

Surgery opportunity with interest in Bariatrics/Advanced Laps :: Illinois :: CompHealth Inc

Job 6511620 Large GI Group looking to add second surgeon to help with demand Huge referral base Incredible earning potential 2-1/2 hours from Chicago Very Competitive salary and fast track to partnership

Multi-Specialty Group seeks 3rd Surgeon - Great Lifestyle :: Wisconsin :: CompHealth Inc

Job 6511905 Join an established thriving practice Be busy from day one Very competitive salary Close to Iowa Border Call 1:3 Great Community - Excellent school system Great dining options - plenty of

General Surgery Opportunity in a Beautiful Plain State :: Kansas :: CompHealth Inc

Job 6512376 Play golf on one of two 18 hole golf courses Looking for a general surgeon who would like to develop a subspecialty Possibility of Hospital employed position or Income Guarantee for year

MIS General Surgery in Upstate Wine and Lake Region :: New York :: CompHealth Inc

Job 659177 Bread and Butter MIS General Surgery Hospital employed position Call coverage of 1:3 Excellent package of benefits and compensation Outdoor activities throughout the entire region Close proximity

Well Known Coastal Resort Area Close to Florida :: Georgia :: CompHealth Inc

Job 6512386 Hospital employed position or can be Solo Beach Front Living 40+ bed hospital needs full time surgeon Very competitive compensation package High profile community Call will be 1:3 Low cost

Employed Hospital Position for General Surgeon :: Tennessee :: CompHealth Inc

Job 6512085 Full service Hospital needs a Bread & Butter practitioner University campus in town provides lots of activities Three major lakes offer water sports, fishing and hunting as popular pastimes

Big Money and Bread & Butter General Surgery :: Louisiana :: CompHealth Inc

Job 6512199 Need is due to growth in the community Full hospital supported recruitment Equal call sharing of 1:3 Work out of one mid-sized hospital Very competitive salary with full benefits 25 Minutes

General Surgeon Needed in the Heart of Ohio :: Ohio :: CompHealth Inc

Job 6511832 Choose from an Employment Model or an Income Guarantee Call is 1:3 Paid Malpractice - Very generous Vacation & CME package Beautiful Community Excellent school system Stable local economy

General Surgery Opportunity in New Mexico :: New Mexico :: CompHealth Inc

Job 1109046-0198 Must have good Trauma Experience (Level II & Level III) Active New Mexico License Ongoing weekend call coverage We offer competitive pay that may include incentives and bonuses We coordinate

Practice on the Banks of the Hudson River :: New York :: CompHealth Inc

Job 6511910 Opportunity to be a hospital employee or join a group of 4 other General Surgeons Call 1:5 or 1:4 depending on how you come in Great family community with lots of recreation and outdoor

Hospital Employed Position in Southwest :: New Mexico :: CompHealth Inc

Job 6511912 Employed position available Will consider new grads and experienced surgeons Can sponsor J-1's OR block time available Competitive compensation package Relocation, commencement Bonus and

OHIO NEEDS A BREAD AND BUTTER SURGEON :: Ohio :: CompHealth Inc

Job 6511988 Join a Premiere Multiple Specialty Group, physician owned and operated Bread & Butter General Surgery Must be Board Eligible or Board Certified Nice Location - progressive with much to see

Southwest's Best Small City :: New Mexico :: CompHealth Inc

Job 6512060 Southwest city needs General Surgeon for busy practice College Town Growth area with good economy Community offers many cultural events, festivals and outdoor recreation activities Climate

AHA: Weight-Loss Surgery Ups Cardiac Function in Kids (CME/CE)

ORLANDO (MedPage Today) -- Bariatric surgery led to sustained improvements in left ventricular mass and diastolic function in morbidly obese teenagers, a researcher reported here.

AHA: Rivaroxaban Cuts Risk of VTE in Joint Replacement (CME/CE)

ORLANDO (MedPage Today) -- Rivaroxaban, an investigative oral factor Xa inhibitor, appears to reduce the risk of deep vein thrombosis by 50% among hip and knee replacement patients when compared with enoxaparin (Lovenox), researchers reported here.

