Long-term results of a randomized, observation-controlled, phase III trial of adjuvant interferon Alfa-2b in hepatocellular carcinoma after curative resection.

Ann Surg. 2012 Jan;255(1):8-17

Authors: Chen LT, Chen MF, Li LA, Lee PH, Jeng LB, Lin DY, Wu CC, Mok KT, Chen CL, Lee WC, Chau GY, Chen YS, Lui WY, Hsiao CF, Whang-Peng J, Chen PJ,

Abstract

OBJECTIVE: To investigate the clinical efficacy of adjuvant interferon alfa-2b (IFNα-2b) therapy on recurrence-free survival (RFS) of patients with postoperative viral hepatitis-related hepatocellular carcinoma (HCC).

BACKGROUND: Despite most individual trials have failed to meet their primary endpoint, recent pooled-data meta-analyses suggest that adjuvant IFN therapy may significantly reduce the incidence of recurrence in curatively ablated HCC.

METHODS: Patients with curative resection of viral hepatitis-related HCC were eligible, and were stratified by underlying viral etiology and randomly allocated to receive either 53 weeks of adjuvant IFNα-2b treatment or observation alone. The primary endpoint of this study was RFS.

RESULTS: A total of 268 patients were enrolled with 133 in the IFNα-2b arm and 135 in the control arm. Eighty percent of them were hepatitis B surface antigen seropositive. At a median follow-up of 63.8 months, 154 (57.5%) patients had tumor recurrence and 84 (31.3%) were deceased. The cumulative 5-year recurrence-free and overall survival rates of intent-to-treat cohort were 44.2% and 73.9%, respectively. The median RFS in the IFNα-2b and control arms were 42.2 (95% confidence interval [CI], 28.1-87.1) and 48.6 (95% CI, 25.5 to infinity) months, respectively (P = 0.828, log-rank test). Adjuvant IFNα-2b treatment was associated with a significantly higher incidence of leucopenia and thrombocytopenia. Thirty-four (24.8%) of treated patients required dose reduction, and 5 (3.8%) of these patients subsequently withdrew from therapy because of excessive toxicity. Adjuvant IFNα-2b only temporarily suppressed viral replication during treatment period.

CONCLUSIONS: In this study, adjuvant IFNα-2b did not reduce the postoperative recurrence of viral hepatitis-related HCC. More potent antiviral therapy deserves to be explored for this patient population. This study is registered at ClinicalTrials.gov and carries the identifier NCT00149565.

PMID: 22104564 [PubMed - indexed for MEDLINE]

Regional recurrence in breast cancer patients with sentinel node micrometastases and isolated tumor cells.

Ann Surg. 2012 Jan;255(1):116-21

Authors: Pepels MJ, de Boer M, Bult P, van Dijck JA, van Deurzen CH, Menke-Pluymers MB, van Diest PJ, Borm GF, Tjan-Heijnen VC

Abstract

OBJECTIVE: The impact of axillary treatment in daily practice on 5-year regional recurrence rate in breast cancer patients with isolated tumor cells or micrometastases in the sentinel node (SLN).

BACKGROUND: Axillary dissection is recommended in patients with tumor-positive SLNs. But, in recent studies, regional recurrence rates seemed low if dissection was omitted.

METHODS: We identified all patients in The Netherlands with invasive breast cancer who had an SLN biopsy before 2006, favorable primary tumor characteristics, and node-negative disease, isolated tumor cells or micrometastases as final nodal status. The primary endpoint was regional recurrence rate. To investigate differences in recurrence rates between patients with and without axillary treatment, a proportional hazard regression was carried out correcting for potential confounders.

RESULTS: In total, 857 patients with node-negative disease, 795 patients with isolated tumor cells, and 1028 patients with micrometastases in the SLN were included. Without axillary treatment, the 5-year regional recurrence rates were 2.3%, 2.0%, and 5.6%, respectively. Compared with patients who underwent axillary treatment, the adjusted hazard ratio for regional recurrence in patients who underwent an SLN procedure only was 1.08 (95% CI, 0.23-4.98) for node-negative disease, 2.39 (95% CI, 0.67-8.48) for isolated tumor cells, and 4.39 (95% CI, 1.46-13.24) for micrometastases. Doubling of tumor size, grade 3 and negative hormone receptor status were also significantly associated with recurrence.

CONCLUSIONS: Not performing axillary treatment in patients with SLN micrometastases is associated with an increased 5-year regional recurrence rate. Axillary treatment is recommended in patients with SLN micrometastases and unfavorable tumor characteristics.

PMID: 22183034 [PubMed - indexed for MEDLINE]

The Carcinoembryonic Antigen Level in the Pancreatic Juice and Mural Nodule Size Are Predictors of Malignancy for Branch Duct Type Intraductal Papillary Mucinous Neoplasms of the Pancreas.

Ann Surg. 2012 Jan 31;

Authors: Hirono S, Tani M, Kawai M, Okada KI, Miyazawa M, Shimizu A, Kitahata Y, Yamaue H

Abstract

OBJECTIVE:: Identification of predictors of malignancy for branch duct type intraductal papillary mucinous neoplasms (IPMN). BACKGROUND:: Main duct type IPMN has been recommended for resection. However, the indications for resection of the branch duct type IPMN have been controversial. METHODS:: We retrospectively analyzed the clinicopathological factors of 134 patients undergoing resection for branch duct type IPMN, excluding main duct type IPMN, to identify predictors of the malignant behavior of this neoplasm. The cutoff values of tumor size, main pancreatic duct (MPD) size, mural nodule size, and carcinoembryonic antigen (CEA) level in the pancreatic juice obtained during preoperative endoscopic retrograde pancreatography (ERP) were analyzed using receiver-operator characteristic curves. RESULTS:: We found 7 significant predictors for malignancy in the branch duct type IPMN in a univariate analysis; jaundice, tumor occupying the pancreatic head, MPD size >5 mm, mural nodule size >5 mm, serum carbohydrate antigen (CA)19-9 level, positive cytology in the pancreatic juice, and CEA level in the pancreatic juice >30 ng/mL. In a multivariate analysis, a mural nodule size >5 mm and a CEA level in the pancreatic juice >30 ng/mL were independent factors associated with malignancy. The positive predictive value of a mural nodule size >5 mm and a CEA level in the pancreatic juice >30 ng/mL was 100%, and the negative predictive value was 96.3%. CONCLUSIONS:: We identified 2 useful predictive factors for malignancy in branch duct type IPMN; a mural nodule size >5 mm and a CEA level in the pancreatic juice obtained by preoperative ERP >30 ng/mL.

PMID: 22301608 [PubMed - as supplied by publisher]

Meta-Analysis of Clinical Efficacy of Pulsed Radio Frequency Energy Treatment.

Ann Surg. 2012 Jan 31;

Authors: Guo L, Kubat NJ, Nelson TR, Isenberg RA

Abstract

OBJECTIVE:: To statistically evaluate published clinical efficacy data related to the use of pulsed radio frequency energy (PRFE) therapy in 3 clinical applications. BACKGROUND:: Numerous clinical studies have reported efficacy outcomes for PRFE therapy use in the palliative treatment of both postoperative and nonpostoperative pain and edema, and for its use as an adjunctive wound-healing (WH) therapeutic. Although diverse in design and endpoint, these studies are amenable to systematic review using both a vote-counting and P-value combination meta-analytic technique. METHODS:: A meta-analysis of efficacy outcomes reported in clinical trials was performed using a vote-counting procedure. In addition, when possible, the sum of logs method of P-value combination was used to determine a significance level for the combined evidence within each endpoint and clinical area. RESULTS:: Of the 186 clinical articles identified after application of selection criteria, there were 25 controlled trials that met criteria for inclusion in vote-counting and P-value combination methods and were used for formal statistical analysis. In total, 1332 patients receiving PRFE treatment were studied. Vote-counting procedure applied to clinical outcomes from controlled studies resulted in a greater number of positive outcomes than neutral outcomes, and zero negative outcomes, for each of the clinical application groups evaluated. The sum of logs P-value method found statistically significant improvement in pain, reduction in edema, and improvement in WH outcomes. CONCLUSIONS:: On the basis of statistical evaluation of published clinical efficacy data, there is strong statistical evidence that PRFE therapy is effective in the treatment of postoperative and nonpostoperative pain and edema and in WH applications.

PMID: 22301609 [PubMed - as supplied by publisher]

Letter to the Editor.

Ann Surg. 2012 Jan 31;

Authors: Hautmd ER, Kalish BT, Cotton BA, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE, Chang DC

PMID: 22301610 [PubMed - as supplied by publisher]

The State of Research and Development in Global Cancer Surgery.

Ann Surg. 2012 Jan 24;

Authors: Purushotham AD, Lewison G, Sullivan R

Abstract

OBJECTIVE:: The objective of this study was to perform an analysis of global cancer surgery research and development trends over the last 10 years across 21 countries. BACKGROUND:: Surgery is the main modality for cancer cure and control globally. Yet, in comparison to other areas such as cancer drugs, we know little about ongoing research activities to inform policymakers. METHODS:: Two subfield filters, surgery research and oncology, were developed and applied to Web of Science. The intersection of these 2 filters identified papers in surgical oncology, and their bibliographic details were downloaded for analysis. This included matching of 5-year citation counts to the papers, impact factor, geographical analysis by country, translational collaboration, involvement in clinical trials, citation on clinical guidelines, and percentage of reviews. RESULT:: Surgical oncology represents about 9% of all cancer research-low in comparison with surgery’s contribution to cancer treatment. The US published the most, followed by Japan which had a high relative commitment to surgery within cancer research, followed by the large West European countries. Although Sweden’s papers were relatively basic, it participated the most in clinical trials. Its papers were also the most cited on clinical guidelines, but contained relatively few reviews, where the UK, Greece, and Belgium scored best. Surgical oncology papers are generally not well cited compared with cancer research overall, but on this measure the Netherlands, the US, and Sweden scored best. International collaboration was measured relative to what might have been expected, on this indicator Canada, Switzerland, and the US were the best performers. CONCLUSIONS:: Globally, low activity-low funding cycle needs to be addressed by new national and supranational policies to support surgical oncology research.

PMID: 22281701 [PubMed - as supplied by publisher]

Putting the Patient First: Honoring Advance Directives Before Surgery.

Ann Surg. 2012 Jan 24;

Authors: Cooper ZR, Powers CL, Cobb JP

PMID: 22281702 [PubMed - as supplied by publisher]

Morbidity Risk Factors After Low Anterior Resection With Total Mesorectal Excision and Coloanal Anastomosis: Retrospective Series of 483 Patients.

Ann Surg. 2012 Jan 26;

Authors: Bennis M, Parc Y, Lefevre JH, Chafai N, Attal E, Tiret E

Abstract

OBJECTIVE:: To report postoperative morbidity after low anterior resection (LAR) and coloanal anastomosis (CAA) for rectal cancer and identify possible risk factors of complications. BACKGROUND:: Coloanal anastomosis after total mesorectal excision (TME) is associated with significant morbidity. Precise data on the specific morbidity and the risk factors are lacking. METHODS:: We analyzed retrospectively 483 consecutive LARs with TME and CAA carried out in a single center between 1996 and 2005. All complications occurring up to 3 months after LAR and up to 3 months after closure of the diverting stoma were graded according to the Dindo classification. RESULTS:: Of 483 patients, 164 (33.9%) suffered at least 1 complication, leading to death in 2 (0.4%) patients. Grade III/IV complications occurred in 69 of 483 (14.2%) patients. Thirty-four (7.0%) patients developed leakage of the CAA and 3 patients had leakage of the small bowel anastomosis after stoma closure. Ileostomy closure was carried out after a mean of 88.7 days (36-630) after LAR. The stoma was not closed in 4 of 456 (0.6%) patients. In multivariate analysis, male sex (P = 0.0216) and postoperative transfusion (P = 0.0025) were associated with complications. Medical complications were furthermore associated with previous thrombembolic events (P = 0.0012) and associated surgery at the time of LAR (P = 0.0010). Circumferential tumor localization was predictive of surgical complications (P = 0.0015). The only factor associated with a risk of leakage was transfusion (P = 0.0216). CONCLUSIONS:: In this series morbidity occurred in 34% and dehiscence of the CAA in 7.0%. Transfusion requirement was an independent risk factor for postoperative complications and anastomotic leakage.

PMID: 22281734 [PubMed - as supplied by publisher]

Perception of Semiquantitative Terms in Surgery.

Ann Surg. 2012 Jan 26;

Authors: Gutknecht S, Kaderli R, Businger A

Abstract

OBJECTIVE:: To assess whether semiquantitative terms (eg, “often” or “rare”), which are often used for achieving informed consent, have the same meaning for laypersons and physicians. BACKGROUND:: To obtain informed consent, physicians have to make their patients aware of the risks of an operation. Thereby, semiquantitative terms are often used. METHODS:: Questionnaire interview among surgeons and randomly approached laypersons. A set of semiquantitative terms was presented to participants for quantification. Pertinent to 8 exemplary complications of common operations, these values were compared among the 2 interviewed groups and corresponding rates in scientific literature. RESULTS:: The questionnaire was completed by 48 surgeons and 582 laypersons in Switzerland. Confronted with corresponding complication rates in literature, laypersons underestimated the risk significantly in 6 of 8 cases. After a simulated informed consent conversation with a surgeon by using semiquantitative terms, laypersons overestimated the complication rate significantly in 7 of 8 cases. An interaction analysis did not show any significant difference between correct estimations of complication rates of respondents who graduated, who had a professional medical background or who had had prior contact with the health care system (eg, medical consultation, hospitalization, operation) compared with the others. CONCLUSIONS:: Laypersons overestimate probabilities of semiquantitative terms named by surgeons. We recommend using “percentages” or “odds ratios” to achieve a more reliable preoperative informed consent.

