Mark S. Lesney

FT. LAUDERDALE, FLA. – Left ventricular assist devices were associated with a significant survival advantage compared with all other support pathways implemented before heart transplant in an analysis of more than 13,000 patients.

There are a variety of support pathways available to eventual heart transplant recipients, but there is little information concerning comparative outcomes of patients bridged with the various treatments. Such information could provide valuable insight for clinical decision making and organ allocation policy, according to Dr. Tara Karamlou.

A large database study was conducted using the United Network Organ Sharing Dataset to track outcomes of status 1 heart transplant recipients from 2000 to 2010. Dr. Karamlou of Seattle Children’s Hospital, and her colleagues, grouped transplant recipients based on the use of support pathways prior to transplant, including patients transitioning from one support pathway to another.

Dr. Karamlou reported her group’s results using Kaplan-Meir plots to compare time-related mortality among the different support-pathway groups. The study sought to uncover multivariable factors for time-related death using hazard regression models, she said at the annual meeting of the Society of Thoracic Surgeons.

There were six initial support pathways used in the 13,250 status 1 heart transplant patients identified in the database. These comprised inotropes (7,607); left ventricular assist devices (LVAD, 4,034); intra-aortic balloon pump (IABP, 729); biventricular assist devices (BIVAD, 521); extracorporeal circulation membrane oxygenation (ECMO, 316); and right ventricular assist devices (RVAD, 43).

"Multivariable analysis showed that LVAD use conferred a significant survival advantage compared with all other support pathways [hazard ratio, 0.71; P greater than .001]," said Dr. Karamlou. All other support treatments showed significantly increased risk of posttransplant death compared with LVAD treatment, including inotropes (HR, 1.1); RVAD (HR, 1.9); and ECMO (HR, 2.2).

There were 2,175 patients in the analysis who transitioned (either escalation or reduction) from one support pathway to another: no support to LVAD; LVAD to BIVAD; inotropes to LVAD; LVAD to inotropes; BIVAD to LVAD; and ECMO to LVAD. Among these patients, those who began with ECMO or BIVAD support followed by LVAD had improved posttransplant survival comparable to that of patients who began on LVAD and continued it throughout their course of pretransplant support.

LVAD support, especially in the setting of bridge to transplant, has clearly undergone several modifications that have made it safer and easier to implant and maintain, she added. Implantation of an LVAD in the current era, based on these findings, has survival superior to all other mechanical circulatory support pathways, and is equivalent to inotropic therapy. Additionally, in patients who are able to be weaned from biventricular support (ECMO and BIVAD therapy), LVAD implantation allows recovery of posttransplant survival to levels equivalent to primary LVAD–only therapy. This finding gives surgeons and cardiologists critical prognostic information regarding triage to pretransplant support pathways.

"Several key issues remain unresolved and, based on our results, will require further investigation. For example, the timing and clinical status of the patient surrounding both initial support and transition (either escalation or de-escalation) could not be determined from our data. In my mind, this is a crucial issue because delayed institution of mechanical support can have serious repercussions and, given the significantly increased risk of death with ECMO and BIVAD, a delay in de-escalation of therapy to LVAD could also confer an important survival disadvantage," she said.

"Organ allocation policy development and clinical decision making might benefit by considering these results in order to maximize the societal benefits of heart transplants," Dr. Karamlou concluded.

Dr. Karamlou reported having no financial disclosures.

FT. LAUDERDALE, FLA. – Left ventricular assist devices were associated with a significant survival advantage compared with all other support pathways implemented before heart transplant in an analysis of more than 13,000 patients.

There are a variety of support pathways available to eventual heart transplant recipients, but there is little information concerning comparative outcomes of patients bridged with the various treatments. Such information could provide valuable insight for clinical decision making and organ allocation policy, according to Dr. Tara Karamlou.

A large database study was conducted using the United Network Organ Sharing Dataset to track outcomes of status 1 heart transplant recipients from 2000 to 2010. Dr. Karamlou of Seattle Children’s Hospital, and her colleagues, grouped transplant recipients based on the use of support pathways prior to transplant, including patients transitioning from one support pathway to another.

Dr. Karamlou reported her group’s results using Kaplan-Meir plots to compare time-related mortality among the different support-pathway groups. The study sought to uncover multivariable factors for time-related death using hazard regression models, she said at the annual meeting of the Society of Thoracic Surgeons.

There were six initial support pathways used in the 13,250 status 1 heart transplant patients identified in the database. These comprised inotropes (7,607); left ventricular assist devices (LVAD, 4,034); intra-aortic balloon pump (IABP, 729); biventricular assist devices (BIVAD, 521); extracorporeal circulation membrane oxygenation (ECMO, 316); and right ventricular assist devices (RVAD, 43).

"Multivariable analysis showed that LVAD use conferred a significant survival advantage compared with all other support pathways [hazard ratio, 0.71; P greater than .001]," said Dr. Karamlou. All other support treatments showed significantly increased risk of posttransplant death compared with LVAD treatment, including inotropes (HR, 1.1); RVAD (HR, 1.9); and ECMO (HR, 2.2).

There were 2,175 patients in the analysis who transitioned (either escalation or reduction) from one support pathway to another: no support to LVAD; LVAD to BIVAD; inotropes to LVAD; LVAD to inotropes; BIVAD to LVAD; and ECMO to LVAD. Among these patients, those who began with ECMO or BIVAD support followed by LVAD had improved posttransplant survival comparable to that of patients who began on LVAD and continued it throughout their course of pretransplant support.

LVAD support, especially in the setting of bridge to transplant, has clearly undergone several modifications that have made it safer and easier to implant and maintain, she added. Implantation of an LVAD in the current era, based on these findings, has survival superior to all other mechanical circulatory support pathways, and is equivalent to inotropic therapy. Additionally, in patients who are able to be weaned from biventricular support (ECMO and BIVAD therapy), LVAD implantation allows recovery of posttransplant survival to levels equivalent to primary LVAD–only therapy. This finding gives surgeons and cardiologists critical prognostic information regarding triage to pretransplant support pathways.

"Several key issues remain unresolved and, based on our results, will require further investigation. For example, the timing and clinical status of the patient surrounding both initial support and transition (either escalation or de-escalation) could not be determined from our data. In my mind, this is a crucial issue because delayed institution of mechanical support can have serious repercussions and, given the significantly increased risk of death with ECMO and BIVAD, a delay in de-escalation of therapy to LVAD could also confer an important survival disadvantage," she said.

"Organ allocation policy development and clinical decision making might benefit by considering these results in order to maximize the societal benefits of heart transplants," Dr. Karamlou concluded.

Dr. Karamlou reported having no financial disclosures.

FT. LAUDERDALE, FLA. – Left ventricular assist devices were associated with a significant survival advantage compared with all other support pathways implemented before heart transplant in an analysis of more than 13,000 patients.

There are a variety of support pathways available to eventual heart transplant recipients, but there is little information concerning comparative outcomes of patients bridged with the various treatments. Such information could provide valuable insight for clinical decision making and organ allocation policy, according to Dr. Tara Karamlou.

A large database study was conducted using the United Network Organ Sharing Dataset to track outcomes of status 1 heart transplant recipients from 2000 to 2010. Dr. Karamlou of Seattle Children’s Hospital, and her colleagues, grouped transplant recipients based on the use of support pathways prior to transplant, including patients transitioning from one support pathway to another.

Dr. Karamlou reported her group’s results using Kaplan-Meir plots to compare time-related mortality among the different support-pathway groups. The study sought to uncover multivariable factors for time-related death using hazard regression models, she said at the annual meeting of the Society of Thoracic Surgeons.

There were six initial support pathways used in the 13,250 status 1 heart transplant patients identified in the database. These comprised inotropes (7,607); left ventricular assist devices (LVAD, 4,034); intra-aortic balloon pump (IABP, 729); biventricular assist devices (BIVAD, 521); extracorporeal circulation membrane oxygenation (ECMO, 316); and right ventricular assist devices (RVAD, 43).

"Multivariable analysis showed that LVAD use conferred a significant survival advantage compared with all other support pathways [hazard ratio, 0.71; P greater than .001]," said Dr. Karamlou. All other support treatments showed significantly increased risk of posttransplant death compared with LVAD treatment, including inotropes (HR, 1.1); RVAD (HR, 1.9); and ECMO (HR, 2.2).

There were 2,175 patients in the analysis who transitioned (either escalation or reduction) from one support pathway to another: no support to LVAD; LVAD to BIVAD; inotropes to LVAD; LVAD to inotropes; BIVAD to LVAD; and ECMO to LVAD. Among these patients, those who began with ECMO or BIVAD support followed by LVAD had improved posttransplant survival comparable to that of patients who began on LVAD and continued it throughout their course of pretransplant support.

LVAD support, especially in the setting of bridge to transplant, has clearly undergone several modifications that have made it safer and easier to implant and maintain, she added. Implantation of an LVAD in the current era, based on these findings, has survival superior to all other mechanical circulatory support pathways, and is equivalent to inotropic therapy. Additionally, in patients who are able to be weaned from biventricular support (ECMO and BIVAD therapy), LVAD implantation allows recovery of posttransplant survival to levels equivalent to primary LVAD–only therapy. This finding gives surgeons and cardiologists critical prognostic information regarding triage to pretransplant support pathways.

"Several key issues remain unresolved and, based on our results, will require further investigation. For example, the timing and clinical status of the patient surrounding both initial support and transition (either escalation or de-escalation) could not be determined from our data. In my mind, this is a crucial issue because delayed institution of mechanical support can have serious repercussions and, given the significantly increased risk of death with ECMO and BIVAD, a delay in de-escalation of therapy to LVAD could also confer an important survival disadvantage," she said.

"Organ allocation policy development and clinical decision making might benefit by considering these results in order to maximize the societal benefits of heart transplants," Dr. Karamlou concluded.

Dr. Karamlou reported having no financial disclosures.

FT. LAUDERDALE, FLA. – The use of full-flow cardiopulmonary bypass, coupled with neurological monitoring, improved cognitive and motor outcomes in a prospective neurologic outcome study of 97 neonates with transposition of the great arteries (both single- and two-ventricle lesions) who underwent an arterial switch operation.

The cohort study, conducted by Dr. Dean B. Andropoulos and his colleagues at the Texas Children’s Hospital in Houston, examined early MRI changes and longer-term neurodevelopmental outcomes after the arterial switch operation (ASO) was performed using a cardiopulmonary bypass (CPB) protocol that avoided deep hypothermic circulatory arrest (DHCA) and low-flow CPB.

The ASO was performed by using CPB with 150-mL/kg per min flows with no low-flow CPB or DHCA; pH stat management; hematocrit 30% or higher; and hypothermia to 24° -28° C. Regional oxygen saturation greater than 50% was maintained by using near infrared spectroscopic monitoring.

Neurologic assessment was performed using brain MRI performed immediately before the operation and 7 days postoperatively. The Bayley Scales of Infant and Toddler Development, Third Edition were used at 12 and 36 months (mean score of 100).

Dextrotransposition of the great arteries was present in 31 of the 97 enrolled patients. Ten of these 31 (32%) had preoperative MRI change, and 19 of 31 (61%) showed new postoperative MRI change, with 75% showing minimal new white matter injury, he said at the annual meeting of the Society of Thoracic Surgeons.

At 2 months, Bayley Scales were performed on 17 of the patients. Their mean cognitive score was 106.5, mean motor score was 90.4, and mean language score was 89.4. Twelve patients had Bayley III testing at 36 months, with a cognitive score of 106.5, motor score of 107.4, and language score of 98.2.

"Our series demonstrates a significant incidence of pre-existing MRI changes, and 61% have new postoperative changes, but all changes in this series were mild," said Dr. Andropoulos.

"At 12 months, the cognitive score of these children was above the population mean, but their motor and language performance was lower. By 36 months, language and motor scores had improved significantly. Thus, full-flow CPB coupled to cerebral monitoring may improve neurological outcomes."

Because of these results, "future studies of ASO patients should include short- and long-term neurodevelopmental studies," he said.

With greatly improved 30-day neonatal arterial switch operation mortality rates (for example, at the Texas Children’s Hospital in Houston there were no 30-day hospital mortalities for 175 ASOs since 2000), there are increasing expectations for better neurologic outcomes, according to Dr. Andropoulos, and such considerations are increasingly important.

Dr. Andropoulos reported having no financial conflicts.

FT. LAUDERDALE, FLA. – The use of full-flow cardiopulmonary bypass, coupled with neurological monitoring, improved cognitive and motor outcomes in a prospective neurologic outcome study of 97 neonates with transposition of the great arteries (both single- and two-ventricle lesions) who underwent an arterial switch operation.

The cohort study, conducted by Dr. Dean B. Andropoulos and his colleagues at the Texas Children’s Hospital in Houston, examined early MRI changes and longer-term neurodevelopmental outcomes after the arterial switch operation (ASO) was performed using a cardiopulmonary bypass (CPB) protocol that avoided deep hypothermic circulatory arrest (DHCA) and low-flow CPB.

The ASO was performed by using CPB with 150-mL/kg per min flows with no low-flow CPB or DHCA; pH stat management; hematocrit 30% or higher; and hypothermia to 24° -28° C. Regional oxygen saturation greater than 50% was maintained by using near infrared spectroscopic monitoring.

Neurologic assessment was performed using brain MRI performed immediately before the operation and 7 days postoperatively. The Bayley Scales of Infant and Toddler Development, Third Edition were used at 12 and 36 months (mean score of 100).

Dextrotransposition of the great arteries was present in 31 of the 97 enrolled patients. Ten of these 31 (32%) had preoperative MRI change, and 19 of 31 (61%) showed new postoperative MRI change, with 75% showing minimal new white matter injury, he said at the annual meeting of the Society of Thoracic Surgeons.

At 2 months, Bayley Scales were performed on 17 of the patients. Their mean cognitive score was 106.5, mean motor score was 90.4, and mean language score was 89.4. Twelve patients had Bayley III testing at 36 months, with a cognitive score of 106.5, motor score of 107.4, and language score of 98.2.

"Our series demonstrates a significant incidence of pre-existing MRI changes, and 61% have new postoperative changes, but all changes in this series were mild," said Dr. Andropoulos.

"At 12 months, the cognitive score of these children was above the population mean, but their motor and language performance was lower. By 36 months, language and motor scores had improved significantly. Thus, full-flow CPB coupled to cerebral monitoring may improve neurological outcomes."

Because of these results, "future studies of ASO patients should include short- and long-term neurodevelopmental studies," he said.

With greatly improved 30-day neonatal arterial switch operation mortality rates (for example, at the Texas Children’s Hospital in Houston there were no 30-day hospital mortalities for 175 ASOs since 2000), there are increasing expectations for better neurologic outcomes, according to Dr. Andropoulos, and such considerations are increasingly important.

Dr. Andropoulos reported having no financial conflicts.

FT. LAUDERDALE, FLA. – The use of full-flow cardiopulmonary bypass, coupled with neurological monitoring, improved cognitive and motor outcomes in a prospective neurologic outcome study of 97 neonates with transposition of the great arteries (both single- and two-ventricle lesions) who underwent an arterial switch operation.

The cohort study, conducted by Dr. Dean B. Andropoulos and his colleagues at the Texas Children’s Hospital in Houston, examined early MRI changes and longer-term neurodevelopmental outcomes after the arterial switch operation (ASO) was performed using a cardiopulmonary bypass (CPB) protocol that avoided deep hypothermic circulatory arrest (DHCA) and low-flow CPB.

The ASO was performed by using CPB with 150-mL/kg per min flows with no low-flow CPB or DHCA; pH stat management; hematocrit 30% or higher; and hypothermia to 24° -28° C. Regional oxygen saturation greater than 50% was maintained by using near infrared spectroscopic monitoring.

Neurologic assessment was performed using brain MRI performed immediately before the operation and 7 days postoperatively. The Bayley Scales of Infant and Toddler Development, Third Edition were used at 12 and 36 months (mean score of 100).

