Surgery - Articles in Press

The unsolved mystery of Johann Georg Wirsung and of (his?) pancreatic duct - Corrected Proof

Claudio Bassi, Giuseppe Malleo — 2010-09-02

Many centuries have passed, and much has been written about the controversial discovery of the pancreatic duct by Johann Georg Wirsung. His brutal death was even more mysterious, the truth being almost certainly blown away in the alleys of Renaissance Padua.

FAST scan: Is it worth doing in hemodynamically stable blunt trauma patients? - Corrected Proof

2010-08-30

Background: During the last decade, focused assessment with sonography for trauma increasingly has become the initial diagnostic modality of choice in trauma patients. It is still questionable, however, whether its use results in the underdiagnosis of intra-abdominal injury. It also remains doubtful whether a positive focused assessment with sonography for trauma affects clinical decision making in hemodynamically stable blunt trauma patients as evidenced through abdominal computerized tomography use. The aim of this study was to evaluate the results of focused assessment with sonography for trauma in hemodynamically stable blunt trauma patients and to determine its role in the diagnostic evaluation of these patients.Methods: We reviewed our prospectively maintained trauma database. In trauma patients at our institute, focused assessment with sonography for trauma examinations are performed by surgery residents and are considered positive when free intra-abdominal fluid is visualized. Abdominal computerized tomography, diagnostic peritoneal lavage, or exploratory laparotomy findings were used as confirmation of intra-abdominal injury.Results: In our 7-year study period, 2,980 trauma patients were evaluated at our institute, of which 2,130 patients underwent a focused assessment with sonography for trauma. In all, 18 patients had an inconclusive focused assessment with sonography for trauma, whereas 7 patients died on arrival, leaving 2,105 patients for our analysis. A total 88 true positive focused assessment with sonography for trauma were conducted. All hemodynamically stable blunt trauma patients who had a positive focused assessment with sonography for trauma (70/88) were confirmed by computerized tomography. Patients who underwent exploratory laparotomy directly (17/88) or diagnostic peritoneal lavage (1/88) as confirmation either had penetrating trauma or became hemodynamically unstable. A total of 1,894 true negative focused assessments with sonography for trauma scans were conducted, with 1,201 confirmed by computerized tomography and the rest by observation. In all, 118 false negative focused assessment with sonography for trauma were performed, of which 44 (37.3%) subsequently required exploratory laparotomy. Five patients had false positive focused assessment with sonography for trauma scans. Focused assessment with sonography for trauma scan had an overall sensitivity of 43%, a specificity of 99%, and positive and negative predictive values of 95% and 94%, respectively. Accuracy was 94.1%. In the hemodynamically stable blunt trauma group, there were 60 patients with true positive focused assessment with sonography for trauma examinations and 87 patients with false negative focused assessment with sonography for trauma examinations. In this group of patients, focused assessment with sonography for trauma had a sensitivity of 41%, specificity of 99%, and positive and negative predictive values of 94% and 95%, respectively. The overall accuracy was 95%.Conclusion: Given the low sensitivity, a negative focused assessment with sonography for trauma without confirmation by computerized tomography may result in missed intra-abdominal injuries. It is also observed in all focused assessment with sonography for trauma positive hemodynamically stable blunt trauma patients, confirmation is preferred through the use of a computerized tomography for better understanding of the intra-abdominal injuries and to decide on operative versus no-operative management. Thus, the use of focused assessment with sonography for trauma in hemodynamically stable blunt trauma patients seems not worthwhile. It should be reserved for hemodynamically unstable patients with blunt trauma.

Impact of anastomotic leak on outcomes after transhiatal esophagectomy - Corrected Proof

2010-08-30

Background: The development of anastomotic leaks and/or strictures can be associated with considerable morbidity and impairment of quality of life. In the current study, we evaluated the outcomes of patients who developed anastomotic complications after esophagectomy to elucidate the impact of these events on morbidity, mortality, and subsequent need for dilation.Methods: We analyzed retrospectively the clinical course of 235 patients who underwent transhiatal esophagectomy for cancer from 2001 to 2009. Patients with confirmed anastomotic leaks were identified and classified with the following scale: class 1: Radiographic leak only, no intervention; class 2: leak requiring opening of the wound, cervical and/or percutaneous drainage; class 3: disruption of anastomosis (10–50% circumference) with perianastomotic abscess requiring video-assisted thoracoscopic surgery or thoracotomy; and class 4: gastric tip necrosis with anastomotic separation (>50% circumference).Results: Anastomotic leaks were encountered in 30 patients (13%). Anastomotic leaks were associated with greater morbidity (70% vs 47%; P = .02) and stricture formation (57% vs 19%; P = .0001). Mortality was not different. Increasing leak class was associated with an increased need for postoperative anastomotic dilations (P = .016).Conclusion: Anastomotic integrity after esophagectomy has a substantial impact on perioperative course and long-term swallowing. A more formal radiographic and endoscopic leak classification system seems justified.

Parathyroidectomy for hypercalcemic crisis: 40 years' experience and long-term outcomes - Corrected Proof

Jennifer Cannon, John I. Lew, Carmen C. Solórzano — 2010-08-30

Background: Hypercalcemic crisis is a serious and potentially life-threatening complication of markedly increased serum calcium concentrations most commonly due to severe primary sporadic hyperparathyroidism (HPT).Methods: A review of 1,310 consecutive patients with severe sporadic HPT who underwent parathyroidectomy at a single institution from April 1970 through July 2009 was performed. Of this series, 88 patients were treated operatively for hypercalcemic crisis associated with signs and symptoms of acute calcium intoxication and/or serum calcium concentrations ≥14 mg/dL (3.5 mmol/L). Clinical presentation, laboratory values, operative success, operative failure, and disease recurrence were compared to noncrisis patients.Results: Preoperative calcium and parathyroid hormone (PTH) concentrations were significantly greater among patients with hypercalcemic crisis. Crisis patients had a greater incidence of mental status changes, fatigue, ectopic glands, and pancreatitis. Postoperatively, calcium and PTH levels were similar. Overall, crisis patients had a lesser rate of operative success compared to noncrisis patients (92% vs 97%). With the advent of intraoperative PTH monitoring–guided focused parathyroidectomy in 1993, success rates equalized (95% vs 97%). There was no difference in disease recurrence. Overall follow-up was 59 months.Conclusion: Hypercalcemic crisis patients are appropriately treated by expeditious parathyroidectomy, but overall have slightly lesser rates of initial operative success than noncrisis patients. Long-term results reveal similar serum calcium, PTH concentrations, and recurrence rates at a mean follow-up of nearly 5 years.

Surveillance after surgical treatment of melanoma: Futility of routine chest radiography - Corrected Proof

2010-08-30

Background: Current recommendations by the National Comprehensive Cancer Network and other groups suggest that follow-up of cutaneous melanoma may include chest radiography (CXR) at 6- to 12-month intervals. The aim of this study was to determine the clinical efficacy of routine CXR for recurrence surveillance in melanoma.Methods: Post hoc analysis was performed on data from a prospective, randomized, multi-institutional study on melanoma ≥1.0 mm in Breslow thickness. All patients underwent excision of the primary melanoma and sentinel node biopsy with completion lymphadenectomy for positive sentinel nodes. Yearly CXR and clinical assessments were obtained during follow-up. Results of routine CXR were compared with clinical disease states over the course of the study.Results: A total of 1,235 patients were included in the analysis over a median follow-up of 74 months (range, 12–138). Overall, 210 patients (17.0%) had a recurrence, most commonly local or in-transit. Review of CXR results showed that 4,218 CXR were obtained in 1,235 patients either before, or in the absence of, initial recurrence. To date, 88% (n = 3,722) CXR are associated with no evidence of recurrence. Of CXR associated with recurrence, only 7.7% (n = 38) of surveillance CXR were read as “abnormal.” Overall, 99% (n = 4,180) of CXR were read as either “normal” or found to be falsely positive (read as “abnormal,” but without evidence of recurrence on investigation). Only 0.9% (n = 38) of all CXR obtained were true positives (“abnormal” CXR, with confirmed first known recurrence). Among these 38 patients with true positive CXR, 35 revealed widely disseminated disease (multiorgan or bilateral pulmonary metastases); only 3 (0.2%) had isolated pulmonary metastases amenable to resection. Sensitivity and specificity for surveillance CXR in detecting initial recurrence were 7.7% and 96.5%, respectively.Conclusion: The routine use of surveillance CXR provides no clinically useful information in the follow-up of patients with melanoma. CXR does not detect recurrence at levels sufficient to justify its routine use and, therefore, cannot be recommended as part of the standard surveillance regimen for these patients.

Multicenter analysis of diaphragm pacing in tetraplegics with cardiac pacemakers: Positive implications for ventilator weaning in intensive care units - Corrected Proof

2010-08-27

Background: Diaphragm pacing (DP) can replace mechanical ventilation in tetraplegics and in trials has assisted respiration in amyotrophic lateral sclerosis patients. This report describes results of DP in patients with cardiac pacemakers.Methods: Prospective, single-center and multicenter, nonrandomized, controlled, interventional protocols under U.S. Food and Drug Administration and/or institutional review board approval were evaluated. Patients underwent laparoscopic diaphragm motor point mapping to identify optimal electrode site for implantation. With diaphragm conditioning, patients were weaned from their ventilator. Perioperative and long-term assessments between the cardiac pacemakers and DP were analyzed for any device-to-device interactions.Results: Over 300 subjects were implanted from 2000 to 2010. Twenty tetraplegics with cardiac pacemakers and DP were analyzed from 6 sites. Subjects ranged from 19 to 61 years old with DP implantation 6 months to 24 years postinjury. There were no immediate or long-term device to device interactions. All patients achieved diaphragm-paced tidal volumes exceeding their basal requirements and, after conditioning, all patients could go >4 hours without mechanical ventilators; 71% could go 24 hours continuously.Conclusion: DP can be safely implanted in tetraplegics having cardiac pacemakers. Applications for temporary use of DP to maintain diaphragm type 1 muscle fiber and improve posterior lobe ventilation may benefit complex critical care patients.