PMID: 22281735 [PubMed - as supplied by publisher]

Letter to the Editor.

Ann Surg. 2012 Jan 26;

Authors: Champion HR

PMID: 22281736 [PubMed - as supplied by publisher]

Systematic Review of the Clinical Effectiveness of Wound-edge Protection Devices in Reducing Surgical Site Infection in Patients Undergoing Open Abdominal Surgery.

Ann Surg. 2012 Jan 20;

Authors: Gheorghe A, Calvert M, Pinkney TD, Fletcher BR, Bartlett DC, Hawkins WJ, Mak T, Youssef H, Wilson S

Abstract

OBJECTIVE:: Assess the existing evidence on the clinical effectiveness of wound-edge protection devices (WEPDs) in reducing the surgical site infection (SSI) rate in patients undergoing open abdominal surgery. BACKGROUND:: Surgical site infections are a common postoperative complication associated with considerable morbidity, extended hospital stay, increased health care costs, and reduced quality of life. Wound-edge protection devices have been used in surgery to reduce SSI rates for more than 40 years; however, they are yet to be cited in major clinical guidelines addressing SSI management. METHODS:: A review protocol was prespecified. A variety of sources were searched in November 2010 for studies containing primary data on the use of WEPDs in reducing SSI compared with standard care in patients undergoing open abdominal surgery. The outcome of interest was a well-specified, clinically based definition of an SSI. No language or time restrictions were applied. The quality assessment of the studies and the quantitative analyses were performed in line with the principles of the Cochrane Collaboration. RESULTS:: Twelve studies reporting primary data from 1933 patients were included in the review. The quality assessment found all of them to be at considerable risk of bias. An exploratory meta-analysis was performed to provide a quantitative indication on the effect of WEPDs. The pooled risk ratio under a random effects model was 0.60 (95% confidence interval, 0.41-0.86), indicating a potentially significant benefit from the use of WEPDs. No indications of significant between-study heterogeneity or publication bias, respectively, were identified. CONCLUSIONS:: Evidence to date suggests that WEPDs may be efficient in reducing SSI rates in patients undergoing open abdominal surgery. However, the poor quality of the existing studies and their small sample sizes raise the need for a large, good quality randomized controlled trial to validate this indication.

PMID: 22270692 [PubMed - as supplied by publisher]

Cost-Effectiveness of Early Colectomy With Ileal Pouch-Anal Anastamosis Versus Standard Medical Therapy in Severe Ulcerative Colitis.

Ann Surg. 2012 Jan 20;

Authors: Park KT, Tsai R, Perez F, Cipriano LE, Bass D, Garber AM

Abstract

BACKGROUND:: Inflammatory bowel diseases are costly chronic gastrointestinal diseases. We aimed to determine whether immediate colectomy with ileal pouch-anal anastamosis (IPAA) after diagnosis of severe ulcerative colitis (UC) was cost-effective compared to the standard medical therapy. METHODS:: We created a Markov model simulating 2 cohorts of 21-year-old patients with severe UC, following them until 100 years of age or death, comparing early colectomy with IPAA strategy to the standard medical therapy strategy. Deterministic and probabilistic analyses were performed. RESULTS:: Standard medical care accrued a discounted lifetime cost of $236,370 per patient. In contrast, early colectomy with IPAA accrued a discounted lifetime cost of $147,763 per patient. Lifetime quality-adjusted life-years gained (QALY-gained) for standard medical therapy was 20.78, while QALY-gained for early colectomy with IPAA was 20.72. The resulting incremental cost-effectiveness ratio (Δcosts/ΔQALY) was approximately $1.5 million per QALY-gained. Results were robust to one-way sensitivity analyses for all variables in the model. Quality-of-life after colectomy with IPAA was the most sensitive variable impacting cost-effectiveness. A low utility value of less than 0.7 after colectomy with IPAA was necessary for the colectomy with IPAA strategy to be cost-ineffective. CONCLUSIONS:: Under the appropriate clinical settings, early colectomy with IPAA after diagnosis of severe UC reduces health care expenditures and provides comparable quality of life compared to exhaustive standard medical therapy.

PMID: 22270693 [PubMed - as supplied by publisher]

Isoflurane Post-conditioning Protects Against Intestinal Ischemia-Reperfusion Injury and Multiorgan Dysfunction via Transforming Growth Factor-β1 Generation.

Ann Surg. 2012 Jan 19;

Authors: Kim M, Park SW, Kim M, Dʼagati VD, Lee HT

Abstract

OBJECTIVE:: This study examined volatile anesthetic-mediated protection against intestinal ischemia-reperfusion injury (IRI). BACKGROUND:: Intestinal IRI is a devastating complication in the perioperative period leading to systemic inflammation and multiorgan dysfunction. Volatile anesthetics, including isoflurane, have anti-inflammatory effects. We aimed to determine whether isoflurane, given after intestinal ischemia, protects against intestinal IRI and the mechanisms involved in this protection. METHODS:: After IACUC approval, mice were anesthetized with pentobarbital and subjected to 30 minutes of superior mesenteric artery ischemia, followed by 4 hours of equianesthetic doses of pentobarbital or isoflurane. Five hours after reperfusion, small intestine tissues were analyzed for morphological injury, apoptosis, neutrophil infiltration, proinflammatory mRNAs, and TGF-(Transforming Growth Factor-)β1 levels. We also assessed hepatic and renal injury after intestinal IRI. RESULTS:: Intestinal IRI with pentobarbital led to significant small intestinal dysfunction with increased mucosal injury, TUNEL (transferase biotin-dUTP nick end-labeling)-positive cells, neutrophil infiltration, and proinflammatory mRNAs as well as elevated plasma alanine aminotransferase and creatinine levels. Isoflurane exposure after IRI led to significant attenuation of intestinal, hepatic, and renal injuries. Furthermore, the protective effects of isoflurane were abolished by treatment with a TGF-β1 neutralizing antibody before induction of IRI. Finally, isoflurane exposure led to increased TGF-β1 levels in intestinal epithelial cells and in plasma. CONCLUSIONS:: Our findings demonstrate that isoflurane post-conditioning protects against small intestinal injury and hepatic and renal dysfunction after severe intestinal IRI via induction of intestinal epithelial TGF-β1. Our findings support therapeutic applications of volatile anesthetics during the intraoperative and postoperative periods and imply an important role of TGF-β1 signaling in modulating multiorgan injury.

PMID: 22266638 [PubMed - as supplied by publisher]

Laparoendoscopic Rendezvous Versus Preoperative ERCP and Laparoscopic Cholecystectomy for the Management of Cholecysto-Choledocholithiasis: Interim Analysis of a Controlled Randomized Trial.

Ann Surg. 2012 Jan 18;

Authors: Tzovaras G, Baloyiannis I, Zachari E, Symeonidis D, Zacharoulis D, Kapsoritakis A, Paroutoglou G, Potamianos S

Abstract

BACKGROUND:: Although the ideal management of cholecysto-choledocholi-thiasis is controversial, the 2-stage approach [endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy, and common bile duct (CBD) clearance followed by laparoscopic cholecystectomy] remains the standard way of management worldwide. One-stage approach using the so-called laparoendoscopic rendezvous (LERV) technique offers some advantages, mainly by reducing the hospital stay and the risk of post-ERCP pancreatitis. OBJECTIVE:: To compare the LERV 1-stage approach with the standard 2-stage approach consisting of preoperative ERCP followed by laparoscopic cholecystectomy for the treatment of cholecysto-choledocholithiasis. SETTING:: Controlled randomized trial, University/Teaching Hospital. METHODS:: Patients with cholecysto-choledocholithiasis were randomized either to LERV or to the 2-stage approach. Both elective and emergency cases were included in the study. Primary endpoint was to detect difference in overall hospital stay, whereas secondary endpoints were (i) to detect differences in morbidity (especially post-ERCP pancreatitis) and (ii) success of CBD clearance. This is an interim analysis of the first 100 randomized patients. RESULTS:: Hospital stay was significantly shorter in the LERV group; median 4 (2-19) days versus 5.5 (3-22) days, P = 0.0004. There was no difference in morbidity and success of CBD clearance between the 2 groups. Post-ERCP amylase value was found significantly lower in the LERV group: median 65 (16-1159) versus 91 (30-1846), P = 0.02. CONCLUSIONS:: Interim analysis of the results suggests the superiority of the LERV technique in terms of hospital stay and post-ERCP hyperamylasemia.

PMID: 22261836 [PubMed - as supplied by publisher]

Resection of Hepatocellular Carcinoma Without Cirrhosis.

Ann Surg. 2012 Jan 17;

Authors: Shrager BJ, Jibara G, Schwartz M, Roayaie S

Abstract

OBJECTIVE:: The aim of this study was to examine the features and outcomes of noncirrhotic patients undergoing resection for hepatocellular carcinoma. BACKGROUND:: Ten percent to 40% of hepatocellular carcinoma cases arise within a noncirrhotic liver parenchyma. Resection is the standard therapy, yet the published resection series from the West are small. METHODS:: From January 1987 to December 2009, our center performed 206 partial liver resections for noncirrhotic hepatocellular carcinoma. We retrospectively reviewed these cases and performed univariate and multivariate analyses for predictors of long-term outcomes. RESULTS:: Eighty-one patients (39.3%) had chronic hepatitis B infection and 23 patients (11.2%) had chronic hepatitis C. The remaining 83 (39.8%) had no underlying liver disease. Average age was 60.2 years, and 68.4% of the patients were male. Average tumor size was 8.2 cm. Overall survival at 5 years was 46.3%. Recurrence at 5 years was 50.0%. Independent predictors for decreased survival were tumor size larger than 7.0 cm, creatinine more than 1.0 mg/dL, satellite nodules, albumin less than 3.5 gm/dL, alpha-fetoprotein more than 100 ng/mL, and any vascular invasion. Chronic hepatitis B virus infection predicted longer survival. Independent predictors for decreased time to recurrence were albumin less than 3.5 gm/dL, any vascular invasion, age more than 60 years, tumor size larger than 7.0 cm, and alpha-fetoprotein more than 100 ng/mL. Treatment of recurrence with either repeat resection or ablation was associated with a median survival of 50.4 months from time of recurrence. CONCLUSIONS:: Hepatocellular carcinoma can develop in a precirrhotic hepatitis C patient. Tumor-related factors such as vascular invasion primarily determine long-term outcomes. Hepatitis B virus-associated tumors seem to have a better prognosis in the noncirrhotic population. Aggressive treatment of recurrence is warranted.

PMID: 22258064 [PubMed - as supplied by publisher]

Feasibility and Safety of Single-Incision Laparoscopic Colectomy: A Systematic Review.

Ann Surg. 2012 Jan 17;

Authors: Makino T, Milsom JW, Lee SW

Abstract

OBJECTIVE:: The aim of this review was to evaluate the feasibility, safety, and potential benefits of single-incision laparoscopic colectomy (SILC). METHODS:: We conducted a comprehensive review for the years 1983 to March 2011 to retrieve all relevant articles. RESULTS:: A total of 23 studies with 378 patients undergoing SILC were reviewed. All studies except 2 used a commercially available single-port device. Range of body mass index was 20.9 to 30.0 kg/m. Ranges of operative times and estimated blood losses were 83 to 225 minutes and 0 to 115 mL, respectively. Of 378 cases, a total of 6 cases (1.6%) were converted to open, 6 (1.6%) to hand-assisted laparoscopic (HALC), and 14 (4.0%) to conventional (multiport) laparoscopic colectomy (MLC) (overall conversion rate, 6.9%). An additional laparoscopic port was used in 4.9% (12/247) cases. Range of harvested lymph nodes number for malignant cases was 13.5 to 27 and surgical margins were negative in all cases. Overall mortality and morbidity rates were 0.5% (2/378) and 12.9% (45/349), respectively. The length of hospital stay (LOS) varied across reports (1.9-9.8 days). Among 5 case-matched studies, 2 showed shorter LOS after SILC than after HALC (2.7 vs 3.3 days) or after MLC/HALC (3.4 vs 4.6/4.9 days). Furthermore, one of these studies reported that maximum pain score on postoperative days 1 and 2 was significantly lower in SILS than in MLC and HALC. CONCLUSIONS:: In early series of highly selected patients, SILC appears to be feasible and safe when performed by surgeons who are highly skilled in laparoscopy. Despite technical difficulties, there may be potential benefits associated with SILC over MLC/HALC but it is yet to be proven objectively.

PMID: 22258065 [PubMed - as supplied by publisher]

The Beneficial Impact of Revision of Kasai Portoenterostomy for Biliary Atresia: An Institutional Study.

