Surgery

Cover 1

2010-09-01

Hepatocyte nuclear factor-kappa β (NF-κB) activation is protective but is decreased in the cholestatic liver with endotoxemia

2010-03-15

Background: Obstructive jaundice (OJ) is an important clinical consideration associated with a high risk of bacteremia. Hepatocyte nuclear factor-kappa B (NF-κB) activation confers an antiapoptotic function. Although the occurrence of hepatocyte apoptosis has been shown in OJ, the activation and role of NF-κB over the time course of OJ in conjunction with endotoxemia have not yet been well defined. We hypothesized that NF-κB activation may be decreased over the time course of OJ and endotoxemia, which leads to severe liver injury. The aim of the current study was to examine whether NF-κB activation can decrease hepatocyte apoptosis and liver injury over the time course of OJ in response to lipopolysaccharide (LPS) administration.Methods: Male C57BL/6 mice were subjected to bile duct ligation and were administered LPS intravenously at 3 days (OJ3) or 14 days (OJ14) after bile duct ligation. NF-κB activation; protein expressions of NF-κB p65, IκB-α, Iκβ-b, and Pin1; immunohistochemistry of poly adenosine diphosphate (ADP)-ribose polymerase p85 fragment (PARP); and serum alanine transaminase (ALT) levels were examined.Results: Hepatocyte NF-κB activation was observed during OJ. After LPS administration, the hepatic NF-κB activation defined by electrophoretic mobility shift assay was decreased in the OJ14 group compared with the OJ3 group, which is consistent with a decrease in NF-κB p65 protein expression. Changes in phosphorylated Iκ-B-β but not phosphorylated IκB-α mirrored these results. Significant hepatocyte apoptosis defined by PARP immunohistochemistry was observed in the LPS-treated OJ14 relative to the LPS-treated OJ3. Hepatic expressions of tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6) in the LPS OJ14 mice were upregulated relative to those in the LPS OJ3. Serum ALT levels increased significantly in the LPS OJ14 relative to other mice. The survival rate was significantly less in the LPS OJ14 relative to other mice.Conclusion: After prolonged OJ, exposure to endotoxemia was associated with a decrease in hepatocyte NF-κB activation and an increase in hepatocyte apoptosis and secondary necrosis, thus resulting in liver dysfunction.

The role of interleukin-1β and platelet-derived growth factor-AB in antifibrosis mediated by native human interferon α

Goran Šantak, Maja Šantak, Dubravko Forčić — 2010-02-22

Background: Commercial preparations of native human interferon alpha (nHuIFN-α) contain several subtypes of interferon-alpha (IFN-α) and traces of other cytokines. Recently, we described its antifibrotic potential and showed nHuIFN-α to have a greater effect than that of recombinant human IFN-α (rHuIFN-α). We hypothesized that cooperation between different cytokines in the nHuIFN-α preparation is essential for this effect. Considerable concentrations of interleukin-1β (IL-1β) and platelet-derived growth factor AB (PDGF-AB) are present in the nHuIFN-α preparations.Methods: We tested the viability and the expression of procollagen type I messenger RNA (mRNA) in MRC5 fibroblasts treated with interleukin-1 beta (IL-1β) and/or PDGF-AB, or the corresponding antibodies in combination with rHuIFN-α or nHuIFN-α.Results: We showed that neither IL-1β nor PDGF-AB significantly affect the viability of MRC5 cells. Furthermore, cell viability was not affected when IL-1β or PDGF-AB were applied along with rHuIFN-α, relative to the viability of cells treated with rHuIFN-α only. In contrast, both cytokines suppressed the synthesis of procollagen type I mRNA. When coadministered with rHuIFN-α, IL-1β enhanced the suppression induced by rHuIFN-α. Conversely, PDGF-AB acted as an antagonist of rHuIFN-α and restored partially the synthesis of procollagen type I mRNA. Interestingly, the addition of IL-1β to the PDGF-AB/rHuIFN-α mix not only abolished the antagonistic activity of PDGF-AB but also decreased the synthesis of procollagen type I mRNA beyond the level achieved by IL-1β/rHuIFN-α. Therefore, IL-1β was able to reverse the activity of PDGF-AB.Conclusion: Our study suggests that IL-1β is an important component of nHuIFN-α preparations, acting directly and indirectly to modulate the action of other components. This study provides insight into these complex cytokine networks, which is necessary for better and safer antifibrotic therapy.

