BACKGROUND & AIMS: BACKGROUND:Several case reports have raised serious concerns about the safety of shoulder surgery in the beach-chair position, related to global cerebral hypoperfusion. We summarize our experiences with 15,014 cases of shoulder arthroscopy over an 11-year period. Our primary aim was to evaluate the incidence of intraoperative or immediate postoperative neurologic events and secondarily to relate other perioperative complications. METHODS:We searched our online deidentified departmental quality improvement and patient safety database for adverse outcomes associated with arthroscopic shoulder surgery performed in the beach-chair position for the 11-year period between April 2001 and November 2011, as well as our hospital-system database and a statewide database. This was compared with the total number of such cases, available from our department billing database. RESULTS:The total rate of adverse events was 0.37%. Neurologic abnormalities suggestive of acute cerebral ischemia or hemorrhage did not occur in the immediate perioperative period. One new neurologic deficit was reported, secondary to ischemic stroke, which occurred 24 hours after the surgery. The most frequent complications detected were unplanned return to care (0.067%), local anesthetic systemic toxicity (0.053%), and airway compromise requiring unplanned intubation (0.033%). Complications were infrequent and did not vary in incidence over the course of the study. CONCLUSIONS:This retrospective study suggests that intraoperative or immediate postoperative stroke is rare when surgery is conducted in beach-chair position in conjunction with regional anesthesia, propofol sedation, and spontaneous respiration via natural airway.

背景与目标：

BACKGROUND & AIMS: PURPOSE:To determine whether corneal topical application of mitomycin-C (MMC) results in measurable plasma levels of systemic absorption. SETTING:Madigan Army Medical Center, Refractive Surgery Center, Fort Lewis, Washington, and Micro-Constants Laboratory, San Diego, California, USA. DESIGN:Case-control study. METHODS:The study comprised male and female active-duty soldiers having excimer laser photorefractive keratectomy with MMC. Patients who met inclusion criteria were asked to provide a blood sample immediately after being treated with MMC 0.2 mg/mL (0.02%) for 30 seconds. Human plasma samples were evaluated by liquid chromatography mass spectrometry to determine whether MMC was present. RESULTS:Thirty samples were submitted for evaluation. There was zero detection of MMC in the submitted samples. The quantifiable limit was greater than 10.0 ng/mL. All samples were below this. CONCLUSIONS:In this study of 30 patients with topical application of MMC for refractive surgery, there was no measurable evidence of systemic absorption. Although systemic absorption has been found with use in larger quantities, it was not known whether MMC toxicity concerns could be extrapolated to the refractive surgery population. This information allows counseling of patients on the extremely low likelihood of systemic absorption or toxicity following current techniques for refractive surgery. FINANCIAL DISCLOSURE:No author has a financial or proprietary interest in any material or method mentioned.

背景与目标：

BACKGROUND & AIMS: :Twenty patients with strabismus and diplopia following surgery for retinal detachment were treated by botulinum toxin injection of the eye muscles. Twelve patients had regained fusion with elimination of diplopia in the primary position at the time of examination, 5 to 96 months after treatment (mean, 24 months). Three patients had partial diplopia elimination, and five patients continued to have diplopia.

背景与目标： : 通过肉毒杆菌毒素注射眼肌治疗20例视网膜脱离术后斜视和复视患者。12名患者在检查时恢复了融合，并在治疗后5至96个月 (平均24个月) 在主要位置消除了复视。3例患者部分复视消除，5例患者继续复视。

