The American Journal of Surgery - Articles in Press

Operative management of massive hernias with associated distended bowel - Corrected Proof

Donald W. Buck, Jordan P. Steinberg, Jonathan Fryer, Gregory A. Dumanian — 2010-02-01

Abstract: Introduction: Hernia patients with a history of recurrent bowel obstructions, chronic bowel dysmotility, and bowel distension have few options for return to a “normal” life. Return of the bowel and adhesiolysis seems the logical surgical solution, but the return of a swollen distended bowel into the abdominal cavity would put patients at a high risk for the development of abdominal compartment syndrome. Hernia repair with large pieces of mesh under tenuous skin flaps to incorporate the bowel into the abdominal cavity has its own set of devastating complications, including mesh infection, extrusion, and fistula formation.Methods: Here we present 4 patients who underwent successful treatment with a combined small bowel resection for volume reduction and simultaneous components separation hernia repair for autogenous closure without mesh.Results: All patients had successful abdominal wall closure without major complications and were tolerating enteral feedings upon discharge.Conclusions: A combined approach of small bowel resection and separation of parts hernia repair is a feasible and successful means for approaching challenging abdominal wall defects with chronically distended bowel. A vicious cycle in which postoperative elevation in intra-abdominal pressure leads to severe systemic consequences can be averted. Moreover, bowel function can be restored and excellent cosmesis achieved, leading to significant improvements in patients' quality of life.

Liver transplantation is an alternative treatment of hepatocellular carcinoma beyond the Milan criteria - Corrected Proof

2010-02-01

Abstract: Background: The decision to perform liver transplantation (LT) or liver resection (LR) for patients with hepatocellular carcinoma (HCC) who are beyond the Milan criteria remains controversial.Methods: We retrospectively analyzed outcome data for 179 patients with HCC beyond the Milan criteria who were treated with LR (n = 135) or LT (n = 44). Univariate and multivariate Cox proportional hazard models were established. Kaplan-Meier survival curves were generated, and a log-rank test was performed to compare group survival status.Results: Patients who underwent LR group were significantly older, had a lower TNM stage, and were more likely to have unilateral disease and noncirrhotic liver. Significantly more patients in the LR group had recurrence (53.3% vs 29.5%) or died (61.5% vs 43.2%) than patients in the LT group. Recurrence-free survival rates were 11.9% for the LR group and 61.5% for the LT group. The median overall survival duration showed no statistically difference between the LR group (28.0 months) and the LT group (50.0 months).Conclusions: LT may be the better choice for patients with HCC beyond the Milan criteria.

Preoperative hematologic markers as independent predictors of prognosis in resected pancreatic ductal adenocarcinoma: neutrophil-lymphocyte versus platelet-lymphocyte ratio - Corrected Proof

Imran Bhatti, Oliver Peacock, Gareth Lloyd, Michael Larvin, Richard I. Hall — 2010-02-01

Abstract: Background: The objective of this study was to investigate whether the preoperative hematologic markers, the platelet-lymphocyte ratio (PLR), or the neutrophil-lymphocyte ratio (NLR) ratio are significant prognostic indicators in resected pancreatic ductal adenocarcinoma.Methods: A total of 84 patients undergoing pancreatoduodenectomy for pancreatic ductal adenocarcinoma over a 10-year period were identified from a retrospectively maintained database.Results: The preoperative NLR was found to be a significant prognostic marker (P = .023), whereas PLR had no significant relationship with survival (P = .642) using univariate Cox survival analysis. The median overall survival in patients with an NLR of ≤3.0 (n = 55) was 13.7, 17.0 months in those with an NLR of 3.0 to 4.0 (n = 17) and 5.9 months in patients with a value of >4.0 (n = 12) (log rank, P = .016). The NLR retained its significance on multivariate analysis (P = .039) along with resection margin status (P = .001).Conclusion: The preoperative NLR represents a significant independent prognostic indicator in patients with resected pancreatic ductal adenocarcinoma, whereas PLR does not.

Multicenter prospective randomized trial comparing modified Limberg flap transposition and Karydakis flap reconstruction in patients with sacrococcygeal pilonidal disease - Corrected Proof

2010-02-01

Abstract: Background: There is still no consensus as to the optimal treatment for sacrococcygeal pilonidal disease (SPD). Many recommend off-midline closure, if any excisional procedure is to be selected.Methods: The authors prospectively studied 145 patients with SPD who presented at 3 hospitals. Patients were randomly assigned to undergo either modified Limberg flap (MLF) transposition (n = 72) or Karydakis flap reconstruction (n = 73). Surgical findings, complications, recurrence rates, and degree of patient satisfaction, evaluated via a standardized telephone interview, were compared.Results: Operation time was longer in the MLF group. There were no significant differences between the two groups in terms of complication rate, length of stay, or recurrence rate. Patients in the Karydakis group reported feeling completely healed more quickly postoperatively. The two groups reported similar rates of satisfaction. Mandatory patient withdrawal from a given study arm because of the orifice straying from the midline occurred more frequently in the Karydakis group.Conclusions: The MLF technique and the Karydakis procedure appear to generate comparable outcomes. With laterally situated orifices, however, the applicability of the Karydakis method may be limited.

Long term follow up for incisional hernia after severe secondary peritonitis—incidence and risk factors - Corrected Proof

2010-02-01

Abstract: Background: In patients with secondary peritonitis, infections of the abdominal cavity might render the abdominal wall susceptible to secondary complications such as incisional hernia (IH).Methods: One hundred ninety-eight patients treated for secondary peritonitis underwent midline laparotomy. Ninety-two surviving patients accessible to clinical follow-up were examined for the occurrence of IH, and risk factors at the time of surgery or during follow-up were determined.Results: During a median follow-up period of 6 years, 54.3% of the patients developed IHs. A high body mass index, coronary heart disease, intense blood loss, requirement for intraoperative or postoperative transfusions, and small bowel perforation as a source of peritonitis were associated with IH.Conclusions: IH occurs quite frequently after surgery for secondary peritonitis. Preexisting risk factors for IH and intraoperative blood loss or requirement for blood transfusions were correlated with the development of IH. Interestingly, surgical technique was not correlated with the development of IH in this series.

