Surgery RSS : Gourt

Permanent Surgery Job in Suburban South Carolina General Surgery South Carolina with CompHealth Inc

Job 659474 Hospital based Surgery group - become a hospital employee Call of 1:2 with possible 1:3 Practice Bread and Butter with Laps at one mid-sized hospital Very competitive salary with productivity

Permanent Surgery Job in Great Alabama Family Oriented Community Seeks General Surgeon Alabama with CompHealth Inc

Job 659431 MGMA Competitive Salary Shared Call Take over thriving practice of a retiring surgeon Large referral base Great family community Incentives/Bonus, Malpractice Paid 4 Weeks Vacation, 1 Week

Permanent Surgery Job in Championship Golf and General Surgery on the Coast California with CompHealth Inc

Job 659412 Central Californian Coast location working out of one hospital 100+ beds Bread and Butter and Laps skills required Call of 1:4, no Trauma Hospital Employee with competitive salary and benefits

Permanent Surgery Job in Great Midwestern Town MSG Looking to Add a General Surgeon Iowa with CompHealth Inc

Job 659377 One or Two years to Shareholder Status Salary plus production bonus Clinic attached to hospital Two hours to Des Moines and Cedar Rapids Focused family community with excellent schools, a

Permanent Surgery Job in Wound Care - Lifestyle Practice Montana with CompHealth Inc

Job 659392 Established Wound Care Center offers fabulous opportunity A dynamic, committed physician, passionate about the miracle of Wound Care, is sought Hospital will arrange for all training and

Permanent Surgery Job in General Surgeon Needed to Join Well Established Group in Beautiful Wine Country Washington with CompHealth Inc

Job 659324 Seeking BC/BE General B & B Surgeon Join large, well established group - great referral base Be busy from Day 1 Very congenial group 1:4 call schedule Excellent compensation and benefits

Permanent Surgery Job in Practice General Surgery as a Hospital Employee Pennsylvania with CompHealth Inc

Job 659338 Hospital seeks BE/BC General Surgeon Employment package offers excellent compensation Benefits package includes malpractice insurance, health benefits, and retirement savings plans Area is

Permanent Surgery Job in One of 100 Best Small Towns in America Alabama with CompHealth Inc

Job 659337 Lots of Referrals Enjoy small town living with proximity to bigger city Great packages to include: income guarantee and expense Commencement Bonus Relocation assistance Marketing assistance

Permanent Surgery Job in Surgeon Needed in Tri-State Area Alabama with CompHealth Inc

Job 659336 Collegial group is seeking to hair another BE/ BC Surgeon Huge service area Great packages to include: Salary and expense Commencement Bonus Relocation assistance Marketing assistance Medical

Permanent Surgery Job in Beautiful Kentucky Community Looking for a General Surgeon Kentucky with CompHealth Inc

Job 659353 BC/BE General Surgeon Must do scopes Private Practice Opportunity Large referral base Opportunity is to take over well established practice of retiring surgeon Call 1:3 CompHealth offers

Permanent Surgery Job in Surgical Oncologist needed for large Northern Virginia Hospital Virginia with CompHealth Inc

Job 657913 BC / BE Surgical Oncologist Must be Fellowship Trained Call 1:5 Salary commensurate with MGMA guidelines Full Benefit Package One Hour to Washington, DC Incentives / Bonus Paid Malpractice

Permanent Surgery Job in Bluegrass Living with Close proximity to Cincinnati Kentucky with CompHealth Inc

Job 659314 Bread and butter with sub-specialties welcome Practice out of one hospital, approx. 100 beds; Call of 1:3 Big money with possible joining of other surgeon or hospital employee Salary or IG

Permanent Surgery Job in Outdoor Paradise Minnesota with CompHealth Inc

Job 613850 Very aggressive compensation package Call of 1:4 Possible loan repayment Join the premier group in northern MN Benefits 100% for employee, 10% copay for family Malpractice Vacation, CME,

Permanent Surgery Job in Scenic Community Oregon with CompHealth Inc

Job 613098 Successful MSG seeks a General Surgeon to join one other Call 1:7 Area is known for rafting, fishing and other water activities Salary, benefits and partnership track Medical, life insurance

Permanent Surgery Job in Lucrative General Surgery Opportunity for 2007 Grad to Join a Group in a Suburb of Metro St. Louis Illinois with CompHealth Inc

Job 657462 Located 15-20 minutes from St. Louis, MO Join a single specialty Group on a Partnership Track Call of 1:5 or better Strong group, great area, friendly people make this a must see opportunity

Permanent Surgery Job in Advanced Laps (MIS) Trained Surgeon needed in this Midwest Community Illinois with CompHealth Inc

Job 658189 Opportunity to join established single specialty group Da Vinci Robotics System in place at this 350 bed modern medical center Must have MIS - Advanced Laps Fellowship training or experience.