Robot-Assisted Surgery Unproven in Children (CME/CE)

Robot-assisted surgery is safe for a number of procedures performed on children, but little evidence exists that it works better than conventional techniques, a new study found.

PET-CT Predicts Complete Response in Head-Neck CA (CME/CE)

Negative PET-CT imaging after chemoradiation for head and neck cancer predicts response to therapy and identifies patients who do not need surgery, data from a small clinical series showed.

Surgical Mistakes Continue Despite VA Initiative (CME/CE)

Despite efforts to reduce them, surgical mistakes involving the wrong patient, wrong procedure, wrong site, or wrong implant continue to occur within the operating room and elsewhere in hospitals, a Veterans Health Administration study found.

Rib Cartilage Safe for Rhinoplasty (CME/CE)

Irradiated homologous rib cartilage was durable, well tolerated, and safe for use in rhinoplasty, long-term follow-up showed.

Continuous Infusions of Local Anesthetics May Lead to Chondrolysis

The FDA has received several reports of chondrolysis after continuous intra-articular infusions of local anesthetics with elastomeric infusion devices.

Spinal Replacement Devices Recalled

All lots of a device used to replace collapsed, damaged, or unstable vertebral bodies in the spine have been recalled by its manufacturer, the FDA said.

Statin Use May Cut Risk of Gallstone Surgery (CME/CE, with video)

Lowering cholesterol with statins may help lower the risk of developing gallstones that require surgery, researchers found.

Chronic Pain Common After Breast CA Surgery (CME/CE, with audio)

Nearly half of breast cancer survivors are plagued by persistent pain years after cancer surgery, researchers found.

AASLD: Liver Reserve Measured in Breath Test (CME/CE)

BOSTON (MedPage Today) -- A simple breath test gives a good overall measure of liver function in patients with chronic viral hepatitis and could help in evaluating potential liver transplant candidates, a researcher said here.

AASLD: Treating Before Transplant Cuts HCV Recurrence (CME/CE)

BOSTON (MedPage Today) -- In patients with advanced liver disease related to hepatitis C, a course of pegylated interferon and ribavirin (Rebetol) before liver transplant may help them avoid recurrence of infection, a researcher said here.

Resident Duty-Hour Cuts Said to Impair Surgical Education, Safety (CME/CE)

Limiting surgical residents' work hours has compromised both surgical education and patient safety, according to an analysis concluding that the 80-hour work week in the U.S. isn't enough.

Traditional CABG Edges Off-Pump Approach (CME/CE, with audio)

Use of a heart-lung machine during coronary-artery bypass grafting (CABG) doesn't impair outcomes or cognition any more than "off-pump" procedures, according to results of a large randomized trial.

Hospital Fined for Wrong-Site Surgery

Rhode Island Hospital, located in Providence, will pay $150,000 and install video cameras in all of its operating rooms after performing its fifth wrong-site surgery since 2007, according to the state's department of health.

About This Journal [About This Journal]

Is Use of Bone-Morphogenetic Proteins for Spine Fusion Surgery Cost-effective? [From JAMA]

Managing Patients With Clinically Significant Cardiac and Carotid Artery Occlusive Disease [From the Archives]

Nonoperative Management of Patients With a Diagnosis of High-grade Small Bowel Obstruction by Computed Tomography [Original Article]

