Surgery - Articles in Press

Early surgical outcomes comparison between robotic and conventional open thyroid surgery for papillary thyroid microcarcinoma - Corrected Proof

2012-01-30

Background: Robotic operations have enabled a safer and more meticulous approach to thyroidectomy with the notable benefit of improved cosmesis and decreases in postoperative pain and swallowing discomfort. The aim of this study was to document the early surgical outcomes of robotic thyroidectomy in patients with papillary thyroid carcinoma (PTC) by comparing it with conventional open thyroidectomy.Methods: From October 2007 to September 2008, 458 patients with PTC underwent thyroidectomy at the Yonsei University Health System. Of these patients, 266 patients were in the conventional open group and 192 patients were in the robotic group. These 2 groups were compared retrospectively with respect to clinicopathologic characteristics and surgical outcomes.Results: The mean follow-up period was 29.1 months. Mean tumor size, incidence of capsular invasion, multiplicity, and central nodal metastasis showed no significant difference between the 2 groups. Total thyroidectomy was performed more frequently in the open group. In terms of operation times, the robotic group had a significantly greater length of time for total thyroidectomy and subtotal thyroidectomy. The total number of retrieved central lymph nodes was greater in the open group (5.7 versus 4.6, P = .004). The 2 groups showed no differences in intraoperative and postoperative complications. The postoperative serum thyroglobulin levels were similar in both groups (0.25 versus 0.22 ng/mL, P = .648) and 2-year follow-up sonography of 433 patients revealed no recurrences. No abnormal I131 uptake was observed in whole-body scans in either group.Conclusion: Robotic thyroidectomy was similar to conventional open thyroidectomy in terms of early surgical outcomes but offers advantages. We conclude that robotic thyroidectomy offers a safe, feasible alternative to conventional open thyroidectomy in patients with PTC.

Liposome-encapsulated curcumin suppresses neuroblastoma growth through nuclear factor-kappa B inhibition - Corrected Proof

2012-01-30

Background: Nuclear factor-κB (NF-κB) has been implicated in tumor cell proliferation and survival and in tumor angiogenesis. We sought to evaluate the effects of curcumin, an inhibitor of NF-κB, on a xenograft model of disseminated neuroblastoma.Methods: For in vitro studies, neuroblastoma cell lines NB1691, CHLA-20, and SK-N-AS were treated with various doses of liposomal curcumin. Disseminated neuroblastoma was established in vivo by tail vein injection of NB1691-luc cells into SCID mice, which were then treated with 50 mg/kg/day of liposomal curcumin 5 days/week intraperitoneally.Results: Curcumin suppressed NF-κB activation and proliferation of all neuroblastoma cell lines in vitro. In vivo, curcumin treatment resulted in a significant decrease in disseminated tumor burden. Curcumin-treated tumors had decreased NF-κB activity and an associated significant decrease in tumor cell proliferation and an increase in tumor cell apoptosis, as well as a decrease in tumor vascular endothelial growth factor levels and microvessel density.Conclusion: Liposomal curcumin suppressed neuroblastoma growth, with treated tumors showing a decrease in NF-κB activity. Our results suggest that liposomal curcumin may be a viable option for the treatment of neuroblastoma that works via inhibiting the NF-κB pathway.

Survival in patients with recurrent hepatocellular carcinoma after primary hepatectomy: Comparative effectiveness of treatment modalities - Corrected Proof

Cheng-Maw Ho, Po-Huang Lee, Wen-Yi Shau, Ming-Chih Ho, Yao-Ming Wu, Rey-Heng Hu — 2012-01-30

Background: Insufficient data are available on the survival of recurrent hepatocellular carcinoma after primary hepatectomy in patients receiving different treatments. We evaluated retrospectively the effects of treatment modalities on long-term survival.Methods: Between 2001 and 2007, 435 posthepatectomy hepatocellular carcinoma patients who developed recurrence were grouped by treatment modality into re-resection, radiofrequency ablation, transarterial chemoembolization, and supportive treatment groups. Treatment strategies for both primary hepatocellular carcinoma and its recurrence were selected using the same criteria. Postrecurrence survival was estimated using the Kaplan–Meier method and compared using the Cox proportional hazard model with adjusted independent prognostic factors. Survival rates after primary resection without recurrence were also compared.Results: In re-resection, radiofrequency ablation, transarterial chemoembolization, and supportive treatment groups, the 2-year postrecurrence survival rates were 90%, 96%, 75%, and 20%, respectively, and the 5-year survival rates were 72%, 83%, 56%, and 0%, respectively. The adjusted hazard of death was less for the re-resection and radiofrequency ablation groups than for the transarterial chemoembolization group, and the adjusted hazard ratios for the re-resection and radiofrequency ablation groups were 0.45 (95% confidence interval, 0.20–0.98) and 0.25 (0.08–0.81), respectively. The adjusted hazard ratio (95% confidence interval) of death for the radiofrequency ablation group compared to the re-resection group was 0.64 (0.19–2.19). Survival in the single resection group did not differ from that in the re-resection and radiofrequency ablation groups.Conclusion: Postrecurrence survival in the re-resection and radiofrequency ablation groups was significantly better than that in the transarterial chemoembolization group and similar to that of patients in the primary resection without recurrence group.

Laparoscopic resection of exocrine carcinoma in central and distal pancreas results in a high rate of radical resections and long postoperative survival - Corrected Proof

2012-01-30

Background: The role of laparoscopic resection in patients with pancreatic cancer remains to be clarified, because previous reports have not clearly defined oncologic outcomes. The objective of the present study was to investigate this question with the rate of R0 resection and long-term survival as endpoints.Methods: This retrospective observational study included prospectively collected data from 40 patients operated laparoscopically with curative intent for exocrine pancreatic malignancies identified among 250 consecutive patients undergoing laparoscopic pancreatic operations since 1997. All 40 patients had histologically verified exocrine pancreatic carcinoma.Results: Ten patients (25%) with typical ductal adenocarcinoma of the pancreas were deemed nonresectable by laparoscopic staging. Laparoscopic distal pancreatectomy was performed in 29 patients; 8 resections were combined with resections of adjacent organs and 1 removal of a malignant intraductal papillary mucinous neoplasm what appeared to be ectopic pancreatic tissue. In 1 patient, the resection was completed by hand-assisted technique, and 1 procedure was converted to open resection. Postoperative morbidity was 23% (n = 7). The median hospital stay was 5 days (range, 1–30). The rate of R0 resections was 93%. Postoperative 3-year survivals rates were 36% for the entire cohort (n = 30) and 30% in typical ductal adenocarcinoma (n = 21).Conclusion: Laparoscopic distal pancreatectomy for exocrine pancreatic carcinoma is comparable with outcomes after open surgery and supports the concept that laparoscopic distal pancreatectomy is a safe, oncologic procedure.

Resection of liver metastases from breast cancer: Estrogen receptor status and response to chemotherapy before metastasectomy define outcome - Corrected Proof

2012-01-30

Background: The oncologic benefit of resecting liver metastases in patients with breast cancer is unclear. This study was performed to identify predictors of survival after hepatectomy.Methods: Between 1997 and 2010, 86 patients underwent resection of breast cancer liver metastases. Clinicopathologic characteristics of the primary breast neoplasm, timing of metastasis development, and treatment were recorded. Response to prehepatectomy chemotherapy was evaluated according to Response Criteria in Solid Tumors criteria, and the best response to chemotherapy during treatment and the response immediately before hepatectomy were noted. Univariate and multivariate analyses were performed to identify predictors of disease-free survival and overall survival.Results: Fifty-nine patients (69%) had estrogen receptor– or progesterone receptor– positive primary breast neoplasms. Fifty-three patients (62%) had a solitary breast cancer liver metastasis, and 73 (85%) had breast cancer liver metastases ≤5 cm. Sixty-five patients (76%) received prehepatectomy hormonal and/or chemotherapy. Four patients (6%) had progressive disease as the best response, and 19 patients (30%) had progressive disease before hepatectomy (P < .001). Seventy percent of patients who received preoperative chemotherapy or hormonal therapy had either response or stable disease immediately before hepatectomy. No postoperative deaths were observed. At a 62-month median follow-up, the disease-free survival and overall survival were 14 and 57 months, respectively. On univariate analysis, estrogen receptor/progesterone receptor status of the primary breast neoplasm, best radiographic response, and preoperative radiographic response were associated with overall survival. On multivariate analysis, estrogen receptor–negative primary breast disease (P = .009; hazard ratio, 3.3; 95% confidence interval, 1.4–8.2) and preoperative progressive disease (P = .003; hazard ratio, 3.8; 95% confidence interval, 1.6–9.2) were associated with decreased overall survival.Conclusion: Resection of breast cancer liver metastases in patients with estrogen receptor–positive disease that is responding to chemotherapy is associated with improved survival. The timing of operative intervention may be critical; resection before progression is associated with a better outcome.

Surgical management for advanced duodenal adenomatosis and duodenal cancer in Dutch patients with familial adenomatous polyposis: A nationwide retrospective cohort study - Corrected Proof

2012-01-24

Background: Duodenal cancer is a major cause of mortality in patients with familial adenomatous polyposis (FAP). The clinical challenge is to perform duodenectomy before cancer develops; however, procedures are associated with complications. Our aim was to gain insight into the pros and cons of prophylactic duodenectomy.Methods: Patients with FAP from the nationwide Dutch polyposis registry who underwent prophylactic duodenectomy or were diagnosed with duodenal cancer were identified and classified as having benign disease or cancer at preoperative endoscopy. Surveillance, clinical presentation, surgical management, outcome, survival, and recurrence were compared.Results: Of 1,066 patients with FAP in the registry, 52 (5%; 25 males) were included: 36 with benign adenomatosis (median: 48 years old; including two (6%) cancer cases diagnosed after operation), and 16 with cancer (median: 53 years old). Cancer cases had been diagnosed with colorectal cancer more often (6% vs 44%; P < .01). Forty-three patients underwent duodenectomy (35 benign/eight cancer): 30-day mortality was 4.7% (n = 2), and in-hospital morbidity occurred in 21 patients (49%), without differences between patients with benign adenomatosis and cancer. Adenomas recurred in reconstructed proximal small bowel in 14 of 28 patients (50%, median time to recurrence: 75 months), and one patient developed cancer. Median survival of all 18 cancer cases in the registry (1.7%; 12 ampullary/six duodenal) was 11 months.Conclusion: Prognosis of duodenal cancer in patients with FAP is poor, which justifies an aggressive approach to advanced benign adenomatosis. Strict adherence to recommended surveillance intervals is essential for a well-timed intervention. Given the substantial morbidity and mortality of duodenectomy, patients’ individual characteristics are to be critically evaluated preoperatively. As adenomas recur, postoperative endoscopic surveillance is mandatory.

