The American Journal of Surgery - Articles in Press

Optimal trocar placement for ergonomic intracorporeal sewing and knotting in laparoscopic hiatal surgery - Corrected Proof

2010-07-20

Abstract: Background: Trocar placement presently is mostly empiric. Our goal was to define simple distances from bony landmarks to locate the optimal ergonomic placement of manipulation trocars for access to the lower esophagus and hiatal orifice, for suture placement, and knotting of the gastric fundus and crura. Hypothesizing that the ideal ergonomic principles of a manipulation angle of 60°, an elevation angle (αe) of 30° to 60°, and an intracorporeal/extracorporeal length ratio (I/E) of working instruments close to 1:1 are interrelated by simple trigonometric functions, the variations of each of these parameters were calculated in a dependent manner for 2 standard lengths of needle holders: 48.5 cm and 58.5 cm.Results: Trocar placement can be calculated easily according to simple formulas dependent on the αe, the distance from the sternoxiphoid junction to the median of the intertrocar span (d) and the vertical distance from the stenoxiphoid junction to the average distance between the apex of the hiatal orifice and the anterior aspect of the esophagus (XH'): when the αe is 30°: d is XH' √2 and when αe is 45°, d is XH'/√2. Likewise, when αe is 30° the intertrocar span (LR) is 2XH', half on either side of the optical axis (d), and when αe is 45°, LR is XH' √2, XH'/√2 on either side of the optical axis. The most ergonomic solution is to work with an αe of 40° to 45° by placing the 2 working (manipulation) trocars, between 10 and 14 cm caudad from the sternoxiphoid junction, between 10 and 12 cm on either side of the longitudinal axis corresponding to the optic-target axis. The shorter needle holder works best in this configuration because the I/E ratio will be between .8 and 1. If, however, the surgeon wants to work with an αe closer to 30°, then the longer needle holder should be used, and the trocars should be placed between 20 and 21 cm from the sternoxiphoid junction, 14.5 to 15 cm on either side of the optical axis. The I/E ratio will vary between 1 and 1.1. When a 1/1 I/E ratio was prioritized, the αe would be 40° and 32°, for the shorter and longer instruments, respectively. The deeper crural closure requires increasing the αe by 2° and 3°, respectively. Hyperlordosis, as obtained by placing a cushion under the patient's back, shortens the distances, allowing placement of the trocars closer to the sternoxiphoid junction.Conclusions: Based on ergonomic principles (manipulation angle, 60°; αe, 40°–45°; and an I/E ratio of working instruments, close to 1:1), simple trigonometric considerations allow easy calculation of the ideal placement of trocars corresponding to working instruments in hiatal surgery necessary for ergonomic dissection, suturing, and intracorporeal knotting. Ideal trocar placement is dependent only on the vertical depth of the target organ.

Collagen in the transversalis fascia of patients with inguinal hernia - Corrected Proof

G.. Pascual, J.M. Bellón — 2010-07-15

We read with interest the recent article by Casanova et al published in the July issue of The American Journal of Surgery. In this study, the authors analyzed type I and III collagen fibers in specimens of transversalis fascia (TF) taken from patients with indirect inguinal hernia and compared their findings with those observed in TF specimens obtained from nonherniated cadavers.

Determinants of outcome in elderly patients with positive sentinel lymph nodes - Corrected Proof

2010-07-09

Abstract: Background: Older women are less likely to receive standard of care treatment for breast cancer.Methods: We examined variables that affected the outcome of elderly patients ≥70 years old among 1,470 patients with invasive cancer with positive sentinel lymph nodes (SLNs).Results: Elderly patients were less likely to undergo mastectomy, completion axillary node dissection (ALND), adjuvant chemotherapy, and radiotherapy (RT) following breast-conserving therapy (BCT) compared with patients <70 years old. The 5-year risk of disease progression and cumulative incidence of breast cancer–specific deaths were not significantly different for both groups. On multivariate analysis, hormone receptor–negative status, number of metastatic lymph nodes, high nuclear grade, and tumor size were the factors independently associated with increased risk of disease progression.Conclusions: Tumor factors were the primary determinants of breast cancer outcomes in our cohort. Elderly patients are less likely to receive aggressive surgical interventions and adjuvant therapy because of perceived life expectancy.

Perioperative synbiotic treatment to prevent infectious complications in patients after elective living donor liver transplantation. A prospective randomized study - Corrected Proof

2010-07-09

Abstract: Background: Although the effect of synbiotic therapy using prebiotics and probiotics has been reported in hepatobiliary surgery, there are no reports of the effect on elective living-donor liver transplantation (LDLT).Methods: Fifty adult patients undergoing LDLT between September 2005 and June 2009 were randomized into a group receiving 2 days of preoperative and 2 weeks of postoperative synbiotic therapy (Bifidobacterium breve, Lactobacillus casei, and galactooligosaccharides [the BLO group]) and a group without synbiotic therapy (the control group). Postoperative infectious complications were recorded as well as fecal microflora before and after LDLT in each group.Results: Only 1 systemic infection occurred in the BLO group (4%), whereas the control group showed 6 infectious complications (24%), with 3 cases of sepsis and 3 urinary tract infections with Enterococcus spp (P = .033 vs BLO group). No other type of complication showed any difference between the groups.Conclusions: Infectious complications after elective LDLT significantly decreased with the perioperative administration of synbiotic therapy.

Patient attitudes to surgeons' attire in an outpatient clinic setting: substance over style - Corrected Proof

Roy Dewayne Edwards, Anne Teresa Saladyga, John Paul Schriver, Kurt Glenn Davis — 2010-07-01

Abstract: Background: It is believed that patients prefer that surgeons convey a professional appearance with traditional business attire and white laboratory coat. We performed a prospective study to assess patient opinions regarding traditional attire versus the wearing surgical scrubs in the outpatient setting.Methods: During a 5-month period, surgeons alternated wearing traditional clothing and surgical scrubs. Adult patients were given a questionnaire assessing their preferences regarding surgeons' clothing.Results: Six hundred twelve patients returned the questionnaire. The majority felt that scrubs were appropriate attire for physicians. Half of the patients felt that wearing white laboratory coats is necessary. A minority felt that their surgeon's dress affects their opinion regarding the care they received. There was no difference between responses regardless of the attire actually worn.Conclusions: Surgeon's clothing choice does not significantly influence patient's opinion of the care they receive. Patients do not have strong preferences for white coats or more traditional surgical attire.

Re: how to avoid unnecessary laparotomies in iatrogenic bile duct injuries? - Corrected Proof

Gennaro Nuzzo, Felice Giuliante, Francesco Ardito, Maria Vellone, Ivo Giovannini — 2010-07-01

We read with interest the letter by Grönroos on our article, “Advantages of multidisciplinary management of bile duct injuries occurring during cholecystectomy.” We definitely agree that nonsurgical procedures play a great role in the treatment of bile duct injuries and, among these, the rendez-vous technique is the most recently described. In our experience, nonsurgical treatments were performed in 36% of major bile duct injuries, and in 40% of all the patients, including the minor injuries. If we consider only the major injuries, in our experience surgery was the definitive treatment in 64% of patients (41 of 64), which is the same rate reported by Grönroos in Karvonen et al (64%; 14 of 22). Therefore, it seems that the general policy of our 2 centers is the same, and that reported laparotomies all were necessary.

