Surgery (SURGERY )

Publisher: Society of University Surgeons; Society for Vascular Surgery (U.S.); Central Surgical Association, Elsevier


For over 60 years, Surgery has published practical, authoritative information about procedures, clinical advances, and major trends shaping general surgery. Each issue features original scientific contributions and clinical reports. Peer-reviewed articles cover topics in oncologic, trauma, gastrointestinal, vascular, and transplantation surgery. The journal also publishes papers from the meetings of its sponsoring societies, the Society of University Surgeons, the Central Surgical Association, and the American Association of Endocrine Surgeons. The journal ranks in the top 3.6% of the 4,779 scientific journals most frequently cited (Science Citation Index). Surgery is recommended for initial purchase in the Brandon-Hill study, Selected List of Books and Journals for the Small Medical Library (1997/98 Edition). Editors: Andrew L. Warshaw, M.D., Michael G. Sarr, M.D.

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Publications in this journal

  • Surgery 01/2015; 157(1):1-5.
  • Surgery 01/2015; 157(1):176-7.
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    ABSTRACT: Laparoscopic distal pancreatectomy is regarded as a feasible and safe surgical alternative to open distal pancreatectomy for lesions of the pancreatic tail and body. The aim of the present systematic review was to provide recommendations for clinical practice and research on the basis of surgical morbidity, such as pancreas fistula, delayed gastric empting, safety, and clinical significance of laparoscopic versus open distal pancreatectomy for malignant and nonmalignant diseases of the pancreas. A systematic literature search (MEDLINE) was performed to identify all types of studies comparing laparoscopic distal pancreatectomy and open distal pancreatectomy. Random effects meta-analyses were calculated after critical appraisal of the included studies and presented as odds ratios or mean differences each with corresponding 95% confidence intervals. A total of 4,148 citations were retrieved initially; available data of 29 observational studies (3,701 patients overall) were included in the meta-analyses. Five systematic reviews on the same topic were found and critically appraised. Meta-analyses showed superiority of laparoscopic distal pancreatectomy in terms of blood loss, time to first oral intake, and hospital stay. All other parameters of operative morbidity and safety showed no difference. Data on oncologic radicality and effectiveness are limited. Laparoscopic distal pancreatectomy seems to be a safe and effective alternative to open distal pancreatectomy. No more nonrandomized trials are needed within this context. A large, randomized trial is warranted and should focus on oncologic effectiveness, defined end points, and cost-effectiveness. Copyright © 2015 Elsevier Inc. All rights reserved.
    Surgery 01/2015; 157(1):45-55.
  • Surgery 01/2015; 157(1):8-9.
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    ABSTRACT: The benefits of anatomic resection in patients with small (<5 cm), solitary hepatocellular carcinomas remain unclear. Outcomes were therefore evaluated in patients who underwent anatomic resection or nonanatomic resection of small solitary hepatocellular carcinomas. Factors affecting overall survival and disease-free survival were investigated in 330 patients who underwent curative hepatectomy for solitary (≤5 cm) hepatocellular carcinomas without macroscopic vascular invasion. In addition, a propensity score matching model with 330 patients was constructed to overcome bias, with subgroups analyzed by tumor diameter (<3 cm and 3-5 cm). ICG-R15 ≥25% was confirmed as being independently associated with poorer overall survival and disease-free survival. One-to-one matching of preoperative characteristics yielded 72 pairs of patients receiving anatomic resection and nonanatomic resection, with long-term outcomes, including overall survival and disease-free survival, being similar in these 2 groups. Subgroup analysis showed that, in patients with tumors <3 cm in diameter, short-term outcomes were better in the nonanatomic resection group than in the anatomic resection group, including significantly reduced operation time (P = .02), blood loss (P = .01), blood transfusion (P < .01), complications (particularly bile leakage and abdominal abscess) (P = .04), and postoperative hospital stay (P < .01). Anatomic resection was not superior to nonanatomic resection in survival outcomes in patients with solitary small hepatocellular carcinomas without macroscopic vascular invasion. Rather, postoperative short-term outcomes were more favorable with nonanatomic resection. Copyright © 2015 Elsevier Inc. All rights reserved.
    Surgery 01/2015; 157(1):27-36.