Topical nanoemulsion therapy reduces bacterial wound infection and inflammation after burn injury

2010-03-02

Background: Nanoemulsions are broadly antimicrobial oil-in-water emulsions containing nanometer-sized droplets stabilized with surfactants. We hypothesize that topical application of a nanoemulsion compound (NB-201) can attenuate burn wound infection. In addition to reducing infection, nanoemulsion therapy may modulate dermal inflammatory signaling and thereby lessen inflammation following thermal injury.Methods: Male Sprague-Dawley rats underwent a 20% total body surface area scald burn to create a partial-thickness burn injury. Animals were resuscitated with Ringer's lactate solution and the wound covered with an occlusive dressing. At 8 hours after injury, the burn wound was inoculated with 1 × 106 colony-forming units (CFUs) of Pseudomonas aeruginosa. NB-201, NB-201 placebo, 5% mafenide acetate solution, or 0.9% saline (control) was applied onto the wound at 16 and 24 hours after burn injury. Skin was harvested 32 hours postburn for quantitative wound culture and determination of inflammatory mediators in tissue homogenates.Results: NB-201 decreased mean bacterial growth in the burn wound by 1,000-fold, with only 13% (3/23) of animals having P. aeruginosa counts greater than 105 CFU/g tissue versus 91% (29/32) in the control group (P < .0001). Treatment with NB-201 attenuated neutrophil sequestration in the treatment group as measured by myeloperoxidase assay and by histology. It also significantly decreased levels of proinflammatory cytokines (interleukin [IL]-1β and IL-6) and the degree of hair follicle cell apoptosis in skin compared to saline-treated controls.Conclusion: Topical NB-201 substantially decreased bacterial growth in a partial-thickness burn model. This decrease in the level of wound infection was associated with an attenuation of the local dermal inflammatory response and diminished neutrophil sequestration. NB-201 represents a novel potent antimicrobial and anti-inflammatory treatment for use in burn wounds.

Medical students' perceptions on factors influencing a surgical career: The fate of general surgery in Greece

2010-03-12

Background: A decline of medical students' interest in a general surgery career is occurring in the Western medical world. We sought data on the mentality of Greek students toward specialty selection, and we determined whether trends indicated a decline in interest for general surgery in Greece.Methods: A structured questionnaire was distributed to 3 groups of medical students: to pre-4th-year (group 1) surgical clerkship, post-4th-year (group 2) surgical clerkship, and post-6th-year internship students in surgery (group 3). The questions covered a wide spectrum of data including career choices, influential factors, and satisfaction rates on educational and training issues.Results: From a total of 500 distributed questionnaires 363 were returned. Most students (63.1%) indicated preference toward nonsurgical (medical) specialties. Surgical specialties within the 3 groups gathered 19.5% (group 1), 26.5% (group 2) and 31.2% (group 3) preference rates. Among surgical specialties, general surgery was chosen by 29.4% in group 1, 10.0% in group 2, and 17.9% in group 3. The most common criterion for specialty selection was “quality of life” (68.6%) among group 1 students and “patient contact” for group 2 and group 3 students (77.3% and 65.3%, respectively). Among the 96 students who chose surgical specialties, the most common criterion for specialty selection was “scientific challenge” (100%) in group 1 and “patient contact” in groups 2 and 3 (62.5% and 69.2%, respectively). The 3 more frequently chosen factors that influenced the “picture” of surgery positively were attending live surgery cases in the operating room (37.6%), clinical experience (29.6%), and patient care (14.4%), followed by assisting in the operating room (8.8%).Conclusion: Our survey suggests a limited interest of Greek medical students for surgical specialties and general surgery in particular. As the medical curriculum is restructured, our data underscore the need for actions by surgical educators and medical school authorities so as to enhance the interest of medical students in general surgery in Greece.