BACKGROUND & AIMS: :Hemorrhage is the most preventable cause of posttraumatic death. Many cases are potentially anatomically salvageable, yet remain lethal without logistics or trained personnel to deliver diagnosis or resuscitative surgery in austere environments. Revolutions in technology for remote mentoring of ultrasound and surgery may enhance capabilities to utilize the skill sets of non-physicians. Thus, our research collaborative explored remote mentoring to empower non-physicians to address junctional and torso hemorrhage control in austere environments. Major studies involved using remote-telementored ultrasound (RTMUS) to identify torso and junctional exsanguination, remotely mentoring resuscitative surgery for torso hemorrhage control, understanding and mitigating physiological stress during such tasks, and the technical practicalities of conducting damage control surgery (DCS) in austere environments. Iterative projects involved randomized guiding of firefighters to identify torso (RCT) and junctional (pilot) hemorrhage using RTMUS, randomized remote mentoring of MedTechs conducting resuscitative surgery for torso exsanguination in an anatomically realistic surgical trainer ("Cut Suit") including physiological monitoring, and trained surgeons conducting a comparative randomized study for torso hemorrhage control in normal (1g) versus weightlessness (0g). This work demonstrated that firefighters could be remotely mentored to perform just-in-time torso RTMUS on a simulator. Both firefighters and mentors were confident in their abilities, the ultrasounds being 97% accurate. An ultrasound-naive firefighter in Memphis could also be remotely mentored from Hawaii to identify and subsequently tamponade an arterial junctional hemorrhage using RTMUS in a live tissue model. Thereafter, both mentored and unmentored MedTechs and trained surgeons completed resuscitative surgery for hemorrhage control on the Cut-Suit, demonstrating practicality for all involved. While remote mentoring did not decrease blood loss among MedTechs, it increased procedural confidence and decreased physiologic stress. Therefore, remote mentoring may increase the feasibility of non-physicians conducting a psychologically daunting task. Finally, DCS in weightlessness was feasible without fundamental differences from 1g. Overall, the collective evidence suggests that remote mentoring supports diagnosis, noninvasive therapy, and ultimately resuscitative surgery to potentially rescue those exsanguinating in austere environments and should be more rigorously studied.

背景与目标： : 出血是创伤后死亡最可预防的原因。许多病例在解剖学上可能是可挽救的，但如果没有后勤人员或训练有素的人员在严峻的环境中进行诊断或复苏手术，则仍然致命。超声波和外科手术远程指导技术的革命可能会增强利用非医生技能的能力。因此，我们的研究合作探索了远程指导，以使非医生能够在严峻的环境中解决交界处和躯干出血控制问题。主要研究包括使用远程远程超声 (RTMUS) 识别躯干和交界性放血，远程指导复苏手术以控制躯干出血，理解和减轻此类任务期间的生理压力，以及在严峻环境中进行损伤控制手术 (DCS) 的技术实用性。迭代项目包括随机指导消防员使用RTMUS识别躯干 (RCT) 和交界 (pilot) 出血，随机远程指导MedTechs在解剖学上逼真的外科训练器 (“切割服”) 中进行躯干放血的复苏手术，包括生理监测，和训练有素的外科医生进行了一项比较随机研究，以正常 (1g) 与失重 (0g) 的躯干出血控制。这项工作表明，可以远程指导消防员在模拟器上执行及时的躯干RTMUS。消防员和导师都对自己的能力充满信心，超声波97% 准确。孟菲斯的一名未经超声检查的消防员也可以从夏威夷进行远程指导，以识别并随后在活组织模型中使用RTMUS填塞动脉交界性出血。此后，经过指导和未经指导的MedTechs和训练有素的外科医生都完成了复苏手术，以控制剪裁服上的出血，这证明了所有参与者的实用性。虽然远程指导并没有减少MedTechs的失血，但它增加了程序信心并减少了生理压力。因此，远程指导可能会增加非医生执行心理艰巨任务的可行性。最后，失重的dc是可行的，与1g没有根本差异。总体而言，集体证据表明，远程指导支持诊断，无创治疗以及最终的复苏手术，以潜在地挽救那些在严峻环境中放血的人，因此应进行更严格的研究。