Requirement and postoperative outcomes of abdominal panniculectomy alone or in combination with other procedures in a bariatric surgery unit - Corrected Proof

Joaquin Ortega, Vicente Navarro, Norberto Cassinello, Salvador Lledó — 2010-07-01

Abstract: Background: A high percentage of patients present with redundant skin folds after bariatric surgery. This study aims to quantify the need for panniculectomy after open bariatric surgery and to analyze the postoperative outcomes.Methods: A retrospective cohort study was performed. The patients were divided into 2 groups: group DLP, patients who underwent an abdominal panniculectomy alone and group DLP+, those who underwent panniculectomy in association with another surgical procedure.Results: Four hundred forty-six patients underwent open bariatric surgery and 130 patients (29%) subsequently required an abdominal dermolipectomy. Seventy-six percent presented also incisional hernia and 8% presented cholelithiasis. Forty-six percent of patients presented postoperative complications: wound seroma/infection (21%), wound dehiscence due to skin necrosis (13%), and hemorrhage/hematoma (10%) were the most frequent. There were no major complications or mortality. DLP+ was not associated with an increase in complications.Conclusions: After open bariatric surgery, an abdominal panniculectomy is often required. This procedure has a high postoperative morbidity in these patients, although complications are usually mild. There is not an increase in the rate of complications when panniculectomy is associated with other procedures.

Commentary for an evidence-based medicine review of lymphadenectomy extent for gastric cancer - Corrected Proof

Sun Hu Yang, You Cheng Zhang — 2010-07-01

K. Slim and his colleagues question whether the American Journal of Surgery has actually endorsed the Quality of Reporting of Meta-analyses (QUOROM) statement and they did not see flow diagrams and funnel plot in our paper to assess publication bias. The QUOROM conference resulted in the QUOROM statement, a checklist, and a flow diagram. The checklist describes the preferred way to present the abstract, introduction, methods, results, and discussion sections of a report of a meta-analysis. It includes such procedures as searches, selection, validity assessment, data abstraction, study characteristics, and quantitative data synthesis, and in the results with “trial flow,” study characteristics, and quantitative data synthesis; research documentation was identified for 8 of the 18 items. The flow diagram provides information about both the numbers of randomized control trials (RCTs) identified, included, and excluded and the reasons for exclusion of trials. In our view, the checklist and flow diagram are the better way to finish meta-analyses for improving the quality of reporting of meta-analyses of clinical RCTs rather than the way to assess publication bias. Actually, these procedures have been elucidated in brief words in the results section of our paper.

Re: A historic perspective on the contributions of surgeons to the understanding of acute pancreatitis - Corrected Proof

Juan Mier — 2010-07-01

The article published in the September issue entitled “A historic perspective on the contributions of surgeons to the understanding of acute pancreatitis” in which the authors pursued a revision article, analyzed remarkable publications starting with papers dated in 1925 to the present day. However, there is insufficient information when the authors describe the timing of surgical intervention. The authors have not made any reference to the only prospective randomized trial comparing early versus late surgical treatment: “Early versus late necrcosectomy in severe acute pancreatitis,” which was published in the American Journal of Surgery in 1997. The aforementioned paper is repeatedly cited as the only prospective and important trial that appointed the crucial decision regarding when to operate in this complex acute illness. In the International Association of Pancreotology “Guidelines for the Surgical Treatment of Acute Pancreatitis,” there are 11 recommendations and the aforementioned article2 was placed as the sixth recommendation for the proper management of acute severe pancreatitis.

Biological scaffolds in reparative surgery for abdominal wall hernias - Corrected Proof

Manuel López-Cano, Manuel Armengol-Carrasco — 2010-07-01

The development of new biological prostheses for clinical use in abdominal wall reconstruction is an exciting and innovative field of research. The encouraging results of Pomahac and Aflaki using a porcine, dermal-derived bioprosthesis for treating complex abdominal wall defects recently published in The American Journal of Surgery invite reflection. Biological materials derived from human or animal sources are degraded gradually, inducing neovascularization and colonization by host cells that progressively cause a site-specific remodeling process until reconstruction of a new and mature autologous fascia is complete. Although this new generation of extracellular matrices may open a new era in the treatment of abdominal wall hernias, there are still many unanswered questions. What is the optimum pattern and density to balance durability of the biomaterial with cellular ingrowth and remodeling? Is cross-linked material better than non–cross-linked? What about recurrence and complications, especially in human beings? What happens if the hernia is a collagen disease in which the ingrowth and remodeling process could, theoretically, be performed with collagen of inferior quality? In addition, the cost of these materials is extremely high.

Development of a simple model for predicting need for surgery in patients who initially undergo conservative management for adhesive small bowel obstruction - Corrected Proof

Issei Komatsu, Yasuharu Tokuda, Gen Shimada, Joshua L. Jacobs, Hisashi Onodera — 2010-07-01

Abstract: Background: Among patients with adhesive small bowel obstruction (ASBO) initially managed with a conservative strategy, predicting risk of operation is difficult.Methods: We investigated ASBO patients at 2 different periods to derive and validate a clinical prediction model for risk of operation.Results: One hundred fifty-four patients were enrolled into the derivation cohort and 96 into the validation cohort. Based on the derived scoring, including age ≥65 years, presence of ascites, and gastrointestinal drainage volume >500 mL on day 3, each patient was classified into 1 of 4 risk classes from low risk to high risk. When applied to the validation cohort, the positive predictive value (PPV) for operation in the high-risk class was 72%, while the negative predictive value (NPV) in the low-risk class was 100% with high sensitivity (100%) and specificity (96%).Conclusions: The prediction model performs well for risk stratification of need for surgical intervention following conservative strategy among ASBO patients.

Corrected Proof

Kirby I. Bland — 2010-07-01

Professor Seymour I. Schwartz, internationally renowned surgeon, physician-scientist, author, educator, cartographer, and art connoisseur, is perhaps best known for his monumental achievement as the founding editor of the Principles of Surgery, now in its 7th edition with over one-half million copies sold. As former Professor and Chairman of the Department of Surgery of the University of Rochester, he has held seminal roles in the leadership of American Surgery, including the American College of Surgeons, the American Board of Surgery, and the American Surgical Association.

The omentum is a site of stromal cell–derived factor 1α production and reservoir for CXC chemokine receptor 4–positive cell recruitment - Corrected Proof

Naveed U. Saqib, Paul G. McGuire, Thomas R. Howdieshell — 2010-07-01

Abstract: Background: The mechanism of the omental response to injury remains poorly defined. This study investigates the omental reaction to a foreign body, examining the role of a chemokine ligand/receptor pair known to play a crucial role in angiogenesis and wound healing.Methods: A ventral hernia, surgically created in the abdominal wall of 6 swine, was repaired with silicone sheeting to activate the omentum. Omental thickness was determined by ultrasonography. Serial stromal cell–derived factor 1α (SDF-1α) concentrations were measured in blood, wound, and peritoneal fluids by enzyme-linked immunosorbent assay.Results: During the 14-day study period, serial ultrasonography showed a 20-fold increase in omental thickness, and enzyme-linked immunosorbent assay revealed a 4-fold increase in SDF-1α concentration in local wound fluid. Omental vessel count and vascular surface area were 8- to 10-fold higher in reactive omentum. Immunohistochemistry showed nearly complete replacement of control omental fat with CXC chemokine receptor 4 (CXCR4)-positive cells by day 14.Conclusions: Activated omentum, important in the SDF-1α/CXCR4 axis, may serve as an intraperitoneal reservoir for recruitment of circulating bone marrow–derived cells vital to healing.