Indeterminate thyroid nodules: A challenge for the surgical strategy

2010-03-25

Background: Because no clinical parameter can establish the final status of a cytologically indeterminate thyroid nodule (ITN) or nodal-metastases in case of malignancy, the initial surgical strategy should define an oncologically adequate procedure with low morbidity.Methods: The prognostic relevance of sex, age, tumor sizes, multifocality, thyroid function, and recurrence was analyzed in 156 consecutive patients according to the presence of malignancy and nodal metastases. The accuracy of frozen sections to reveal malignancy was determined. Clinical parameters were compared with regard to their ability to identify malignancy and nodal metastases in an ITN to determine an appropriate initial operative strategy.Results: One hundred and eighteen (75.6%) patients underwent (total) thyroidectomy, 37 (23.7%) patients underwent hemithyroidectomy, and 1 patient underwent isthmus resection. Fifty-five (35.3%) patients showed malignancy. First step lymphadenectomy (lymph node dissection along the recurrent laryngeal nerve before removing the thyroid lobe) was performed in 142 patients documenting 10 nodal metastases. Comparing benign and malignant ITN, no association was found for sex (P = .17), age (P = 1.0), tumor sizes (P = .33, P = .12, P = .19 for ≤30 mm, ≤40 mm, and ≤50 mm, respectively), or thyroid function (P = .26). The determination of malignancy by frozen section showed a sensitivity of 30.9% and a specificity of 100%. No permanent hypoparathyroidism or recurrent laryngeal nerve palsy was observed postoperatively.Conclusion: Because of the failure of available clinical parameters to predict malignancy in cytologically ITN, hemithyroidectomy in unilateral goiter and thyroidectomy in bilateral goiter is recommended. Ipsilateral “first step central neck dissection” on the side of ITN offers the advantages of oncologically adequate resection and staging with a low morbidity, as well as avoids reoperation.

Subclinical lymph node metastasis in papillary thyroid microcarcinoma: A study of 551 resections

2010-03-02

Background: In clinically node-negative papillary thyroid microcarcinoma (PTMC), the frequency of subclinical lymph node metastasis (LNM) in the central cervical compartment (subclinical central LNM) has been reported to be as great as 65%. Routine prophylactic central compartment lymph node dissection (CLND) has been debated, because the risk of operative complications might outweigh its prognostic benefit. We aimed to study clinicopathologic factors associated with subclinical central LNM to be considered for determination of prophylactic CLND.Methods: A total of 551 patients diagnosed with clinically node-negative PTMC from 2005 to 2009 were included. All patients underwent total thyroidectomy (TT) and prophylactic CLND. Clinicopathologic risk factors of subclinical central LNM were analyzed. In addition, we investigated recurrences and postoperative complications after TT and CLND.Results: Among the 551 patients, 202 (37%) had subclinical central LNM. On univariate and multivariate analyses, male gender, tumor multifocality, and extrathyroidal extension were independently predictive of subclinical central LNM. During 3-year follow-up, there were no recurrences in the central cervical compartment. The frequency of permanent hypocalcemia and permanent vocal fold palsy were 1.1% and 1.3%, respectively.Conclusion: Frequency of subclinical central LNM was high in PTMC. It was managed effectively with prophylactic CLND. In addition, prophylactic CLND did not cause significant permanent morbidities. We recommend that clinicopathologic features, such as male gender, tumor multifocality, and extrathyroidal extension, be considered for determination of prophylactic CLND in patients with PTMC.

Correlation between indeterminate aspiration cytology and final histopathology of thyroid neoplasms

2010-03-17

Background: Of all thyroid nodules assessed by fine needle aspiration cytology (FNAC), 10–20% are classified as indeterminate/atypical. Traditionally, this group is considered to primarily represent follicular neoplasia. We hypothesize that papillary carcinoma accounts for a significant proportion of lesions classified as “atypical” on FNAC.Methods: This retrospective study includes 228 patients who had an atypical FNAC result and who were subsequently found to have a malignancy on histologic examination of the excised thyroid lesion. Patients with papillary microcarcinomas, defined as lesions less than 10-mm diameter, were excluded. The study period was from 1987 to 2005. The patients were divided chronologically into 3 groups (n = 76) for analysis: group 1, December 1987–March 1997; group 2, July 1997–October 2002; and group 3, October 2002–December 2005.Results: Age- and sex-distribution of the 3 groups were not significantly different. Median nodule size of group 3 was significantly smaller. The distributions of histopathology of the 3 time periods were significantly different overall (P = .0325). Prevalence of papillary carcinoma was not statistically significant (33/76 vs 34/76 vs 46/76; P = .0636), but showed a statistical significant trend to increase over time (P = .0349). Prevalence of follicular variant papillary carcinoma was also found to be significantly different between the groups (7/76 vs 12/76 vs 19/76; P = .0320; P = .0349).Conclusion: Papillary carcinoma accounted for most histopathologically confirmed cancers that had an atypical cytology. Papillary cancer in this group of patients trended up, probably due to a significant increase in the diagnosis of follicular variant of papillary cancer.