Ann Surg. 2012 Jan 17;

Authors: Bondoc AJ, Taylor JA, Alonso MH, Nathan JD, Wang Y, Balistreri WF, Bezerra JA, Ryckman FC, Tiao GM

Abstract

OBJECTIVE:: To determine whether portoenterostomy (PE) revision in patients afflicted with biliary atresia (BA) is a viable treatment option and, if so, identify which patients may benefit. BACKGROUND:: BA, the most common cause of neonatal liver disease, results in biliary tract obstruction and hepatic fibrosis. Kasai PE is the initial surgical intervention performed and, if successful, restores drainage and preserves the native liver. Portoenterostomy failure warrants liver transplantation, but because of complications related to transplantation, treatment strategies to salvage the native liver may be beneficial. Using uniformly applied criteria, we have revised PEs to delay or avoid transplantation. METHODS:: A retrospective review of medical records of patients diagnosed with BA since 1983 was performed. Patient demographics, symptoms, indications for revision, laboratory values, and outcomes were recorded. A cohort of patients who underwent revision after initial PE was identified. Survival rates were assessed using the Kaplan-Meier method. For patients who required transplantation, operative data from the revised PE cohort were compared with those from the unrevised PE cohort. A Cox proportional hazards model was used to determine covariates predictive of a favorable outcome. RESULTS:: Of 181 children who underwent PE, 24 underwent revision. Adequate biliary drainage, as evidenced by normalized conjugated bilirubin levels, was achieved in 75% of revised patients. Overall survival in patients who underwent revision, regardless of transplantation, was 87%. Among patients who underwent PE revision, 46% have survived with their native liver. CONCLUSION:: Experience at our center suggests that with appropriate patient selection, PE revision may delay the need for liver transplanation yielding encouraging patient outcomes.

PMID: 22258066 [PubMed - as supplied by publisher]

Microvascular Breast Reconstruction and Lymph Node Transfer for Postmastectomy Lymphedema Patients.

Ann Surg. 2012 Jan 9;

Authors: Saaristo AM, Niemi TS, Viitanen TP, Tervala TV, Hartiala P, Suominen EA

Abstract

OBJECTIVE:: Postoperative lymphedema after breast cancer surgery is a challenging problem. Recently, a novel microvascular lymph node transfer technique provided a fresh hope for patients with lymphedema. We aimed to combine this new method with the standard breast reconstruction. METHODS:: During 2008-2010, we performed free lower abdominal flap breast reconstruction in 87 patients. For all patients with lymphedema symptoms (n = 9), we used a modified lower abdominal reconstruction flap containing lymph nodes and lymphatic vessels surrounding the superficial circumflex vessel pedicle. Operation time, donor site morbidity, and postoperative recovery between the 2 groups (lymphedema breast reconstruction and breast reconstruction) were compared. The effect on the postoperative lymphatic vessel function was examined. RESULTS:: The average operation time was 426 minutes in the lymphedema breast reconstruction group and 391 minutes in the breast reconstruction group. The postoperative abdominal seroma formation was increased in patients with lymphedema. Postoperative lymphoscintigraphy demonstrated at least some improvement in lymphatic vessel function in 5 of 6 patients with lymphedema. The upper limb perimeter decreased in 7 of 9 patients. Physiotherapy and compression was no longer needed in 3 of 9 patients. Importantly, we found that human lymph nodes express high levels of endogenous lymphatic vessel growth factors. Transfer of the lymph nodes and the resulting endogenous growth factor expression may thereby induce the regrowth of lymphatic network in the axilla. No edema problems were detected in the lymph node donor area. CONCLUSION:: Simultaneous breast and lymphatic reconstruction is an ideal option for patients who suffer from lymphedema after mastectomy and axillary dissection.

PMID: 22233832 [PubMed - as supplied by publisher]

The relationship between hospital lung cancer resection volume and patient mortality risk.

Ann Surg. 2011 Dec;254(6):1032-7

Authors: Kozower BD, Stukenborg GJ

Abstract

OBJECTIVE: To evaluate the volume-outcome relationship after lung cancer resection using 3 alternative measures of the effect of volume.

SUMMARY BACKGROUND DATA: Many studies of lung cancer resection indicate that hospital volume predicts mortality. However, controversy exists regarding the strength and validity of this association. Because thresholds of procedure volume are used to recommend the regionalization of care, investigation of the validity of the volume-outcome relationship is necessary.

METHODS: Lung cancer resection patients were identified in the 2007 Nationwide Inpatient Sample. Hospital volume was measured using 3 different methods: as a continuous linear function, as a nonlinear function using restricted cubic splines, and as the frequently used method of quintile categories. The statistical significance of the relationship between hospital volume and mortality risk was assessed, adjusted for patient age, comorbid disease, and for correlated events within hospitals.

RESULTS: Forty thousand four hundred and sixty lung cancer resection patients from 436 hospitals were identified. All 3 models demonstrated excellent performance characteristics (C index = 0.92, Nagelkerke R = 0.37). No significant association was demonstrated between hospital procedure volume and in-hospital mortality when measured as a linear or nonlinear function using splines. However, a statistically significant relationship was found for volume categorized into quintiles, although its relative contribution to the predictive capacity of the model was very small (likelihood ratio = 2.55, P = 0.04).

CONCLUSIONS: The apparent impact of hospital lung cancer resection volume on mortality is dependent on how volume is defined and entered into the regression equation. Hospital lung cancer resection volume is not a predictor of mortality and should not be used as a proxy measure for surgical quality.

PMID: 21562402 [PubMed - indexed for MEDLINE]

Triple positive tumor markers for hepatocellular carcinoma are useful predictors of poor survival.

Ann Surg. 2011 Dec;254(6):984-91

Authors: Kiriyama S, Uchiyama K, Ueno M, Ozawa S, Hayami S, Tani M, Yamaue H

Abstract

OBJECTIVE: To determine the importance of the expression pattern of multiple tumor markers for hepatocellular carcinoma (HCC) with regard to the tumor malignancy and patient survival.

BACKGROUND: Several studies have indicated that HCC tumor markers, including alpha-fetoprotein (AFP), Lens culinaris agglutinin-reactive fraction of AFP and des-γ-carboxy prothrombin were predictors of HCC malignancy. However, few reports have shown the relevance of the expression pattern of these 3 tumor markers with regard to patient prognosis. We herein reported the influence of the expression pattern of these 3 tumor markers on HCC malignancy and patient prognosis.

METHODS: This retrospective study analyzed 185 patients who underwent hepatectomy for HCC between January 1999 and May 2009. The relationships between clinical parameters and these 3 tumor markers were analyzed. Cox proportional hazards regression analyses were performed to estimate risk factors for recurrence and survival. Furthermore, the relationships between pathological parameters and the expression patterns of the 3 tumor markers were analyzed.

RESULTS: From clinical parameters, expression patterns of 3 tumor markers were related to maximum tumor size and macrovascular invasion in image findings. Multivariate analyses revealed independent risk factors for recurrence or survival to be the Child-Pugh score, the presence of multiple tumors, and triple positive tumor marker expression. From pathological findings, microvascular invasion and an Edmondson-Steiner classification of III or IV were related to the expression patterns of the 3 tumor markers.

CONCLUSIONS: Triple positive tumor markers for HCC showed poor prognosis and invasive characteristics in pathological findings. Examination of these markers would be useful for predicting the degree of HCC malignancy.

PMID: 21606837 [PubMed - indexed for MEDLINE]

Forty-year experience with flow-diversion surgery for patients with congenital choledochal cysts with pancreaticobiliary maljunction at a single institution.

Ann Surg. 2011 Dec;254(6):1050-3

Authors: Takeshita N, Ota T, Yamamoto M

Abstract

BACKGROUND: Congenital choledochal cyst with pancreaticobiliary maljunction (PBM) is known as a high-risk factor for various complications such as cholangitis, pancreatitis, and carcinogenesis of the biliary system by mutual refluxes of bile and pancreatic juice. Furthermore, it is not rare to suffer from postoperative complications if the wrong operative procedure is chosen. Therefore, we sought to review the relationship between operative procedure for types I and IV-A (Todani’s classification) congenital choledochal cyst with PBM, and long-term treatment outcome.

SUBJECTS AND METHODS: A retrospective review was carried out of 144 patients who underwent flow diversion surgery in our institution during the 40-year period from 1968 to 2008 and who did not have a coexisting malignant tumor at the time of surgery.

RESULTS: Of these 144 patients, 137 underwent complete cyst excision and 7 underwent pancreas head resection as flow diversion surgery. The follow-up periods ranged from 1 to 345 months and from 1 to 271 months (average, 100.2 and 94.1) in patients with type I and type IV-A cysts, respectively. Regarding surgical treatment outcome, postoperative progress was good in 130 (90.3%) of the 144 patients. Fourteen patients required hospitalization for long-term postoperative complications such as cholangitis, pancreatitis, intrahepatic calculi, pancreatic calculus, and carcinogenesis during postoperative follow-up. Of these, 2 patients who underwent surgery for type IV-A cysts died because of secondary biliary cirrhosis with liver failure and advanced intrahepatic cholangiocarcinoma, respectively.

CONCLUSIONS: The present study shows that flow diversion surgery for congenital choledochal cysts with PBM significantly reduces the risk of subsequent development of malignancy in the biliary tract, and it is vital to choose the appropriate operative procedure to prevent occurrence of these postoperative complications.

PMID: 21659852 [PubMed - indexed for MEDLINE]

The effect of the CMS national coverage decision on the performance and outcomes of bariatric surgery for medicare recipients in the U.S.

Ann Surg. 2011 Dec;254(6):866-7

Authors: Schirmer B

PMID: 22076070 [PubMed - indexed for MEDLINE]

A most unusual patient at the Massachusetts General Hospital.

Ann Surg. 2011 Dec;254(6):845-9

Authors: Ruhnke GW, Warshaw AL

Abstract

This year marks 200 years of patient care at the Massachusetts General Hospital (MGH). In celebration of this milestone, a unique Grand Rounds case is presented. A 450-year-old rotund man admitted 60 times presents with a classic triad of periumbilical pain, bilateral plantar burns, and a frozen scalp. Although this triad may at first strike a cord of familiarity among seasoned clinicians, the disease mechanism is truly noteworthy, being clarified only after a detailed occupational history. Ergo, the lessons hark back to the days of yesteryear, when the history and physical served as the cornerstone of Yuletide clinical diagnosis. A discussion of epidemiology and prognosis accompanies a detailed examination of the pathophysiholiday. Although some consider this patient uncouth, as you will see, he is quite a medical sleuth. The long-standing relationship between this patient and the MGH prompted his family to write a letter of appreciation, which will remind the reader of the meaning that our care brings to patients and their families. Harvey Cushing, who completed his internship at the MGH in 1895, professed “A physician is obligated to consider more than a diseased organ, more even than the whole man-he must view the man in his world.” We hope this unusual Grand Rounds case intrigues you as it reminds you of Cushing’s lesson and wishes you a joyous holiday season.

PMID: 22107737 [PubMed - indexed for MEDLINE]

Adjuvant hepatic arterial infusional chemotherapy: revisiting the past or a new era?

Ann Surg. 2011 Dec;254(6):857-9

Authors: Nagorney DM, Grothey A

PMID: 22107739 [PubMed - indexed for MEDLINE]

The short-term outcomes of conventional and single-port laparoscopic surgery for colorectal cancer.

Ann Surg. 2011 Dec;254(6):933-40

Authors: Kim SJ, Ryu GO, Choi BJ, Kim JG, Lee KJ, Lee SC, Oh ST

Abstract

OBJECTIVE: The aim of this study was to show the safety and feasibility of single-port laparoscopic surgery (SPLS) by comparing its short-term outcomes with those following conventional laparoscopic surgery.

SUMMARY BACKGROUND DATA: Single-port laparoscopic surgery maximizes the advantages of laparoscopic surgery, and therefore it can be an ultimate attainment of laparoscopic surgery. However, no comparative study has addressed its role in colorectal cancer.

METHODS: Prospectively collected data of patients who had undergone either conventional laparoscopic surgery (n = 106) or SPLS (n = 73) for colorectal cancer between March 2006 and May 2010 were analyzed retrospectively. The short-term outcomes of these 2 operative modalities were compared.

RESULTS: Of the 179 study subjects, 103 (57.5%) had colon cancer and 76 (42.5%) had rectal cancer. Various operative methods, from right hemicolectomy to abdominoperineal resection, were used according to location through either conventional laparoscopic or SPLS approach. In its comparison, mean surgical time was greater in the SPLS group (255 vs 276 minutes, P < 0.008). Acquired length of sufficient surgical margins and the number of harvested lymph nodes were comparable. Postoperative recovery was faster in the SPLS group, in terms of shorter time duration before first flatus (SPLS vs conventional laparoscopic surgery; 2.5 ± 1.2 vs 3.2 ± 1.8 days, P = 0.004), earlier initiation of free oral fluids (1.8 ± 2.2 vs 2.6 ± 1.7 days, P = 0.000) and of a solid diet (4.2 ± 2.9 vs 6.5 ± 2.7 days, P = 0.000), less frequent usage of parenteral narcotics (2.2 ± 3.2 vs 3.5 ± 4.0 times, P = 0.029), and shorter hospital stay (9.6 ± 9.6 vs 15.5 ± 9.8 days, P = 0.000).

CONCLUSION: This study shows that SPLS is both safe and feasible in colorectal cancer, and that it has equivalent or better short-term outcomes than conventional laparoscopic surgery. Accordingly, the authors conclude that SPLS can be an alternative to conventional laparoscopic surgery for colorectal cancer.

PMID: 22107740 [PubMed - indexed for MEDLINE]

Radiation therapy for prostate cancer increases the risk of subsequent rectal cancer.

Ann Surg. 2011 Dec;254(6):947-50

Authors: Margel D, Baniel J, Wasserberg N, Bar-Chana M, Yossepowitch O

Abstract

PURPOSE: To assess whether radiation therapy for prostate cancer (PCa) increases the risk of metachronous rectal cancer (RCa) and compare outcomes of RCa after radiation therapy and surgery.

PATIENTS AND METHODS: The Israel Cancer Registry was queried to identify patients with PCa and RCa diagnosed between 1982 and 2005. The age adjusted standardized incidence ratio (SIR) of RCa was defined as the ratio between the observed and expected (calculated) RCa cases and compared among the following: overall Israeli male population, patients with PCa treated with radiation therapy, patients with PCa treated surgically. The medical records of men diagnosed with RCa were reviewed and clinical characteristics retrieved.