A vanishing species - Corrected Proof

Leon Morgenstern — 2010-07-01

It is disconcerting to learn that half of the world's living species are in a state of decline. Some have disappeared forever like the dodo bird and the steller sea cow. Others are seriously threatened with extinction, like the lemurs and the sea turtles. They are the so-called endangered species. A mammalian biped that has recently been recognized as endangered is Chirugus generalis, more commonly known as “the general surgeon.”

Visfatin and gallstone disease - Corrected Proof

Teoman Dogru, Muammer Kara, Cemal Nuri Ercin, Cihan Meral, Gökhan Erdem — 2010-06-28

Visfatin is a recently described adipose tissue–derived protein, which has insulin-mimetic actions. Adipocyte visfatin expression and plasma concentrations increase in some, but not all, forms of obesity, both in animals and humans. Visfatin exerts its insulin-mimetic action by binding to the insulin receptor, and there is evidence that it may contribute to the development of the metabolic syndrome.

Preoperative platelet–lymphocyte ratio in resected pancreatic ductal carcinoma: is it meaningful? - Corrected Proof

Ismael Domínguez, Carlos Fernández-del Castillo — 2010-06-28

The article by Smith and colleagues published in the April issue of the American Journal of Surgery describes preoperative platelet–lymphocyte (PL) ratio as an independent prognostic factor in resected pancreatic ductal carcinoma. The data were collected from a prospectively maintained database and included 110 cases of histologically confirmed pancreatic ductal carcinoma. It is a well-designed study with clear objectives and adequate sample selection, but there are some questions regarding its relevance.

Operative performance in laparoscopic cholecystectomy using the Procedural-Based Assessment tool - Corrected Proof

Sudip K. Sarker, M. Maciocco, A. Zaman, I. Kumar — 2010-06-24

Abstract: Aims: The Intercollegiate Surgical Curriculum Project (ISCP) has devised assessment tools for index operations to assess trainee technical skills. In this study we used the Procedural-Based Assessment (PBA) tool to evaluate operations performed by trainees.Methods: Live and simulated laparoscopic cholecystectomies were performed by trainees. Two experienced surgeons assessed each operation blindly and independently.Results: Eighty-four live (supervised) and 112 simulated (unsupervised) operations were performed by 28 trainees. Mean inter-rater reliability was kappa = .86 and .84 for live and simulated operations, respectively. Construct validity using Mann–Whitney for generic technical skills was significant for live and simulated operations, P ≤ .05. Assessing specific technical skills showed construct validity for simulated unsupervised operations only, Mann–Whitney P < .05, but not for supervised live operations, Mann–Whitney P > .05.Conclusions: The PBA showed good inter-rater reliability. Assessing generic technical skills, PBA showed construct validity for both types of operations and for specific technical skills in the unsupervised simulated operations. We conclude that the PBA seems to be a reliable and valid assessment tool for generic technical skills in unsupervised simulated and live supervised laparoscopic cholecystectomies.

Outcome of oncoplastic breast surgery in 90 prospective patients - Corrected Proof

Tuomo J. Meretoja, Catarina Svarvar, Tiina A. Jahkola — 2010-06-23

Abstract: Background: Oncoplastic breast surgery refers to a wide range of techniques with a parallel goal of safely removing all malignant breast tissue while achieving the best possible esthetic outcome. We report the results of our oncoplastic breast operations from 2005 to 2007.Methods: Ninety selected breast cancer patients were treated with a variety of oncoplastic operations. The patients were prospectively monitored. Radiotherapy and systemic adjuvant treatment were given according to national guidelines.Results: Fifteen patients had an immediate surgical complication, of which 8 required a reoperation. Eleven patients had an inadequate surgical margin and required a completion mastectomy. During a median follow-up of 26 months no local or regional recurrences were noticed. Three patients developed distant metastases.Conclusions: Oncoplastic breast surgery offers tools for breast conservation in patients otherwise destined for mastectomy or poor esthetic outcome. Despite the high proportion of patients in this series with large-volume ductal carcinoma in situ (DCIS) or extensive intraductal component, the use of oncoplastic techniques achieved negative margins with acceptable cosmetic results in the majority (84%) of patients.

Compliance with guidelines to prevent surgical site infections: As simple as 1-2-3? - Corrected Proof

2010-06-23

Abstract: Background: The purpose of this study was to assess predictive factors and compliance with surgical site infection (SSI) prevention guidelines at 2 county hospitals.Design: Chart review and analysis of laparotomy patients undergoing colorectal, hysterectomy, or abdominal vascular procedures over two 6-month periods 1 year apart and evaluation of safety climate using the Safety Attitudes Questionnaire (SAQ).Results: Overall compliance with all antibiotic prophylaxis guidelines was 62% (n = 442). Gynecologic surgery was an independent predictor of compliance with antibiotic prophylaxis guidelines in elective cases, and nonemergency status was an independent predictor when all cases were considered. Postoperative normothermia was predicted by hospital, procedure length, initial intraoperative temperature, and service. The SAQ had a 91% response rate. Contrary to expected, safety domain scores and agreement with statements on collaboration and teamwork were not predictive of compliance.Conclusion: Interventions to improve poor compliance with infection prevention guidelines must be multifaceted, hospital- and service-specific, and resilient during emergencies. Good safety and teamwork climate are not sufficient.

Improved detection does not fully explain the rising incidence of well-differentiated thyroid cancer: a population-based analysis - Corrected Proof

Luc G.T. Morris, David Myssiorek — 2010-06-21

Abstract: Background: The increasing incidence of thyroid cancer may be an artifact of increased diagnostic scrutiny, permitting detection of smaller, subclinical thyroid cancers. Our objective was to examine trends in the incidence of well-differentiated thyroid cancers with large size and adverse pathological features.Methods: Detailed population-based analysis of incidence trends in well-differentiated thyroid carcinoma (1973–2006) in the Surveillance Epidemiology and End Results (SEER) cancer registry, using weighted least squares and Joinpoint regression models.Results: The incidence of well-differentiated thyroid cancer (WDTC) in the United States has tripled since 1973 (P < .0001). Incidence trends differ significantly between geographic regions and racial groups. Large WDTCs, including those >4 cm or >6 cm, have more than doubled in incidence (P < .0001). Cancers with extrathyroidal extension and with cervical metastases have also more than doubled in incidence (P < .0001).Conclusions: While the model of improving screening does explain increased diagnoses of small thyroid cancers, significant rises in the incidence of large cancers, and cancers with clinically significant pathological adverse features, are harder to explain. Alternative hypotheses, including a true increase in cancer incidence, would seem to merit exploration.

Structured teaching versus experiential learning of palliative care for surgical residents - Corrected Proof

2010-06-10

Abstract: Background: Previous end-of-life and palliative care curricula for surgical residents have shown improved learner confidence, but have not measured cognitive knowledge or skill acquisition.Methods: A nonrandomized trial evaluated a structured palliative care curriculum for 7 postgraduate year 2 surgical residents (intervention group) compared with 6 postgraduate year 5 surgical residents (comparison group). Outcomes were measured using an 18-item knowledge test, a 20-minute objective structured clinical examination simulating an intensive care unit family conference, and a survey measuring self-confidence.Results: The mean knowledge test scores for the intervention group, both before and after undergoing the structured palliative care curriculum, were no different from the comparison group. There was also no difference in objective structured clinical examination scores between the 2 groups. The intervention group felt less comfortable managing pain, breaking bad news, or addressing ethical issues.Conclusions: Junior surgical residents have similar palliative care knowledge to senior residents without a palliative care curriculum. After participating in a palliative care curriculum, they have simulated skills that are similar to chief residents. However, self-confidence is lower among junior residents despite undergoing a palliative care curriculum.