Incidence and risk factors for the development of incisional hernia following elective laparoscopic versus open colon resections - Corrected Proof

2010-02-01

Abstract: Background: There are few studies that compare the incidence of incisional hernia following elective laparoscopic colon resection to open colectomy and determine the risk factors for its development.Methods: Elective open and laparoscopic colon resections performed between February 2002 and May 2007 were reviewed. In the laparoscopic group, mesenteric transection was performed via intracorporeal division for left-sided colectomy and via extracorporeal technique for right-sided colectomy. The ileocolic anastomosis was performed by extracorporeal stapling for right colectomies and by intracorporeal for left colectomies.Results: Two hundred eighteen patients (mean age 62 years, 52% male) underwent elective colon resection (50% open, 5% hand-assisted, and 45% laparoscopic). Six percent of the cases that started as laparoscopic were converted and are included in the open group. Mean follow-up was 26 months. The overall incisional hernia rate was 16% (open and minimally invasive group 17% vs 15%, P = .14). Hernia was not dependent on the type of resection, indication, or extraction site. Body mass index >36 kg/m2, male gender, and surgical site infection were risk factors for hernia development.Conclusions: Laparoscopic colectomy does not reduce the development of incisional hernia.

Moral angst for surgical residents: a qualitative study - Corrected Proof

Eva Knifed, Aunshu Goyal, Mark Bernstein — 2010-01-25

Abstract: Background: The ethical dilemmas that residents experience throughout their training have not been explored qualitatively from surgical residents' perspectives.Methods: Grounded theory methodology was used. All University of Toronto surgical, otolaryngology, and obstetrics and gynecology residents were invited to participate. Twenty-eight face-to-face interviews were conducted. Interviews were transcribed and analyzed by 3 reviewers.Results: Five encompassing themes emerged: (1) residents prefer operating with another resident while the staff watches; (2) residents felt that patients were rarely well informed about their role; (3) residents develop good relationships with patients; (4) residents felt ethically obliged to disclose intraoperative errors; and (5) residents experience ethical distress in certain teaching circumstances.Conclusions: Residents encounter ethical dilemmas leading to moral angst during their surgical training and need to feel safe to discuss these openly. Staff and residents should work together to establish optimal communication and teaching situations.

Contemporary virtual reality laparoscopy simulators: quicksand or solid grounds for assessing surgical trainees? - Corrected Proof

Anthony S. Thijssen, Marlies P. Schijven — 2010-01-18

Abstract: Background: A demand for safe, efficient laparoscopic training tools has prompted the introduction of virtual reality (VR) laparoscopic simulators, which might be used for performance assessment. The purpose of this review is to determine the value of VR metrics in laparoscopic skills assessment.Data sources: An exhaustive search of the MEDLINE and EMBASE databases was performed to identify publications concerning construct, concurrent and predictive validation of VR simulators. Of 643 publications found, 42 were included in this review. Studies into all 3 types of validation showed a large heterogeneity in study design. Although concurrence of VR metrics with box trainer metrics, mental aptitude tests, and in vivo surgical performance was generally weak, several metrics demonstrated construct validity in selected simulators.Conclusions: Using the right simulator, tasks, and metrics, trainees' and experts' laparoscopic skills can reliably be compared. However, VR simulators cannot yet predict levels of real life surgical skills.

Donor/recipient algorithm for management of the middle hepatic vein in right graft live donor liver transplantation - Corrected Proof

2010-01-15

Abstract: Background: The aim of this study was to delineate an algorithm for donor and recipient criteria and middle hepatic vein (MHV) management in right-graft live-donor liver transplantation (LDLT) on the basis of computerized 3-dimensional computed tomographic image analysis.Methods: Data on 94 consecutive right-graft LDLTs were prospectively collected. Graft and remnant data for the first 23 cases were retrospectively evaluated by means of 3-dimensional computed tomographic reconstructions, and on the basis of that preliminary series, a graft selection algorithm using 3 parameters—hepatic vein dominance classification, graft and remnant graft volume/body weight ratios, and congestion volumes—was created. It was subsequently applied to the next 71 right-graft LDLTs.Results: Fifty-nine right grafts contained the MHV. Four of the 12 grafts with no MHVs required MHV reconstructions. In 18 cases, small liver grafts were used. The postoperative function of liver grafts and remnants with versus without MHVs was not statistically different.Conclusions: The proposed algorithm favored the inclusion of the MHV with the right grafts. It also allowed for the procurement of grafts that were potentially small for size without compromising donor or recipient safety.

A prospective randomized controlled trial of internal versus external drainage with pancreaticojejunostomy for pancreaticoduodenectomy - Corrected Proof

2010-01-15

Abstract: Background: A stent often is placed across the pancreaticojejunostomy. However, there is no report compared between internal drainage and external drainage.Methods: We conducted a prospective randomized trial (NCT00628186 registered at http://ClinicalTrials.gov) with 100 patients who underwent pancreaticoduodenectomy and we compared the effects on postoperative course.Results: The incidence of pancreatic fistula according to the International Study Group on Pancreatic Fistula criteria was not different (external, 20%; vs internal, 26%), and the incidence of the other complications was similar between stent types. The median postoperative hospital stay was 21 days (range, 8–163 d) in the internal drainage group, which was shorter than the median stay of 24 days (range, 21–88 d) in the external drainage group (P = .016).Conclusions: Both internal drainage and external drainage were safety devices for pancreaticojejunostomy. Internal drainage simplifies postoperative managements and it might shorten postoperative stay for pancreaticoduodenectomy.

Metabolic syndrome is an important factor for the evolution of prognosis of colorectal cancer: survival, recurrence, and liver metastasis - Corrected Proof

2010-01-15

Abstract: Background: Several studies have shown that metabolic syndrome (MS) was a risk factor for colorectal cancer, but few studies have reported the relationship between MS and the prognosis of colorectal cancer.Methods: Data were collected from 507 cases of colorectal carcinoma between January 2002 and March 2007 to establish the database. These patients were divided into 2 groups based on the presence of MS. We tested the prognostic value of MS in the patients. The risk of adverse events was examined by Cox proportional hazard modeling.Results: The rates of liver metastasis and tumor recurrence were higher in the group of patients with colorectal cancer accompanied by MS. Moreover, MS is one of the important elements that independently can influence the survival (colonic carcinoma: hazard ratio [HR], 1.633; 95% confidence interval [CI], 1.039–2.565; rectal carcinoma: HR, 1.939, 95% CI, 1.076–3.494) and liver metastasis (colonic carcinoma: HR, 2.619; 95% CI, 1.288–5.324; rectal carcinoma: HR, 2.814; 95% CI, .962–2.888) of both colonic and rectal carcinoma patients, and MS patients have the highest risk with worse survival and liver metastases compared with other parameters.Conclusions: The results suggest that MS may be an important prognostic factor for colorectal cancer, decreasing the incidence of MS may improve the therapeutic efficacy of colorectal cancer.