Objective To determine the natural history and treatment of high-grade small bowel obstruction (HGSBO). Small bowel obstruction is a frequent complication of abdominal surgery. Complete and strangulating obstructions are managed operatively while partial obstructions receive a trial of nonoperative therapy. The management and outcome of patients with HGSBO diagnosed by computed tomography (CT) has not been examined. Design Retrospective medical record review. Outcomes for nonoperative vs operative management were analyzed using Fisher exact and log-rank tests. Setting Tertiary care referral center. Patients One thousand five hundred sixty-eight consecutive patients admitted from the emergency department with a diagnosis of small bowel obstruction between 2000 and 2005 by CT criteria. Main Outcome Measures Recurrence of symptoms and complications. Results One hundred forty-five patients (9%) with HGSBO were identified, with 88% follow-up (median, 332 days; range, 4-2067 days). Sixty-six (46%) were successfully managed nonoperatively while 79 (54%) required an operation. Length of stay and complications were significantly increased in the operative group (4.7 days vs 10.8 days and 3% vs 23%; P < .001). Nonoperative management was associated with a higher recurrence rate (24% vs 9%; P < .005) and shorter time to recurrence (39 days vs 105 days; P < .005) compared with operative intervention. Computed tomography signs of ischemia, admission laboratory results, and presence of cancer or inflammatory bowel disease were not predictive of an operation. Conclusions Patients with HGSBO by CT can be managed safely with nonoperative therapy; however, they have a significantly higher rate of recurrence requiring readmission or operation within 5 years.

Questioning the Small-Bowel Obstruction Paradigm [Invited Critique]

Downwardly Mobile: The Accidental Cost of Being Uninsured [Original Article]

Hypothesis Given the pervasive evidence of disparities in screening, hospital admission, treatment, and outcomes due to insurance status, a disparity in outcomes in trauma patients (in-hospital death) among the uninsured may exist, despite preventive regulations (such as the Emergency Medical Treatment and Active Labor Act). Design Data were collected from the National Trauma Data Bank from January 1, 2002, through December 31, 2006 (version 7.0). We used multiple logistic regression to compare mortality rates by insurance status. Setting The National Trauma Data Bank contains information from 2.7 million patients admitted for traumatic injury to more than 900 US trauma centers, including demographic data, medical history, injury severity, outcomes, and charges. Patients Data from patients (age, ≥18 years; n = 687 091) with similar age, race, injury severity, sex, and injury mechanism were evaluated for differences in mortality by payer status. Main Outcome Measure In-hospital death after blunt or penetrating traumatic injury. Results Crude analysis revealed a higher mortality for uninsured patients (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.36-1.42; P < .001). Controlling for sex, race, age, Injury Severity Score, Revised Trauma Score, and injury mechanism (adjusted for clustering on hospital), uninsured patients had the highest mortality (OR, 1.80; 95% CI, 1.61-2.02; P < .001). Subgroup analysis of young patients unlikely to have comorbidities revealed higher mortality for uninsured patients (OR, 1.89; 95% CI, 1.66-2.15; P < .001), as did subgroup analyses of patients with head injuries (OR, 1.65; 95% CI, 1.42-1.90; P < .001) and patients with 1 or more comorbidities (OR, 1.52; 95% CI, 1.30-1.78; P < .001). Conclusions Uninsured Americans have a higher adjusted mortality rate after trauma. Treatment delay, different care (via receipt of fewer diagnostic tests), and decreased health literacy are possible mechanisms.

Trauma of the Uninsured: Comment on "Downwardly Mobile: The Accidental Cost of Being Uninsured" [Invited Critique]

Identification of Specific Quality Improvement Opportunities for the Elderly Undergoing Gastrointestinal Surgery [Original Article]

Hypothesis Specific complications occur more frequently in elderly patients undergoing major gastrointestinal (GI) tract operations that may represent opportunities for quality improvement. Design Retrospective cohort study. Setting One hundred twenty-one hospitals participating in American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Patients Using the ACS-NSQIP participant use file (2005-2006), patients undergoing upper gastrointestinal tract (n = 4115), hepatobiliary or pancreatic (n = 3364), and colorectal (n = 17 268) operations at 121 hospitals were examined. Main Outcome Measures Risk-adjusted 30-day outcomes were assessed using regression modeling adjusting for patient characteristics, comorbidities, and surgical procedures. The elderly were defined as those older than 75 years. Results Between January 1, 2005, and December 31, 2006, a total of 54 747 patients who underwent major GI tract operations were identified from the ACS-NSQIP data file. In the elderly, overall perioperative morbidity was 1.2 to 2 times higher and mortality was 2.9 to 6.7 times higher than in younger patients after adjusting for differences in preoperative comorbidities. Irrespective of procedure type, the elderly were significantly more likely to experience cardiac (acute myocardial infarction and cardiac arrest), pulmonary (pneumonia, pulmonary embolism, and respiratory failure), and urologic (urinary tract infection and renal failure) complications. However, surgical site infections, postoperative bleeding events, deep venous thromboses, and rates of return to the operating room did not differ significantly by age. Conclusions Morbidity and mortality are markedly higher in older patients. Quality measures for the elderly currently address only myocardial infarction, surgical site infection, and deep venous thrombosis. If care for the elderly is to be improved, quality improvement initiatives need to be expanded to include postoperative pulmonary and renal complications.