Open intraperitoneal versus retromuscular mesh repair for umbilical hernias less than 3cm diameter - Corrected Proof

2010-06-10

Abstract: Background: Mesh techniques are the preferable methods for repair of small ventral hernias, as a primary suture repair shows high recurrence rates. The aim of this prospective study was to compare the retromuscular sublay technique with the intraperitoneal underlay technique for primary umbilical hernias.Methods: From February 2004 to April 2007, all patients treated for umbilical hernias with maximum diameters of 3 cm were prospectively followed. During the first period of 15 months, all patients were treated with retromuscular repair using a large pore mesh (Vypro). After that period, for all patients, mesh repair using an intraperitoneal Ventralex patch was performed. All patients underwent general anesthesia. This analysis included 116 patients, of whom 56 had retromuscular repair (group I; mean age, 54.8 years; mean body mass index, 28.2 kg/m2) and 60 had open intraperitoneal repair (group II; mean age, 48.1 years; mean body mass index, 29.4 kg/m2). Operating time was evaluated as skin-to-skin time, and drain management was noted for both techniques. Follow-up was ≥2 years for all patients, and both early and late complications were registered, including seroma and hematoma formation, wound infection, fistula formation, and recurrence rates. Preoperative and postoperative pain was evaluated using a visual analogue scale (range, 0–10) on the day of the first outpatient visit; on postoperative days 1, 7, and 21; and after 1 year. Quality of life was estimated using the EQ-5D questionnaire 1 year after surgery. All data were analyzed using SPSS version 15 software. Wilcoxon's rank-sum test was used to analyze continuous variables, and repeated-measures analysis of variance was used for visual analogue scale scores. The χ2 test and Fisher's exact test were used to assess the differences between categorical data. P values < .05 were considered statistically significant.Results: The mean operative times were 79.9 minutes in group I and 33.9 minutes in group II (P < .001). The mean hospital stay was significantly longer in group I (3.8 vs 2.1 days, P < .001). Seromas and superficial wound infections in the early postoperative period were not different between both groups, although seromas occurred more frequent in the retromuscular group. Postoperative visual analogue scale scores were significantly lower with the intraperitoneal technique at all time points (P < .003, repeated-measures analysis of variance). However, 3 patients with the Ventralex patch had to be readmitted for severe pain. The recurrence rate was higher with the intraperitoneal repair (n = 5 [8.3%] vs n = 2 [3.6%]) than for the retromuscular mesh repair, but not statistically significant. Quality of life was comparable in the two groups after 1 year.Conclusions: The open intraperitoneal technique using a Ventralex mesh for umbilical hernias seems a very elegant and quick technique. However, possibly because of the less controllable mesh deployment, recurrence rates seem higher. In case open mesh repair is the preferred treatment, a retromuscular repair should be the first choice.

Stapler vs suture closure of pancreatic remnant after distal pancreatectomy: a meta-analysis - Corrected Proof

Wei Zhou, Ran Lv, Xianfa Wang, Yiping Mou, Xiujun Cai, Ingrid Herr — 2010-06-10

Abstract: Background: Suture closure and stapler closure of the pancreatic remnant after distal pancreatectomy are the techniques used most often. The ideal choice remains a matter of debate.Methods: Five bibliographic databases covering 1970 to July 2009 were searched.Results: Sixteen articles met the inclusion criteria. Stapler closure was performed in 671 patients, while suture closure was conducted in 1,615 patients. The pancreatic fistula rate ranged from 0% to 40.0% for stapler closure of the pancreatic stump and from 9.3% to 45.7% for the suture closure technique. There were no significant difference between the stapler and suture closure groups with respect to the pancreatic fistula formation rate (22.1% vs 31.2%; odds ratio, .85; 95% confidence interval, .66–1.08), although there was a trend toward favoring stapler closure. In 4 studies including 437 patients, stapler closure was associated with a trend (not statistically significant) toward a reduction in intra-abdominal abscess (odds ratio, .53; 95% confidence interval, .24–1.15).Conclusions: No significant differences occur between suture and stapler closure with respect to the pancreatic fistula or intra-abdominal abscess after distal pancreatectomy, though there is a trend favoring stapler closure.

The demographics of modern burn care: should most burns be cared for by non-burn surgeons? - Corrected Proof

Gary A. Vercruysse, Walter L. Ingram, David V. Feliciano — 2010-06-10

Abstract: Background: Minor burns represent .96% to 1.5% of emergency department visits, yet burn center referral is common. Analysis of the Grady Memorial Hospital Burn Center was conducted to examine the feasibility and savings if burns were managed locally with consultation as needed.Methods: Data on 776 consecutive admissions to Grady Memorial Hospital Burn Center between November 2005 and July 2007 were prospectively reviewed. National and international cohorts were compared.Results: Patients' mean age was 31 years, 69.8% were male, and 87% were insured. Thirty-nine percent were transfers. Seventy-six percent of transfers (51% of air transfers) and 70% of all admissions were for ≤10% total body surface area burns. Helicopter transport cost $12,500 and averaged 48 miles. Eighty percent of burns were hot water (scald), grease, or flame burns, and 31% required skin grafting.Conclusions: Most burns require assessment, debridement, and dressing changes. Grafting is rarely necessary. Patients are transferred because of a lack of training, and patients suffer economic burden and treatment delay. Savings could be realized were patients treated locally with select burn center referral. Video consultation and mentoring can help with triage and care of minor burns. Major burns require burn center referral. International practice reinforces these results.

Bassini and the vanished art of pure tissue inguinal hernioplasty - Corrected Proof

M. Tuveri, R. Demontis, E. Nicolò, S. Pisu — 2010-06-10

L.A. Danto, in a communication published in this journal, denounced the potential danger of all those surgical strategies meant to prevent the chronic inguinodynia arising after an inguinal hernia repair with the use of a prosthetic mesh, and the almost complete abandon of the traditional inguinal hernioplasty. As reported in many series, the incidence of postoperative inguinodynia is not the only increased complication after mesh hernioplasty. The nature and properties of the prosthetic material pose in fact a high risk of complications as protrusion, extrusion, infection and intestinal fistulization, and most importantly, once in place, is rigid, passive, adynamic, and aphysiological. In turn, this increase in complications seems not to have been counterbalanced by a long-lasting decrease in the recurrence rate.

Calcium pyrophosphate dihydrate deposition disease of the spleen - Corrected Proof

Yuan-Chun Hsu, Chen-Wang Chang, Chun-Lu Lin, Chuan-Tsai Lai — 2010-06-10

Abstract: Calcium pyrophosphate dihydrate deposition disease (CPPD), also known as pseudogout or chondrocalcinosis, is a variety of metabolic arthropathy caused by the deposition of calcium pyrophosphate dihydrate crystals in and around joints. Despite many case reports, extra-articular CPPD often goes unrecognized. Here, we report a unique case of pancreatic tail pseudocyst and CPPD of the spleen. To the best of our knowledge, CPPD of the spleen has not been reported in the literature.