Variations in surgical outcomes associated with hospital compliance with safety practices - Corrected Proof

2012-01-19

Background: The Leapfrog Group aims to improve patient safety by promoting hospital compliance with National Quality Forum (NQF) safe practices. It is unknown, however, whether implementation of these safety practices improve outcomes after high-risk operations.Methods: We conducted a cross-sectional analysis of 658 nationwide hospitals that responded to the 2005 Leapfrog Group Hospital Quality & Safety survey. A total of 79,462 patients were identified from Medicare claims data who underwent a pancreatectomy, hepatectomy, esophagectomy, open aortic aneurysm repair, colectomy, or gastrectomy procedure from 2004 through 2006. Random effects logistic regression models were used to estimate the association between hospital compliance with NQF safe practices and risk-adjusted odds of complications, rate of failure to rescue, and mortality after adjusting for patient- and hospital-level confounders.Results: Of the 658 hospitals that responded to surveys, 41% had fully implemented NQF safe practices and 59% reported partial compliance with these standards. Compared with hospitals with partial NQF compliance, we found evidence that hospitals with full compliance had an increased likelihood of diagnosing a complication after any of the 6 high-risk operations (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.03–1.25), but had a decreased likelihood of failure to rescue (OR, 0.82; 95% CI, 0.71–0.96), and a decreased odds of mortality (OR, 0.80; 95% CI, 0.71–0.91).Conclusion: Despite having a greater rate of postoperative complications, hospitals fully complying with safe practices were associated with less failure to rescue and decreased mortality after high-risk operations. These results highlight the importance of having hospital systems in place to promote safety and manage postoperative complications.

A controlled clinical trial of the effect of gastric bypass surgery and intensive lifestyle intervention on nocturnal hypertension and the circadian blood pressure rhythm in patients with morbid obesity - Corrected Proof

2012-01-19

Background: Nocturnal hypertension, increased night-to-day systolic blood pressure (BP) ratio and nondipper status (night-to-day systolic BP ratio > 0.9) are associated with an increased risk of cardiovascular disease. Our aim was to compare the 1-year effect of Roux-en-Y gastric bypass (RYGB) vs a program of intensive lifestyle intervention (ILI) only on nocturnal hypertension and circadian BP rhythm.Methods: The study participants were part of a 1-year, controlled clinical trial comparing the effect of RYGB or ILI on obesity-related comorbidities. Ninety participants (49 in the RYGB group) successfully completed 24-hour ambulatory BP monitoring at baseline and follow-up and were eligible subsequently for analysis.Results: A total of 71 subjects (79%) had nocturnal hypertension at baseline. The number of subjects with nocturnal hypertension decreased from 42 to 14 in the RYGB group (P ≤ .001) and from 29 to 27 (P = .791) in the ILI group. Subjects in the RYGB group had a lesser adjusted odds ratio (OR) of nocturnal hypertension at follow-up (OR 0.15; 95% confidence interval, 0.05–0.42; P ≤ .001); however, after further adjustment for weight loss, there was no additional beneficial effect of RYGB (P = .674). No differences between groups regarding improvement in the night-to-day systolic BP ratio were found after adjustment for 24-hour systolic pressure (P = .107). Both interventions showed a decrease in the proportion of subjects classified as nondippers, namely, 44% (P ≤ .001) and 28% (P = .002) in the RYGB and ILI groups, respectively.Conclusion: Only RYGB was associated with a decrease in the prevalence of nocturnal hypertension. Both interventions showed an improvement in dipper status, although RYGB was more effective.

Impact of subcentimeter margin on outcome after hepatic resection for colorectal metastases: A meta-regression approach - Corrected Proof

2012-01-19

Background: The optimal margin width and its influence on outcomes after hepatic resection for colorectal liver metastases is still controversial: a meta-analysis was conducted to analyze the impact of subcentimeter margin width on patient and disease-free survival after resection.Methods: A systematic search was performed, covering the last decade, following the Meta-analysis Of Observational Studies in Epidemiology guidelines. Relative risks (RRs) for patient and disease-free survival (DFS) were calculated after resection in relationship to a margin width >1 cm (R0 > 1 cm) and between 1 mm and 1 cm (R0 < 1 cm) using the DerSimonian and Laird random-effects model. Meta-regression was applied for covariate adjustment.Results: Eleven observational studies were identified involving 2823 patients. Overall, 59.1% of patients were R0 < 1 cm and 40.9% were R0 > 1 cm. Meta-analysis showed that compared with patients with margins R0 > 1 cm, a R0 < 1 cm margin lead to decreased 1-, 3-, and 5-year DFS with a RR of 1.17 (95% confidence interval [CI] 1.07–1.27), 1.38 (95% CI 1.16–1.65), and 1.55 (95% CI 1.25–1.91), respectively, but patient survival was obviously affected (P > .05 in all cases). Patients with margins of R0 < 1 cm differ from those with R0 > 1 cm for greater proportions of multiple metastases (RR 1.43; 95% CI 0.25–1.61) and synchronous bowel disease (RR 1.42; 95% CI 0.8–1.92). Meta-regression showed that these two covariates had a significant impact on DFS but not on patient survival.Conclusion: A resection margin width >1 cm is desirable even if patient survival is at best only slightly affected by subcentimeter margin as a consequence of a decreased DFS. The presence of multiple metastases and synchronous bowel neoplasm represent potential study selection biases that significantly decrease DFS; well-conducted, matched analyses consequently are essential to clarify the issue.

Selection algorithm for posterior versus lateral approach in laparoscopic adrenalectomy - Corrected Proof

Orhan Agcaoglu, Dursun Ali Sahin, Allan Siperstein, Eren Berber — 2012-01-19

Background: There are no objective selection criteria described in the literature for the laparoscopic posterior retroperitoneal (PR) vs lateral transabdominal (LT) approach in a given patient. The aim of this study is to quantify the algorithm we have been using in our practice.Methods: Within 11 years, 219 patients underwent laparoscopic adrenalectomy at one institution. The laparoscopic LT technique was used in patients with unilateral tumors >6 cm. In those patients with unilateral tumors <6 cm, anthropometric parameters were used to select between laparoscopic PR and LT approaches. These parameters were quantified for 82 patients from computed tomography scans and their effects on operative time were calculated. Statistical analyses were performed by use of the t test and logistic regression analysis.Results: Fifty-two patients underwent laparoscopic LT and 30 patients underwent PR adrenalectomy. Patients were selected for the PR approach if the distance from Gerota’s fascia to the skin was less than 5 cm and the 12th rib was at or rostral to the level of renal hilum. On multivariate analysis, total operative time correlated with body mass index in the LT approach and thickness of the perinephric fat and the distance between the adrenal tumor and the upper pole of kidney in the PR approach.Conclusion: In this study, we have described an objective algorithm that can be used to select patients with unilateral adrenal tumors <6 cm for a laparoscopic PR or LT approach with favorable perioperative outcomes.

Bile leakage after hepatobiliary and pancreatic surgery: Is the ISGLS definition too simple? - Corrected Proof

Dhiraj Sonbare — 2012-01-18

The International Study Group of Liver Surgery (ISGLS) classification is retrospective. Unlike classifications for laparoscopic bile duct injuries, which help in the management of postoperative bile leaks, the ISGLS classification is not prospective, which would help with management. In addition, postoperative cholecystectomy bile leaks take into account vascular injuries associated with bile leak, which is missing in the present classification.

Prognostic impact of marginal resection for patients with solitary hepatocellular carcinoma: Evidence from 570 hepatectomies - Corrected Proof

2012-01-13

Background: During resection of a hepatocellular carcinoma, surgeons encounter occasionally a situation where marginal resection is inevitable because of a close association between the hepatocellular carcinoma and major vasculature and/or underlying impaired liver function. We investigated the impact of marginal resection on recurrence-free survival after a resection of a solitary hepatocellular carcinoma.Methods: The data of 570 patients who underwent macroscopically curative hepatectomy for a solitary hepatocellular carcinoma in our institution between 1990 and 2007 were analyzed. Marginal resection and non–marginal resection were defined as a cancer-negative surgical margin of ≤1 mm and a surgical margin of >1 mm, respectively. The macroscopic appearance of the hepatocellular carcinoma was classified as the simple nodular type or non–simple nodular type based on the classification of the Liver Cancer Study Group of Japan, and patients were categorized into 4 groups: group A, simple nodular type with cirrhosis; group B, simple nodular type without cirrhosis; group C, non–simple nodular type with cirrhosis; and group D, non–simple nodular type without cirrhosis.Results: The surgical margins were diagnosed as cancer-positive in 31 patients, as marginal resection in 165 patients, and as non–marginal resection in 374 patients. The marginal resection group showed a better recurrence-free survival than the positive surgical margin group (P = .001), and also a worse recurrence-free survival than the non–marginal resection group (P = .003). In groups A, B, and C, the recurrence-free survival rates were similar between marginal resection and non–marginal resection patients (P = .458), while in group D, marginal resection was a significant poor prognostic factor of recurrence-free survival in both univariate and multivariate analyses.Conclusion: Marginal resection is acceptable in group A, B, and C patients, because it did not negatively affect postoperative recurrence-free survival.

