An assessment of different scoring systems in cirrhotic patients undergoing nontransplant surgery.

BACKGROUND: Determining surgical risk in cirrhotic patients is difficult and multiple scoring systems have sought to quantify this risk. The purpose of our study was to assess the impact of Childs-Turcotte-Pugh (CTP), Model of End-Stage Liver Disease (MELD), and MELD-Sodium (MELD-Na) scores on postoperative morbidity and mortality for cirrhotic patients undergoing nontransplant surgery. METHODS: We performed a single-center retrospective review of all cirrhotic patients who underwent nontransplant surgery under general anesthesia over a 6-year period of time to analyze outcomes using the 3 scoring systems. RESULTS: Sixty-four cirrhotic patients (mean age, 57 y; 62 men) underwent nontransplant surgery under general anesthesia. A CTP score of ≥ 7.5 was associated with an 8.3-fold increased risk of 30-day morbidity, a MELD score of ≥ 14.5 was associated with a 5.4-fold increased risk of 3-month mortality, and a MELD-Na score ≥ 14.5 was associated with a 4.5-fold increased risk of 1-year mortality. Emergent surgery, the presence of ascites, and low serum sodium level were associated significantly with morbidity and 1-year mortality. CONCLUSIONS: The major strengths of the 3 scoring systems are for CTP in estimating 30-day morbidity, MELD for estimating 3-month mortality, and MELD-Na for estimating 1-year mortality.

Emergency canine surgery in a deployed forward surgical team: a case report.

INTRODUCTION: Forward surgical teams (FSTs) perform a variety of non-doctrinal functions. During their deployment to Afghanistan, the 541st FST (Airborne) performed emergency surgery on a German shepherd military working dog (MWD). METHODS: Retrospective examination of a case of veterinary surgery in a deployed FST. RESULTS: A 5 1/2-year-old German shepherd MWD presented with extreme lethargy, tachycardia, excessive drooling, and a firm, distended abdomen. These conditions resulted from gastric dilatation with volvulus. Since evacuation to a veterinarian was untenable, emergency laparotomy was performed in the FST. The gastric dilatation with volvulus was treated by detorsion and gastropexy, and the canine patient fully recovered. CONCLUSION: Canine surgery can be safely performed in an FST. Based on the number of MWDs deployed throughout the theater, FSTs may be called upon to care for them in the absence of available veterinary care.

Patient surveillance after treatment for soft-tissue sarcoma.

About 1% of all cancers are soft tissue sarcomas (STS); about 60% of these occur in the extremities. Post-treatment surveillance programs are designed to identify recurrence, new primary cancers, and complications of therapy early enough to increase survival duration and quality of life. The intensity of surveillance varies among surgeons. We hypothesized that geographic factors would account for much of this variation. The 1,592 members of the Society of Surgical Oncology were surveyed regarding their personal postoperative STS surveillance strategy using standardized clinical vignettes and a questionnaire based on the vignettes. Practice patterns were analyzed by US Census Region, Metropolitan Statistical Area (MSA), and managed care organization (MCO) penetration rate, using repeated measures analysis of variance. The study end-point was surveillance intensity. Mean follow-up intensity for the 12 surveillance modalities on the questionnaire was highly correlated with tumor size, grade, and year post surgery. Controlling for tumor stage, grade, and year post surgery, the practice location of the surgeon infrequently impacted surveillance intensity. MSA was a significant (p<0.05) predictor only of office visit frequency. MCO penetration rate significantly predicted only the frequency of urinalysis and tumor-site MRI. US Census Region significantly predicted only the frequency of LFTs. Geographic factors do not generally predict self-reported surveillance practice patterns for patients after curative-intent STS surgery. The overall variation in follow-up intensity appears to reflect factors not evaluated, such as the absence of high-quality evidence supporting any particular strategy and the quality of patients' insurance.

Humanitarian assistance in Afghanistan: a prospective evaluation of clinical effectiveness.