Complicated hernia presentation in patients with advanced cirrhosis and refractory ascites: Management and outcome

Dana A. Telem, Thomas Schiano, Celia M. Divino — 2010-03-26

Background: Our purpose was to determine optimal management of and outcome after umbilical herniorrhaphy in patients with advanced cirrhosis and refractory ascites.Methods: A retrospective chart review was performed of 21 patients with advanced cirrhosis who underwent umbilical herniorrhaphy at The Mount Sinai Medical Center from 2002 to 2008. Univariate, multivariate, and Kaplan-Meier analysis was performed.Results: Twenty-one patients had refractory ascites: 15 presented with incarceration and 6 with spontaneous umbilical rupture. The mortality rate was 5% and morbidity rate 71%. Two patients required perioperative liver transplantation, and 5 developed ascites-related wound complications. Follow-up at a mean of 36 months demonstrated a 20% mortality rate due to liver disease; 5% required liver transplantation and 6% had a recurrent hernia. In addition to diuretics and albumin, perioperative management of ascites consisted of preoperative transjugular intrahepatic portosystemic shunt (TIPS; n = 6), postoperative TIPS (n = 2), and closed-suction drains (n = 7). The wound complication rate was 17% in patients who underwent preoperative TIPS versus 27% in patients who did not undergo preoperative TIPS (P = NS). TIPS placement postoperatively controlled ascites adequately without additional complication in 2 patients. In this series, use of closed-suction drains did not appear to decrease ascites-related complications. Spontaneous umbilical rupture was an independent risk factor for adverse outcome. For patients presenting with umbilical rupture, preoperative TIPS and semi-elective repair appeared to improve perioperative and 36-month outcome as compared with emergent repair.Conclusion: Preoperative TIPS in conjunction with semi-elective repair when feasible appears preferable, particularly for patients with spontaneous umbilical rupture. The lower than anticipated mortality rate was attributed to institutional experience and to the multidisciplinary approach to patient care.

Incisional ventral hernias: Review of the literature and recommendations regarding the grading and technique of repair

2010-03-22

Despite advances in surgical technique and prosthetic technologies, the risks for recurrence and infection are high following the repair of incisional ventral hernias. High-quality data suggest that all ventral hernia repairs should be reinforced with prosthetic repair materials. The current standard for reinforced hernia repair is synthetic mesh, which can reduce the risk for recurrence in many patients. However, permanent synthetic mesh can pose a serious clinical problem in the setting of infection. Assessing patients' risk for wound infection and other surgical-site occurrences, therefore, is an outstanding need. To our knowledge, there currently exists no consensus in the literature regarding the accurate assessment of risk of surgical-site occurrences in association with or the appropriate techniques for the repair of incisional ventral hernias. This article proposes a novel hernia grading system based on risk factor characteristics of the patient and the wound. Using this system, surgeons may better assess each patient's risk for surgical-site occurrences and thereby select the appropriate surgical technique, repair material, and overall clinical approach for the patient. A generalized approach and technical considerations for the repair of incisional ventral hernias are outlined, including the appropriate use of component separation and the growing role of biologic repair materials.

The intraoperative Surgical Apgar Score predicts postdischarge complications after colon and rectal resection

Scott E. Regenbogen, Liliana Bordeianou, Matthew M. Hutter, Atul A. Gawande — 2010-03-15