Permanent Surgery Job in General Surgery Practice Opportunity Close to Metro Chicago Illinois with CompHealth Inc

Job 658587 Great location only 90 minutes to Chicago Bread & butter General Surgeon with modern surgical skills Must do advanced Laps Join another surgeon on a partnership track or be set up in a solo

Permanent Surgery Job in Big Money - Hospital Employed - Join a great group of Surgeons! Indiana with CompHealth Inc

Job 657861 Hospital Employed Position Salary $275,000, plus incentives Be Busy from Day One Recruiting due to retirement of 1 surgeon Call 1:3 Hospital looking to hire immediately Paid Malpractice Loan

Permanent Surgery Job in Lucrative Vascular Surgery Opportunity in a Progressive Historic City Iowa with CompHealth Inc

Job 657373 Practice in a 200 bed modern facility Call 1-4 Very lucrative potential - very little HMO or managed care in area Will considered new grads or experienced Under Served area will support qualified

Permanent Surgery Job in Bread & Butter General Surgery Opportunity-Develop Advanced Laps., Bariatrics, Vascular, Colorectal, Kansas with CompHealth Inc

Job 615635 Bread & Butter General surgery need with modern surgical skills- Develop Either Advanced Laps Practice, Bariatrics, Vascular, Colorectal, or Surgical Oncology --any specialty training can

HCV-Positive Liver Recipients Do Well with Older Grafts

ST. LOUIS -- Older donor livers do not predispose hepatitis C-positive transplant recipients to worse outcomes, a 10-year prospective database analysis indicated.

Antibiotic Timing Affects Risk of Pediatric Surgical Infections

BALTIMORE -- Giving children prophylactic antibiotics an hour or less before they undergo spinal surgery reduces the risk of deep post-surgical infections, researchers here said.

Kidney Transplant Outcome Improved in High-Risk Patients

LOS ANGELES -- The prospect of a successful kidney transplant for sensitized patients with high anti-HLA antibody levels improves by a combination of intravenous immune globulin and rituximab (Rituxan), researchers here said.

Clinician Education Found Effective for Fall Prevention

NEW HAVEN, Conn. -- Fall-related injuries dropped after physicians and a cross-section of others in the healthcare community were taught strategies to help older patients stay on their feet, a controlled trial showed.

Outcomes Excellent for Joint Replacement in Older Adults

BOSTON -- Older patients who had hip or knee replacement for severe osteoarthritis took several weeks to recover but had excellent long-term outcomes, a prospective study found.

Cardiovascular Surgeon Michael DeBakey, M.D., Dies at 99

HOUSTON -- Michael E. DeBakey, M.D., one of the towering figures of cardiovascular surgery during the second half of the 20th century, has died at the age of 99.

AOSSM: Pitchers as Young as 14 Get Reconstructive Elbow Surgery

ORLANDO -- Ulnar collateral ligament reconstruction of the elbow -- the so-called Tommy John surgery -- has returned more than 80% of athletes, some as young as 14, to at least a pre-injury level of competition, according to a single-center study.

Slim Evidence for Organ Graft Outcomes in HIV Patients

PLYMOUTH MEETING, Pa. -- The evidence addressing key questions about results of kidney or liver transplants in HIV patients is small and inconclusive, according to a report by the ECRI Institute here.

Allograft ACL Repair Questioned in Young Active Patients

ORLANDO -- Using tissue from cadavers to reconstruct anterior cruciate ligaments in young active patients is associated with a failure rate of nearly 25%, a researcher said here.

FDA Strengthens Fluoroquinolone Tendon Warnings

ROCKVILLE, Md. -- The FDA announced today it will require a boxed warning about the risk of tendinitis and tendon rupture on the labels of fluoroquinolone antibiotics, heightening attention to an existing caution.

Graft-Success Risk Higher for a Woman Getting Male Kidney

BASEL, Switzerland -- Male-to-female kidney transplants may reduce graft-success rates, possibly because of minor histocompatibility antigens encoded by genes on the Y chromosome, a large retrospective study found.

Nutritional Support Linked to Lower Brain Trauma Mortality

NEW YORK -- The traumatically injured brain apparently needs early high-calorie nutritional support, according to investigators here.

FDA Warns on Off-Label Cervical Use of Bone Morphogenetic Protein

ROCKVILLE, Md. -- The FDA issued an advisory today on life-threatening complications from the off-label use of recombinant human bone morphogenetic protein (rhBMP) in cervical-spine fusion procedures.

MRSA Changes Face of Osteomyelitis

Explain to interested patients that pediatric osteomyelitis cases grew more severe and took longer to treat as time passed, apparently because of increasing prevalence of antibiotic-resistant Staphylococcus aureus.

Sudden Deafness Linked to Increased Risk of Stroke

TAIPEI, Taiwan -- Sudden sensorineural hearing loss may signal an increased risk of a stroke within five years, researchers here found.

The Long-term Results of a Randomized Clinical Trial of Laparoscopy-assisted Versus Open Surgery for Colon Cancer.

This clinical randomized trial compared the long-term results of laparoscopy-assisted colon resection with the open colon resection for nonmetastatic colon cancer. The Kaplan-Meier analysis demonstrated that patients treated by laparoscopy-assisted colectomy have a higher probability of cancer-related survival than those treated by open surgery (P = 0.02).Page: 1DOI: 10.1097/SLA.0b013e31816a9d65Authors: Lacy, Antonio M. MD, PhD *; Delgado, Salvadora MD, PhD *; Castells, Antoni MD, PhD +; Prins, Hubert A. MD, PhD *; Arroyo, Vicente MD, PhD +; Ibarzabal, Ainitze MD, PhD *; Pique, Josep M. MD, PhD +

Long-term Results of Laparoscopic-assisted Colectomy Are Comparable to Results After Open Colectomy.

Page: 8DOI: 10.1097/SLA.0b013e31817c965dAuthors: McLeod, Robin MD

Comparing Outcomes of Laparoscopic Versus Open Bariatric Surgery.

This study uses nationally representative, population-based data to examine outcomes of laparoscopic versus gastric bypass surgery.Page: 10DOI: 10.1097/SLA.0b013e31816d953aAuthors: Weller, Wendy E. PhD *; Rosati, Carl MD, FRCSC +

The Success of Laparoscopic Bariatric Surgery-It Has Come of Age and It Is Safe.

