True benefit or selection bias: an analysis of laparoscopic versus open splenectomy from the ACS-NSQIP.

BACKGROUND: By virtue of the benefits associated with minimally invasive approaches, laparoscopic splenectomy (LS) is believed to have better patient-related outcomes compared to open splenectomy (OS). However, there are limited data directly comparing the two techniques. METHODS: Patients who underwent elective LS and OS between 2005 and 2010 were identified from the public use file of the ACS-NSQIP database using the Current Procedural Terminology codes 38120 and 38100. Patients who had concomitant procedures were excluded. Because of the nonrandom assignment of surgical techniques, a selection bias could have been responsible for the differences in patient outcomes. Therefore, patient characteristics and comorbidities that were available and could have been potential confounders were compared and regression analysis was performed to determine independent risk factors associated with serious and overall morbidity as well as mortality. RESULTS: During the study period 1,644 and 851 patients underwent LS and OS, respectively. Compared to patients who underwent LS, patients who had OS had a longer median length of hospital stay (3 vs. 6 days, P < 0.0001) and higher incidences of serious (7 vs. 17 %, P < 0.0001) and overall morbidity (12 vs. 25 %, P < 0.0001) and mortality (1.4 vs. 3.3 %, P = 0.02). However, there were certain significant differences in the characteristics and comorbidities of the patients that could have confounded outcomes. On regression analysis, OS was not associated with higher mortality (OR = 1.43, 95 % CI 0.7-2.7, P = 0.28) but was associated with higher serious morbidity (OR = 1.8, 95 % CI 1.4-2.3, P = 0.001) and overall morbidity (OR = 2.0, 95 % CI 1.6-2.4, P = 0.0001). CONCLUSION: After adjusting for available confounders, patients who underwent LS had lower morbidity and similar mortality rates. Although certain confounders such as previous surgical history, underlying pathology, and spleen size could still have potentially influenced outcomes, the data suggest that patient outcomes after LS are excellent and when technically possible a minimally invasive technique should be the preferred approach for splenectomy.

Does resident involvement effect surgical times and complication rates during laparoscopic appendectomy for uncomplicated appendicitis? An analysis of 16,849 cases from the ACS-NSQIP.

BACKGROUND: Controversy exists regarding whether resident involvement during surgery impacts patient outcomes. We compared surgical times and perioperative complications of patients undergoing laparoscopic appendectomy with and without residents. METHODS: Patients undergoing laparoscopic appendectomy for uncomplicated acute appendicitis during 2005 to 2008 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. RESULTS: During the study period, 16,849 patients underwent laparoscopic appendectomy for uncomplicated appendicitis (residents participated in 68% of procedures). There were no statistical and/or clinically meaningful differences between median age, sex, body mass index, American Society of Anesthesiology score, and morbidity probability between the 2 groups, suggesting that case mix was not a significant confounder. Patients undergoing laparoscopic appendectomy with residents compared with patients undergoing laparoscopic appendectomy without residents had a higher incidence of serious and overall morbidity and longer surgical times. However, surgical times and complications were similar between residents in postgraduate years 1 to 5. CONCLUSIONS: Regardless of the postgraduate year level, resident involvement resulted in a clinically appreciable increase in surgical times and a statistically significant increase in certain complications.

Single incision laparoscopic right hemicolectomy for colon cancer: less is more?

Single incision laparoscopic colectomy has been reported to be safe and feasible using several techniques and devices. The authors' report their experience with a single incision laparoscopic colectomy performed in a lateral to medical fashion using a commercially developed access device with standard laparoscopic instruments.

Knowledge and attitudes regarding colorectal cancer screening among medical students: a tale of two schools.

Colorectal cancer (CRC) screening has been shown to decrease the incidence of CRC cancers and decrease mortality. Studies show that the most important predictor of patient compliance with CRC screening is physician recommendation. We assessed the knowledge and attitudes of medical students regarding cancer screening. A study-specific questionnaire was distributed to medical students (MS) at two medical schools. There was a significant difference in the percentage of correctly answered questions regarding screening recommendations between first year MS and all other years for both schools. However, MS attitudes towards CRC screening were consistent between classes and schools. Although most MS had positive attitudes regarding cancer screening our survey identified several important deficits in knowledge.

The Extent of Axillary Lymph Node Clearance Required Following Detection of Sentinel Node Micrometastases.

Sentinel node (SN) micrometastases are an indication to proceed to axillary clearance. The aim of this study is to determine the extent and level of axillary clearance required for patients with SN micrometastases. All patients with SN micrometastases which were followed by axillary clearances from 1999 to 2007 were identified. Slides were reviewed by a histopathologist to detail characteristics of SN micrometastases including size and site. The SN micrometastases and primary tumor characteristics were correlated with the presence and level of non-SN micrometastases. Fifty patients who had micrometastases followed by axillary clearances were identified. Of those 18% (n = 9) had non-SN metastases.Seven patients had metastases to level I, one patient had metastases to level I and III and one patient had non-SN metastases to level III only. No patient had metastases to level II. Patients with non-SN metastases had very limited number of non-SNs involved (maximum 2 non-SNs). No variable, including site of the micrometastasis, was predictive of non-SN metastases. In patients with SN micrometastases, a limited level I axillary clearance can be justified in view of the low number of additional nodes involved and in particular, the low (4%) rate of spread to level II / III nodes.

The value of level III clearance in patients with axillary and sentinel node positive breast cancer.

BACKGROUND: The value of level III axillary clearance is contentious, with great variance worldwide in the extent and levels of clearance performed. OBJECTIVE: To determine rates of level III positivity in patients undergoing level I-III axillary clearance, and identify which patients are at highest risk of involved level III nodes. METHODS: From a database of 2850 patients derived from symptomatic and population-based screening service, 1179 patients who underwent level I-III clearance between the years 1999-2007 were identified. The pathology, surgical details, and prior sentinel nodes biopsies of patients were recorded. RESULTS: Eleven hundred seventy nine patients had level I-III axillary clearance. Of the patients, 63% (n = 747) were node positive. Of patients with node positive disease, 23% (n = 168) were level II positive and 19% (n = 141) were level III positive. Two hundred fifty patients had positive sentinel node biopsies prior to axillary clearance. Of these, 12% (n = 30) and 9% (n = 22) were level II and level III positive, respectively. On multivariate analysis, factors predictive of level III involvement in patients with node positive disease were tumor size (P < 0.001, OR = 1.36; 95% CI: 1.2-1.5), invasive lobular disease (P < 0.001, OR = 3.6; 95% CI: 1.9-6.95), extranodal extension (P < 0.001, OR = 0.27; 95% CI: 0.18-0.4), and lymphovascular invasion (P = 0.04, OR = 0.58; 95% CI: 0.35-1). Lobular invasive disease (P = 0.049, OR = 4.1; 95% CI: 1-16.8), extranodal spread (P = 0.003, OR = 0.18; 95% CI: 0.06-0.57), and having more than one positive sentinel node (P = 0.009, OR = 4.9; 95% CI: 1.5-16.1) were predictive of level III involvement in patients with sentinel node positive disease. CONCLUSION: Level III clearance has a selective but definite role to play in patients who have node positive breast carcinoma. Pathological characteristics of the primary tumor are of particular use in identifying those who are at various risk of level III nodal involvement.