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In This Issue of JAMA Surgery |

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JAMA Surg. 2013;148(7):583. doi:10.1001/jamasurg.2013.2198.
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As part of efforts to control spending growth, the Centers for Medicare and Medicaid Services and other policy makers are scrutinizing the care provided at Critical Access Hospitals (CAHs). In this context, Gadzinski et al used the Nationwide Inpatient Sample to both characterize surgical care provided at CAHs and compare mortality, length of stay, and costs associated with common inpatient surgeries performed in CAHs vs non-CAHs. For most procedures, no evidence for mortality differences was found. However, despite shorter hospital stays, costs at CAHs were 10% to 30% higher. Although these findings suggest the potential for cost savings, changes in payment policy for CAHs could diminish access to surgical care for rural populations.

Patients with bilateral liver metastases are less likely to be resectable with conventional techniques than patients with metastases confined to one side. Karanicolas et al reviewed a prospective database of 2123 operative cases of hepatic colorectal metastases to compare outcomes in patients with bilateral metastases treated with ablation and/or resection (n = 95) with outcomes in patients treated with bilateral resection (n = 141). Patients treated with ablation had a lower blood loss (300 vs 500 mL; P < .01) and a shorter length of hospital stay (7 vs 9 days; P < .01) compared with patients treated with bilateral resection. Five-year overall survival was similar between groups and compared favorably with historical results from patients with unilateral resected hepatic metastases (56% vs 49%). Ablative therapies extend the capability of delivering potentially curative treatment for bilateral hepatic colorectal metastases and should be considered for these patients.

The half-life of parathyroid hormone (PTH) may be affected by patient characteristics, including age, sex, race, body mass, index (BMI), and renal function. In this study by Leiker et al of 306 patients who underwent minimally invasive parathyroidectomy with intraoperative PTH (IOPTH) monitoring, IOPTH kinetic profiles were fitted to an exponential decay curve to determine the half-life of the IOPTH for individual patients. The median IOPTH half-life was 3 minutes, 9 seconds. On multivariate median regression analysis, age, BMI, and age × BMI interaction affected the IOPTH half-life. The IOPTH half-life increased with increasing BMI, although this effect was negligible after age 55 years. However, the differences are relatively small, and the clinical implications are likely not significant. Current IOPTH criteria can continue to be applied to all patients undergoing parathyroidectomy for sporadic primary hyperparathyroidism.

Chronic cough can be caused by gastroesophageal reflux disease; however, treatment outcome has been difficult to predict because of the lack of an objective testing modality that accurately detects reflux-related cough. Based on normative data established previously, “abnormal proximal exposure” was defined as laryngopharyngeal reflux occurring in 1 or more times per day and/or high-esophageal reflux occurring 5 or more times per day as detected by hypopharyngeal multichannel intraluminal impedance (HMII). Patients with chronic cough and abnormal proximal exposure (n = 16) underwent antireflux surgery. Of 16 patients, 13 (81%) had a complete resolution, and 3 (19%) had significant improvement in their cough at a median follow-up of 4.2 months. In this series by Hoppo et al, most patients with chronic cough patients (73%) had abnormal proximal exposure documented by HMII. This testing modality is likely to improve the sensitivity of laryngopharyngeal reflux diagnosis and better elucidate those who will respond to antireflux surgery.

Durazzo et al investigated the role of race in treatment of patients with critical lower extremity ischemia. Using data from 774 399 discharge records, they used multiple logistic regression to control for confounding factors such as disease severity, insurance status, age, and comorbidities. They found blacks to have 1.77 times the odds of receiving an amputation compared with whites. Furthermore, contrary to current beliefs that the disparity is mainly secondary to differences in access, they found that the disparity is magnified in settings where resources are greatest.

In a retrospective study, Robb et al collect data from a multicenter database of 2670 patients who underwent resection of junctional and gastric adenocarcinomas from 1997 to 2010. The primary end point was to identify predictive factors of 30-day postoperative mortality. Within this population, 665 patients were treated with neoadjuvant chemotherapy. Multivariate analysis revealed metastatic disease at diagnosis and poor tolerance of neoadjuvant therapy (grade III/IV toxicity) as independent predictors of higher postoperative mortality. Centers performing at least 10 resections per year were found to be protective against postoperative death. This large national cohort study highlights that patients suffering high-grade toxicity to neoadjuvant therapy have higher rates of postoperative death. Analysis of this subgroup has not been performed in trials demonstrating the survival benefit of perioperative chemotherapy and should be included in future prospective studies.