RESULTS: Of 29,593 men diagnosed with PCa, 2163 were treated with radiation therapy, 6762 were treated surgically and 20,068 patients were treated with either primary androgen deprivation therapy or offered watchful waiting. Of the entire study cohort, 194 (0.65%) patients were diagnosed with subsequent RCa. Compared to the overall male population and stratified by treatment modality, the risk of developing RCa after radiation therapy was significantly increased (SIR = 1.81, 95% CI 1.2-2.5), whereas it was not increased in those managed by surgery (SIR = 1.22, 95% CI 0.85-1.65). RCa after radiation therapy was diagnosed at a more advanced stage, translating into inferior disease specific survival.

CONCLUSIONS: Compared to men diagnosed with PCa managed by surgery, we observed an increased risk of RCa in patients treated with radiation therapy. Further studies are needed to validate these findings and assess whether routine colonoscopic surveillance is warranted after pelvic radiation.

PMID: 22107741 [PubMed - indexed for MEDLINE]

The artificial bowel sphincter: a single institution experience over a decade.

Ann Surg. 2011 Dec;254(6):951-6

Authors: Wong MT, Meurette G, Wyart V, Glemain P, Lehur PA

Abstract

OBJECTIVE: A report on the long-term results of a consecutive series of patients implanted with the Acticon Neosphincter.

METHOD: Data were reviewed from a prospective database. From May 1996 to Jan 2010, 52 patients (46 women), mean age 51.5 ± 14.8 years, with severe fecal incontinence for a mean of 10.6 ± 10.5 years, were implanted with 85 devices. All patients had failed conservative management, including 13 with unsuccessful prior surgical treatments. Indications for implantation were sphincter destruction (45), pudendal neuropathy (12), congenital malformation (7), and perineal colostomy (4). Preoperative assessment included anal endosonography, anorectal manometry, and electrophysiologic testing. Incontinence (Wexner) and Quality of Life scores were recorded prior to the procedure and at each follow-up visit, together with annual anal physiology assessments. Cumulative risks of device revision and explantation were evaluated using Kaplan-Meier survival curves.

RESULTS: Mean follow-up was 64.3 ± 46.5 months (range, 2-169); 26 patients (50%) required revisions after a mean of 57.7 ± 35.0 months, with 73.1% due to a leaking cuff from a microperforation; 14 patients (26.9%) required definitive explantation after a mean of 14.6 ± 7.9 months, with the majority (42.9%) due to infection; and 9 patients were lost to follow-up. In 35 patients (67.3%) with an activated device, there were significant improvements in both median Wexner (P < 0.0001) and Quality-of-life scores (P = 0.0286). There was a significant difference between preoperative resting anal pressures and closed pressures at activation (P < 0.0001) and latest follow-up (P < 0.0001).

CONCLUSION: With careful patient selection, meticulous surgical technique, and dedicated surveillance, favorable long-term results can be achieved with acceptable rates of revision and explantation.

PMID: 22107742 [PubMed - indexed for MEDLINE]

Unilateral subtotal adrenalectomy for pheochromocytoma in multiple endocrine neoplasia type 2 patients: a feasible surgical strategy.

Ann Surg. 2011 Dec;254(6):1022-7

Authors: Scholten A, Valk GD, Ulfman D, Borel Rinkes IH, Vriens MR

Abstract

OBJECTIVE: To determine the best surgical strategy for pheochromocytoma in multiple endocrine neoplasia type 2 (MEN2) patients.

BACKGROUND: Pheochromocytomas occur in 50% to 60% of MEN2 patients, approximately half of them eventually develop bilateral disease. Unilateral subtotal adrenalectomy as primary surgery for pheochromocytoma in these patients may avoid or postpone the need for corticosteroid replacement therapy and the risk of Addisonian crisis, but is not yet widely accepted.

METHODS: We conducted a retrospective cohort study including 61 MEN2 patients with pheochromocytoma who were treated at the University Medical Center Utrecht between 1959 and 2010. Surgery was classified into 4 adrenalectomy groups: bilateral total, unilateral total, bilateral subtotal, and unilateral subtotal.

RESULTS: Primary surgery involved 22 bilateral total, 30 unilateral total, 2 bilateral subtotal, and 7 unilateral subtotal adrenalectomies. Twenty-one patients developed ipsilateral or contralateral recurrence after a median follow-up of 13.4 ± 10.8 years (range: 0.1-41.8). Unilateral total and unilateral subtotal adrenalectomy had similar rates of recurrence (P = 0.232) and survival time (5.5 versus 8.8 years; P = 0.170). Steroid replacement after bilateral total adrenalectomy led to complications in 8 patients. Reoperations for recurrence included unilateral total adrenalectomy in 12 patients, after which 10 needed steroid replacement (with complications in 3) and unilateral subtotal adrenalectomy in 5 patients, after which none needed replacement therapy. Ipsilateral recurrence after reoperation was similar between these groups.

CONCLUSIONS: Unilateral subtotal adrenalectomy is a feasible surgical strategy for pheochromocytoma in MEN2 patients. It has comparable recurrence rates and eventually less complications of steroid replacement compared to unilateral total adrenalectomy.

PMID: 22107743 [PubMed - indexed for MEDLINE]

Postoperative ileus after laparoscopic colectomy: elusive and expensive.

Ann Surg. 2011 Dec;254(6):1075; author reply 1075-6

Authors: Pavoor R, Milsom J

PMID: 22107744 [PubMed - indexed for MEDLINE]

Lymph node metastases in cancer: a new way to look at things.

Ann Surg. 2011 Dec;254(6):1078-9

Authors: Sterpetti AV

PMID: 22107745 [PubMed - indexed for MEDLINE]

Do routinely repeated computed tomography scans in traumatic brain injury influence management? A prospective observational study in a level 1 trauma center.

Ann Surg. 2011 Dec;254(6):1028-31

Authors: Connon FF, Namdarian B, Ee JL, Drummond KJ, Miller JA

Abstract

OBJECTIVE: To prospectively examine the clinical role of routine repeat computed tomographic scans of the brain (CTB) in patients with traumatic head injury.

SUMMARY BACKGROUND DATA: The use of routine serial CTB after traumatic head injury is recommended by some authors, but remains controversial.

METHODS: From March 2007 to October 2008, all patients with traumatic head injury admitted to the Royal Melbourne Hospital, a metropolitan, Level I trauma center, were prospectively studied. After the initial computed tomography brain scans, any subsequent CTBs were assessed and were recorded as being either “clinically indicated” or “routine” and ensuing medical and surgical management. Inpatient information was recorded and comparisons made according to indication for CTB, Glasgow Coma Scale, and management changes.

RESULTS: A total of 651 patients were admitted with traumatic head injury over the 20-month study period. Of those, 39 underwent immediate craniotomy/craniectomy and were excluded from analysis. Another 25 were excluded due to incomplete data, leaving 591 patients for analysis. Of the 591 assessed, 401 were discharged with no further computed tomography investigation. One hundred and ninety patients underwent a total of 305 repeat brain scans, of which 149 were clinically indicated, whereas 156 were obtained as a “routine” investigation with no deterioration in patients’ neurological status. Of the repeated scans, 71 were improved, 169 were unchanged, and 64 were worse. None of the 156 patients who received a “routine” CTB required a change in management. The 149 CTB performed for clinical deterioration resulted in a change in management in 28 patients (19%). The patients who underwent “indicated” computed tomographic scans and subsequently required a change in management were on average younger (P < 0.001) and more severely head injured (P = 0.001) than the patients not requiring a change in management.

CONCLUSIONS: No patients from our cohort with a “routine” repeat CTB required a change in management. Given the costs and potential risks of routine repeat CTB, and lack of demonstrable benefit, the practice should be reconsidered. Repeat CTB is clearly indicated in patients with deteriorating neurological status, especially younger and more severely head-injured patients.

PMID: 22112983 [PubMed - indexed for MEDLINE]

Assessment of Prognostic Circulating Tumor Cells in a Phase III Trial of Adjuvant Immunotherapy After Complete Resection of Stage IV Melanoma.

Ann Surg. 2011 Dec 26;

Authors: Hoshimoto S, Faries MB, Morton DL, Shingai T, Kuo C, Wang HJ, Elashoff R, Mozzillo N, Kelley MC, Thompson JF, Lee JE, Hoon DS

Abstract

OBJECTIVE:: To verify circulating tumor cell (CTC) prognostic utility in stage IV resected melanoma patients in a prospective international phase III clinical trial. BACKGROUND:: Our studies of melanoma patients in phase II clinical trials demonstrated prognostic significance for CTCs in patients with AJCC stage IV melanoma. CTCs were assessed to determine prognostic utility in follow-up of disease-free stage IV patients pre- and during treatment. METHODS:: After complete metastasectomy, patients were prospectively enrolled in a randomized trial of adjuvant therapy with a whole-cell melanoma vaccine, Canvaxin, plus Bacille Calmette-Guerin (BCG) versus placebo plus BCG. Blood specimens obtained pretreatment (n = 244) and during treatment (n = 214) were evaluated by quantitative real-time reverse-transcriptase polymerase chain reaction (qPCR) for expression of MART-1, MAGE-A3, and PAX3 mRNA biomarkers. Univariate and multivariate Cox analyses examined CTC biomarker expression with respect to clinicopathological variables. RESULTS:: CTC biomarker(s) (≥1) was detected in 54% of patients pretreatment and in 86% of patients over the first 3 months. With a median follow-up of 21.9 months, 71% of patients recurred and 48% expired. CTC levels were not associated with known prognostic factors or treatment arm. In multivariate analysis, pretreatment CTC (> 0 vs. 0 biomarker) status was significantly associated with disease-free survival (DFS; HR 1.64, P = 0.002) and overall survival (OS; HR 1.53, P = 0.028). Serial CTC (>0 vs. 0 biomarker) status was also significantly associated with DFS (HR 1.91, P = 0.02) and OS (HR 2.57, P = 0.012). CONCLUSION:: CTC assessment can provide prognostic discrimination before and during adjuvant treatment for resected stage IV melanoma patients. Study registration ID# NCT00052156.

PMID: 22202581 [PubMed - as supplied by publisher]

Vagal Innervation of Hepatic Portal Vein and Liver Is Not Necessary for Roux-En-Y Gastric Bypass Surgery-Induced Hypophagia, Weight Loss, and Hypermetabolism.

Ann Surg. 2011 Dec 26;

Authors: Shin AC, Zheng H, Berthoud HR

Abstract

OBJECTIVE:: To determine the role of the common hepatic branch of the abdominal vagus on the beneficial effects of Roux-en-Y gastric bypass (RYGB) on weight loss, food intake, food choice, and energy expenditure in a rat model. BACKGROUND:: Although changes in gut hormone patterns are the leading candidates in RYGB’s effects on appetite, weight loss, and reversal of diabetes, a potential role for afferent signaling through the vagal hepatic branch potentially sensing glucose levels in the hepatic portal vein has recently been suggested in a mouse model of RYGB. METHODS:: Male Sprague-Dawley rats underwent either RYGB alone (RYGB; n = 7), RYGB + common hepatic branch vagotomy (RYGB + HV; n = 6), or sham procedure (sham; n = 9). Body weight, body composition, meal patterns, food choice, energy expenditure, and fecal energy loss were monitored up to 3 months after intervention. RESULTS:: Both RYGB and RYGB + HV significantly reduced body weight, adiposity, meal size, and fat preference, and increased satiety, energy expenditure, and respiratory exchange rate compared with sham procedure, and there were no significant differences in these effects between RYGB and RYGB + HV rats. CONCLUSIONS:: Integrity of vagal nerve supply to the liver, hepatic portal vein, and the proximal duodenum provided by the common hepatic branch is not necessary for RYGB to reduce food intake and body weight or increase energy expenditure. Specifically, it is unlikely that a hepatic portal vein glucose sensor signaling RYGB-induced increased intestinal gluconeogenesis to the brain depends on vagal afferent fibers.

PMID: 22202582 [PubMed - as supplied by publisher]

Tumor Deposits in Colorectal Cancer: A Moving Target.

Ann Surg. 2011 Dec 26;

Authors: Greene FL

PMID: 22202583 [PubMed - as supplied by publisher]

Multidimensional Analysis of Learning Curve for Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy in Peritoneal Surface Malignancies.

Ann Surg. 2011 Dec 26;

Authors: Kusamura S, Baratti D, Deraco M

Abstract

OBJECTIVE:: To evaluate the learning curve of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in treating peritoneal surface malignancies (PSM). SUMMARY AND BACKGROUND:: CRS and HIPEC to treat PSM is a complex procedure with a significant morbidity. A long-lasting training program is required to acquire expertise in this type of operation. METHODS:: We performed CRS using peritonectomy procedures. HIPEC through the closed abdomen technique employed cisplatin and mitomycin-C or cisplatin and doxorubicin. Risk-adjusted sequential probability ratio test was used to assess the learning curve on a series of 420 cases of PSM on the basis of rates of incomplete cytoreduction and G3-5 morbidity (NCI-CTCAE v3). We determined control limits setting the type I/II error rates and unacceptable odds ratios (ORs) for the outcomes being studied. We performed the risk adjustment using logistic regression model. RESULTS:: Rates of incomplete cytoreduction, G3-5 morbidity, and postoperative mortality rates were 10.2%, 28.5%, and 2.1%, respectively. The risk-adjusted sequential probability ratio test curve crossed the lower control limit at the 137th and 149th case, respectively, for incomplete cytoreduction and G3-5 morbidity. At those points, the actual ORs are lower than the prespecified ORs for outcomes being studied. Therefore, we estimated that approximately 140 cases are necessary to ensure surgical proficiency in CRS and HIPEC. CONCLUSIONS:: CRS and HIPEC to treat PSM has a steep learning curve requiring 140 procedures to acquire expertise.