Dextrotransposition of the great arteries was present in 31 of the 97 enrolled patients. Ten of these 31 (32%) had preoperative MRI change, and 19 of 31 (61%) showed new postoperative MRI change, with 75% showing minimal new white matter injury, he said at the annual meeting of the Society of Thoracic Surgeons.

At 2 months, Bayley Scales were performed on 17 of the patients. Their mean cognitive score was 106.5, mean motor score was 90.4, and mean language score was 89.4. Twelve patients had Bayley III testing at 36 months, with a cognitive score of 106.5, motor score of 107.4, and language score of 98.2.

"Our series demonstrates a significant incidence of pre-existing MRI changes, and 61% have new postoperative changes, but all changes in this series were mild," said Dr. Andropoulos.

"At 12 months, the cognitive score of these children was above the population mean, but their motor and language performance was lower. By 36 months, language and motor scores had improved significantly. Thus, full-flow CPB coupled to cerebral monitoring may improve neurological outcomes."

Because of these results, "future studies of ASO patients should include short- and long-term neurodevelopmental studies," he said.

With greatly improved 30-day neonatal arterial switch operation mortality rates (for example, at the Texas Children’s Hospital in Houston there were no 30-day hospital mortalities for 175 ASOs since 2000), there are increasing expectations for better neurologic outcomes, according to Dr. Andropoulos, and such considerations are increasingly important.

Dr. Andropoulos reported having no financial conflicts.

FT. LAUDERDALE, FLA – Early repair – within one week – of acquired ventral septal defect in patients with myocardial infarction was associated with a significantly higher mortality rate than was later repair in a retrospective review.

Acquired ventral septal defect (VSD), a relatively rare but devastating complication of myocardial infarction, frequently leads to cardiogenic shock and death. Surgical repair is generally required, although there is a high mortality.

To identify risk factors for poor patient outcomes, a study of the Society for Thoracic Surgeons National Database was performed to characterize patients undergoing post-MI VSD surgical repair, Dr. George J. Arnaoutakis said at the annual meeting of the Society of Thoracic Surgeons.

This retrospective review identified all adults (patients greater than 18 years of age) who underwent post-MI VSD repair between 1999 and 2010. The primary outcome measure was operative mortality and patients with congenital VSD were excluded.

"This largest to date study examining post-MI VSD repair was done in part to provide a surgical benchmark for future comparisons as percutaneous closure devices emerge to treat this condition," noted Dr. Arnaoutakis of the division of cardiac surgery at Johns Hopkins University, Baltimore.

The demographics of the 2,876 patients included in the study were a mean age of 68 years; 56.5% of the patients were men; and 7.5% of patients had prior coronary artery bypass grafting (CABG) surgery. Operative characteristics included preoperative support with an intraaortic balloon pump (65%); urgent status (35%); emergent status (49.7%); and concomitant CABG (63.9%).

Timing of surgery was found to be an important predictor of risk, with 54% mortality occurring in patients who had repair less than 7 days after MI, and 18% mortality in those patients who had their surgery greater than 7 days after MI. Multivariate analysis also showed that the timing of MI with relation to VSD repair was independently associated with operative mortality.

Overall, major morbidity and mortality was high, at nearly 77%. Other surgical characteristics significantly associated with higher mortality included longer cardiopulmonary bypass time, preoperative dialysis, emergent surgery, and shock.

"Ventricular septal rupture remains a devastating complication after myocardial infarction," he said, with a shorter time interval between MI and surgical repair of the VSD, being highly associated with operative mortality, Dr Arnaoutakis summarized.

He did point out that one flaw in this study based on the STS Database was that it could not account for patients who died while waiting for VSD repair, which might influence the results. In addition the overall incidence of acquired VSD was too low to determine the effect of individual surgeon or center volume on mortality rates.

Dr. Arnaoutakis agreed with audience suggestions that given the high overall mortality rate of surgical VSD closure, perhaps consideration of the new percutaneous closure devices and the possibility of ventricular assist device support might be reasonable options.

Dr. Arnaoutakis reported having no financial conflicts. Another researcher on the project reported research support from HeartWare International Inc. and Thoratec Corp.

FT. LAUDERDALE, FLA – Early repair – within one week – of acquired ventral septal defect in patients with myocardial infarction was associated with a significantly higher mortality rate than was later repair in a retrospective review.

Acquired ventral septal defect (VSD), a relatively rare but devastating complication of myocardial infarction, frequently leads to cardiogenic shock and death. Surgical repair is generally required, although there is a high mortality.

To identify risk factors for poor patient outcomes, a study of the Society for Thoracic Surgeons National Database was performed to characterize patients undergoing post-MI VSD surgical repair, Dr. George J. Arnaoutakis said at the annual meeting of the Society of Thoracic Surgeons.

This retrospective review identified all adults (patients greater than 18 years of age) who underwent post-MI VSD repair between 1999 and 2010. The primary outcome measure was operative mortality and patients with congenital VSD were excluded.

"This largest to date study examining post-MI VSD repair was done in part to provide a surgical benchmark for future comparisons as percutaneous closure devices emerge to treat this condition," noted Dr. Arnaoutakis of the division of cardiac surgery at Johns Hopkins University, Baltimore.

The demographics of the 2,876 patients included in the study were a mean age of 68 years; 56.5% of the patients were men; and 7.5% of patients had prior coronary artery bypass grafting (CABG) surgery. Operative characteristics included preoperative support with an intraaortic balloon pump (65%); urgent status (35%); emergent status (49.7%); and concomitant CABG (63.9%).

Timing of surgery was found to be an important predictor of risk, with 54% mortality occurring in patients who had repair less than 7 days after MI, and 18% mortality in those patients who had their surgery greater than 7 days after MI. Multivariate analysis also showed that the timing of MI with relation to VSD repair was independently associated with operative mortality.

Overall, major morbidity and mortality was high, at nearly 77%. Other surgical characteristics significantly associated with higher mortality included longer cardiopulmonary bypass time, preoperative dialysis, emergent surgery, and shock.

"Ventricular septal rupture remains a devastating complication after myocardial infarction," he said, with a shorter time interval between MI and surgical repair of the VSD, being highly associated with operative mortality, Dr Arnaoutakis summarized.

He did point out that one flaw in this study based on the STS Database was that it could not account for patients who died while waiting for VSD repair, which might influence the results. In addition the overall incidence of acquired VSD was too low to determine the effect of individual surgeon or center volume on mortality rates.

Dr. Arnaoutakis agreed with audience suggestions that given the high overall mortality rate of surgical VSD closure, perhaps consideration of the new percutaneous closure devices and the possibility of ventricular assist device support might be reasonable options.

Dr. Arnaoutakis reported having no financial conflicts. Another researcher on the project reported research support from HeartWare International Inc. and Thoratec Corp.

FT. LAUDERDALE, FLA – Early repair – within one week – of acquired ventral septal defect in patients with myocardial infarction was associated with a significantly higher mortality rate than was later repair in a retrospective review.

Acquired ventral septal defect (VSD), a relatively rare but devastating complication of myocardial infarction, frequently leads to cardiogenic shock and death. Surgical repair is generally required, although there is a high mortality.

To identify risk factors for poor patient outcomes, a study of the Society for Thoracic Surgeons National Database was performed to characterize patients undergoing post-MI VSD surgical repair, Dr. George J. Arnaoutakis said at the annual meeting of the Society of Thoracic Surgeons.

This retrospective review identified all adults (patients greater than 18 years of age) who underwent post-MI VSD repair between 1999 and 2010. The primary outcome measure was operative mortality and patients with congenital VSD were excluded.

"This largest to date study examining post-MI VSD repair was done in part to provide a surgical benchmark for future comparisons as percutaneous closure devices emerge to treat this condition," noted Dr. Arnaoutakis of the division of cardiac surgery at Johns Hopkins University, Baltimore.

The demographics of the 2,876 patients included in the study were a mean age of 68 years; 56.5% of the patients were men; and 7.5% of patients had prior coronary artery bypass grafting (CABG) surgery. Operative characteristics included preoperative support with an intraaortic balloon pump (65%); urgent status (35%); emergent status (49.7%); and concomitant CABG (63.9%).

Timing of surgery was found to be an important predictor of risk, with 54% mortality occurring in patients who had repair less than 7 days after MI, and 18% mortality in those patients who had their surgery greater than 7 days after MI. Multivariate analysis also showed that the timing of MI with relation to VSD repair was independently associated with operative mortality.

Overall, major morbidity and mortality was high, at nearly 77%. Other surgical characteristics significantly associated with higher mortality included longer cardiopulmonary bypass time, preoperative dialysis, emergent surgery, and shock.

"Ventricular septal rupture remains a devastating complication after myocardial infarction," he said, with a shorter time interval between MI and surgical repair of the VSD, being highly associated with operative mortality, Dr Arnaoutakis summarized.

He did point out that one flaw in this study based on the STS Database was that it could not account for patients who died while waiting for VSD repair, which might influence the results. In addition the overall incidence of acquired VSD was too low to determine the effect of individual surgeon or center volume on mortality rates.

Dr. Arnaoutakis agreed with audience suggestions that given the high overall mortality rate of surgical VSD closure, perhaps consideration of the new percutaneous closure devices and the possibility of ventricular assist device support might be reasonable options.

Dr. Arnaoutakis reported having no financial conflicts. Another researcher on the project reported research support from HeartWare International Inc. and Thoratec Corp.

In December 1948, Dr. Rudolph Nissen, later famed for his esophageal surgery technique called fundoplication, operated on Albert Einstein, at the Jewish Hospital in Brooklyn, New York to remove intestinal cysts. Einstein was simultaneously diagnosed with a large intact aneurysm of his abdominal aorta.

Using a then pioneering technique, Dr. Nissen wrapped cellophane around Einstein’s aneurysm in order to induce fibrosis and limit expansion. Most likely because of this timely intervention, the renowned physicist survived over 5 years before succumbing to aneurysm rupture.

At the time of Einstein’s treatment, cellophane wrapping was still a breakthrough technology for the treatment of aortic aneurysms, one of the first highly successful interventions for the disorder.

Cellophane film was invented by a Swiss textile engineer Jacques E. Brandenberger in 1908. It was produced as a polymer of cellulose. Improvements in cellophane continued, making cellophane an invaluable tool for waterproofing products, and in 1930, the first cellophane tape was developed by Dick Drew in 1930 by coating the sheets with adhesive.

The ability of cellophane to constrict blood vessels was first demonstrated by Page in 1939, who used it to induce artificial nephritis and hypertension in dogs for research use by wrapping cellophane around the kidneys. The development of polyethylene cellophane was an important breakthrough as it produced a more intense fibrotic reaction as compared to other types of the polymer.

It’s first human clinical use for aneurysms was reported in 1943 by Dr. Paul W. Harrison and Dr. Jacob A. Chandy who successfully treated two arteriovenous aneurysms of the subclavian arteries with cellophane, leading to their gradually elimination. They were inspired by the work of H.E. Pearse in 1940, who demonstrated the ability of cellophane as an improved method of gradually obliterating the lumen of blood vessels, such as the internal carotid artery, in place of clamps and banding.

It is interesting that several reports indicated that pure polyethylene cellophane was nonreactive, whereas the standard "impure" material obtained from the primary manufacturer, E.I. DuPont Nemours Company of Wilmington, Delaware, proved highly reactive, according to J.K. Poppe, who reported his excellent results with the compound in treating syphilitic aneurysms in 1947 and 1948.

In the 1950s, the real breakthrough came in the surgical repair of aneurysms. Although the surgery by Dr. Charles Dubost performed of an AAA repair using a homograft in March 29, 1951, is the most well-known, two other successful procedures were performed first. On February 26 of that year, Dr. Norman Freeman and Dr. Frank Leeds used a vein inlay autograft from the left common iliac vein and its bifurcation sutured into the abdominal aorta and iliac arteries of a 55-year-old man with a large, asymptomatic aneurysm. And on March 2, 1951, Dr. Paul Schafer and Dr. Creighton Hardin of the University of Kansas resected an aneurysm with an indwelling shunt after clamping the aorta and replacing it with a human homograft. The patient died after 29 days from a leak in the native aortic wall.

But the use of prosthetic grafts soon after would lead to a new standard of care, starting with Vorhees, who in 1952 used a Vinyon-N cloth as a plastic arterial substitute, but dramatically improved in 1954 when Dr. Michael DeBakey and Dr. Denton Cooley (see page 11) refined the design of the Dacron graft in 1954.

But this was of no avail in saving Einstein, for as he had reached his mid 70s, he resigned himself after suffering from various chronic illnesses for over 39 years, to an acceptance of what he saw as the inevitable. "The devil has put a penalty on all things we enjoy in life," he quipped. "Either we suffer in our health, or we suffer in our soul, or we get fat."

His aneurysm ruptured on April 13, 1955 and he entered Princeton hospital on April 15, but refused any further operation. He died from complications arising from the rupture on April 18, more than 5 years after he had had the offending aorta swathed in cellophane.

Surgically placed grafts remained the treatment of choice for aortic aneurysms until 1990, when Dr. Juan Parodi introduced the first successful endovascular graft in Argentina, launching the modern endovascular treatment revolution.

Selected Sources:

Kantha, S.S., (1992) Medical Hypotheses 42:340-6.

Poppe, J.K. (1948 ) American Heart Journal 36:252-6.

Yao, J. S.T. (2003) Cardiovascular Surgery 11:413-5.

In December 1948, Dr. Rudolph Nissen, later famed for his esophageal surgery technique called fundoplication, operated on Albert Einstein, at the Jewish Hospital in Brooklyn, New York to remove intestinal cysts. Einstein was simultaneously diagnosed with a large intact aneurysm of his abdominal aorta.

Using a then pioneering technique, Dr. Nissen wrapped cellophane around Einstein’s aneurysm in order to induce fibrosis and limit expansion. Most likely because of this timely intervention, the renowned physicist survived over 5 years before succumbing to aneurysm rupture.

At the time of Einstein’s treatment, cellophane wrapping was still a breakthrough technology for the treatment of aortic aneurysms, one of the first highly successful interventions for the disorder.

Cellophane film was invented by a Swiss textile engineer Jacques E. Brandenberger in 1908. It was produced as a polymer of cellulose. Improvements in cellophane continued, making cellophane an invaluable tool for waterproofing products, and in 1930, the first cellophane tape was developed by Dick Drew in 1930 by coating the sheets with adhesive.

The ability of cellophane to constrict blood vessels was first demonstrated by Page in 1939, who used it to induce artificial nephritis and hypertension in dogs for research use by wrapping cellophane around the kidneys. The development of polyethylene cellophane was an important breakthrough as it produced a more intense fibrotic reaction as compared to other types of the polymer.

It’s first human clinical use for aneurysms was reported in 1943 by Dr. Paul W. Harrison and Dr. Jacob A. Chandy who successfully treated two arteriovenous aneurysms of the subclavian arteries with cellophane, leading to their gradually elimination. They were inspired by the work of H.E. Pearse in 1940, who demonstrated the ability of cellophane as an improved method of gradually obliterating the lumen of blood vessels, such as the internal carotid artery, in place of clamps and banding.

It is interesting that several reports indicated that pure polyethylene cellophane was nonreactive, whereas the standard "impure" material obtained from the primary manufacturer, E.I. DuPont Nemours Company of Wilmington, Delaware, proved highly reactive, according to J.K. Poppe, who reported his excellent results with the compound in treating syphilitic aneurysms in 1947 and 1948.

