Surgery News - May 2008 - (Page 2)

NEWS SURGERY NEWS • M AY 2 0 0 8 Is Obesity Protective in Abdominal Cancer Surgery? B Y P AT R I C E W E N D L I N G Else vier Global Medical Ne ws C H I C A G O — Obesity was not a risk factor for postoperative mortality or major complications in patients undergoing major intra-abdominal cancer surgery, according to data from a prospective, multicenter risk-adjusted cohort study of 2,258 patients. As observed in previous studies, however, obesity was a risk factor for minor complications, primarily wound infections. Importantly, underweight patients had a fivefold increased risk of postoperative death, perhaps a consequence of their underlying poor nutritional status or impaired immunity, investigator Dr. John T. Mullen reported at a symposium sponsored by the Society of Surgical Oncology. “The prejudice that overweight and obese patients are at increased risk for serious adverse outcomes after major cancer surgery is not justified,” he said. “Paradoxically, overweight status and mild obe- sity status may be protective of low mortality.” This possible “obesity paradox” warrants further study, whereas underweight patients might benefit from perioperative nutritional supplementation to mitigate their increased risk of mortality, Dr. Mullen, a surgical oncologist with Beth Israel Deaconess Medical Center, Boston, and associates concluded. Underweight patients in the study were significantly more likely to have lost more than 10% of their body weight in the 6 months prior to surgery and to have a lower mean preoperative serum albumin level than other patients have. Using National Institutes of Health–defined body mass index (BMI) classes, 55 patients were stratified as underweight (BMI up to 18.5 kg/m2), 819 as normal (BMI 18.6-25), 811 as overweight (BMI 25.1-30), 357 as obese I (BMI 30.1-35), 137 as obese II (BMI 35.1-40), and 79 as obese III (BMI above 40). Patients underwent the following procedures from October 2001 to September 2004 at hospitals that participated in the Patient Safety in Surgery Study of the National Surgical Quality Improvement Program: 29 esophagectomy, 223 gastrectomy, 554 hepatectomy, 699 pancreatectomy, and 753 low anterior resection/proctectomy. The risk of postoperative death was greatest at the extremes of BMI class, with a 30-day mortality rate of 9% among underweight patients, 2% among normal weight, 2.1% among overweight, 0.84% among obese I, 0.73% among obese II, and 3.8% among obese III, said Dr. Mullen, an ACS Fellow. In a multivariate analysis that examined 97 variables, the risk of postoperative death was significantly higher for underweight patients, with an odds ratio of 5.24, compared with patients stratified as normal (OR 1.00), overweight (OR 1.06), obese I (OR 0.61), obese II (OR 0.45), and obese III (OR 1.67). The 30-day morbidity rate was 22% (OR 0.94), 23% (OR 1.00), 26% (OR 1.22), 29% (OR 1.42), 30% (OR 1.42), and 33% (OR 1.50), respectively, he said. There was a progressive and significant increase in minor complications, which included only urinary tract and wound infections, with increasing BMI class: underweight 9%, normal weight 13%, overweight 14%, obese I 17%, obese II 18%, and obese III 25%, said Dr. Mullen, who received no funding for the study and reported no conflicts of interest. There were no differences among the BMI classes in total operative time or number of patients returning to the operating room. Obesity has long been considered a potential risk factor for poor surgical outcomes, yet the published data are conflicting, Dr. Mullen said. The few studies that have examined outcomes after major cancer surgery have shown only an increased incidence of intra-abdominal and superficial wound infections. They were limited, however, by small numbers, retrospective design, limited patient followup, heterogeneity, and types of procedures studied, he said. FDA-Approved Sealant Rivals Staples for Burn Grafts sealant recently approved by the Food and Drug Administration for Afibrin autologous skin grafts in pediadhering atric and adult burn patients provides an alternative to staples and sutures, according to the agency. The sealant, derived from pooled human plasma, will be available in July and will be marketed under the trade name Artiss by Baxter Healthcare Corp. Approval was based on a multicenter study of 138 patients whose mean age was 31 years (15% of the patients were aged 718 years). Each patient had one split-thickness skin graft attached with surgical staples and another attached with Artiss. Artiss was determined to be as good as staples in attaining complete wound closure, according to the FDA: At 28 days, 45% of the Artiss-treated wounds and 37% of the stapled wounds had completely closed. Adverse reactions with Artiss were skin graft failure (5 of the 138 patients ) and pruritus (2 of the 138 patients). Artiss is almost identical to Tisseel, another fibrin sealant manufactured by Baxter, but contains a much lower concentration of thrombin (4 IU/mL vs. 500 IU/mL in Tisseel), so it provides surgeons “more time to position skin grafts over burns before the graft begins to adhere to the skin,” according