Pancreatic cyst aspiration analysis for cystic neoplasms: Mucin or carcinoembryonic antigen—Which is better? - Corrected Proof

2010-08-27

Background: Differentiation between the various pathologies presenting as a cystic pancreatic lesion is clinically important but often challenging. We have previously advocated the performance of endoscopic ultrasound (EUS) with aspiration and determination of mucin and carcinoembryonic antigen (CEA) content. We sought to report the results of this ongoing protocol and determine the relative importance of cyst fluid mucin and CEA for the diagnostic process.Methods: The institutions prospectively maintained pancreatic cyst database was accessed to identify patients who had undergone pancreatic EUS and cyst aspiration as part of their evaluation. Only those patients who had subsequently undergone resection were selected, with histopathology being the gold standard for comparison.Results: From January 2000 to July 2009, 174 patients with pancreatic cystic disease underwent surgery, 121 of whom had an EUS with aspiration attempted at our institution with specimens sent for mucin and CEA. Based on histopathology, 86 mucinous lesions were identified, including 44 cystadenomas, 34 intraductal papillary mucinous neoplasms, 7 mucinous adenocarcinomas, and 1 intraductal oncocytic papillary neoplasm; 42 were nonmucinous lesions. The median cyst CEA levels were significantly higher in the mucinous lesions group at 850 versus 2 ng/mL (P = .001). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive diagnostic likelihood ratio, and negative diagnostic likelihood ratio (NDLR) were calculated respectively for mucin alone (0.80, 0.40, 0.61, 0.63, 1.33, 0.68); CEA alone (0.93, 0.43, 0.51, 0.91, 1.63, 0.16); cytology alone (0.38, 0.9, 0.92, 0.31, 3.67, 0.69); mucin or CEA (0.83, 0.65, 0.87, 0.57, 2.51, 0.26); mucin or CEA or cytology (0.92, 0.52, 0.86, 0.68, 1.91, 0.15); mucin plus CEA (0.96, 0.34, 0.25, 0.97, 1.45, 0.12); mucin plus cytology (0.25, 0.97, 0.96, 0.29,7.25, 0.78); CEA plus cytology (0.12, 1.00, 1.00, 0.26, ∞, 0.88); and mucin plus CEA plus cytology (0.08, 1.00, 1.00, 0.25, ∞, 0.92).Conclusion: Assessment of cyst mucin and CEA are complementary, with the best profile obtained when both markers are determined along with cytology. This combination provides a good sensitivity, PPV, and NDLR, as well as reasonable PPV and PDNR.

Comparison of outcomes after laparoscopic versus open appendectomy for acute appendicitis at 222 ACS NSQIP hospitals - Corrected Proof

2010-08-27

Background: The benefit of laparoscopic (LA) versus open (OA) appendectomy, particularly for complicated appendicitis, remains unclear. Our objectives were to assess 30-day outcomes after LA versus OA for acute appendicitis and complicated appendicitis, determine the incidence of specific outcomes after appendectomy, and examine factors influencing the utilization and duration of the operative approach with multi-institutional clinical data.Methods: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database (2005–2008), patients were identified who underwent emergency appendectomy for acute appendicitis at 222 participating hospitals. Regression models, which included propensity score adjustment to minimize the influence of treatment selection bias, were constructed. Models assessed the association between surgical approach (LA vs OA) and risk-adjusted overall morbidity, surgical site infection (SSI), serious morbidity, and serious morbidity/mortality, as well as individual complications in patients with acute appendicitis and complicated appendicitis. The relationships between operative approach, operative duration, and extended duration of stay with hospital academic affiliation were also examined.Results: Of 32,683 patients, 24,969 (76.4%) underwent LA and 7,714 (23.6%) underwent OA. Patients who underwent OA were significantly older with more comorbidities compared with those who underwent LA. Patients treated with LA were less likely to experience an overall morbidity (4.5% vs 8.8%; odds ratio [OR], 0.60; 95% confidence interval [CI], 0.54–0.68) or a SSI (3.3% vs 6.7%; OR, 0.57; 95% CI, 0.50–0.65) but not a serious morbidity (2.6% vs 4.2%; OR, 0.86; 95% CI, 0.74–1.01) or a serious morbidity/mortality (2.6% vs 4.3%; OR, 0.87; 95% CI, 0.74–1.01) compared with those who underwent OA. All patients treated with LA were significantly less likely to develop individual infectious complications except for organ space SSI. Among patients with complicated appendicitis, organ space SSI was significantly more common after laparoscopic appendectomy (6.3% vs 4.8%; OR, 1.35; 95% CI, 1.05–1.73). For all patients with acute appendicitis, those treated at academic-affiliated versus community hospitals were equally likely to undergo LA versus OA (77.0% vs 77.3%; P = .58). Operative duration at academic centers was significantly longer for both LA and OA (LA, 47 vs 38 minutes [P < .0001]; OA, 49 vs 44 minutes [P < .0001]). Median duration of stay after LA was 1 day at both academic-affiliated and community hospitals.Conclusion: Within ACS NSQIP hospitals, LA is associated with lower overall morbidity in selected patients. However, patients with complicated appendicitis may have a greater risk of organ space SSI after LA. Academic affiliation does not seem to influence the operative approach. However, LA is associated with similar durations of stay but slightly greater operative times than OA at academic versus community hospitals.

Industrial relations with academic health care and professional medical associations: What's all the fuss? Who cares anyway? - Corrected Proof

William Turnipseed — 2010-08-27

The health care system in our country is experiencing increased scrutiny as political efforts of reform are coupled with ethical questions of propriety regarding relationships between biomedical industries, academic health centers, and professional medical associations. One of the core issues in both political and ethical arenas is cost control and how to allocate monies to cover patient care and medical education, as well as research and development in an equitable, transparent, and unbiased manner. Another problem is the apparent breach of integrity in the relationship between the health care system and industry. Intentional deception, off-label marketing, failure to publish untoward results, and huge salaries to surrogate physicians exposed in criminal prosecution by government and state agencies have fostered a stormy debate within the medical profession itself, altered policy within professional associations, and restructured physician interaction with the biomedical industry. These revelations have fostered congressional passage of the “Sunshine Act,” which mandates financial disclosure for medical professionals involved in research and development activities with industry as part of the recently enacted health care reform act.

Robotic distal pancreatectomy: Cost effective? - Corrected Proof

2010-08-27

Background: Minimally invasive techniques and even robotics in pancreaticobiliary surgery are being used increasingly. Cost-effectiveness is a practical burden associated with the introduction of surgical innovation. This study compares the costs and the outcomes of open, laparoscopic, and robotic distal pancreatectomies. We hypothesized that robotic distal pancreatectomy is cost-effective.Methods: Between August 2008 and August 2009, 77 distal pancreatectomies were performed at a single academic medical center. A retrospective analysis of prospectively collected data on demographics, short-term outcomes, and direct cost was performed.Results: Thirty-two open distal pancreatectomies, 28 laparoscopic distal pancreatectomies, and 17 robotic distal pancreatectomies were performed. Age, American Society of Anesthesia preoperative risk score, and specimen length were similar. Indications for laparoscopic distal pancreatectomies and robotic distal pancreatectomies included more cystic neoplasms (49%) and fewer malignancies (29%) versus open distal pancreatectomies (16% and 47%). Spleen preservation occurred in 65% robotic distal pancreatectomies versus 12% and 29% in open distal pancreatectomies and laparoscopic distal pancreatectomies (P < .05). The operative time averaged 298 minutes in robotic distal pancreatectomies versus 245 and 222 minutes in open distal pancreatectomies and laparoscopic distal pancreatectomies (P < .05). Blood loss and morbidity were similar with no mortality. The length of stay was 4 days in robotic distal pancreatectomies versus 8 and 6 in open distal pancreatectomies and laparoscopic distal pancreatectomies (P < .05). The total cost was $10,588 in robotic distal pancreatectomies versus $16,059 and $12,986 in open distal pancreatectomies and laparoscopic distal pancreatectomies.Conclusion: These data suggest direct hospital costs are comparable among all groups. They suggest a shorter length of stay in robotic versus laparoscopic or open approaches. Finally, spleen and vessel preservation rates may improve with a robotic approach at the expense of increased operative time. In summary, robotic distal pancreatectomy is safe and cost effective in selected cases.

Pancreatic surgery: Evolution at a high-volume center - Corrected Proof

2010-08-27

Background: Advances in imaging, minimally invasive techniques, and regionalization have changed pancreatic surgery. Therefore, the aims of this report are to determine whether the pancreatic operations or the spectrum of disease have evolved at a high-volume center.Methods: From 1996 through 2009, 2,004 pancreatic operations were performed at Indiana University Hospital. The operations, pathology, and outcomes for 1996–2003 were compared with 2004–2009.Results: In 2004–2009, more operations/year were performed (215 vs 89; P < .01) and patients were older (58.8 years vs 55.8 years; P < .01). In recent years, more pancreatoduodenectomies (55.0% vs 50.4%) and fewer pancreatojejunostomies (6.2% vs 12.6%) and Beger/Frey procedures (2.6% vs 4.8%) were performed (P < .05). In 2004–2009, pylorus preservation (81.1% vs 64.4%), laparoscopic distal pancreatectomy (33.9% vs 0%), and splenic preservation (25.3% vs 2.2%) were carried out more frequently (P < .001). Pathology review revealed more tumors (68.8% vs 60.4%) and less pancreatitis (29.2% vs 34.4%; P < .01). Thirty-day mortality improved from 2.5% to 1.8%.Conclusion: At a high-volume pancreatic surgery center, the number and age of the patients, the percentage of pancreatic resections, preservation of the pylorus and spleen as well as laparoscopic procedures, and the percentage of patients with tumors all have increased, whereas the outcomes continued to improve.

Expression of the Sonic Hedgehog pathway molecules in synchronous follicular adenoma and papillary carcinoma of the thyroid gland in predicting malignancy - Corrected Proof

Kirbylee K. Nelson, Paolo Gattuso, Xiulong Xu, Richard A. Prinz — 2010-08-27

Background: Recent studies have shown that the Sonic Hedgehog pathway plays an important role in tumorigenesis and cancer proliferation. The Sonic Hedgehog pathway is required for normal thyroid gland development, but when activated as a result of gene mutation or overexpression, it may stimulate thyroid tumor cell proliferation. This study determines whether 3 molecules, Patched, Smoothened, and Sonic Hedgehog, involved in the Sonic Hedgehog pathway are overexpressed equally in synchronous follicular thyroid adenoma and papillary thyroid carcinoma.Methods: Eighteen patients with synchronous follicular thyroid adenoma and papillary thyroid carcinoma underwent thyroidectomy. Immunohistochemistry was performed on the paraffin-embedded tissue to detect expression of Patched, Smoothened, and Sonic Hedgehog in both tumor types. The expression in these neoplasms was graded by 2 observers.Results: Five patients had insufficient tumor tissue and were removed from the analysis. Patched expression was detected in 5 of 13 (38%) follicular adenomas and 5 of 12 (42%) papillary carcinomas. Smoothened was expressed in 4 of 13 (31%) follicular adenomas and 3 of 13 (23%) papillary carcinomas. Sonic Hedgehog was expressed in 4 of 13 (31%) follicular adenomas and 11 of 13 (85%) papillary carcinomas.Conclusion: Expression of the 3 molecules involved in the Sonic Hedgehog pathway was similar in follicular thyroid adenoma, but Sonic Hedgehog expression was a more sensitive indicator of malignancy in papillary thyroid carcinoma. The Sonic Hedgehog molecule may become a diagnostic marker when the cytologic or histologic features are not characteristic of a papillary carcinoma. Greater understanding of the Sonic Hedgehog pathway may provide molecular methods for preventing or treating papillary thyroid carcinoma.