In the 1950s, the real breakthrough came in the surgical repair of aneurysms. Although the surgery by Dr. Charles Dubost performed of an AAA repair using a homograft in March 29, 1951, is the most well-known, two other successful procedures were performed first. On February 26 of that year, Dr. Norman Freeman and Dr. Frank Leeds used a vein inlay autograft from the left common iliac vein and its bifurcation sutured into the abdominal aorta and iliac arteries of a 55-year-old man with a large, asymptomatic aneurysm. And on March 2, 1951, Dr. Paul Schafer and Dr. Creighton Hardin of the University of Kansas resected an aneurysm with an indwelling shunt after clamping the aorta and replacing it with a human homograft. The patient died after 29 days from a leak in the native aortic wall.

But the use of prosthetic grafts soon after would lead to a new standard of care, starting with Vorhees, who in 1952 used a Vinyon-N cloth as a plastic arterial substitute, but dramatically improved in 1954 when Dr. Michael DeBakey and Dr. Denton Cooley (see page 11) refined the design of the Dacron graft in 1954.

But this was of no avail in saving Einstein, for as he had reached his mid 70s, he resigned himself after suffering from various chronic illnesses for over 39 years, to an acceptance of what he saw as the inevitable. "The devil has put a penalty on all things we enjoy in life," he quipped. "Either we suffer in our health, or we suffer in our soul, or we get fat."

His aneurysm ruptured on April 13, 1955 and he entered Princeton hospital on April 15, but refused any further operation. He died from complications arising from the rupture on April 18, more than 5 years after he had had the offending aorta swathed in cellophane.

Surgically placed grafts remained the treatment of choice for aortic aneurysms until 1990, when Dr. Juan Parodi introduced the first successful endovascular graft in Argentina, launching the modern endovascular treatment revolution.

Selected Sources:

Kantha, S.S., (1992) Medical Hypotheses 42:340-6.

Poppe, J.K. (1948 ) American Heart Journal 36:252-6.

Yao, J. S.T. (2003) Cardiovascular Surgery 11:413-5.

In December 1948, Dr. Rudolph Nissen, later famed for his esophageal surgery technique called fundoplication, operated on Albert Einstein, at the Jewish Hospital in Brooklyn, New York to remove intestinal cysts. Einstein was simultaneously diagnosed with a large intact aneurysm of his abdominal aorta.

Using a then pioneering technique, Dr. Nissen wrapped cellophane around Einstein’s aneurysm in order to induce fibrosis and limit expansion. Most likely because of this timely intervention, the renowned physicist survived over 5 years before succumbing to aneurysm rupture.

At the time of Einstein’s treatment, cellophane wrapping was still a breakthrough technology for the treatment of aortic aneurysms, one of the first highly successful interventions for the disorder.

Cellophane film was invented by a Swiss textile engineer Jacques E. Brandenberger in 1908. It was produced as a polymer of cellulose. Improvements in cellophane continued, making cellophane an invaluable tool for waterproofing products, and in 1930, the first cellophane tape was developed by Dick Drew in 1930 by coating the sheets with adhesive.

The ability of cellophane to constrict blood vessels was first demonstrated by Page in 1939, who used it to induce artificial nephritis and hypertension in dogs for research use by wrapping cellophane around the kidneys. The development of polyethylene cellophane was an important breakthrough as it produced a more intense fibrotic reaction as compared to other types of the polymer.

It’s first human clinical use for aneurysms was reported in 1943 by Dr. Paul W. Harrison and Dr. Jacob A. Chandy who successfully treated two arteriovenous aneurysms of the subclavian arteries with cellophane, leading to their gradually elimination. They were inspired by the work of H.E. Pearse in 1940, who demonstrated the ability of cellophane as an improved method of gradually obliterating the lumen of blood vessels, such as the internal carotid artery, in place of clamps and banding.

It is interesting that several reports indicated that pure polyethylene cellophane was nonreactive, whereas the standard "impure" material obtained from the primary manufacturer, E.I. DuPont Nemours Company of Wilmington, Delaware, proved highly reactive, according to J.K. Poppe, who reported his excellent results with the compound in treating syphilitic aneurysms in 1947 and 1948.

In the 1950s, the real breakthrough came in the surgical repair of aneurysms. Although the surgery by Dr. Charles Dubost performed of an AAA repair using a homograft in March 29, 1951, is the most well-known, two other successful procedures were performed first. On February 26 of that year, Dr. Norman Freeman and Dr. Frank Leeds used a vein inlay autograft from the left common iliac vein and its bifurcation sutured into the abdominal aorta and iliac arteries of a 55-year-old man with a large, asymptomatic aneurysm. And on March 2, 1951, Dr. Paul Schafer and Dr. Creighton Hardin of the University of Kansas resected an aneurysm with an indwelling shunt after clamping the aorta and replacing it with a human homograft. The patient died after 29 days from a leak in the native aortic wall.

But the use of prosthetic grafts soon after would lead to a new standard of care, starting with Vorhees, who in 1952 used a Vinyon-N cloth as a plastic arterial substitute, but dramatically improved in 1954 when Dr. Michael DeBakey and Dr. Denton Cooley (see page 11) refined the design of the Dacron graft in 1954.

But this was of no avail in saving Einstein, for as he had reached his mid 70s, he resigned himself after suffering from various chronic illnesses for over 39 years, to an acceptance of what he saw as the inevitable. "The devil has put a penalty on all things we enjoy in life," he quipped. "Either we suffer in our health, or we suffer in our soul, or we get fat."

His aneurysm ruptured on April 13, 1955 and he entered Princeton hospital on April 15, but refused any further operation. He died from complications arising from the rupture on April 18, more than 5 years after he had had the offending aorta swathed in cellophane.

Surgically placed grafts remained the treatment of choice for aortic aneurysms until 1990, when Dr. Juan Parodi introduced the first successful endovascular graft in Argentina, launching the modern endovascular treatment revolution.

Selected Sources:

Kantha, S.S., (1992) Medical Hypotheses 42:340-6.

Poppe, J.K. (1948 ) American Heart Journal 36:252-6.

Yao, J. S.T. (2003) Cardiovascular Surgery 11:413-5.

The modern SVS is a vibrant blend of two rich historical and co-evolving traditions – the original SVS and the American Association for Vascular Surgery (AAVS) which merged in 2003 under the leadership of Dr. Jack Cronenwett (SVS) and Dr. Thomas Riles (AAVS). It was a merger that sanctified a long cooperative relationship that had existed between the two organizations.

The original SVS was the brainchild of Dr. James Ross Veal, according to Dr. James S.T. Yao in his history of the SVS beginnings. The society was inaugurated at the Fairmont Hotel in San Francisco on July 3, 1946, at a meeting which chose its name, elected its officers, and 31 charter members. A year later, its first annual meeting was held on June 8, 1947, in Atlantic City, and in a sense this heralded the dawn of modern arterial reconstructive surgery, though it was not until Dr. Robert R. Linton’s ninth presidential address in 1955, that such an address dealt with arterial reconstruction.

Among the charter members was the "father of vascular surgery," Dr. Rudolph Matas of Tulane University. In his acceptance of a ceremonial gavel in his honor, which he passed into the permanent custody of the SVS, he reminisced on how it was on May 5, 1888, "the first actual demonstration of the new principle that repair of an injured or damaged blood vessel could be obtained without the suppression of its blood-carrying function. It took place at the Charity Hospital [wood from one of its stairway posts was used to make the gavel]."

Courtesy National Library of Medicine

This operation, which Dr. Matas himself performed, relegated to the dustbin of history "the fundamental maxim of that great master of vascular surgery, Antonio Scarpa, in the late 18^th century, namely that no wound or injury of an artery could be repaired without a total suppression of its blood-carrying function."

The Matas gavel remains a treasured artifact and was used for many years as the symbol of presidential transition in the SVS.

The first SVS president, Dr. Alton Ochsner, gave his address, entitled "Venous Thromboembolism," at the first annual meeting. From then on the SVS continued incremental growth, expanding and refining its goals and structure and improving the tenor of its annual meeting. The first SVS constitution was drawn up by the committee and then adopted in June 1949, although the documents regarding it are lost to time. The first extant version is from 1955, according to SVS chronicler and charter member Dr. Harris B. Shumacker, Jr.

The official original SVS seal, carrying the image of another vascular surgery pioneer, John Hunter, was designed and implemented on the membership certificate by SVS Secretary Henry Swan in 1955. In 1958, the journal, Surgery, became the official organ of SVS and would remain so for 25 years.

By 1964, SVS began expanding its scope. That year, the SVS requested representation on the Board of Governors of the American College of Surgeons, which occurred in 1965. Also in the 1960s, the SVS pledged its support to the National Society of Medical Research and expanded its ties to the American Heart Association, gaining representation on its Joint Committee on Stroke.

Early lobbying efforts in this period included society support for a bill to establish a National Medical Devices Standard Commission, inspired by the SVS’s keen interest in the safety and composition of surgical implants.

In June, 1973, the first proposal of a Committee for Vascular Surgery on the American Board of Surgery was made, and ultimately implemented several years later. This brought renewed and vigorous interest in the issue of vascular training, which has continued ever since, and by the early 1980s, the American Board of Surgery was offering a Special Certification in General Vascular Surgery in consultation with SVS and AAVS, which provided institutional guidelines for training.

In 1986, SVS created a Foundation for Research and Education, which would, in 1989, under the foundation presidency of Dr. Michael Ellis DeBakey (another SVS charter member), undergo a name change to the Lifeline Foundation, which included sponsorship or responsibility for a variety of research and training oriented awards, grants, and initiatives. This tradition is carried on by the SVS Foundation.

Courtesy Baylor College of Medicine

In summarizing the fifth decade of SVS (1987-1996), Dr. Yao cites the introduction of endovascular techniques as a drastic change in the landscape of vascular practice. The sixth decade (1997-2006) "witnessed a milestone of transformation" with the merger of SVS and AAVS. "We were finally united as an independent surgical specialty."

Since the earliest years, AAVS and SVS had close ties, with both cooperating in 1984 to inaugurate the Journal of Vascular Surgery, which became the official organ of both groups and remains so for the combined SVS to this day. The founding editors were Dr. Michael DeBakey and Dr. Emerick Szilagyi.

In 1988, SVS established the Crawford Critical Issues Forum at the annual meeting, which was soon to incorporate members of the then North American Chapter of the International Society for Cardiovascular Surgery, the forerunner of AAVS.

In 2001, Dr. Robert Hobson served as the first president of the renamed AAVS. In his address at the 49^th annual meeting of the organization, he highlighted some of its major accomplishments including their then recent efforts to launch a new website called VascularWeb and the establishment of the American Vascular Association (AVA), with the assistance of SVS. The AVA was a division devoted to public education in vascular disease, which after the merger with SVS would become one with the Lifeline Foundation.

Summarizing the unity of the two organizations, in his SVS Presidential address in 2003, Dr. Jack Cronenwett stated, "It is clear that the SVS and AAVS have functioned as a single entity representing vascular surgery for many years."

He detailed the history of the two organizations and the logic of their merger from their consistent meetings together for more than three decades, from their fundraising effort, and from their shared committees, including the Joint Council established in 1975.

So significant was the Joint Council, according to Dr. Cronenwett, that "by the year 2000, the individual society council meetings lasted only one hour, but were followed by a seven-hour Joint Council meeting involving 45 persons, where all the important business of the societies was conducted." Surprisingly, the council was never incorporated legally or had authority to take action, but made decisions only by consensus of both societies, Dr. Cronenwett said.

It was this Joint Council that charged the SVS and AAVS presidents in 2002 to "investigate the management and governance of the societies and to develop specific proposals to address these concerns." It was a charge that led to the, almost inevitable, in retrospect, merger of the two societies a year later.

Dr. K. Craig Kent credited the merger with invigorating and transforming SVS, as he said in his 2007 presidential address: "Where was SVS five years ago? There were two societies, a division of leadership and competition between SVS and AAVS. SVS had no central administrative support ... Where is SVS today? I would say strong and well. This began with the merger of SVS and AAVS in 2003 to create an all inclusive society. We now have an office in Chicago with central administrative leadership. We have a Vascular Surgery Board within the American Board of Surgery and a primary certificate."

He went on to praise the new mature infrastructure of SVS and herald its major initiatives. Since its creation, the Chicago office has been run under the support of SVS Executive Director Rebecca M. Maron and has provided support and continuity to all SVS presidents since.

Major successes have occurred under the auspices of the SVS in promoting the interests vascular surgery in the Congress, according to Dr. K. Wayne Johnston in his 2008 presidential address.

"The first realization that we could have a direct impact in Washington came in 1997. At that time SVS faced major reductions in practice expense payments from Medicare. SVS convinced a number of key Senators and Congressmen that underrepresented specialties at the American Medical Association, such as vascular surgery, should have the opportunity to submit their supplemental practice expense data for review. SVS was the first speciality society to submit supplemental data from many members across the country, and our efforts saved millions of dollars in lost income," stated Dr. Johnston.

A second major legislative victory, The Screening Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act occurred in 2005, two years after the merger, with the new SVS serving as the lead organization in the National Aneurysm Alliance, with Immediate Past-President Dr. Robert Zwolak as the key operative in the coalition.

A third, although only partial victory, according to Dr. Johnston, came when SVS, with the aid of the Society for Vascular Ultrasound, mounted a successful effort to remove specific ultrasound services from major cuts in the Deficit Reduction Act of 2005.

SVS continues to work to promote the interests of vascular surgeons and their patients in a period of turbulent government medical reform.

A breakthrough in education occurred when the Accreditation Council for Graduate Medical Education approved the Primary Certificate in vascular surgery, which took effect July 1, 2008, and allows for more educational options and a more focused program for vascular trainees.

A good summary of the modern SVS can be found in the words of Dr. Anton Sidawy in his 2010 presidential address.

"Over the last few decades ... the Society and the specialty had to overcome obstacles, reinvent themselves, and take on major endeavors, and in doing so, we became stronger and expanded our horizons to better serve patients with vascular disease. Throughout it all, the Society and the specialty remained true and faithful to our core values of integrity, professionalism, and commitment to our members and patients," said Dr. Sidawy.

Sources:

Cronenwett, J. L. J. Vasc. Surg. 2004; 39:1-8.

Hobson, R. W., J. Vasc. Surg. 2002; 35:1-7.

Johnston, K. W., J. Vasc. Surg. 2008; 48:1613-9.

Kent, K. C., J. Vasc. Surg. 2008; 47: 231-6.

Shumacker, H. B. "The Society for Vascular Surgery. A History: 1945- 1983," The Society for Vascular Surgery, 1984; 583 pp.

Sidawy, A. N., J. Vasc. Surg. 2011; 510-6.

Yao, J. S. T., J. Vasc. Surg. 2010;51: 776-9.

The modern SVS is a vibrant blend of two rich historical and co-evolving traditions – the original SVS and the American Association for Vascular Surgery (AAVS) which merged in 2003 under the leadership of Dr. Jack Cronenwett (SVS) and Dr. Thomas Riles (AAVS). It was a merger that sanctified a long cooperative relationship that had existed between the two organizations.

The original SVS was the brainchild of Dr. James Ross Veal, according to Dr. James S.T. Yao in his history of the SVS beginnings. The society was inaugurated at the Fairmont Hotel in San Francisco on July 3, 1946, at a meeting which chose its name, elected its officers, and 31 charter members. A year later, its first annual meeting was held on June 8, 1947, in Atlantic City, and in a sense this heralded the dawn of modern arterial reconstructive surgery, though it was not until Dr. Robert R. Linton’s ninth presidential address in 1955, that such an address dealt with arterial reconstruction.

Among the charter members was the "father of vascular surgery," Dr. Rudolph Matas of Tulane University. In his acceptance of a ceremonial gavel in his honor, which he passed into the permanent custody of the SVS, he reminisced on how it was on May 5, 1888, "the first actual demonstration of the new principle that repair of an injured or damaged blood vessel could be obtained without the suppression of its blood-carrying function. It took place at the Charity Hospital [wood from one of its stairway posts was used to make the gavel]."