The effect of adding fish oil to parenteral nutrition on hepatic mononuclear cell function and survival after intraportal bacterial challenge in mice - Corrected Proof

2012-01-13

Background: Parenteral nutrition (PN) is indispensable for meeting caloric and substrate needs of patients who cannot receive adequate amounts of enteral nutrition; however, PN impairs hepatic immunity. We examined the effects of ω-3 and -6 polyunsaturated fatty acids, added individually to fat-free PN, on hepatic immunity in a murine model. We focused on serum liver enzymes, cytokine production, histopathology, and the outcomes after intraportal bacterial challenge.Methods: Male Institute of Cancer Research mice were randomized into 4 groups; ad libitum chow (CHOW), fat-free PN (FF-PN), PN + fish oil (FO-PN), or PN + safflower oil (SO-PN). After the mice had been fed for 5 days, hepatic mononuclear cells (MNCs) were isolated. The number of MNCs was counted and cytokine production (tumor necrosis factor [TNF]-α and interleukin [IL]-10) by hepatic MNCs in response to lipopolysaccharide (LPS) was measured. Blood samples were analyzed for hepatobiliary biochemical parameters. Moreover, 1.0 × 107 pseudomonas aeruginosa were delivered by intraportal injection. Survival and histology were examined.Results: Hepatic MNC numbers were significantly less in the FO-PN and FF-PN than in the CHOW group, whereas the SO-PN group showed moderate recovery of hepatic MNC numbers. The CHOW, FO-PN, and SO-PN groups showed LPS dose-dependent increases in TNF-α levels. These increases were blunted in the FF-PN group. IL-10 levels were increased LPS dose-dependently in the CHOW and FO-PN groups, but no marked changes were observed with LPS stimulation in the SO-PN and FF-PN groups. Plasma levels of aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase were significantly greater in the FF-PN than in the FO- and SO-PN and CHOW groups. The FO-PN group showed significantly improved survival compared with the SO-PN and FF-PN groups, showing essentially no morphologic hepatic abnormalities.Conclusion: Addition of fish oil to PN was advantageous in terms of reversing PN-induced deterioration of hepatic immunity, as reflected by altered cytokine production. Fish oil administration was also useful for preventing PN-induced hepatobiliary dysfunction. These changes seem to result in better survival and to protect against severe tissue damage after intraportal bacterial challenge. This therapy may have the potential to ameliorate PN-induced impairment of host immunity and thereby decrease morbidity and mortality.

The state of performance on the American Board of Surgery Qualifying Examination and Certifying Examination and the effect of residency program size on program pass rates - Corrected Proof

John L. Falcone, Giselle G. Hamad — 2012-01-13

Examinees must pass both the American Board of Surgery (ABS) Qualifying Examination (QE) and the ABS Certifying Examination (CE) to become board certified. The Residency Review Committee (RRC) expects that residency programs maintain a 65% first-time examinee pass rate on the ABS Examinations. Higher individual performance on the ABS QE and ABS CE has been linked with Alpha Omega Alpha status, medical class rank, the United States Medical Licensing Examination Step 1 score, United States Medical Licensing Examination Step 2 score, and the ABS In-Training Examination performance. Overall residency program pass rates on the ABS QE and the ABS CE from 2006 to 2011 are electronically published. Predictors for residency program performance are unknown.

Novel use of electronic whiteboard in the operating room increases surgical team compliance with pre-incision safety practices - Corrected Proof

2012-01-13

Background: Despite evidence that use of a checklist during the pre-incision time out improves patient morbidity and mortality, compliance with performing the required elements of the checklist has been low. In an effort to improve compliance, a standardized time out interactive Electronic Checklist System [iECS] was implemented in all hospital operating room (OR) suites at 1 institution. The purpose of this 12-month prospective observational study was to assess whether an iECS in the OR improves and sustains improved surgical team compliance with the pre-incision time out.Methods: Direct observational analyses of preprocedural time outs were performed on 80 cases 1 month before, and 1 and 9 months after implementation of the iECS, for a total of 240 observed cases. Three observers, who achieved high interrater reliability (kappa = 0.83), recorded a compliance score (yes, 1; no, 0) on each element of the time out. An element was scored as compliant if it was clearly verbalized by the surgical team.Results: Pre-intervention observations indicated that surgical staff verbally communicated the core elements of the time out procedure 49.7 ± 12.9% of the time. After implementation of the iECS, direct observation of 80 surgical cases at 1 and 9 months indicated that surgical staff verbally communicated the core elements of the time out procedure 81.6 ± 11.4% and 85.8 ± 6.8% of the time, respectively, resulting in a statistically significant (P < .0001) increase in time out procedural compliance.Conclusion: Implementation of a standardized, iECS can dramatically increase compliance with preprocedural time outs in the OR, an important and necessary step in improving patient outcomes and reducing preventable complications and deaths.

Video-assisted thoracoscopic surgery for esophageal cancer attenuates postoperative systemic responses and pulmonary complications - Corrected Proof

2012-01-13

Background: Less invasive operations such as laparoscopic surgery have been developed for treating gastrointestinal malignancies. However, the advantages of video-assisted thoracoscopic surgery for esophageal cancer (VATS-e) with regard to postoperative morbidity and mortality remains controversial.Methods: We investigated the postoperative clinical course of patients who underwent esophagectomy for esophageal cancer in terms of systemic inflammatory response syndrome (SIRS) induced by VATS-e (VATS-e group) or conventional open surgery (OS group) combined with laparoscopic gastric tube reconstruction.Results: Compared with the OS group (n = 27), the VATS-e group (n = 22) had a greater thoracic operation time (VATS-e versus OS, 181 ± 56 vs 143 ± 45 minutes, respectively), and lesser duration of stay in the intensive care unit (17 ± 2 vs 32 ± 21 hours, respectively). The VATS-e group also had a lesser SIRS duration (1.5 vs 4.3 days), a lesser incidence of SIRS, a lesser number of positive SIRS criteria, and lesser serum interleukin-6 levels immediately after operation and on postoperative day (POD) 1. The heart rate in the VATS-e group was less than that in the OS group on POD 3. The respiratory rate in the VATS-e group was significantly less than that in the OS group on PODs 3, 5, and 7. Although no difference was observed in the frequencies of postoperative complications between the 2 groups, the VATS-e group had less postoperative pneumonia.Conclusion: VATS-e attenuates postoperative SIRS, and is therefore a potentially less invasive operative procedure.

Capturing the teachable moment: A grounded theory study of verbal teaching interactions in the operating room - Corrected Proof

2012-01-13

Background: Teaching in the operating room is one of the major cornerstones of surgical education. As time available for intraoperative resident teaching diminishes, such teaching time becomes increasingly precious. We studied how surgeons communicate with residents during an operation, with the goal of enhancing intraoperative teaching opportunities.Methods: Grounded theory methodology was used to investigate intraoperative verbal communication during four videotaped surgical procedures. Utterance-by-utterance analysis was performed to generate codes for each surgeon–resident interaction. Interactions were then analyzed to determine the percentage time spent in verbal teaching, number of topics covered, times each topic was visited, and time per topic.Results: Four main types of teaching surgeon–resident verbal interaction were identified from 1306 interactions. Instrumental interactions were intended solely to move the operation forward. Pure teaching interactions served to educate the trainee, shape judgment, or enhance performance. Instrumental and Teaching interactions were directive but also contained teaching. Banter was discussion unrelated to the operation. Analysis of a subset of the operations demonstrated 13–29 topics covered per procedure, with each topic addressed between 1 and 8 times, and 25–330 seconds spent per topic. Most teaching instances were prompted by errors in resident performance.Conclusion: Instances of verbal teaching were numerous, arose opportunistically in this study, and focused typically on multiple points. To maximize teaching opportunities, the authors propose a structured approach to intraoperative teaching that involves identification of a limited set of specific learning objectives, followed by intraoperative teaching and postoperative debriefing targeted to those objectives.

Heparin-binding epidermal growth factor–like growth factor (HB-EGF) preserves gut barrier function by blocking neutrophil-endothelial cell adhesion after hemorrhagic shock and resuscitation in mice - Corrected Proof

Hong-yi Zhang, Iyore James, Chun-Liang Chen, Gail E. Besner — 2011-12-12

Background: We have shown that heparin-binding epidermal growth factor-like growth factor (HB-EGF) protects the intestines from injury in several different animal models, including hemorrhagic shock and resuscitation (HS/R). The current study was designed to explore the mechanisms underlying the anti-inflammatory role of HB-EGF in preservation of gut barrier function after injury.Methods: In vivo, HS/R was induced in wild-type and neutropenic mice, with or without administration of HB-EGF, and intestinal permeability determined by use of the everted gut sac method. In vitro, cultured human umbilical vein endothelial cells (HUVECs) and freshly isolated human peripheral blood mononuclear cells (PMNs) were used to determine the effects of HB-EGF on HUVEC-PMN adhesion, reactive oxygen species production in PMN, adhesion molecule expression in HUVEC and PMN, and the signaling pathways involved.Results: We found that administration of HB-EGF to healthy mice led to preservation of gut barrier function after HS/R. Likewise, induction of neutropenia in mice also led to preservation of gut barrier function after HS/R. Administration of HB-EGF to neutropenic mice did not lead to further improvement in gut barrier function. In vitro studies showed that HB-EGF decreased neutrophil-endothelial cell (PMN-EC) adherence by down-regulating adhesion molecule expression in EC via the phosphoinositide 3-kinase–Akt pathway, and by inhibiting adhesion molecule surface mobilization and reactive oxygen species production in PMN.Conclusion: These results indicate that HB-EGF preserves gut barrier function by inhibiting PMN and EC activation, thereby blocking PMN-EC adherence after HS/R in mice, and support the future use of HB-EGF in disease states manifested by hypoperfusion injury.