Modified gold nanoparticle vectors: A biocompatible intracellular delivery system for pancreatic islet cell transplantation - Corrected Proof

2010-08-27

Background: Islet transplantation is an emerging therapy for type 1 diabetes mellitus with variable success. Molecular therapeutics is a promising approach to improve islet graft function and transplant outcomes. Traditional delivery vectors, however, have poor cell penetration and generally lead to compromised islet function. Modified gold nanoparticles represent a potential alternative in that they are taken up into cells efficiently and have unique binding properties. The objective of this study was to investigate whether gold nanoparticles can transfect islets uniformly without compromising cellular function.Methods: Cy5-oligonucleotide-conjugated gold nanoparticle islet transfection was evaluated using confocal microscopy and flow cytometry. Isolated mice and human islets were transfected and evaluated for mitochondrial potential changes, calcium influx, and insulin secretion in response to glucose challenge and in vivo graft function.Results: Highly efficient gold nanoparticle uptake was observed. Transfected islets demonstrated normal mitochondrial function, calcium influx, and insulin release when stimulated by glucose. These islets produced a 100% diabetes cure rate after transplantation. Intraperitoneal glucose tolerance test demonstrated similar graft function as controls.Conclusion: We describe the development of a modified gold nanoparticle approach that allows for the efficient and nontoxic transfection of not only single cells but also more complex tissue architectures, such as pancreatic islets, both in vitro and in vivo.

Recurrent hyperparathyroidism and forearm parathyromatosis after total parathyroidectomy - Corrected Proof

2010-08-27

Background: In multiple endocrine neoplasia type I and renal failure, the type of initial parathyroidectomy for hyperparathyroidism may influence the operative risks and development of recurrence. We compared subtotal parathyroidectomy with total parathyroidectomy and immediate forearm autotransplantation (TPFA) in a large series with long-term follow-up.Methods: The data of patients treated from 1977 to 2009 by initial or reoperative TPFA or subtotal parathyroidectomy were examined for outcomes including the interval to sites and tissue patterns of recurrence.Results: Permanent hypoparathyroidism was rare and uninfluenced by disease type. Neither initial procedure nor underlying disease affected the mean time to reoperation for recurrent hyperparathyroidism. In renal failure, reoperation was more common after TPFA than subtotal parathyroidectomy (5/19, 26% vs 11/193, 6%; P = .008). Twelve patients required forearm reoperation after TPFA, which was often complicated by parathyromatosis (7/12, 58%). Further reoperative forearm surgery was more likely after explant excision than after en bloc resection (7/11 vs 0/8; P = .01) and occurred sooner in renal failure than in multiple endocrine neoplasia type I (mean 4.4 vs 9 years; P = .04). Permanent hypoparathyroidism was rare and uninfluenced by disease type.Conclusion: Because of frequent recurrence, TPFA should be abandoned as a treatment of renal hyperparathyroidism. In multiple endocrine neoplasia type I, subtotal parathyroidectomy has similar outcomes to TPFA. Forearm autotransplantation can be complicated by parathyromatosis, and surgeons should be prepared for reoperative en bloc resection.

Clinical framework to guide operative decision making in disconnected left pancreatic remnant (DLPR) following acute or chronic pancreatitis - Corrected Proof

2010-08-27

Background: Disconnected left pancreatic remnant (DLPR) presents clinically as a pancreatic fistula, pseudocyst, or obstructive pancreatitis. Optimal operative treatment, either distal pancreatectomy (DP) or internal drainage (ID), remains unknown. This paper critically evaluates our operative experience in patients with DLPR.Methods: A retrospective analysis of a consecutive case series from a single, high-volume institution was carried out. A total of 76 patients with radiographic-confirmed DLPR (computed tomography + endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography) who had operations between November 1995 and September 2008 were included. Pancreas preservation (the use of ID) was our default unless anatomic, physiologic, or technical factors precluded it. Follow-up to July 2009 was done (median follow-up, 22 months). Standard statistical methodology was used (P < .05 = statistical significance).Results: The mean age of this cohort was 52 years (range, 18–85); 57% of the patients were male. A total of 59 (73%) had acute pancreatitis, whereas 17 (22%) had chronic pancreatitis. Presentation was pseudocyst in 53%, pancreatic fistula in 34%, and obstructive pancreatitis in 13%. Resection (DP) and drainage (ID) options were utilized equally for each clinical presentation as follows: pseudocyst, 60/40; pancreatic fistula, 50/50; or obstructive pancreatitis, 50/50. The strongest driver for DP (92%) was a small pancreatic remnant and splenic vein thrombosis. In contrast, large pancreatic remnants had ID 70% of the time. No differences in short- or long-term outcomes between DP or ID options were identified.Conclusion: Using anatomic, physiologic, and technical factors to guide operative choice in DLPR, we report a 74% success rate with DP and an 82% success rate with ID at a median follow-up of 22 months. A pancreatic remnant size >6 cm favored ID options over resection.

Impact of standardized trauma documentation to the hospital's bottom line - Corrected Proof

Stephen L. Barnes, Matt Waterman, David MacIntyre, Jeff Coughenour, James Kessel — 2010-08-27

Background: The dichotomy between clinical and hospital revenue generation for trauma care is well established. Many trauma programs require hospital support for fiscal survival. We evaluated the impact of standardized clinical documentation to the hospital's bottom line at our trauma center.Methods: Standardized documentation templates for evaluation and management were created with a focus on accuracy and efficiency. Documentation was completed jointly by residents and faculty following standard guidelines of linkage. Trauma service characteristics, case mix index, reimbursement rate, payer distribution, hospital charges, cost, and payments were compared before and after standardization. Professional revenue was not evaluated. Analysis was performed using a commercially available spreadsheet computer application.Results: A 24% increase in the hospital's net income for trauma care, constituting $1.45 million, was realized despite a 12% decrease in patient volume. Admission profitability increased by 42%. Collection rates and payer mix were unchanged. Increases in both injury severity score and case mix index were seen (P < .05) after implementation of the program. Length of stay was decreased significantly.Conclusion: An effective standardized documentation strategy for trauma care results in significant fiscal gains in hospital reimbursement.

Decreased contractile response to endothelin-1 of peripheral microvasculature from diabetic patients - Corrected Proof

2010-08-23

Background: We compared the contractile responses to endothelin-1 (ET-1) with and without the inhibition of ET-A receptors and protein kinase C-alpha (PKC-α) in the human peripheral microvasculature of diabetic and case-matched, nondiabetic patients.Methods: Chest wall skeletal muscle was harvested from patients with and without diabetics undergoing cardiac surgery. Peripheral arterioles (90–180 μm in diameter) were dissected from the harvested tissue. Microvascular constriction was assessed by videomicroscopy in response to ET-1 with and without an endothelin-A (ET-A) receptor antagonist, an endothelin B (ET-B) antagonist, or a PKC-α inhibitor.Results: ET-1 induced a dose-dependent contractile response of skeletal muscle arterioles from diabetic and nondiabetic patients. The contractile response of diabetic arterioles from both prebypass and postbypass to ET-1 (10−9 mol/L) was decreased compared with those of nondiabetic patients (P < .05). The contractile responses of microvessels of both diabetics and nondiabetics to ET-1 were inhibited in the presence of either ET-A receptor antagonist BQ123 (10−7 mol/L) or the PKC-α inhibitor safingol (2 × 10−5 mol/L, P < .05, respectively). In contrast, the ET-1–induced vasoconstriction was not affected by the administration of the ET-B receptor antagonist BQ788 (10−7 mol/L). There were no differences in skeletal muscle levels of the ET-A and ET-B receptors between diabetic and nondiabetic groups.Conclusion: Diabetic patients demonstrated a decreased contractile response to ET-1 in human peripheral microvasculature. The contractile response of diabetic vessels to ET-1 occurs via activation of ET-A receptors and PKC-α. These results provide novel mechanisms of ET-1–induced contraction in vasomotor dysfunction in patients with diabetes.

Early gastric cancer with signet-ring cell histologic type: Risk factors of lymph node metastasis and indications of endoscopic surgery - Corrected Proof

2010-08-23

Background: To clarify the biologic behavior of the early signet-ring cell cancers (SRCs) by comparing the clinicopathologic features and the incidence of lymph node metastasis between different histologic types of early gastric cancer (EGC) and to propose the indications of endoscopic surgery for SRCs.Methods: Clinicopathologic features and the incidence of lymph node metastasis of 422 EGCs were retrospectively reviewed and compared according to the histologic type.Results: Clinicopathologic features, incidence of node metastasis, prognosis, as well as the incidence of recurrence for SRCs, were similar to those of differentiated cancers (DCs), however, significantly different from those of undifferentiated cancers (UDCs). Tumor size, histologic type, lymphatic and/or blood vessel invasion (LBVI), and depth of invasion were independent factors predicting node metastasis for EGCs. For DCs and SRCs with mucosal invasion and ≤2 cm in diameter without LBVI, no metastatic lymph node was detected (95% CI, 0–5.0). Also, for DCs and SRCs with mucosal invasion and >2 cm in diameter without LBVI, or with submucosal invasion and ≤2 cm in diameter without LBVI, no metastatic lymph node was detected (95% CI, 0–3.0).Conclusion: Clinicopathologic features of SRCs were similar with DCs, but different from other UDCs. Consequently, the treatment strategy for SRCs might be similar with that for DCs. According to the incidence of node metastasis, we propose SRCs with mucosal invasion without LBVI, or with submucosal invasion and ≤2 cm in diameter without LBVI, might be suitable for endoscopic surgery.

Gastroesophageal reflux disease after lung transplantation: Pathophysiology and implications for treatment - Corrected Proof

2010-08-23

Background: Gastroesophageal reflux disease (GERD) is thought to be a risk factor for the development or progression of chronic rejection after lung transplantation. However, the prevalence of GERD and its risk factors, including esophageal dysmotility, hiatal hernia and delayed gastric emptying after lung transplantation, are still unknown. In addition, the prevalence of Barrett's esophagus, a known complication of GERD, has not been determined in these patients. The purpose of this study was to determine the prevalence and extent of GERD, as well as the frequency of these risk factors and complications of GERD in lung transplant patients.Methods: Thirty-five consecutive patients underwent a combination of esophageal function testing, upper endoscopy, barium swallow, and gastric emptying scan after lung transplantation.Results: In this patient population, the prevalence of GERD was 51% and 22% in those who had been retransplanted. Of patients with GERD,36% had ineffective esophageal motility (IEM), compared with 6% of patients without GERD (P = .037). No patient demonstrated hiatal hernia on barium swallow. The prevalence of delayed gastric emptying was 36%. The prevalence of biopsy-confirmed Barrett's esophagus was 12%.Conclusion: Our study shows that, after lung transplantation, more than half of patients had GERD, and that GERD was more common after retransplantation. IEM and delayed gastric emptying are frequent in patients with GERD. Hiatal hernia is rare. The prevalence of Barrett's esophagus is not negligible. We conclude that GERD is highly prevalent after lung transplantation, and that delayed gastric emptying and Barrett's esophagus should always be suspected after lung transplantation because they are common risks factors and complications of GERD.