Is oval flap reconstruction a good modification for treating pilonidal sinuses? - Corrected Proof

2010-06-10

Abstract: Background: Flap techniques are acceptable for the surgical treatment of pilonidal sinuses. This study assessed a new modification of the rhomboid flap technique.Methods: The study included 133 patients with pilonidal disease who were treated between April 2004 and April 2009. The pilonidal sinus was removed with an oval excision, and an oval head rhomboid flap was prepared to reduce flap necrosis.Results: The mean age of the patients was 27.4 ± 4.6 years (range, 13–80). The rate of minor postoperative complications was 11.3%. The mean hospital stay was 2.3 ± .8 days (range, 1–6). The rate of recurrence was 1.5%. Regarding cosmetic results, 116 (87%) patients were very pleased, 15 (11.2%) were pleased, and 5 (3%) were displeased. The mean follow-up period was 22.5 ± 12.4 months (range, 5–57).Conclusions: The oval flap reconstruction method is a recommended procedure that produces fewer ischemic flaps with a low rate of recurrence and acceptable cosmesis.

Duodenal polypoid lipoma with bleeding - Corrected Proof

2010-06-10

Abstract: Duodenal lipomas are rare; most are asymptomatic and are found incidentally via endoscopy or surgery. We report a case of duodenal polypoid lipoma with active bleeding. Although endoscopic treatment was scheduled initially, surgical intervention ultimately was indicated.

Laparoscopic colorectal surgery in elderly patients: a case-control study of 15 years of experience - Corrected Proof

2010-06-04

Abstract: Introduction: The aim of this study was to review the impact of age (≥75 years) on the short-term outcomes of laparoscopic colorectal surgery.Methods: Three hundred seventy-nine patients under 70 years of age and 91 patients 75 years and older were analyzed. Quantification of comorbidities was performed using the Charlson Weighted Comorbidity Index. Outcome measures were postoperative complications and 30-day mortality.Results: There was no difference in the occurrence of postoperative complications between the younger and older patients. Bivariate analysis revealed that patient age was not a risk factor of major complications (odds ratio = 1.2; 95% confidence interval, .6–2.3). Although bivariate analysis revealed that older age had a statistically significant odds ratio for 30-day mortality (odds ratio = 12.8; 95% confidence interval, 1.3–125.4), multivariate analysis revealed that it was a weighted comorbidity index score of 5 or more (P = .02) and long operative time (P = .01) that were independent predictors of 30-day mortality and not age per se.Conclusions: Age is not an independent predictor of morbidity and mortality in laparoscopic colorectal cancer surgery.

Transfer of training in the development of intracorporeal suturing skill in medical student novices: a prospective randomized trial - Corrected Proof

Claude Muresan, Tommy H. Lee, Jacob Seagull, Adrian E. Park — 2010-05-10

Abstract: Background: To help optimize the use of limited resources in trainee education, we developed a prospective randomized trial to determine the most effective means of teaching laparoscopic suturing to novices.Methods: Forty-one medical students received rudimentary instruction in intracorporeal suturing, then were pretested on a pig enterotomy model. They then were posttested after completion of 1 of 4 training arms: laparoscopic suturing, laparoscopic drills, open suturing, and virtual reality (VR) drills. Tests were scored for speed, accuracy, knot quality, and mental workload (National Aeronautics and Space Administration [NASA] Task Load Index).Results: Paired t tests were used. Task time was improved in all groups except the VR group. Knot quality improved only in the open or laparoscopic suturing groups. Mental workload improved only for those practicing on a physical laparoscopic trainer.Conclusions: For novice trainees, the efficacy of VR training is questionable. In contrast, the other training methods had benefits in terms of time, quality, and perceived workload.

Changes in acid–base balance during electrolytic ablation in an ex vivo perfused liver model - Corrected Proof

2010-05-10

Abstract: Background: Electrolytic ablation (EA) destroys tissues through extreme pH changes in the local microenvironment. An ex vivo perfused liver model was used to assess the systemic effects of EA on the acid–base balance without the influence of compensatory organs (lungs and kidneys).Methods: Eleven pigs were perfused extracorporeally at 39°C with autologous blood; 4 also underwent EA after 1 hour of reperfusion. Arterial blood samples were obtained hourly.Results: pH and CO2 levels did not change throughout the experiments. A significant increase of HCO3-, anion gap, base excess, and lactate was present after the third hour. No differences were observed between EA experiments and controls.Conclusions: EA does not alter the acid–base balance even when the confounding influence of compensatory organs is removed. Such findings should be considered when planning ablations in patients with renal failure or respiratory diseases in which EA could avoid undesirable metabolic changes.

Nuclear factor kappa B–dependent gene transcription in cholecystokinin- and tumor necrosis factor-α–stimulated isolated acinar cells is regulated by p38 mitogen-activated protein kinase - Corrected Proof

Deborah E. Williard, Erik Twait, Zuobiao Yuan, A. Brent Carter, Isaac Samuel — 2010-04-23

Abstract: Background: Mitogen-activated protein (MAP) kinases and nuclear factor kappa B (NF-κB) are implicated in early stages of acute pancreatitis pathogenesis. We investigated the relationship between the p38 MAP kinase and NF-κB in isolated acinar cells.Methods: Isolated rodent acinar cells were stimulated with agonists after infection with an adenovector containing a luciferase promoter driven only by NF-κB and an adenovector containing the dominant negative (DN) form of p38 (empty vector in controls).Results: Initial immunoblots confirmed that the agonist stimulated p38 activation in acinar cells was substantially attenuated by DN p38 overexpression. Stimulation of native cholecystokinin (CCK)-A receptors or tumor necrosis factor-α (TNF-α) receptors promoted a significant increase in NF-κB-dependent gene transcription in cells infected with the empty vector, while overexpression of DN p38 significantly abrogated NF-κB-dependent luciferase activity.Conclusions: These findings support our hypothesis that p38 is involved in the activation of proinflammatory nuclear transcription factors such as NF-κB in pancreatic exocrine cells.

Diminishing morbidity with the increased use of sentinel node biopsy in breast carcinoma - Corrected Proof

Andrea Bafford, Michele Gadd, Xiangmei Gu, Stuart Lipsitz, Mehra Golshan — 2010-04-22