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    ABSTRACT: Rectal hyposensitivity (RH) can lead to fecal incontinence (FI). Sacral nerve stimulation (SNS) is known to modulate rectal sensation, but no data about affecting FI owing to RH are available. This prospective study aimed to assess the therapeutic effect of temporary SNS on patients with FI owing to RH. Twenty-four patients with FI owing to RH had temporary SNS (4 weeks on followed by 1 week off). Before SNS (baseline), after 4 weeks of stimulation (on), and at the end of the off week we recorded first constant sensation (FCS), defecatory desire volume (DDV), maximum tolerated volume (MTV), anal pressures, bowel diaries, Wexner incontinence score, and FI quality-of-life score (FIQOL). There were significant decreases in DDV and MTV during the on-treatment period (P < .0001); this decrease was not significant during the off period. FCS was not significantly affected by SNS. FI episodes significantly improved during the on period in 22 patients (from 5.3 to 1.1 per week; P < .0001) and mean Wexner incontinence score improved from 13.3 to 1.7 (P < .0001). Anal pressures (resting and squeeze) significantly increased during the on period but not during the off period. There was significant improvement in FIQOL during the on period only. SNS can be effective in restoring continence and improving QOL in patients with FI owing to RH. Improved continence might be related to improvement of rectal sensation and/or increased anal pressure. The washout effect of SNS on the continence score, DDV, and MTV after cessation of stimulation needs to be explained. Copyright © 2015 Elsevier Inc. All rights reserved.
    Surgery 01/2015; 157(1):56-63.
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    ABSTRACT: To evaluate the relationship between the BRAF V600E mutation and clinicopathologic parameters and to assess the impact of the BRAF V600E mutation and established risk scores on survival in patients with papillary thyroid carcinoma (PTC). Retrospective analysis of a consecutive, single-institutional cohort of patients with PTC larger than 1 cm. Clinical risk scores according to the Metastases, Age, Completeness of Resection, Invasion, Size (MACIS), European Organisation for Research and Treatment of Cancer (EORTC), and tumor, node, metastases (TNM) scoring systems were determined. BRAF exon 15 mutation analysis was performed by polymerase chain reaction and Sanger sequencing. BRAF V600E mutations were found in 75/116 (65%) PTC. The rates for 5- and 10-year overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) were 92% and 87%, 98% and 96%, and 96% and 94%, respectively. Low MACIS scores were associated with longer OS (10 y 95% vs 75%, P = .008), DSS (10 y 100% vs 89%, P = .02) and RFS (100% vs 85%, P = .006). Comparable survival advantages were observed for patients with early EORTC scores and low TNM stage. BRAF V600E mutation status was not associated with clinicopathologic characteristics of aggressive behavior such as extrathyroidal extension, lymph node metastases, higher T-categories, male sex, and greater age. Furthermore, BRAF V600E mutation status was not correlated with clinical risk scores and decreased survival. In concordance with other studies, we did not find a negative prognostic impact of a positive BRAF V600E mutation status on survival. In contrast, the risk algorithms MACIS, EORTC score, and TNM stage were associated with impaired prognosis. Therefore, clinical staging systems represent better tools for risk stratification than BRAF V600E mutation status. Copyright © 2015 Elsevier Inc. All rights reserved.
    Surgery 01/2015; 157(1):119-125.
  • Surgery 01/2015; 157(1):6-7.
  • Surgery 01/2015; 157(1):178-9.
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    ABSTRACT: Increasing ambient temperature to prevent intraoperative patient hypothermia remains widely advocated despite unconvincing evidence of efficacy. Heat stress is associated with decreased cognitive and psychomotor performance across multiple tasks but remains unexamined in an operative context. We assessed the impact of increased ambient temperature on laparoscopic operative performance and surgeon cognitive stress. Forty-two performance measures were obtained from 21 surgery trainees participating in the counter-balanced, within-subjects study protocol. Operative performance was evaluated with adaptations of the validated, peg-transfer, and intracorporeal knot-tying tasks from the Fundamentals of Laparoscopic Surgery program. Participants trained to proficiency before enrollment. Task performance was measured at two ambient temperatures, 19 and 26°C (66 and 79°F). Participants were randomly counterbalanced to initial hot or cold exposure before crossing over to the alternate environment. Cognitive stress was measured using the validated Surgical Task Load Index (SURG-TLX). No differences in performance of the peg-transfer and intracorporeal knot-tying tasks were seen across ambient conditions. Assessed via use of the six bipolar scales of the SURG-TLX, we found differences in task workload between the hot and cold conditions in the areas of physical demands (hot 10 [3-12], cold 5 [2.5-9], P = .013) and distractions (hot 8 [3.5-15.5], cold 3 [1.5-5.5], P = .001). Participant perception of distraction remained greater in the hot condition on full scoring of the SURG-TLX. Increasing ambient temperature to levels advocated for prevention of intraoperative hypothermia does not greatly decrease technical performance in short operative tasks. Surgeons, however, do report increased perceptions of distraction and physical demand. The impact of these findings on performance and outcomes during longer operative procedures remains unclear. Copyright © 2015 Elsevier Inc. All rights reserved.