Antiplatelet agents, warfarin, and epidemic intracranial hemorrhage - Corrected Proof

2010-08-23

Background: Atrial fibrillation prophylaxis with warfarin and strong antiplatelet agent use in cardiovascular diseases has increased the incidence of anticoagulation in the elderly. We studied traumatic intracranial hemorrhage (TICH) in patients ≥55 years of age on anticoagulation and antiplatelet agents in a stable population.Methods: We used a Level 1 Trauma Center registry study comparing TICH in patients on anticoagulation drugs during the index periods 1999 to 2000 (T1) and 2007 to 2008 (T2).Results: A total of 526 TICH patients were seen in T1 and T2 (age, 77.6 vs 77.5 years; not significant [NS]), with the rate doubling from 6.2% to 12.3% of all trauma activations (P < .01). There was no increase in atrial fibrillation, warfarin use, or CHADS2 scores in atrial fibrillation patients on anticoagulation therapy. TICH in patients taking antiplatelet agents increased 5-fold (2.2 % vs 10.3%; P < .01). Overall TICH mortality rate was the same (12.4% vs 12.2%, NS). TICH mortality among patients on therapeutic warfarin was greater in T1 (26%; P < .05), but mortality was similar to TICH in patients not on anticoagulants in T2 (19% vs 12.2%, NS), suggesting treatment improved. Prevalence and mortality of TICH in patients on antiplatelet agents were similar to TICH in patients on warfarin.Conclusion: TICH in patients on anticoagulants is epidemic in patients ≥55 years of age. Despite national trends, our well-served population has not seen an increase in warfarin use for atrial fibrillation. Instead, use of antiplatelet agents has increased and is associated with an increased incidence of TICH.

Review of outcomes of primary liver cancers in children: Our institutional experience with resection and transplantation - Corrected Proof

2010-08-23

Background: Operative intervention plays an important role in the management of primary liver cancers in children. Recent improvements in diagnostic modalities, pre- and postoperative chemotherapy, and operative technique have all led to improved survival in these patients. Both hepatic resection and orthotopic liver transplantation are effective operations for pediatric liver tumors; which intervention is pursued is based on preoperative extent of disease. This is a review of our institution's experience with operative management of pediatric liver cancer over an 18-year period.Methods: A retrospective chart review from 1990 to 2007 identified patients who were ≤18 years old who underwent operative intervention for primary liver cancer. Demographics, type of operation, intraoperative details, pre- and postoperative management, as well as outcomes were recorded for all patients.Results: Fifty-four patients underwent 57 operations for primary liver cancer, 30 of whom underwent resection; the remaining 27 underwent orthotopic liver transplantation. The mean age at diagnosis was 41 months. Twenty patients had stage 1 or 2 disease and 34 patients had stage 3 or 4 disease. Forty-eight (89%) patients received preoperative chemotherapy. Postoperative chemotherapy was given to 92% of patients. Mean overall and intensive care unit duration of stay were 18 and 6 days, respectively. About 45% of patients had a postoperative complication, including hepatic artery thrombosis (n = 8), line sepsis (n = 6), mild acute rejection (n = 3), biliary stricture (n = 2), pneumothorax (n = 2), incarcerated omentum (n = 1), Horner's syndrome (n = 1), and urosepsis (n = 1). Only 6 patients had a recurrence of their cancer, 5 after liver resection, 3 of whom later received a transplant. There was only 1 recurrence after liver transplantation. There was 1 perioperative mortality from cardiac arrest. Overall survival was 93%.Conclusion: Operative intervention plays a critical role in the management of primary liver cancer in the pediatric population. Neoadjuvant chemotherapy can be given if the tumor seems unresectable at diagnosis. If chemotherapy is unable to sufficiently downstage the tumor, orthotopic liver transplantation becomes the patient's best option. Our institution has had considerable experience with both resection and liver transplantation in the treatment of pediatric primary liver cancer, with good long-term outcomes.

Collateral damage: The effect of patient complications on the surgeon's psyche - Corrected Proof

2010-08-23

Background: The effect of patient complications on physicians is not well understood. Our objective was to determine the impact of a surgeon's complication(s) on his/her emotional state and job performance.Methods: An anonymous survey was distributed to Midwest Surgical Society members and attending surgeons within the Grand Rapids, Michigan, community.Results: There were 123 respondents (30.5% response rate). For the majority of participants, the first complication that had a significant emotional impact on them occurred during residency (51.2%). Most respondents reported this did not impair their professional functioning (77.2%). If a major complication was first experienced after residency, this had a greater likelihood of causing impairment (P < .05). Surgeons primarily dealt with the emotional impact by discussing it with a surgical partner (87.8%). Alcohol or other substance use increased in 6.5% of those surveyed. Most respondents (58.5%) felt it was difficult to handle the emotional effects of complications throughout their careers and this did not improve with experience.Conclusion: The majority of surgeons agreed that it was difficult to handle the emotional effects of complications throughout their careers. Efforts should be made to increase awareness of unrecognized emotional effects of patient complications and improve access to support systems for surgeons.

Development of a novel method of progressive temporary abdominal closure - Corrected Proof

Michael D. Goodman, Timothy A. Pritts, Betty J. Tsuei — 2010-08-23

Background: This paper describes our experience with a novel method of temporary abdominal closure that permits frequent reassessment of the abdominal contents and progressive reapproximation of the fascial edges without compromising definitive fascial closure outcomes.Methods: We developed a novel method of temporary abdominal closure, which we have named the frequent assessment temporary abdominal closure (FASTAC). The records of patients who underwent planned relaparotomy during 5 years were reviewed. The data collected included patient demographics, indication for operation, number of operations, duration of temporary abdominal closure placement, hospital duration of stay, method of definitive abdominal closure, and subsequent ventral hernia repair.Results: One hundred and thirty-three patients underwent 308 temporary abdominal closure placements, including 16 patients who had a FASTAC placed for open abdomen management. FASTAC remained in place for a significantly greater time with more frequent reassessment. Fascial closure techniques were not different in FASTAC patients. FASTAC patients had a significantly greater duration of stay, which suggests selective placement in a more complicated patient population. The materials for frequent assessment temporary abdominal closure cost only $38 compared with $350 for a large piece of Silastic.Conclusion: FASTAC is a novel, cost-effective method of temporary abdominal closure that allows for frequent bedside intra-abdominal surveillance, maintains abdominal domain, and does not compromise abdominal closure outcomes in the management of the open abdomen.

Exogenous high-mobility group box 1 improves myocardial recovery after acute global ischemia/reperfusion injury - Corrected Proof

2010-08-20

Background: High-mobility group box 1 (HMGB1) is a mediator of inflammation with dose-dependent effects. In the setting of regional myocardial infarction, a high-dose HMGB1 treatment decreases myocardial function, whereas low-dose HMGB1 improves function; however, it is unknown what role HMGB1 has in the setting of global ischemia/reperfusion (I/R) injury. We hypothesized that a low-dose HMGB1 treatment would improve myocardial functional recovery and decrease infarct size after global I/R injury in association with increased levels of cardioprotective paracrine factors and decreased inflammation.Methods: Adult rat hearts were isolated and perfused using the Langendorff method and were subjected to global I/R and treatment with either the vehicle, 200-ng HMGB1, or 1-μg HMGB1. The treatment was administered during 1 min at the start of reperfusion, and myocardial function was measured for 60 min of reperfusion. At the end of reperfusion, the hearts were sectioned and incubated in triphenyltetrazolium chloride to assess myocardial infarct size or homogenized to measure levels of inflammatory cytokines and growth factors.Results: Postischemic treatment with 200-ng HMGB1 significantly improved myocardial functional recovery after global I/R in association with decreased infarct size and decreased interleukin-1 (IL-1), IL-6, IL-10, and vascular endothelial growth factor (VEGF) levels. In addition, 1-μg HMGB1 decreased myocardial inflammation but did not result in subsequent improvement in functional recovery.Conclusion: In the setting of global I/R, 200-ng postischemic HMGB1 treatment improves myocardial function and decreases infarct size in association with suppressed myocardial inflammation. These results suggest a potential role for exogenous HMGB1therapy in the acute postischemic period.

Two-stage brachial-basilic transposition fistula provides superior patency rates for dialysis access in a safety-net population - Corrected Proof

Eduardo Gonzalez, Jeffry L. Kashuk, Ernest E. Moore, Stuart Linas, Angela Sauaia — 2010-08-20

Background: Guidelines of the National Kidney Foundation recommending aggressive pursuit of autogenous fistulae for dialysis access in lieu of prosthetic arteriovenous grafts have stimulated a renewed interest in transposed brachial-basilic fistulae as an alternative technique for upper arm access in patients who may not be candidates for a lower arm radial-cephalic or forearm brachial-cephalic fistula. We hypothesized that in our safety-net population, where radial-cephalic and brachial-cephalic often are not possible, brachial-basilic would provide patency rates superior to arteriovenous grafts and equivalent to radial-cephalic and brachial-cephalic fistulae.Methods: We analyzed retrospectively our most recent 2.5-year experience with dialysis access procedures at our metropolitan safety-net hospital. Procedures were grouped as follows: radial-cephalic, brachial-cephalic, brachial-basilic, and arteriovenous grafts. The access outcomes measured were primary failure, time to use, need for intervention, and primary as well as secondary patency. Differences in age, sex, race, renal function (Modification of Diet in Renal Disease), baseline diagnoses (diabetes mellitus, hypertension, coronary artery disease, and peripheral vascular disease), as well as the number of previous accesses, were adjusted in the analysis. Logistic regression was used to identify independent predictors of primary failure, and Kaplan-Meier plots assessed differences in primary patency rates. A log of the time variables was used to approximate normal distribution.Results: In all, 193 patients were included in this study as follows: radial-cephalic, 75 (39%) patients; brachial-cephalic, 35 (18%) patients; brachial-basilic, 33 (17%) patients; and arteriovenous grafts, 50 (26%) patients. Primary patency means differed marginally between groups (P = .08), and when grafts were excluded from the analysis, no difference was found between primary patency in all autogenous fistula techniques (P = .88). Kaplan-Meier plots showed that when analyzing the first 35 weeks, a significantly lower primary patency among graft recipients early after the procedure was noted, and a higher performance of BB after 20 weeks was noted (log-rank P = .05, Wilcoxon P = .004). Furthermore, secondary patency did not vary significantly between groups (P = .62). Radial-cephalic were more likely to fail primarily when compared with the other access groups (P = .03), and in a univariate analysis, underlying hypertension was associated with a lower risk of primary failure (P = .01) compared with other diagnoses. A logistic regression stepwise selection showed that the underlying diagnoses of peripheral vascular disease, diabetes mellitus, or coronary artery disease were associated with a greater risk of primary failure compared with those with HTN (P = .001; odds ratio, 4.05; 95% confidence interval, 1.71–9.59), as well as the presence of a previously failed access (P = .04; odds ratio, 2.39; 95% confidence interval, 1.08–5.67).Conclusion: In a safety-net population, our results suggest that 2-stage brachial-basilic transposition fistulae provide patency rates equivalent to brachial-cephalic and radial-cephalic fistulae and superior to grafts. Although 2 procedures are required, brachial-basilic fistulae provide a reliable access and should be considered the next choice when radial-cephalic and/or brachial-cephalic are not possible.