Background: We previously developed an intraoperative 10-point Surgical Apgar Score—based on blood loss, lowest heart rate, and lowest mean arterial pressure—to predict major complications after colorectal resection. However, because complications often arise after uncomplicated hospitalizations, we sought to evaluate whether this intraoperative metric would predict postdischarge complications after colectomy.Methods: We linked our institution's National Surgical Quality Improvement Program database with an Anesthesia Intraoperative Management System for all colorectal resections over 4 years. Using Chi-square trend tests and logistic regression, we evaluated the Surgical Apgar Score's prediction for major postoperative complications before and after discharge.Results: Among 795 colectomies, there were 230 (29%) major complications within 30 days; 45 (20%) after uncomplicated discharges. Surgical Apgar Scores predicted both inpatient complications and late postdischarge complications (both P < .0001). Late complications occurred from 0 to 27 (median, 11) days after discharge; the most common were surgical site infections (42%), sepsis (24%), and venous thromboembolism (16%). In pairwise comparisons against average-scoring patients (Surgical Apgar Scores, 7–8), the relative risk of postdischarge complications trended lower, to 0.6 (95% confidence interval [CI], 0.2–1.7) for those with the best scores (9–10); and were significantly higher, at 2.6 (95% CI, 1.4–4.9) for scores 5–6, and 4.5 (95% CI, 1.8–11.0) for scores 0–4.Conclusion: The intraoperative Surgical Apgar Score remained a useful metric for predicting postcolectomy complications arising after uncomplicated discharges. Even late complications may thus be related to intraoperative condition and events. Surgeons could use this intraoperative metric to target low-scoring patients for intensive postdischarge surveillance and mitigation of postdischarge complications after colectomy.

The antiendotoxin agent taurolidine potentially reduces ischemia/reperfusion injury through its metabolite taurine

2010-03-12

Background: Cardiopulmonary bypass results in ischemia/reperfusion (I/R)-induced endotoxemia. We conducted a prospective randomized trial to investigate the effect of taurolidine, an antiendotoxin agent with antioxidant and membrane-stabilizing properties, on patients undergoing coronary artery bypass grafting (CABG).Methods: A total of 60 patients undergoing CABG were randomized into 4 groups. St Thomas' Hospital cold crystalloid cardioplegia was used in groups A and B, and cold blood cardioplegia in groups C and D. Groups A and C received a placebo infusion of normal saline, whereas groups B and D were administered intravenous taurolidine. Arrhythmias induced by pro- and anti-inflammatory cytokines (interleukin [IL]-6 and IL-10), and I/R were assessed perioperatively.Results: Administration of taurolidine in crystalloid cardioplegia patients resulted in a significant decrease in serum IL-6 and an increase in serum IL-10 at 24 hours postaortic unclamping compared to placebo (P < .0001). Although not statistically significant, this trend in serum IL-6 decrease was mirrored in the blood cardioplegia patients (P = .068). Taurolidine treatment also significantly decreased I/R-induced arrhythmias compared to placebo in the crystalloid cardioplegia patients (P < .003). There were fewer I/R-induced arrhythmias compared to placebo in the blood cardioplegia patients; the difference, however, was marginal and not statistically significant (P = .583).Conclusion: This study demonstrates that administration of taurolidine in CABG patients induces a potent anti-inflammatory response that is associated with a significant decrease in arrhythmias.

Effects of perioperative immunonutrition on cell-mediated immunity, T helper type 1 (Th1)/Th2 differentiation, and Th17 response after pancreaticoduodenectomy

2010-03-15

Background: The mechanisms of immunonutrition on reducing infectious complications are still poorly understood. This prospective randomized study was designed to determine whether immunonutrition influences the following factors: cell-mediated immunity, differentiation of T helper type 1 (Th1) and Th2 cells, interleukin (IL)-17-producing CD4+ helper T (Th17) cell response, and infectious complication rate after pancreaticoduodenectomy.Methods: Thirty patients who underwent pancreaticoduodenectomy were divided into 3 groups. Ten patients in the perioperative group received immune-enhancing diets enriched with arginine, omega-3 fatty acids, and RNA for 5 days before operative resection, which was prolonged after operative resection by enteral infusion. Ten patients in the postoperative group received early postoperative enteral infusion of the same enriched formula with no artificial nutrition before operative resection. Ten patients in the control group received total parenteral nutrition postoperatively. The primary endpoint was immune responses; the secondary endpoint was the rate of infectious complications.Results: Concanavalin A (Con A)- or phytohemagglutinin (PHA)-stimulated lymphocyte proliferation and natural killer cell activity were significantly higher in the perioperative group than in the other groups. Messenger RNA (mRNA) expression levels of T-bet, interferon-γ (IFN-γ), related orphan receptor γt (RORγt), and interleukin-17F (IL-17F) were significantly higher in the perioperative group than in the other groups. In the perioperative group, the rate of infectious complications was significantly reduced compared with that in the other groups.Conclusion: Perioperative immunonutrition reduced stress-induced immunosuppression after a major stressful operative resection. The modulation of Th1/Th2 differentiation and Th17 response may play important roles in this immunologic effect.