OBJECTIVE: To examine the clinical effectiveness of patient encounters during humanitarian assistance (HA) missions performed by the 48th Combat Support Hospital in Afghanistan. METHODS: Data were prospectively gathered from missions in the villages of Aroki (January 21, 2003), Tangee (March 25, 2003), and Turkman (April 22, 2003). Health care providers evaluated the effectiveness of each patient encounter using a data-gathering instrument with clearly defined outcome measures. RESULTS: A total of 1,887 patients were seen during the three missions. Forms were incomplete for 112 patients and not used for 33 dental patients. For the remaining 1,742 individuals, probable cures were achieved as follows: adult males, 31%; adult females, 52%; male children, 46%; and female children, 54% (all patients, 46%, p < 0.001). After adjusting for acute care that was supportive in nature during the final mission, probable cures were achieved as follows: adult males, 22%; adult females, 16%; male children, 34%; and female children, 27%. During this final operation, 73% (p < 0.001) of patients received care that was unnecessary, unlikely to produce a cure, or was merely supportive in nature. CONCLUSIONS: During HA missions performed by the 48th Combat Support Hospital, the majority of patient encounters did not result in curative treatments. The effectiveness of medical care during HA missions cannot be assumed and future operations should include assessments of outcomes to optimize their value.

Endoscopy in a deployed combat support hospital: maintaining military end-strength.

OBJECTIVE: The objective was to examine the safety and efficacy of the 48th Combat Support Hospital's use of diagnostic endoscopy in Afghanistan. METHODS: A retrospective review was performed on the medical records of all endoscopy patients treated at the 48th Combat Support Hospital in Bagram, Afghanistan, from December 6, 2002 through June 7, 2003. RESULTS: Twenty-four patients (male, 21; female, 3; mean age, 35 years) underwent 28 endoscopic procedures as follows: colonoscopy, 14; esophagogastroduodenoscopy (EGD), 13; and flexible sigmoidoscopy, 1. Four patients underwent both EGD and colonoscopy. There were no complications. Of the 18 U.S. military patients, 3 (15%) were evacuated for further evaluation and/or treatment and 1 (5%) patient underwent an elective screening colonoscopy. For 14 of 17 U.S. military personnel (82%), the endoscopic procedures obviated evacuation from Afghanistan. CONCLUSIONS: Diagnostic colonoscopy and EGD were valuable and safe adjuncts that precluded evacuations out of theater for 82% of military patients. Endoscopy should be used when U.S. military operations necessitate the deployment of large numbers of forces for protracted periods.

Operation Enduring Freedom: the 48th Combat Support Hospital in Afghanistan.

OBJECTIVE: To examine the experience of the 48th Combat Support Hospital (CSH) while deployed to Afghanistan, with an emphasis on trauma care. MATERIALS AND METHODS: Before redeployment, a retrospective review was performed on the medical records of all patients treated at the 48th CSH from December 6, 2002 through June 7, 2003. RESULTS: During the 6-month period, 10,679 patients were evaluated and/or treated. There were 477 hospital admissions (adults, 387; children, 90; trauma, 204) and 634 operating room procedures. The most common mechanisms of injury were land mines/unexploded ordinance (74 = 36%) and gunshot wounds (41 = 20%). Extremities were the most common site. A total of 358 cases was performed on 168 trauma patients (mean, 2 cases per patient; range, 1-12). There were 63 complications in 40 trauma patients and 11 patients died. CONCLUSIONS: The 48th CSH supported military and humanitarian operations with an ongoing process of re-evaluation, adaptation, and medical education that resulted in low morbidity and mortality rates.

Long-term management of patients after potentially curative treatment of extremity soft tissue sarcoma: practice patterns of members of the Society of Surgical Oncology.

The optimal strategy for follow-up of extremity soft tissue sarcoma patients after primary treatment with curative intent is not known. The 1592 members of the Society of Surgical Oncology (SSO) were sent a survey to determine their practices. Office visits and chest X-rays were the most frequently performed items for all years. Complete blood count and liver function tests were the most commonly ordered blood tests, but many respondents did not order any blood tests routinely. Imaging studies of the extremities were recommended for most patients during the first postoperative year. Postoperative surveillance strategies after sarcoma treatment vary appreciably among surgeons. Surgeon age, tumor size, tumor grade, and geographic location of the surgeon account for only a modest amount of the variation, suggesting that lack of evidence supporting any particular strategy is the factor responsible for most of the variation. Efforts to provide high-quality evidence on this topic are warranted.