Postoperative parathyroid hormone testing decreases symptomatic hypocalcemia and associated emergency room visits after total thyroidectomy - Corrected Proof

Linda Youngwirth, Joy Benavidez, Rebecca Sippel, Herbert Chen — 2010-08-20

Background: Symptomatic hypocalcemia, the most common complication of total thyroidectomy, can lead to postoperative emergency room visits for laboratory testing and intravenous calcium infusion. A method to identify patients reliably at risk for postoperative hypocalcemia could allow prophylactic treatment to avoid this. We hypothesized that quick parathyroid hormone testing within 4 hours of thyroidectomy and a protocol to treat parathyroid-hormone–deficient patients would reduce symptomatic hypocalcemia, eliminating the need for emergency room visits.Methods: After January 1, 2006, 271 consecutive patients underwent total thyroidectomy with postoperative parathyroid hormone testing (group 1). Patients with parathyroid hormone levels <10 pg/mL were treated according to a newly instituted protocol with 0.25-ug calcitriol twice daily and 2–6 g of calcium carbonate daily for 1 week. Patients with parathyroid hormone levels ≥10 pg/mL were treated with calcium only. Group 2 consisted of 100 consecutive patients who underwent total thyroidectomy prior to 2006 without parathyroid hormone testing and were treated according to surgeon preference and serum calcium levels.Results: Patients in the 2 groups were similar with regard to age, sex, and thyroiditis. However, patients in group 1, who had parathyroid hormone testing, had greater postoperative calcium levels (P < .005). Also, patients in group 2 had a higher incidence of malignancy (P = .04). Importantly, patients in group 1 had a lesser incidence of symptomatic hypocalcemia (7% vs 17%; P = .005). Furthermore, the number of patients who made visits to the emergency room was less in patients who had parathyroid hormone testing compared with those who did not (1.8% vs 8.0%; P = .008).Conclusion: Postoperative parathyroid hormone testing reliably identifies patients at risk for hypocalcemia after thyroid surgery. Moreover, parathyroid hormone testing and calcitriol administration to patients at risk decreases the incidence of hypocalcemia and associated emergency room visits after total thyroidectomy. Therefore, patients with postoperative serum parathyroid hormone levels <10 pg/mL after thyroid surgery should be treated with calcitriol and calcium to prevent symptomatic hypocalcemia.

Intestinal malrotation: Varied clinical presentation from infancy through adulthood - Corrected Proof

Deepika Nehra, Allan M. Goldstein — 2010-08-19

Background: The purpose of this study was to determine the incidence and clinical presentation of intestinal malrotation from infancy through adulthood by examining the experience of a single institution caring for patients of all ages with this condition.Methods: We conducted a retrospective review on all patients diagnosed with intestinal malrotation at Massachusetts General Hospital between 1992 and 2009. Patient demographics, clinical history, diagnostic tests, operative procedures, and outcome variables were recorded. Patients were divided into 3 age groups: infants (<1 year), children (1–18 years), and adults (18 years).Results: We identified 170 patients, of whom 31% were infants, 21% were children, and 48% were adults. Infants nearly always presented with emesis (93%), whereas adults most commonly presented with abdominal pain (87%), and less often with emesis (37%) or nausea (31%). The incidence of volvulus declined with age, from 37% to 22% to 12%, in each of the 3 age groups, respectively. Although infants were most often diagnosed within hours or days of symptom onset, 59% of children and 32% of adults experienced symptoms for years before diagnosis. Upper gastrointestinal series was the most common imaging study performed in infants and children, but was replaced by abdominal computed tomography in adults. All infants and children underwent a Ladd's procedure, compared with only 61% of adults. The majority of patients experienced resolution of symptoms after operative intervention, although this decreased slightly with age.Conclusion: Intestinal malrotation can occur in patients of any age and, in contrast with traditional teaching, nearly half of these patients may present during adulthood. An increased awareness of this entity and an understanding of its varied presentation at different ages may reduce time to diagnosis and improve patient outcome.

Prophylactic total gastrectomy for individuals with germline CDH1 mutation - Corrected Proof

2010-08-19

Background: Germline mutation of the CDH1 gene, which encodes for the E-cadherin adhesion protein, is rare but confers an estimated lifetime risk of hereditary diffuse gastric cancer of 87%. Fewer than 100 prophylactic total gastrectomies have been reported for this condition.Methods: Patients with germline CDH1 mutation who underwent multidisciplinary counseling followed by prophylactic total gastrectomy were reviewed.Results: Ten patients (6 male, 4 female) with a median age of 42 years (range, 26–51) underwent prophylactic total gastrectomy between 2006 and 2009. Of the 6 families represented, there were 4 missense, 1 frameshift, and 1 splice site mutation. Median time from genetic testing to surgery was 3 months (range, 1–7). All patients had an upper endoscopy before surgery, identifying only 1 patient with a focus of diffuse gastric cancer. After prophylactic total gastrectomy, extensive pathologic analysis demonstrated that 9 patients had up to 77 foci of noninvasive cancer, and 2 of these patients had 4–12 foci of T1 invasive cancer. Median operative time was 213 minutes; there were no anastomotic leaks, and the length of stay was 7–8 days. One patient had a complication within 30 days (pulmonary embolism), and 3 patients had late complications (2 small bowel obstructions and 1 anastomotic stricture). Median weight loss at 6 months was 19%.Conclusion: The majority of patients with germline CDH1 mutation have foci of noninvasive or invasive gastric cancer by middle age. Serial upper endoscopies provide inadequate screening. Prophylactic total gastrectomy is the procedure of choice for definitive treatment.

A statewide consortium of surgical care: A longitudinal investigation of vascular operative procedures at 16 hospitals - Corrected Proof

2010-08-19

Background: Regional surgical quality improvement consortiums are becoming more common. Herein we have reported the effectiveness of a statewide consortium focusing on open vascular operative procedures.Methods: The statewide Michigan Surgical Quality Consortium was established in 2005 with 16 hospitals that report cases of vascular open operative intervention, in a sampling manner consistent with the private sector National Surgical Quality Improvement Program. Data are abstracted by onsite trained nurses using defined and validated pre-, peri-, and postoperative variables with 30-day follow-up. Outpatient and emergent cases were excluded. We compared outcomes over the course of the consortium (era I, April 2005–March 2007; era II, April 2007–March 2008) via univariate and multivariate techniques.Results: Era I (n = 2,453) and era II (n = 3,409) cases were similar in age (mean, 68 years), gender (61% male), relative value units (mean, 21), and distribution of Current Procedural Terminology codes. Duration of stay and operative time decreased by 15% and 11%, respectively, when comparing era I with era II (P < .001). Mortality at 30 days was not different between eras I and II (2.7% vs 2.5%; P = NS), but morbidity was decreased (15.8% vs 13.8%; P = .02). Specific decreases were noted in sepsis and pulmonary, but not cardiac or renal, complications. When evaluating both eras, modifiable variables (able to be altered by the surgeon) for morbidity included increased length of operation (odds ratio [OR], 1.004; 95% confidence interval [CI], 1.003–1.005; P < .0001), hypertension (OR, 1.46; 95% CI, 1.03–2.1; P = .03), and blood transfusion (OR, 2.8; 95% CI, 2.04–3.88; P < .0001). However, anemic patients (11%; hematocrit <30) who were transfused were less likely to suffer morbidity (OR, 56; 95% CI, 0.47–0.67; P < .0001) than those transfused who were not anemic. The absolute 2% reduction in complications led to a $172 cost savings for the payers per patient in era II compared with era I.Conclusion: A statewide quality-of-care consortium with timely feedback of data was associated with decreased morbidity over a relatively short follow-up period in vascular patients. Focusing on best processes in real-world practice, such as appropriate transfusion and length of operation, may further improve vascular surgical outcomes.

Progressive postinjury thrombocytosis is associated with thromboembolic complications - Corrected Proof

2010-08-19

Background: Our previous investigation demonstrated that despite routine chemoprophylaxis, thrombelastography, which is a comprehensive test measuring the viscoelastic properties of blood, identified a hypercoagulable state in a cohort of critically ill surgical patients that was associated with thromboemobolic events. Furthermore, because thrombelastography allows for the comprehensive assessment of coagulation status, this work suggested that platelet hyperactivity is a component of the hypercoagulable state. We hypothesized that progressive postinjury thrombocytosis contributes to a hypercoagulable state that is associated with thrombelastography.Methods: One thousand four hundred and forty severely injured patients surviving >48 h were entered into a database prospectively over 12 years. The variables that were evaluated in associated with thrombocytosis (platelet count >450,000) included age, Injury Severity Score, packed red blood cell transfusions in 12 h, and thromboemobolic complications (TE) (deep venous thrombosis, pulmonary embolus, mesenteric thrombosis, stroke, and arterial thrombosis). The time frame for the development of thrombocytosis was assessed at greater or less than 7 days postinjury. Logistic regression was used to identify the independent variables predictive of thrombocytosis and to adjust the association of thrombocytosis with TE for other risk factors. C-statistic was used to assess the discriminative power of thrombocytosis for prediction of TE.Results: The mean age was 37.4 ± 0.4 years. The Injury Severity Score was 29.3 ± 0.3, and mean red blood cell transfusions in 12 h was 4.4 ± 0.2 units. Injury via blunt force occurred in 76% of patients, and 72% of patients were male. Thrombocytosis was identified in 447 (31%) patients and was noted almost exclusively >7 days postinjury (98%). TE developed in 35 (8%) of the 447 patients with thrombocytosis, compared with 45 (4.5%) of the remaining 993 patients who did not develop thrombocytosis. Persistent thrombocytosis >7 days was associated with TE (P > .0001). Logistic regression analysis indicated that when adjusted for intensive care unit duration of stay, transfusions, age, and Injury Severity Score, patients with sustained thrombocytosis more than 3 days were noted to have a 1.4 × increased risk of TE (odds ratio, 1.12; 95% confidence interval, 1.04–1.2; P = .002; C-statistic = 0.82).Conclusion: Persistent thrombocytosis in critically injured patients receiving routine chemoprophylaxis is associated with thrombotic complications. Subsequent investigation is warranted to differentiate enzymatic from platelet hypercoagulability to ascertain the role of antiplatelet therapy for prevention of TE.

Different patterns of cancer incidence among African American and Caucasian renal allograft recipients - Corrected Proof

2010-08-19

Background: Little data are available regarding cancer incidence in separately analyzed African American renal allograft recipients, with no study examining in detail the incidence and relative distribution of individual post-transplant malignancies versus those occurring in Caucasians.Methods: We compared the incidence of non–skin cancer occurring in 495 African Americans transplanted at our center from 1984 to 2007 and followed through June 2009 with that occurring in 11,155 patients in the Canadian Organ Replacement Registry transplanted from 1981 to 1998 and followed through December 1999, of which 97% were Caucasian.Results: Despite a shorter follow-up, the overall incidence of non–skin cancer, as well as that of prostate, renal cell, pancreatic, and esophageal cancer, was significantly higher in the African American group. Cancers of the prostate and pancreas comprised a significantly higher fraction of neoplasms occurring in the African American group, whereas lip cancer did so in the Canadian Organ Replacement Registry group.Conclusion: In our pilot study, the overall incidence of non–skin cancers was higher in African American versus Caucasian renal allograft recipients, reflecting a significantly different relative distribution of cancer types that follows cancer incidence trends by race in the general population in several but not all cases. If verified in subsequent studies, these findings have important implications with regard to the need for transplant programs to tailor cancer education and pretransplant and post-transplant surveillance appropriately to the African American patient.