Radiation-induced platelet-endothelial cell interactions are mediated by P-selectin and P-selectin glycoprotein ligand-1 in the colonic microcirculation - Corrected Proof

2011-12-08

Background: Antiplatelet reagents have been reported to protect against intestinal damage associated with abdominal radiotherapy, but the mechanisms behind radiation-induced platelet-endothelium interactions are not known. We sought to define the adhesive mechanisms that regulate radiotherapy-induced platelet−endothelial cell interactions in the colon.Methods: All mice except the controls were exposed to abdominal radiation with a single dose of 20 Gray. Mice were pretreated with an isotype-matched control antibody or a monoclonal antibody directed against either P-selectin or P-selectin glycoprotein ligand-1 (PSGL-1). Platelet and leukocyte rolling and adhesion in the colon were determined by use of inverted intravital fluorescence microscopy 16 hours after radiation. Radiation-induced intestinal leakage of fluorescein isothiocyanate−conjugated dextran was examined in separate experiments.Results: Immunoneutralization of P-selectin decreased radiation-provoked platelet rolling by 87% and adhesion by 63%. Moreover, inhibition of PSGL-1 decreased platelet rolling and adhesion by 77% and 83%, respectively, in animals exposed to radiation. Similarly, inhibition of P-selectin and PSGL-1 decreased radiation-induced leukocyte rolling and adhesion by more than 84% and 90%, respectively, in the colon. In contrast, inhibition of P-selectin or PSGL-1 had no impact on radiation-induced intestinal leakage. In addition, systemic depletion of platelets and leukocytes did not affect intestinal barrier dysfunction in radiated animals.Conclusion: This study demonstrates that radiation-provoked platelet and leukocyte accumulation are mediated in part by P-selectin and PSGL-1. Radiation-induced gut leakage, however, is independent of accumulation of platelets and leukocytes in the intestinal microvasculature.

Comparison of intraoperative time use and perioperative outcomes for robotic versus laparoscopic adrenalectomy - Corrected Proof

Koray Karabulut, Orhan Agcaoglu, Shamil Aliyev, Allan Siperstein, Eren Berber — 2011-12-06

Background: Recently, robotic techniques have been described for adrenalectomy. However, scant data exist in the literature regarding the comparison of robotic with the conventional laparoscopic approach. We aimed to analyze intraoperative time use and perioperative outcomes in robotic vs laparoscopic adrenalectomy for both lateral transabdominal (LT) and posterior retroperitoneal (PR) approaches.Methods: A robotic adrenalectomy program was started in September 2008, and techniques for both the LT (n = 32) and PR (n = 18) approaches were established. Data of robotic cases were compared with those of 50 consecutive laparoscopic cases (LT = 32, PR = 18) before the onset of the program from a prospective, institutional review board-approved database. Operative times for individual steps of the procedures were captured from operative video recordings, including docking, exposure, dissection, and hemostasis.Results: For both LT and PR approaches, there was no difference when we compared the robotic with the laparoscopic groups regarding demographics, tumor type, and body mass index. For the LT approach, despite larger tumor size (x ± SEM) in the robotic vs the laparoscopic group (4.7 ± 0.4 vs 3.8 ± 0.4 cm, P = .05), the operative times were similar (168 ± 10 minutes vs 159 ± 8 minutes, P = .5). There was no difference between the two approaches regarding the time spent for the individual steps of the operation. In the PR approach, with similar tumor sizes (2.7 ± 0.3 cm vs 2.3 ± 0.3 cm, P = .4), operative time (minutes) was equivalent (166 ± 9 vs 170 ± 15; P = .8). Time spent intra-operatively for each step was similar, except for shorter hemostasis time in the robotic group (23 ± 4 minutes vs 42 ± 9 minutes, P = .03). The robotic docking time (21 vs 25 minutes) decreased by 50% in the second year of the study for both approaches. The presence of two staff surgeons vs a staff and a fellow decreased operative time for the robotic LT (P < .02) but not the robotic PR approach. For laparoscopic and robotic procedures, the morbidity was 10% and 2%, respectively. Overall, hospital stay was 1.5 ± 0.9 days (range, 1–4 vs 1.1 ± 0.3 days) (range, 1–2; P = .006). The percentage of patients requiring more than 1 day of hospital stay was 28% vs 14% (P = .09).Conclusion: To our knowledge, this is the first study reporting an intraoperative time analysis for robotic adrenalectomy. Intraoperative time use was similar between the laparoscopic and robotic groups for both LT and PR approaches. However, the morbidity was less and hospital stay was shorter after the robotic procedures.

Surgery in the early middle ages: Evidence of cauterisation from Pisa - Corrected Proof

Antonio Fornaciari, Valentina Giuffra — 2011-11-18

Archeologic excavations carried out in the famous Cathedral Square of Pisa brought to light a multiple ground grave dating to the early Middle Ages (8th–10th Centuries AD). The well preserved skull of an adult female aged about 30 years revealed some form of “surgical” intervention. In the central part of the frontal bone, 4 cm from the bregma, a 20 × 17 mm elliptical lesion limited by a shallow 1-mm thick groove is easily visible (, A); the surface of the lesion appears to be finely cribrose with minute bone crests radially disposed around a more marked central crest (, B). The endocranial surface is intact. The lesion appears to be the result of an inflammatory process of the soft tissues and the periostium that involved the underlying skull vault.

Incisional hernia after abdominal closure with slowly absorbable versus fast absorbable, antibacterial-coated sutures - Corrected Proof

Christoph Justinger, Jan Erik Slotta, Martin Karl Schilling — 2011-11-17

Background: Incisional hernia remains among the most common complications after midline incision of the abdominal wall. The role of the suture material used for abdominal wall closure remains controversial. To decrease bacterial adherence to surgical sutures, braided suture materials with antibacterial activity (Vicryl plus, Ethicon, Inc) were developed. This is the first study to analyze long-term results using an antibacterial-braided suture material for abdominal wall closure in a large clinical trial.Methods: To analyze the effects of Triclosan-coated suture material (Vicryl plus) on the development of incisional hernia, we performed a 36-month follow-up of 1,018 patients who had a primary midline incision for elective abdominal surgery. In the first time period, a PDS II loop suture was used. In the second observation period, we used Vicryl plus. All variables were recorded prospectively in a database. The primary outcome was the number of incisional hernias. Risk factors for the development of incisional hernias were collected prospectively to compare the 2 groups.Results: The overall incisional hernia rate in the 36-month follow-up period was 14.6%. Analyzing the influence of the suture material used on the development of incisional hernia, we did not find differences between the 2 groups (PDS II, 14%; Vicryl plus, 15.2%). In the multivariate analysis of possible factors in the study population, only body mass index (BMI) showed a significant influence on the development of incisional hernias. Despite the incidence of wound infections being less in the Vicryl plus group (6.1% vs 11.9%; P < .05), there were no difference in incidence of incisional hernia between the 2 groups.Conclusion: Fast absorbable sutures with antibacterial coating (Tricosan) do not increase the hernia rate after midline abdominal incision compared with slowly absorbable sutures, when wound infection rates are decreased by coating the fast absorbable suture with Triclosan. The development of incisional hernia is significantly increasing in patients with a BMI >30 kg/m2.

NBCA medical adhesive (n-butyl-2-cyanoacrylate) versus suture for patch fixation in Lichtenstein inguinal herniorrhaphy: A randomized controlled trial - Corrected Proof

Ying-mo Shen, Wen-bing Sun, Jie Chen, Su-jun Liu, Ming-gang Wang — 2011-11-17

Background: We compared the effectiveness of n-butyl-2-cyanoacrylate (NBCA) and traditional suture for patch fixation in Lichtenstein tension-free herniorrhaphy for inguinal hernias.Methods: A total of 110 patients with primary unilateral inguinal hernia were assigned randomly to either experimental or control groups. In the experimental group, NBCA adhesive was used during Lichtenstein herniorrhaphy; traditional suture was used in the control group. We evaluated operation time, postoperative duration of stay, visual analogue scale (VAS) pain score, incidence of chronic pain and hematoma formation, and hernia recurrence.Results: There was no hernia recurrence or wound infection in either group. In the experimental group, 2 local hematomas occurred while no patients experienced chronic postoperative pain; in the control group, 10 hematomas occurred, and 6 patients experienced chronic pain. There was no difference in postoperative duration of stay between the groups (P > .05), but the experimental group had a lesser operation time and postoperative VAS score (P < .05).Conclusion: The use of NBCA medical adhesive in tension-free inguinal herniorrhaphy is effective and safe.

Decrease in donor heart injury by recombinant clusterin protein in cold preservation with University of Wisconsin solution - Corrected Proof

2011-11-17

Background: Donor organ injury during cold preservation before transplantation negatively impacts graft survival. Clusterin (CLU) is a chaperonic protein, and its expression confers donor hearts resistance to cold ischemic injury. This study was conducted to evaluate if the supplement of recombinant CLU protein (rCLU) protects donor organs from injury during cold storage with University of Wisconsin (UW) solution.Methods: Human endothelial cell cultures were used as an in vitro model. Heart transplantation in mice was used as an in vivo model. Cell membrane disruption or death was indicated by the release of lactate dehydrogenase (LDH). Donor injury was determined by its functional recovery, and histologic and biochemical analyses.Results: Supplement of rCLU to UW solution protected cultured human endothelial cells from cold-induced cell necrosis, as evidenced by a decrease in both release of LDH and the number of ethidium bromide-stained necrotic cells. The protective activity of rCLU was associated with enhanced membrane fluidity at cold temperature. During cold storage of heart organs in UW solution, supplemental rCLU significantly decreased LDH release from heart tissue. In a preclinical model of transplantation, heart grafts after cold preservation with rCLU-containing UW solution had better functional recovery and decreased perivascular inflammation, neutrophil infiltration, and cardiac cell death, including apoptosis and necrosis, that correlated with lower levels of serum creatine kinase and LDH in recipients.Conclusion: Our data suggest that supplement of CLU protein in a cold preservation solution may have potential in improving cold preservation of donor organs in transplantation.