Courtesy National Library of Medicine

This operation, which Dr. Matas himself performed, relegated to the dustbin of history "the fundamental maxim of that great master of vascular surgery, Antonio Scarpa, in the late 18^th century, namely that no wound or injury of an artery could be repaired without a total suppression of its blood-carrying function."

The Matas gavel remains a treasured artifact and was used for many years as the symbol of presidential transition in the SVS.

The first SVS president, Dr. Alton Ochsner, gave his address, entitled "Venous Thromboembolism," at the first annual meeting. From then on the SVS continued incremental growth, expanding and refining its goals and structure and improving the tenor of its annual meeting. The first SVS constitution was drawn up by the committee and then adopted in June 1949, although the documents regarding it are lost to time. The first extant version is from 1955, according to SVS chronicler and charter member Dr. Harris B. Shumacker, Jr.

The official original SVS seal, carrying the image of another vascular surgery pioneer, John Hunter, was designed and implemented on the membership certificate by SVS Secretary Henry Swan in 1955. In 1958, the journal, Surgery, became the official organ of SVS and would remain so for 25 years.

By 1964, SVS began expanding its scope. That year, the SVS requested representation on the Board of Governors of the American College of Surgeons, which occurred in 1965. Also in the 1960s, the SVS pledged its support to the National Society of Medical Research and expanded its ties to the American Heart Association, gaining representation on its Joint Committee on Stroke.

Early lobbying efforts in this period included society support for a bill to establish a National Medical Devices Standard Commission, inspired by the SVS’s keen interest in the safety and composition of surgical implants.

In June, 1973, the first proposal of a Committee for Vascular Surgery on the American Board of Surgery was made, and ultimately implemented several years later. This brought renewed and vigorous interest in the issue of vascular training, which has continued ever since, and by the early 1980s, the American Board of Surgery was offering a Special Certification in General Vascular Surgery in consultation with SVS and AAVS, which provided institutional guidelines for training.

In 1986, SVS created a Foundation for Research and Education, which would, in 1989, under the foundation presidency of Dr. Michael Ellis DeBakey (another SVS charter member), undergo a name change to the Lifeline Foundation, which included sponsorship or responsibility for a variety of research and training oriented awards, grants, and initiatives. This tradition is carried on by the SVS Foundation.

Courtesy Baylor College of Medicine

In summarizing the fifth decade of SVS (1987-1996), Dr. Yao cites the introduction of endovascular techniques as a drastic change in the landscape of vascular practice. The sixth decade (1997-2006) "witnessed a milestone of transformation" with the merger of SVS and AAVS. "We were finally united as an independent surgical specialty."

Since the earliest years, AAVS and SVS had close ties, with both cooperating in 1984 to inaugurate the Journal of Vascular Surgery, which became the official organ of both groups and remains so for the combined SVS to this day. The founding editors were Dr. Michael DeBakey and Dr. Emerick Szilagyi.

In 1988, SVS established the Crawford Critical Issues Forum at the annual meeting, which was soon to incorporate members of the then North American Chapter of the International Society for Cardiovascular Surgery, the forerunner of AAVS.

In 2001, Dr. Robert Hobson served as the first president of the renamed AAVS. In his address at the 49^th annual meeting of the organization, he highlighted some of its major accomplishments including their then recent efforts to launch a new website called VascularWeb and the establishment of the American Vascular Association (AVA), with the assistance of SVS. The AVA was a division devoted to public education in vascular disease, which after the merger with SVS would become one with the Lifeline Foundation.

Summarizing the unity of the two organizations, in his SVS Presidential address in 2003, Dr. Jack Cronenwett stated, "It is clear that the SVS and AAVS have functioned as a single entity representing vascular surgery for many years."

He detailed the history of the two organizations and the logic of their merger from their consistent meetings together for more than three decades, from their fundraising effort, and from their shared committees, including the Joint Council established in 1975.

So significant was the Joint Council, according to Dr. Cronenwett, that "by the year 2000, the individual society council meetings lasted only one hour, but were followed by a seven-hour Joint Council meeting involving 45 persons, where all the important business of the societies was conducted." Surprisingly, the council was never incorporated legally or had authority to take action, but made decisions only by consensus of both societies, Dr. Cronenwett said.

It was this Joint Council that charged the SVS and AAVS presidents in 2002 to "investigate the management and governance of the societies and to develop specific proposals to address these concerns." It was a charge that led to the, almost inevitable, in retrospect, merger of the two societies a year later.

Dr. K. Craig Kent credited the merger with invigorating and transforming SVS, as he said in his 2007 presidential address: "Where was SVS five years ago? There were two societies, a division of leadership and competition between SVS and AAVS. SVS had no central administrative support ... Where is SVS today? I would say strong and well. This began with the merger of SVS and AAVS in 2003 to create an all inclusive society. We now have an office in Chicago with central administrative leadership. We have a Vascular Surgery Board within the American Board of Surgery and a primary certificate."

He went on to praise the new mature infrastructure of SVS and herald its major initiatives. Since its creation, the Chicago office has been run under the support of SVS Executive Director Rebecca M. Maron and has provided support and continuity to all SVS presidents since.

Major successes have occurred under the auspices of the SVS in promoting the interests vascular surgery in the Congress, according to Dr. K. Wayne Johnston in his 2008 presidential address.

"The first realization that we could have a direct impact in Washington came in 1997. At that time SVS faced major reductions in practice expense payments from Medicare. SVS convinced a number of key Senators and Congressmen that underrepresented specialties at the American Medical Association, such as vascular surgery, should have the opportunity to submit their supplemental practice expense data for review. SVS was the first speciality society to submit supplemental data from many members across the country, and our efforts saved millions of dollars in lost income," stated Dr. Johnston.

A second major legislative victory, The Screening Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act occurred in 2005, two years after the merger, with the new SVS serving as the lead organization in the National Aneurysm Alliance, with Immediate Past-President Dr. Robert Zwolak as the key operative in the coalition.

A third, although only partial victory, according to Dr. Johnston, came when SVS, with the aid of the Society for Vascular Ultrasound, mounted a successful effort to remove specific ultrasound services from major cuts in the Deficit Reduction Act of 2005.

SVS continues to work to promote the interests of vascular surgeons and their patients in a period of turbulent government medical reform.

A breakthrough in education occurred when the Accreditation Council for Graduate Medical Education approved the Primary Certificate in vascular surgery, which took effect July 1, 2008, and allows for more educational options and a more focused program for vascular trainees.

A good summary of the modern SVS can be found in the words of Dr. Anton Sidawy in his 2010 presidential address.

"Over the last few decades ... the Society and the specialty had to overcome obstacles, reinvent themselves, and take on major endeavors, and in doing so, we became stronger and expanded our horizons to better serve patients with vascular disease. Throughout it all, the Society and the specialty remained true and faithful to our core values of integrity, professionalism, and commitment to our members and patients," said Dr. Sidawy.

Sources:

Cronenwett, J. L. J. Vasc. Surg. 2004; 39:1-8.

Hobson, R. W., J. Vasc. Surg. 2002; 35:1-7.

Johnston, K. W., J. Vasc. Surg. 2008; 48:1613-9.

Kent, K. C., J. Vasc. Surg. 2008; 47: 231-6.

Shumacker, H. B. "The Society for Vascular Surgery. A History: 1945- 1983," The Society for Vascular Surgery, 1984; 583 pp.

Sidawy, A. N., J. Vasc. Surg. 2011; 510-6.

Yao, J. S. T., J. Vasc. Surg. 2010;51: 776-9.

The modern SVS is a vibrant blend of two rich historical and co-evolving traditions – the original SVS and the American Association for Vascular Surgery (AAVS) which merged in 2003 under the leadership of Dr. Jack Cronenwett (SVS) and Dr. Thomas Riles (AAVS). It was a merger that sanctified a long cooperative relationship that had existed between the two organizations.

The original SVS was the brainchild of Dr. James Ross Veal, according to Dr. James S.T. Yao in his history of the SVS beginnings. The society was inaugurated at the Fairmont Hotel in San Francisco on July 3, 1946, at a meeting which chose its name, elected its officers, and 31 charter members. A year later, its first annual meeting was held on June 8, 1947, in Atlantic City, and in a sense this heralded the dawn of modern arterial reconstructive surgery, though it was not until Dr. Robert R. Linton’s ninth presidential address in 1955, that such an address dealt with arterial reconstruction.

Among the charter members was the "father of vascular surgery," Dr. Rudolph Matas of Tulane University. In his acceptance of a ceremonial gavel in his honor, which he passed into the permanent custody of the SVS, he reminisced on how it was on May 5, 1888, "the first actual demonstration of the new principle that repair of an injured or damaged blood vessel could be obtained without the suppression of its blood-carrying function. It took place at the Charity Hospital [wood from one of its stairway posts was used to make the gavel]."

Courtesy National Library of Medicine

This operation, which Dr. Matas himself performed, relegated to the dustbin of history "the fundamental maxim of that great master of vascular surgery, Antonio Scarpa, in the late 18^th century, namely that no wound or injury of an artery could be repaired without a total suppression of its blood-carrying function."

The Matas gavel remains a treasured artifact and was used for many years as the symbol of presidential transition in the SVS.

The first SVS president, Dr. Alton Ochsner, gave his address, entitled "Venous Thromboembolism," at the first annual meeting. From then on the SVS continued incremental growth, expanding and refining its goals and structure and improving the tenor of its annual meeting. The first SVS constitution was drawn up by the committee and then adopted in June 1949, although the documents regarding it are lost to time. The first extant version is from 1955, according to SVS chronicler and charter member Dr. Harris B. Shumacker, Jr.

The official original SVS seal, carrying the image of another vascular surgery pioneer, John Hunter, was designed and implemented on the membership certificate by SVS Secretary Henry Swan in 1955. In 1958, the journal, Surgery, became the official organ of SVS and would remain so for 25 years.

By 1964, SVS began expanding its scope. That year, the SVS requested representation on the Board of Governors of the American College of Surgeons, which occurred in 1965. Also in the 1960s, the SVS pledged its support to the National Society of Medical Research and expanded its ties to the American Heart Association, gaining representation on its Joint Committee on Stroke.

Early lobbying efforts in this period included society support for a bill to establish a National Medical Devices Standard Commission, inspired by the SVS’s keen interest in the safety and composition of surgical implants.

In June, 1973, the first proposal of a Committee for Vascular Surgery on the American Board of Surgery was made, and ultimately implemented several years later. This brought renewed and vigorous interest in the issue of vascular training, which has continued ever since, and by the early 1980s, the American Board of Surgery was offering a Special Certification in General Vascular Surgery in consultation with SVS and AAVS, which provided institutional guidelines for training.

In 1986, SVS created a Foundation for Research and Education, which would, in 1989, under the foundation presidency of Dr. Michael Ellis DeBakey (another SVS charter member), undergo a name change to the Lifeline Foundation, which included sponsorship or responsibility for a variety of research and training oriented awards, grants, and initiatives. This tradition is carried on by the SVS Foundation.

Courtesy Baylor College of Medicine

In summarizing the fifth decade of SVS (1987-1996), Dr. Yao cites the introduction of endovascular techniques as a drastic change in the landscape of vascular practice. The sixth decade (1997-2006) "witnessed a milestone of transformation" with the merger of SVS and AAVS. "We were finally united as an independent surgical specialty."

Since the earliest years, AAVS and SVS had close ties, with both cooperating in 1984 to inaugurate the Journal of Vascular Surgery, which became the official organ of both groups and remains so for the combined SVS to this day. The founding editors were Dr. Michael DeBakey and Dr. Emerick Szilagyi.

In 1988, SVS established the Crawford Critical Issues Forum at the annual meeting, which was soon to incorporate members of the then North American Chapter of the International Society for Cardiovascular Surgery, the forerunner of AAVS.

In 2001, Dr. Robert Hobson served as the first president of the renamed AAVS. In his address at the 49^th annual meeting of the organization, he highlighted some of its major accomplishments including their then recent efforts to launch a new website called VascularWeb and the establishment of the American Vascular Association (AVA), with the assistance of SVS. The AVA was a division devoted to public education in vascular disease, which after the merger with SVS would become one with the Lifeline Foundation.

Summarizing the unity of the two organizations, in his SVS Presidential address in 2003, Dr. Jack Cronenwett stated, "It is clear that the SVS and AAVS have functioned as a single entity representing vascular surgery for many years."

He detailed the history of the two organizations and the logic of their merger from their consistent meetings together for more than three decades, from their fundraising effort, and from their shared committees, including the Joint Council established in 1975.

So significant was the Joint Council, according to Dr. Cronenwett, that "by the year 2000, the individual society council meetings lasted only one hour, but were followed by a seven-hour Joint Council meeting involving 45 persons, where all the important business of the societies was conducted." Surprisingly, the council was never incorporated legally or had authority to take action, but made decisions only by consensus of both societies, Dr. Cronenwett said.

It was this Joint Council that charged the SVS and AAVS presidents in 2002 to "investigate the management and governance of the societies and to develop specific proposals to address these concerns." It was a charge that led to the, almost inevitable, in retrospect, merger of the two societies a year later.

Dr. K. Craig Kent credited the merger with invigorating and transforming SVS, as he said in his 2007 presidential address: "Where was SVS five years ago? There were two societies, a division of leadership and competition between SVS and AAVS. SVS had no central administrative support ... Where is SVS today? I would say strong and well. This began with the merger of SVS and AAVS in 2003 to create an all inclusive society. We now have an office in Chicago with central administrative leadership. We have a Vascular Surgery Board within the American Board of Surgery and a primary certificate."

He went on to praise the new mature infrastructure of SVS and herald its major initiatives. Since its creation, the Chicago office has been run under the support of SVS Executive Director Rebecca M. Maron and has provided support and continuity to all SVS presidents since.

Major successes have occurred under the auspices of the SVS in promoting the interests vascular surgery in the Congress, according to Dr. K. Wayne Johnston in his 2008 presidential address.

"The first realization that we could have a direct impact in Washington came in 1997. At that time SVS faced major reductions in practice expense payments from Medicare. SVS convinced a number of key Senators and Congressmen that underrepresented specialties at the American Medical Association, such as vascular surgery, should have the opportunity to submit their supplemental practice expense data for review. SVS was the first speciality society to submit supplemental data from many members across the country, and our efforts saved millions of dollars in lost income," stated Dr. Johnston.

A second major legislative victory, The Screening Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act occurred in 2005, two years after the merger, with the new SVS serving as the lead organization in the National Aneurysm Alliance, with Immediate Past-President Dr. Robert Zwolak as the key operative in the coalition.

A third, although only partial victory, according to Dr. Johnston, came when SVS, with the aid of the Society for Vascular Ultrasound, mounted a successful effort to remove specific ultrasound services from major cuts in the Deficit Reduction Act of 2005.

SVS continues to work to promote the interests of vascular surgeons and their patients in a period of turbulent government medical reform.

A breakthrough in education occurred when the Accreditation Council for Graduate Medical Education approved the Primary Certificate in vascular surgery, which took effect July 1, 2008, and allows for more educational options and a more focused program for vascular trainees.

A good summary of the modern SVS can be found in the words of Dr. Anton Sidawy in his 2010 presidential address.

"Over the last few decades ... the Society and the specialty had to overcome obstacles, reinvent themselves, and take on major endeavors, and in doing so, we became stronger and expanded our horizons to better serve patients with vascular disease. Throughout it all, the Society and the specialty remained true and faithful to our core values of integrity, professionalism, and commitment to our members and patients," said Dr. Sidawy.

Sources:

Cronenwett, J. L. J. Vasc. Surg. 2004; 39:1-8.

Hobson, R. W., J. Vasc. Surg. 2002; 35:1-7.

Johnston, K. W., J. Vasc. Surg. 2008; 48:1613-9.

Kent, K. C., J. Vasc. Surg. 2008; 47: 231-6.

Shumacker, H. B. "The Society for Vascular Surgery. A History: 1945- 1983," The Society for Vascular Surgery, 1984; 583 pp.