Secondary operations are frequently required to complete the surgical phase of therapy in the era of breast conservation and sentinel lymph node biopsy.

BACKGROUND: Breast conservation therapy (BCT) is an oncologically equivalent and cosmetically preferable alternative to mastectomy for most early-stage breast cancers. The number of operations required to complete the surgical phase of therapy with BCT has not been widely reported. METHODS: From our institutional tumor registry, we reviewed the records of all patients receiving primary surgical therapy for breast cancer from January 1, 1998, to June 30, 2002. There were 204 patients with 210 breast cancers in the cohort. These cancers were initially managed with either BCT (n = 150) or mastectomy (modified radical mastectomy or total mastectomy with sentinel lymph node biopsy) (n = 60). We compared the percentages of patients in each group who required additional surgeries to obtain clear margins, manage axillary disease, or otherwise complete the surgical phase of therapy. Patients with secondary surgery related to long-term local recurrence were excluded. RESULTS: Fifty-one percent of patients initially managed with BCT required additional surgery compared with 12% in the mastectomy group (P <0.05). Factors independently associated with multiple surgeries among all patients included management with BCT (odds ratio [OR] 5.4, P = 0.01) and positive margins at initial excision (OR 4.7, P <0.01). Significant independent predictors of positive margins included BCT (OR 11.9, P <0.01); disease stage (OR 6.7, P <0.01); submission of supplemental margins in addition to the main specimen (OR 2.8, P = 0.03); and positive nodes (OR 1.1, P = 0.04). Breast conservation was ultimately successful in 95% of patients who underwent BCT. CONCLUSIONS: Patients undergoing BCT may require multiple surgeries to reconcile successful breast conservation with sound oncologic resection.

Extremity soft tissue sarcoma patient follow-up: tumor grade and size affect surveillance strategies after potentially curative surgery.

A large recent survey disclosed considerable variation in the intensity of follow-up after potentially curative surgery for extremity soft tissue sarcoma among highly credentialed clinicians. The source of the variation is not known. The survey was reanalyzed to investigate whether tumor grade and size account for the variation. The 1,592 members of the Society of Surgical Oncology were surveyed to measure their follow-up practices for 10 years after initial therapy for extremity sarcoma. Repeated-measures analysis of variance was used to measure the relationship among follow-up practice patterns and tumor grade, tumor size, and years after surgery. The 318 respondents who performed surgery and also carried out long-term follow-up for their patients with extremity soft tissue sarcoma were considered evaluable; 94% were general surgeons and 5% were orthopedic surgeons. Office visit, complete blood count, liver function tests, chest X-ray, chest computed tomography, extremity computed tomography, and extremity magnetic resonance imaging were ordered significantly more frequently with increasing tumor grade and size. Tumor grade and size significantly impacted physician practice patterns in post-treatment follow-up, although the degree of variation attributable to these variables was modest. These data permit rational design of a randomized clinical trial of two alternative follow-up plans.

Predictive value of intraoperative touch preparation analysis of sentinel lymph nodes for axillary metastasis in breast cancer.