PMID: 22202584 [PubMed - as supplied by publisher]

The Impact of Obesity on Perioperative Outcomes After Laparoscopic Colorectal Resection: A Review.

Ann Surg. 2011 Dec 20;

Authors: Makino T, Shukla PJ, Rubino F, Milsom JW

Abstract

OBJECTIVE:: It is commonly perceived that surgery in obese patients is associated with worse outcomes than in nonobese patients. Because of the increasing prevalence of obesity and colonic diseases in the world population, the impact of obesity on outcomes of laparoscopic colectomy remains an important subject. The aim of this review was to evaluate the feasibility and safety of laparoscopic colectomy for colorectal diseases in obese patients compared with nonobese patients. METHODS:: We conducted a comprehensive review for the years 1983-2010 to retrieve all relevant articles. RESULTS:: A total of 33 studies were found to be eligible and included 3 matched case control studies and 1 review article. Obesity, often accompanied by preexisting comorbidities, was associated with longer operative times and higher rates of conversion to open procedures mainly because of the problem of exposure and difficulties in dissection. Although some studies showed obesity was associated with increased postoperative morbidity including cardiopulmonary and systemic complications, or ileus leading to longer hospital stay, there was no evidence about the negative impact of obesity on intraoperative blood loss, perioperative mortality, and reoperation rate. Whether obesity is a risk factor for wound infection after laparoscopic colectomy remains unclear. Though sometimes in obese patients, additional number of ports were necessary to successfully complete the procedure laparoscopically, obesity did not influence the number of dissected lymph nodes in cancer surgery. Lastly, the postoperative recovery of gastrointestinal function was similar between obese and nonobese patients. CONCLUSIONS:: Laparoscopic colorectal surgery appears to be a safe and reasonable option in obese patients offering the benefits of a minimally invasive approach, with no evidence for compromise in treatment of disease.

PMID: 22190113 [PubMed - as supplied by publisher]

Correlation Between Radiographic Classification and Pathological Grade of Portal Vein Wall Invasion in Pancreatic Head Cancer.

Ann Surg. 2011 Dec 8;

Authors: Nakao A, Kanzaki A, Fujii T, Kodera Y, Yamada S, Sugimoto H, Nomoto S, Nakamura S, Morita S, Takeda S

Abstract

OBJECTIVES:: A retrospective study was performed to clarify the correlation between radiographic type of portal vein (PV) invasion and pathological grade of PV wall invasion, and their correlation with postoperative prognosis. BACKGROUND:: In many patients with pancreatic cancer, PV resection is necessary to increase resectability and obtain cancer-free margins. METHODS:: We analyzed 671 patients who had undergone surgery for invasive adenocarcinoma of the pancreas between July 1981 and June 2010. Radiographic types of PV invasion of pancreatic head cancer were classified into A (normal), B (unilateral narrowing), C (bilateral narrowing), or D (complete obstruction with collateral veins), by portography or computed tomography. Pathological grades of PV wall invasion were classified as 0 (no invasion), 1 (tunica adventitia), 2 (tunica media), or 3 (tunica intima). RESULTS:: Four hundred and sixty-three patients underwent resection, and PV resection was performed in 297. Combined arterial vessel resection was performed in 16 cases. No significant difference in operative mortality was observed between PV preservation (0.6%) and PV-only resection (2.1%), and no operative deaths occurred after 1999. Radiographic classification of PV invasion correlated with incidence of pathological PV wall invasion. In pancreatic head carcinoma, no pathological PV wall invasion was observed in type A (n = 111). Pathological PV invasion was observed in 51% of type B (42/82), 74% of type C (72/97), and 93% of type D (63/68). Long-term survival (>5 years) was observed in types A and B, and grades 0 and 1 subgroups. CONCLUSIONS:: Pancreatectomy with PV resection can be performed safely. Even in radiographic classification type B, pathological PV wall invasion was observed in 51% of patients. Long-term survival was observed in types A and B, and grades 0 and 1.

PMID: 22156923 [PubMed - as supplied by publisher]

Angiogenesis in Synchronous and Metachronous Colorectal Liver Metastases: The Liver as a Permissive Soil.

Ann Surg. 2011 Dec 8;

Authors: van der Wal GE, Gouw AS, Kamps JA, Moorlag HE, Bulthuis ML, Molema G, de Jong KP

Abstract

OBJECTIVE:: Resection of a primary colorectal carcinoma (CRC) can be accompanied by rapid outgrowth of liver metastases, suggesting a role for angiogenesis. The aim of this study is to investigate whether the presence of a primary CRC is associated with changes in angiogenic status and proliferation/apoptotic rate in synchronous liver metastases and/or adjacent liver parenchyma. METHODS:: Gene expression and localization of CD31, HIF-1α, members of the vascular endothelial growth factor (VEGF) and Angiopoietin (Ang) system were studied using qRT-PCR and immunohistochemistry in colorectal liver metastases and nontumorous-adjacent liver parenchyma. Proliferation and apoptotic rate were quantified. Three groups of patients were included: (1) simultaneous resection of synchronous liver metastases and primary tumor (SS-group), (2) resection of synchronous liver metastases 3 to 12 months after resection of the primary tumor [late synchronous (LS-group)], and (3) resection of metachronous metastases >14 months after resection of the primary tumor (M-group). RESULTS:: In all 3 groups a higher expression of the angiogenic factors was encountered in adjacent liver parenchyma as compared to the metastases. VEGFR-2 gene expression was abundant in adjacent liver parenchyma in all 3 groups. VEGF-A and VEGFR-1 were prominent in adjacent parenchyma in the SS-group. The SS-group showed the highest Ang-2/Ang-1 ratio both in the metastases and the adjacent liver. This was accompanied by a high turnover of tumor cells. CONCLUSION:: In the presence of the primary tumor, the liver parenchyma adjacent to the synchronous liver metastases provides an angiogenic prosperous environment for metastatic tumor growth.

PMID: 22156924 [PubMed - as supplied by publisher]

National Variation in Outcomes and Costs For Splenic Injury and the Impact of Trauma Systems: A Population-Based Cohort Study.

Ann Surg. 2011 Dec 8;

Authors: Hamlat CA, Arbabi S, Koepsell TD, Maier RV, Jurkovich GJ, Rivara FP

Abstract

OBJECTIVE:: To measure national variation in splenectomy rates, mortality, and costs for hospitalized patients with splenic injury and the impact of state trauma systems on these outcomes. METHODS:: Using the HCUP State Inpatient Database for 2001, 2004, and 2007, all patients hospitalized with splenic injury were identified from 19 participating states. Multivariate regression was performed to compare splenectomy rates, inpatient mortality, and costs between states. Inclusiveness of statewide trauma systems was categorized based on the proportion of hospitals designated as a trauma center. RESULTS:: Of 33,131 patients, 26.2% underwent splenectomy, 6.1% died, and median hospital costs were $14,317. After adjusting for patient, injury, and hospital characteristics, there was a 1.7-fold variation (RR 1.67; 95% CI, 1.39-2.01) among the 19 states in rates of splenectomy. Adjusted inpatient mortality varied more than 2-fold between the highest and lowest states (RR 2.43; 95% CI, 1.76-3.37). Adjusted hospital costs varied over 60% between the highest and lowest states (cost ratio 1.61; 95% CI, 1.41-1.83). States with the most inclusive trauma systems had significantly lower splenectomy rate (RR 0.79; 95% CI, 0.68-0.92) and lower mortality (RR 0.71; 95% CI, 0.58-0.87), but similar hospital costs (CR 1.05; 95% CI, 0.95-1.16) compared to states with exclusive or no trauma systems. CONCLUSIONS:: Significant geographic variation in the management, outcome, and costs for splenic injury exists in the United States, and may reflect differences in quality of care. Inclusive trauma systems seem to improve outcomes without increasing hospital costs.

PMID: 22156925 [PubMed - as supplied by publisher]

Infusion of CD133+ Bone Marrow-Derived Stem Cells After Selective Portal Vein Embolization Enhances Functional Hepatic Reserves After Extended Right Hepatectomy: A Retrospective Single-Center Study.

Ann Surg. 2011 Dec 8;

Authors: Esch JS, Schmelzle M, Fürst G, Robson SC, Krieg A, Duhme C, Tustas RY, Alexander A, Klein HM, Topp SA, Bode JG, Häussinger D, Eisenberger CF, Knoefel WT

Abstract

OBJECTIVE:: This study was designed to evaluate the clinical outcome of patients undergoing portal vein embolization (PVE) and autologous CD133 bone marrow-derived stem cell (CD133 BMSC) application before extended right hepatectomy. BACKGROUND:: We have previously shown that portal venous infusion of CD133 BMSCs substantially increases hepatic proliferation, when compared with PVE alone. METHODS:: Among 40 consecutive patients with a median follow-up of 28 months (7.4-57.2) scheduled for extended right hepatectomy, we compared a preconditioned group with PVE and CD133 BMSC cotreatment (PVE+SC group, n = 11) and a group pretreated only with PVE (PVE group, n = 11). Functional and overall outcomes after extended right hepatectomy were evaluated. Patients without presurgical treatment served as controls (n = 18). RESULTS:: In preconditioned patients, mean hepatic growth of segments II/III 14 days after PVE in the PVE+SC group was significantly higher (138.66 mL ± 66.29) when compared with that of PVE group patients (62.95 mL ± 40.03; P = 0.004). There were no significant differences among all 3 groups regarding general and oncological characteristics and functional parameters on postoperative day (POD) 7. Lack of hepatic preconditioning, extrahepatic extension of resection, and postoperative complications were of negative prognostic value, using univariate analysis (P < 0.05). In multivariate analysis, freedom from postoperative major complications (P = 0.012), coagulation status on POD 7 (international normalized ratio < 1.4; P = 0.027), and presurgical expansion of the future liver remnant volume (P = 0.048) were positively associated with overall survival. Post hoc analysis revealed a better survival for the PVE+SC group (P = 0.028) compared with the PVE group (P = 0.094) and compared with controls. CONCLUSION:: Promising data from this survival analysis suggest that PVE, together with CD133 BMSC pretreatment, could positively impact overall outcomes after extended right hepatectomy.

PMID: 22156926 [PubMed - as supplied by publisher]

Implementation of Molecular Phenotyping Approaches in the Personalized Surgical Patient Journey.

Ann Surg. 2011 Dec 8;

Authors: Mirnezami R, Kinross JM, Vorkas PA, Goldin R, Holmes E, Nicholson J, Darzi A

Abstract

OBJECTIVE:: The present review describes commonly employed metabolic profiling platforms and discusses the current and likely future application of these technologies in surgery. BACKGROUND:: The metabolic adaptations that occur in response to surgical illness and trauma are incompletely understood. Evaluating these will be critical to the development of personalized surgical health solutions. Metabonomics is an advancing field in systems biology, which provides a means of interrogating these metabolic shifts. METHODS:: Recent literature regarding metabolic profiling technologies and their applications in surgical practice are discussed. Future strategies are proposed for the incorporation of these and next-generation technologies in the evaluation of all steps in the patient surgical pathway. RESULTS:: Metabolite-based profiling has provided valuable insights into the metabolic irregularities that occur in cancer development and progression across a variety of cancer subclasses including colorectal, breast, prostate, and lung cancers. In addition, metabolic modeling has shown considerable promise in other surgical conditions including trauma and sepsis and in the assessment of pharmacotherapeutic efficacy. DISCUSSION:: Metabonomics offers a posttranscriptional view of system activity providing functional information downstream of the genome and proteome. Information at this level will provide the surgeon with a novel means of evaluating major socioeconomic problems such as cancer and sepsis. In addition, the rapid nature of emerging next generation profiling platforms provides a viable means of “real-time” perioperative metabolic assessment and optimization.

PMID: 22156927 [PubMed - as supplied by publisher]

Hospital Quality and the Cost of Inpatient Surgery in the United States.

Ann Surg. 2011 Dec 8;

Authors: Birkmeyer JD, Gust C, Dimick JB, Birkmeyer NJ, Skinner JS

Abstract

CONTEXT:: Payers, policy makers, and professional organizations have launched a variety of initiatives aimed at improving hospital quality with inpatient surgery. Despite their obvious benefits for patients, the likely impact of these efforts on health care costs is uncertain. In this context, we examined relationships between hospital outcomes and expenditures in the US Medicare population. METHODS:: Using the 100% national claims files, we identified all US hospitals performing coronary artery bypass graft, total hip replacement, abdominal aortic aneurysm repair, or colectomy procedures between 2005 and 2007. For each procedure, we ranked hospitals by their risk- and reliability-adjusted outcomes (complication and mortality rates, respectively) and sorted them into quintiles. We then examined relationships between hospital outcomes and risk-adjusted, 30-day episode payments. RESULTS:: There was a strong, positive correlation between hospital complication rates and episode payments for all procedures. With coronary artery bypass graft, for example, hospitals in the highest complication quintile had average payments that were $5353 per patient higher than at hospitals in the lowest quintile ($46,024 vs $40,671, P < 0.001). Payments to hospitals with high complication rates were also higher for colectomy ($2719 per patient), abdominal aortic aneurysm repair ($5279), and hip replacement ($2436). Higher episode payments at lower-quality hospitals were attributable in large part to higher payments for the index hospitalization, although 30-day readmissions, physician services, and postdischarge ancillary care also contributed. Despite the strong association between hospital complication rates and payments, hospital mortality was not associated with expenditures. CONCLUSIONS:: Medicare payments around episodes of inpatient surgery are substantially higher at hospitals with high complications. These findings suggest that local, regional, and national efforts aimed at improving surgical quality may ultimately reduce costs and improve outcomes.