Pretreating mesenchymal stem cells with interleukin-1β and transforming growth factor-β synergistically increases vascular endothelial growth factor production and improves mesenchymal stem cell–mediated myocardial protection after acute ischemia - Corrected Proof

2011-11-17

Background: Mesenchymal stem cells (MSCs) improve postischemic myocardial function in part through their secretion of growth factors such as vascular endothelial growth factor (VEGF). Pretreating MSCs with various cytokines or small molecules can improve VEGF secretion and MSC-mediated cardioprotection. However, whether 1 cytokine can potentiate the effect of another cytokine in MSC pretreatment to achieve a synergistic effect on VEGF production and cardioprotection is poorly studied.Methods: MSCs were treated with interleukin (IL)-1β and/or transforming growth factor (TGF)-β1 for 24 hours before experiments. VEGF production was determined by enzyme-linked immunosorbent assay. Isolated hearts from adult male Sprague-Dawley rats were subjected to 15 minutes of equilibration, 25 minutes of ischemia, and 40 minutes reperfusion. Hearts (n = 5–7 per group) were randomly infused with vehicle, untreated MSCs, or MSCs pretreated with IL-1β and/or TGF-β1. Specific inhibitors were used to delineate the roles of p38 mitogen-activated protein kinase (MAPK) and SMAD3 in IL-1β– and TGF-β1–mediated stimulation of MSCs.Results: MSCs cotreated with IL-1β and TGF-β1 exhibited synergistically increased VEGF secretion, and they greatly improved postischemic myocardial functional recovery. Ablation of p38 MAPK and SMAD3 activation with specific inhibitors negated both IL-1β– and TGF-β1–mediated VEGF production in MSCs and the ability of these pretreated MSCs to improve myocardial recovery after ischemia.Conclusion: Pretreating MSCs with 2 cytokines may be useful to fully realize the potential of cell-based therapies for ischemic tissues.

Forging successful interdisciplinary research collaborations: A nationwide survey of departments of surgery - Corrected Proof

Caren A. Heller, Fabrizio Michelassi — 2011-11-17

Background: Our aim was to estimate the prevalence of academic surgeons engaged in interdisciplinary collaborations and identify success factors and challenges to establishing these collaborations.Methods: Chairs of surgery at US medical schools and selected hospitals and research institutes were surveyed in 2009 to determine the frequency, types, outcomes, and value of interdisciplinary collaborations; National Institutes of Health funding for these collaborations; major barriers and success factors; and departmental and institutional activities to promote collaborations.Results: Eighty-two department chairs (58%) completed the survey. Ninety-three percent answered that their faculty engaged in interdisciplinary collaborations, and 71% stated that it was critical for their research success. On average, 27% of full-time MDs/MD-PhDs were involved in collaborations compared to 81% of PhDs within their departments. The most frequent collaborators included other clinical (43%) and basic science (24%) departments. Only 5% indicated that their most frequent collaborators were with other university programs, primarily with bioengineering or biomedical engineering. Collaborations resulted most often in publications, research opportunities for surgical residents, and National Institutes of Health funding. Pilot funding and active networking were key success factors. Longer chair tenure was statistically significantly associated with more success factors and fewer barriers to collaborations. Surgeons were much less likely to participate in institution-wide efforts than in departmental activities, although these activities were ongoing in more than two-thirds of institutions.Conclusion: Surgeons value collaborations as critical for their research success. Our survey indicates the potential for additional collaborations through more involvement with institutional efforts and with other university faculty. Stable, supportive department chairs are critical to establishing these activities.

The experience of burnout across different surgical specialties in the United Kingdom: A cross-sectional survey - Corrected Proof

2011-11-17

Background: We used a cross-sectional e-mail survey to assess the prevalence of psychological morbidity across different surgical specialties and identify predictor variables of burnout in surgeons.Method: The survey was sent to 1971 surgeons from 127 National Health Service (NHS) hospital trusts across the United Kingdom. Burnout prevalence and mood were assessed using the Maslach Burnout Inventory-General Survey and Profile of Mood States (POMS), respectively. Demographic and POMS factors were investigated as predictors of burnout using linear and stepwise regression analyses.Results: Responses to the survey were received from 342 surgeons (17% response rate). One-third of 313 respondents showed high mean levels of burnout on exhaustion (2.32; standard deviation [SD], 1.62) and cynicism (2.34; SD, 1.44) subscales. Some specialties worked significantly more hours per week (F[8, 252] = 2.89; P = .004), but burnout prevalence did not differ significantly between specialty, grade, age, gender, hours worked per week, or years spent in post. The number of years in specialty (β = −0.17; P = .003) independently predicted surgeons’ scores on exhaustion. POMS factors significantly predicted burnout, where fatigue (β = 0.58; P < .001) was the best predictor of exhaustion scores, depression (β = 0.28; P < .001) the best predictor of cynicism, and vigor (β = 0.29; P < .001) the best predictor of professional efficacy. Management issues were cited as contributing to psychological morbidity.Conclusion: UK surgeons show high levels of cynicism and exhaustion burnout irrespective of their specialty, grade, or hours worked per week. Surgeons’ mood profiles significantly predicted burnout, indicating the POMS could be used as part of an assessment for preventive interventions. NHS management and infrastructure are highlighted as influences on surgeons’ psychological health.

The outcome of resected cystic pancreatic endocrine neoplasms: A case-matched analysis - Corrected Proof

2011-11-17

Introduction: Cystic pancreatic endocrine neoplasms (CPENs) are uncommon tumors with uncertain disease biology and ill-defined diagnostic features.Methods: A prospectively maintained pancreatic cyst registry was queried, and 31 cases of CPEN that were resected between 1995 and 2010 were identified. Patient and lesion characteristics were detailed and compared with resected non-PEN cystic lesions. Recurrence and survival outcome were compared with 31 noncystic PENs matched for functional status, differentiation, size, World Health Organization classification, grade, and presence of metastases.Results: During the study period, CPENs accounted for 7% of resected pancreatic cysts (31/469) and 12% of resected PENs (31/255). CPENs were primarily sporadic (94%), solitary (87%), nonfunctioning (100%), and incidentally discovered (68%). The median diameter was 2.1 cm (range, 0.9–6.2 cm), and preoperative imaging identified septations in 29%, a solid component in 26%, and cyst wall enhancement or a characteristic hypervascular rim in 45% of cases. Preoperative imaging and/or cytology suggested the diagnosis of CPEN in 61%. Compared with resected nonendocrine cystic lesions, CPEN were less frequently symptomatic, less likely to contain septations, and smaller. Compared with matched noncystic PENs, CPENs had comparable demographic, radiologic, and pathologic features and statistically similar long-term outcome (5-year disease-free survival: CPEN: 100% vs PEN: 86%, P = .947).Conclusion: In this study, CPENs were primarily asymptomatic small lesions that could be characterized in the majority of cases by cyst wall enhancement on preoperative imaging and/or cytologic assessment. No significant difference in recurrence or survival outcome was identified between cystic and noncystic PENs.

Reduction in endotoxemia, oxidative and inflammatory stress, and insulin resistance after Roux-en-Y gastric bypass surgery in patients with morbid obesity and type 2 diabetes mellitus - Corrected Proof

2011-11-17

Background: Roux-en-Y gastric bypass (RYGB) results in profound weight loss and resolution of type 2 diabetes mellitus (T2DM). The mechanism of this remarkable transition remains poorly defined. It has been proposed that endotoxin (lipopolysaccharide [LPS]) sets inflammatory tone, triggers weight gain, and initiates T2DM. Because RYGB may diminish LPS from endogenous and exogenous sources, we hypothesized that LPS and the associated cascade of oxidative and inflammatory stress would diminish after RYGB.Methods: Fifteen adults with morbid obesity and T2DM undergoing RYGB were studied. After an overnight fast, a baseline blood sample was collected the morning of surgery and at 180 days to assess changes in glycemia, insulin resistance, LPS, mononuclear cell nuclear factor (NF)-κB binding and mRNA expression of CD14, TLR-2, TLR-4, and markers of inflammatory stress.Results: At 180 days after RYGB, subjects had a significant decrease in body mass index (52.1 ± 13.0 to 40.4 ± 11.1), plasma glucose (148 ± 8 to 101 ± 4 mg/dL), insulin (18.5 ± 2.2 mμU/mL to 8.6 ± 1.0 mμU/mL) and HOMA-IR (7.1 ± 1.1 to 2.1 ± 0.3). Plasma LPS significantly reduced by 20 ± 5% (0.567 ± 0.033 U/mL to 0.443 ± 0.022E U/mL). NF-κB DNA binding decreased significantly by 21 ± 8%, whereas TLR-4, TLR-2, and CD-14 expression decreased significantly by 25 ± 9%, 42 ± 8%, and 27 ± 10%, respectively. Inflammatory mediators CRP, MMP-9, and MCP-1 decreased significantly by 47 ± 7% (10.7 ± 1.6 mg/L to 5.8 ± 1.0 mg/L), 15 ± 6% (492 ± 42 ng/mL to 356 ± 26 ng/mL) and 11 ± 4% (522 ± 35 ng/mL to 466 ± 35 ng/mL), respectively.Conclusion: LPS, NF-κB DNA binding, TLR-4, TLR-2, and CD14 expression, CRP, MMP-9, and MCP-1 decreased significantly after RYGB. The mechanism underlying resolution of insulin resistance and T2DM after RYGB may be attributable, at least in part, to the reduction of endotoxemia and associated proinflammatory mediators.