Catastrophic antiphospholipid syndrome (Asherson's syndrome) presenting with a splenic rupture - Corrected Proof

Keiichi Okano, Minoru Oshima, Keitaro Kakinoki, Hiroaki Dobashi, Yasuyuki Suzuki — 2010-08-16

A previously healthy 51-year-old Japanese woman was admitted to our hospital as an emergency case because of hemorrhagic shock owing to intra-abdominal bleeding without any trauma. The patient was conscious, blood pressure was 56/38 mm Hg, pulse 90 beats/min, and body temperature was 36.8°C. Her abdomen was distended and diffusely tender. Rebound tenderness was noted, but the abdominal defense reflex was absent. Bowel sounds were silent and there was no flatus. The patient had a past history of 3 spontaneous abortions, but no history of laparotomy. Laboratory tests revealed a leukocyte count of 8,690/mm3 with 82% neutrophils and 4.5% lymphocytes, 6.6 g/dL hemoglobin, 19.3% hematocrit, and a platelet count of 11,000/mm3. Coagulation tests revealed a prothrombin time of 33% (International Normalized Ratio, 2.0), activated partial thromboplastin time of 54.6 seconds, and antithrombin III of 58%. Total proteins were 4.0 mg/dL with albumin at 2.1 g/dL. The fasting blood glucose level, liver enzyme level, creatinine, uric acid, amylase, lipase, and electrolytes were within normal limits.

Esophagogastroduodenoscopy-associated gastrointestinal perforations: A single-center experience - Corrected Proof

2010-08-16

Background: Esophagogastroduodenoscopy (EGD) is commonly used in the diagnosis and treatment of gastrointestinal (GI) disorders. Our aim was to define the risk of perforation associated with EGD and identify patients who required operative intervention.Methods: We retrospectively reviewed 72 patients from our institution plus 5 transferred patients who sustained EGD-associated perforations from January 1996 through July 2008. Percutaneous endoscopic gastrostomy, endoscopic ultrasonography, endoscopic retrograde cholangiopancreatography, transthoracic echocardiography, and concurrent colonoscopy procedures were excluded.Results: Perforations in 72 of 217,507 EGD procedures were identified (incidence, 0.033%); 124,844 EGDs included an interventional procedure and 92,663 were examination only. The incidence of perforation was similar whether an interventional procedure was performed or not (0.040% vs 0.029%; P = .181). The esophagus was injured most commonly (51%), followed by the duodenum (32%), jejunum (6%), stomach (3%), and common bile duct (3%). Overall mortality after perforation was 17% with a morbidity rate of 40%. Thirty-eight patients (49%) were initially treated nonoperatively, 7 of whom (18%) failed nonoperative management. The only factors we could determine that were associated with failure were free fluid or contrast extravasation on computed tomography (75% vs 23% [P < .005] and 33% vs 0% [P = .047], respectively). The morbidity of failures was equivalent to those who underwent initial operative management (63% vs 61%; P = .917), with mortality seeming to be greater (43% vs 21%; P = .09).Conclusion: EGD is safe in the majority of patients; however, iatrogenic perforation is associated with considerable morbidity and mortality. Nonoperative management of GI perforation can be successful if there is no evidence of contrast extravasation or free fluid on radiographic studies. If nonoperative management fails, the outcomes may be worse than those treated initially with operative repair.

Time from diagnosis to definitive operative treatment of operable breast cancer in the era of multimodal imaging - Corrected Proof

2010-08-16

Background: The primary objective of this study was to determine if the increasing use of multimodal breast imaging has influenced the time between the diagnosis of an operable breast cancer and definitive operative intervention over the past decade. Secondary objectives were to determine whether a higher number of imaging studies, or specifically magnetic resonance images (MRIs) were independent predictors of a longer treatment delay, or lead to a greater chance of having a mastectomy.Methods: We retrospectively reviewed patients treated at a large, academic medical center with operable breast cancer between February 1, 1998, and August 31, 2008.Results: Time to treatment significantly increased over the study time period (mean of 21.8 days in 1998, 31.3 days in 2003, 41.1 days in 2008). In 2008, the only study year in which MRI was routinely used, patients with an MRI had a longer median time to treatment of 43 days versus 32 days for those who did not (P = .054). Those who had a preoperative MRI had a higher relative risk of having a mastectomy at 1.8 (95% confidence interval, 0.85–3.76; P = .33), although this result did not reach significance.Conclusion: The time to treatment of operable breast cancer has increased over the past 10 years, and multimodal breast imaging is likely associated with this increase. The effect of this increase on the type of operative procedure chosen and the impact on subsequent outcomes is unknown.

A single institution's experience with single incision cholecystectomy compared to standard laparoscopic cholecystectomy - Corrected Proof

Jeffrey S. Fronza, John G. Linn, Alexander P. Nagle, Nathaniel J. Soper — 2010-08-16

Background: The advent of single incision laparoscopic surgery has brought renewed attention to cholecystectomy due to the promise of improved cosmesis and less parietal trauma. Small series have demonstrated the feasibility of single incision laparoscopic cholecystectomy (LC). Our series adds to the literature by demonstrating a variety of ancillary techniques that may be employed to perform single incision LC safely, and compares our early experience with that of our standard LC.Methods: We performed a retrospective chart review of patients who underwent single incision LC between February 2008 and April 2009. These patients were compared with an equal number of randomly selected patients undergoing LC during the same period. We identified 25 attempted single incision LC, which were included in our analysis.Results: Single incision LC was successfully performed in 21 patients, with only 4 patients requiring conversion to LC. No patients in either group had acute cholecystitis. The critical view of safety was documented in 20 of 21 patients undergoing a successful single incision LC compared with all patients undergoing LC. Operative time was significantly longer in the single incision group. Complications were minor and comparable between the 2 groups. In 9 patients (43%) a suture passer helped to retract the gallbladder. In 8 patients (38%) 1 or 2 Prolene sutures placed by means of a Keith needle helped to retract the gallbladder over the liver and/or helped to retract the infundibulum. In 2 patients, ≥1 supplemental 5-mm port was utilized. In 5 patients (24%), no supplementary retraction was necessary.Conclusion: Single incision LC is technically more challenging than LC, but can be performed safely by experienced laparoscopic surgeons with results comparable with LC.

Malpractice litigation after thyroid surgery: The role of recurrent laryngeal nerve injuries, 1989–2009 - Corrected Proof

Shabirhusain S. Abadin, Edwin L. Kaplan, Peter Angelos — 2010-08-16

Background: Recurrent laryngeal nerve injuries remain a complication that is a source of concern to both surgeons and patients. RLN monitoring has gained popularity in recent years despite a lack of evidence showing decreased rates of recurrent laryngeal nerve injury when nerve monitoring is used. We sought to explore malpractice litigation in thyroid surgery with respect to recurrent laryngeal nerve monitoring. With increased public awareness and surgeon use of recurrent laryngeal nerve monitoring, we hypothesize an increase in its use in malpractice litigation in the area of thyroid surgery.Methods: Using the LexisNexis Academic legal database, a retrospective review of all relevant federal and state cases from 1989 to 2009 was performed using the search terms “thyroid,” “surgery,” and “medical malpractice.” From this search, data were compiled including year and state of the court's decision, the outcome of the trial, the type of complication, any mention of recurrent laryngeal nerve monitoring, and the specialty of the surgeon who performed the procedure. The cases that were settled out of court were not included in this analysis.Results: A total of 143 medical malpractice cases involving thyroid surgery were retrieved from our search from 1989 to 2009. After reviewing all cases, 33 cases in which the alleged negligence occurred after thyroid surgery were used for analysis. Of these cases, 15 involved recurrent laryngeal nerve injury; interestingly, no mention of recurrent laryngeal nerve monitoring was noted in any of the cases.Conclusion: Although recurrent laryngeal nerve monitoring has become more widely available and used, there is no evidence that its use or nonuse has played a role in malpractice litigation in the last 20 years. recurrent laryngeal nerve injury remains a cause of malpractice litigation.

Pseudoangiomatous stromal hyperplasia of the breast: A contemporary approach to its clinical and radiologic features and ideal management - Corrected Proof

2010-08-16

Background: Pseudoangiomatous stromal hyperplasia (PASH) is a benign, proliferative lesion of the breast whose clinical relevance, presentation, and optimal treatment remains described incompletely. The purpose of this study is to review the clinical, radiologic, and histopathologic features and appropriate management.Methods: Patients diagnosed with PASH were identified from our pathology database between 2000 and 2009. Clinicopathologic data including presentation, diagnosis, imaging, and histology were reviewed. All specimens were confirmed by a single pathologist.Results: We identified PASH in 80 patients. Median follow-up was 3.71 years (range, 0.45–9.42). Age ranged from 12 to 65 (median, 45) and 95% were female. Lesions were palpable in 56% and found on imaging in the remainder. Core biopsy was performed in 65 of 80 patients (81%), which confirmed a diagnosis of PASH in 65%. The other 23 of 65 patients (35%) required operative excision for diagnosis. There was a progression rate of 26% in the observation arm versus 13% in the excision arm. A diagnosis of cancer or carcinoma in situ was seen in 30% at or before the diagnosis of PASH.Conclusion: PASH may present as a mass, radiologic lesion, or incidentally in pathology specimens. It may be associated with cancerous or precancerous lesions. A diagnosis on core biopsy in the absence of suspicious radiologic features may be managed with follow-up and imaging at a 6-month interval. In this series, 35% of patients with PASH had a negative core biopsy. Growth, suspicious radiologic findings, or inconclusive biopsy warrants surgical excision. Close surveillance is necessary given its recurrence rate of 13–26%.

Trends in age for hepatoportoenterostomy in the United States - Corrected Proof

2010-08-16

Background: Biliary atresia is a rare but devastating disease for which hepatoportoenterostomy remains the primary intervention. Increased age at the time of hepatoportoenterostomy is associated with unfavorable outcomes. In this study, we examined trends in age at the time of hepatoportoenterostomy and explored hospital and patient factors associated with more timely diagnosis and treatment.Methods: Median ages of patients undergoing hepatoportoenterostomy for biliary atresia were compared using the Kids' Inpatients Database from 1997, 2000, 2003, and 2006. The patient and hospital factors associated with later treatment were compared.Results: Of 192 patients, 13.5% had surgery in 1997, 13.5% in 2000, 36.5% in 2003, and 36.5% in 2006. The overall median age was 65.5 days; the median age was 64 days in 1997, 57.5 days in 2000, 69 days in 2003, and 64 days in 2006 (P = .80). Overall, 71% of patients were treated at non–children's hospitals, and although the proportion has increased over time, the trend did not reach significance (P = .12). Hispanic and African American patients were more likely to undergo hepatoportoenterostomy after 60 days of life compared with white patients (Hispanic patients: odds ratio, 3.6; 95% confidence interval, 1.1–12.5; P = .04; African American patients: odds ratio, 2.2; 95% confidence interval, 0.8–6.3; P = .14). Compared with specialized children's centers, treatment at non–children's hospitals was associated with delayed hepatoportoenterostomy (odds ratio, 3.5; 95% confidence interval, 1.2–9.8; P = .02).Conclusion: Although early hepatoportoenterostomy is associated with improved outcomes for children with biliary atresia, our study shows the median age at surgery has not significantly changed over 2 decades. Both hospital and socioeconomic factors play a role in the early treatment of biliary atresia.