PMID: 22156928 [PubMed - as supplied by publisher]

Preclinical Investigation of Nanoparticle Albumin-Bound Paclitaxel as a Potential Treatment for Adrenocortical Cancer.

Ann Surg. 2011 Dec 8;

Authors: Demeure MJ, Stephan E, Sinari S, Mount D, Gately S, Gonzales P, Hostetter G, Komorowski R, Kiefer J, Grant CS, Han H, Von Hoff DD, Bussey KJ

Abstract

BACKGROUND:: Traditional drug discovery methods have a limited role in rare cancers. We hypothesized that molecular technology including gene expression profiling could expose novel targets for therapy in adrenocortical carcinoma (ACC), a rare and lethal cancer. SPARC (secreted protein acidic rich in cysteine) is an albumin-binding matrix-associated protein that is proposed to act as a mechanism for the increased efficacy of a nanoparticle albumin-bound preparation of the antimicrotubular drug Paclitaxel (nab-paclitaxel). METHODS:: The transcriptomes of 19 ACC tumors and 4 normal adrenal glands were profiled on Affymetrix U133 Plus2 expression microarrays to identify genes representing potential therapeutic targets. Immunohistochemical analysis for target proteins was performed on 10 ACC, 6 benign adenomas, and 1 normal adrenal gland. Agents known to inhibit selected targets were tested in comparison with mitotane in the 2 ACC cell lines (H295R and SW-13) in vitro and in mouse xenografts. RESULTS:: SPARC expression is increased in ACC samples by 1.56 ± 0.44 (μ ± SD) fold. Paclitaxel and nab-paclitaxel show in vitro inhibition of H295R and SW-13 cells at IC50 concentrations of 0.33 μM and 0.0078 μM for paclitaxel and 0.35 μM and 0.0087 μM for nab-paclitaxel compared with mitotane concentrations of 15.9 μM and 46.4 μM. In vivo nab-paclitaxel treatment shows a greater decrease in tumor weight in both xenograft models than mitotane. CONCLUSIONS:: Biological insights garnered through expression profiling of ACC tumors suggest further investigation into the use of nab-paclitaxel for the treatment of ACC.

PMID: 22156929 [PubMed - as supplied by publisher]

The Business of Quality in Surgery.

Ann Surg. 2011 Dec 8;

Authors: Flum DR, Pellegrini CA

PMID: 22156930 [PubMed - as supplied by publisher]

Clinicopathological Characteristics and Molecular Analyses of Multifocal Intraductal Papillary Mucinous Neoplasms of the Pancreas.

Ann Surg. 2011 Dec 1;

Authors: Matthaei H, Norris AL, Tsiatis AC, Olino K, Hong SM, Dal Molin M, Goggins MG, Canto M, Horton KM, Jackson KD, Capelli P, Zamboni G, Bortesi L, Furukawa T, Egawa S, Ishida M, Ottomo S, Unno M, Motoi F, Wolfgang CL, Edil BH, Cameron JL, Eshleman JR, Schulick RD, Maitra A, Hruban RH

Abstract

OBJECTIVE:: To examine the clinicopathologic features and clonal relationship of multifocal intraductal papillary mucinous neoplasms (IPMNs) of the pancreas. BACKGROUND:: Intraductal papillary mucinous neoplasms are increasingly diagnosed cystic precursor lesions of pancreatic cancer. Intraductal papillary mucinous neoplasms can be multifocal and a potential cause of recurrence after partial pancreatectomy. METHODS:: Thirty four patients with histologically documented multifocal IPMNs were collected and their clinicopathologic features catalogued. In addition, thirty multifocal IPMNs arising in 13 patients from 3 hospitals were subjected to laser microdissection followed by KRAS pyrosequencing and loss of heterozygosity (LOH) analysis on chromosomes 6q and 17p. Finally, we sought to assess the clonal relationships among multifocal IPMNs. RESULTS:: We identified 34 patients with histologically documented multifocal IPMNs. Synchronous IPMNs were present in 29 patients (85%), whereas 5 (15%) developed clinically significant metachronous IPMNs. Six patients (18%) had a history of familial pancreatic cancer. A majority of multifocal IPMNs (86% synchronous, 100% metachronous) were composed of branch duct lesions, and typically demonstrated a gastric-foveolar subtype epithelium with low or intermediate grades of dysplasia. Three synchronous IPMNs (10%) had an associated invasive cancer. Molecular analysis of multiple IPMNs from 13 patients demonstrated nonoverlapping KRAS gene mutations in 8 patients (62%) and discordant LOH profiles in 7 patients (54%); independent genetic alterations were established in 9 of the 13 patients (69%). CONCLUSIONS:: The majority of multifocal IPMNs arise independently and exhibit a gastric-foveolar subtype, with low to intermediate dysplasia. These findings underscore the importance of life-long follow-up after resection for an IPMN.

PMID: 22167000 [PubMed - as supplied by publisher]

A Functional Variant of Lipopolysaccharide Binding Protein Predisposes to Sepsis and Organ Dysfunction in Patients with Major Trauma.

Ann Surg. 2011 Dec 1;

Authors: Zeng L, Gu W, Zhang AQ, Zhang M, Zhang LY, Du DY, Huang SN, Jiang JX

Abstract

OBJECTIVE:: To determine the hypothesis that genetic variations of the lipopolysaccharide-binding protein (LBP) gene influence risk for the development of sepsis and multiple organ dysfunction (MOD) in patients with major trauma. BACKGROUND:: Lipopolysaccharide-binding protein plays a central role in innate immune response as the first line of defense and directing the microbial-induced activation of the inflammatory host response. Although a total of 112 single nucleotide polymorphisms (SNPs) have been identified so far within the entire LBP gene, only a few SNPs have been studied. METHODS:: Nine haplotype tagging SNPs (htSNPs) were selected from 51 SNPs with a minor allele frequency of ≥5% using the HapMap database for the Chinese Han population. Two independent cohorts of major trauma patients were recruited. The 9 htSNPs were genotyped using pyrosequencing method and analyzed in relation to the risk of development of sepsis and MOD, LBP production, and lipopolysaccharide (LPS)-induced activation of peripheral blood leukocytes. Moreover, the functionality of the rs2232618 polymorphism was assessed by the observation of its effects on the binding and activation of LPS and the LBP-CD14 interaction. RESULTS:: Among the 9 htSNPs, only the rs2232618 was significantly associated with higher susceptibility to sepsis and MOD in the 2 independent cohorts of major trauma patients recruited from southwest and eastern China. This SNP was also significantly associated with LPS-induced activation of peripheral blood leukocytes. In addition, the rs2232618 polymorphism could enhance LBP protein activities, showing significant increases in LPS binding to macrophages, LPS-induced cellular activation, and LBP-CD14 interaction at the presence of the variant LBP protein. CONCLUSIONS:: The rs2232618 polymorphism is a functional SNP and confers host susceptibility to sepsis and multiple organ dysfunction in patients with major trauma.

PMID: 22167001 [PubMed - as supplied by publisher]

Reflux and Belching After 270 Degree Versus 360 Degree Laparoscopic Posterior Fundoplication.

Ann Surg. 2011 Dec 1;

Authors: Broeders JA, Bredenoord AJ, Hazebroek EJ, Broeders IA, Gooszen HG, Smout AJ

Abstract

OBJECTIVE:: To investigate differences in effects of 270 degrees (270 degrees LPF) and 360 degrees laparoscopic posterior fundoplication (360 degrees LPF) on reflux characteristics and belching. BACKGROUND:: Three hundred sixty degrees LPF greatly reduces the ability of the stomach to vent ingested air by gastric belching. This frequently leads to postoperative symptoms including inability to belch, gas bloating and increased flatulence. Two hundred seventy degrees LPF allegedly provides less effective reflux control compared with 360 degrees LPF, but theoretically may allow for gastric belches (GBs) with a limitation of gas-related symptoms. METHODS:: Endoscopy, stationary esophageal manometry, and 24-hour impedance-pH monitoring off PPIs was performed before and 6 months after fundoplication for PPI-refractory gastroesophageal reflux disease (n = 14 270 degrees LPF vs. n = 28 360 degrees LPF). GBs were defined as gas components of pure gas and mixed reflux episodes reaching the proximal esophagus. Absolute reductions (Δ) were compared. RESULTS:: Reflux symptoms and the 24-hour incidence of acid (Δ -77.6 vs. -76.7), weakly acidic (Δ -9.4 vs. -6.6), liquid (Δ -59.0 vs. -49.8) and mixed reflux episodes (Δ -28.0 vs. -33.5) were reduced to a similar extent after 270° LPF and 360° LPF, respectively. The reduction in proximal, mid-esophageal and distal reflux episodes were similar in both groups as well. Persistent symptoms were not related to acid or weakly acidic reflux. Two hundred seventy degrees LPF had no significant impact on the number of gas reflux episodes (Δ -3.6; P = 0.363), whereas 360 degrees LPF significantly reduced gas reflux episodes (Δ -17.0; P = 0.002). After 270 degrees LPF, GBs (Δ -29.3 vs. -50.6; P = 0.026) were significantly less reduced and the prevalence of gas bloating (7.1% vs. 21.4%; P = 0.242) and increased flatulence (7.1% vs. 42.9%; P = 0.018) was lower compared to 360 degrees LPF. Twenty-eight patients (67%) showed supragastric belches (SGBs) before and after surgery. The increase in SGBs without reflux (Δ +32.4 vs. +25.5) and the decrease in reflux-associated SGBs (Δ -12.1 vs. -14.0) were similar after 270 degrees LPF and 360 degrees LPF. CONCLUSIONS:: Two hundred seventy degrees LPF and 360 degrees LPF alter the belching pattern by reducing GBs (air venting from stomach) and increasing SGBs (no air venting from stomach). However, gas reflux and GBs are reduced less after 270 degrees LPF than after 360 degrees LPF, resulting in more air venting from the stomach and less gas bloating and flatulence, whereas reflux is reduced to a similar extent in the short-term.

PMID: 22167002 [PubMed - as supplied by publisher]

Prognostic Value of the 7th AJCC/UICC TNM Classification of Noncardia Gastric Cancer: Analysis of a Large Series From Specialized Western Centers.

Ann Surg. 2011 Dec 1;

Authors: Marrelli D, Morgagni P, de Manzoni G, Coniglio A, Marchet A, Saragoni L, Tiberio G, Roviello F

Abstract

OBJECTIVE:: To conduct a retrospective evaluation of the 7th-TNM classification of gastric cancer (GC) on a prospectively collected database. BACKGROUND:: The recent TNM introduced relevant changes to GC classification. METHODS:: Data regarding 2090 consecutive patients with noncardia GC operated upon between 1991 and 2005 at 5 specialized centers were considered. The application of the new TNM was simulated, and its prognostic value was estimated. RESULTS:: Relevant changes in stage distribution between 6th and 7th TNM were observed, mainly regarding the shift of a large proportion of cases from stages IB to IIA and from IIIA and IV to stages IIIB and IIIC. Cancer-related 10-year survival probability was 53% ± 1%. Different survival rates between new T (T2 vs. T3, P < 0.001) and N categories (N1 vs. N2, P < 0.001) were observed. Survival rate of N3a subgroup (7-15 involved lymph nodes) was significantly better than N3b (>15 involved lymph nodes; P < 0.001). Stages IB and IIA of the 7th TNM showed similar prognosis, whereas significant differences were observed among all other subgroups. The analysis of TNM categories within 7th TNM stages revealed nonhomogeneous survival rates in stages IIB, IIIB, and IV. CONCLUSIONS:: The 7th AJCC/UICC TNM classification of noncardia GC identifies subgroups of patients with different prognosis. Stage distribution and stage-related survival changed notably from the 6th edition. Some improvements may be suggested from our data, with special reference to a higher prognostic weight of N status and the separation of N3a and N3b categories for stage grouping.

PMID: 22167003 [PubMed - as supplied by publisher]

Incorporation of Sentinel Lymph Node Metastasis Size Into a Nomogram Predicting Nonsentinel Lymph Node Involvement in Breast Cancer Patients With a Positive Sentinel Lymph Node.

Ann Surg. 2011 Dec 1;

Authors: Mittendorf EA, Hunt KK, Boughey JC, Bassett R, Degnim AC, Harrell R, Yi M, Meric-Bernstam F, Ross MI, Babiera GV, Kuerer HM, Hwang RF

Abstract

BACKGROUND AND OBJECTIVE:: Sentinel lymph node (SLN) metastasis size is an important predictor of non-SLN involvement. The goal of this study was to construct a nomogram incorporating SLN metastasis size to accurately predict non-SLN involvement in patients with SLN-positive disease. METHODS:: We identified 509 patients with invasive breast cancer with a positive SLN who underwent completion axillary lymph node dissection (ALND). Clinicopathologic data including age, tumor size, histology, grade, presence of multifocal disease, estrogen and progesterone receptor status, HER2/neu status, presence of lymphovascular invasion (LVI), number of SLN(s) identified, number of positive SLN(s), maximum SLN metastasis size and the presence of extranodal extension were recorded. Univariate and multivariate logistic regression analyses identified factors predictive of positive non-SLNs. Using these variables, a nomogram was constructed and subsequently validated using an external cohort of 464 patients. RESULTS:: On univariate analysis, the following factors were predictive of positive non-SLNs: number of SLN identified (P < 0.001), number of positive SLN (P < 0.001), SLN metastasis size (P < 0.001), extranodal extension (P < 0.001), tumor size (P = 0.001), LVI (P = 0.019), and histology (P = 0.034). On multivariate analysis, all factors remained significant except LVI. A nomogram was created using these variables (AUC = 0.80; 95% CI, 0.75-0.84). When applied to an external cohort, the nomogram was accurate and discriminating with an AUC = 0.74 (95% CI, 0.68-0.77). CONCLUSION: SLN metastasis size is an important predictor for identifying non-SLN disease. In this study, we incorporated SLN metastasis size into a nomogram that accurately predicts the likelihood of having additional axillary metastasis and can assist in personalizing surgical management of breast cancer.