to the FDA. Artiss contains aprotinin, a fibrinolysis inhibitor. It is applied in a thin layer. The availability of Artiss “can help surgeons using a fibrin sealant to finetune graft placement on burn sites,” Dr. Jesse L. Goodman, director of the FDA’s Center for Biologics Evaluation and Research, said in an FDA statement announcing the approval. The warnings and precautions section of the Artiss label points out that because Artiss is derived from human plasma, it potentially can transmit infectious diseases and, theoretically, the agent that causes Creutzfeldt-Jakob disease. It is for topical use only and is not approved for hemostasis. At press time, Baxter did not have a price available for Artiss. —Elizabeth Mechcatie SURGERY NEWS SURGERY NEWS Editor in Chief, SURGERY NEWS Lazar J. Greenfield, M.D., FACS ACS Director of Communications Linn Meyer EDITORIAL ADVISORY BOARD Anesthesiology: Robert Morell, M.D., Clinical Associate Professor of Anesthesia, Fort Walton Beach Medical Center Bariatric: Myriam J. Curet, M.D., FACS, Professor of Surgery, Stanford University Cardiothoracic: Mark S. Allen, M.D., FACS, Professor of Surgery, Mayo Clinic Cardiothoracic: Fred A. Crawford, Jr., M.D., FACS, Chairman, Department of Surgery, Medical University of South Carolina Colorectal: Robert Madoff, M.D., FACS, Professor of Surgery, University of Minnesota Endocrine Surgery: Robert Udelsman M.D., FACS, Chairman, Department of Surgery, Yale University Ethics: James W. Jones, M.D., Ph.D., FACS, Visiting Professor of Medicine and Medical Ethics, Baylor University Information Technology: Patricia L. Turner, M.D., FACS, Assistant Professor of Surgery, University of Maryland Minimally Invasive and Gastrointestinal: Gerald M. Fried, M.D., FACS, Professor of Surgery, McGill University Neurological: Hunt Batjer, M.D., FACS, Michael J. Marchese Professor, Northwestern University Obstetrics and Gynecology: William J. Hoskins, M.D., FACS, Executive Director of Surgical Activities, Memorial Sloan-Kettering Cancer Center Ophthalmology: Natalie C. Kerr, M.D., FACS, Chief, Pediatric Ophthalmology Service, University of Tennessee Orthopedic: Mark R. Belsky, M.D., FACS, Chief of Orthopedic Surgery, Newton-Wellesley Hospital Otolaryngology: Mark Weissler, M.D., FACS, J.P. Riddle Distinguished Professor, University of North Carolina Pediatric Surgery: Thomas F. Tracy, Jr., M.D., FACS, Pediatric Surgeon-in-Chief, Hasbro Children's Hospital Plastic Surgery: Linda Phillips, M.D., FACS, Truman G. Blocker Jr., M.D. Distinguished Professor, University of Texas Resident/Associate Society: Ted A. James, M.D., Assistant Professor of Surgery, University of Vermont Surgical Oncology: James P. Neifeld, M.D., FACS, Chairman, Department of Surgery, Virginia Commonwealth University Transplantation: Jeffrey Punch, M.D., FACS, Associate Professor of Surgery, University of Michigan Trauma (Burns and Mass Casualties): Steven E. Wolf, M.D., FACS, Professor of Surgery, University of Texas Trauma and Critical Care: Grace S. Rozycki, M.D., FACS, Professor of Surgery, Emory University Urology: Badrinath R. Konety, M.D., FACS, Vice Chair, Dept. of Urology, University of California at San Francisco Vascular: Linda Harris, M.D., FACS, Associate Professor of Surgery, Millard Fillmore Hospital SURGERY NEWS is the official newspaper of the American College of Surgeons and provides the practicing surgeon with timely and relevant news and commentary about clinical developments and about the impact of health care policy on the profession and on surgical practice today. Content for SURGERY NEWS is provided by International Medical News Group and Elsevier Global Medical News. Content for the NEWS FROM THE COLLEGE is provided by the American College of Surgeons. The ideas and opinions expressed in SURGERY NEWS do not necessarily reflect those of the College or the Publisher. The American College of Surgeons and Elsevier Society News Group, a division of Elsevier Inc., will not assume responsibility for damages, loss, or claims of any kind arising from or related to the information contained in this publication, including any claims related to the products, drugs, or services mentioned herein. POSTMASTER: Send changes of address (with old mailing label) to Circulation, SURGERY NEWS, 60 B Columbia Rd., 2nd flr., Morristown, NJ 07960. The American College of Surgeons’ headquarters is located at 633 N. Saint Clair St., Chicago, IL 60611-3211. SURGERY NEWS (ISSN 1553-6785) is published monthly for the American College of Surgeons by Elsevier Inc., 60 B Columbia Rd., 2nd flr., Morristown, NJ 07960; 973-290-8200; fax 973-290-8250. ELSEVIER SOCIETY NEWS GROUP, A DIVISION OF INTERNATIONAL MEDICAL NEWS GROUP President, IMNG Alan J. Imhoff Director, ESNG Mark Branca Executive Director, Editorial Mary Jo M. Dales Executive Edi

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Surgery News - May 2008 Contents New Lung Approach Speeds Extubation Innovative GI Procedures May Improve Diabetes Quality Programs Differ on Risk Data Crystal Ball Medical Modeling Ventricular Valve Taking Stock

Surgery News - May 2008

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