BACKGROUND & AIMS: OBJECTIVES:The role of surgery in stage IV gallbladder (GB) cancer is not well established. This study analyses prognostic factors in patients with stage IV GB cancer following surgical resection with the aim of identifying a subgroup of patients who might benefit from surgical resection. METHODS:Clinicopathological details were analysed for 94 patients who were surgically treated for stage IV GB cancer at Seoul National University Hospital. RESULTS:Median survival was 8 months in patients with either stage IVa or IVb disease. Sixteen patients (17.0%) underwent resection with curative intent, which increased overall survival over that in patients undergoing palliative surgery (P < 0.001). No survival benefit was seen following surgery with curative intent in patients with stage IVa disease (P = 0.764). Surgery with curative intent resulted in a survival benefit in patients with stage IVb disease, patients with an isolated liver metastasis near the GB bed (median survival: 31 months vs. 9 months; P < 0.001) and patients with limited numbers of peritoneal implantations (median survival: 20 months vs. 6 months; P = 0.002). Preoperative serum carcinoembryonic antigen (CEA) (P = 0.018), surgery with curative intent (P = 0.045) and adjuvant chemotherapy (P = 0.002) were independent prognostic factors in patients with stage IV GB cancer. CONCLUSIONS:Surgery in combination with systemic chemotherapy may be beneficial in carefully selected patients with stage IVb GB cancer.

背景与目标：

BACKGROUND & AIMS: BACKGROUND:In 2013, the Declaration of Helsinki changed to mandate that all research studies involving human subjects, rather than just clinical trials alone, must have a protocol registered in a publicly accessible database prior to the enrolment of the first patient. The objective of this work was to assess the number of research studies involving human participants published in leading journals of plastic surgery that had either published a protocol or registered a protocol with a publicly accessible database. MATERIALS AND METHODS:This systematic review examined all research articles involving human participants published in Plastic and Reconstructive Surgery, The Journal of Plastic Reconstructive and Aesthetic Surgery and The Annals of Plastic Surgery from 1st April 2014-31st March 2015. The primary outcome measure was whether each study had either published or registered a protocol with any mainstream registry database. ClinicalTrials.gov, the International Standard Randomized Control Trial Number (ISRCTN) registry, the WHO (World Health Organisation) International Clinical Trials Registry Platform, The Cochrane Collaboration, the Research Registry, PROSPERO and PubMed were all reviewed. RESULTS:Of 595 included articles, the most common study designs were case series (n = 185, 31.1%). There were 24 randomized controlled trials (RCTs, 4.0%). A total of 24 studies had a protocol registered (4.0%). The most common database to register a protocol was with ClinicalTrials.gov (n = 17). The study design that most commonly had a registered protocol was the RCT (n = 8 of 24, 33.3% of RCTs). Three studies published a protocol in a journal (0.6%). CONCLUSION:Publication or registration of protocols for recent studies involving human participants in major plastic surgery journals is low. There is considerable scope to improve this and guidance is provided.

背景与目标：

BACKGROUND & AIMS: BACKGROUND:Early and late dumping are complications of gastric bypass surgery. Early dumping occurs within an hour after eating, when the emptying of food into the small intestine triggers rapid fluid shifts into the intestinal lumen and the release of gastrointestinal hormones, resulting in gastrointestinal and vasomotor symptoms. Late dumping occurs between 1 and 3 hours after carbohydrate ingestion and is caused by an exaggerated insulin release, resulting in hypoglycemia. Almost no data are currently available on the prevalence of early and late dumping or their impact on health-related quality of life (QoL). OBJECTIVES:To study the prevalence of early and late dumping in a large population of patients having undergone a primary Roux-en-Y gastric bypass (RYGB) and its effect on QoL. SETTING:Cross-sectional study at a single bariatric department in the Medical Center Leeuwarden, The Netherlands between 2008 and 2011. METHODS:In 2013, this descriptive cohort study approached by email or post all patients who underwent a primary RYGB in the setting between 2008 and 2011 in one hospital. These patients were asked to fill in standardized questionnaires measuring their QoL (RAND-36), anxiety and depression (HADS), fatigue (MFI-20) and any disease specific indicators of early and late dumping syndrome. RESULTS:The questionnaire was completed and returned by 351 of 613 patients (57.1%) and 121 nonobese volunteers. Participants were mostly female (80%), aged 42 (40-54 years), with an excess weight loss of 76.8% [IQR 61-95] after RYGB surgery 2.3 [ IQR 1.6-3.4] years earlier. Self-reported complaints of moderate to severe intensity suggestive of early and late dumping were present in 18.8% and 11.7% of patients, respectively. Patients with early and late dumping demonstrated significantly lower scores on the RAND-36 and HADS compared with patients without dumping. No differences were seen in the MFI-20 scores between patients with or without early and late dumping. CONCLUSION:In this descriptive cohort, self-reported complaints suggestive of early and late dumping of moderate-to-severe intensity were, respectively, 18.8% and 11.7% in a cohort after primary gastric bypass surgery. These complaints were associated with markedly reduced health-related QoL.

