Validation of the Surgical Apgar Score in a veteran population undergoing general surgery.

BACKGROUND: The Surgical Apgar Score (SAS, a 10-point score calculated using limited intraoperative data) can correlate with postoperative morbidity and mortality after general surgery. We evaluated reliability of SAS in a veteran population. STUDY DESIGN: We prospectively collected demographics, medical history, type of surgery, and postoperative outcomes for any veteran undergoing general surgery at our institution (2006-2011). We categorized patients in 4 SAS groups and compared differences in morbidity and mortality. RESULTS: Our study population included 2,125 patients (SAS ≤4: n = 29; SAS 5-6: n = 227; SAS 7-8: n = 797; SAS 9-10: n = 1,072). Low-SAS patients were likely to have significant preoperative comorbidities and to undergo major surgery, and had increased postoperative morbidity and 30-day mortality. CONCLUSIONS: The SAS is easily calculated from 3 routinely available intraoperative measurements, correlates with fixed preoperative risk (acute conditions, pre-existing comorbidities, operative complexity), and effectively identifies veterans at high risk for postoperative complications.

Safety of hepatic resections in obese veterans.

OBJECTIVE: To determine the effects of body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) on outcomes after liver resection performed at Veterans Affairs medical centers. DESIGN, SETTING, AND PATIENTS: We queried the Veterans Affairs Surgical Quality Improvement Program database for liver resections (2005-2008) and grouped the patients into 5 BMI categories: normal weight (BMI 18.5-24.9), overweight (BMI 25.0-29.9), obese class 1 (BMI 30.0-34.9), obese class 2 (BMI 35.0-39.9), and obese class 3 (BMI ≥ 40.0). Differences in risk factors and perioperative complications across groups were analyzed in univariate and multivariate analyses. RESULTS: Of 403 patients who underwent hepatectomy, 106 (26%) were normal weight, 161 (40%) were overweight, 94 (23%) were obese class 1, 31 (8%) were obese class 2, and 11 (3%) were obese class 3. Among these groups, higher BMI was associated with increased rates of hypertension (52%, 61%, 77%, 77%, and 73%, respectively; P = .002) and diabetes (18%, 27%, 36%, 39%, and 45%, respectively; P = .04) and lower incidence of smokers (53%, 35%, 30%, 16%, and 9%, respectively; P < .001). The BMI groups were similar in demographic characteristics and metrics correlating with preexisting liver disease. There were no differences across BMI groups in overall and specific morbidity or in length of stay. Compared with the other groups, obese class 3 patients received more blood transfusions (mean [SD], 4.3 [2.7] in obese class 3 patients vs 1.1 [0.2] in normal-weight patients; P = .02) and had a higher 30-day mortality (27% in obese class 3 patients vs 6% in normal-weight patients; P = .05). Multivariate analyses confirmed obese class 3 as an independent predictor of postoperative mortality. CONCLUSIONS: Obesity did not increase postoperative complications after liver resection in veterans. After adjusting for other clinical factors, extreme obesity (BMI ≥ 40.0) was an independent risk factor for increased mortality.

Percutaneous treatment of thoracic duct injuries.

BACKGROUND: Major thoracic or neck surgery or penetrating trauma can cause injury to the thoracic duct and development of a chylothorax. Chylothorax results in metabolic and immunologic disorders that can be life threatening, with a mortality rate reaching 50%. The management of chyle leaks is dependent on the etiology and daily output. Interventions are used to treat only leaks unresponsive to medical management or those with an output exceeding 1,000 ml/day. METHODS: This study reviewed the existing literature on the percutaneous management of chyle leaks. The authors evaluated five case series and three case reports inclusive of 90 patients in which percutaneous treatment for chylothorax was attempted between 1998 and 2004. RESULTS: For 71 patients, percutaneous treatment was technically successful, and chylothorax resolved in 49 of the patients (69%). Percutaneous treatment of chylothorax was associated with a 2% morbidity rate and no mortality. For 19 patients whose percutaneous approach failed, either surgical ligation or pleurodesis was performed. CONCLUSIONS: The percutaneous management of chyle leak is feasible, with low morbidity and mortality rates and a high rate of effectiveness. This approach should be considered before more invasive procedures.

Impact of mandatory resident work hour limitations on medical students' interest in surgery.

BACKGROUND: The number of US medical students applying for general surgery residency has been declining. Recent studies have shown that the issue of "controllable lifestyle" has become a critical factor in medical students' decision-making process. We postulate that widespread implementation of resident work hour limitations would bolster medical students' interest in pursuing surgical careers. STUDY DESIGN: Students from New York University School of Medicine were surveyed about their attitudes toward work hour limitations and its effect on their interest in pursuing a surgical residency. One hundred thirty-two students participated. RESULTS: Nearly 95% of respondents believed that work hour limitations were a positive change and, if all other factors were equal, they would choose a training program that used work hour limitations over one that did not. The most common reasons cited in favor of limits were improvements in resident lifestyle (42%) and patient safety (34%). Fifty-three percent of respondents indicated that presence of work hour limitations alone would increase their interest in considering a surgical residency and only 2% of medical students indicated that it would lessen their interest in surgery. Not surprisingly, intellectual interest in a specialty was the most important factor in choosing a residency for 86% of students. Nevertheless, work hour limitations were designated a higher priority than future salary by 55% of medical students. CONCLUSIONS: The presence of work hour limitations has a positive impact on medical students' interest in surgery. Widespread implementation of work hour limitations may bolster the number of applications for surgical residency.

Attitudes of applicants for surgical residency toward work hour limitations.

BACKGROUND: There is an ongoing debate regarding the merits of resident work-hour limitations. We postulated that this issue would be a factor in the decision-making process of applicants to surgical residency. METHODS: Candidates for surgical residency at a university-based program completed an anonymous survey during their visit. Data was analyzed by analysis of variance and the chi-square test. RESULTS: Most candidates viewed work-hour limitations as being favorable to their future training. Nevertheless, work-hour limitations ultimately were not a critical factor in the decision-making process compared with issues such as quality of training and program reputation. Candidates ranked "reading in surgery" the most likely way they would spend the leisure time afforded by work-hour limitations. CONCLUSIONS: Most applicants for surgical residency consider work hour-limitations as being favorable to their training and view the extra free time as an opportunity for furthering their education. However, other issues take precedence when choosing a residency.