Surgery and Old Age: An Age Old Question [Invited Critique]

Death After Colectomy: It's Later Than We Think [Original Article]

Background Clinical outcomes are increasingly subject to objective assessment and professional accountability. Informed consent relies on accurate estimation of operative risk. Current scoring systems for assessment of operative mortality after colorectal surgery (CRS) almost uniformly report 30-day mortality and may not represent true risk. Design Prospective cohort. Setting University-affiliated Veterans Affairs Medical Center. Patients All patients who underwent resections of the colon and/or rectum (as the principal operation) at a single hospital whose data are captured in the Veterans Affairs National Surgical Quality Improvement Program (VA-NSQIP) database from January 1, 2000, through December 31, 2006. Main Outcome Measures Mortality at 30 days and 90 days. Results The VA-NSQIP cohort included 186 patients who underwent CRS, including 148 patients who underwent elective procedures (79.6%) and 38 patients who underwent emergency procedures (20.4%). All but 8 patients were men, with a median age of 67 years (range, 26-92 years). Laparoscopic operations comprised 24.2% and open operations comprised 75.8%. Most (60.8%) were performed for neoplasms. The actual 30-day mortality rates (all, elective, and emergency procedures) were 4.3%, 1.4%, and 15.8%, respectively. These rates closely mirrored the calculated VA-NSQIP risk-adjusted observed-to-expected ratio for 30-day mortality (4.8%, 1.8%, and 18.2%, respectively). However, mortality at 90 days increased substantially to 9.1%, 4.1%, and 28.9%, respectively. Conclusion The 30-day mortality significantly underreports the true risk of death after CRS. The 90-day mortality rate should be included as a standard outcome measure after CRS because it serves as a better estimation of risk for counseling patients.

Incorrect Surgical Procedures Within and Outside of the Operating Room [Original Article]

Objective To describe incorrect surgical procedures reported from Veterans Health Administration (VHA) Medical Centers from 2001 to mid-2006 and provide proposed solutions for preventing such events. Design Descriptive study. Setting Veterans Health Administration Medical Centers. Participants Veterans of the US Armed Forces. Interventions The VHA instituted an initial directive, "Ensuring Correct Surgery and Invasive Procedures," in January 2003. The directive was updated in 2004 to include non–operating room (OR) invasive procedures and incorporated requirements of The Joint Commission Universal Protocol for preventing wrong-site operations. Main Outcome Measures The categories included 5 incorrect event types (wrong patient, side, site, procedure, or implant), major or minor surgical procedures, location in or out of the OR, therapeutic or diagnostic events, adverse event or close call, inpatient or ambulatory events, specialty department, body segment, and severity and probability of harm. Results We reviewed 342 reported events (212 adverse events and 130 close calls). Of these, 108 adverse events (50.9%) occurred in an OR, and 104 (49.1%) occurred elsewhere. When examining adverse events only, ophthalmology and invasive radiology were the specialties associated with the most reports (45 [21.2%] each), whereas orthopedics was second to ophthalmology for number of reported adverse events occurring in the OR. Pulmonary medicine cases (such as wrong-side thoracentesis) and wrong-site cases (such as wrong spinal level) were associated with the most harm. The most common root cause of events was communication (21.0%). Conclusions Incorrect ophthalmic and orthopedic surgical procedures appear to be overrepresented among adverse events occurring in ORs. Outside the OR, adverse events by invasive radiology were most frequently reported. Incorrect surgical procedures are not only an OR challenge but also a challenge for events occurring outside of the OR. We support earlier communication based on crew resource management to prevent surgical adverse events.