A novel technique for hepaticojejunostomy for nondilated bile ducts: a purse-string anastomosis with an intra-anastomotic biodegradable biliary stent - Corrected Proof

2010-01-15

Abstract: In non-dilated bile ducts, performing a well-functioning hepaticojejunal anastomosis (HJ) may be challenging. We investigated a novel technique for small-caliber HJ: a purse-string anastomosis with an intra-anastomotic biodegradable stent. HJ was performed randomly either conventionally with interrupted sutures without any stent (n = 5; conventional) or using the novel purse-string technique with a 4-mm caliber polylactide-barium sulfate biodegradable biliary stent (n = 4; pursestring + stent) in minipigs with bile ducts 3.5–4.0 mm in caliber. The anastomosis creation time was not different in the groups. In the conventional group 2 complications occurred: 1 early anastomotic leakage, and 1 late anastomotic stricture. The remaining animals (3/5 in conventional, and 4/4 in purse-string + stent group) had normal liver histology and function, and developed no signs of complications during the 6-month follow-up. All biodegradable stents disappeared by 3 months. At 6 months, the HJ caliber was smaller in the conventional (5 [1–9] mm) than in the purse-string + stent group (12 [4–15] mm; P < .05). We conclude that this novel HJ technique is easy and safe to perform, and ensures a well-functioning anastomosis in nondilated bile ducts.

Outcome of ligation of the inferior vena cava in the modern era - Corrected Proof

2010-01-15

Abstract: Background: Ligation of the significantly injured infrarenal inferior vena cava (IVC) is an accepted practice in the setting of damage control surgery. This is a report of inpatient management, outcomes, and long-term follow-up in 25 patients after IVC ligation.Methods: The records of patients with injuries to the IVC treated in an urban level I trauma center from 1995 to 2008 were reviewed. Demographics, injury severity, and outcome data were recorded. In addition, outpatient records were reviewed and telephone interviews were conducted to assess for the presence and severity of long-term sequelae.Results: One hundred patients had IVC injuries, and 25 (25%) underwent ligation. Location of injury was infrarenal in 54 patients, suprarenal in 21, retrohepatic in 15, and suprahepatic in 10. Twenty-two of 54 (41%) injuries to the infrarenal IVC and 3 of 21 (14%) injuries to the suprarenal IVC were ligated. Patients who underwent ligation had a significantly higher Injury Severity Score (ISS) (22 vs 15, P < .001), a higher transfusion requirement (26 U vs 12 U, P < .001), a longer hospital length of stay (78 days vs 26 days, P = .02), a longer intensive care unit length of stay (24 days vs 9 days, P < .001), and a higher mortality (59% vs 21%, P < .001). Ten of 13 early survivors of infrarenal IVC ligation received early below knee fasciotomy. Three other patients with normal compartment pressures were treated expectantly without development of a compartment syndrome. The 1 survivor of suprarenal ligation had below knee fasciotomies and had normal renal function by 1 month post injury, despite an initial creatinine elevation from .7 mg/dL to 3.2 mg/dL. Ten (40%) patients with IVC ligation survived to hospital discharge (9 infrarenal, 1 suprarenal), and long-term follow-up data are available in 8 patients (7 infrarenal, 1 suprarenal). At an average of 42 months (11–117 months), no patient has significant lower extremity edema or dysfunction.Conclusions: (1) Ligation of the infrarenal IVC is an acceptable damage control technique, although it remains associated with a high mortality. Ligation of the suprarenal IVC may be done, if necessary, although few survivors of this technique exist. (2) Early fasciotomy is generally required, but occasional patients may be treated expectantly, based on measurements of compartment pressures. (3) Long-term sequelae in survivors of IVC ligation for trauma are rare.

A tale of two trainers: virtual reality versus a video trainer for acquisition of basic laparoscopic skills - Corrected Proof

Anders J. Debes, Rajesh Aggarwal, Indran Balasundaram, Morten B. Jacobsen — 2010-01-15

Abstract: Background: This study aimed to assess the transferability of basic laparoscopic skills between a virtual reality simulator (MIST-VR) and a video trainer box (D-Box).Methods: Forty-six medical students were randomized into 2 groups, training on MIST-VR or D-Box. After training with one modality, a crossover assessment on the other was performed.Results: When tested on MIST-VR, the MIST-VR group showed significantly shorter time (90.3 seconds vs 188.6 seconds, P <.001), better economy of movements (4.40 vs 7.50, P <.001), and lower score (224.7 vs 527.0, P <.001). However, when assessed on the D-Box, there was no difference between the groups for time (402.0 seconds vs 325.6 seconds, P = .152), total hand movements (THC) (289 vs 262, P = .792), or total path length (TPL) (34.9 m vs 34.6 m, P = .388).Conclusion: Both simulators provide significant improvement in performance. Our results indicate that skills learned on the MIST-VR are transferable to the D-Box, but the opposite cannot be demonstrated.

Lessons learned from 416 cases of nipple discharge of the breast - Corrected Proof

Mary Morrogh, Anna Park, Elena B. Elkin, Tari A. King — 2010-01-15

Abstract: Background: For patients with nipple discharge (ND), surgical duct excision is often required to exclude underlying malignancy. Our objective was to define clinical predictors of malignancy and examine the utility of common preoperative studies.Study Design: We retrospectively identified 475 patients presenting with a chief complaint of ND from 1995 to 2005; 416 (88%) were eligible for review.Results: Following standard evaluation (clinical breast examiation/mammogram/ultrasound), 129 of 416 (31%) were considered to have physiological ND and were managed expectantly, whereas 287 of 416 (69%) underwent further evaluation (cytology/ductography/magnetic resonance imaging) followed by biopsy ± surgery. Clinical features associated with pathological ND included bloody ND (adjusted odds ratio 3.7) and spontaneous ND (adjusted OR 3.2). Biopsy/surgery identified a causative lesion in 259 of 287 (90%), of which 37% were either malignant (n = 65) or high-risk (n = 30) lesions. The sole clinical predictor of malignant/high-risk lesion was a palpable mass (adjusted odds ratio 4.3). Preoperative evaluation identified 76 of 95 (80%) malignant/high-risk lesions, whereas 19 of 95 (20%) were identified by duct excision alone.Conclusions: Although clinical stratification alone reliably identified patients with pathological ND, neither the clinical characteristics nor preoperative studies can reliably distinguish between benign and malignant pathology. Surgical duct excision remains the gold standard to exclude underlying malignancy.