Page: 16DOI: 10.1097/SLA.0b013e31817c964dAuthors: Sarr, Michael G. MD

Surgical Treatment of Persistent Hyperparathyroidism After Renal Transplantation.

Persistent hyperparathyroidism after kidney transplantation (3HPT) usually regresses within the first months after transplantation. Parathyroidectomy for 3HPT is therefore uncommon. Consequently, few studies have been published on this topic. We review current knowledge about the pathogenesis, epidemiology, and clinical complications of 3HPT and discuss the surgical strategies.Page: 18DOI: 10.1097/SLA.0b013e3181728a2dAuthors: Triponez, Frederic MD *; Clark, Orlo H. MD +; Vanrenthergem, Yves MD ++; Evenepoel, Pieter MD ++

Postoperative Complications in the Seriously Mentally Ill: A Systematic Review of the Literature.

A systematic review of the literature found only 12 studies addressing clinical postoperative complications among patients with diagnoses of serious mental illness such as schizophrenia or major depressive disorder. This sparse evidence suggests higher risk for these patients and clearly indicates that more research is needed to inform perioperative risk management.Page: 31DOI: 10.1097/SLA.0b013e3181724f25Authors: Copeland, Laurel A. PhD *+; Zeber, John E. PhD *+; Pugh, Mary Jo PhD *++; Mortensen, Eric M. MD, MSc *++; Restrepo, Marcos I. MD, MSc *++; Lawrence, Valerie A. MD, MSc *++

Gracilis Muscle Interposition for the Treatment of Rectourethral, Rectovaginal, and Pouch-vaginal Fistulas: Results in 53 Patients.

The gracilis muscle is a versatile source of well-vascularized tissue for perineal reconstructions. This study aimed to review our experience with the gracilis muscle interposition for complex perineal fistulas.Page: 39DOI: 10.1097/SLA.0b013e31817d077dAuthors: Wexner, Steven D. MD; Ruiz, Dan E. MD; Genua, Jill MD; Nogueras, Juan J. MD; Weiss, Eric G. MD; Zmora, Oded MD

Peritoneal Drainage or Laparotomy for Neonatal Bowel Perforation?: A Randomized Controlled Trial.

In an international randomized controlled trial comparing peritoneal drain with laparotomy in extremely low birth weight infants with pneumoperitoneum, there was no survival advantage with drain and most patients required laparotomy.Page: 44DOI: 10.1097/SLA.0b013e318176bf81Authors: Rees, Clare M. MB, ChB, MRCS *; Eaton, Simon PhD *; Kiely, Edward M. FRCSI, FRCS, FRCPCH(Hon) *; Wade, Angie M. PhD, CStat +; McHugh, Kieran FRCR ++; Pierro, Agostino MD, FRCS(Engl), FRCS(Edin), FAAP(Hon) *

Systematic Review and Meta-Analysis of the Role of Defunctioning Stoma in Low Rectal Cancer Surgery.

In this study, a systematic review and a meta-analysis of the role of defunctioning stoma in low rectal cancer surgery were performed, revealing that a stoma reduces the rate of clinically relevant anastomotic leakages. Furthermore, overall mortality rates were comparable. Thus, creation of a defunctioning stoma is recommended in surgery for low rectal cancers.Page: 52DOI: 10.1097/SLA.0b013e318176bf65Authors: Huser, Norbert MD *; Michalski, Christoph W. MD *; Erkan, Mert MD *; Schuster, Tibor MSc +; Rosenberg, Robert MD *; Kleeff, Jorg MD *; Friess, Helmut MD *

Use of Recombinant Activated Factor VII in Patients Without Hemophilia: A Meta-Analysis of Randomized Control Trials.

A meta-analysis of 22 randomized controlled trials with 3184 participants showed recombinant activated factor VII to be associated with a reduced need for transfusion (OR, 0.54; 95% CI, 0.34-0.86) and a possibly reduced risk of death (OR, 0.88; 95% CI, 0.71-1.09) but without an increased risk of thromboembolism (OR, 1.17; 95% CI, 0.87-1.58) compared with placebo in patients without hemophilia.Page: 61DOI: 10.1097/SLA.0b013e318176c4ecAuthors: Hsia, Cyrus C. MD +; Chin-Yee, Ian H. MD +; McAlister, Vivian C. MB *

Transoral Endoscopic Fundoplication in the Treatment of Gastroesophageal Reflux Disease: The Anatomic and Physiologic Basis for Reconstruction of the Esophagogastric Junction Using a Novel Device.

This first objective assessment of the endolumenal approach to fundoplication in a canine model demonstrated procedural safety, long-term serosal apposition, and esophagogastric junction reconstruction similar to the Nissen fundoplication. Short-term follow-up demonstrated normalization of esophageal acid exposure.Page: 69DOI: 10.1097/SLA.0b013e31817c9630Authors: Jobe, Blair A. MD *; O'Rourke, Robert W. MD +; McMahon, Barry P. MS, PhD ++; Gravesen, Flemming MS [S]; Lorenzo, Cedric MD +; Hunter, John G. MD +; Bronner, Mary MD [P]; Kraemer, Stefan J. M. MD **

Major Hepatectomy for the Treatment of Complex Bile Duct Injury.