Patient Safety Systems: A Long Way to Go [Invited Critique]

Treatment of Hepatic Epithelioid Hemangioendothelioma: A Single-Institution Experience With 25 Cases [Original Article]

Objective To examine treatment of hepatic epithelioid hemangioendothelioma (EHE), a rare vascular tumor with a variable course. Treatment modalities at our institution include liver resection, transplantation, and catheter-based therapies. Design, Patients, and Main Outcome Measures Retrospective review of 25 patients treated for hepatic EHE (1976-2007). We examined treatment modality, overall survival, complications, and clinicopathologic characteristics. Results Of the 25 patients treated for hepatic EHE, 17 underwent liver transplantation (LT); 4, transcatheter arterial chemoembolization (TACE); 2, resection; and 2, TACE followed by LT. Twelve patients (48%) were male. The median age at diagnosis was 38 years (range, 9 months to 72 years). Mean overall survival was 167 (95% confidence interval [CI], 123-212) months, with 172 (124-220) months in the LT group and 83 (54-112) months in the TACE group. The 2 patients in the resection group remain alive after 19 and 71 months. The 2 patients treated with TACE followed by LT died after 13 and 113 months. Extrahepatic disease was identified as a predictor of outcome. Patients with extrahepatic disease treated with TACE fared better than those treated with surgical approaches (mean survival, 83.0 [95% CI, 54.2-111.8] vs 38.8 [23.7-53.8] months; P = .12). Conclusions Hepatic EHE is a rare tumor that can be treated with surgical or nonsurgical approaches. In our experience, LT is used for patients with advanced local disease, whereas TACE is the primary modality when extrahepatic disease or comorbid conditions prohibiting LT are present. To our knowledge, this is the largest single-institution experience describing the various therapeutic modalities in the treatment of hepatic EHE.

Getting a Handlle on Managing Rare Tumors [Invited Critique]

Splenic Salvage After Intraoperative Splenic Injury During Colectomy [Original Article]

Objective To determine the optimal surgical management of splenic injury encountered during colectomy. Design Retrospective review from 1992 to 2007. Setting Mayo Clinic in Rochester, Minnesota, a tertiary care center. Patients A cohort of patients who sustained splenic injury during colectomy from 1992 to 2007. Main Outcome Measures Overall 30-day major morbidity and mortality and overall 5-year survival. Results Of 13 897 colectomies, we identified 59 splenic injuries (0.42%). Of these, 33 (56%) were in men; there was a median age of 68 years (range, 30-93 years) and a median body mass index of 25.5 (range, 15-54). Thirty-seven injuries (63%) occurred during elective surgery, 6 (10%) occurred without splenic flexure mobilization, and 5 (8.4%) occurred during minimally invasive surgery. Injury was successfully managed by primary repair in 10 (17%), splenorrhaphy in 4 (7%), and splenectomy in 45 cases (76%). Four injuries (7%) were unrecognized and resulted in reoperation and splenectomy. Multiple attempts at splenic salvage were performed in 30 (51%); of these, 21 (70%) required splenectomy. More than 2 attempts at salvage was associated with splenectomy (P = .03). The 30-day major morbidity and mortality rates were 34% and 17%, respectively. Sepsis was the most common complication, with no confirmed episodes of postsplenectomy sepsis. Median survival after splenic injury was 7.25 years. There was no significant association between the surgical management of splenic injuries and short- or long-term outcomes. Conclusions Splenic injury is an infrequent but morbid complication. Splenic salvage is frequently unsuccessful; our data suggest that surgeons should not be reluctant to perform splenectomy when initial repair attempts fail.