Analysis of anatomic variants of mesenteric veins by 3-dimensional portography using multidetector-row computed tomography - Corrected Proof

2010-01-15

Abstract: Background: It is important to be aware of mesenteric venous variants to perform peripancreatic surgery. We investigated the usefulness of 3-dimensional (3-D) portography.Methods: Vessels were reconstructed using computer software in 102 patients undergoing multidetector-row computed tomography (MDCT) scheduled for gastrointestinal or hepatobiliary-pancreatic surgery.Results: The superior mesenteric vein (SMV) was composed of single and double trunks around the splenoportal confluence in 78 and 24 patients, respectively. The inferior mesenteric vein joined the splenic vein (68.5%), SMV (18.5%), and splenoportal confluence (7.6%). The left gastric vein joined the splenic vein (46.3%), portal vein (39.0%), and splenoportal confluence (14.7%). Seventy-nine patients showed a gastrocolic trunk, mostly composed of the right gastroepiploic vein and veins from the colonic hepatic flexure. Intraoperative findings were identical to 3-D diagnosis in 68 gastrectomized and 9 pancreatectomized patients.Conclusion: Although mesenteric venous tributaries are complex, 3-D portography is helpful for surgeons to safely perform peripancreatic surgery.

Conservative treatment of vascular prosthetic graft infection is associated with high mortality - Corrected Proof

2010-01-15

Abstract: Background: The aim of this study was to identify patient-related and/or disease-related factors that influence outcomes in patients with vascular prosthetic graft infections.Methods: Through the hospital patient administration system, between January 1997 and December 2007, a total of 44 patients were diagnosed with central prosthetic graft infections. Univariate and multivariate analyses were performed to define factors predictive of mortality.Results: Thirty-three men and 11 women (mean age, 71 years) were included. There was considerable comorbidity. Coagulase-negative Staphylococcus and S aureus were isolated in almost 50% of the patients. The mean follow-up duration was 5 years, during which 20 patients (46%) died. The main causes of death were related to vascular disease. Conservative treatment with antibiotics was the only variable with significant predictive value on multivariate analysis (hazard ratio, 3.62; 95% confidence interval, 1.17–11.24; P = .02).Conclusions: Conservative treatment of prosthetic graft infections was associated with high mortality; therefore, it should be limited to a specific group. Patients who are not capable of undergoing open repair may benefit from conservative management. Otherwise, aggressive open treatment seems indicated.

Localized peripancreatic plasma cell Castleman disease - Corrected Proof

2010-01-15

Abstract: Castleman disease (CD) is a rare, benign, and usually systemic lymphoproliferative disorder. Unicentric Castleman disease of the pancreas is extremely rare, with only less than 10 cases described in the literature. We describe a case of an isolated peripancreatic localization of a plasma cell–type Castleman disease, its clinical presentation, the diagnostic evaluation, and the cure of disease by surgical excision.

Laparoscopic approach of surgical treatment for primary hepatolithiasis: a cohort study - Corrected Proof

Eric C.H. Lai, Tang Chung Ngai, George P.C. Yang, Michael K.W. Li — 2009-12-04

Abstract: Background: The aim of the current study was to evaluate the perioperative and long-term outcome of a laparoscopic approach for management of primary hepatolithiasis.Methods: From January 1995 to June 2008, 55 consecutive patients with primary hepatolithiasis who underwent laparoscopic partial hepatectomy and laparoscopic bile duct exploration were analyzed. Immediate outcomes included stone clearance rate, operative morbidity, and mortality. Long-term outcomes included stone recurrence rate and hepatolithiasis-related mortality.Results: Nineteen patients underwent laparoscopic left lateral sectionectomy and 36 patients underwent laparoscopic bile duct exploration. Twenty-five patients also underwent concomitant laparoscopic choledochoduodenostomy bypass. The operative morbidity and mortality rates were 25.5% and 1.8%, respectively. Four procedures needed open conversion. The immediate stone clearance rate was 90.9%, and the final stone clearance rate was 94.5% after subsequent choledochoscopic treatment. With a mean follow-up of 59 ± 30 months, recurrent stones developed in 3 patients. One patient died of advanced cholangiocarcinoma.Conclusions: In selected patients with primary hepatolithiasis, a laparoscopic approach of definitive treatment is safe and effective with good immediate and long-term outcomes.

Overexpression of LAPTM4B promotes growth of gallbladder carcinoma cells in vitro - Corrected Proof

2009-12-03

Abstract: Background: The overexpression of LAPTM4B-35 in gallbladder carcinoma (GBC) and its clinicopathologic and prognostic significance have been previously shown. Thus, this gene may play a role in the growth of GBC cells.Methods: The pcDNA3-AE containing the complete open reading frame of LAPTM4B (lysosome-associated protein transmembrane-4β) and mock (pcDNA3) plasmids were transiently transfected into GBC-SD cells. Cell proliferation, cell cycle distribution, and protein expression were evaluated by 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl-tetrazolium assay, flow cytometry, and Western blot, respectively.Results: Cells transfected with pcDNA3-AE revealed accelerated proliferation, less serum dependence, and significant cell cycle progression compared with cells transfected with mock plasmid and parent cells. These phenotypes were accompanied by upregulated expression of C-myc, c-Fos, c-Jun, cyclin D1, and cyclin E and downregulated expression of P16 and P-27.Conclusions: LAPTM4B overexpression promotes the growth of GBC cells in vitro by regulating the expression levels of some proliferation-associated proteins. Therefore, the LAPTM4B gene might be used as a novel therapeutic target of GBC.

Endoscopically unmanageable bleeding from duodenal ulcers: a job for the vascular surgeon or the interventional radiologist? - Corrected Proof

Romaric Loffroy, Basem Abualsaud, Jean-Pierre Cercueil, Denis Krausé — 2009-12-03

We read with great interest the article by Burris et al published recently in the American Journal of Surgery reporting emergent gastroduodenal artery embolization by fellowship-trained vascular surgeons in patients with upper gastrointestinal bleeding from duodenal peptic ulcers. We have several comments.

Response to the letter to the editor submitted by Loffroy et al - Corrected Proof

Panos Kougias — 2009-12-03

Bleeding from duodenal ulcers that does not respond to endoscopic intervention is a formidable problem that occurs in patients with significant comorbid conditions and is associated with significant morbidity and mortality. In light of this, my coauthors and I welcomed the letter from Loffroy et al, assuming that it would initiate a constructive dialogue focused on the current issues and clinical complexities of this challenging entity. I hate to admit that the enthusiasm eased quickly after we read through a letter that is full of creative, factually incorrect statements that are not supported by objective evidence and that demonstrates throughout a poor understanding of the training and health care standards in the United States.

