Is it safe? Appendectomies at night at a low-volume center.

OBJECTIVE: Recent literature reports an increased risk of morbidity and mortality in nonemergency operations performed during nonregular duty hours at large institutions. Of the nonemergency operations performed after regular duty hours, appendectomies remain the most common. The study seeks to answer the question as to whether it is safe to continue performing appendectomies during non-normal duty hours at a low-volume institution. DESIGN: The study is a retrospective cohort review examining 102 appendectomies for suspected appendicitis over a 46-month period from July 2005 to May 2010. The total number of cases, gender, type of procedure, start and stop time, and complications were recorded and analyzed. SETTING: Keesler Medical Center, located on Keesler Air Force Base, Mississippi. PARTICIPANTS: All patients with appendectomies for presumed appendicitis observed between July 2005 and May 2010. RESULTS: No statistical difference was found between complication rates during off-duty hours and normal duty hours at our institution (p = 0.619; odds ratio = 0.34722, 95% confidence interval = 0.035-2.45). CONCLUSIONS: Performing appendectomies after regular-duty hours at our institution does not increase the risk of mortality and morbidity.

Venous thromboembolic disease in trauma and surveillance ultrasonography.

BACKGROUND: The literature reports a wide variation in the incidence of venous thromboembolic (VTE) disease in trauma patients. The performance of routine surveillance venous duplex ultrasound of bilateral lower extremities is controversial. Furthermore, recent examinations of the national trauma databank registry have suggested that routine duplex surveillance is associated with higher deep venous thrombosis (DVT) detection rates. MATERIALS AND METHODS: We examined the incidence and risk factors for VTE disease in 2827 trauma patients admitted over a 2-y period to a state-verified level I trauma center. Detailed chart review was carried out for patients with VTE disease. We then evaluated the effects of a routine bilateral lower extremity duplex surveillance guideline on VTE detection in the subset of injury patients admitted to the trauma service. RESULTS: We found an approximately 2% incidence of venous thromboembolic disease in a mostly blunt trauma population. Amongst patients with VTE disease, the most common risk factors were obesity and significant head injury. We then evaluated the 998 patients with injury who were admitted to the trauma service 1 y before and after surveillance guideline implementation. Despite a nearly 5-fold increase in the number of duplex scans, with a substantial increase in cost, we found no significant difference in the incidence of DVT. CONCLUSIONS: Our preliminary data argue against the use of routine duplex surveillance of lower extremities for DVT in trauma patients. A larger, prospective analysis is necessary to confirm these findings.

Classic groin hernia repair...lest we forget.

Currently, operative repair of inguinal hernia is most often performed using one of the open mesh procedures or laparoscopic techniques. These newer approaches minimize anatomical dissection critical to the time-honored traditional hernia surgery described by Bassini, Halsted, McVay, Laroque, Shouldice, and other early pioneers. The familiarity with groin anatomy and the technical skill gained in performing these operations is currently missing from present-day surgical residency training. This article reviews 5 classic hernia operations described by the surgeons whose name they bear, with a view toward better understanding the authors' techniques and philosophies. Each of these operations, though considered by some as of historical interest only, offers today's surgeon reliable alternatives when the simple application of mesh by open or laparoscopic technique is inappropriate. (Curr Surg 62:249-252. Published by Elsevier Inc. on behalf of the Association of Program Directors in Surgery.).

The spectrum of treatment and future diagnosis of early non-small cell lung carcinoma.

PURPOSE: Review the surgical treatment of 56 patients at a single institution of early stage non-small cell lung carcinoma (NSCLC). Briefly review the literature to report the current indications for limited pulmonary resection. Discuss newer methods of assessing early stage NSCLC. METHODS: We reviewed 56 lobectomies performed at the Biloxi Veterans Administration Medical Center from January 1992 to December 1997 for NSCLC to report the incidence of N1 positive lymph nodes and survival data. Additionally, a search of PubMed, Ovid, and MDConsult.com, using search parameters of non-small cell lung carcinoma, limited pulmonary resection, lobectomy, and comorbidity, were used to determine indications for treating non-small cell lung carcinoma. RESULTS: N1 positive lymph nodes occurred in 11 out of 56 patients; 4 were identified preoperatively. In this sample, 21 patients were Stage IA, 21 Stage IB, 6 Stage IIA, and 8 Stage IIB, and their 4-year median survival was as follows: (IA) greater than 44.80 months, (IB) greater than 48.0 months, (IIA) greater than 25.28 months, and (IIB) = 11.18 months. Four-year survival rates by stage were IA= 10/21 (47.62%), IB= 14/21 (66.67%), IIA= 2/6 (33.33%), and IIB= 0/8 (0.0%). CONCLUSIONS: The 4-year survival data we reviewed were less favorable than is reported by others. Patient medical comorbidity, patient age, and sample size are thought to account for this difference. According to our literature review, reasons for limited pulmonary resection include poor physical performance, marginal lung reserve, synchronous bilateral tumors, and superior sulcus tumors (T3) in which the tumor primarily invades the chest wall. Heavier consideration of these indications might have improved the outcomes seen in this population.