Tuesday, February 17, 2009

Journal Rundown

Another scintillating peak into the surgical literature. This week we do the February 2009 issue of JACS.

1)Laparoscopic Appendectomy—Is it Worth the Cost? Trend Analysis in the US from 2000 to 2005
Emanuel Sporn, Gregory F. Petroski, Gregory J. Mancini, J. Andres Astudillo, Brent W. Miedema, Klaus Thaler

The Issue: Another episode in the ongoing laparoscopic vs. open appendectomy wars.
Design: A retrospective review of patients from the Nationwide Inpatient Sample (2000-2005) who were treated for acute appendicitis with either open appendectomy (OA) or laparoscopic appendectomy (LA). A trend analysis was then performed to assess length of stay, costs, and complications.
Results: LA results in higher costs and increased morbidity!
The Bottom Line: Obviously, I'm a major proponent of the lap appy and this paper seems to suggest that I'm totally off track. But it's not such a great paper, frankly. It's a retrospective review of patients from a national database and it only looks at in-hospital costs and complications. It's not a randomized controlled trial. It doesn't consider post-hospital costs and complications (like the post op day #5 wound infection that you get in open appies and has to be opened and packed in the office setting). And I just don't think it's appropriate to make defining proclamations on open vs. lap appy based on accumulated data from 9 years ago. When I was a resident, I would say that 90% of the appendectomies I did were of the open variety. The only guys doing lap appy were the Pediatric surgeons and a couple of the bariatric guys. Nobody was comfortable with it. It's like trying to decide if the forward pass is a suitable form of offensive football strategy based on completion rates from the Knute Rockne era. In 2000, the laparoscopic appendectomy was still a bit controversial and a majority of academic surgeons simply were not comfortable doing anything other than making a McBurney's incision in the right lower quadrant. Now that lap appy is a 10-15 minute case in experienced hands, the discrepancy in accrued costs due to lengthy OR time ought to narrow. Now is the time to conduct a multi-institutional RCT directly comparing lap vs open. A paper like this one doesn't have any real purpose. It's not good science and it doesn't correlate with what happens in the real world.

2)Impact of Obesity on Perioperative Morbidity and Mortality after Pancreaticoduodenectomy, 18 December 2008
Timothy K. Williams, Ernest L. Rosato, Eugene P. Kennedy, Karen A. Chojnacki, Jocelyn Andrel, Terry Hyslop, Cataldo Doria, Patricia K. Sauter, Jordan Bloom, Charles J. Yeo, Adam C. Berger

The Skinny: Obese patients who undergo a Whipple have a slightly higher complication rate. Or do they:
There were 103 (42.9%) normal-weight, 71 (29.6%) overweight, and 66 (27.5%) obese patients. There were 5 perioperative deaths (2.1%), with no differences across BMI categories. A significant difference in median operative duration and blood loss between obese and normal-weight patients was identified (439 versus 362.5 minutes, p = 0.0004; 650 versus 500 mL, p = 0.0139). In addition, median length of stay was significantly longer for BMI (9.5 versus 8 days, p = 0.095). Although there were no significant differences in superficial wound infections, obese patients did have an increased rate of serious complications compared with normal-weight patients (24.2% versus 13.6%, respectively; p = 0.10)."

Obese patients undergoing PD have a substantially increased blood loss and longer operative time but do not have a substantially increased length of postoperative hospital stay or rate of serious complications."

Um, I'm confused. Anyway, it's a single-institutional, retrospective review. Not so useful. Plus, every other paper on Whipple and obesity seems to suggest that complications are higher the fatter you are. Which makes sense.

3)Operations for Intrahepatic Cholangiocarcinoma: Single-Institution Experience of 158 Patients
Hauke Lang, Georgios C. Sotiropoulos, George Sgourakis, Klaus J. Schmitz, Andreas Paul, Philip Hilgard, Thomas Zöpf, Tanja Trarbach, Massimo Malagó, Hideo A. Baba, Christoph E. Broelsch

The Bottom Line: Cholangiocarcinoma has historically been associated with grim outcomes (median survival <1 yr after diagnosis). This paper reviews the work of a group of surgeons at a hospital in Germany and their experience with cholangiocarcinoma. 53 cases were prospectively evaluated. Basically, they found that R0 resections (when you are able to remove the whole tumor with clean margins, i.e. no residual microscopic disease) led to 1-,3-, and 5-year survival rates of 71%, 38%, and 30%. That's outstanding. But to get these R0 resections, the German surgeons had to perform complicated anatomic liver resections in many of the cases. These are not operations you want your local surgeon doing. Liver transplant surgeons need to be doing these complicated liver whacks. This paper further supports this idea.

4)Effect of Short-Term Pretrial Practice on Surgical Proficiency in Simulated Environments: A Randomized Trial of the “Preoperative Warm-Up” Effect, 04 December 2008
Kanav Kahol, Richard M. Satava, John Ferrara, Marshall L. Smith

The Bottom Line: This one is great. The idea is to test the hypothesis that "warming up" prior to an operation will improve a surgeon's performance. So participants were randomized to various warm-up cohorts: calisthenics, hatha yoga, jumping jacks, an hour of Super Mario Brothers on Playstation and they were then evaluated based on subsequent dexterity and surgical skill performance. Actually that's not true. I'm being an ass. The "warm-up" consisted of performing some desultory maneuvers with laparoscopic tools and pegs and rubber beads and moving those beads from one spot to another. What they found was that warm-up "does positively affect proficiency during postcall condition characterized by fatigue and sleep deprivation. " That's interesting, but what are we supposed to do with the information? Morning stretches before rounds and cases? Do we make Peyton Manning perform a series of bureaucratically designated exercises prior to taking the field? I mean, we're all professionals here. We all know what we need to do to get ready for an operation. You're not going to catch me moving a bunch of rubber beads on a laparoscopic simulator before my next gallbladder any time soon.


Anonymous said...

I used to do Anesthesia Warm Ups, 5 sets of leaving through "Soap Opera Digest", finger limber ups for those tough IV starts, and gotta remember to do some calf stretches every 1/2 hour or so to break up any DVTs...

Anonymous said...

No Comments!?!?! Guess I'll have to take up the slack cause thats just the kinda guy I am...a few questions...
1: Whats more fun for the Surgeon? Lap or Open?
2: Fat people have more complications after a Huge Operation? Duh...and did you know they exhale anesthetic gases for DAYS after one of those long operations??...thats the real reason ICU rounds are so soporiffic...
3: So when I get that Cholangiocarcinoma I'm usin my Lufthansa Luft-Geld Kilometers to...what was the name of that hospital???
4: You don't do ANY kind of warmup??? Heck, even Sandy Koufax through a few pitches between innings...

Gotta question...do Lefthanded Surgeons meet the same Intolerance I got in Anesthesia??? bein forced to Intubate with your non-dominant hand, not bein allowed to move the Anesthesia Machine for your convenience...??? I don't ever think I've seen a Surgeon cut with his left hand, except maybe for a few OB/GYNs, but they aren't really Surgeons...

Keep up the Literature Reviews...I like it, even if nobody else does,


Victor Lazaron said...

I also appreciate the journal review - though the papers discussed are all crap. Unfortunately we need to be much more careful about the kind of crap we publish. You may have noticed it only takes one paper to get the bean-counters and guideline writers to propose some new change in the so-called "standard of care". We used to be more careful in how we interpreted the literature. Now we need to be much more careful in what we put out there for the idiots to misinterpret for us.

Anonymous said...

My statistics & design of experiments profs said that p values >= 0.05 were quite poor.