The use of touch preparation for the evaluation of sentinel lymph nodes in breast cancer - Corrected Proof

2009-12-03

Abstract: Background: This study was undertaken to evaluate the accuracy of touch preparation (touch prep) in the evaluation of sentinel lymph nodes (SLNs).Methods: We performed a retrospective review of 402 breast cancer patients who underwent SLN biopsy.Results: A SLN was identified in 381 patients. Of 61 patients with a true positive result, 59 underwent axillary node dissection, and in 22 the SLN was the only node with metastases. Thirty-six (9.44%) had at least 1 false negative result. Twenty-five with a false negative results were due to macrometastases, with 17 (2.4%) false negatives occurring in patients with invasive ductal and 6 (5.5%) in those with invasive lobular histology, P = .04. Touch prep had an overall sensitivity of 62.89% and specificity of 98.94%.Conclusions: Touch prep for the evaluation of SLNs in breast cancer compares favorably to reported results for frozen section. False negative findings are more likely with micrometastases and invasive lobular histology.

Current status of radioactive seed for localization of non palpable breast lesions - Corrected Proof

2009-12-03

Abstract: Background: Wire-localized breast biopsy (WLBB) remains the standard method for the surgical excision of nonpalpable breast lesions. Because of many of its shortcomings, most important a high microscopic positive margin rate, alternative approaches have been described, including radioactive seed localization (RSL). This review highlights the literature regarding RSL, including safety, the ease of the procedure, billing, and oncologic outcomes.Methods: Medline and PubMed were searched using the terms “radioactive seed” and “breast.” All peer-reviewed studies were included in this review.Conclusions: RSL is a promising approach for the resection of nonpalpable breast lesions. It is a reliable and safe alternative to WLBB. RSL is at least equivalent compared with WLBB in terms of the ease of the procedure, removing the target lesion, the volume of breast tissue excised, obtaining negative margins, avoiding a second operative intervention, and allowing for simultaneous axillary staging.

Hepatic intraductal oncocytic papillary carcinoma - Corrected Proof

Andrei Cocieru, Kilak Kesha, Hani El-Fanek, Pierre F. Saldinger — 2009-11-30

Abstract: The authors report a case of hepatic intraductal oncocytic papillary carcinoma, a very rare subtype of hepatic papillary cholangiocarcinoma with only 8 cases reported so far in the English literature.

Long-term symptomatic outcome and radiologic assessment of laparoscopic hiatal hernia repair - Corrected Proof

2009-11-06

Abstract: Background: The long-term durability of laparoscopic repair of paraesophageal hiatal herniation is uncertain. This study focuses on the long-term symptomatic and radiologic outcome of laparoscopic paraesophageal herniation repair.Methods: Between 2000 and 2007, 70 patients (49 females, mean age ± standard deviation 60.6 ± 10.9 years) undergoing laparoscopic repair of paraesophageal herniation were studied prospectively. After a mean follow-up of 45.6 ± 23.8 months, symptomatic (65 patients, 93%) and radiologic follow-up (60 patients, 86%) was performed by standardized questionnaires and esophagograms.Results: The symptomatic outcome was successful in 58 patients (89%), and gastroesophageal anatomy was intact in 42 patients (70%). The addition of a fundoplication was the only significant predictor of an unfavorable radiologic outcome in the univariate analysis (odds ratio .413; 95% confidence interval, .130 to 1.308; P = .125).Conclusions: The long-term symptomatic outcome of laparoscopic repair of paraesophageal hiatal herniation was favorable in 89% of patients, and 70% had successful anatomic repair. The addition of a fundoplication did not prevent anatomic herniation.

Clinically diagnosed groin hernias without a peritoneal sac at laparoscopy—what to do? - Corrected Proof

Christian Hollinsky, Simone Sandberg — 2009-10-19

Abstract: Background: Groin or femoral hernias may be concealed behind intact peritonea when the laparoscopic transabdominal preperitoneal (TAPP) mesh technique is used. The aim of this study was to determine the causes, frequency, and surgical procedures in cases of clinically diagnosed hernias without peritoneal defects.Methods: A prospective controlled study comprising 1795 consecutive patients undergoing 2190 laparoscopic TAPP herniorraphies was conducted. All hernias were first subjected to clinical investigations by the surgeons. Intraoperatively, all suspicious hernias were examined with regard to the presence of peritoneal hernial sacs.Results: Of 2190 hernias, no hernia was seen transperitoneally in the laparoscopic procedures in 136 cases (6.2%). Forty-one femoral hernias (30.1%) were concealed behind intact peritonea. Forty-six lateral (33.8%) and 31 medial (22.8%) defects were sacless sliding fatty inguinal hernias.Conclusions: When using the TAPP technique, in addition to femoral hernias, especially sacless sliding fatty inguinal hernias may be overlooked because of intact peritonea. Therefore, in cases of clinically diagnosed inguinal hernias, the preperitoneal space should be inspected intraoperatively to avoid unsatisfactory results.

Letters to the Editor - Corrected Proof

Michael Rosen — 2009-10-19

I would like to thank Dr. Fujita for his excellent questions regarding my experience with polyester mesh in ventral hernia repair. As Dr. Fujita points out, the primary focus of this study was to evaluate the safety of the polyester-based mesh and not the surgical details of the mesh placement. However, I would strongly agree with Dr. Fujita that surgical technique is extremely important in all ventral hernia repairs and probably has more to do with ultimate outcomes than the prosthetic mesh chosen in most circumstances. As pointed out, there are multiple techniques for placing the mesh in a retrorectus position. Perhaps I can take a moment to describe in detail my preferred technique. In routine open ventral hernia repair, I typically enter the peritoneal cavity and perform a complete adhesiolysis to identify all defects carefully. Next, I enter the retrorectus space adjacent to the linea alba, and continue the dissection to the linea semilunaris. In most patients the rectus muscle is anywhere from 5 to 10 cm in width and gives ample mesh overlap. In multiply recurrent hernias the rectus muscle can be substantially smaller, providing inadequate overlap. One approach to obtain wider coverage as described by Novitsky et al is to enter and remain in the preperitoneal space. Although it should be pointed out that these investigators first enter the peritoneal space, complete adhesiolysis, and then enter the preperitoneal space similar to my technique, I have found the preperitoneum, particularly underneath the rectus muscle, to be a very attenuated plane and difficult to achieve reliably. Therefore, in this situation, it is my preference to enter the retrorectus space initially, and continue the dissection to the lateral border of the rectus muscle. At a point approximately 1 cm medial to the lateral boarder of the posterior rectus sheath, I incise the posterior rectus sheath and enter the preperitoneal space and continue the dissection in the preperitoneal plane as far laterally as the psoas muscle if necessary in the same plane as that described by Novitsky et al. Entering this plane medial to the perforating nerves of the rectus muscle preserves the function of this muscle.