    Surgery 01/2015; 157(1):87-95.
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    ABSTRACT: Nerve-preserving surgery has been provided for patients with rectal cancer; however, sexual dysfunction remains a common complication of rectal cancer surgery. This study explored the efficacy of udenafil to treat erectile dysfunction in male patients who underwent total mesorectal excision (TME) for rectal cancer. We conducted a randomized, double-blind, placebo-controlled clinical trial involving 80 male patients who had decreased International Index of Erectile Function-5 (IIEF-5) scores after TME for rectal cancer. Patients received placebo (50 mg) or udenafil (50 mg) for 12 weeks. The primary outcome variable was the change in IIEF-5 scores. The secondary outcome variables were Sexual Encounter Profile (SEP) questions 2 (Q2) and 3 (Q3), and the Global Assessment Question (GAQ). Baseline IIEF-5 scores, SEP Q2 and Q3 responses, and spontaneous erection rates were consistent in both groups. At the end of treatment, the change in IIEF-5 scores from the baseline was significantly higher in the udenafil group than it was in the placebo group (mean IIEF-5 score, 4.8 ± 4.0 vs 2.0 ± 1.7; P < .05). Responses to SEP Q2, SEP Q3, and GAQ were significantly higher in the udenafil group than they were in the placebo group (SEP Q2, P = .025; SEP Q3, P = .044; GAQ, P < .001). Treatment-related adverse events (n = 4) were all mild in severity. Oral udenafil was deemed safe and effective for the treatment of erectile dysfunction in patients who underwent TME for rectal cancer. Copyright © 2015 Elsevier Inc. All rights reserved.
    Surgery 01/2015; 157(1):64-71.
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    ABSTRACT: Although radiofrequency ablation (RFA) is an effective local ablative technique for the treatment of hepatocellular carcinoma (HCC), the optimal treatment for recurrence after RFA has not been established. Between September 2002 and December 2011, 46 hepatectomies (salvage group) were performed for intrahepatic (local or multifocal) recurrent HCC after RFA. The difference between the imaging findings before RFA and at the time of salvage resection, especially in the Local recurrent group, and the short-term and long-term outcomes after salvage surgery were analyzed retrospectively by comparing them with those for a matched control group (n = 46) and with those of patients who underwent a second hepatic resection for HCC recurrence after an initial hepatic resection during the same period (n = 155). The tumor-occupying region was more distributed widely before the salvage resection compared with that before RFA, and a more extensive operation would have been required (rather than the RFA) in the local group. An evaluation of the short-term outcomes revealed that salvage resection required a longer operative time and was associated with a greater frequency of morbidity. The long-term outcomes of the salvage group were poorer than those of patients who underwent repeat hepatic resection for HCC recurrence after an initial hepatic resection. The indications for RFA should be determined carefully, because recurrence after RFA may be associated with a more aggressive pattern of recurrence, and the long-term results after salvage resection are unsatisfactory. Copyright © 2014 Elsevier Inc. All rights reserved.
    Surgery 12/2014;
  • Surgery 12/2014;
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    ABSTRACT: During examination of the vocal cords (VC) using transcutaneous laryngeal ultrasonography (TLUSG), 3 sonographic landmarks (namely, false VC [FC], true VC [TC], and arytenoids [AR]) are often seen. However, it remains unclear which landmark provides a more reliable assessment and whether seeing more landmarks improves the diagnostic accuracy and reliability. We evaluated prospectively 245 patients from 2 centers. One assessor from each center performed all TLUSG examinations and their findings were validated by direct laryngoscopy. All 3 sonographic landmarks were routinely visualized whenever possible. The rate of visualization and diagnostic accuracy between the 3 landmarks were compared. Eighteen patients suffered postoperative VC palsy (VCP). Both centers had comparable visualization or assessability rate of ≥1 sonographic landmark (94.9 and 95.3%; P = 1.000) and 100% sensitivity on postoperative TLUSG. The rates of FC, TC, and AR visualization were 92.7%, 36.7%, and 89.8%, respectively. The sensitivity, specificity, and diagnostic accuracy and the proportion of true positives, false positives, and true negatives between using 1, 2, landmarks and 3 landmarks were comparable (P > .05). Each sonographic landmark had similar reliability and diagnostic accuracy. Identifying all 3 sonographic landmarks was not mandatory and visualizing normal movement in one of the sonographic landmarks would be sufficient to exclude VCP. Copyright © 2014 Elsevier Inc. All rights reserved.