Sidawy, A. N., J. Vasc. Surg. 2011; 510-6.

Yao, J. S. T., J. Vasc. Surg. 2010;51: 776-9.

NATIONAL HARBOR, MD – Local delivery of an antibiotic using impregnated bone-cement beads enabled sterile cultures to be achieved in the majority of infected surgical sites before final repair or graft replacement, according to a small, retrospective study reported by Dr. Dennis F. Bandyk.

This type of nonbiodegradable antibiotic implant is especially useful in cases of infection related to a groin incision, he said at the annual meeting of the Eastern Vascular Society.

"You can make these drug-delivery beads in the operating room in about 10 to 15 minutes.

"After EVAR [endovascular aneurysm repair], we have about a 5% incidence of surgical site infection. Arterial revascularization in the literature has a 10% to 30% infection rate, [and] it’s 18% in lengthy lower limb revascularization at our institution in Tampa. Major amputations generally range from a 15% to 25% infection rate, with 22% for the last 3 years at Tampa. The problem likely exists because of colonization with staph, particularly MRSA [methicillin-resistant Staphylococcus aureus], of injured and ischemic tissue, especially with involvement of the groin," Dr. Bandyk said.

"We have no decent methods of preventing these sorts of surgical site infections," he noted. The approach that his group takes to treat these infections is to use sequential in situ antibiotic treatment.

"I believe that many of the SSIs [surgical site infections] we have follow this theme of a biofilm-mediated infection," he said. Specific pathogenic strains colonize the area; they produce an extracellular matrix that then creates selective antibiotic resistance, since many of the antibiotics don’t penetrate biofilms.

The reported study comprised a 7-year case audit of 78 patients (55% male) who had complex SSI following peripheral arterial repair, treatment of an infected hip, or above- or below-knee lower limb amputation (12 infected stumps).

Antibiotic delivery directly to the wounds was mediated via the use of polymethyl methacrylate (PMMA) bone-cement beads. For gram-positive infection, which occurred in 70% of patients, the beads were impregnated with vancomycin (2 g/40 g PMMA) in the early part of the case series. Daptomycin (1.5 g/40 g PMMA) was found superior to vancomycin during in vitro testing, and became the antibiotic of choice for patients seen later in the case series. Tobramycin (2 g/40 g PMMA) was used for gram-negative infection, seen in 30% of patients. This was coupled to culture-specific parenteral antibiotics for 3-6 weeks. MRSA accounted for at least half of all early and late infections, and thus MRSA must be taken into account when comparing therapy options.

Infected surgical sites were explored and cultured, and based on a Gram stain of pus or a prior culture result, PMMA antibiotic-impregnated beads were implanted into the wound after soft tissue debridement, including the adjunct use of wound irrigants such as the "brown volcano" – a mixture of salt, peroxide, and Betadine – which disrupts biofilms.

Arterial infections underwent an average of 2.3 debridements. Surgical wounds were primarily closed with a planned bead exchange 3-5 days later (often repeated one to three times) to confirm sterilization prior to graft preservation or in situ graft replacement. The main outcomes were rates of wound sterilization (negative culture) based on wound type, procedures for persistent infection, and freedom from arterial repair infection.

In terms of outcomes, there were no cases of limb loss, higher-level amputation, or death at 30 days. The rate of recurrent infection was 7% over a mean follow-up period of 3 years. Sterile wound cultures were achieved in 91% of cases after 1-3 bead exchanges. Daptomycin beads appeared to work the most rapidly, Dr. Bandyk added.

"So you can sterilize the wound with the prosthetic in place," he noted.

Because of this strategy’s success, his group has transitioned to treating almost 58% of their SSIs in this way, said Dr. Bandyk, professor of surgery at the University of South Florida, Tampa.

"You can make these drug-delivery beads in the operating room in about 10 to 15 minutes. Vancomycin is bacteriostatic and does not penetrate biofilms; daptomycin is a bacteriocidal antibiotic that does penetrate biofilms," he explained.

In addition, because the use of antibiotic beads in general "isn’t anything new, you get paid for putting it in and paid for pulling it out."

Discussion after the presentation focused on the expense of daptomycin versus vancomycin and the difficulty of obtaining it in many institutions due to cost and issues of antibiotic stewardship. Dr. Bandyk responded, "I thought we were surgeons. Most surgeons believe that we should use a bactericidal agent that can get to the tissue with a chance of killing the bacteria that are there. I didn’t realize that we were in this sort of price war with the hospital. If you look at what a biofilm infection is, you will understand why vancomycin doesn’t work."

In response to a question as to whether the type of incision was an issue regarding SSI, Dr. Bandyk said: "It’s the patient that’s producing the infection, and certain patient characteristics, so it isn’t necessarily how we’re closing, which way we are putting the incision ... So don’t blame yourself for every surgical site infection. It’s the patient factors that are operative in many of these cases. Of almost all of our infections that occurred, two-thirds came from the MRSA-colonized patient," he said.

Dr. Bandyk reported being on the speakers bureau and having received funding from Cubist Pharmaceuticals, the manufacturer of daptomycin (Cubicin).

NATIONAL HARBOR, MD – Local delivery of an antibiotic using impregnated bone-cement beads enabled sterile cultures to be achieved in the majority of infected surgical sites before final repair or graft replacement, according to a small, retrospective study reported by Dr. Dennis F. Bandyk.

This type of nonbiodegradable antibiotic implant is especially useful in cases of infection related to a groin incision, he said at the annual meeting of the Eastern Vascular Society.

"You can make these drug-delivery beads in the operating room in about 10 to 15 minutes.

"After EVAR [endovascular aneurysm repair], we have about a 5% incidence of surgical site infection. Arterial revascularization in the literature has a 10% to 30% infection rate, [and] it’s 18% in lengthy lower limb revascularization at our institution in Tampa. Major amputations generally range from a 15% to 25% infection rate, with 22% for the last 3 years at Tampa. The problem likely exists because of colonization with staph, particularly MRSA [methicillin-resistant Staphylococcus aureus], of injured and ischemic tissue, especially with involvement of the groin," Dr. Bandyk said.

"We have no decent methods of preventing these sorts of surgical site infections," he noted. The approach that his group takes to treat these infections is to use sequential in situ antibiotic treatment.

"I believe that many of the SSIs [surgical site infections] we have follow this theme of a biofilm-mediated infection," he said. Specific pathogenic strains colonize the area; they produce an extracellular matrix that then creates selective antibiotic resistance, since many of the antibiotics don’t penetrate biofilms.

The reported study comprised a 7-year case audit of 78 patients (55% male) who had complex SSI following peripheral arterial repair, treatment of an infected hip, or above- or below-knee lower limb amputation (12 infected stumps).

Antibiotic delivery directly to the wounds was mediated via the use of polymethyl methacrylate (PMMA) bone-cement beads. For gram-positive infection, which occurred in 70% of patients, the beads were impregnated with vancomycin (2 g/40 g PMMA) in the early part of the case series. Daptomycin (1.5 g/40 g PMMA) was found superior to vancomycin during in vitro testing, and became the antibiotic of choice for patients seen later in the case series. Tobramycin (2 g/40 g PMMA) was used for gram-negative infection, seen in 30% of patients. This was coupled to culture-specific parenteral antibiotics for 3-6 weeks. MRSA accounted for at least half of all early and late infections, and thus MRSA must be taken into account when comparing therapy options.

Infected surgical sites were explored and cultured, and based on a Gram stain of pus or a prior culture result, PMMA antibiotic-impregnated beads were implanted into the wound after soft tissue debridement, including the adjunct use of wound irrigants such as the "brown volcano" – a mixture of salt, peroxide, and Betadine – which disrupts biofilms.

Arterial infections underwent an average of 2.3 debridements. Surgical wounds were primarily closed with a planned bead exchange 3-5 days later (often repeated one to three times) to confirm sterilization prior to graft preservation or in situ graft replacement. The main outcomes were rates of wound sterilization (negative culture) based on wound type, procedures for persistent infection, and freedom from arterial repair infection.

In terms of outcomes, there were no cases of limb loss, higher-level amputation, or death at 30 days. The rate of recurrent infection was 7% over a mean follow-up period of 3 years. Sterile wound cultures were achieved in 91% of cases after 1-3 bead exchanges. Daptomycin beads appeared to work the most rapidly, Dr. Bandyk added.

"So you can sterilize the wound with the prosthetic in place," he noted.

Because of this strategy’s success, his group has transitioned to treating almost 58% of their SSIs in this way, said Dr. Bandyk, professor of surgery at the University of South Florida, Tampa.

"You can make these drug-delivery beads in the operating room in about 10 to 15 minutes. Vancomycin is bacteriostatic and does not penetrate biofilms; daptomycin is a bacteriocidal antibiotic that does penetrate biofilms," he explained.

In addition, because the use of antibiotic beads in general "isn’t anything new, you get paid for putting it in and paid for pulling it out."

Discussion after the presentation focused on the expense of daptomycin versus vancomycin and the difficulty of obtaining it in many institutions due to cost and issues of antibiotic stewardship. Dr. Bandyk responded, "I thought we were surgeons. Most surgeons believe that we should use a bactericidal agent that can get to the tissue with a chance of killing the bacteria that are there. I didn’t realize that we were in this sort of price war with the hospital. If you look at what a biofilm infection is, you will understand why vancomycin doesn’t work."

In response to a question as to whether the type of incision was an issue regarding SSI, Dr. Bandyk said: "It’s the patient that’s producing the infection, and certain patient characteristics, so it isn’t necessarily how we’re closing, which way we are putting the incision ... So don’t blame yourself for every surgical site infection. It’s the patient factors that are operative in many of these cases. Of almost all of our infections that occurred, two-thirds came from the MRSA-colonized patient," he said.

Dr. Bandyk reported being on the speakers bureau and having received funding from Cubist Pharmaceuticals, the manufacturer of daptomycin (Cubicin).

NATIONAL HARBOR, MD – Local delivery of an antibiotic using impregnated bone-cement beads enabled sterile cultures to be achieved in the majority of infected surgical sites before final repair or graft replacement, according to a small, retrospective study reported by Dr. Dennis F. Bandyk.

This type of nonbiodegradable antibiotic implant is especially useful in cases of infection related to a groin incision, he said at the annual meeting of the Eastern Vascular Society.

"You can make these drug-delivery beads in the operating room in about 10 to 15 minutes.

"After EVAR [endovascular aneurysm repair], we have about a 5% incidence of surgical site infection. Arterial revascularization in the literature has a 10% to 30% infection rate, [and] it’s 18% in lengthy lower limb revascularization at our institution in Tampa. Major amputations generally range from a 15% to 25% infection rate, with 22% for the last 3 years at Tampa. The problem likely exists because of colonization with staph, particularly MRSA [methicillin-resistant Staphylococcus aureus], of injured and ischemic tissue, especially with involvement of the groin," Dr. Bandyk said.

"We have no decent methods of preventing these sorts of surgical site infections," he noted. The approach that his group takes to treat these infections is to use sequential in situ antibiotic treatment.

"I believe that many of the SSIs [surgical site infections] we have follow this theme of a biofilm-mediated infection," he said. Specific pathogenic strains colonize the area; they produce an extracellular matrix that then creates selective antibiotic resistance, since many of the antibiotics don’t penetrate biofilms.

The reported study comprised a 7-year case audit of 78 patients (55% male) who had complex SSI following peripheral arterial repair, treatment of an infected hip, or above- or below-knee lower limb amputation (12 infected stumps).

Antibiotic delivery directly to the wounds was mediated via the use of polymethyl methacrylate (PMMA) bone-cement beads. For gram-positive infection, which occurred in 70% of patients, the beads were impregnated with vancomycin (2 g/40 g PMMA) in the early part of the case series. Daptomycin (1.5 g/40 g PMMA) was found superior to vancomycin during in vitro testing, and became the antibiotic of choice for patients seen later in the case series. Tobramycin (2 g/40 g PMMA) was used for gram-negative infection, seen in 30% of patients. This was coupled to culture-specific parenteral antibiotics for 3-6 weeks. MRSA accounted for at least half of all early and late infections, and thus MRSA must be taken into account when comparing therapy options.

Infected surgical sites were explored and cultured, and based on a Gram stain of pus or a prior culture result, PMMA antibiotic-impregnated beads were implanted into the wound after soft tissue debridement, including the adjunct use of wound irrigants such as the "brown volcano" – a mixture of salt, peroxide, and Betadine – which disrupts biofilms.

Arterial infections underwent an average of 2.3 debridements. Surgical wounds were primarily closed with a planned bead exchange 3-5 days later (often repeated one to three times) to confirm sterilization prior to graft preservation or in situ graft replacement. The main outcomes were rates of wound sterilization (negative culture) based on wound type, procedures for persistent infection, and freedom from arterial repair infection.

In terms of outcomes, there were no cases of limb loss, higher-level amputation, or death at 30 days. The rate of recurrent infection was 7% over a mean follow-up period of 3 years. Sterile wound cultures were achieved in 91% of cases after 1-3 bead exchanges. Daptomycin beads appeared to work the most rapidly, Dr. Bandyk added.

"So you can sterilize the wound with the prosthetic in place," he noted.

Because of this strategy’s success, his group has transitioned to treating almost 58% of their SSIs in this way, said Dr. Bandyk, professor of surgery at the University of South Florida, Tampa.

"You can make these drug-delivery beads in the operating room in about 10 to 15 minutes. Vancomycin is bacteriostatic and does not penetrate biofilms; daptomycin is a bacteriocidal antibiotic that does penetrate biofilms," he explained.

In addition, because the use of antibiotic beads in general "isn’t anything new, you get paid for putting it in and paid for pulling it out."

Discussion after the presentation focused on the expense of daptomycin versus vancomycin and the difficulty of obtaining it in many institutions due to cost and issues of antibiotic stewardship. Dr. Bandyk responded, "I thought we were surgeons. Most surgeons believe that we should use a bactericidal agent that can get to the tissue with a chance of killing the bacteria that are there. I didn’t realize that we were in this sort of price war with the hospital. If you look at what a biofilm infection is, you will understand why vancomycin doesn’t work."

In response to a question as to whether the type of incision was an issue regarding SSI, Dr. Bandyk said: "It’s the patient that’s producing the infection, and certain patient characteristics, so it isn’t necessarily how we’re closing, which way we are putting the incision ... So don’t blame yourself for every surgical site infection. It’s the patient factors that are operative in many of these cases. Of almost all of our infections that occurred, two-thirds came from the MRSA-colonized patient," he said.

Dr. Bandyk reported being on the speakers bureau and having received funding from Cubist Pharmaceuticals, the manufacturer of daptomycin (Cubicin).

In a world of rapidly changing technology and educational demands, innovative training methods are required to prepare the next generation of cardiothoracic surgeons. The Thoracic Surgery Directors Association and the Joint Council on Thoracic Surgery Education Inc. have developed programs to ensure that CT residents receive the best possible training.

A prime example of these efforts is the annual TSDA Cardiothoracic Surgery Resident Boot Camp. The 2011 Boot Camp was held July 14-17 at the continuing education center of the University of North Carolina at Chapel Hill.

First-year residents from 24 thoracic surgery residency programs across the country joined faculty, led by Dr. James Fann of Stanford (Calif.) University, Dr. Rick Feins of UNC Chapel Hill, and Dr. George Hicks Jr. of the University of Rochester (N.Y.), with the goal of gaining valuable insights into surgical techniques and expanding their base of thoracic surgery knowledge.

The program was developed and hosted by the TSDA and was funded in part through a grant from the JTCSE.

Photos courtesy of the Thoracic Surgery Directors Association

Now in its fourth year, the boot camp uses cardiothoracic simulator–based training to give residents some of the basic skill sets necessary to enhance their residency educational experience, especially in the operating room.

This year, procedures included cardiopulmonary bypass, aortic valve repair, anastomosis, lung ventilation, and lobectomy.