Major hepatectomy is an effective treatment for patients with complex hilar bile duct injuries. Although this procedure is associated with a high morbidity rate, our good long-term results suggest that major hepatectomy should be considered as a salvage solution before liver transplantation or recourse to metallic stents.Page: 77DOI: 10.1097/SLA.0b013e31817b65f2Authors: Laurent, Alexis MD, PhD; Sauvanet, Alain MD; Farges, Olivier MD, PhD; Watrin, Thierry MD; Rivkine, Emmanuel MD; Belghiti, Jacques MD

Intrahepatic Cholangiocarcinoma: Rising Frequency, Improved Survival, and Determinants of Outcome After Resection.

Intrahepatic cholangiocarcinoma (IHC) incidence has increased dramatically in the last 16 years with resection offering the best opportunity for long-term survival. Patients with large, node-positive, or multifocal IHC seem to derive little benefit with resection. The recent increase in survival seems largely because of improved nonoperative therapy for unresectable disease and may be related to increased use of regional chemotherapy.Page: 84DOI: 10.1097/SLA.0b013e318176c4d3Authors: Endo, Itaru MD *[//]; Gonen, Mithat PhD +; Yopp, Adam C. MD *; Dalal, Kimberly M. MD *; Zhou, Qin PhD +; Klimstra, David MD ++; D'Angelica, Michael MD *; DeMatteo, Ronald P. MD, PhD *; Fong, Yuman MD *; Schwartz, Lawrence MD [S]; Kemeny, Nancy MD [P]; O'Reilly, Eileen MD [P]; Abou-Alfa, Ghassan K. MD [P]; Shimada, Hiroshi MD [//]; Blumgart, Leslie H. MD *; Jarnagin, William R. MD *

Results of Pancreaticoduodenectomy in Patients With Periampullary Adenocarcinoma: Perineural Growth More Important Prognostic Factor Than Tumor Localization.

Among the clinicopathological characteristics, perineural invasion is a more important prognostic variable than the origin of the tumor in 121 patients with either carcinoma of the pancreatic head, the distal bile duct, ampulla of Vater, or duodenum.Page: 97DOI: 10.1097/SLA.0b013e31817b6609Authors: van Roest, Margijske H. G. MD *; Gouw, Annette S. H. MD, PhD +; Peeters, Paul M. J. G. MD, PhD *; Porte, Robert J. MD, PhD *; Slooff, Maarten J. H. MD, PhD *; Fidler, Vaclav PhD ++; de Jong, Koert P. MD, PhD *

Challenges in Surgical Management of Abdominal Pain in the Neutropenic Cancer Patient.

Sixty patients with abdominal pain and neutropenia were examined for their presentation, treatment, and outcomes. Abdominal pain as a symptom in neutropenic patients continues to be a diagnostic and therapeutic challenge and is associated with a high mortality rate. Surgery should be delayed, when possible, to allow for neutrophil recovery.Page: 104DOI: 10.1097/SLA.0b013e3181724fe5Authors: Badgwell, Brian D. MD *; Cormier, Janice N. MD, MPH *; Wray, Curtis J. MD *; Borthakur, Gautam MBBS +; Qiao, Wei MS ++; Rolston, Kenneth V. MD [S]; Pollock, Raphael E. MD, PhD *

Carotid Artery Stenting Compared to Carotid Endarterectomy Performed Exclusively in a Veteran Population: One Center's Experience With Midterm Results.

This is a retrospective review of one center's experience with carotid artery stenting (CAS) and carotid endarterectomy (CEA) in a veteran population. Major adverse event rates for CAS and CEA are comparable with previously published national standards.Page: 110DOI: 10.1097/SLA.0b013e318176c49dAuthors: Brown, Katherine E. DO *; Fanciullo, Dustin J. MD +; Hicks, Taylor MD +; Landau, David S. MD +; Baraniewski, Henry M. MD +; Morasch, Mark D. MD *; Matsumura, Jon S. MD *; Pearce, William H. MD *; Eskandari, Mark K. MD *; Kibbe, Melina R. MD *

Visceral Injury and Systemic Inflammation in Patients Undergoing Extracorporeal Circulation During Aortic Surgery.

Visceral injury and inflammation are evaluated in patients undergoing extracorporeal circulation for thoracic or thoracoabdominal aortic aneurysm repair. The extent of intestinal injury correlated significantly with systemic inflammation.Page: 117DOI: 10.1097/SLA.0b013e3181784cc5Authors: Hanssen, Sebastiaan J. MD *+++; Derikx, Joep P. MD *+; Vermeulen Windsant, Iris C. MD *+++; Heijmans, John H. MD, PhD [S]; Koeppel, Thomas A. MD, PhD ++; Schurink, Geert Willem MD, PhD +++[P]; Buurman, Wim A. PhD *+; Jacobs, Michael J. MD, PhD +++[P]

Gender Differences in Pediatric Burn Patients: Does It Make a Difference?

The aim of the present study was to compare hospital course and physiologic markers between severely burned pediatric females and males in a large unicenter study. We found that female burned patients exert an attenuated inflammatory and hypermetabolic response compared with males, which is associated with improved muscle protein net balance and preservation of lean body mass, leading to shortened hospital stay.Page: 126DOI: 10.1097/SLA.0b013e318176c4b3Authors: Jeschke, Marc G. MD, PhD *+; Mlcak, Ronald P. PhD *; Finnerty, Celeste C. PhD *+; Norbury, William B. MD *; Przkora, Rene MD *; Kulp, Gabriela A. MS *; Gauglitz, Gerd G. MD *; Zhang, Xiao-Jun PhD *+; Herndon, David N. MD, FACS *+

Introduction of Bias By Merging Patients With Initial Surgery and Reoperations in Analysis of Survival.