BACKGROUND: Accurate intraoperative diagnosis of axillary malignancy facilitates completion axillary lymph node dissection (ALND) at the time of initial surgery. The capability to address both the primary tumor and axillary disease in a single procedure offers several advantages. This study was designed to define the predictive value of intraoperative touch preparation analysis of sentinel lymph nodes for axillary metastasis in breast cancer and to evaluate the ability of the technique to facilitate accurate synchronous ALND. METHODS: A consecutive cohort of patients with breast cancer at an Army medical center underwent intraoperative touch preparation analysis of sentinel lymph nodes concordant with initial excision. Those found to have sentinel nodes positive by touch preparation analysis underwent ALND at the initial procedure. Patients with negative sentinel nodes by touch preparation analysis, but positive by final pathology, underwent subsequent ALND. Results of the touch preparation analysis were compared with the final pathology. RESULTS: Over a 16-month period, 71 consecutive patients with breast cancer underwent initial excision and touch preparation analysis of 162 sentinel lymph nodes. Final pathology confirmed axillary metastasis in 32% (23 of 71) of patients. Of these, intraoperative touch preparation analysis identified 48% (11 of 23). There were no false positives or unnecessary axillary dissections based upon touch preparation results. Per sentinel node, the positive predictive value was 100%, the sensitivity was 47%, and the specificity was 100%. On a per patient basis, the positive predictive value was 100%, and the sensitivity and specificity were 48% and 100%, respectively. CONCLUSIONS: Intraoperative touch preparation analysis is an effective adjunct to sentinel lymph node biopsy. In our series, it facilitated a definitive cancer operation at the time of initial surgery in nearly 50% of patients, and ensured that no patient underwent an unnecessary axillary dissection.

How surgeon age affects surveillance strategies for extremity soft tissue sarcoma patients after potentially curative treatment.

BACKGROUND: The optimal strategy for follow-up of extremity soft tissue sarcoma patients after potentially curative treatment remains unknown. We investigated whether the date of completion of formal surgical training affects choice of surveillance strategy. MATERIALS AND METHODS: The 1,592 members of the Society of Surgical Oncology were asked how often they use 12 separate surveillance modalities during years 1-5 and 10 postsurgery. The motivation underlying follow-up was assessed separately. Repeated-measures analysis of variance was used to compare practice patterns by the year in which the surgeon's formal surgery training was completed, controlling for tumor grade, tumor size, and year postsurgery. RESULTS: Of the 716 respondents, 318 performed surgery and also provided long-term postoperative surveillance for their patients. These respondents were considered evaluable. Erythrocyte sedimentation rate, extremity X ray, and bone scan were the follow-up tests which differed significantly among physician age groups. Surgeons who completed training more than 30 years ago ordered erythrocyte sedimentation rate more frequently (P < 0.001). Surgeons in the 21-30 year category ordered extremity X ray and bone scan more frequently (P < 0.05), but the absolute differences among age groups were quite small. Older surgeons were also significantly more likely to believe that follow-up is clinically worthwhile. CONCLUSIONS: The posttreatment surveillance practice patterns of the members of the Society of Surgical Oncology caring for extremity soft tissue sarcoma patients vary only marginally with the length of time since completion of training. Postgraduate education may be one factor homogenizing surgeon behavior in this important aspect of cancer patient care.

Surgical caseload in army general surgery programs: a 10-year retrospective.

PURPOSE: Over the past decade, the Army Medical Department (AMEDD) has been affected by a military-wide drawdown. The volume and acuity of patients appears to be declining, raising questions regarding quantity and quality in Army surgical training programs. The purpose of this study is to examine the caseloads of Army general surgery programs compared with national averages, and to compare the board examination performance of Army residents with national pass rates. METHODS: The program directors of all 6 Army training programs were requested to submit resident caseloads and performance on qualifying and certifying examinations from 1990 to 2000. The Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Surgery (ABS) provided resident statistics summaries and board examination statistics, respectively, for the same period. Total caseloads, chief resident cases, performance in defined categories, and board pass rates of military residents were compared with national averages. RESULTS: Four of the 6 programs submitted the requested data. The average caseload for Army residents, both total and chief residents, has been lower than the national average over the past decade. Nationally, total case numbers have gradually increased while military changes have been variable. The number of chief resident cases has trended steadily downward in Army programs at a rate exceeding the national average. The volume of procedures in endoscopy, thoracic, and breast surgery in the Army generally exceeds those recorded outside of the military. Despite the decline in surgical cases in the military, the pass rates in both the certifying and qualifying examinations among Army graduates have been consistently higher than the national average. CONCLUSIONS: Residents who train in Army programs perform fewer operative cases than do their counterparts in civilian programs. The downward trend in the number of chief resident cases over the last 10 years is likely reflective of the changes in military medicine. Despite these trends, Army residency graduates continue to exceed national performance averages on the ABS qualifying and certifying examinations.