PMID: 22167004 [PubMed - as supplied by publisher]

Pure Transvaginal Appendectomy Versus Traditional Laparoscopic Appendectomy for Acute Appendicitis: A Prospective Cohort Study.

Ann Surg. 2011 Dec 1;

Authors: Roberts KE, Solomon D, Mirensky T, Silasi DA, Duffy AJ, Rutherford T, Longo WE, Bell RL

Abstract

OBJECTIVE:: This report describes the first cohort study comparing pure transvaginal appendectomies (TVAs) to traditional 3-port laparoscopic appendectomies (LAs). METHODS:: Between August 2008 and August 2010, 42 patients were offered a pure TVA. Patients who did not wish to undergo a TVA underwent a LA and served as the control group. Demographic data, operative time, length of stay, patient controlled analgesia (PCA) 12-hour-morphine utilization, complications, return to normal activity, and return to work were recorded. RESULTS:: Eighteen of 40 enrolled patients underwent a pure TVA. Two patients refused to participate in this study. Mean age (TVA: 31.3 ± 2.5 years vs. LA: 28.2 ± 2.3 years, P = 0.36), mean body mass index (TVA: 23.7 ± 1.2 kg/m vs. LA: 23.6 ± 0.7 kg/m, P = 0.96) mean operative time (TVA: 44.4 ± 4.5 minutes vs. LA: 39.8 ± 2.6 minutes, P = 0.38), and mean length of hospital stay (TVA: 1.1 ± 0.1 days vs. LA: 1.2 ± 0.1 days, P = 0.53) were not statistically significant. However, mean postoperative morphine-use (TVA: 8.7 ± 2.0 mg vs. LA: 23.0 ± 3.4 mg, P < 0.01), return to normal activity (TVA: 3.3 ± 0.4 days vs. LA: 9.7 ± 1.6 days, P < 0.01), and return to work (TVA: 5.4 ± 1.1 days vs. LA: 10.7 ± 1.5 days, P = 0.01) were statistically significant. One conversion in the TVA group to a LA was necessary because of inability to maintain adequate pneumoperitoneum. Four complications were observed: 1 intraabdominal abscess and 1 case of urinary retention in the TVA group; 1 early postoperative bowel obstruction and 1 case of urinary retention in the LA group. CONCLUSIONS:: Pure TVA is a safe and well-tolerated procedure with significantly less pain and faster recovery compared to traditional LA. This study is registered with www.clinicaltrials.gov as NCT00806429.

PMID: 22167005 [PubMed - as supplied by publisher]

Use of Advance Directives for High-Risk Operations: A National Survey of Surgeons.

Ann Surg. 2011 Dec 1;

Authors: Redmann AJ, Brasel KJ, Alexander CG, Schwarze ML

Abstract

OBJECTIVE:: To characterize surgeons’ beliefs and approach to the use of an advance directive in the decision to perform high-risk operations. BACKGROUND:: Prior work suggests many surgeons regard advance directives as antithetical to the goals of surgical therapy, yet little is known about surgeons’ approach to high-risk operations for patients with directives limiting postoperative care. METHODS:: We sent a self-administered survey by US mail to 2100 randomly selected vascular, neurologic, and cardiothoracic surgeons. We used stepwise logistic regression to determine the relationship between explanatory variables and: (1) how often surgeons discuss advance directives preoperatively, and (2) how advance directives limiting postoperative life-supporting therapy influence the decision to operate. RESULTS:: The adjusted response rate was 55%. All surgeons reported discussing the potential for unanticipated outcomes and nearly all (95%) discussed the need for postoperative life-supporting therapy. More than four-fifths (81%) reported discussing patient preferences to limit postoperative life-supporting therapy during informed consent. Approximately one half of respondents (52%) either sometimes or always discuss advance directives before surgery, with younger physicians less likely to do so than more experienced surgeons (odds ratio [OR] = 0.46, 95% confidence intervals [CI] = 0.06-0.85). More than one half (54%) of surgeons reported they would decline to operate on patients who have an advance directive limiting postoperative life-supporting therapy. CONCLUSIONS:: Many surgeons do not routinely discuss advanced directives preoperatively and more than one half reported they would decline to operate on patients whose directives limit postoperative care. This practice may limit the expression of patient preferences during decision making for high-risk operations.

PMID: 22167006 [PubMed - as supplied by publisher]

Core Needle Biopsy Rate for New Cancer Diagnosis in an Interdisciplinary Breast Center: Evaluation of Quality of Care 2007-2008.

Ann Surg. 2011 Dec 1;

Authors: Linebarger JH, Landercasper J, Ellis RL, Gundrum JD, Marcou KA, De Maiffe BM, Hudak JM, Andersen JJ

Abstract

OBJECTIVE:: The purpose of this study is to evaluate the rate of minimally invasive biopsy for diagnosis of breast cancer at an interdisciplinary breast center. BACKGROUND:: Percutaneous core needle biopsy (CNB) is optimal for minimizing surgery for the diagnosis of benign and malignant lesions of the breast while preserving surgery for definitive resection. Core needle biopsy increases patient satisfaction and reduces the cost of diagnosis and treatment. Despite the endorsement of CNB by many professional organizations, the literature documents underutilization. METHODS:: Institutional review board approval was obtained. An audit of a single institution’s prospectively maintained cancer databases was performed for all breast cancers diagnosed in 2007 and 2008. Methods of diagnosis included image-guided and freehand-guided CNB, image-guided vacuum assisted needle biopsy, image-guided fine needle aspiration, punch biopsy, and open surgical biopsy. RESULTS:: Three hundred sixty new breast cancers were diagnosed in 2007 and 2008. Malignancy was diagnosed by minimally invasive techniques in 350/360 (97%) cancers. CONCLUSION:: A very high rate of accurate tissue diagnosis of breast cancer by minimally invasive techniques is achievable.

PMID: 22167007 [PubMed - as supplied by publisher]

Proficiency Assessment of Gesture Analysis in Laparoscopy by Means of Surgeon’s Musculo-Skeleton Model.

Ann Surg. 2011 Dec 14;

Authors: Cavallo F, Pietrabissa A, Megali G, Troia E, Sinigaglia S, Dario P, Mosca F, Cuschieri A

Abstract

OBJECTIVE:: This article presents the implementation of surgeon’s musculo-skeletal model for gesture analysis in laparoscopy, thereby providing a complete account of the objective metrics needed to evaluate surgical performance and to improve the design of new surgical instruments including robotic instrumentation for surgical procedures. BACKGROUND:: Previous published work has been based exclusively on the kinematics involved whereas, this study is focused on the dynamics and muscle contraction analysis to assess loads on bones and muscle fatigue during simulation of surgical interventions. METHODS:: Nine medical students and 2 fully trained surgeons participated in the experimental sessions using a virtual laparoscopic simulator. Movement was acquired by means of an Optical Localization System and processed by means of the biomechanical software platform ADAMS-LifeMOD. RESULTS:: The musculo-skeletal analysis allows calculation of how the muscles are used and their respective mean work during the exercises. Results, relative to biceps and trapezius for left and right arm, clearly demonstrate different proficiencies between surgeons and medical students and highlight differences in using different surgical instruments and assumption of different postures. CONCLUSIONS:: The model provides data on the evaluation of biomechanical parameters of surgical gesture not only in kinematic terms but also includes analysis of the dynamics of muscle contraction analysis during surgical manipulations.

PMID: 22173201 [PubMed - as supplied by publisher]

Short-Term Outcomes Following Open Versus Minimally Invasive Esophagectomy for Cancer in England: A Population-Based National Study.

Ann Surg. 2011 Dec 14;

Authors: Mamidanna R, Bottle A, Aylin P, Faiz O, Hanna GB

Abstract

OBJECTIVE:: To compare short-term outcomes of open and minimally invasive esophagectomy (MIE) for cancer. BACKGROUND DATA:: Numerous studies have demonstrated the safety and possible advantages of MIE in selected cohorts of patients. The increasing use of MIE is not coupled with conclusive evidence of its benefits over “open” esophagectomy, especially in the absence of randomized trials. METHODS:: Hospital Episode Statistics data were analyzed from April 2005 to March 2010. This is a routinely collected database of all English National Health Service Trusts. Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures, 4th revision (OPCS-4), procedure codes were used to identify index resections and International Statistical Classification of Diseases, 10th Revision (ICD-10), diagnostic codes were used to ascertain comorbidity status and complications. Thirty-day in-hospital mortality, medical complications, and surgical reinterventions were analyzed. Unadjusted and risk-adjusted regression analyses were undertaken. RESULTS:: Seven thousand five hundred and two esophagectomies were undertaken; of these, 1155 (15.4%) were MIE. In 2009-2010, 24.7% of resections were MIE. There was no difference in 30-day mortality (4.3% vs 4.0%; P = 0.605) and overall medical morbidity (38.0% vs 39.2%; P = 0.457) rates between open and MIE groups, respectively. A higher reintervention rate was associated with the MIE group than with the open group (21% vs 17.6%, P = 0.006; odds ratio, 1.17; 95% confidence interval, 1.00-1.38; P = 0.040). CONCLUSIONS:: Minimally invasive esophagectomy is increasingly performed in the United Kingdom. Although the study confirmed the safety of MIE in a population-based national data, there are no significant benefits demonstrated in mortality and overall morbidity. Minimally invasive esophagectomy is associated with higher reintervention rate. Further evidence is needed to establish the long-term survival of MIE.

PMID: 22173202 [PubMed - as supplied by publisher]

A Postoperative Nomogram for Local Recurrence Risk in Extremity Soft Tissue Sarcomas After Limb-Sparing Surgery Without Adjuvant Radiation.

Ann Surg. 2011 Dec 2;

Authors: Cahlon O, Brennan MF, Jia X, Qin LX, Singer S, Alektiar KM

Abstract

PURPOSE:: To develop a nomogram based on clinicopathologic factors to quantify the risk of local recurrence (LR) after limb-sparing surgery without adjuvant radiation (RT). METHODS:: Review of our prospective sarcoma database identified 684 patients with primary, nonmetastatic, extremity STS treated with limb-sparing surgery alone between June 1982 and December 2006. No patient received adjuvant radiation or chemotherapy. Age, sex, grade, depth, size, site, margin status and histology were analyzed for prognostic significance with respect to local recurrence rates using Gray’s test. Variables which were significant in univariate analysis at the 0.05 level were entered into a multivariate competing risk regression model. On the basis of the multivariate analysis, a nomogram for predicting the 3- and 5-year risk of LR was developed using R libraries cmprsk and QHScrnomo. Concordance index (C-index) was calculated to evaluate the discriminatory power of the prognostic model. RESULTS:: With a median follow-up of 58 months for censored patients (73 months for all patients), the overall 3- and 5-year actuarial local recurrence rates were 11% and 13%, respectively. Factors included in the nomogram were age (≤50 vs. >50), size (≤5 vs. >5 cm), margin status (negative vs. positive), grade (low vs. high), and histology (atypical lipomatous tumor/well differentiated liposarcoma vs. other). The STS nomogram predicted the local recurrence rate with a C-index of 0.73. CONCLUSIONS:: A nomogram for extremity STS that includes age, size, margin status, grade of tumor, and histology predicts the 3- and 5-year risk of local recurrence after limb-sparing surgery in the absence of adjuvant RT.

PMID: 22143203 [PubMed - as supplied by publisher]

Impact of Lymphadenectomy on the Oncologic Outcome of Patients With Adrenocortical Carcinoma.

Ann Surg. 2011 Dec 2;

Authors: Reibetanz J, Jurowich C, Erdogan I, Nies C, Rayes N, Dralle H, Behrend M, Allolio B, Fassnacht M,

Abstract

OBJECTIVE:: Adrenocortical carcinoma (ACC) is a rare malignancy with an unfavorable prognosis. The impact of a locoregional lymph node dissection (LND) has never been defined in this disease. We report the disease-specific outcome of patients treated with or without LND during primary adrenalectomy. METHODS:: The medical records of patients followed by the German ACC Registry were retrospectively reviewed. Patients with incomplete resection or distant metastases were excluded. Only if the histologic analysis retrieved 5 or more lymph nodes, an intended LND was assumed (LND group). The predefined primary end point of the study was disease-specific survival. RESULTS:: Of 283 included patients, 47 patients (16.6%) were treated with LND, whereas 236 patients (83.4%) underwent surgery without LND. Patients who underwent LND had a larger median tumor size (12.0 cm, range: 2.3-30 cm vs 10.0 cm, range: 4.0-39 cm, P = 0.007) and were more often treated by multivisceral resection (LND: 47.8% vs no-LND: 18.1%; P < 0.001). The other baseline characteristics (age, sex, endocrine activity, Weiss score, Ki-67 index, and adjuvant treatment) did not differ significantly. Median follow-up of all patients still alive was 40 months (range: 6-326). Multivariate analysis adjusted for age, tumor stage, multivisceral resection, adjuvant treatment, and lymph nodes status on preoperative imaging demonstrated a significantly reduced risk for tumor recurrence (hazard ratio: 0.65; 95% confidence interval: 0.43-0.98; P = 0.042) and for disease-related death (hazard ratio: 0.54; 95% confidence interval: 0.29-0.99; P = 0.049) in LND patients when compared with no-LND patients. CONCLUSIONS:: Our retrospective data indicate that locoregional LND improves tumor staging and leads to a favorable oncologic outcome in patients with localized ACC.