Abstract: Background: Sentinel lymph node biopsy has largely replaced axillary node dissection in the staging of women with clinically negative axillas. The aim of this study was to compare the morbidity of sentinel node biopsy only, sentinel node biopsy followed by axillary dissection, and axillary node dissection only.Methods: Retrospective review of a prospectively maintained database of patients who underwent sentinel lymph node biopsy, axillary lymph node dissection, or both between June 1996 and August 2008 was performed. The incidence of postoperative complications, including arm cellulitis, diminished shoulder range of motion, axillary hematoma, intercostal brachial nerve injury, pulmonary embolus or deep-vein thrombosis, lymphocele requiring aspiration, wound dehiscence, and wound infection, was compared among the 3 groups using Fisher's exact test.Results: Of the 6,847 axillary operations performed, 2,745 (40%) were sentinel node biopsy only, 1,825 (27%) were sentinel lymph node biopsy followed by completion axillary dissection, and 2,277 (33%) were axillary dissection only. The mean node retrieval was 2 for sentinel node biopsy, 13 for sentinel node biopsy and completion axillary dissection, and 14 for axillary dissection. The mean age was 58 years. The overall complication rate was higher during the first half of the study period than during the second half (9.9% vs 3.9%, P < .0001). Axillary dissection had the highest overall complication rate (11.1%), followed by sentinel node biopsy and completion axillary dissection (7.3%), followed by sentinel node biopsy alone (2.6%) (P < .0001). Significantly less shoulder range of motion limitation, axillary hematoma, and lymphocele requiring aspiration were seen after sentinel node biopsy alone than after sentinel node biopsy plus completion axillary dissection or axillary dissection alone (P < .0001). Wound infection was also significantly less common after sentinel node biopsy than after axillary dissection (P = .02). No difference was seen in incidence of postoperative pulmonary embolus or deep-vein thrombosis, arm cellulitis, intercostal brachial nerve injury, or wound dehiscence.Conclusions: Sentinel lymph node biopsy is less morbid than sentinel node biopsy followed by completion axillary dissection and axillary node dissection alone. The morbidity of axillary surgery has decreased over time.

Intravenous leiomyomatosis: diagnosis and follow-up with multislice computed tomography - Corrected Proof

2010-04-22

Abstract: Intravenous leiomyomatosis is a rare disease, which appears histologically benign but is clinically aggressive. It is characterized by the intraluminal growth of leiomyomas in the intrauterine and systemic veins. Intravenous leiomyomatosis was reported to have originated in the uterus and extended into the right ventricle via the inferior vena cava (IVC). In these circumstances, it is fatal. Multislice compute tomography (MSCT) allows an early and accurate preoperative diagnosis, resulting in a higher rate of surgical resection and improved survival. The authors present 3 cases of intravenous leiomyomatosis with a history of uterine leiomyoma and hysterectomy. The lesions were found to have extended through the IVC into the right cardiac cavities and were confirmed to be intravenous leiomyomatosis by surgery.

Prevention of seroma formation after mastectomy and axillary dissection by lymph vessel ligation and dead space closure: a randomized trial - Corrected Proof

2010-04-22

Abstract: Introduction: We aimed to reduce the incidence of seroma formation by altering surgical technique.Methods: Two hundred one breast cancer patients were randomly divided into 2 arms: arm 1 was operated on using an altered surgical technique, which is to ligate all of the tissue connecting axillary vein bundles to the specimen, to suture the anterior edge of the latissimus dorsi to the chest wall, and to fix the skin flap to the underlying muscle by subcutaneous sutures; arm 2 was operated on using the conventional technique.Results: The drainage volume, in the initial 3 days, for patients in arm 1 was significantly less than that for patients in arm 2 (P < .01). The duration of drainage in arm 1 was shorter than that in arm 2 (P < .01). The incidence of seroma formation in arm 1 (2%) was significantly less than that in arm 2 (14%) (P < .01).Conclusion: The modified operating technique is an effective approach to reducing the incidence of seroma formation after mastectomy and axillary dissection.

Epidermal growth factor receptor (EGFR) intron 1 polymorphism and clinical outcome in pancreatic adenocarcinoma - Corrected Proof

2010-04-22

Abstract: Background: Epidermal growth factor receptor (EGFR) intron 1 has a polymorphic region of CA repeats that is believed to be associated with increased EGFR expression, tumor aggressiveness, and worse survival in cancer patients.Methods: A large population of pancreatic adenocarcinoma patients was investigated to evaluate this polymorphism as a potential prognostic marker of clinical outcome. Deoxyribonucleic acid obtained from 50 resected pancreatic adenocarcinomas and from 85 diagnostic endoscopic ultrasound-guided fine-needle aspiration procedures corresponding to patients with unresectable tumors was included. The correlation between CA repeat length and EGFR messenger ribonucleic acid levels was also examined.Results: Analysis of the 135 patients revealed no correlation between EGFR intron 1 CA repeat length and tumor stage. There was no difference in overall patient survival when stratified by allele length. A correlation between EGFR intron 1 length and EGFR transcript and protein levels could not be established.Conclusions: The length of the EGFR intron 1 CA repeats does not correlate with levels of EGFR expression and cannot be used as marker of clinical prognosis in pancreatic cancer patients.

Intracellular oxygenation and cytochrome oxidase C activity in ischemic preconditioning of steatotic rabbit liver - Corrected Proof

2010-04-22

Abstract: Background: Mild to moderate steatotic livers are used as marginal donors in liver transplantation. Very little is known about the mechanisms of ischemia reperfusion (IR) injury (IRI) in fatty liver. This study aimed to establish whether cytochrome oxidase C (COX) activity is compromised by IRI in fatty liver and whether ischemic preconditioning (IPC) can protect COX activity.Methods: New Zealand rabbits were fed on a high-cholesterol diet for 8 weeks to induce moderate hepatic steatosis. Three groups were tested. The IR group underwent 60 minutes of ischemia, followed by 7 hours of reperfusion. The IPC group (IPC + IR) underwent 5 minutes of ischemia, followed by 10 minutes of reperfusion and then 60 minutes of ischemia and 7 hours of reperfusion. The control group (sham) underwent the same surgical procedure, but ischemia was not induced. Deoxyhemoglobin, oxyhemoglobin, and change in the redox state of COX was continuously monitored in vivo by near-infrared spectroscopy. COX and citrate synthase (CS) activity assays were carried out on liver biopsy specimens in vitro. Bile was collected continuously during the procedure and analyzed using proton nuclear magnetic resonance spectroscopy.Results: The IR group had decreased COX activity and tissue oxygenation represented by deoxyhemoglobin, oxyhemoglobin, COX, and elevated redox ratios of lactate/pyruvate and β-hydroxybutarate/acetoacetate in vivo and a decrease in COX and CS activity in vitro. The IPC + IR group showed higher levels of all measured parameters in vivo and showed a smaller decrease in COX and CS activity in vitro.Conclusion: This study shows that IRI affects COX activity in fatty livers. This is attenuated by IPC.

A prospective randomized controlled trial to compare Pringle maneuver, hemihepatic vascular inflow occlusion, and main portal vein inflow occlusion in partial hepatectomy - Corrected Proof

2010-04-22

Abstract: Background: Blood loss during liver resection and the need for perioperative blood transfusions have negative impact on perioperative morbidity, mortality, and long-term outcomes.Methods: A randomized controlled trial was performed on patients undergoing liver resection comparing hemihepatic vascular inflow occlusion, main portal vein inflow occlusion, and Pringle maneuver. The primary endpoints were intraoperative blood loss and postoperative liver injury. The secondary outcomes were operating time, morbidity, and mortality.Results: A total of 180 patients were randomized into 3 groups according to the technique used for inflow occlusion during hepatectomy: the hemihepatic vascular inflow occlusion group (n = 60), the main portal vein inflow occlusion group (n = 60), and the Pringle maneuver group (n = 60). Only 1 patient in the hemihepatic vascular occlusion group required conversion to the Pringle maneuver because of technical difficulty. The Pringle maneuver group showed a significantly shorter operating time. There were no significant differences between the 3 groups in intraoperative blood loss and perioperative mortality. The degree of postoperative liver injury and complication rates were significantly higher in the Pringle maneuver group, resulting in a significantly longer hospital stay.Conclusions: All 3 vascular inflow occlusion techniques were safe and efficacious in reducing blood loss. Patients subjected to hemihepatic vascular inflow occlusion, or main portal vein inflow occlusion responded better than those with Pringle maneuver in terms of earlier recovery of postoperative liver function. As hemihepatic vascular inflow occlusion was technically easier than main portal vein inflow occlusion, it is recommended.