Seeking out multidisciplinary approaches to teaching, the TSDA boot camp faculty also brought in guest speakers from the world of 3-D gaming and aviation. Ron Maness, a former pilot with the U.S. Air Force Thunderbirds, offered insights into how pilots use simulation to avoid errors in the cockpit. Additionally, Richard Boyd from Lockheed Martin Virtual World Labs spoke about how 3-D simulation tools for health care could make analysis and training fast, safe, and measurable.

"Other professional fields have made great gains when it comes to quality by using simulations in teaching," said Dr. Feins. "Sharing multidisciplinary learning approaches with up-and-coming residents is a great way to expand and build on their current knowledge base."

Feedback from the residents that was reported at the TSDA website indicated that Boot Camp III was a success. "Boot Camp was perfectly [set up] to introduce career advancement in cardiac and thoracic surgery," noted one resident in an evaluation.

"The hand-picked faculty was a key element to the camp and collectively they shared the goal of introducing foreign concepts in the field and did it in a very [nonintimidating] fashion."

Director feedback also expressed strong support of the boot camp’s benefits, with 91% of program directors saying that their resident’s experience was very or extremely helpful. Resident boot camp participants displayed similar enthusiasm for the program, indicating that it was a "phenomenal experience," and a "fantastic opportunity," according to a TSDA summary.

This weekend-long course incorporated simulated emergency scenarios and surgery demonstrations, with residents able to spend extensive one-on-one time with the faculty, from whom they gained guidance along with the finer points of cardiothoracic surgery basics.

Faculty and resident assessments were integrated into the curriculum throughout the weekend, providing valuable data on surgical skills, teaching methods, and simulator-based competencies, according to the TSDA.

"We are pleased to have such a high level of participation this year," said Dr. Hicks, president of TSDA and the boot camp program director. "The faculty was enthusiastic and patient. Overall, it was a great experience, and TSDA is committed to providing continued simulation training for surgical residents."

Industry and institutional donations, including instruments, tissue, simulators, and supplies, were provided by the University of North Carolina, B-Line Medical, the Chamberlain Group, Covidien, CryoLife, Ethicon Endo-Surgery, Karl Storz Endoscopy, Maquet Cardiovascular, Medtronic, Olympus America, Pilling Division of Teleflex Medical, Scanlan International, Sorin Group, and St. Jude Medical.

Powerpoints of the educational session presentations, photos of the meeting, a faculty listing, and a list of supporting organizations are available at the TSDA website (www.tsda.org/sections/meetings/2011%20Boot%20Camp/index.html.)

Educating Mentors

For the second year, in conjunction with the residents’ boot camp, the JCTSE conducted its Educate the Educators (EtE) program. The EtE program was held July 14-17 in Chapel Hill and was developed based on the specific needs of cardiothoracic surgeons.

According to a statement by the JCTSE surgical director of education, Dr. Edward D. Verrier, "the combination of these two programs achieving their goals bodes well for the future of cardiothoracic surgery education. The TSDA’s [boot camp] provided incoming residents with an experiential foundation and hands-on practice in basic cardiothoracic operating skills and the JCTSE’s EtE program enhanced the teaching skills of cardiothoracic surgical faculty and promoted the concept of career advancement through education."

The objectives of the EtE course were derived from national surveys of U.S.-based cardiothoracic surgery faculty and residents. The findings from these surveys guided EtE course codirectors, Dr. Stephen C. Yang of Johns Hopkins University in Baltimore and Dr. Ara Vaporciyan of the University of Texas, Houston, according to the JCTSE.

The 2.5-day program focused on the effective delivery of skills-based education (simulation and intraoperative teaching) and methods to convert educational efforts into career advancement (grants and promotion); it included adult learning theory, how to teach in the operating room, curriculum development and implementation, how to improve assessment skills, and how to use the science of education as a faculty advancement tool.

The goal of the program, according to the JCTSE, is to better prepare attendees to enhance educational efforts at their home institution. This enhancement may come in the form of initiating a skills laboratory with a complete curriculum or developing a separate program to address a specific educational need.

Dr. Yang said in a JTCSE summary of the meeting, "I think EtE 2011 was even more successful than last year due in part to the return of stellar faculty from the 2010 program and additions to that faculty. Attendees arrived with a high level of enthusiasm, interest, and energy, most likely driven by the information they receive about the program they were about to attend but as well as feedback they received from last year’s attendees. This year’s attendees definitely left with an eagerness to encourage other colleagues to attend the course in the future."

According to the JCTSE, connections will be maintained with those who attended both the 2010 and 2011 EtE programs "to help guide them as they make inroads into improving cardiothoracic surgery education. The JCTSE remains committed to building an ‘army of educators’ who will lead the new wave of education for the next generation of CT surgeons."

In a world of rapidly changing technology and educational demands, innovative training methods are required to prepare the next generation of cardiothoracic surgeons. The Thoracic Surgery Directors Association and the Joint Council on Thoracic Surgery Education Inc. have developed programs to ensure that CT residents receive the best possible training.

A prime example of these efforts is the annual TSDA Cardiothoracic Surgery Resident Boot Camp. The 2011 Boot Camp was held July 14-17 at the continuing education center of the University of North Carolina at Chapel Hill.

First-year residents from 24 thoracic surgery residency programs across the country joined faculty, led by Dr. James Fann of Stanford (Calif.) University, Dr. Rick Feins of UNC Chapel Hill, and Dr. George Hicks Jr. of the University of Rochester (N.Y.), with the goal of gaining valuable insights into surgical techniques and expanding their base of thoracic surgery knowledge.

The program was developed and hosted by the TSDA and was funded in part through a grant from the JTCSE.

Photos courtesy of the Thoracic Surgery Directors Association

Now in its fourth year, the boot camp uses cardiothoracic simulator–based training to give residents some of the basic skill sets necessary to enhance their residency educational experience, especially in the operating room.

This year, procedures included cardiopulmonary bypass, aortic valve repair, anastomosis, lung ventilation, and lobectomy.

Seeking out multidisciplinary approaches to teaching, the TSDA boot camp faculty also brought in guest speakers from the world of 3-D gaming and aviation. Ron Maness, a former pilot with the U.S. Air Force Thunderbirds, offered insights into how pilots use simulation to avoid errors in the cockpit. Additionally, Richard Boyd from Lockheed Martin Virtual World Labs spoke about how 3-D simulation tools for health care could make analysis and training fast, safe, and measurable.

"Other professional fields have made great gains when it comes to quality by using simulations in teaching," said Dr. Feins. "Sharing multidisciplinary learning approaches with up-and-coming residents is a great way to expand and build on their current knowledge base."

Feedback from the residents that was reported at the TSDA website indicated that Boot Camp III was a success. "Boot Camp was perfectly [set up] to introduce career advancement in cardiac and thoracic surgery," noted one resident in an evaluation.

"The hand-picked faculty was a key element to the camp and collectively they shared the goal of introducing foreign concepts in the field and did it in a very [nonintimidating] fashion."

Director feedback also expressed strong support of the boot camp’s benefits, with 91% of program directors saying that their resident’s experience was very or extremely helpful. Resident boot camp participants displayed similar enthusiasm for the program, indicating that it was a "phenomenal experience," and a "fantastic opportunity," according to a TSDA summary.

This weekend-long course incorporated simulated emergency scenarios and surgery demonstrations, with residents able to spend extensive one-on-one time with the faculty, from whom they gained guidance along with the finer points of cardiothoracic surgery basics.

Faculty and resident assessments were integrated into the curriculum throughout the weekend, providing valuable data on surgical skills, teaching methods, and simulator-based competencies, according to the TSDA.

"We are pleased to have such a high level of participation this year," said Dr. Hicks, president of TSDA and the boot camp program director. "The faculty was enthusiastic and patient. Overall, it was a great experience, and TSDA is committed to providing continued simulation training for surgical residents."

Industry and institutional donations, including instruments, tissue, simulators, and supplies, were provided by the University of North Carolina, B-Line Medical, the Chamberlain Group, Covidien, CryoLife, Ethicon Endo-Surgery, Karl Storz Endoscopy, Maquet Cardiovascular, Medtronic, Olympus America, Pilling Division of Teleflex Medical, Scanlan International, Sorin Group, and St. Jude Medical.

Powerpoints of the educational session presentations, photos of the meeting, a faculty listing, and a list of supporting organizations are available at the TSDA website (www.tsda.org/sections/meetings/2011%20Boot%20Camp/index.html.)

Educating Mentors

For the second year, in conjunction with the residents’ boot camp, the JCTSE conducted its Educate the Educators (EtE) program. The EtE program was held July 14-17 in Chapel Hill and was developed based on the specific needs of cardiothoracic surgeons.

According to a statement by the JCTSE surgical director of education, Dr. Edward D. Verrier, "the combination of these two programs achieving their goals bodes well for the future of cardiothoracic surgery education. The TSDA’s [boot camp] provided incoming residents with an experiential foundation and hands-on practice in basic cardiothoracic operating skills and the JCTSE’s EtE program enhanced the teaching skills of cardiothoracic surgical faculty and promoted the concept of career advancement through education."

The objectives of the EtE course were derived from national surveys of U.S.-based cardiothoracic surgery faculty and residents. The findings from these surveys guided EtE course codirectors, Dr. Stephen C. Yang of Johns Hopkins University in Baltimore and Dr. Ara Vaporciyan of the University of Texas, Houston, according to the JCTSE.

The 2.5-day program focused on the effective delivery of skills-based education (simulation and intraoperative teaching) and methods to convert educational efforts into career advancement (grants and promotion); it included adult learning theory, how to teach in the operating room, curriculum development and implementation, how to improve assessment skills, and how to use the science of education as a faculty advancement tool.

The goal of the program, according to the JCTSE, is to better prepare attendees to enhance educational efforts at their home institution. This enhancement may come in the form of initiating a skills laboratory with a complete curriculum or developing a separate program to address a specific educational need.

Dr. Yang said in a JTCSE summary of the meeting, "I think EtE 2011 was even more successful than last year due in part to the return of stellar faculty from the 2010 program and additions to that faculty. Attendees arrived with a high level of enthusiasm, interest, and energy, most likely driven by the information they receive about the program they were about to attend but as well as feedback they received from last year’s attendees. This year’s attendees definitely left with an eagerness to encourage other colleagues to attend the course in the future."

According to the JCTSE, connections will be maintained with those who attended both the 2010 and 2011 EtE programs "to help guide them as they make inroads into improving cardiothoracic surgery education. The JCTSE remains committed to building an ‘army of educators’ who will lead the new wave of education for the next generation of CT surgeons."

In a world of rapidly changing technology and educational demands, innovative training methods are required to prepare the next generation of cardiothoracic surgeons. The Thoracic Surgery Directors Association and the Joint Council on Thoracic Surgery Education Inc. have developed programs to ensure that CT residents receive the best possible training.

A prime example of these efforts is the annual TSDA Cardiothoracic Surgery Resident Boot Camp. The 2011 Boot Camp was held July 14-17 at the continuing education center of the University of North Carolina at Chapel Hill.

First-year residents from 24 thoracic surgery residency programs across the country joined faculty, led by Dr. James Fann of Stanford (Calif.) University, Dr. Rick Feins of UNC Chapel Hill, and Dr. George Hicks Jr. of the University of Rochester (N.Y.), with the goal of gaining valuable insights into surgical techniques and expanding their base of thoracic surgery knowledge.

The program was developed and hosted by the TSDA and was funded in part through a grant from the JTCSE.

Photos courtesy of the Thoracic Surgery Directors Association

Now in its fourth year, the boot camp uses cardiothoracic simulator–based training to give residents some of the basic skill sets necessary to enhance their residency educational experience, especially in the operating room.

This year, procedures included cardiopulmonary bypass, aortic valve repair, anastomosis, lung ventilation, and lobectomy.

Seeking out multidisciplinary approaches to teaching, the TSDA boot camp faculty also brought in guest speakers from the world of 3-D gaming and aviation. Ron Maness, a former pilot with the U.S. Air Force Thunderbirds, offered insights into how pilots use simulation to avoid errors in the cockpit. Additionally, Richard Boyd from Lockheed Martin Virtual World Labs spoke about how 3-D simulation tools for health care could make analysis and training fast, safe, and measurable.

"Other professional fields have made great gains when it comes to quality by using simulations in teaching," said Dr. Feins. "Sharing multidisciplinary learning approaches with up-and-coming residents is a great way to expand and build on their current knowledge base."

Feedback from the residents that was reported at the TSDA website indicated that Boot Camp III was a success. "Boot Camp was perfectly [set up] to introduce career advancement in cardiac and thoracic surgery," noted one resident in an evaluation.

"The hand-picked faculty was a key element to the camp and collectively they shared the goal of introducing foreign concepts in the field and did it in a very [nonintimidating] fashion."

Director feedback also expressed strong support of the boot camp’s benefits, with 91% of program directors saying that their resident’s experience was very or extremely helpful. Resident boot camp participants displayed similar enthusiasm for the program, indicating that it was a "phenomenal experience," and a "fantastic opportunity," according to a TSDA summary.

This weekend-long course incorporated simulated emergency scenarios and surgery demonstrations, with residents able to spend extensive one-on-one time with the faculty, from whom they gained guidance along with the finer points of cardiothoracic surgery basics.

Faculty and resident assessments were integrated into the curriculum throughout the weekend, providing valuable data on surgical skills, teaching methods, and simulator-based competencies, according to the TSDA.

"We are pleased to have such a high level of participation this year," said Dr. Hicks, president of TSDA and the boot camp program director. "The faculty was enthusiastic and patient. Overall, it was a great experience, and TSDA is committed to providing continued simulation training for surgical residents."

Industry and institutional donations, including instruments, tissue, simulators, and supplies, were provided by the University of North Carolina, B-Line Medical, the Chamberlain Group, Covidien, CryoLife, Ethicon Endo-Surgery, Karl Storz Endoscopy, Maquet Cardiovascular, Medtronic, Olympus America, Pilling Division of Teleflex Medical, Scanlan International, Sorin Group, and St. Jude Medical.

Powerpoints of the educational session presentations, photos of the meeting, a faculty listing, and a list of supporting organizations are available at the TSDA website (www.tsda.org/sections/meetings/2011%20Boot%20Camp/index.html.)

Educating Mentors

For the second year, in conjunction with the residents’ boot camp, the JCTSE conducted its Educate the Educators (EtE) program. The EtE program was held July 14-17 in Chapel Hill and was developed based on the specific needs of cardiothoracic surgeons.

According to a statement by the JCTSE surgical director of education, Dr. Edward D. Verrier, "the combination of these two programs achieving their goals bodes well for the future of cardiothoracic surgery education. The TSDA’s [boot camp] provided incoming residents with an experiential foundation and hands-on practice in basic cardiothoracic operating skills and the JCTSE’s EtE program enhanced the teaching skills of cardiothoracic surgical faculty and promoted the concept of career advancement through education."

The objectives of the EtE course were derived from national surveys of U.S.-based cardiothoracic surgery faculty and residents. The findings from these surveys guided EtE course codirectors, Dr. Stephen C. Yang of Johns Hopkins University in Baltimore and Dr. Ara Vaporciyan of the University of Texas, Houston, according to the JCTSE.

The 2.5-day program focused on the effective delivery of skills-based education (simulation and intraoperative teaching) and methods to convert educational efforts into career advancement (grants and promotion); it included adult learning theory, how to teach in the operating room, curriculum development and implementation, how to improve assessment skills, and how to use the science of education as a faculty advancement tool.

The goal of the program, according to the JCTSE, is to better prepare attendees to enhance educational efforts at their home institution. This enhancement may come in the form of initiating a skills laboratory with a complete curriculum or developing a separate program to address a specific educational need.