    Surgery 12/2014; 156(6):1590-6.
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    ABSTRACT: One-fifth of all patients with small-intestinal neuroendocrine tumors (SI-NETs) present with or develop peritoneal carcinomatosis (PC). Our aim was to determine the prognosis and genetic profiles of tumors in patients with PC compared with tumors in patients without PC. We included SI-NET patients (cases with PC, n = 73, and controls without PC, n = 468) who underwent operation between 1985 and 2012. The Lyon prognostic index was used to correlate the amount of PC to survival. DNA samples from patients with (n = 8) and without (n = 7) PC were analyzed with a single-nucleotide polymorphism array (HumanOmni2.5 BeadChip, Illumina) to investigate genetic disparities between groups. Patients with PC had poorer survival (median 5.1 years) than controls (11.1 years). An advanced postoperative Lyon prognostic index was a negative prognostic marker for survival by multivariable analysis (P = .042). Patients with and without PC clustered differently based on loss of heterozygosity and copy number variation data from single-nucleotide polymorphism array of the primary tumors (P = .042). SI-NET patients with PC have poor survival, which diminishes with increasing PC load after surgery. Clustering based on copy number variation and loss of heterozygosity data suggests different genotypes in primary tumors comparing patients with and without PC. Copyright © 2014 Elsevier Inc. All rights reserved.
    Surgery 12/2014; 156(6):1512-22.
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    ABSTRACT: Cell adhesion molecules, represented by the immunoglobulin family and selectins, play an important role in the progression of cancer. A correlation between selectins and tumor aggressiveness has been demonstrated in several reports. Eighty-eight patients (mean age, 41.0 ± 14 years) with papillary thyroid carcinoma (conventional variant and sized approximately 20 mm) were divided in 2 groups: 41 with encapsulated tumors and 47 with tumors with extrathyroidal extension. E-selectin expression was evaluated by immunohistochemical staining and semiquantitative real-time reverse-transcription polymerase chain reaction and normalized by calculating the z-score (positive: value above the population mean; negative: below the mean). Lymph node metastasis (LNM) was found in 2 of 41 encapsulated tumors (4.8%) and in 19 of 47 tumors (40.4%) with extrathyroidal extension. BRAF mutation was present in 21 encapsulated tumors (51.2%) and in 31 tumors with extrathyroidal extension (65.9%). The mean E-selectin z-score was -0.32 for encapsulated tumors and 0.28 for tumors with extrathyroidal extension. E-selectin expression correlates with neoplastic infiltration (P = .04), the American Joint Commission on Cancer stage (P = .02), and BRAF mutation (P = .03). E-selectin overexpression in association with BRAF mutation status could promote a more aggressive phenotype in papillary thyroid carcinoma. Copyright © 2014 Elsevier Inc. All rights reserved.
    Surgery 12/2014; 156(6):1550-8.
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    ABSTRACT: Acupuncture is a safe and well-tolerated treatment for pain relief. Previous studies supported the effectiveness of several acupuncture techniques for postoperative pain. The aim of this randomized, controlled trial was to evaluate the efficacy of acupuncture in reducing pain after thyroid surgery. We randomized 121 patients to a control group (undergoing only standard postoperative analgesic treatment with acetaminophen) and an acupuncture group, undergoing also either electroacupuncture (EA) or traditional acupuncture (TA). Pain was measured according to intraoperative remifentanil use, acetaminophen daily intake, Numeric Rating Scale (NRS), and McGill Pain Questionnaire on postoperative days (POD) 1-3. Acupuncture group required less acetaminophen than controls at POD 2 (P = .01) and 3 (P = .016). EA patients required less remifentanil (P = .032) and acetaminophen than controls at POD 2 (P = .004) and 3 (P = .008). EA patients showed a trend toward better NRS and McGill scores from POD 1 to 3 compared with controls. EA patients had a lower remifentanil requirement and better NRS and McGill scores than TA patients. No differences occurred between TA patients and controls. Acupuncture may be effective in reducing pain after thyroid surgery. EA is more useful; TA achieves no significant effects. Copyright © 2014 Elsevier Inc. All rights reserved.
    Surgery 12/2014; 156(6):1605-13.