An expanding role for apolipoprotein E in sepsis and inflammation - Corrected Proof

Kelley Chuang, Erica L. Elford, Jill Tseng, Briana Leung, Hobart W. Harris — 2010-04-22

Abstract: Background: Apolipoprotein E (apoE), a component of plasma lipoproteins, plays an important, but poorly defined role in sepsis. We have shown that injecting apoE increases septic mortality in a rat model of gram-negative bacterial sepsis, with concomitant hepatic natural killer T (NKT) cell proliferation and activation. The presumed mechanism for this apoE-mediated mortality is that apoE can bind and traffic antigens, presumed to include lipopolysaccharide (LPS), and promote activation of dendritic cells (DC) with subsequent NKT activation and cytokine release. Thus, we sought to prove that LPS was the antigen responsible for the increased NKT activation enhanced by the presence of apoE.Methods: We isolated murine marrow-derived DCs, pulsed them with lipid antigen (LPS, and positive controls alpha-galactosylceramide [α-GalCer] and isoglobotrihexosylceramide 3 [iGb3]) with or without apoE, and then cocultured the DCs with hybridoma NKTs. NKT activation was measured by interleukin-2 (IL-2) supernatant levels using enzyme-linked immunosorbent assay (ELISA).Results: LPS at different concentrations was a weak stimulus for NKT activation regardless of apoE presence. When apoE was present, iGb3, an endogenous ligand analog, elicited more than a 2-fold increase in IL-2 response when compared with iGb3 alone (P < .05).Conclusions: These results indicate an endogenous ligand, not LPS, may be responsible for NKT activation. A molecular remnant similar to iGb3 could act as a damage-associated molecular pattern and play a prominent role in animal models of sepsis.

Isolated caudate lobe resection for hepatic tumor: surgical approaches and perioperative outcomes - Corrected Proof

Yi Wang, Lei Y. Zhang, Lei Yuan, Fu.Y. Sun, Tian G. Wei — 2010-04-22

Abstract: Background: Caudate lobe of the liver is relatively inaccessible because of its deep location and lying between the major vascular structures. Therefore, isolated caudate lobe resection (ICLR) is a much challengeable operation.Methods: Review of prospectively collected data from patients who underwent ICLR for hepatic tumor.Results: Forty-six patients (mean age 46.8 years) underwent ICLR for malignant (39 cases) and benign (7 cases) hepatic tumors. ICLRs were performed by 3 different approaches and in different ways of hepatic vascular control: without any vascular control in 7 patients, under Pringle maneuver in 26 patients, and under sequential inflow and outflow vascular occlusion in 13 patients. There were no perioperative deaths, and the postoperative complication rate was 8.7% (4/46). The mean operative time was 174.5 ± 44.3 minutes and the mean estimated intraoperative blood loss was 504.4 ± 356.2 mL.Conclusions: ICLR is a technically demanding but safe procedure. Choice of surgical approaches and ways of hepatic vascular control should be based on tumor location and surgeons'experience.

Duration of DVT prophylaxis in the surgical patient and its relation to quality issues - Corrected Proof

James Muntz — 2010-04-22

Abstract: Background: Venous thromboembolism (VTE) is a major cause of mortality and morbidity in patients after major surgery. The US Acting Surgeon General issued a “call to action” to reduce the number of VTE cases nationwide.Data Sources: PubMed literature searches were performed to identify original studies.Results and Conclusions: Noncompliance with VTE guidelines is common in clinical practice. Thromboprophylaxis is frequently stopped on discharge, not meeting recommendations for standard-duration prophylaxis (7–10 days) because of shorter hospital stays or for extended-duration prophylaxis (10–35 days). Appropriate pharmacologic prophylaxis options for orthopedic surgery patients include the low–molecular-weight heparins (LMWHs), fondaparinux, or warfarin (10–35 days). For patients undergoing abdominal surgery for cancer, the LMWHs are recommended beyond hospitalization (up to 28 days). Performance measures should help establish VTE-prevention policies that close the gap between guideline recommendations and clinical practice in a greater number of hospitals.

Invited commentary on “duration of prophylaxis in the surgical patient and its relation to quality issues” - Corrected Proof

Elliott R. Haut — 2010-04-22

The accompanying article by Dr Muntz is an excellent review of the evidence showing how poor a job American medicine as a whole does in the arena of prophylaxis for venous thromboembolism (VTE) in surgical patients. The article concisely summarizes the evidence-based guidelines that we should apply to patients undergoing major surgical procedures (with a significant focus on orthopedic surgery). The author then goes on to cite article after article showing that patients simply do not get the VTE prevention that they should. Some studies suggest that compliance with “best practice” may be low as 3% in certain patient subsets and hovers around the 50% range for many patient groups. When I first heard these statistics years ago, I was shocked; how could we be doing such a poor job when such good evidence exists? Clearly, I am not the only person appalled at these data. Samuel Z. Goldhaber, a national leader in VTE prevention efforts, has suggested that “the disconnect between evidence and execution as it relates to DVT prevention amounts to a public health crisis.” The Agency for Healthcare Research and Quality has suggested that the #1 ranked opportunity for patient safety improvement is “appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk.” The US Surgeon General's “Call to Action to Prevent Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)” also highlights the importance of getting this information more in the public eye. Educational efforts are clearly needed in this arena, yet education alone will not solve the problem.

The incidence of bariatric surgery has plateaued in the U.S. - Corrected Proof

Edward H. Livingston — 2010-04-22

Abstract: Background: Estimates of the procedure incidence for bariatric surgery have been derived primarily from surveys of bariatric surgeons or from inpatient data sources. New population-representative databases of outpatient surgery are available that enable accurate estimations of bariatric surgery case volumes.Methods: The 2006 National Hospital Discharge Survey, National Inpatient Sample, and National Survey of Ambulatory Surgery were assessed for bariatric surgery procedures. Data were compared with inpatient data from 1993 to 2007. Procedure costs were estimated.Results: The incidence of bariatric surgery has plateaued at approximately 113,000 cases per year. Open gastric bypass now constitutes only 3% of all cases but costs $4,800 less than laparoscopic procedures. Laparoscopic gastric banding is performed in 37% of all bariatric surgery cases and costs the same as laparoscopic gastric bypass to perform. Complication rates have fallen from 10.5% in 1993 to 7.6% of all cases in 2006. Bariatric surgery costs the health economy at least $1.5 billion annually.Conclusions: Despite predictions of continued growth of bariatric surgery, it appears that the annual incidence for these operations has remained stable since 2003. Most operations are performed laparoscopically, but open gastric bypass is substantially less costly than laparoscopic operations. Despite its simplicity, laparoscopic gastric banding costs the same as gastric bypass. There is no cost savings associated with ambulatory bariatric surgery.