Evaluation of the International Study Group of Pancreatic Surgery definition of post-pancreatectomy hemorrhage in a high-volume center - Corrected Proof

2011-11-17

Background: Although postpancreatectomy hemorrhage (PPH) is observed infrequently after pancreatic surgery, it remains a serious complication with a high rate of mortality. Recently, the International Study Group of Pancreatic Surgery (ISGPS) issued a new definition for PPH. To evaluate and validate this new definition, we analyzed data retrospectively from our center.Methods: Data from 945 patients who underwent pancreatic surgery in our department between October 1993 and December 2009 were identified retrospectively from our prospective database with regard to the occurrences of PPH. We graded the hemorrhages recorded in our database according to the ISGPS consensus definition. We assessed the clinical course, morbidity, mortality, and duration of hospital stay for patients with grade B and C PPHs in comparison with patients who underwent pancreatic resections without hemorrhage.Results: Grade B PPH after pancreatic surgery occurred in 16 patients (1.7%), and grade C PPH occurred in 38 patients (4.0%). Mortality was significantly increased in PPH grades B and C compared with control patients (25.9% vs 2.0%; P < .001) and contributed to nearly one-half of the mortality in the present series. Morbidity was also increased in patients with grade B (76.5%) and C (94.6%) PPH compared with control patients (59.6%; P < .001). Grade B and C PPH correlated significantly with the incidence of grade C postoperative pancreatic fistula (14.8% vs 1.9%), grade C delayed gastric emptying (18.5% vs 4.0%), and wound infection (38.9% vs 13.5%) compared with control patients.Conclusion: This is the first clinical evaluation of the ISGPS PPH definition. Our data indicate that the new definition correlates well with morbidity, mortality, and duration of hospital stay. The definition, therefore, seems suitable for clinical and scientific applications.

Clinical relevance of single nucleotide polymorphisms of the high mobility group box 1 protein gene in patients with major trauma in Southwest China - Corrected Proof

2011-11-03

Background: High-mobility group box protein 1 (HMGB1) is a pivotal late mediator involved in the development of sepsis and multiple organ dysfunction syndrome (MODS) in critically ill patients. While several single nucleotide polymorphisms (SNPs) have been demonstrated to be critical determinants for outcome of critically ill patients, little is known about the clinical relevance of SNPs of the HMGB1 gene up to date.Methods: A total of 3 tag SNPs of the HMGB1 gene were selected using HapMap database and linkage disequilibrium analysis. The tag SNPs were genotyped using a pyrosequencing methodology in 556 unrelated patients with major trauma. Peripheral whole blood samples obtained immediately after admission were determined for HMGB1 production in response to ex vivo lipopolysaccharide (LPS) stimulation.Results: The rs2249825 SNP and the haplotype TCG were significantly associated with LPS–induced HMGB1 production by peripheral blood leukocytes. There were also significant differences in sepsis morbidity rate and MOD scores among patients with different genotypes of the rs2249825. In addition, the patients with the wild-type haplotype TCG had a lesser sepsis morbidity rate and MOD scores than those without the TCG haplotype.Conclusion: A total of 3 SNPs might act as tag SNPs for the entire HMGB1 gene. The rs2249825 and the haplotype TCG might be used as relevant risk estimate for the development of sepsis and MODS in patients with major trauma.

Pancreas-sparing duodenectomy with regional lymphadenectomy for pTis and pT1 ampullary carcinoma - Corrected Proof

2011-10-28

Background: The role of pancreas-sparing duodenectomy (PSD) in the treatment of ampullary carcinoma (Amp Ca) with local lymph node metastasis remains controversial. The aim of this study was to investigate the feasibility, safety, and long-term prognosis of PSD with regional lymphadenectomy in the treatment of early-stage (pTis/pT1) Amp Ca with or without regional lymph node metastasis.Methods: Between May 2005 and November 2009, 31 consecutive patients with Amp Ca were enrolled in this study; 25 underwent PSD. A retrospective control group of 28 patients who underwent pancreatoduodenectomy (PD) for Amp Ca during the same period was established. These 2 groups were matched in terms of demographic data, tumor size, and TNM classification.Results: In the PSD group, 9 patients (36%) had regional lymph node metastasis, and 23 patients (92%) had R0 resection. Patients who underwent PSD achieved favorable results in intraoperative blood loss, duration of hospital stay, and morbidity rate. The 3-year overall and disease-free survival in PSD group were 72% and 61%, respectively. There were no differences in hospital mortality and long-term survival between the 2 groups, even for patients with lymph node metastasis (N1).Conclusion: PSD with regional lymphadenectomy is feasible and safe in the treatment of pTis/pT1 Amp Ca with or without regional lymph node metastasis. Long-term survival and morbidity rates are also favorable. PSD can be performed as an alternative of PD in selected patients with Amp Ca.

Designing a proficiency-based, content validated virtual reality curriculum for laparoscopic colorectal surgery: A Delphi approach - Corrected Proof

Vanessa N. Palter, Maurits Graafland, Marlies P. Schijven, Teodor P. Grantcharov — 2011-10-24

Background: Although task training on virtual reality (VR) simulators has been shown to transfer to the operating room, to date no VR curricula have been described for advanced laparoscopic procedures. The purpose of this study was to develop a proficiency-based VR technical skills curriculum for laparoscopic colorectal surgery.Methods: The Delphi method was used to determine expert consensus on which VR tasks (on the LapSim simulator) are relevant to teaching laparoscopic colorectal surgery. To accomplish this task, 19 international experts rated all the LapSim tasks on a Likert scale (1–5) with respect to the degree to which they thought that a particular task should be included in a final technical skills curriculum. Results of the survey were sent back to participants until consensus (Cronbach’s α >0.8) was reached. A cross-sectional design was utilized to define the benchmark scores for the identified tasks. Nine expert surgeons completed all identified tasks on the “easy,” “medium,” and “hard” settings of the simulator.Results: In the first round of the survey, Cronbach’s α was 0.715; after the second round, consensus was reached at 0.865. Consensus was reached for 7 basic tasks and 1 advanced suturing task. Median expert time and economy of movement scores were defined as benchmarks for all curricular tasks.Conclusion: This study used Delphi consensus methodology to create a curriculum for an advanced laparoscopic procedure that is reflective of current clinical practice on an international level and conforms to current educational standards of proficiency-based training.

Acid suppression increases rates of Barrett’s esophagus and esophageal injury in the presence of duodenal reflux - Corrected Proof

2011-10-24

Background: The contribution of gastric acid to the toxicity of alkaline duodenal refluxate on the esophageal mucosa is unclear. This study compared the effect of duodenal refluxate when acid was present, decreased by proton pump inhibitors (PPI), or absent.Methods: We randomized 136 Sprague-Dawley rats into 4 groups: group 1 (n = 33) were controls; group 2 (n = 34) underwent esophagoduodenostomy promoting “combined reflux”; group 3 (n = 34) underwent esophagoduodenostomy and PPI treatment to decrease acid reflux; and group 4, the ‘gastrectomy’ group (n = 35) underwent esophagoduodenostomy and total gastrectomy to eliminate acid in the refluxate. Esophaguses were examined for inflammatory, Barrett’s, and other histologic changes, and expression of proliferative markers Ki-67, proliferating cell nuclear antigen (PCNA), and epidermal growth factor receptor (EGFR).Results: In all reflux groups, the incidence of Barrett’s mucosa was greater when acid was suppressed (group C, 62%; group D, 71%) than when not suppressed (group B, 27%; P = 0.004 and P < .001). Erosions were more frequent in the PPI and gastrectomy groups than in the combined reflux group. Edema (wet weight) and ulceration was more frequent in the gastrectomy than in the combined reflux group. Acute inflammatory changes were infrequent in the PPI group (8%) compared with the combined reflux (94%) or gastrectomy (100%) groups, but chronic inflammation persisted in 100% of the PPI group. EGFR levels were greater in the PPI compared with the combined reflux group (P = .04). Ki-67, PCNA, and combined marker scores were greater in the gastrectomy compared with the combined reflux group (P = .006, P = .14, and P < .001).Conclusion: Gastric acid suppression in the presence of duodenal refluxate caused increased rates of inflammatory changes, intestinal metaplasia, and molecular proliferative activity. PPIs suppressed acute inflammatory changes only, whereas chronic inflammatory changes persisted.

Determinants of a short convalescence after laparoscopic transabdominal preperitoneal inguinal hernia repair - Corrected Proof

2011-10-19

Background: Evidence-based recommendations for the expected duration of convalescence after laparoscopic groin hernia repair are not available, and objective reasons for prolonged convalescence are not clear. Our main aim was to establish the expected duration of convalescence using preoperative recommendations to the patient and to identify the limiting factors for early (postoperative) resumption of normal activities after laparoscopic transabdominal preperitoneal inguinal herniorraphy (TAPP).Methods: This was a single-center prospective study. The intervention (the recommendation to the patient) was 1 day for convalescence. Several predefined factors were investigated for their influence on the duration of convalescence and the risk of early postoperative pain. Predefined, clinically justified reasons for not resuming normal activities within the first 3 postoperative days were also registered.Results: Between August 2009 and August 2010, 185 consecutive male patients with groin hernia were enrolled prospectively, and 162 patients were available for analysis. Convalescences from work and leisure activities were a median of 5 days (range, 1–40) and 3 days (range, 1–49), respectively (P = .34). Preoperative expectations of convalescence from work (the number of days) was the only factor to explain prolonged convalescence from work (P < .001). Postoperative, self-registered planned sick leave, and complaints of pain and fatigue were the dominant reasons for not resuming normal activities within the first 3 days after operation. Younger age was the only factor found to explain the intensity of postoperative pain (P < .001).Conclusion: Postoperative convalescence (return to work or normal activities) was between 3 and 5 days after TAPP in patients who were counseled about a 1-day expected convalescence. The expectation of convalescence from work was an important reason for delayed convalescence beyond 1 day.

Use of 3-dimensional imaging reconstruction in the treatment of advanced intra-abdominal desmoid tumors - Corrected Proof

2011-10-17

Desmoid tumors are histologically benign but locally aggressive neoplasms of fibroblast origin. They are sporadic or associated with familial adenomatous polyposis and may arise from any musculoaponeurotic structure in the body. The treatment of choice for advanced and symptomatic intra-abdominal desmoid tumors is operative excision, which is challenging because of their propensity to involve major vascular structures such as the root of the mesentery.