Page: 137DOI: 10.1097/SLA.0b013e31817c9879Authors: Machens, Andreas MD; Dralle, Henning MD

Introduction of Bias By Merging Patients With Initial Surgery and Reoperations in Analysis of Survival.

Page: 137DOI: 10.1097/SLA.0b013e31817c98c0Authors: Cupisti, Kenko MD; Yang, Qin PhD; Ohmann, Christian PhD; Knoefel, Wolfram T. MD

Re: Right Hepatic Trisectionectomy for Hepatobiliary Disease: Results and an Appraisal of Its Current Role.

Page: 138DOI: 10.1097/SLA.0b013e31817d9c4fAuthors: Vauthey, Jean-Nicolas MD; Palavecino, Martin MD; Curley, Steven A. MD; Abdalla, Eddie K. MD

Re: Right Hepatic Trisectionectomy for Hepatobiliary Disease: Results and an Appraisal of Its Current Role.

Page: 139DOI: 10.1097/SLA.0b013e31817c98e4Authors: Lodge, J Peter A. MD, FRCS

Who Is Benefited by Perioperative Statin Therapy?

Page: 140DOI: 10.1097/SLA.0b013e31817c989eAuthors: Fujita, Tetsuji MD

Additional Effects of Statins in Surgical Patients.

Page: 140DOI: 10.1097/SLA.0b013e31817c98afAuthors: Paraskevas, Kosmas I. MD, FASA; Mikhailidis, Dimitri P. MD, FFPM, FRCPath, FRCP; Athyros, Vassilios G. MD

Additional Effects of Statins in Surgical Patients.

Page: 141DOI: 10.1097/SLA.0b013e31817c98d3Authors: Williams, Trevor MD, MPH

A Nomogram for Predicting Disease-specific Survival After Hepatic Resection for Metastatic Colorectal Cancer.

Page: 141DOI: 10.1097/SLA.0b013e31817cfd09Authors: Tez, Mesut MD; Tez, Selda MD

A Nomogram for Predicting Disease-specific Survival After Hepatic Resection for Metastatic Colorectal Cancer.

Page: 142DOI: 10.1097/SLA.0b013e31817cfd19Authors: Kattan, Michael W. MD; Fong, Yuman MD

Use of Severely Steatotic Grafts in Liver Transplantation.

Page: 142DOI: 10.1097/SLA.0b013e31817cfd2bAuthors: Verran, Deborah MBChB; Dilworth, Pamela; Tang, Patrick; McCaughan, Geoffrey MBBS, PhD

Use of Severely Steatotic Grafts in Liver Transplantation.

Page: 143DOI: 10.1097/SLA.0b013e31817cfd3bAuthors: McCormack, Lucas MD *; Petrowsky, Henrik MD; Mullhaupt, Beat MD; Weber, Markus MD; Clavien, Pierre-Alain MD, PhD FACS, FRACS (Eng), FRCS (Ed)

ABOUT THIS JOURNAL: About This Journal

PRESIDENTIAL ADDRESS: Caveamus Surgeones: Five Great Threats to Surgery in the New Millennium

PAPER: Effect of Multiple-Nodal Basin Drainage on Cutaneous Melanoma

Hypothesis The number of nodal basins draining a primary cutaneous melanoma is not an independent predictor of outcome. Design Post hoc analysis of patients entered into a randomized, prospective study. Setting Multi-institutional academic and community medical centers. Patients Patients aged 18 to 70 years with melanoma 1.0 mm or greater Breslow thickness. Interventions Wide local excision and sentinel lymph node biopsy were performed on all patients; patients with sentinel lymph node metastases underwent completion lymphadenectomy. Patients with multiple–nodal basin drainage were compared with those with single–nodal basin drainage. Main Outcome Measures Sentinel lymph node status, locoregional recurrence-free survival, disease-free survival, and overall survival. Results A total of 2060 patients with single–nodal basin drainage (n = 1709 [83% of cohort]) were included in the analysis, with a median follow-up of 50 months. On univariate analysis, the group with multiple–nodal basin drainage (n = 351) was associated with female sex and primary tumor regression (P < .001). In addition, multiple–nodal basin drainage was associated with truncal primary tumor location (73.2%), while single–nodal basin drainage was more common for extremity tumors (50.9%; P < .001). On multivariate analysis, there were no differences in the rate of sentinel lymph node metastasis, disease-free survival, or overall survival between the groups. Interestingly, locoregional recurrence was significantly worse in the single–nodal basin drainage group (P = .003). Conclusions Multiple–nodal basin drainage does not confer a worse prognosis for patients with cutaneous melanoma. In fact, single–nodal basin drainage appears to be associated with a greater risk of locoregional recurrence.