Is impaired hepatic arterial buffer response a risk factor for biliary anastomotic stricture in liver transplant recipients?

2010-03-15

Background: Blood flow to the liver is partly maintained by the hepatic arterial buffer response (HABR), which is an intrinsic autoregulatory mechanism. Temporary clamping of the portal vein (PV) results in augmentation in hepatic artery flow (augHAF). Portal hyperperfusion impairs HAF due to the HABR in liver transplantation (LT). The aim of this study is to examine the effect of the HABR on biliary anastomotic stricture (BAS).Methods: In 234 cadaveric whole LTs, PV flow (PVF), basal HAF, and augHAF were measured intra-operatively after allograft implantation. All recipients with a vascular complication were excluded. Buffer capacity (BC) was calculated as (augHAF – basal HAF)/PVF to quantify the HABR. Recipients were divided into 2 groups based on their BC: low BC (<0.074; n = 117) or high BC (≥0.074; n = 117).Results: Of the 234 recipients, 23 (9.8%) had early BAS (≤60 days after LT) and 18 (7.7%) had late BAS (>60 days after LT). The incidence of late BAS and bile leakage was similar between the groups; however, the incidence of early BAS in the low BC group was greater than that in the high BC group (15% vs 5.1%; P = .0168). In the multivariate analysis, low BC (P = .0325) and bile leakage (P = .0002) were found to be independent risk factors affecting early BAS.Conclusion: Recipients with low BC who may have impaired HABR are at greater risk of early BAS after LT. Intraoperative measurements of blood flow help predict the risk of BAS.

Evaluation of a pediatric protocol of intrapleural urokinase for pleural empyema: A prospective study

Giorgio Stefanutti, Vittorina Ghirardo, Angelo Barbato, Piergiorgio Gamba — 2010-03-22

Background: Intrapleural urokinase has been shown to be effective in the treatment of pleural effusions in children. However, optimal dosing in children is debated. The aim of this study was to prospectively evaluate a specific pediatric protocol of intrapleural urokinase.Methods: All children admitted to a single institution over a 6-year period with a diagnosis of pleural empyema were managed with chest tube and fibrinolytics. Clinical data were collected prospectively. Urokinase (56,000 IU in 56 mL saline/m2 body surface) was administered twice daily, and was continued until resolution of the effusion. Further operative treatment was considered if urokinase treatment was unsuccessful after ≥3 days. Results are shown as median values (interquartile range).Results: Forty-one consecutive children aged 4.4 (3.2–6.9) years were included in the study, and received 420,000 (280,000–750,000) IU of urokinase over 7 (4–8) days. Suction through the chest drain was applied for 8 (6-10) days, and IV antibiotics were discontinued after 12 (10–15) days from the start of intrapleural fibrinolytics. Four children (9.8%) required 5 additional operative procedures (3 thoracoscopic debridements and 2 minithoracotomic debridements). Patients were discharged after 13 (11–16) days from the beginning of intrapleural urokinase. No major side effects attributable to urokinase were observed.Conclusion: Intrapleural instillation of urokinase according to a specific pediatric protocol results in a high success rate when applied as a primary treatment in children with pleural empyema. Administration of a size-adjusted dose of urokinase proved to be safe and could optimize drug utilization.

The first (and second) craniofacial operation at the Johns Hopkins Hospital: The case of the flying rib!

Michael G. Sarr — 2010-07-12

It was a huge deal—the first craniofacial case to be performed at the Johns Hopkins Hospital. The time was 1976 (or maybe 1977), and everyone was incredibly excited—nurses, residents, plastic surgery staff, the leadership of the Department of Surgery, the leadership of the hospital, and, of course, me as the young, naïve intern. This practice was to be the start of a new era in pediatric craniofacial reconstructive surgery at the Johns Hopkins Hospital.

Banding in Bangkok, CABG in Calcutta: The United States physician and the growing field of medical tourism

Elliott Mark Weiss, Peter F. Spataro, Ira J. Kodner, Jason D. Keune — 2010-09-01

Through joint sponsorship with the American College of Surgeons, the quarterly Ethics articles published by SURGERY will now offer the reader the option of earning 1 CME credit per article. These articles can be used to earn credit for three years from the time of publication.