Technical aspects of mesh repair for ventral hernia - Corrected Proof

Tetsuji Fujita — 2009-10-19

In the study by Rosen that primarily evaluated the safety of synthetic meshes in 109 patients who received either laparoscopic or open mesh repair for ventral hernia, intraperitoneal fixation of polyester mesh protected with a collagen hydrogel anti-adhesive barrier and extraperitoneal use of unprotected polyester mesh were associated with an acceptable mesh infection rate (2.7%) and a low recurrence rate (2.7%). In 79 patients with an average fascial defect width of 11 cm, laparoscopic repair was attempted, in which the mesh was sized to achieve overlap of the mesh with the abdominal wall tissue by at least 4 cm and was fixed with tacks as well as transfascial nonabsorbable sutures. In a more complex group of 30 patients with an average defect width of 20 cm, open mesh repair was performed by using the modified Rives-Stoppa technique. According to the brief description of surgical details, it appears that the peritoneal cavity was entered through the hernia sac in all patients, but whether or how the peritoneum was reapproximated was not clear. After open mesh repairs, 2 patients (6%) experienced complications with postoperative ileus. The short- and long-term outcomes of a modified Rives-Stoppa ventral hernia repair with preservation of the hernia sac in 254 patients have been reported. In that study, the rate of postoperative ileus was very low (.4%) and the overall hernia recurrence rate was 5% with a mean follow-up duration of 70 months. Not opening the sac may decrease the risk of postoperative ileus. It seems likely that Rosen placed the mesh between the posterior rectus fascia and rectus muscle, as opposed to the preperitoneal space posterior to the posterior rectus fascia as described by Novitsky et al. If so, a wide lateral overlap between the mesh and the fascial edge might be limited in patients with a huge multiply recurrent incisional hernia.

The Delorme repair for full-thickness rectal prolapse: A retrospective review - Corrected Proof

Giovanni Milito, Federica Cadeddu, Ivana Selvaggio, Michele Grande — 2009-10-19

We read with interest the article about surgical treatment of rectal prolapse with the Delorme procedure by Lieberth et al. Based on the results of their retrospective review of 76 patients, the investigators recommended the Delorme repair to a larger number of patients, not only to the elderly and those at high risk for surgery. Nevertheless, they reported a recurrence rate of 14.5% and an overall complication rate of 25%, which is noteworthy.

Perioperative management and outcome of general and abdominal surgery in hemophiliacs - Corrected Proof

2009-10-19

Abstract: Background: The aim of the current study was to investigate perioperative management and outcome of surgery in hemophiliacs.Methods: Fifty-five hemophiliacs underwent surgery (appendectomy, cholecystectomy, inguinal hernia repair, hemorrhoidectomy). Surgical procedures in hemophiliacs and matched pairs were analyzed for duration of surgery, drainages, hospital stay, factor use (VIII, IX), and complications. Factor substitution was analyzed. Mann–Whitney U and Kruskal-Wallis tests were used (P < .05).Results: No significant differences were found for duration of drains and operation time in hemophiliacs versus matched pairs. Significance for duration of hospital stay compared with controls was found in hemophiliacs for appendectomy, inguinal hernia repair, and hemorrhoidectomy but not for cholecystectomy. In both groups, complications were low without significant differences.Conclusions: This study found no significant differences in perioperative data and postoperative outcome in hemophiliacs compared with nonhemophiliacs due to the excellent perioperative interdisciplinary management at our Hemophilia Center with prolonged hospital stay in hemophiliacs.

The prognosis of gastric cardia cancer after R0 resection - Corrected Proof

2009-10-19

Abstract: Background: The aim of this study was to evaluate the prognosis of gastric cardia cancers in comparison with other gastric cancers.Methods: The medical records of 251 patients with gastric cardia cancers and 6568 patients with other gastric cancers who underwent R0 resection were reviewed. Clinicopathologic characteristics and survival were analyzed.Results: Gastric cardia cancer was associated with more advanced staging and less favorable clinicopathologic features at diagnosis compared with other gastric cancers. The overall 5-year survival rates were 79.7% and 84.6% in patients with cardia cancer and other cancers, respectively. There were no significant differences in survival curves between the groups at any stage. Lymph node metastasis was an independent prognostic factor for disease-free survival. The length of the proximal margin was not associated with locoregional tumor recurrence.Conclusions: Although patients with gastric cardia cancers are diagnosed at an advanced stage, the long-term survival rates are similar to those with other gastric cancers. If curative resection with negative resection margin can be achieved, pN category is the only prognostic factor for survival.

Standardized pelvic drainage of anastomotic leaks following anterior resection without diversional stomas - Corrected Proof

Junjie Peng, Jiade Lu, Ye Xu, Zuqing Guan, Minghe Wang, Guoxiang Cai, Sanjun Cai — 2009-10-19

Abstract: Background: Anastomotic leakage is a serious complication in rectal cancer surgery. More than one third of rectal cancer patients with low anterior resection (LAR) will receive defunctional stomas during primary operation.Methods: Six hundred thirty-nine consecutive rectal cancer patients, whose tumors were located 5 to 12 cm from the anal verge, were treated with LAR. A standardized pelvic drainage for all these patients and selective irrigation for patients with leakage were conducted, and defunctional stoma was used as a salvage modality. All the anastomoses were all extraperitonealized during primary operations.Results: The anastomotic leakage rate was 7.04%. Male gender and location of tumor were found to be risk factors for leakage in patients with LAR. The overall stoma rate was 1.88%. Nearly 75% of leakage could be cured by irrigation-suction without surgical intervention. Severe complications, such as peritonitis, fistula, and obstruction, were strong predictors of irrigation failure.Conclusions: Extraperitonealized anastomosis and pelvic drainage obtained a very low rate of defunctional stoma for LAR. Pelvic irrigation-suction was an effective modality to resolve anastomotic leakage.

Large neomucosal space 25 years after mesh repair of ventral hernia - Corrected Proof

Julian E. Losanoff, Walter A. Salwen, Marc D. Basson, Edi Levi — 2009-10-19

Abstract: A 64-year-old, otherwise healthy, male patient presented with a malodorous abdominal wall fistula of recent onset. He gave a history of mesh repair of ventral hernia 25 years ago. Computed tomography scan of the abdomen revealed a 15 cm × 15 cm thick-walled cavity inside the abdomen adjacent to bowel loops and the prosthetic mesh. Resection of the mass included a 25-cm segment of small bowel. Histopathology revealed a thick-walled large cavity lined with mucosa, surrounding a large wrinkled sheet of permanent mesh.