CALL FOR PAPERS: Disparities in Health Care

PAPER: Experience With 208 Resections for Intraductal Papillary Mucinous Neoplasm of the Pancreas

Hypothesis Intraductal papillary mucinous neoplasm (IPMN) is an increasingly recognized disease of the pancreas. We report our experience with pancreatic resection for IPMN. Design Retrospective review from 1992 through 2005 with additional independent histopathologic confirmation. Setting Mayo Clinic Rochester, a tertiary care center. Patients All patients who underwent primary resection for pancreatic IPMN. Main Outcome Measures Disease-specific operative outcomes, survival, and recurrence patterns. Results Of 208 patients (mean age, 66 years) with IPMN of the pancreas, 168 underwent partial pancreatectomy, and 40 underwent total pancreatectomy; 88 were classified as having adenoma, 38 as having borderline neoplasm, 19 as having carcinoma in situ, and 63 as having invasive carcinoma. The prevalence of a malignant neoplasm was 64% in patients with main duct IPMN compared with 18% in patients with branch duct IPMN. Re-resection of the initial pancreatic margin was necessary in 21% of patients. Final negative margins were achieved in 89% of patients. Five-year survival with noninvasive IPMN was 94%. Patients with invasive IPMN had a similar 5-year survival compared with a matched cohort with ductal adenocarcinoma (31% vs 24%; P = .26). In patients with invasive IPMN, 58% experienced disease recurrence. In patients with noninvasive IPMN, 10% experienced disease recurrence after partial pancreatectomy and 0% experienced disease recurrence after total pancreatectomy. Conclusions Patients with main duct IPMN or high-risk branch duct IPMN should be considered for targeted pancreatectomy. Invasive IPMN behaves as aggressively as ductal adenocarcinoma, but resection seems to provide the only potential for cure. Even with negative resection margins, the pancreatic remnant harbors a risk of recurrence and, thus, careful long-term surveillance is warranted.

PAPER: Factors Related to Attrition in Surgery Residency Based on Application Data

Objective To determine whether variables in the surgery resident selection process will predict attrition or performance during residency training. Design Retrospective study. Setting A university residency program. Participants A total of 111 categorical surgery residents matched during a 10-year period (1991-2000). Main Outcome Measures Satisfactory outcome included successful completion of training and the American Board of Surgery examinations on the first attempt. Participants with a satisfactory outcome were stratified into good or marginal performance based on adverse actions during residency. Results Of 111 residents studied, 28 (25.2%) had an unsatisfactory outcome; attrition occurred in 25 (22.5%). Univariate analysis identified the following variables as predictors of unsatisfactory outcome: age at entry older than 29 years (P = .005), female sex (P = .02), courses repeated (P = .01), "C" grades on transcript (P = .01), no participation in team sports (P = .02), and lack of superlative comments in the dean's letter (P = .03). The following variables were retained in the multivariate model: age older than 29 years (odds ratio [OR], 0.11; 95% confidence interval [CI], 0.02-0.47; P = .003), summary comments in the dean's letter (OR, 4.57; 95% CI, 2.00-10.43; P < .001), participation in team sports (OR, 4.96; 95% CI, 1.36-18.05; P = .02), and merit scholarship in medical school (OR, 0.25; 95% CI, 0.08-0.78; P = .02). Conclusions Attrition can be predicted from factors identified on residency applications, with nonacademic factors being more important. Among residents who completed the program, no predictors of performance were identified.

PAPER: Carotid Angioplasty and Stenting vs Carotid Endarterectomy for Treatment of Asymptomatic Disease: Single-Center Experience

Background Carotid angioplasty and stenting (CAS) with embolic protection is an acceptable alternative to carotid endarterectomy (CEA) in selected patients with symptomatic cervical carotid artery disease. Whether outcomes after CAS are comparable to those after CEA in the larger population of patients with asymptomatic disease is unclear. Hypothesis Carotid angioplasty and stenting performed in patients with asymptomatic disease will result in early outcomes equivalent to those with CEA performed in patients with asymptomatic disease at our center and in 2 landmark studies of CEA. Design Single-center retrospective review. Setting Urban hospital. Patients Three hundred twenty-six patients (202 men [62%] and 124 women [38%]; mean age, 71 years) with asymptomatic carotid artery stenoses treated with either CAS (n = 120) or CEA (n = 206) between January 1, 2001, and December 31, 2006. Overall mean degree of stenosis was 81.2%. Interventions Carotid angioplasty and stenting was performed using self-expanding nitinol stents coupled with a mechanical embolic protection system. Carotid endarterectomy was performed using general anesthesia with selective shunting based on carotid stump pressure. Main Outcome Measures Stroke, myocardial infarction, and death rates at 30 days after surgery. Results At 30 days after surgery, there was no statistical difference between outcomes after CAS (2 strokes [1.7%], 2 myocardial infarctions [1.7%], and 1 death [0.8%]) compared with CEA (2 strokes [1.0%], 3 myocardial infarctions [1.5%], and no deaths). Conclusion Vascular surgeons who have advanced catheter-based skills can safely perform CAS in patients with asymptomatic disease with periprocedural results comparable to those with CEA.

PAPER: Long-term Outcome of Patients With Elevated Parathyroid Hormone Levels After Successful Parathyroidectomy for Sporadic Primary Hyperparathyroidism

Hypothesis Untreated long-term elevated parathyroid hormone (PTH) levels after successful parathyroidectomy may predict recurrent hyperparathyroidism (HPT). Although elevated PTH levels have been reported in eucalcemic patients after parathyroidectomy for sporadic primary HPT, the long-term clinical significance of this finding remains unclear. Design Retrospective case series. Setting Tertiary referral center. Patients Five hundred seventy-six consecutive patients with HPT. Intervention Parathyroidectomy guided by intraoperative monitoring of PTH levels. Main Outcome Measures Overall incidence of elevated PTH levels (measurements of ≥ 70 pg/mL at any time during follow-up) and recurrent HPT (hypercalcemia and elevated PTH levels more than 6 months after parathyroidectomy). Results Of the 505 patients who underwent successful parathyroidectomy in this series and were followed up for more than 6 months, 337 (66.7%) consistently had PTH levels within the reference range, and 168 (33.3%) had elevated PTH levels. Of the 168 patients with elevated PTH levels, only 8 (4.8%) developed recurrent disease. The earliest recurrence occurred 2 years postoperatively. Factors associated with elevated PTH levels included advanced age, higher preoperative PTH levels, and mild postoperative renal insufficiency. Conclusion Although one-third of the patients had elevated PTH levels after successful parathyroidectomy, most of these patients with elevated PTH levels (95%) will achieve long-term eucalcemia.