Weathering a “perfect storm” in surgical education

Scott E. Regenbogen — 2010-09-01

In June, I graduated from the Massachusetts General Hospital (MGH) surgical residency program as a member of the first class to carry the stigma of a program on probation. As an intern, my work hours were regulated, not by national accrediting agencies, but rather by the demands of senior residents, the needs of patients, and my own crippling fear of something going wrong on my watch. The chief resident of the East and West surgical services—a sixth-year “super-chief”—was one of the most respected physicians in the hospital. And resident independence on the ward service was practically sacrosanct. My objective as an intern was, more than anything, to do whatever it would take to, eventually, at the end of this road, be as good as the senior residents I looked up to from the start.

Surgical residency, class of 2010: The kids are all right

Andrew J. Meltzer — 2010-09-01

The Massachusetts General Hospital (MGH) surgery class of 2010 has the dubious distinction of being the first class to complete the surgical residency program (“The Program”) under the Accreditation Council on Graduate Medical Education (ACGME) duty hour restrictions, colloquially known as the “80-hour work week.” It is likely that many among this publication's readership will consider this class, and all subsequent alumni, to be graduates of a modified and less challenging surgical training program. Some may even suggest that future certificates of completion and curriculum vitae should designate our trifling accomplishment in some special manner—an asterisk, for example, as proposed for the Roger Maris(∗) or Barry Bonds(∗) records. Alternatively, it would be very much in line with The (MGH) Program's New England heritage to embellish our short, white jackets with a scarlet “80” to remind all witnesses of our sins. Whichever method is chosen, we alumni of The Program can agree that some distinction must be made. After all, it is abundantly clear that the residents are not what they used to be. (I will ignore, for now, former Program Director Charlie Ferguson's rejoinder: “That's okay; neither is the staff.”)

Identification of traumatic, right-sided diaphragm rupture in a patient with newly diagnosed situs inversus

A. Britton Christmas, Brittany N. Knick, Amirreza T. Motameni, William S. Miles — 2009-06-10

This section features outstanding photographs of clinical materials selected for their educational value or message, or possibly their rarity. The images are accompanied by brief case reports (limit 2 typed pages, 4 references). Our readers are invited to sumit items for consideration.

Endoscopic therapy as a first-line therapy for pancreatic-pleural fistula

Deepak Kumar Bhasin, Surinder Singh Rana — 2010-09-01

To the Editors: We read with interest the case report and review of literature by King et al on the management of pancreatic-pleural fistula. The authors concluded that prolonged periods of medical therapy tend to delay the resolution of the fistula, and that operative treatment is successful more often than prolonged medical therapy. We agree with the authors that prolonged medical therapy involving suppression of pancreatic secretion by nil-per-oral, proton pump inhibitors, somatostatin or its analogs, and parenteral nutrition is expensive and has variable results. These fistulae have been managed traditionally operatively, but recent advances in endoscopic interventions have revolutionized the management of pancreatic fistulae. The endoscopic transpapillary stent or nasopancreatic drain (NPD) placement has shown excellent results in treatment of pancreatic-pleural fistula.

Response to “Endoscopic therapy as a first-line therapy for pancreatic-pleural fistula”

Jonathan C. King, Howard A. Reber, O. Joe Hines — 2010-09-01

To the Editors: We thank Bhasin and Rana for their thoughts and highlight of their 6 patients with pancreatic-pleural fistula. Their experience with nasopancreatic drainage (NPD) to treat pancreatic ductal disruptions resulting in both pancreatic ascites and pancreatic-pleural fistula is extensive considering the relative rarity of the pathology. It is impressive that in each of their patients with pancreatic-pleural fistula resolved without any surgical procedures and with minimal morbidity, no deaths, and no recurrences. This is particularly impressive considering the morbidity and mortality reported in our review of the literature (16% morbidity, 3% mortality for all comers). These figures highlight the fact that patients with pancreatic-pleural fistula are typically quite ill at the time of presentation, often with significant comorbidities that complicate their acute illness.

One hundred and seven family members with the rearranged during transfection V804M proto-oncogene mutation presenting with simultaneous medullary and papillary thyroid carcinomas, rare primary hyperparathyroidism, and no pheochromocytomas: Is this a new syndrome–MEN 2C?