Endoscopic, endoluminal fundoplication for gastroesophageal reflux disease: Initial experience and lessons learned - Corrected Proof

Vic Velanovich — 2010-08-16

Background: Several devices have been developed to create an antireflux barrier endoscopically for the treatment of gastroesophageal reflux disease. All have failed to provide long-term symptom relief, were associated with clinically important complications, or were otherwise removed from the market. A new device, the Esophyx (Endogastric Solutions, Redmond, WA), provides the closest approximation experimentally to a standard Belsy fundoplication. This report describes an initial experience with this device.Methods: Patients considered candidates for endoscopic fundoplication include those with symptomatic gastroesophageal reflux disease, a small (<2 cm) hiatal hernia, objective pathologic evidence of gastroesophageal reflux disease, and an absence of other esophageal motility disorders. The procedure was conducted under general anesthesia with a surgeon operating the device and an endoscopist operating the gastroscope. H-fasteners were placed from the esophagus to the gastric cardia with the goal of creating an approximately 270–300° fundoplication approximately 3–4 cm in length. Symptom severity was measured with the GERD-HRQL instrument (best possible score 0, worst possible score 50). The patients were followed-up for complications and symptom improvement.Results: In all, 26 patients underwent an attempted endoscopic fundoplication. Two patients could not be completed because of the inability to pass the device. Of the 24 patients who underwent endoscopic fundoplication, 20 had the typical symptoms of gastroesophageal reflux disease, 4 had symptoms of laryngopharyngeal reflux, and 4 had recurrent symptoms after a Nissen fundoplication. There was 1 major complication of a gastric mucosal tear that led to bleeding and the need for a blood transfusion. Nineteen (79%) patients reported satisfaction with their symptom relief. Of those dissatisfied, 2 had symptoms of laryngopharyngeal reflux, 1 had functional heartburn, 1 had associated gastroparesis, and 1 had clear failure with gastroesophageal reflux disease. The median GERD-HRQL score improved from 25 (interquartile range, 19.5–28.5) to 5 (interquartile range, 3–9; P = .0004).Conclusion: Endoscopic fundoplication with the Esophyx device is feasible with satisfactory initial results. Endoscopic fundoplication seems to be best suited for patients with small hiatal hernias and mild-to-moderate typical symptoms; however, subsequent trials are needed to assess the long-term effectiveness of the technique.

Incidental radiographic findings after injury: Dedicated attention results in improved capture, documentation, and management - Corrected Proof

2010-08-13

Background: With liberal use of computed tomography in the diagnostic management of trauma patients, incidental findings are common and represent a major patient-care and medical–legal concern. Consequently, we began an initiative to capture, notify, and documentadequately incidental finding events with a dedicated incidental finding coordinator. We hypothesized a dedicated incidental finding coordinator would increase incidental finding capture and promote notification, follow-up, and documentation of incidental finding events.Methods: A quality-improvement project to record and follow-up incidental findings postinjury was initiated at our level I trauma center (April 2007–March 2008, prededicated incidental finding). Because of concerns for inadequate documentation of identified incidental finding events, we implemented a dedicated incidental finding coordinator (April 2008–March 2009, postdedicated incidental finding). The dedicated incidental finding coordinator documented incidental findings daily from trauma admission radiology final reads. Incidental findings were divided into 3 groups, category 1: attention prior to discharge; category 2: follow-up with primary doctor within 2 weeks; category 3: no specific follow-up. For category 1 incidental findings, in-hospital consultation of the appropriate service was verified. On discharge, patient notification, follow-up, and documentation of events were confirmed. Certified mail or telephone contact was used to notify either the patient or the primary doctor in those who lacked appropriate notification or documentation.Results: Admission rates and incidental finding categories were similar across the 2 time periods. Implementation of a dedicated incidental finding coordinator resulted in more than a 165% increase in incidental finding capture (n = 802 vs n = 302, P < .001). Patient notification was attempted, and appropriate documentation of events was confirmed in 99.8% of patients. Patient notification was verified, and follow-up was initiated in 95.8% of cases.Conclusion: The implementation of a dedicated incidental finding coordinator resulted in more than a 2.5-fold higher capture of incidental findings. Dedicated attention to incidental findings resulted in a near complete initiation of patient notification, follow-up, and hospital record documentation of incidental finding events. Inadequate patient notification and follow-up would delay appropriate care and potentially would result in morbidity or even mortality. A dedicated incidental finding coordinator represents a potential solution to this patient-care and medical–legal dilemma.

Verification of proficiency in basic skills for postgraduate year 1 residents - Corrected Proof

2010-08-13

Background: The American College of Surgeons and Association of Program Directors in Surgery Phase 1 curriculum involves basic surgical skills instructional modules and Verification of Proficiency. This article is a study and revision of beta versions of the Verification of Proficiency instruments.Methods: Postgraduate year 1 residents were tested on 11 skills after undergoing lab instruction and practice. Deidentified videotaped performances were scored and data were analyzed to identify correlations between individual checklist items and failure.Results: In all, 23 residents underwent Verification of Proficiency over 2 years; 8 (35%) passed all Verification of Proficiency examinations at the first attempt, 15 (65%) failed at least 1 module, and 11 (48%) failed at least 2 modules. Residents who failed to demonstrate proficiency underwent mandatory remediation and retested until their scores were considered proficient. Scrutiny of the results revealed checklist items that were predictive independently of overall failure. The pass rate was significantly greater in 2009 compared with 2008 after the introduction of rater training and consequences for failure.Conclusion: Verification of Proficiency provides a framework to evaluate learner progress toward skills proficiency. That we achieved 100% faculty compliance with more than 250 performances speaks to the feasibility of Verification of Proficiency. This approach should facilitate a more widespread Verification of Proficiency acceptance as a step closer to developing a final proficiency examination for basic surgical skills in postgraduate year 1 residents.

Do preclinical background and clerkship experiences impact skills performance in an accelerated internship preparation course for senior medical students? - Corrected Proof

Wenjing Zeng, Julie Woodhouse, L. Michael Brunt — 2010-08-13

Background: Dedicated skills courses may help to prepare 4th-year medical students for surgical internships. The purpose of this study was to analyze the factors that influence the preparedness of 4th-year medical students planning a surgical career, and the role that our skills course plays in that preparedness.Methods: A comprehensive skills course for senior medical students matching in a surgical specialty was conducted each spring from 2006 through 2009. Students were surveyed for background skills, clerkship experience, and skills confidence levels (1–5 Likert scale). Assessment included 5 suturing and knot-tying tasks pre- and postcourse and a written examination. Data are presented as mean values ± standard deviations; statistical analyses were by 2-tailed t test, linear regression, and analysis of variance.Results: Sixty-five 4th-year students were enrolled; most common specialties were general surgery (n = 22) and orthopedics (n = 16). Thirty-five students were elite musicians (n = 16) or athletes (n = 19) and 8 regular videogamers. Suturing task times improved significantly from pre- to postcourse for all 5 tasks (total task times pre, 805 ± 202 versus post, 627 ± 168 seconds [P < .0001]) as did confidence levels for 8 skills categories, including management of on-call problems (P < .05). Written final examination proficiency (score ≥70%) was achieved by 81% of students. Total night call experience 3rd year was 23.3 ± 10.7 nights (7.3 ± 4.3 surgical call) and 4th year 10.5 ± 7.4 nights (7.2 ± 6.8 surgical call). Precourse background variables significantly associated with outcome measures were athletics with precourse suturing and 1-handed knot tying (P < .05); general surgery specialty and instrument tying (P = .012); suturing confidence levels and precourse suturing and total task times (P = .024); and number of nonsurgical call nights with confidence in managing acute on-call problems (P = .028). No significant correlation was found between these variables and postcourse performance.Conclusion: Completion of an accelerated skills course results in comparable levels of student performance postcourse across a variety of preclinical backgrounds and clerkship experiences.

Dr John W. Kirklin (1917–2004): A unique surgeon - Corrected Proof

Joaquin S. Aldrete — 2010-08-13

I first met Dr John W. Kirklin in January of 1964 when I was assigned as a second assistant resident to his cardiovascular surgery service at the Mayo Clinic in Saint Mary's Hospital. Dr Kirklin was an outstanding surgeon in every way—an accomplished technical surgeon, an innovator, a developer, an educator, and in every way a high achiever. He did 4–6 major operations each of 4 days a week and his service had 30 or more hospitalized patients almost all the time. As a teacher, he emphasized the importance of following a logical, sequential process of decision making in managing patients. He always sat down with patients and their relatives and discussed the disease process, its natural history, and the alternative treatments and made his recommendations of operation with its expectations and risks. After the conclusion of his operations, he would inform the waiting relatives, via telephone, that the procedure had been completed and he would discuss the results of the operation with the relatives later that day. We all learned not only from his operative methods, but also by his example of how to treat the patients and their relatives in a professional, truthful, and compassionate way.

Progression and survival results after radical hepatic metastasectomy of indolent advanced neuroendocrine neoplasms (NENs) supports an aggressive surgical approach - Corrected Proof

2010-08-05

Background: Neuroendocrine neoplasms most commonly metastasize to the liver. Operative extirpation of neuroendocrine neoplasm hepatic metastases improves symptoms and seems to improve survival, but subsequent evidence is required. The current study evaluates the progression-free survival and overall survival of patients after resection (with or without ablation) of neuroendocrine neoplasm hepatic metastases. As a secondary endpoint, the prognostic factors associated with progression-free survival and overall survival were evaluated.Methods: Seventy-four patients with neuroendocrine neoplasm hepatic metastases underwent hepatic resection between December 1992 and December 2009. Thirty-eight patients underwent synchronous cryoablation. Patients were assessed radiologically and serologically at monthly intervals for the first 3 months and then at 6-month intervals after treatment. Progression-free survival and overall survival were determined; clinicopathologic and treatment-related factors associated with progression-free survival and overall survival were evaluated through univariate and multivariate analyses.Results: No patient was lost to follow-up. The median follow-up for the patients who were alive was 41 months (range, 1–162). The median progression-free survival and overall survival after hepatic resection were 23 and 95 months, respectively. Five- and 10-year overall survival were 63% and 40%, respectively. Two independent factors were associated with overall survival: histologic grade (P < .001) and extrahepatic disease (P = .021). The only independent predictor for progression-free survival was pathologic margin status (P = .023).Conclusion: In selected patients, aggressive operative extirpation of neuroendocrine neoplasm hepatic metastases is effective in achieving long-term survival. Disease progression, however, is a common occurrence; therefore, a multimodality treatment approach for progressive disease is necessary. Integrating the knowledge of identified prognostic factors can both improve patient selection and identify patients at greatest risk of treatment failure.