背景与目标：

BACKGROUND & AIMS: BACKGROUND:Evidence-based guidelines recommend limited perioperative diagnostic imaging for new breast cancer diagnoses. For patients aged >65 years, conventional imaging use (mammography, plain radiographs, and ultrasound) has remained stable, whereas advanced imaging (computed tomography [CT], nuclear medicine scans [positron emission tomography/bone scans], and magnetic resonance imaging [MRI]) use has increased. In this study, the authors evaluated traditional and advanced imaging use among younger patients (aged ≤ 65 years) undergoing breast cancer surgery. METHODS:The MarketScan Commercial Claims and Encounters Research Database from 2005 through 2008 was analyzed to evaluate the use of conventional and advanced diagnostic imaging associated with surgery for ductal carcinoma in situ (DCIS) or stage I through III invasive breast cancer. RESULTS:The study cohort included 52,202 women (13% with DCIS and 87% with stage I-III breast cancer). The proportion of patients undergoing conventional imaging remained stable, whereas the average number of conventional imaging tests per patient increased from 4.21 tests in 2005 to 4.79 tests per patient in 2008 (P < .0001). For advanced imaging, the proportion of women who underwent imaging increased from 48.8% in 2005 to 68.8% in 2008 (P < .0001), as did the number of tests per patient (from 1.53 tests in 2005 to 1.98 tests in 2008; P < .0001). MRI examinations accounted for nearly all of the increase in advanced imaging. Patients who underwent MRI examinations received significantly more traditional imaging tests compared with to those who did not, indicating that these tests are additive and are not replacing traditional imaging. CONCLUSIONS:The current results demonstrate that the use of perioperative breast MRI has increased among women aged <65 years. Further study is indicated to determine whether the benefits of this procedure justify increased use.

背景与目标：

BACKGROUND & AIMS: BACKGROUND:Central venous oxygen saturation (ScvO2) remains the gold standard surrogate for tissue oxygen extraction in paediatric cardiac surgery. Near-infrared spectroscopy (NIRS) has been developed as a non-invasive diagnostic tool for regional oxygen saturation. The aim was to compare regional oxygen saturation measured by NIRS with ScvO2 in postoperative paediatric cardiac patients. METHODS:In this prospective study, we included newborns and infants younger than 45 days undergoing heart surgery. We recorded continuous ScvO2 and NIRS regional saturation placed on the forehead (B) and right flank (S) for 48 h postoperatively. A Bland-Altman's analysis was used to assess the agreement between these measurements. RESULTS:A total of 23 patients were included with a median age of 12 days (2-46) and median weight of 3.1 kg (2.3-4.47). The mean difference (MD) ScvO2- B NIRS was 10.45% with limits of agreement (LOA) -17.23 to 38.13% and ScvO2- S NIRS MD 7.16% with LOA: -25.51 to 39.84%. The single ventricle ScvO2- S NIRS subgroup had MD within ± 5%; however, wide LOA was observed. The remaining subgroups showed MD nearly above ± 5%, with wide LOA. CONCLUSIONS:The regional oxygen saturation of brain and kidney did not match ScvO2 as estimation of global tissue perfusion. Nevertheless, NIRS may still provide information regarding regional circulation that may help in the management of neonatal cardiac surgery patients.