Classification of the celiac axis stenosis owing to median arcuate ligament compression, based on severity of the stenosis with subsequent proposals for management during pancreatoduodenectomy - Corrected Proof

2011-10-17

Background: After pancreatoduodenectomy in patients with celiac axis stenosis or obstruction, it becomes problematic to maintain the upper abdominal organ blood flow, especially to the liver. The aim of this study was to investigate the celiac axis stenosis caused by median arcuate ligament (MAL) compression and to classify it according to preoperative image findings.Methods: From January 1989 to November 2010, 562 patients underwent operations for diseases of the pancreatic head region in our department. To diagnose celiac artery compression by the MAL, angiography was used in the early period and 3-dimensional image reconstruction of multidetector-row computed tomography was used from 2004. The morphologic characteristics of the celiac axis stenosis were analyzed during intraoperative treatment.Results: Twelve (2.1%) patients were diagnosed with MAL compression, and 8 of these patients only underwent MAL division to restore the celiac artery blood flow. One patient required conservation of the collateral circulation, and 2 patients needed arterial reconstruction. In the analysis of the level of origin of the celiac axis, there were no remarkable differences between nonstenotic and stenotic cases, or between mild and severe stenotic cases. Morphologic grades were defined based on the preoperative image findings and consequent intraoperative treatments.Conclusion: Preoperative grading of celiac axis stenosis could make pancreatoduodenectomy safer with maintenance of the upper abdominal organ blood flow in patients with MAL compression.

CpG island methylator phenotype infers a poor disease-free survival in locally advanced rectal cancer - Corrected Proof

2011-10-17

Background: Locally advanced rectal cancers are treated with preoperative radiochemotherapy (RCT). However, subsets of patients have no benefit from preoperative treatment. Since epigenetic modifications, including DNA methylation, may influence response to neoadjuvant treatment we studied the CpG island methylator phenotype (CIMP) in patients who received a 5-fluouracil based RCT.Methods: One hundred fifty patients with locally advanced rectal cancer, treated within a phase III clinical trial (CAO/ARO/AIO-94 and -04), were included in this analysis. CIMP was assessed by methylation specific PCR (MSP) using RUNX3, SOCS1, NEUROG1, IGF2, and CACNA1G as a marker panel. Loss of mismatch repair gene (MMR) expression was assessed by immunohistochemistry for a subset of patients. KRAS and BRAF mutation status were assessed using Sanger sequencing.Results: The CIMP status could be established in all 150 patients. Fifteen (10%) revealed CIMP positivity (≥3 methylated promoters), whereas 135 patients (90%) where classified as CIMP negative. Analysis for MMR status did not reveal any microsatellite instability (MSI). A single mutation of the BRAF gene (D594G) was detected. The KRAS gene (exon 1, 2, and 3) was mutated in 65 tumors (43%) but was not correlated to a specific CIMP status. Three- and 5-year disease-free survival was notably worse in CIMP positive patients (56% and 0% vs 80% and 75%; P < .01) suggesting an increased likelihood of poor clinical outcome (HR 5.5; 95%CI: [2.1, 13.9]).Conclusion: CIMP positivity, defined by methylation of at least 3 specific gene promoters, is an infrequent event in locally advanced rectal cancer. However, it increases the likelihood of distant metastases. Therefore, the CIMP status may be included as a molecular marker for the identification of high-risk patients and might contribute to individual treatment stratification.

Ectopic lingual thyroid with a multinodular goiter - Corrected Proof

2011-10-17

A 60-year old Chinese man presented complaining of dysphagia and fullness in his throat. Clinically, a large mass was palpable at the root of his tongue and computed tomography showed its extension to completely occlude the oropharynx (). Although his thyroid gland was notably absent, his thyroid function tests were normal and technetium Tc-99m scans revealed a distinctive uptake in the mass that was subsequently excised via a trans-cervical, trans-hyoid approach (). Histologic analysis confirmed the diagnosis of a multinodular goiter and he was immediately started on a course of thyroxine supplements. Follow-up visits have been largely unremarkable with significant amelioration of his complaints.

Thyroid lobectomy for treatment of well differentiated intrathyroid malignancy - Corrected Proof

2011-10-17

Background: There remains controversy over the type of surgery appropriate for T1T2N0 well differentiated thyroid cancers (WDTC). Current guidelines recommend total thyroidectomy for all but the smallest lesions, despite previous evidence from large institutions suggesting that lobectomy provides similar excellent results. The objective of this study was to report our experience of T1T2N0 WDTC managed by either thyroid lobectomy or total thyroidectomy.Methods: Eight hundred eighty-nine patients with pT1T2 intrathyroid cancers treated surgically between 1986 and 2005 were identified from a database of 1810 patients with WDTC. Total thyroidectomy was carried out in 528 (59%) and thyroid lobectomy in 361 (41%) patients. Overall survival (OS), disease-specific survival (DSS) and recurrence-free survival (RFS) were determined by the Kaplan-Meier method. Factors predictive of outcome by univariate and multivariate analysis were determined using the log rank test and Cox proportional hazards method respectively.Results: With a median follow-up of 99 months, the 10-yr OS, DSS, and RFS for all patients were 92%, 99%, and 98% respectively. Univariate analysis showed no significant difference in OS by extent of surgical resection. Multivariate analysis showed that age over 45 yr and male gender were independent predictors for poorer OS, whereas T stage and type of surgery were not. Comparison of the thyroid lobectomy group and the total thyroidectomy group showed no difference in local recurrence (0% for both) or regional recurrence (0% vs 0.8%, P = .96).Conclusion: Patients with pT1T2 N0 WDTC can be safely managed by thyroid lobectomy alone.

Primary hyperparathyroidism in the underinsured: A study of 493 patients - Corrected Proof

2011-10-14

Background: Disparities may exist in the care of patients with primary hyperparathyroidism (HPT). This study examines the presentation and outcomes of underinsured patients undergoing parathyroidectomy.Methods: We divided 493 HPT patients who underwent initial parathyroidectomy from 2000 to 2008 at a single institution into 2 groups: underinsured patients (group 1; n = 94) evaluated and treated at a county hospital, and patients with insurance (group 2; n = 399). Univariate and multivariate analysis adjusting for race and ethnicity were conducted to determine the association of being underinsured with several clinical variables.Results: More patients in group 1 compared with group 2 were of black or Hispanic background (92% vs 44%; P < .0001). Group 1 patients had higher mean preoperative serum calcium and PTH levels: 12.1 vs 11.8 mg/dL (P = .009) and 263 vs 198 pg/mL (P = .03), respectively. Seven group 1 (7.4%) and 7 group 2 (1.8%) patients presented with hypercalcemic crisis (P = .003). On multivariate analysis, underinsurance was associated with higher serum calcium levels (P = .011) and hypercalcemic crisis at presentation (odds ratio, 5.59; 95% confidence interval, 1.45–21.51; P = .012). Follow-up was shorter in group 1 patients (15 vs 24 months; P < .001) and postoperative PTH levels were higher (76 vs 48 pg/mL; P < .001). Other perioperative data were not different between the groups.Conclusion: Underinsured patients with HPT may present with higher serum calcium and PTH levels, are more likely to have hypercalcemic crisis, and less likely to return for follow-up. Underfunded health insurance coverage may account for differences seen in this study.

Telling the tale of Rapunzel syndrome - Corrected Proof

Vladimir Neychev, John Famiglietti, Pierre F. Saldinger — 2011-10-14

A 26-year-old woman was brought to the emergency department with mild abdominal discomfort, increasing nausea, and worsening constipation over the previous several days. She had a history of attention deficit hyperactivity disorder, mild mental retardation, and laparotomy for gastroduodenal trichobezoar at 11 years of age. The physical examination revealed diffuse nonspecific abdominal pain and a firm mass palpable in the epigastric region. Laboratory studies were unremarkable. Abdominal radiography suggested another bezoar, which was confirmed by upper gastrointestinal study with oral contrast (). Laparotomy was performed, and a large trichobezoar (490 g) forming a cast of the entire distal esophagus, stomach, and duodenal sweep was removed (). She recovered from the surgical procedure without complications and was discharged to home on postoperative day 4 with a recommendation for psychiatric follow-up.

High predictive accuracy of Aldosteronoma Resolution Score in Japanese patients with aldosterone-producing adenoma - Corrected Proof

2011-10-14

Background: Primary aldosteronism caused by aldosterone-producing adenoma is the most common curable cause of secondary hypertension, but despite resection, many patients continue to require antihypertensive medications to control their blood pressure postoperatively. The Aldosteronoma Resolution Score is a preoperative 4-item predictive model for the complete postoperative resolution of hypertension. Our aim was to validate the accuracy of this model in predicting postoperative resolution of hypertension in Japanese patients.Methods: The records of 91 Japanese patients who underwent unilateral adrenalectomy for aldosterone-producing adenoma were surveyed retrospectively. Patients were distributed into 2 groups according to whether blood pressure was normal without antihypertensive medications at 6 months postoperatively. Clinical and biochemical data were evaluated at baseline and after the 6-month follow-up.Results: At 6 months, blood pressure had normalized in 45% of the patients without antihypertensive medications. Multivariate logistic regression analysis revealed that patients who had complete resolution of hypertension were significantly more likely to have been taking ≤2 antihypertensive medications preoperatively, have a duration of hypertension of <6 years, and be female. The predictive accuracy of the Aldosteronoma Resolution Score was assessed using the area under the curve of receiver operator characteristics analysis. The value of the area under the curve was 0.81.Conclusion: Our external validation revealed that the Aldosteronoma Resolution Score developed using Western data can identify accurately Japanese individuals with aldosterone-producing adenoma who are likely to have complete resolution of hypertension after adrenalectomy.