Dr. Yang said in a JTCSE summary of the meeting, "I think EtE 2011 was even more successful than last year due in part to the return of stellar faculty from the 2010 program and additions to that faculty. Attendees arrived with a high level of enthusiasm, interest, and energy, most likely driven by the information they receive about the program they were about to attend but as well as feedback they received from last year’s attendees. This year’s attendees definitely left with an eagerness to encourage other colleagues to attend the course in the future."

According to the JCTSE, connections will be maintained with those who attended both the 2010 and 2011 EtE programs "to help guide them as they make inroads into improving cardiothoracic surgery education. The JCTSE remains committed to building an ‘army of educators’ who will lead the new wave of education for the next generation of CT surgeons."

"Don’t have surgery in July!" This is the folk wisdom regarding the purported "July Phenomenon" – the perception that it is more dangerous to have an operation in July than at any other time of year. July heralds the onslaught of new interns; July also means that current residents are given additional duties and responsibility. "Why risk an operation in a month when trainee inexperience must surely dilute the quality of patient care?" is the intuitive assumption.

A recent study reported in ‘Surgery’, however, showed that this concern is unfounded.

Multivariate analysis indicated that only 1 out of the 10 most common surgical procedures (lower extremity artery bypass grafting) showed a significant increase in mortality concurrent with the so-called July Phenomenon (odds ratio, 1.34; P = .034).

The researchers also found that there was no significant increase in serious adverse events (SAE) for any of the procedures (Surgery 2011;150:332-8).

The previous medical literature shows no consensus on the subject. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) suggested that greater rates of postsurgical problems were related to that time of year (Ann. Surg. 2007;246:456-62).

In contrast, studies in obstetrics and neurology showed that no July Phenomenon existed, as did surgical studies in specialties including trauma, pediatric neurosurgery, and cardiac surgery, according to Dr. Bryan A. Ehlert and colleagues at East Carolina University, Greenville, N.C.

To investigate the issue in a broader surgical context, Dr. Ehlert and his colleagues studied the ACS-NSQIP database records of 89,473 patients who had the 10 most common inpatient operative procedures in 2005-2007.

They compared 26,287 patients who had surgery in the July 1–Sept. 30 quarter (called the "first academic quarter," or FAQ) with a control population of 63,186 patients who had equivalent surgery during the rest of the year (Oct. 1–June 30).

They assessed the following 10 procedures: appendectomy, (lower extremity) artery bypass graft, initial reducible ventral hernia repair, laparoscopic appendectomy, laparoscopic cholecystectomy, laparoscopic gastric bypass, partial colectomy, rechanneling of artery, repair of bowel opening, and small-bowel resection.

The two populations showed no significant differences in a wide variety of demographic characteristics including age (average, about 54 years); sex (about 45% male); and presence of coronary artery disease, renal disease, peripheral vascular disease (PVD/PAD), and diabetes. Slight but significant differences were found only in the presence of hypertension (50.0% in the FAQ group vs. 48.4% in controls, respectively) and history of smoking (24.0% vs. 23.4%).

Especially important to the study, there was no significant difference in resident participation in patient care (72.7% vs. 73.0%) or the highest resident level in postgraduate year (2.6 years each).

"Although July might seem intuitively to be a precarious time to undergo an operation due to the influx of new interns and increased responsibilities of rising residents, our findings for the most part discount the presence of a ‘July Phenomenon’ in surgical patients," the authors stated.

Discrepancies between the previous ACS-NSQIP report and their findings were attributed to the much larger sample size in the current study (183 centers vs. 18).

They postulated that the lower extremity bypass graft FAQ group showed greater mortality than did the control group because the vascular subsets had a significantly greater modified Charlson comorbidity index, compared with the nonvascular subsets in the FAQ population (CCI, 3.72 vs. 1.56; P less than .001).

"New surgery interns may not be as adept at recognizing the needs of these patients who are often sicker. As a result, these patient populations may benefit from more senior residents and attending physician involvement as new interns learn how to manage patients with complex cardiovascular disease," they suggested.

A weakness of the study reported by the authors is the crude estimate of patient outcomes, which focuses only on morbidity and mortality and does not include data on duration of stay, medication errors, or cost-effectiveness – all of which could possibly be affected by new interns.

For example, they noted that new interns may be more likely to order more unnecessary laboratory tests, or they may fail to remove invasive devices or monitoring devices that are no longer needed, which may in turn lead to increased infections.

In addition, they also stated that interns may have more difficulties when confronted with rarer operations than the 10 most common procedures that were evaluated.

The researchers disclosed no conflicts that the journal deemed relevant to report.

"Don’t have surgery in July!" This is the folk wisdom regarding the purported "July Phenomenon" – the perception that it is more dangerous to have an operation in July than at any other time of year. July heralds the onslaught of new interns; July also means that current residents are given additional duties and responsibility. "Why risk an operation in a month when trainee inexperience must surely dilute the quality of patient care?" is the intuitive assumption.

A recent study reported in ‘Surgery’, however, showed that this concern is unfounded.

Multivariate analysis indicated that only 1 out of the 10 most common surgical procedures (lower extremity artery bypass grafting) showed a significant increase in mortality concurrent with the so-called July Phenomenon (odds ratio, 1.34; P = .034).

The researchers also found that there was no significant increase in serious adverse events (SAE) for any of the procedures (Surgery 2011;150:332-8).

The previous medical literature shows no consensus on the subject. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) suggested that greater rates of postsurgical problems were related to that time of year (Ann. Surg. 2007;246:456-62).

In contrast, studies in obstetrics and neurology showed that no July Phenomenon existed, as did surgical studies in specialties including trauma, pediatric neurosurgery, and cardiac surgery, according to Dr. Bryan A. Ehlert and colleagues at East Carolina University, Greenville, N.C.

To investigate the issue in a broader surgical context, Dr. Ehlert and his colleagues studied the ACS-NSQIP database records of 89,473 patients who had the 10 most common inpatient operative procedures in 2005-2007.

They compared 26,287 patients who had surgery in the July 1–Sept. 30 quarter (called the "first academic quarter," or FAQ) with a control population of 63,186 patients who had equivalent surgery during the rest of the year (Oct. 1–June 30).

They assessed the following 10 procedures: appendectomy, (lower extremity) artery bypass graft, initial reducible ventral hernia repair, laparoscopic appendectomy, laparoscopic cholecystectomy, laparoscopic gastric bypass, partial colectomy, rechanneling of artery, repair of bowel opening, and small-bowel resection.

The two populations showed no significant differences in a wide variety of demographic characteristics including age (average, about 54 years); sex (about 45% male); and presence of coronary artery disease, renal disease, peripheral vascular disease (PVD/PAD), and diabetes. Slight but significant differences were found only in the presence of hypertension (50.0% in the FAQ group vs. 48.4% in controls, respectively) and history of smoking (24.0% vs. 23.4%).

Especially important to the study, there was no significant difference in resident participation in patient care (72.7% vs. 73.0%) or the highest resident level in postgraduate year (2.6 years each).

"Although July might seem intuitively to be a precarious time to undergo an operation due to the influx of new interns and increased responsibilities of rising residents, our findings for the most part discount the presence of a ‘July Phenomenon’ in surgical patients," the authors stated.

Discrepancies between the previous ACS-NSQIP report and their findings were attributed to the much larger sample size in the current study (183 centers vs. 18).

They postulated that the lower extremity bypass graft FAQ group showed greater mortality than did the control group because the vascular subsets had a significantly greater modified Charlson comorbidity index, compared with the nonvascular subsets in the FAQ population (CCI, 3.72 vs. 1.56; P less than .001).

"New surgery interns may not be as adept at recognizing the needs of these patients who are often sicker. As a result, these patient populations may benefit from more senior residents and attending physician involvement as new interns learn how to manage patients with complex cardiovascular disease," they suggested.

A weakness of the study reported by the authors is the crude estimate of patient outcomes, which focuses only on morbidity and mortality and does not include data on duration of stay, medication errors, or cost-effectiveness – all of which could possibly be affected by new interns.

For example, they noted that new interns may be more likely to order more unnecessary laboratory tests, or they may fail to remove invasive devices or monitoring devices that are no longer needed, which may in turn lead to increased infections.

In addition, they also stated that interns may have more difficulties when confronted with rarer operations than the 10 most common procedures that were evaluated.

The researchers disclosed no conflicts that the journal deemed relevant to report.

"Don’t have surgery in July!" This is the folk wisdom regarding the purported "July Phenomenon" – the perception that it is more dangerous to have an operation in July than at any other time of year. July heralds the onslaught of new interns; July also means that current residents are given additional duties and responsibility. "Why risk an operation in a month when trainee inexperience must surely dilute the quality of patient care?" is the intuitive assumption.

A recent study reported in ‘Surgery’, however, showed that this concern is unfounded.

Multivariate analysis indicated that only 1 out of the 10 most common surgical procedures (lower extremity artery bypass grafting) showed a significant increase in mortality concurrent with the so-called July Phenomenon (odds ratio, 1.34; P = .034).

The researchers also found that there was no significant increase in serious adverse events (SAE) for any of the procedures (Surgery 2011;150:332-8).

The previous medical literature shows no consensus on the subject. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) suggested that greater rates of postsurgical problems were related to that time of year (Ann. Surg. 2007;246:456-62).

In contrast, studies in obstetrics and neurology showed that no July Phenomenon existed, as did surgical studies in specialties including trauma, pediatric neurosurgery, and cardiac surgery, according to Dr. Bryan A. Ehlert and colleagues at East Carolina University, Greenville, N.C.

To investigate the issue in a broader surgical context, Dr. Ehlert and his colleagues studied the ACS-NSQIP database records of 89,473 patients who had the 10 most common inpatient operative procedures in 2005-2007.

They compared 26,287 patients who had surgery in the July 1–Sept. 30 quarter (called the "first academic quarter," or FAQ) with a control population of 63,186 patients who had equivalent surgery during the rest of the year (Oct. 1–June 30).

They assessed the following 10 procedures: appendectomy, (lower extremity) artery bypass graft, initial reducible ventral hernia repair, laparoscopic appendectomy, laparoscopic cholecystectomy, laparoscopic gastric bypass, partial colectomy, rechanneling of artery, repair of bowel opening, and small-bowel resection.

The two populations showed no significant differences in a wide variety of demographic characteristics including age (average, about 54 years); sex (about 45% male); and presence of coronary artery disease, renal disease, peripheral vascular disease (PVD/PAD), and diabetes. Slight but significant differences were found only in the presence of hypertension (50.0% in the FAQ group vs. 48.4% in controls, respectively) and history of smoking (24.0% vs. 23.4%).

Especially important to the study, there was no significant difference in resident participation in patient care (72.7% vs. 73.0%) or the highest resident level in postgraduate year (2.6 years each).

"Although July might seem intuitively to be a precarious time to undergo an operation due to the influx of new interns and increased responsibilities of rising residents, our findings for the most part discount the presence of a ‘July Phenomenon’ in surgical patients," the authors stated.

Discrepancies between the previous ACS-NSQIP report and their findings were attributed to the much larger sample size in the current study (183 centers vs. 18).

They postulated that the lower extremity bypass graft FAQ group showed greater mortality than did the control group because the vascular subsets had a significantly greater modified Charlson comorbidity index, compared with the nonvascular subsets in the FAQ population (CCI, 3.72 vs. 1.56; P less than .001).

"New surgery interns may not be as adept at recognizing the needs of these patients who are often sicker. As a result, these patient populations may benefit from more senior residents and attending physician involvement as new interns learn how to manage patients with complex cardiovascular disease," they suggested.

A weakness of the study reported by the authors is the crude estimate of patient outcomes, which focuses only on morbidity and mortality and does not include data on duration of stay, medication errors, or cost-effectiveness – all of which could possibly be affected by new interns.

For example, they noted that new interns may be more likely to order more unnecessary laboratory tests, or they may fail to remove invasive devices or monitoring devices that are no longer needed, which may in turn lead to increased infections.

In addition, they also stated that interns may have more difficulties when confronted with rarer operations than the 10 most common procedures that were evaluated.

The researchers disclosed no conflicts that the journal deemed relevant to report.

Major Finding: Mortality was significantly increased (though less than 1%) in only 1 of the 10 most common operations – lower artery bypass grafting – at the beginning of the academic year as compared with any other quarter.

Data Source: A database analysis of 89,473 patients undergoing the 10 most common inpatient operative procedures from 2005 to 2007.

Disclosures: The authors had no disclosures deemed relevant to report by the journal.

“Don't have surgery in July!” This is the folk wisdom regarding the purported “July Phenomenon” – the perception that it is more dangerous to have an operation in July than at any other time of year. July heralds the onslaught of new interns; July also means that current residents are given additional duties and responsibility. “Why risk an operation in a month when trainee inexperience must surely dilute the quality of patient care?” is the intuitive assumption.

A recent study, however, showed that this concern is unfounded. Multivariate analysis indicated that only 1 out of the 10 most common surgical procedures (lower extremity artery bypass grafting) showed a significant increase in mortality concurrent with the so-called July Phenomenon (odds ratio, 1.34; P = .034). The researchers also found that there was no significant increase in serious adverse events (SAE) for any of the procedures (Surgery 2011;150:332-8).

The previous medical literature shows no consensus on the subject. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) suggested that greater rates of postsurgical problems were related to that time of year (Ann. Surg. 2007;246:456-62). In contrast, studies in obstetrics and neurology showed that no July Phenomenon existed, as did surgical studies in specialties including trauma, hediatric neurosurgery, and cardiac surgery, according to Dr. Bryan A. Ehlert and colleagues at East Carolina University, Greenville, N.C.

To investigate the issue in a broader surgical context, Dr. Ehlert and his colleagues studied the ACS-NSQIP database records of 89,473 patients who had the 10 most common inpatient operative procedures in 2005-2007. They compared 26,287 patients who had surgery in the July 1–Sept. 30 quarter (called the “first academic quarter,” or FAQ) with a control population of 63,186 patients who had equivalent surgery during the rest of the year (Oct. 1–June 30) for the following 10 procedures: appendectomy, (lower extremity) artery bypass graft, initial reducible ventral hernia repair, laparoscopic appendectomy, laparoscopic cholecystectomy, laparoscopic gastric bypass, partial colectomy, rechanneling of artery, repair of bowel opening, and small-bowel resection.

The two populations showed no significant differences in a wide variety of demographic characteristics including age (average, about 54 years); sex (about 45% male); and presence of coronary artery disease, renal disease, peripheral vascular disease (PVD/PAD), and diabetes. Slight but significant differences were found only in the presence of hypertension (50.0% in the FAQ group vs. 48.4% in controls, respectively) and history of smoking (24.0% vs. 23.4%). Especially important to the study, there was no significant difference in resident participation in patient care (72.7% vs. 73.0%) or the highest resident level in postgraduate year (2.6 years each).

“Although July might seem intuitively to be a precarious time to undergo an operation due to the influx of new interns and increased responsibilities of rising residents, our findings for the most part discount the presence of a 'July Phenomenon' in surgical patients,” the authors stated. Discrepancies between the previous ACS-NISQIP report and their findings were attributed to the much larger sample size in the current study (183 centers vs. 18).

They postulated that the lower extremity bypass graft FAQ group showed greater mortality than did the control group because the vascular subsets had a significantly greater modified Charlson comorbidity index, compared with the nonvascular subsets in the FAQ population (CCI, 3.72 vs. 1.56; P less than .001).

“New surgery interns may not be as adept at recognizing the needs of these patients who are often sicker. As a result, these patient populations may benefit from more senior residents and attending physician involvement as new interns learn how to manage patients with complex cardiovascular disease,” they suggested.

A weakness of the study reported by the authors is the crude estimate of patient outcomes, which focuses only on morbidity and mortality and does not include data on duration of stay, medication errors, or cost-effectiveness – all of which could possibly be affected by new interns. For example, they noted that new interns may be more likely to order more unnecessary laboratory tests, or they may fail to remove invasive devices or monitoring devices that are no longer needed, which may in turn lead to increased infections.