背景与目标：

BACKGROUND & AIMS: BACKGROUND:Laparoscopic gastric bypass surgery (LGBS) has become the most widely used bariatric procedure due to its beneficial long-term outcomes for patients with morbid obesity. However, it is unclear whether racial differences in admission for LGBS have changed over time compared to racial differences in all other admissions. We aimed to investigate the trends and differences in the use of LGBS among white, African-American, and Hispanic patients from 2002 to 2008. METHODS:We performed a secondary analysis of data on obese adult patients operated between 2002 and 2008, using the Nationwide Inpatient Sample (NIS) database. The probability of being admitted for LGBS was estimated using logistic regression with race, year, and year by race interaction as predictors, controlling for numerous patient and hospital characteristics. RESULTS:Among 1,704,972 obese hospitalized patients captured through NIS from 2002 to 2008, 2.6 % underwent LGBS (2.8 % Whites, 1.7 % African-Americans, and 2.6 % Hispanics). In adjusted analysis, obese African-American (OR 0.48, p < 0.001) and Hispanic patients (OR 0.59, p < 0.001) were less likely to be admitted for LGBS than white patients in 2002. Race-year interactions showed that the odds of African-Americans undergoing LGBS significantly increased from 2002 to 2008 compared with Whites (annual OR 1.03, p < 0.001) while no such increase was detected for Hispanics (annual OR 1.02, p = 0.11). In 2008, African-American (OR 0.58, p < 0.001) and Hispanic patients (OR 0.65, p < 0.001) still had lower odds than white patients. CONCLUSIONS:This is the first study showing that the difference in the use of LGBS between obese African-American and white patients declined between 2002 and 2008. However, LGBS use still remained significantly lower for both African-American and Hispanic patients in 2008 compared with white patients.

背景与目标：

BACKGROUND & AIMS: INTRODUCTION:Significant malnutrition exists in a high percentage of patients with head and neck cancer. Malnutrition is associated with defects in immune function that may impair the host response to malignancy. Malnutrition and immunosupression make patients highly susceptible to postoperative infections and complications. OBJECTIVES:Some studies of patients receiving immuno-nutrition in the perioperative period in head and neck cancer have shown beneficial effects on clinical outcome and inmune status. The authors carried out a systematic review of randomised control trials to determine whether perioperative immunonutrition has a role in the treatment of head and neck cancer. METHODS:14 trials of polymeric nutritional supplementation with immunonutrition were identified. Two studies compared two types of immunonutrition. RESULTS:A reduction in the length of postoperative hospital stay was seen in some trials, but the reason for this reduction is not clear. Some studides showed statistical differences with less complications in arginine-enhanced group and also showed a significant decrease of fistula complications in patients treated with a high arginine dose enhanced formula, if compared with a medium dose of arginine. CONCLUSION:[corrected] Those planning future studies face challenges. A suitable powered clinical trial is required before firm recommendations can be made on the use of immunonutrition in head and neck cancer patients postoperatively.

背景与目标：

BACKGROUND & AIMS: OBJECTIVE:Of pediatric patients with Crohn disease, 20% to 30% undergo surgery within 10 years. Although disease relapses and reoperations are common, long-term functional outcomes and quality of life (QoL) are unclear. METHODS:In 2010, we reviewed the hospital records of all pediatric patients with CD who had undergone intestinal resections during childhood in 2 major tertiary care hospitals between 1985 and 2008 and mailed out questionnaires that asked about health outcomes and QoL. We compared the QoL of the patients and a group of matched controls randomly chosen from the Population Register Centre. RESULTS:In total, 36 children had undergone bowel resection a median of 10 years earlier and had at least 2 years of follow-up. Disease activation (verified at endoscopy) requiring medical or surgical treatment occurred in 94% (median 1.8 years after primary resection). At least 1 surgical complication occurred in 77%, and 54% underwent re-resection. The patients reported a median stool frequency of 3 stools during the day and zero at night, with 33% being totally continent. Overall, 96% were completely or moderately satisfied with the outcome of the surgery. The QoL was comparable between the patients and controls, but school or work absences diminished the QoL of the patients. CONCLUSIONS:Surgery for pediatric-onset CD is risky even under expert care. Disease relapses and bowel re-resections are common during the first decade after primary surgery. In the long term, however, bowel function is acceptable and the QoL is comparable between patients and their peers.