Wasif et al assess the influence of physician specialty on the management of patients with soft tissue sarcoma of the extremities. They hypothesized that clinical specialty leads to bias in recommendations for adjuvant radiation or chemotherapy following surgery. The study was conducted via a national survey of physicians from medical, surgical, radiation, and orthopedic oncology specializing in sarcoma care. Patient- and tumor-specific factors influencing recommendations for radiation or chemotherapy were identified. We show that specialty bias exists in treatment recommendations overall, as well as for specific clinical indications. These results emphasize the importance of multidisciplinary consultations prior to the formulation of a treatment plan and should be of interest to any physician involved in the treatment of soft tissue sarcoma of the extremities.

Given increasing emphasis on establishing the value of medical technologies, Epstein et al examined the impact of minimally invasive surgery on medical expenditures and worker productivity. They compared health care plan spending and workplace absenteeism among a national sample of nonelderly adults with employer-sponsored health insurance who underwent either the standard or minimally invasive option for 6 types of surgery. For minimally invasive procedures, the mean health care plan spending was statistically significantly lower for 3 types of surgery and higher for 2. Minimally invasive procedures were associated with lower absenteeism for 4 types of surgery. They projected that, in 2009, more than 500 000 individuals with employer-sponsored health insurance nationally underwent the 6 types of minimally invasive surgery, which were associated with reductions of $8.9 billion in health care plan spending and more than 53 000 person-years of workplace absenteeism.

Hawn et al assessed the importance of the timing of prophylactic antibiotic administration in a national cohort patients undergoing hip or knee arthroplasty, colorectal surgical procedures, arterial vascular surgical procedures, and hysterectomy (32 459 operations). The overall surgical site infection (SSI) rate was 4.6%, and the median time between antibiotic infusion and incision was 28 minutes, but ranged from 480 minutes prior to incision to 380 minutes after incision. In multivariable analyses, considering timing as a continuous variable, there was no association between antibiotic timing and SSI. In general additive models, prophylactic antibiotic timing ranked 15th of the 16 variables in explaining the risk of SSI. Vancomycin was associated with higher SSI occurrence for orthopedic procedures, whereas cefazolin or quinolone in combination with an anaerobic agent were associated with fewer SSI events for colorectal procedures.

Optimal staging of the ileal pouch anastomosis (IPAA) procedures for patients with active ulcerative colitis (aUC) is unclear. At institution of Hicks et al, 80% of patients presenting with severe aUC undergo a proctocolectomy with an ileoanal J pouch reconstruction at their initial operation, regardless of steroid and/or anti–tumor necrosis factor (TNF) use. In the absence of hemodynamic instability, patients with aUC undergoing immediate IPAA creation appear to have outcomes similar to those of patients who are initially treated with subtotal colectomy. Their data suggest that steroids and anti-TNF agents alone do not justify the decision to avoid IPAA creation at the first operation, as long as it is performed by a high-volume inflammatory bowel disease surgeon.

The localization of gastrointestinal bleeding can be difficult and clinically challenging despite the availability of various endoscopic and radiological techniques. This is particular true when patients present with obscure gastrointestinal bleeding and continue to bleed from an unidentified source. Clinically, a marked discrepancy often exists between radiological and/or endoscopic localization and intraoperative findings of the potential bleeding site in the gastrointestinal tract, making it difficult for surgeons to know exactly where and how much to resect. Pai et al describe a novel technique that will allow surgeons to precisely identify the area of abnormal pathology intraoperatively and perform a targeted resection.

CLINICAL REVIEW & EDUCATION

To clarify the risks and benefits of inferior vena cava filters and augmented doses of heparin products in patients undergoing bariatric surgery, Brotman and colleagues conducted a systematic review and meta-analysis of studies that examined different prophylactic strategies to prevent venous thromboembolism (VTE) in this surgical population. The authors identified 5 studies of filter placement and 8 studies of pharmacologic strategies. All included studies were observational in design. There was no evidence that augmented doses of heparin products are more effective than standard doses in preventing thrombosis. Patients who received filters were more likely to have VTE and more likely to die than those not undergoing filter placement. However, patients at highest risk for VTE were more likely to receive more intensive prophylactic interventions, limiting the ability of the authors to confidently attribute adverse clinical outcomes to the prophylactic strategies used.

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