Role of antibiotics in the severity of cholecystitis - Corrected Proof

Weekitt Kittisupamongkol — 2009-10-19

I read with interest the article by Lee et al. The authors do not mention how many patients received antibiotics in the study. The prescription of such medications is common and may affect the severity of cholecystitis. Failure to consider this factor may bias the relationship between body mass index and the severity of cholycystitis.

Surgical treatment of nonparasitic cysts of the liver: open versus laparoscopic treatment - Corrected Proof

2009-09-14

Abstract: Background: The aim of this study was to compare the immediately postoperative and follow-up results of open and laparoscopic surgery of hepatic cysts in a tertiary hepatobiliary referral center.Materials and Methods: From March 1999 to February 2007, 59 patients underwent surgical treatment for nonparasitic liver cysts. Patients were assigned to the laparoscopic (n = 42) or open group (n = 17) for analysis.Results: Three conversions to open procedures had to be performed in the laparoscopic group. One patient had to be reoperated because of a bile leakage in the laparoscopic group. Follow-up examination showed 2 recurrences in the laparoscopic and 3 in the open group. Three out of 17 patients in the open group had to be operated for incisional hernias. Time to previous activities was significantly shorter after laparoscopy.Conclusions: Laparoscopic treatment of symptomatic nonparasitic liver cysts is superior concerning short- and long-term results in a vast majority of cases.

The ratio between metastatic and examined lymph nodes is an independent prognostic factor for patients with resectable middle and distal bile duct carcinoma - Corrected Proof

2009-07-14

Abstract: Background: The lymph node ratio, defined as the ratio between the number of lymph node metastasis and the total number of lymph nodes examined, has been reported to be an important prognostic factor in other gastrointestinal carcinomas except middle and distal bile duct carcinomas.Methods: Between 1991 and 2004, 62 consecutive patients who underwent surgery for middle and distal bile duct carcinoma were retrospectively analyzed concerning prognostic factors.Results: The median number of lymph nodes examined was 12 (range 5 to 38). The overall 5-year survival rates of patients with lymph node ratio of 0, lymph node ratio of 0 to .2, and lymph node ratio >.2 were 62%, 41%, and 0%, respectively. A multivariate analysis revealed that a lymph node ratio >.2 and perineural invasion were independent predictive factors for survival.Conclusions: Lymph node ratio >.2 is an important factor to predict survival after resected middle and distal bile duct carcinoma.

Long-term follow-up results of breast cancer patients with sentinel lymph node biopsy using periareolar injection - Corrected Proof

2009-07-14

Abstract: Background: Areolar injection for sentinel lymph node biopsy (SLNB) in breast cancer surgery has been adopted by many institutions. However, only one study has reported the follow-up results for patients whose SLNB was performed with this injection method alone.Methods: Three hundred eighty patients with breast cancer underwent SLNB with periareolar injection of both blue dye and radiotracer. The follow-up consisted of a physical examination every 3 months and annual mammography.Results: Of 380 patients with SLNB, 261 were found to have negative sentinel lymph nodes so that no ALND was performed. At a median follow-up of 39 months (range 13–74), 2 of the 261 patients developed axillary recurrence for an axillary relapse incidence of .77%. Five-year distant disease-free survival was 96.9%, and overall survival was 99.4%.Conclusions: The incidence of axillary recurrence for the areolar injection method was low and consistent with that reported in other observational studies using other injection methods.

Torsion of the primary epiploic appendagitis: a case series and review of the literature - Corrected Proof

2009-06-12

Abstract: Background: Differential diagnosis and appropriate treatment of epiploic appendagitis (EA) is a dilemma for general surgeons because of nonspecific signs and symptoms.Methods: Twelve patients (3 women and 9 men, average age 40 years, range 18–82 years) who were diagnosed as having EA upon presenting to the emergency department or at the time of discharge between April 2002 and September 2008 were included.Results: The major presenting symptom was abdominal pain. Physical examination revealed well-localized tenderness in all cases (n = 12); in addition, rebound tenderness and distention were also observed. Laboratory blood tests were normal except for 4 patients who had leukocytosis. Seven cases were diagnosed by an abdominal computed tomography scan. Five patients required surgical intervention, whereas the remaining did not.Conclusions: Surgeons should be aware of this self-limiting disease that mimics many other intra-abdominal acute conditions. An abdominal computed tomography scan has a significant role in accurate diagnosis of EA before surgery to avoid unnecessary surgical interventions.

Anastomotic leakage after laparoscopic resection of rectal cancer: The impact of fibrin glue - Corrected Proof

Jung Wook Huh, Hyeong Rok Kim, Young Jin Kim — 2009-06-01

Abstract: Background: The aim of this study was to evaluate whether the use of fibrin glue as a sealant over an anastomosis is a risk factor for anastomotic leakage after laparoscopic rectal cancer surgery.Methods: Prospective data were collected from 223 patients with rectal cancer who underwent laparoscopic resection without defunctioning stoma.Results: A total of 104 patients underwent laparoscopic rectal resection, followed by the application of fibrin glue over the stapled anastomosis, while 119 underwent surgery alone. No difference in clinically significant leakage was observed between the fibrin and the nonfibrin groups (5.8% vs 10.9%, P = .169). In multivariate analysis, extraperitoneal tumor location and operation duration >220 minutes were independently associated with anastomotic leakage.Conclusions: Significant predictors of anastomotic leakage include extraperitoneal tumor location and operation length >220 minutes. Fibrin glue application over the stapled anastomosis was not found to be significantly associated with anastomotic leakage.

Visfatin—a proinflammatory adipokine—in gallstone disease - Corrected Proof

2009-05-12

Abstract: Background: Visfatin is increasingly associated with several obesity-related diseases. The study is to evaluate if aberrant expression of circulating visfatin occurs in gallstone disease.Methods: An enzyme-linked immunosorbent assay was used to examine serum visfatin levels in 79 patients with cholesterol gallstones, 71 with pigment gallstones, and 223 healthy controls. The chemical composition of extracted gallstones was determined by Fourier transform infrared spectroscopy.Results: Serum visfatin levels were markedly elevated in the cholesterol and pigment gallstones in comparison with healthy controls. Furthermore, increased visfatin levels were associated with formation of the cholesterol and pigment gallstones. Intriguingly, a significant positive correlation between serum visfation levels and white cell count was noted in the cholesterol gallstones and controls. Moreover, the positive correlation in the cholesterol gallstones was more significant in the body mass index ≥25 subgroup than in the body mass index <25 subgroup.Conclusions: Gallstone disease is associated with altered circulating visfatin. The proinflammatory effect of circulating visfatin in gallstone disease deserves further investigation.