背景与目标：

BACKGROUND & AIMS: STUDY DESIGN:Lung volumes and thoracic anatomy were measured from low-dose computed tomography (CT) scans preoperatively and 2 years following thoracoscopic anterior spinal fusion (TASF) for adolescent idiopathic scoliosis (AIS). OBJECTIVE:The aim of this study was to assess changes in lung volume after TASF surgical correction. SUMMARY OF BACKGROUND DATA:AIS patients are known to have decreased pulmonary function as a consequence of their spinal and ribcage deformity. Several studies have evaluated changes in pulmonary function clinically after scoliosis correction surgery showing varied results. To date, there have been no published studies using CT to evaluate lung volume changes following TASF. METHODS:Twenty-three female AIS patients with both pre- and 2 years postoperative low-dose CT scans were selected from an ethically approved, historical databank. Three-dimensional lung volumes were reconstructed to determine anatomical lung volumes. Right and left lung volumes, total lung volume, and right-to-left lung volume ratio were obtained as well as hemithoracic symmetry, to indicate the extent of thorax deformity. Cobb angle, rib hump, levels fused in surgery, and patient height were used for correlation analysis with the lung volume results. RESULTS:Left lung volume, total lung volume, and hemithoracic ratio all increased significantly 2 years after surgery. There was no significant change in right-to-left lung volume ratio (P = 0.36). Statistical regression found significant positive correlation between lung volume changes, reduction in Cobb angle, increase in height, and improvement in hemithoracic symmetry ratio. CONCLUSION:TASF resulted in a statistically significant increase in lung volume following surgery, as well as improvement in the symmetry of the thoracic architecture; however, the postoperative lung volumes remained in the lower 50th percentile relative to females without thoracic deformity. Furthermore, change in lung volume was significantly correlated with changes in Cobb angle, hemithoracic asymmetry, and increased patient height, which are important consequences of thoracic deformity correction surgery. LEVEL OF EVIDENCE:3.

背景与目标：

BACKGROUND & AIMS: BACKGROUND:To explore correlation between the quality of surgery and outcome in high-risk soft tissue sarcoma (STS) patients treated within a phase III randomized trial. PATIENTS AND METHODS:In the trial, all patients received three cycles of preoperative chemotherapy (CT) with epirubicin 120 mg/m(2) and ifosfamide 9 g/m(2) and were randomly assigned to receive two further postoperative cycles. Radiotherapy (RT) could be delivered in the preoperative or postoperative setting. The association between surgical margins and overall survival (OS) was studied in a univariate and multivariate fashion. RESULTS:Two hundred and fifty-two patients completed the whole treatment and were operated conservatively. At a median follow-up of 60 months (IQR, 45-74 months), the 5-year OS was 0.73, even in patients with positive and negative margins. The 5-year cumulative incidence (CI) of local recurrence (LR) in patients with positive and negative microscopic margins was 0.17 (standard error, SE, 0.08) and 0.03 (SE, 0.01), respectively. In the subgroup of patients receiving combined preoperative CT-RT and with positive surgical margins, the CI of LR was 0. CONCLUSIONS:In this setting of high-risk STS treated by preoperative CT or CT-RT, the negative impact of positive margins on the outcome was limited. When close margins can be anticipated preoperative CT-RT may be a reasonable option to maximize the chance of cure.

背景与目标：

BACKGROUND & AIMS: INTRODUCTION:Transrectal natural orifice translumenal endoscopic surgery (NOTES) requires a good endoluminal view and adequate intrarectal bacterial clearance in the working area. We developed a new occlusion balloon unit with an easily detachable inflation device, which allows the surgeon a clear working area distal to the balloon. MATERIAL AND METHODS:The effectiveness of the sealing balloon and the extent of macroscopic and histopathological injury to the bowel wall at the site of balloon placement were examined in 12 pigs. RESULTS:The mean time to place and inflate the balloon unit was 12.0 ± 3.5 min, effective air-tightness lasted for 21.0 ± 12.0 min. There was no leakage of dye (methylene blue) past the balloon when pressure was maintained >6.70 ± 0.08 kPa (6.62-6.78 kPa). After gut irrigation, good visibility was maintained in the working area for six hours, and adequate bacterial clearance was maintained for three hours. There were no macroscopic signs of intestinal wall damage at the site of balloon placement. Histopathological examination showed only patchy mucosal damage and submucosal thrombus at the site of balloon placement. CONCLUSION:This newly-developed occlusion balloon unit helps to establish good visibility and adequate bacterial clearance for endoluminal surgical procedures.

背景与目标：