A newly synthetic vitamin E derivative, E-Ant-S-GS, attenuates lung injury caused by cecal ligation and puncture-induced sepsis in rats - Corrected Proof

2011-10-14

Background: Cytokine activation and the ensuing spread of damage to distant organs play a central role in sepsis caused by generalized peritonitis, which accompanies surgical conditions such as gastrointestinal perforation. Anti-inflammatory properties have been discovered in endogenous substances such as vitamin E; we evaluated, in a rat model of peritonitis-induced sepsis, the newly synthetic vitamin E derivative E-Ant-S-GS, in which the endogenous substances vitamin E, glutathione, 5-OH-anthranilic acid, and succinic acid are chemically linked.Methods: We used a model of sepsis in male Wistar rats with the cecal ligation and puncture (CLP) method. To evaluate the anti-inflammatory effects of E-Ant-S-GS, we measured serum interleukin-6 (IL-6) levels at various times after CLP. To assess the effects of E-Ant-S-GS in acute lung injury, we evaluated histologically lung tissue 12 hours after CLP by hematoxylin–eosin staining. In addition, myeloperoxidase (MPO) activity and expression of protease-activated receptor 1 (PAR1) and high mobility group box 1 (HMGB1) in the lung were determined.Results: Serum IL-6 levels increased progressively after the CLP procedure; this cytokine induction was attenuated by E-Ant-S-GS. Increased MPO activity in lung tissue and marked changes in lung histology caused by CLP-induced sepsis were also ameliorated by E-Ant-S-GS. In addition, E-Ant-S-GS suppressed the upregulation of PAR1 and HMGB1 in the lungs after CLP.Conclusion: The newly synthetic vitamin E derivative E-Ant-S-GS showed anti-inflammatory actions and organ-protective effects in a rat model of sepsis, suggesting its potential clinical use as a therapeutic agent against systemic inflammation.

An extremely rare portal annular pancreas for pancreaticoduodenectomy with a special note on the pancreatic duct management in the dorsal pancreas - Corrected Proof

Ippei Matsumoto, Makoto Shinzeki, Takumi Fukumoto, Yonson Ku — 2011-10-14

A previously healthy 81-year-old woman with general fatigue was admitted to our hospital in June 2009. Her blood chemistry data were within normal limits except for slightly elevated liver function values. Serum levels of carbohydrate antigen 19-9 and carcinoembryonic antigen were both normal. Gastroduodenoscopy showed an erosive tumor in the ampulla of Vater. Dynamic computed tomography (CT) revealed bilateral intrahepatic biliary dilatation, and the superior mesenteric vein (SMV) circumferentially embedded in the body of the pancreas, as well as a slightly dilated main pancreatic duct (MPD) in the tissue behind the SMV (). The MPD was found posteriorly to the SMV and the accessory pancreatic duct (APD) was seen anteriorly to the SMV. The 2 ducts joined in the body of the pancreas to the left side of the SMV. A preoperative diagnosis was cancer of the ampulla of Vater accompanying a portal annular pancreas (PAP). The patient underwent pancreaticoduodenectomy (PD). Intraoperatively, after transection of the pancreas on the SMV, we saw the parenchyma of the uncinate process communicating behind the SMV with the body of the pancreas (, A). We inserted a small tube into the cut orifice of the distal APD and performed intraoperative pancreatography. The dilated MPD and the point of the ductal conjunction were confirmed (, B and C). Pancreaticojejunostomy was performed after a second pancreatic transection at the distal side of the ductal conjunction. Histologically, the resected specimen revealed an adenocarcinoma of the ampulla of Vater. The postoperative course was uneventful and the patient was discharged on postoperative day 32.

Pancreatic acinar cell carcinoma - Corrected Proof

Gianpiero Gravante, Robert N. Williams, Ashley R. Dennison, David J. Bowrey — 2011-10-10

A 79-year-old man had multiple admissions with abdominal pain and significant weight loss. A gastroscopy revealed mild esophagitis and gastritis, while a computed tomographic scan revealed a 9.1 × 8.5 cm (on axial section) heterogeneous solid-appearing rounded lesion in the lesser curvature of the stomach. The mass compressed the tail of the pancreas, was in close contact with the 3rd and 4th parts of the duodenum, and was thought to represent a gastrointestinal stromal tumor–type tumor. A second computed tomographic scan performed 1 month later revealed an increase in size. A splenectomy, distal pancreatectomy, and partial gastrectomy (posterior stomach) were performed. Postoperative recovery was uneventful.

Segmental intestinal autotransplantation after extensive enterectomy for removal of large intra-abdominal desmoid tumors of the mesentery root: Initial experience - Corrected Proof

2011-10-10

The advances and growing experience with multivisceral and intestinal transplantation opens new opportunities for the operative treatment of intra-abdominal tumors considered unresectable by conventional techniques. In this case report, we describe our initial experience with the treatment of 2, large, intra-abdominal recurrent desmoid tumors involving a substantial portion of small bowel mesentery and encasing the mesenteric vasculature. Complete removal of the tumors was impossible without sacrificing critical blood supply to the small bowel. A conventional approach would require total enterectomy and subsequent short bowel syndrome with the need for long-term total parenteral nutrition (TPN). Our operative plan was to harvest a portion of the small bowel with an adequate vascular pedicle before removing the tumor and subsequently perform small bowel autotransplantation.

Trainee satisfaction in surgery residency programs: Modern management tools ensure trainee motivation and success - Corrected Proof

2011-10-10

Objective: To assess trainee satisfaction in their surgery residency with a validated instrument and identify the contributing factors.Background: Currently, surgery is deemed unattractive by medical students and ignored by many candidates planning to enter an academic career. New insights on the rational for such lack of interest are needed. Job satisfaction is a central concept in organizational and behavioral research that is well understood by large companies such as Google, IBM, and Toyota. Similar assessment can likewise be used to improve trainee satisfaction in surgery residency.Methods: A survey among 2039 surgery residents was conducted in three European countries analyzing satisfaction at work using the Global Job Satisfaction Instrument (validated in Emergency Room physicians). Crucial factors covering different aspects of surgery residency where identified using the GJS instrument combined with multiple logistic regression analysis.Results: With an overall response rate of 23%, we identified trainee dissatisfaction in one third of residents. Factors affecting satisfaction related almost exclusively to training issues, such as assignment of surgery procedures according to skills (OR 4.2), training courses (OR 2.7), availability of a structured training curriculum (OR 2.4), bedside teaching, and availability of morbidity-mortality conferences (OR 2.3). A good working climate among residents (OR 3.7) and the option for part time work (OR 2.1) were also significant factors for trainee satisfaction. Increased working hours had a modest (OR 0.98)—though cumulative— negative effect. The sex of the trainee was not related to trainee satisfaction.Conclusion: Validated measurement of job satisfaction as used in the industry appears to be an efficient tool to assess trainee satisfaction in surgery residency and thereby identify the key contributing factors. Improvement of conceptual training structures and working conditions might facilitate recruitment, decrease drop-out, and attract motivated candidates with possibly better quality of care.

Role of histone deacetylase expression in intrahepatic cholangiocarcinoma - Corrected Proof

2011-10-10

Introduction: Histone deacetylase (HDAC) plays an important role in chromatin remodeling and gene expression, and in regulating cell cycle progression and differentiation. Furthermore, hypoxic conditions in the malignant tumor enhance HDAC function and increased HDAC activity is closely involved in worse malignant behavior through hypoxia inducible factor (HIF) activation. The aim of this study was to elucidate the correlation between HDAC expression and tumor malignant behavior including HIF-1α expression in intrahepatic cholangiocarcinoma (IHCC).Methods: Thirty-five patients with IHCC who underwent hepatic resection were evaluated. HDAC1 and HIF-1α expressions were determined immunohistochemically, and the patients were divided into 2 groups: the HDAC1 positive group (n = 21) and the HDAC1 negative group (n = 14). Clinicopathologic variables including HIF-1α expression were compared between the 2 groups.Results: HDAC1 expression correlated significantly with higher stage carcinoma, lymph node metastasis, and vascular invasion. The prognosis in the HDAC1 positive group was poorer than in the HDAC1 negative group (5-year survival: 78% vs 8%, P = .001). Furthermore, disease free survival rate in the HDAC1 positive group had significantly worse than that in the HDAC1 negative group (P = .0003). In the multivariate analysis, HDAC1 positive expression was identified as the only independent prognostic factor for disease free survival (Hazard Ratio: 7.194, P = .0018). Furthermore, there was a significant correlation between HDAC1 expression and HIF-1α expression (P = .007).Conclusion: These findings suggested that HDAC1 positive expression was a potential new prognostic indicator of IHCC, and a possible promising molecular target through the regulation of HIF-1α.

Robot-assisted laparoscopic ultrasonography for hepatic surgery - Corrected Proof

2011-10-10

Introduction: This study describes and evaluates a novel, robot-assisted laparoscopic ultrasonographic device for hepatic surgery. Laparoscopic liver surgery is being performed with increasing frequency. One major drawback of this approach is the limited capability of intraoperative ultrasonography (IOUS) using standard laparoscopic devices. Robotic surgery systems offer the opportunity to develop new tools to improve techniques in minimally invasive surgery. This study evaluates a new integrated ultrasonography (US) device with the da Vinci Surgical System for laparoscopic visualization, comparing it with conventional handheld laparoscopic IOUS for performing key tasks in hepatic surgery.Methods: A prototype laparoscopic IOUS instrument was developed for the da Vinci Surgical System and compared with a conventional laparoscopic US device in simulation tasks: (1) In vivo porcine hepatic visualization and probe manipulation, (2) lesion detection accuracy, and (3) biopsy precision. Usability was queried by poststudy questionnaire.Results: The robotic US proved better than conventional laparoscopic US in liver surface exploration (85% success vs 73%; P = .030) and tool manipulation (79% vs 57%; P = .028), whereas no difference was detected in lesion identification (63 vs 58; P = .41) and needle biopsy tasks (57 vs 48; P = .11). Subjects found the robotic US to facilitate better probe positioning (80%), decrease fatigue (90%), and be more useful overall (90%) on the post-task questionnaire.Conclusion: We found this robot-assisted IOUS system to be practical and useful in the performance of important tasks required for hepatic surgery, outperforming free-hand laparoscopic IOUS for certain tasks, and was more subjectively usable to the surgeon. Systems such as this may expand the use of robotic surgery for complex operative procedures requiring IOUS.