Abdominal Wall Reconstruction: Lessons Learned From 200 "Components Separation" Procedures [Original Article]

Objectives To determine the efficacy and describe the evolution of the "components separation" technique for abdominal wall repair in 200 consecutive patients. Design Retrospective medical record review. Setting Northwestern Memorial Hospital, Chicago, Illinois. Patients Two hundred consecutive patients who underwent ventral hernia repair using the components separation technique. Interventions Biological and permanent meshes were used in select patients to augment the repair of the midline fascial closure but were not used as "bridging" materials. Main Outcome Measures Hernia recurrence rates and major and minor complication rates for the overall series and for the different techniques. Results Primary components separation (n = 158) yielded a 22.8% recurrence rate. Closure of the midline tissues with augmentation of the repair using an acellular cadaveric dermis underlay (n = 18) had a 33.3% recurrence rate requiring a second operation, whereas intra-abdominal soft polypropylene mesh (n = 18) had 0% recurrence (P = .04). Elevated body mass index was a significant risk factor predicting hernia recurrence (P = .003). Contamination (P = .04) and enterocutaneous fistula (P = .02) at the time of surgery were associated with increased major complications, whereas body mass index (P = .01) and diabetes mellitus (P = .04) were associated with increased minor complications. Conclusions Large complex hernias can be reliably repaired using the components separation technique despite the presence of open wounds, the need for bowel surgery, and numerous comorbidities. The long-term strength of the hernia repair is not augmented by acellular cadaveric dermis but seems to be improved with soft polypropylene mesh.

Effect of Stitch Length on Wound Complications After Closure of Midline Incisions: A Randomized Controlled Trial [Original Article]

Hypothesis In midline incisions closed with a single-layer running suture, the rate of wound complications is lower when a suture length to wound length ratio of at least 4 is accomplished with a short stitch length rather than with a long one. Design Prospective randomized controlled trial. Setting Surgical department. Patients Patients operated on through a midline incision. Intervention Wound closure with a short stitch length (ie, placing stitches <10 mm from the wound edge) or a long stitch length. Main Outcome Measures Wound dehiscence, surgical site infection, and incisional hernia. Results In all, 737 patients were randomized: 381 were allocated to a long stitch length and 356, to a short stitch length. Wound dehiscence occurred in 1 patient whose wound was closed with a long stitch length. Surgical site infection occurred in 35 of 343 patients (10.2%) in the long stitch group and in 17 of 326 (5.2%) in the short stitch group (P = .02). Incisional hernia was present in 49 of 272 patients (18.0%) in the long stitch group and in 14 of 250 (5.6%) in the short stitch group (P < .001). In multivariate analysis, a long stitch length was an independent risk factor for both surgical site infection and incisional hernia. Conclusion In midline incisions closed with a running suture and having a suture length to wound length ratio of at least 4, current recommendations of placing stitches at least 10 mm from the wound edge should be changed to avoid patient suffering and costly wound complications. Trial Registration clinicaltrials.gov Identifier: NCT00508053

Outcomes From 3144 Adrenalectomies in the United States: Which Matters More, Surgeon Volume or Specialty? [Original Article]

Objective To assess the effect of surgeon volume and specialty on clinical and economic outcomes after adrenalectomy. Design Population-based retrospective cohort analysis. Setting Healthcare Cost and Utilization Project Nationwide Inpatient Sample. Participants Adults (≥18 years) undergoing adrenalectomy in the United States (1999-2005). Patient demographic and clinical characteristics, surgeon specialty (general vs urologist), surgeon adrenalectomy volume, and hospital factors were assessed. Main Outcome Measures The 2 test, analysis of variance, and multivariate linear and logistic regression were used to assess in-hospital complications, mean hospital length of stay (LOS), and total inpatient hospital costs. Results A total of 3144 adrenalectomies were included. Mean patient age was 53.7 years; 58.8% were women and 77.4% white. A higher proportion of general surgeons were high-volume surgeons compared with urologists (34.1% vs 18.2%, P < .001). Low-volume surgeons had more complications (18.2% vs 11.3%, P < .001) and their patients had longer LOS (5.5 vs 3.9 days, P < .001) than did high-volume surgeons; urologists had more complications (18.4% vs 15.2%, P = .03) and higher costs ($13 168 vs $11 732, P = .02) than did general surgeons. After adjustment for patient and provider characteristics in multivariate analyses, surgeon volume, but not specialty, was an independent predictor of complications (odds ratio = 1.5, P < .002) and LOS (1.0-day difference, P < .001). Hospital volume was associated only with LOS (0.8-day difference, P < .007). Surgeon volume, specialty, and hospital volume were not predictors of costs. Conclusion To optimize outcomes, patients with adrenal disease should be referred to surgeons based on adrenal volume and laparoscopic expertise irrespective of specialty practice.