In addition, they also stated that interns may have more difficulties when confronted with rarer operations than the 10 most common procedures that were evaluated.

Major Finding: Mortality was significantly increased (though less than 1%) in only 1 of the 10 most common operations – lower artery bypass grafting – at the beginning of the academic year as compared with any other quarter.

Data Source: A database analysis of 89,473 patients undergoing the 10 most common inpatient operative procedures from 2005 to 2007.

Disclosures: The authors had no disclosures deemed relevant to report by the journal.

“Don't have surgery in July!” This is the folk wisdom regarding the purported “July Phenomenon” – the perception that it is more dangerous to have an operation in July than at any other time of year. July heralds the onslaught of new interns; July also means that current residents are given additional duties and responsibility. “Why risk an operation in a month when trainee inexperience must surely dilute the quality of patient care?” is the intuitive assumption.

A recent study, however, showed that this concern is unfounded. Multivariate analysis indicated that only 1 out of the 10 most common surgical procedures (lower extremity artery bypass grafting) showed a significant increase in mortality concurrent with the so-called July Phenomenon (odds ratio, 1.34; P = .034). The researchers also found that there was no significant increase in serious adverse events (SAE) for any of the procedures (Surgery 2011;150:332-8).

The previous medical literature shows no consensus on the subject. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) suggested that greater rates of postsurgical problems were related to that time of year (Ann. Surg. 2007;246:456-62). In contrast, studies in obstetrics and neurology showed that no July Phenomenon existed, as did surgical studies in specialties including trauma, hediatric neurosurgery, and cardiac surgery, according to Dr. Bryan A. Ehlert and colleagues at East Carolina University, Greenville, N.C.

To investigate the issue in a broader surgical context, Dr. Ehlert and his colleagues studied the ACS-NSQIP database records of 89,473 patients who had the 10 most common inpatient operative procedures in 2005-2007. They compared 26,287 patients who had surgery in the July 1–Sept. 30 quarter (called the “first academic quarter,” or FAQ) with a control population of 63,186 patients who had equivalent surgery during the rest of the year (Oct. 1–June 30) for the following 10 procedures: appendectomy, (lower extremity) artery bypass graft, initial reducible ventral hernia repair, laparoscopic appendectomy, laparoscopic cholecystectomy, laparoscopic gastric bypass, partial colectomy, rechanneling of artery, repair of bowel opening, and small-bowel resection.

The two populations showed no significant differences in a wide variety of demographic characteristics including age (average, about 54 years); sex (about 45% male); and presence of coronary artery disease, renal disease, peripheral vascular disease (PVD/PAD), and diabetes. Slight but significant differences were found only in the presence of hypertension (50.0% in the FAQ group vs. 48.4% in controls, respectively) and history of smoking (24.0% vs. 23.4%). Especially important to the study, there was no significant difference in resident participation in patient care (72.7% vs. 73.0%) or the highest resident level in postgraduate year (2.6 years each).

“Although July might seem intuitively to be a precarious time to undergo an operation due to the influx of new interns and increased responsibilities of rising residents, our findings for the most part discount the presence of a 'July Phenomenon' in surgical patients,” the authors stated. Discrepancies between the previous ACS-NISQIP report and their findings were attributed to the much larger sample size in the current study (183 centers vs. 18).

They postulated that the lower extremity bypass graft FAQ group showed greater mortality than did the control group because the vascular subsets had a significantly greater modified Charlson comorbidity index, compared with the nonvascular subsets in the FAQ population (CCI, 3.72 vs. 1.56; P less than .001).

“New surgery interns may not be as adept at recognizing the needs of these patients who are often sicker. As a result, these patient populations may benefit from more senior residents and attending physician involvement as new interns learn how to manage patients with complex cardiovascular disease,” they suggested.

A weakness of the study reported by the authors is the crude estimate of patient outcomes, which focuses only on morbidity and mortality and does not include data on duration of stay, medication errors, or cost-effectiveness – all of which could possibly be affected by new interns. For example, they noted that new interns may be more likely to order more unnecessary laboratory tests, or they may fail to remove invasive devices or monitoring devices that are no longer needed, which may in turn lead to increased infections.

In addition, they also stated that interns may have more difficulties when confronted with rarer operations than the 10 most common procedures that were evaluated.

Major Finding: Mortality was significantly increased (though less than 1%) in only 1 of the 10 most common operations – lower artery bypass grafting – at the beginning of the academic year as compared with any other quarter.

Data Source: A database analysis of 89,473 patients undergoing the 10 most common inpatient operative procedures from 2005 to 2007.

Disclosures: The authors had no disclosures deemed relevant to report by the journal.

“Don't have surgery in July!” This is the folk wisdom regarding the purported “July Phenomenon” – the perception that it is more dangerous to have an operation in July than at any other time of year. July heralds the onslaught of new interns; July also means that current residents are given additional duties and responsibility. “Why risk an operation in a month when trainee inexperience must surely dilute the quality of patient care?” is the intuitive assumption.

A recent study, however, showed that this concern is unfounded. Multivariate analysis indicated that only 1 out of the 10 most common surgical procedures (lower extremity artery bypass grafting) showed a significant increase in mortality concurrent with the so-called July Phenomenon (odds ratio, 1.34; P = .034). The researchers also found that there was no significant increase in serious adverse events (SAE) for any of the procedures (Surgery 2011;150:332-8).

The previous medical literature shows no consensus on the subject. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) suggested that greater rates of postsurgical problems were related to that time of year (Ann. Surg. 2007;246:456-62). In contrast, studies in obstetrics and neurology showed that no July Phenomenon existed, as did surgical studies in specialties including trauma, hediatric neurosurgery, and cardiac surgery, according to Dr. Bryan A. Ehlert and colleagues at East Carolina University, Greenville, N.C.

To investigate the issue in a broader surgical context, Dr. Ehlert and his colleagues studied the ACS-NSQIP database records of 89,473 patients who had the 10 most common inpatient operative procedures in 2005-2007. They compared 26,287 patients who had surgery in the July 1–Sept. 30 quarter (called the “first academic quarter,” or FAQ) with a control population of 63,186 patients who had equivalent surgery during the rest of the year (Oct. 1–June 30) for the following 10 procedures: appendectomy, (lower extremity) artery bypass graft, initial reducible ventral hernia repair, laparoscopic appendectomy, laparoscopic cholecystectomy, laparoscopic gastric bypass, partial colectomy, rechanneling of artery, repair of bowel opening, and small-bowel resection.

The two populations showed no significant differences in a wide variety of demographic characteristics including age (average, about 54 years); sex (about 45% male); and presence of coronary artery disease, renal disease, peripheral vascular disease (PVD/PAD), and diabetes. Slight but significant differences were found only in the presence of hypertension (50.0% in the FAQ group vs. 48.4% in controls, respectively) and history of smoking (24.0% vs. 23.4%). Especially important to the study, there was no significant difference in resident participation in patient care (72.7% vs. 73.0%) or the highest resident level in postgraduate year (2.6 years each).

“Although July might seem intuitively to be a precarious time to undergo an operation due to the influx of new interns and increased responsibilities of rising residents, our findings for the most part discount the presence of a 'July Phenomenon' in surgical patients,” the authors stated. Discrepancies between the previous ACS-NISQIP report and their findings were attributed to the much larger sample size in the current study (183 centers vs. 18).

They postulated that the lower extremity bypass graft FAQ group showed greater mortality than did the control group because the vascular subsets had a significantly greater modified Charlson comorbidity index, compared with the nonvascular subsets in the FAQ population (CCI, 3.72 vs. 1.56; P less than .001).

“New surgery interns may not be as adept at recognizing the needs of these patients who are often sicker. As a result, these patient populations may benefit from more senior residents and attending physician involvement as new interns learn how to manage patients with complex cardiovascular disease,” they suggested.

A weakness of the study reported by the authors is the crude estimate of patient outcomes, which focuses only on morbidity and mortality and does not include data on duration of stay, medication errors, or cost-effectiveness – all of which could possibly be affected by new interns. For example, they noted that new interns may be more likely to order more unnecessary laboratory tests, or they may fail to remove invasive devices or monitoring devices that are no longer needed, which may in turn lead to increased infections.

In addition, they also stated that interns may have more difficulties when confronted with rarer operations than the 10 most common procedures that were evaluated.

Despite similarities in patient outcomes, a short delay in the time of operating room availability for urgent cases was associated with significantly increased hospital costs in a retrospective study of patients undergoing appendectomy. The added costs were deemed likely due to hospital inefficiencies, according to the results published in the August issue of Surgery.

The study comprised 443 patients with acute appendicitis treated by appendectomy at a single institution between 2004 and 2009. Perforated or gangrenous appendicitis occurred in 13% of the patients, 4.9% had a pathologically normal appendicitis, and 24.5% of the patients underwent open appendectomy.

The patients had a mean age of 34.9 years, with an average gap time (the time from case booking to surgery start) of 224 minutes. The hypothesis was that operating room (OR) availability as measured by gap time would be related to total cost for hospitalization, according to Dr. Rajeev Dhupar and his colleagues at the University of Pittsburgh (Surgery 2011;150:299-305).

Patients were stratified with a cutoff gap time of 1, 2, 3, and 4 hours for final analysis. The average cost for patients with a gap time of less than 2 hours was $6,862 vs. $9,558 for a gap time of greater than 2 hours – a significant 39% difference. When costs were allocated to different services within the hospital, surgery and laboratory costs were statistically significant contributors to the difference.

The authors speculated that gap time is likely capturing a general difference in the efficiency of care for the patient associated with peak times in the use of the OR.

They found that patients with longer gap times had significantly longer surgery times and significantly higher costs of surgery ($3,657 at less than 2 hours’ gap time vs. $4,330 for greater than 2 hours) and laboratory costs ($294 vs. $469, respectively), with almost every other cost allocation trending higher. For example, costs for nursing were $1,138 vs. $1,495.

There was no significant difference in total length of stay with regard to gap time, "suggesting these incremental costs are in fact caused by hospital inefficiency rather than a difference in a duration of service," the researchers wrote.

They speculated that their "counterintuitive" findings that "peak times of OR activity are also the less efficient" could be because "although maximum daytime operating use might offset fixed costs in that single-cost center, this could be negated by a higher overall cost of care for urgent cases." They also speculated that this might also apply to elective cases and not just urgent ones.

"We anticipate that this finding for the care of appendicitis will hold true for most if not all urgent care cases. Such data might facilitate a true cost-benefit analysis that ultimately would drive hospital management toward optimal efficiency rather than optimal capacity," the researchers concluded.

Study limitations included the fact that costs are analyzed from the perspective of the hospital and do not reflect the direct cost to the payer. In addition, using total loaded hospital costs has significant limitations in truly representing the variable costs that can be allocated to an individual patient, according to the researchers.

The authors reported no disclosures relevant to the study as determined by the journal.

Despite similarities in patient outcomes, a short delay in the time of operating room availability for urgent cases was associated with significantly increased hospital costs in a retrospective study of patients undergoing appendectomy. The added costs were deemed likely due to hospital inefficiencies, according to the results published in the August issue of Surgery.

The study comprised 443 patients with acute appendicitis treated by appendectomy at a single institution between 2004 and 2009. Perforated or gangrenous appendicitis occurred in 13% of the patients, 4.9% had a pathologically normal appendicitis, and 24.5% of the patients underwent open appendectomy.

The patients had a mean age of 34.9 years, with an average gap time (the time from case booking to surgery start) of 224 minutes. The hypothesis was that operating room (OR) availability as measured by gap time would be related to total cost for hospitalization, according to Dr. Rajeev Dhupar and his colleagues at the University of Pittsburgh (Surgery 2011;150:299-305).

Patients were stratified with a cutoff gap time of 1, 2, 3, and 4 hours for final analysis. The average cost for patients with a gap time of less than 2 hours was $6,862 vs. $9,558 for a gap time of greater than 2 hours – a significant 39% difference. When costs were allocated to different services within the hospital, surgery and laboratory costs were statistically significant contributors to the difference.

The authors speculated that gap time is likely capturing a general difference in the efficiency of care for the patient associated with peak times in the use of the OR.

They found that patients with longer gap times had significantly longer surgery times and significantly higher costs of surgery ($3,657 at less than 2 hours’ gap time vs. $4,330 for greater than 2 hours) and laboratory costs ($294 vs. $469, respectively), with almost every other cost allocation trending higher. For example, costs for nursing were $1,138 vs. $1,495.

There was no significant difference in total length of stay with regard to gap time, "suggesting these incremental costs are in fact caused by hospital inefficiency rather than a difference in a duration of service," the researchers wrote.

They speculated that their "counterintuitive" findings that "peak times of OR activity are also the less efficient" could be because "although maximum daytime operating use might offset fixed costs in that single-cost center, this could be negated by a higher overall cost of care for urgent cases." They also speculated that this might also apply to elective cases and not just urgent ones.

"We anticipate that this finding for the care of appendicitis will hold true for most if not all urgent care cases. Such data might facilitate a true cost-benefit analysis that ultimately would drive hospital management toward optimal efficiency rather than optimal capacity," the researchers concluded.

Study limitations included the fact that costs are analyzed from the perspective of the hospital and do not reflect the direct cost to the payer. In addition, using total loaded hospital costs has significant limitations in truly representing the variable costs that can be allocated to an individual patient, according to the researchers.

The authors reported no disclosures relevant to the study as determined by the journal.

Despite similarities in patient outcomes, a short delay in the time of operating room availability for urgent cases was associated with significantly increased hospital costs in a retrospective study of patients undergoing appendectomy. The added costs were deemed likely due to hospital inefficiencies, according to the results published in the August issue of Surgery.

The study comprised 443 patients with acute appendicitis treated by appendectomy at a single institution between 2004 and 2009. Perforated or gangrenous appendicitis occurred in 13% of the patients, 4.9% had a pathologically normal appendicitis, and 24.5% of the patients underwent open appendectomy.

The patients had a mean age of 34.9 years, with an average gap time (the time from case booking to surgery start) of 224 minutes. The hypothesis was that operating room (OR) availability as measured by gap time would be related to total cost for hospitalization, according to Dr. Rajeev Dhupar and his colleagues at the University of Pittsburgh (Surgery 2011;150:299-305).

Patients were stratified with a cutoff gap time of 1, 2, 3, and 4 hours for final analysis. The average cost for patients with a gap time of less than 2 hours was $6,862 vs. $9,558 for a gap time of greater than 2 hours – a significant 39% difference. When costs were allocated to different services within the hospital, surgery and laboratory costs were statistically significant contributors to the difference.

The authors speculated that gap time is likely capturing a general difference in the efficiency of care for the patient associated with peak times in the use of the OR.

They found that patients with longer gap times had significantly longer surgery times and significantly higher costs of surgery ($3,657 at less than 2 hours’ gap time vs. $4,330 for greater than 2 hours) and laboratory costs ($294 vs. $469, respectively), with almost every other cost allocation trending higher. For example, costs for nursing were $1,138 vs. $1,495.

There was no significant difference in total length of stay with regard to gap time, "suggesting these incremental costs are in fact caused by hospital inefficiency rather than a difference in a duration of service," the researchers wrote.

They speculated that their "counterintuitive" findings that "peak times of OR activity are also the less efficient" could be because "although maximum daytime operating use might offset fixed costs in that single-cost center, this could be negated by a higher overall cost of care for urgent cases." They also speculated that this might also apply to elective cases and not just urgent ones.

"We anticipate that this finding for the care of appendicitis will hold true for most if not all urgent care cases. Such data might facilitate a true cost-benefit analysis that ultimately would drive hospital management toward optimal efficiency rather than optimal capacity," the researchers concluded.

Study limitations included the fact that costs are analyzed from the perspective of the hospital and do not reflect the direct cost to the payer. In addition, using total loaded hospital costs has significant limitations in truly representing the variable costs that can be allocated to an individual patient, according to the researchers.

The authors reported no disclosures relevant to the study as determined by the journal.