PAPER: Analysis of 900 Appendiceal Carcinoid Tumors for a Proposed Predictive Staging System

Background Appendiceal carcinoid tumors (ACTs) are rare, and little is known about the long-term prognosis for these tumors because no staging system exists. Therefore, we sought to investigate prognostic factors associated with ACTs and to create a predictive staging system to accurately estimate prognosis. Hypothesis In patients with ACTs, TNM staging will accurately predict prognosis. Design Retrospective review of 15 983 patients with carcinoid tumors in the Surveillance Epidemiology and End Results (SEER) database from January 1, 1977, to December 31, 2004. Setting SEER database study. Participants Nine hundred patients with ACTs (552 females and 348 males; mean age, 47.1 years [age range, 9-89 years]; mean size of the primary tumor, 2.4 cm [range, 0.1-11.5 cm]). Main Outcome Measure Clinicopathologic features in patients with ACTs that affect prognosis using a newly created TNM staging system incorporating these parameters. Results Lymph node metastasis was found in 137 patients (24%), and distant metastatic disease in 89 patients (10%). Stage-specific survival was statistically significant between stages (P < .001) but not within stages. At multivariate analysis, patient age, primary tumor size, histologic features, lymph node involvement, and distant metastasis were significant factors predicting survival. Conclusions Our newly developed TNM staging system accurately predicts prognosis in patients with ACTs. A TNM staging system for ACTs will be helpful not only for physician education about factors that affect the outcome with this disease but also to observe trends in prognosis.

PAPER: Effect of Hospital Type and Volume on Lymph Node Evaluation for Gastric and Pancreatic Cancer

Hypothesis For gastric and pancreatic cancer, regional lymph node evaluation is important to accurately stage disease in a patient and may be associated with improved survival. We hypothesized that National Comprehensive Cancer Network (NCCN), National Cancer Institute (NCI)–designated institutions, and high-volume hospitals examine more lymph nodes for gastric and pancreatic malignant neoplasms than do low-volume centers and community hospitals. Design Volume-outcome study. Setting Academic research. Patients Using the National Cancer Data Base (January 1, 2003, to December 31, 2004), patients were identified who underwent resection for gastric (n = 3088) and pancreatic (n = 1130 [pancreaticoduodenectomy only]) cancer. Main Outcome Measures Multivariable logistic regression analysis was used to assess the effect of hospital type and volume on nodal evaluation (≥15 nodes). Results Only 23.2% of patients with gastric cancer and 16.4% of patients with pancreatic cancer in the United States underwent evaluation of at least 15 lymph nodes. Patients undergoing surgery had more lymph nodes examined at NCCN-NCI hospitals than at community hospitals (median, 12 vs 6 for gastric cancer and 9 vs 6 for pancreatic cancer; P < .001). Patients at highest-volume hospitals had more lymph nodes examined than patients at low-volume hospitals (median, 10 vs 6 for gastric cancer and 8 vs 6 for pancreatic cancer; P < .001). On multivariable analysis, patients undergoing surgery at NCCN-NCI and high-volume hospitals were more likely to have at least 15 lymph nodes evaluated compared with patients undergoing surgery at community hospitals and low-volume centers (P < .001 and P =.02, respectively). Conclusions Nodal examination is important for staging, adjuvant therapy decision making, and clinical trial stratification. Moreover, differences in nodal evaluation may contribute to improved long-term outcomes at NCCN-NCI centers and high-volume hospitals for patients with gastric and pancreatic cancer.

PAPER: Liver Transplant for Hepatitis C Virus: Effect of Using Older Donor Grafts on Short- and Medium-Term Survival

Hypothesis Older donor grafts will provide suitable results of liver transplant, even in recipients with hepatitis C virus (HCV). Although HCV remains the leading indication for liver transplant in adults in the United States, it is associated with HCV recurrence, increased graft loss, and reduced survival. In addition, recent studies suggest that the use of older donors in recipients with HCV is associated with significantly worsened short- and long-term survival. Design Prospective database analysis. Setting Washington University School of Medicine. Patients Between January 1, 1997, and June 30, 2006, a total of 579 liver transplants were performed. Ninety pediatric transplants were excluded. Of the remaining 489 adult patients (84.5%), 187 (38.2%) had HCV and 302 (61.8%) had other indications. Main Outcome Measures Patient and graft survival, recurrence of HCV, and need for and results of retransplant. Results At 1, 3, and 5 years, overall patient survival was 88.1%, 78.3%, and 69.2%, respectively, and graft survival was 85.6%, 75.6%, and 65.6%, respectively, in patients with HCV. There was no significant difference in patient or graft survival between patients with and those without HCV. Recurrent HCV with clinically significant disease was 20% at 1 year and 62% at 10 years. Seventy-two patients received transplants from donors 60 years or older (24 of 187 [12.8%] with HCV and 48 of 302 [15.9%] without HCV). No difference was demonstrated in short- or medium-term patient or graft survival in recipients of grafts from older donors. Conclusion The increasing use of marginal donors, including carefully selected older donors, does not seem to adversely affect short- or medium-term results and may be a source of additional organs for expanding liver transplant waiting lists.