Radiofrequency ablation of unresectable liver tumors: factors associated with incomplete ablation or local recurrence - Corrected Proof

2010-04-22

Abstract: Background: Radiofrequency ablation (RFA) of liver tumors is associated with a risk of incomplete ablation or local recurrence.Methods: One hundred sixty-eight patients with 311 unresectable liver tumors were included. Effects of different variables on incomplete ablation and local recurrence were analyzed.Results: There were 132 hepatocellular carcinomas and 179 liver metastases. Tumor size was 24 (±13) mm. Two hundred twenty-six tumors were treated percutaneously, and 85 through open approach (associated with liver resection in 42 cases). There was no mortality. Major morbidity rate was 7%. Incomplete ablation and local recurrence rates were 14% and 18.6%. Follow-up was 29 months. On multivariate analysis, factors associated with incomplete ablation were tumor size (>30 mm vs ≤30 mm, P = .004) and approach (percutaneous vs open, P = .0001). Factors associated with local recurrence were tumor size (>30 mm vs ≤30 mm, P = .02) and patient age (>65 years vs ≤65 years, P = .05).Conclusions: RFA is effective to treat unresectable liver tumors. However, there is a risk of incomplete ablation when percutaneously treating tumors >30 mm. When tumor ablation is completely achieved, the main factor associated with local recurrence is tumor size >30 mm.

Florid papillomatosis of the male nipple - Corrected Proof

Massimiliano Tuveri, Pietro Giorgio Calò, Cristina Mocci, Angelo Nicolosi — 2010-04-22

Abstract: The authors present a case of an adenoma of the nipple in a 61-year-old man who reported a 6-month history of nodularity and itching at his left nipple. Examination revealed a firm, well-defined, vascularized tumor measuring .8 cm that altered the normal anatomy of the nipple. A total excision of the nipple and areola was performed. The histological diagnosis was adenoma of the nipple. No recurrent tumor has been observed during 4 years of postoperative follow-up. An adequate excision of the lesion is curative without any risk of recurrence or development of malignancy.

Control of presacral venous bleeding during rectal surgery - Corrected Proof

Stylianos Germanos, Ioannis Bolanis, Mahmud Saedon, Sotirios Baratsis — 2010-04-22

Abstract: Background: Presacral venous hemorrhage is an uncommon but potentially life-threatening complication of rectal surgery. It is difficult to control presacral venous hemorrhage with conventional hemostatic measures and several alternative methods for hemostasis have been proposed. We described our experience of using the combination of a hemostatic matrix and an absorbable hemostat as an alternative method of hemostasis.Methods: From September 2007 to March 2009, 83 patients underwent rectal surgery for cancer, ulcerative colitis, or familial adenomatous polyposis. Three patients (3.6%) had severe presacral hemorrhage, which was controlled by the combined use of a hemostatic matrix (FloSeal; Baxter, USA) and an absorbable hemostat (Surgicel Fibrillar; Ethicon, USA).Results: Intraoperative blood transfusion was required in 1 patient. Postoperative blood loss was minimal and drain was removed on day 4 in all 3 patients.Conclusions: The use of synthetic hemostatic agents is an effective and simple way to arrest presacral bleeding where conventional methods fail.

Prognostic factors and patterns of recurrence in esophageal cancer assert arguments for extended two-field transthoracic esophagectomy - Corrected Proof

2010-04-22

Abstract: Background: High recurrence rates determine the dismal outcome in esophageal cancer. We reviewed our experiences and defined prognostic factors and patterns of recurrences after curatively intended transthoracic esophagectomy.Methods: Between January 1991 and December 2005, 212 consecutive patients underwent a radical transthoracic esophagectomy with extended 2-field lymphadenectomy. Recurrence rates, survival, and prognostic factors were analyzed (minimal follow-up period, 2 y).Results: Radicality was obtained in 85.6%. The median follow-up period was 26.6 months. The overall recurrence rate at 1, 3, and 5 years was 28%, 44%, and 64%, respectively, and locoregional recurrence rate was 17%, 27%, and 43%, respectively. Overall survival rates, including postoperative deaths, were 45% and 34% at 3 and 5 years, respectively. pT stage and lymph node (LN) ratio greater than .20 were independent prognostic factors for survival and recurrences. Radicality was most prognostic for survival, and for N+ greater than 4 positive LN for recurrences.Conclusions: Radicality and LN ratio are strong prognostic factors. High radicality and adequate nodal assessment are guaranteed by an extended transthoracic approach.

Antibiotic prophylaxis for severe acute pancreatitis - Corrected Proof

Peter B. Imrey, Ryan Law — 2010-04-22

Jafri et al, in a recent meta-analysis of antibiotic prophylaxis for severe acute pancreatitis, concluded that, “The present meta-analysis presents conclusive evidence that antibiotic prophylaxis for SAP is not beneficial in protecting against infected necrosis, surgical intervention, or reducing mortality” (p. 812). This conclusion rests on a basic error in statistical reasoning, with potential consequences that could seriously disadvantage patients. This is despite the evident care with which the authors have executed their literature search and analysis.

Use of tumescent mastectomy technique as a risk factor for native breast skin flap necrosis following immediate breast reconstruction - Corrected Proof

2010-04-22

Abstract: Background: Native breast skin flap necrosis is a complication that can result from ischemic injury following mastectomy and can compromise immediate breast reconstruction. The tumescent mastectomy technique has been advocated as a method of allowing sharp dissection with decreased blood loss and perioperative analgesia. This study was performed to determine whether the technique increases the risk for skin flap necrosis in an immediate breast reconstruction setting.Methods: Three hundred eighty consecutive mastectomies with immediate reconstruction over a 6-year period were reviewed and divided into 2 cohorts for comparison: 100 tumescent and 280 nontumescent mastectomy cases. The incidence of minor and major skin flap necrosis was evaluated.Results: The use of tumescent mastectomy (odds ratio [OR], 3.93; P < .001), prior radiation (OR, 3.19; P = .011), patient age (OR, 1.59; P = .006), and body mass index (OR, 1.11; P = .004) were significant risk factors for developing postoperative major native skin flap necrosis.Conclusions: The use of the tumescent mastectomy technique appears to be associated with a substantial increase in the risk for postoperative major skin flap necrosis in an immediate breast reconstruction setting.

Expressions of the anti-apoptotic genes Bag-1 and Bcl-2 in colon cancer and their relationship - Corrected Proof

Nianfeng Sun, Qingyi Meng, Ailing Tian — 2010-04-21

Abstract: Background: The aims of this study were to investigate the expressions and significance of the antiapoptotic genes Bag-1 and Bcl-2 in colon cancer and to evaluate their relationship.Methods: The expressions of Bag-1 and Bcl-2 were examined in 128 colon cancer and 20 normal colon tissue samples by reverse-transcription polymerase chain reaction and immunohistochemical technique (streptavidin-biotin-peroxidase complex method).Results: Bag-1 and Bcl-2 were expressed in colorectal cancer tissues but not in normal colorectal tissues by reverse-transcription polymerase chain reaction. The expression of Bag-1 in colon cancer was closely correlated with pathologic grade, distance metastasis, Duke stage, and prognosis, but it had no effect on the pathologic type, tumor diameter, depth of invasion, and lymphoid node metastasis of the cancer. By contrast, Bcl-2 had no significant correlation with all the clinical and pathologic factors. There was a positive correlation between Bag-1 and Bcl-2 in the development of colon cancer.Conclusions: High expressions of Bag-1 and Bcl-2 proteins in colon cancer were found. They might be regarded as biomarkers for the diagnosis of the early stage of colon cancer. In addition, they have significant relevance for the prognosis of colon cancer.