Factors That Determine Satisfaction With Surgical Treatment of Low-Income Women With Breast Cancer [Original Article]

Objective To analyze the relationship between patient satisfaction with surgical treatment and 4 consultation skills and processes of the surgeons (time spent, listens carefully, explains concepts in a way the patient can understand, and shows respect for what the patient has to say), controlling for a range of patient, surgeon, and treatment characteristics. Design Cross-sectional survey. Setting The Breast and Cervical Cancer Treatment Program for the state of California. Patients A statewide sample of 789 low-income women who received treatment for breast cancer from February 1, 2003, through September 31, 2005. Main Outcome Measure Satisfaction with surgical treatment. Results Three of every 4 women reported being extremely satisfied with the treatment they received from their surgeon. African American women and those with arm swelling were less likely to be satisfied, whereas those reporting that the surgeon always spent enough time and explained concepts in a way they could understand were more likely to report greater satisfaction. Conclusion Our findings highlight the importance of 2 relatively simple behaviors that surgeons can easily implement to increase patient satisfaction, which can be of potential benefit in the litigious world of today.

Measures to Prevent Pancreatic Fistula After Pancreatoduodenectomy: A Comprehensive Review [Review Article]

Objective To review the current evidence on the efficacy of various interventions directed toward prevention of pancreatic fistula after pancreatoduodenectomy. Data Sources A MEDLINE database search from January 1, 1990, to August 31, 2008, was performed to identify relevant articles using the keywords pancreatoduodenectomy, pancreaticojejunostomy, pancreaticogastrostomy, pancreatic anastomotic leakage, and pancreatic fistula. Additional articles were identified by a manual search of the references from the key articles. Study Selection Case reports were excluded from this study. Data Extraction Of the identified studies, only those published in English describing meta-analyses or randomized controlled trials were considered first. In those aspects with limited or no randomized controlled trials, nonrandomized comparative studies and case series were included also. Data Synthesis The prophylactic use of perioperative somatostatin and its analogues to prevent pancreas-related complications after pancreatic surgery remains controversial and does not result in a reduction of operative mortality. There is no clear evidence for or against a particular type of pancreaticoenteric anastomosis. Pancreaticoenterostomy cannot be replaced by pancreatic ductal obliteration. Pancreaticogastrostomy is equivalent to pancreaticojejunostomy in perioperative morbidity and mortality. Conclusion More large-scale comparative studies and randomized controlled trials are required to determine the optimum pharmacologic interventions and technique of pancreaticoenteric anastomosis after pancreatoduodenectomy.

Benign Fibroepithelial Polyp Arising in the Bronchus: A Case Report and Review of the Literature [Resident's Forum]

Benign endobronchial polyps are rare findings that present a diagnostic dilemma not only for the clinician but also for the pathologist. We describe a man with repeated visits to emergency departments for coughing spells who ultimately underwent bronchoscopy and biopsy. The biopsy specimen was initially diagnosed as a leiomyoma, but the final pathologic diagnosis of the gross specimen was a benign fibroepithelial polyp. We present the clinical history of this patient along with a brief review of the published literature regarding this rare clinical entity.

Image of the Month--Quiz Case [Special Feature]

Image of the Month--Diagnosis [Special Feature]

Image of the Month--Quiz Case [Special Feature]

Image of the Month--Diagnosis [Special Feature]

The Life and Times of Allen Oldfather Whipple: The Missionary and the Surgeon [Book Reviews]