P.R.K. Bhargav — 2010-09-01

To the Editors: Shifrin et al have done a commendable job in bringing out this paper. The idea of MEN 2C syndrome for the phenotypic features in your study is welcome. I have a few queries and comments to put forth. First, it is not clear from your methods if an annual calcitonin assay was done in RET-positive but nonoperated cases? Second, what was your follow-up protocol and results with regard to hypercalcitoninemia and recurrences? Third, the phenomenon of genetic anticipation is interesting. In spite of variation in time of diagnosis, the clinical presentation of medullary thyroid cancer (MTC) at an elderly age as late as 75 years is untenable as the person may rarely survive from MTC till then. Fourth, if papillary thyroid cancer (PTC) is proved to be a phenotypic component of this proposed syndrome, it will further strengthen the case for prophylactic thyroidectomy. Last, it is unique that PTC secondary to ret-PTC rearrangements coexisting with gain of function RET mutations in MTC occurs as in other syndromes like Carney's complex, Werner's syndrome, and McCune-Albright syndrome with their own complex genetics. In the future, RET mutation registries may unfold more well-defined mutation-specific syndromes with distinct phenotypic features.

One hundred and seven member family with the rearranged during transfection V804M proto-oncogene mutation presenting with simultaneous medullary and papillary thyroid carcinomas, rare primary hyperparathyroidism, and no pheochromocytomas: Is this a new syndrome–MEN 2C?

Alexander L. Shifrin, Angela M. Fay, Cristina Z. Xenachis, Jerome J. Vernick — 2010-09-01

To the Editors: We would like to thank Dr Bhargav for his interest in our paper and his good questions and observations. First, we would like to clarify our protocol. The majority of the family members that we discussed were diagnosed within 2 years prior to submission of this report. All patients were followed by an endocrinologist or endocrine surgeon and were tested with calcitonin assay at the time of their first evaluation along with RET testing.

2010-09-01

Surgery

Cover 1

Hepatocyte nuclear factor-kappa β (NF-κB) activation is protective but is decreased in the cholestatic liver with endotoxemia

The role of interleukin-1β and platelet-derived growth factor-AB in antifibrosis mediated by native human interferon α

Topical nanoemulsion therapy reduces bacterial wound infection and inflammation after burn injury

Medical students' perceptions on factors influencing a surgical career: The fate of general surgery in Greece

Indeterminate thyroid nodules: A challenge for the surgical strategy

Subclinical lymph node metastasis in papillary thyroid microcarcinoma: A study of 551 resections

Correlation between indeterminate aspiration cytology and final histopathology of thyroid neoplasms

Complicated hernia presentation in patients with advanced cirrhosis and refractory ascites: Management and outcome

Incisional ventral hernias: Review of the literature and recommendations regarding the grading and technique of repair

The intraoperative Surgical Apgar Score predicts postdischarge complications after colon and rectal resection

The antiendotoxin agent taurolidine potentially reduces ischemia/reperfusion injury through its metabolite taurine

Effects of perioperative immunonutrition on cell-mediated immunity, T helper type 1 (Th1)/Th2 differentiation, and Th17 response after pancreaticoduodenectomy

Is impaired hepatic arterial buffer response a risk factor for biliary anastomotic stricture in liver transplant recipients?

Evaluation of a pediatric protocol of intrapleural urokinase for pleural empyema: A prospective study

The first (and second) craniofacial operation at the Johns Hopkins Hospital: The case of the flying rib!

Banding in Bangkok, CABG in Calcutta: The United States physician and the growing field of medical tourism

Weathering a “perfect storm” in surgical education

Surgical residency, class of 2010: The kids are all right

Identification of traumatic, right-sided diaphragm rupture in a patient with newly diagnosed situs inversus

Endoscopic therapy as a first-line therapy for pancreatic-pleural fistula

Response to “Endoscopic therapy as a first-line therapy for pancreatic-pleural fistula”

One hundred and seven family members with the rearranged during transfection V804M proto-oncogene mutation presenting with simultaneous medullary and papillary thyroid carcinomas, rare primary hyperparathyroidism, and no pheochromocytomas: Is this a new syndrome–MEN 2C?

One hundred and seven member family with the rearranged during transfection V804M proto-oncogene mutation presenting with simultaneous medullary and papillary thyroid carcinomas, rare primary hyperparathyroidism, and no pheochromocytomas: Is this a new syndrome–MEN 2C?

Table of Contents