PAPER: A Massive Transfusion Protocol to Decrease Blood Component Use and Costs

Hypothesis A massive transfusion protocol (MTP) decreases the use of blood components, as well as turnaround times, costs, and mortality. Design Retrospective before-and-after cohort study. Setting Academic level I urban trauma center. Patients and Methods Blood component use was compared in 132 patients during a 2-year period following the implementation of an MTP; 46 patients who were treated the previous year served as historical control subjects. Intervention Introduction of an MTP that included recombinant factor VIIa for patients with exsanguinating hemorrhage. Main Outcome Measures The amount of each blood component transfused, turnaround times, blood bank and hospital charges, and mortality rates. Results After introduction of the MTP, there was a significant decrease in packed red blood cells, plasma, and platelet use. The turnaround time for the first shipment was less than 10 minutes, and the time between the first and second shipments was reduced from 42 to 18 minutes, compared with historical controls. The decreased use of blood products represented a savings of $2270 per patient or an annual savings of $200 000, despite increased costs for recombinant factor VIIa. There was no difference in mortality in either group; it remained around 50%. Thromboembolic complications did not increase, despite a significant increase in the use of recombinant factor VIIa. Conclusions The MTP resulted in a reduction in the use of blood components with improved turnaround times and significant savings. Mortality was unaffected. The use of recombinant factor VIIa did not increase thromboembolic complications in these patients.

PAPER: Breast Sentinel Lymph Node Dissection Before Preoperative Chemotherapy

Hypothesis Timing of sentinel lymph node dissection (SLND), before or after preoperative chemotherapy (PC), for breast cancer is controversial. Design Single-institution experience with SLND before PC. Setting Data from prospectively collected Yale-New Haven Breast Center Database. Patients Fifty-five SLNDs were performed before PC for invasive breast cancer in clinically node-negative patients between October 1, 2003, and September 30, 2007. The results are compared with patients who underwent SLND and definitive breast and axillary surgery before chemotherapy (control group; n = 463 SLNDs). Interventions If sentinel nodes (SNs) were negative before PC, no axillary lymph node dissection (ALND) was performed. If SNs were positive, ALND was performed after PC at the time of definitive breast surgery. Main Outcome Measures Sentinel node identification rate, false-negative rate, rate of positivity, and rate of residual disease in axilla. Results Of the 55 SLNDs performed before PC, 30 (55%) had a positive SN. The SN identification rate was 100% and the clinical false-negative rate was 0%. In the control group of those with a positive SN, 55% (56 of 101 patients) had no additional positive nodes, 25% (25 of 101) had 1 to 3 positive nodes, and 20% (20 of 101) had 4 or more positive nodes. In the group with a positive SN before PC, 69% (18 of 26 patients) had no additional positive nodes after PC, 27% (7 of 26) had 1 to 3 nodes, and 4% (1 of 26) had 4 or more nodes. Among the SN-positive patients, a pathologic complete response in the breast was found in 4 of 18 patients who had a tumor-free axilla after PC. Conclusions Sentinel lymph node dissection before PC allows accurate staging of the axilla for prognosis and treatment decisions. Despite downstaging by PC, a significant percentage of patients had residual nodal disease in the axillary dissection.

PAPER: Surgical Management and Outcomes of 165 Colonoscopic Perforations From a Single Institution

Background Increasing use of colonoscopy is making iatrogenic perforations more common. We herein present our experience with operative management of colonoscopic-related perforations. Design Retrospective review (1980-2006). Setting Tertiary referral center. Patients A total of 258 248 colonoscopies performed in patients, from which we identified 180 iatrogenic perforations (incidence, 0.07%). Of these, 165 perforations were managed operatively. Results Patients underwent primary repair (29%), resection with primary anastomosis (33%), or fecal diversion (38%). Patients presenting within 24 hours (78%) were more likely to have minimal peritoneal contamination (64 patients [50%] vs 6 [17%]; P = .01) and to undergo primary repair or resection with anastomosis (86 [67%] patients vs 13 [36%]; P < .01). Patients presenting after 24 hours (22%) were more likely to have feculent contamination (16 patients [44%] vs 4 [11%]; P = .02) and to receive an ostomy (23 patients [64%] vs 43 [33%]; P = .02). The sigmoid colon was the most frequent site of perforation, followed by the cecum (53% and 24%, respectively; P < .001); blunt or torque injury exceeded polypectomy and thermal injuries (55% vs 27% and 18%, respectively; P < .001). Patients with blunt injuries were more likely to receive a stoma than were those with polypectomy and thermal perforations (44 patients vs 9 and 9, respectively; P = .02), as were patients with feculent peritonitis compared with those with moderate and minimal soilage (28 patients [78%] vs 28 [42%] and 6 [10%] respectively; P = .002). Operative morbidity was 36%, with a mortality rate of 7%. Multivariate analysis indicated that blunt injuries, poor bowel preparation, corticosteroid use, and being younger than 67 years were risk factors for postoperative morbidity (P ≤ .01); no factors correlated with death. Conclusions Colonoscopic perforation occurs in fewer than 1 in 1000 patients and is associated with significant morbidity and mortality. Prompt diagnosis and operative therapy are critical in most cases.

CORRECTION: Incorrect Author Surname in: A Longitudinal Analysis of the General Surgery Workforce in the United States, 1981-2005

FROM JAMA: Lowering the Bariatric Surgery Minimum Body Mass Index Threshold

SPECIAL FEATURE: Image of the Month--Quiz Case

SPECIAL FEATURE: Image of the Month--Diagnosis