The association of acute aortic dissection with Helicobacter pylori virulence specific serotypes: Distinct diversity of systemic antibodies to CagA and VacA genotypes - Corrected Proof

2010-08-05

Background: Previous studies reported an association between chronic Helicobacter pylori infection and cardiovascular disease; however, controversy still exists regarding the presence of bacterial genomic material in atherosclerotic plaques. Currently, the genetic polymorphisms of H. pylori have been investigated and many virulence factors have been identified. No one has tried to associate these polymorphisms with aortic dissections. This study evaluated whether more virulent strains of H. pylori represent a risk factor for acute ascending aorta dissections.Methods: The serologic status for H. pylori and type I strains were determined in 100 patients who underwent operative repair of acute, ascending aorta dissection and in 100 population-based control subjects matched fully for clinical, demographic, and socioeconomic characteristics. The specimens from dissected aorta were evaluated to identify the presence of bacterial genomic material in surgical patients.Results: No evidence of genomic material from H. pylori was found in the specimens. The prevalence of positive H. pylori serology was greater in patients than in controls (72 vs 50) with an adjusted odds ratio 2.8 (95% confidence interval, 1.8–4.1; P = .006). Patients with aortic dissection also had a greater prevalence of vacuolating cytotoxin gene subtypes s1m1 (73% vs 31%) with an odds ratio of 6.0 (95% confidence interval, 3.1–11; P < .001). Patients who were positive for vacuolating cytotoxin gene subtypes s1m1 were similar in demographic and clinical features compared with other patients.Conclusion: The findings provide support for the hypothesis that an association exists between the more virulent type I strains of H. pylori (vacuolating cytotoxin gene subtypes s1m1) infection and acute aortic dissection. The mechanism(s) underlying the association remain to be elucidated.

Chronic pancreatitis complicated by cavernous transformation of the portal vein: Contraindication to surgery? - Corrected Proof

2010-08-05

Background: A subgroup of patients with chronic pancreatitis and severe incapacitating pain develop mesentericoportal vascular complications with extrahepatic portal hypertension (EPH) and subsequent cavernous transformation. The purpose of this study was to address the question of whether a noninterventional approach regarding surgery is justified.Methods: A total of 702 patients with chronic pancreatitis underwent major pancreatic surgery. EPH with cavernous transformation was diagnosed in 21 (3%; group C) and EPH without cavernous transformation in 60 (9%; group B). The remaining 621 patients (88%; group A) showed no evidence for extrahepatic hypertension or cavernous transformation. Prospectively collected data were analyzed with respect to perioperative parameters, outcomes, quality of life, and our previously established pain score.Results: Patients in groups C and B had longer history and greater severity of pain (P = .0001). Group C had the longest operative times (P > .05) and greatest requirements of intraoperatively transfused packed red blood cells (P < .05). Morbidity was greater in group C compared with groups B and A (88% vs 55% vs 35%; P < .001). Mortality was 10% (2/21) in group C, compared with 1.3% (8/621) in group A and 0% in group B (P = .008). Quality of life as well as pain scores significantly improved postoperatively in group C, and were comparable to those in groups A and B (P < .001).Conclusion: Concomitant cavernous transformation in patients with chronic pancreatitis increases the operative risk significantly. Alternative treatment modalities should be evaluated thoroughly in every individual patient to offer every patient the best available treatment. Nevertheless, operative intervention is often the only treatment possible and improvements in quality of life and pain alleviation justify operative interventions.

Optimal duration of prophylactic antibiotic administration for elective colon cancer surgery: A randomized, clinical trial - Corrected Proof

2010-07-23

Background: Procedures for perioperative infection prophylaxis in elective colon cancer surgery consist of preoperative mechanical preparation, chemical preparation with oral antibiotic administration, perioperative intravenous antibiotic administration, and others. However, the optimal combination of these procedures and drugs and their durations of administration have not yet been established. A randomized study was conducted to determine the optimal duration of perioperative antibiotic administration with use of mechanical and chemical preparation.Methods: A total of 370 patients who were to undergo elective colon cancer surgery were randomized into 2 groups. After mechanical and chemical preparations, a single, 1-g dose of flomoxef was administered immediately before surgery to patients in group A. Flomoxef 1 g was administered twice daily for a total of 4 days from the day of surgery to postoperative day 3 to patients in group B.Results: Comparison was performed between 179 patients in group A and 181 patients in group B with analyzable data. The incidences of incisional surgical site infections (SSIs), organ/space SSIs, and remote infections (RIs) were 15 patients (8.4%), 1 patient (0.6%), and 8 patients (4.5%), respectively, in group A, and 13 patients (7.2%), 2 patients (1.1%), and 6 patients (3.3%), respectively, in group B. There were no differences in the incidence of incisional SSIs, organ/space SSIs, or RIs between groups A and B.Conclusion: It was shown that a single dose of intravenous antibiotic immediately before surgery is sufficient as perioperative infection prophylaxis in elective colon cancer surgery when mechanical and chemical preparation is performed.

Disseminated intravascular coagulation at an early phase of trauma is associated with consumption coagulopathy and excessive fibrinolysis both by plasmin and neutrophil elastase - Corrected Proof

2010-07-23

Background: The aims of the present study were to confirm the consumption coagulopathy of disseminated intravascular coagulation with the fibrinolytic phenotype at an early phase of trauma and to test the hypothesis that thrombin-activatable fibrinolysis inhibitor, neutrophil elastase, and plasmin contribute to the increased fibrinolysis of this type of disseminated intravascular coagulation. Furthermore, we hypothesized that disseminated intravascular coagulation at an early phase of trauma progresses dependently to disseminated intravascular coagulation with a thorombotic phenotype from 3 to 5 days after injury.Methods: Fifty-seven trauma patients, including 30 patients with disseminated intravascular coagulation and 27 patients without disseminated intravascular coagulation, were studied prospectively. Levels of thrombin-activatable fibrinolysis inhibitor, tissue-type plasminogen activator plasminogen activator inhibitor-1 complex, plasmin alpha2 plasmin inhibitor complex, D-dimer, neutrophil elastase, and fibrin degradation product by neutrophil elastase were measured on days 1, 3, and 5 after trauma. The prothrombin time, fibrinogen, fibrin/fibrinogen degradation product, antithrombin, and lactate also were measured.Results: Independent of the lactate levels, disseminated intravascular coagulation patients showed a prolonged prothrombin time, lesser fibrinogen and antithrombin levels, and increased levels of fibrin/fibrinogen degradation product on day 1. Disseminated intravascular coagulation diagnosed on day 1 continued to late-phase disseminated intravascular coagulation on days 3 and 5 after trauma. Increased levels of tissue-type plasminogen activator plasminogen activator inhibitor-1 complex, plasmin alpha2 plasmin inhibitor complex, D-dimer, neutrophil elastase, and fibrin degradation product by neutrophil elastase but not thrombin-activatable fibrinolysis inhibitor were observed in the disseminated intravascular coagulation patients. No correlation was observed between plasmin alpha2 plasmin inhibitor complex and fibrin degradation product by neutrophil elastase in disseminated intravascular coagulation patients. Multiple regression analysis showed the disseminated intravascular coagulation score and the tissue-type plasminogen activator plasminogen activator inhibitor-1 complex levels on day 1 to correlate with the total volume of transfused blood. Patient prognosis deteriorated in accordance with the increasing disseminated intravascular coagulation severity.Conclusion: Disseminated intravascular coagulation at an early phase of trauma is associated with consumption coagulopathy and excessive fibrinolysis both by plasmin and neutrophil elastase independent of hypoperfusion and continues to disseminated intravascular coagulation at a late phase of trauma. Increased fibrinolysis requires more blood transfusions, contributing to a poor patient outcome.

Propranolol decreases cardiac work in a dose-dependent manner in severely burned children - Corrected Proof

Felicia N. Williams, David N. Herndon, Gabriela A. Kulp, Marc G. Jeschke — 2010-07-02

Background: Severe burn is followed by profound cardiac stress. Propranolol, a nonselective β1, β2-receptor antagonist, decreases cardiac stress, but little is known about the dose necessary to cause optimal effect. Thus, the aim of this study was to determine in a large, prospective, randomized, controlled trial the dose of propranolol that would decrease heart rate ≥15% of admission heart rate and improve cardiac function. Four-hundred six patients with burns >30% total body surface area were enrolled and randomized to receive standard care (controls; n = 235) or standard care plus propranolol (n = 171).Methods: Dose–response and drug kinetics of propranolol were performed. Heart rate and mean arterial pressure (MAP) were measured continuously. Cardiac output (CO), cardiac index, stroke volume, rate–pressure product, and cardiac work (CW) were determined at regular intervals. Statistical analysis was performed using analysis of variance with Tukey and Bonferroni corrections and the Student t test when applicable. Significance was accepted at P < .05.Results: Propranolol given initially at 1 mg/kg per day decreased heart rate by 15% compared with control patients, but was increased to 4 mg/kg per day within the first 10 days to sustain treatment benefits (P < .05). Propranolol decreased CO, rate–pressure product, and CW without deleterious effects on MAP. The effective plasma drug concentrations were achieved in 30 minutes, and the half-life was 4 hours.Conclusion: The data suggest that propranolol is an efficacious modulator of the postburn cardiac response when given at a dose of 4 mg/kg per day, and decreases and sustains heart rate 15% below admission heart rate.

Chemokine receptor CXCR4 overexpression predicts recurrence for hormone receptor-positive, node-negative breast cancer patients - Corrected Proof

2010-07-02

Background: The expected outcome for hormone receptor-positive, node-negative patients should be favorable. However, some patients do develop metastatic disease and the mechanism for this observation is poorly understood. CXCR4 is a chemokine receptor that has been implicated to play a pivotal role in breast cancer growth and metastasis. Its predictive role has not been fully evaluated. We determined to see whether CXCR4 can predict outcome in this subset of patients.Methods: We accrued and analyzed data from 101 patients with hormone receptor-positive, node-negative breast cancers. The CXCR4 level was detected using Western blots and its level was defined as either low (<6.6-fold) or high (≥6.6-fold). Primary end points were systemic cancer recurrence and death. Statistical analysis performed included Spearman's correlation, Kaplan-Meier survival analysis, and Cox proportional hazard model.Results: Although benign breast tissues had an undetectable level of CXCR4, all 101 cancer specimens had overexpressed CXCR4 (mean 6.4 ± 3.4-fold). There were 79 patients in the low CXCR4 group and 22 patients in the high CXCR4 group. High CXCR4 overexpression was predictive of both cancer recurrence (P = .002) and overall survival (P = .0012).Conclusion: High CXCR4 overexpression in primary tumors was predictive of worse outcomes in hormone receptor-positive, node-negative breast cancer patients.