Intrahepatic cholangiocarcinoma: analysis of 44 consecutive resected cases including 5 cases with repeat resections - Corrected Proof

2009-05-12

Abstract: Background: Prognosis after resection for intrahepatic cholangiocarcinoma (ICC) remains unsatisfactory. There remains no effective therapy after recurrent ICC.Objective: The current study sought to evaluate risk factors associated with recurrent ICC and possible therapies after resection.Method: A review of data from patients who underwent potentially curative resection for ICC was performed.Results: A total of 44 potentially curative resections were performed from 1995 to 2008. Mortality was 0% and morbidity was 35%. The 5-year overall and recurrence-free survival rates were 43% and 39%, respectively. Multivariate analysis identified the presence of multiple nodules and poor histologic grade as independent negative prognostic factors for overall and recurrent-free survival. Postoperative recurrence occurred in 25 patients (57%). Solitary recurrence occurred in 5 patients (liver, n = 4; lung, n = 1), all of who had undergone surgical resection. Three of the 5 patients survived for more than 5 years after 2 resections.Conclusion: Prognosis after curative resection of solitary ICC appears favorable. In selected patients with sequential single hepatic or pulmonary recurrence, repeat resection may prolong survival.

Re: Sleep deprivation, fatigue, medical error and patient safety - Corrected Proof

Colin Sugden, Rajesh Aggarwal, Ara Darzi — 2009-05-12

We read with interest the editorial discussing the impact of the Institute of Medicine (IOM) report on surgical practice. While we understand the authors concerns regarding the potential impact reduced working hours may have on continuity of care, we feel that, in an era of increased public awareness of medical error and professional pressure to improve patient safety, it is particularly important that, as a profession, we are cognizant of the performance effects of sleep deprivation and fatigue.

Sustained low-efficiency dialysis versus continuous veno-venous hemofiltration for postsurgical acute renal failure - Corrected Proof

2009-04-20

Abstract: Background: In postsurgical acute renal failure patients with moderate unstable hemodynamics or fluid overload, the choice of dialysis modality is difficult. This study was performed to compare the outcomes between the sustained low-efficiency dialysis (SLED) and continuous veno-venous hemofiltration (CVVH) in these patients.Methods: Sequential postsurgical acute renal failure patients undergoing acute dialysis with CVVH (2002–2003), or SLED (2004–2005) as a result of severe fluid overload or moderately unstable hemodynamics were analyzed. Multivariate analyses of comorbidity, disease severity before initiating dialysis, biochemical measurements, and hemodynamic parameters for 3 days after the first dialysis session were performed by fitting multiple logistic regression models to predict patient's 30-day after hospital discharge (AHD) mortality.Results: Among the 101 recruited patients, 38 received SLED and the rest received CVVH. The 30-day AHD mortality was 62.4%. The independent risk factors of 30-day AHD mortality included older age (P = .008), lower first postdialysis mean arterial pressure (MAP) (P = .021), higher first postdialysis blood urea nitrogen level (P = .009), and absence of a history of hypertension (P = .002). A further linear regression analysis found that dialysis using SLED was associated with higher first postdialysis MAP (P = .003).Conclusions: Among the postsurgical patients requiring acute dialysis with severe fluid overload or moderately unstable hemodynamics, the patients treated with SLED had a higher first postdialysis MAP than those treated with CVVH, which led to lower mortality. Further multicenter randomized clinical trials of larger sample size are needed to compare the effects of SLED and CVVH on the outcomes of postsurgical acute dialysis patients.

How international electives could save general surgery - Corrected Proof

Andrew A. Gumbs, Milton A. Gumbs, Zachary Gleit, Mary Ann Hopkins — 2009-01-30

One of the driving forces for many American surgeons to become a surgeon is to one day work with a humanitarian organization, such as Doctors Without Borders, 3 of the authors for which have volunteered. However, there are many barriers to participating in such organizations. The rising cost of medical school and subsequent loans and the diminishing economic returns of being a surgeon in the United States mean that few American surgeons have the opportunity to work with such organizations until after retirement, if ever. Despite these barriers and others, interest at all levels of training remains high. A recent publication in the Journal of the American College of Surgeons explored the level of interest of general surgery residents at a large American academic center in taking an international elective. By analysis of questionnaires, 98% of residents were found to be interested in an international elective. Although these same residents were concerned about financial constraints and limitations imposed by the Residency Review Commission on elective time, almost half of all residents were willing to use their own vacation time and financial resources to be able to take such an elective.

Pancreatoduodenectomy using a no-touch isolation technique - Corrected Proof

2008-12-19

Abstract: Background: Pancreatoduodenectomy is the only effective treatment for cancers of the periampullary region. Because surgeons usually grasp tumors during pancreatoduodenectomy, this procedure may increase the risk of squeezing and shedding the cancer cells into the portal vein, retroperitoneum, and/or peritoneal cavity. In an effort to overcome these problems, we have developed a surgical technique for no-touch pancreatoduodenectomy.Methods: From March 2005 through May 2008, 42 patients have been operated on following this technique. Resected margins were microscopically analyzed.Results: We describe a technique for pancreatoduodenectomy using a no-touch isolation technique. We resect cancers with wrapping them within Gerota's fascia and transect the retroperitoneal margin along the right surface of the superior mesenteric artery and abdominal aorta without grasping tumors.Conclusions: No-touch pancreatoduodenectomy has many potential advantages that merit further investigation in future randomized controlled trials.

Inguinodynia and ilioinguinal neurectomy - Corrected Proof

Lawrence A. Danto — 2008-09-15

Abstract: The value of open inguinal herniorraphy without mesh is being lost. Mesh herniorraphy is being inappropriately used as the standard of care. The complication of inguinodynia is occurring at inappropriately high rates. Ilioinguinal neurectomy is not a simple solution.

Complications of endoscopic retrograde cholangiopancreatography: when to operate? An algorithmic approach - Corrected Proof

Siamak Milanchi, Alexander Allins, Andrew Klein, Simon Lo — 2008-08-26

Endoscopic retrograde cholangiopancreatography (ERCP) is a well established and commonly used procedure with the nationwide annual frequency ranging between 40,000 and 50,000 cases. The overwhelming majority of the procedures are performed by qualified gastroenterologists who, over the last several decades, have accumulated a vast fund of knowledge dealing with the indications, technique variations, and complications of ERCP. By comparison, few surgeons are proficient in ERCP. However, surgeons are called upon to evaluate occasional patients who develop complications following this procedure. Thus, we feel that surgeons should be aware of the most frequently encountered types of ERCP complications, the diagnostic modalities available, and the potential treatment options.