PMID: 22143204 [PubMed - as supplied by publisher]

In-Transit Intramammary Sentinel Lymph Nodes From Malignant Melanoma of the Trunk.

Ann Surg. 2011 Dec 2;

Authors: Lyo V, Jaigirdar AA, Thummala S, Morita ET, Treseler PA, Kashani-Sabet M, Leong SP

Abstract

OBJECTIVE:: Our goal was to determine the incidence and outcomes of intramammary in-transit sentinel lymph nodes (IMSLN) from primary malignant melanoma (MM) of the trunk. We hypothesize that regional metastasis to the breast from anterior trunk MM also occurs via the lymphatic system to these intramammary in-transit sentinel lymph nodes. BACKGROUND:: MM is the most common solid tumor metastasis to the breast. The mechanism of intramammary (IM) metastasis is generally attributed to hematogenous rather than lymphatic spread. METHODS:: We retrospectively reviewed medical records from all patients who underwent selective sentinel lymph node dissection at the UCSF Melanoma Center from 1993 to 2008 after the approval of UCSF Committee on Human Research. Of the 1911 cases, we found 614 patients with primary MM located on the trunk, and queried their medical records for in-transit SLN and SLNs in the breast. Data from preoperative lymphoscintigraphy, intraoperative lymphatic mapping, operative notes, and pathology and clinic notes were gathered. RESULTS:: Of the 1911 patients with MM, 169 (8.9%) and 420 (22.0%) had anterior and posterior trunk lesions, respectively, and 25 patients (1.3%) with flank lesions (lateral abdominal wall below the rib cage, above the iliac crest). Of the anterior trunk population, 18 patients had in-transit SLNs. The vast majority of these patients (14 of 18, 77.8%) had in-transit IMSLN. Of patients with posterior trunk melanoma, 27 patients had in-transit nodes with 1 patient having IMSLNs. Of patients with flank melanomas, 3 patients had in-transit nodes with 1 patient having IMSLNs. Interestingly, all patients with IMSLNs had primary lesions located inferior to the breasts. Two of the 16 patients with IMSLNs had micrometastasis to IMSLN; 1 patient died and the other currently is disease free 4 years after initial SLND. Four of the 32 patients with non-IM in-transit nodes had micrometastases to these in-transit nodes. Of all patients with trunk melanomas, 4 patients had micrometastases to axillary SLNs (AxSLNs). Three of the 4 patients with positive AxSLNs also had positive in-transit nodes whereas only half of the patients with positive in-transit SLNs had positive AxSLNs. CONCLUSIONS:: IMSLNs exist in the breast. Our results establish an anatomic basis for lymphatic metastasis to the breast from primary cutaneous melanoma mainly from the anterior trunk inferior to the breasts. For anterior trunk melanomas, IMSLNs should not be overlooked during SLND as they may harbor micrometastasis.

PMID: 22143205 [PubMed - as supplied by publisher]

Development and Validation of a Novel Stratification Tool for Identifying Cancer Patients at Increased Risk of Surgical Site Infection.

Ann Surg. 2011 Dec 2;

Authors: Anaya DA, Cormier JN, Xing Y, Koller P, Gaido L, Hadfield D, Chemaly RF, Feig BW

Abstract

OBJECTIVE:: To identify cancer-specific predictors of postoperative surgical site infection (SSI), and to develop a risk-stratification prognostic tool and compare its performance with traditional measures. BACKGROUND:: The incidence and risk factors for SSI in cancer patients are unknown; current risk-stratification tools are not cancer-specific. METHODS:: A prospective cohort study of patients undergoing elective operations (n = 503) at a tertiary cancer center was conducted. SSI was assessed using postdischarge active surveillance. Multivariate logistic regression analyses were performed to identify predictors of SSI, and β-coefficients were used to create a scoring system. The sum of these was used to create a Risk of Surgical Site Infection in Cancer (RSSIC) score. The RSSIC was validated using bootstrapping techniques, and its discrimination was compared with the National Nosocomial Infection Surveillance (NNIS) risk index. RESULTS:: The 30-day SSI incidence was 24%. Significant predictors of SSI included preoperative chemotherapy (OR = 1.94 [95% CI, 1.16-3.25]), clean-contaminated wounds (OR = 2.1 [95% CI, 1.24-3.55]), operative time ≥2 hours (OR = 1.75 [95% CI, 1.01-3.04]) and ≥4 hours (OR = 2.24 [95% CI, 1.22-4.1]), and surgical site: groin (OR = 4.65 [95% CI, 1.69-12.83]), and head/neck (OR = 0.12 [95% CI, 0.02-0.89]). The RSSIC score stratified patients into 4 risk strata for SSI. The performance of this score exceeded that of the NNIS score (AUC = 0.70 vs. 0.63, respectively; P = 0.01). CONCLUSION:: SSIs are common following cancer surgery. Preoperative chemotherapy, in addition to other common risk factors, was identified as a significant predictor for SSI in cancer patients. The RSSIC improves risk-stratification of cancer patients and identifies those that may benefit from more aggressive or novel preventive strategies.

PMID: 22143206 [PubMed - as supplied by publisher]

Critical Role of Activated Protein C in Early Coagulopathy and Later Organ Failure, Infection and Death in Trauma Patients.

Ann Surg. 2011 Nov 30;

Authors: Cohen MJ, Call M, Nelson M, Calfee CS, Esmon CT, Brohi K, Pittet JF

Abstract

BACKGROUND:: Recent studies have identified an acute traumatic coagulopathy that is present on admission to the hospital and is independent of iatrogenic causes. We have previously reported that this coagulopathy is due to the association of severe injury and shock and is characterized by a decrease in plasma protein C (PC) levels. Whether this early coagulopathy and later propensity to infection, multiple organ failure and mortality are associated with the activation of PC pathway has not been demonstrated and constitutes the aim of this study. METHODS AND FINDINGS:: This was a prospective cohort study of 203 major trauma patients. Serial blood samples were drawn on arrival in the emergency department, and at 6, 12, and 24 hours after admission to the hospital. PT, PTT, Va, VIIIa, PC aPC t-PA, and D-dimer levels were assayed. Comprehensive injury, resuscitation, and outcome data were prospectively collected.A total of 203 patients were enrolled. Patients with tissue hypoperfusion and severe traumatic injury showed a strong activation of the PC which was associated with a coagulopathy characterized by inactivation of the coagulation factors V and VIII and a derepression of the fibrinolysis with high plasma levels of plasminogen activator and high D-dimers. Elevated plasma levels of activated PC were significantly associated with increased mortality, organ injury, increased blood transfusion requirements, and reduced ICU ventilator-free days. Finally early depletion of PC after trauma is associated with a propensity to posttraumatic ventilator-associated pneumonia. CONCLUSIONS:: Acute traumatic coagulopathy occurs in the presence of tissue hypoperfusion and severe traumatic injury and is mediated by activation of the PC pathway. Higher plasma levels of aPC upon admission are predictive of poor clinical outcomes after major trauma. After activation, patients who fail to recover physiologic plasma values of PC have an increased propensity to later nosocomial lung infection.

PMID: 22133894 [PubMed - as supplied by publisher]

Distribution of Lymph Node Metastases is an Independent Predictor of Survival for Sigmoid Colon and Rectal Cancer.

Ann Surg. 2011 Nov 30;

Authors: Huh JW, Kim YJ, Kim HR

Abstract

OBJECTIVE:: This study evaluated the prognostic significance of the distribution of lymph node metastases (LND) in patients with colorectal cancer. BACKGROUND:: The impact of the LND on survival in colorectal cancer is unknown. METHODS:: A total of 1205 consecutive patients who underwent potentially curative surgery for sigmoid colon or rectal cancer with high ligation of the inferior mesenteric artery (IMA) from January 1997 to February 2008 were assigned to 4 groups based on LND: LND0, no lymph node metastases-615 patients (51.0%); LND1, metastases in the pericolic nodes-324 patients (26.9%); LND2, metastases in the intermediate nodes-172 patients (14.3%); and LND3, node metastases at the origin of the IMA-94 patients (7.8%). RESULTS:: The 5-year overall survival rates of patients with LND0, LND1, LND2, and LND3 were 83%, 63%, 52%, and 28%, respectively (P < 0.001). The 5-year disease-free survival rates of patients with LND0, LND1, LND2, and LND3 were 83%, 54%, 43%, and 21%, respectively (P < 0.001). On multivariate analysis, LND was an independent prognostic factor for both overall survival and disease-free survival. However, the 5-year local recurrence-free survival rate was not inversely related to the LND. On a subset analysis that compared stage III disease with stage IV disease, the 5-year overall survival and disease-free survival rates were 45% and 31% for the patients with stage IV disease compared with 40% and 32% for the patients with stage III, LND3 disease, respectively (P = 0.761 and 0.704). For the patients with pN1 tumors, the overall survival and disease-free survival did not differ significantly according to the LND (P = 0.471 and 0.347, respectively). However, for patients with pN2 tumors, the overall survival and disease-free survival curves among the LND groups significantly differed (P < 0.001 and <0.001, respectively). CONCLUSION:: LND is an independent predictor of survival for colorectal cancer patients, but it does not predict local recurrence. The N categorization including LND may enhance the prognostic value of the TNM staging system for patients with node-positive sigmoid colon or rectal cancer.

PMID: 22133895 [PubMed - as supplied by publisher]

Effects of the Introduction of the WHO “Surgical Safety Checklist” on In-Hospital Mortality: A Cohort Study.

Ann Surg. 2011 Nov 24;

Authors: van Klei WA, Hoff RG, van Aarnhem EE, Simmermacher RK, Regli LP, Kappen TH, van Wolfswinkel L, Kalkman CJ, Buhre WF, Peelen LM

Abstract

OBJECTIVE:: To evaluate the effect of implementation of the WHO’s Surgical Safety Checklist on mortality and to determine to what extent the potential effect was related to checklist compliance. BACKGROUND:: Marked reductions in postoperative complications after implementation of a surgical checklist have been reported. As compliance to the checklists was reported to be incomplete, it remains unclear whether the benefits obtained were through actual completion of a checklist or from an increase in overall awareness of patient safety issues. METHODS:: This retrospective cohort study included 25,513 adult patients undergoing non-day case surgery in a tertiary university hospital. Hospital administrative data and electronic patient records were used to obtain data. In-hospital mortality within 30 days after surgery was the main outcome and effect estimates were adjusted for patient characteristics, surgical specialty and comorbidity. RESULTS:: After checklist implementation, crude mortality decreased from 3.13% to 2.85% (P = 0.19). After adjustment for baseline differences, mortality was significantly decreased after checklist implementation (odds ratio [OR] 0.85; 95% CI, 0.73-0.98). This effect was strongly related to checklist compliance: the OR for the association between full checklist completion and outcome was 0.44 (95% CI, 0.28-0.70), compared to 1.09 (95% CI, 0.78-1.52) and 1.16 (95% CI, 0.86-1.56) for partial or noncompliance, respectively. CONCLUSIONS:: Implementation of the WHO Surgical Checklist reduced in-hospital 30-day mortality. Although the impact on outcome was smaller than previously reported, the effect depended crucially upon checklist compliance.

PMID: 22123159 [PubMed - as supplied by publisher]

Perineural Invasion and Lymph Node Involvement as Indicators of Surgical Outcome and Pattern of Recurrence in the Setting of Preoperative Gemcitabine-Based Chemoradiation Therapy for Resectable Pancreatic Cancer.

Ann Surg. 2011 Nov 24;

Authors: Takahashi H, Ohigashi H, Ishikawa O, Gotoh K, Yamada T, Nagata S, Tomita Y, Eguchi H, Doki Y, Yano M

Abstract

OBJECTIVE:: To analyze the histopathological indicators significantly associated with surgical outcome and the pattern of recurrence in the setting of preoperative gemcitabine-based chemoradiation therapy (CRT) and subsequent pancreatectomy. BACKGROUND:: Clinicopathological assessment of the resected specimen is an indispensable tool for predicting patient prognosis and localizing high-risk sites for tumor relapse. This procedure is also essential for the establishment of efficient postoperative follow-up protocols in the setting of a preoperative CRT strategy. METHODS:: In a prospective phase II clinical trial at our hospital, 110 patients received preoperative CRT and subsequent resection. All 110 resected cases were included in this study. We employed disease-free survival (DFS) as a surgical outcome, and the pattern of recurrence was divided into 2 categories: (1) recurrence in the abdominal cavity (RAC), defined as either a locoregional or a peritoneal recurrence; or (2) distant recurrence (DR), defined as cancer recurrence in a distant organ. Clinicopathological variables were analyzed in association with DFS, RAC, and DR. RESULTS:: Positive nodal involvement and perineural invasion were independent factors that were significantly associated with an unfavorable DFS (P = 0.021 and P = 0.026, respectively). The presence of perineural invasion was the single independent variable significantly associated with an increased risk of RAC (P = 0.002), whereas the status of nodal involvement was the single independent variable significantly associated with an increased risk of DR (P = 0.013). CONCLUSIONS:: The status of nodal involvement and perineural invasion in resected specimens are significantly associated with DFS and clearly predict the pattern of recurrence in the setting of a preoperative gemcitabine-based CRT strategy. This study is registered at UMIN-CTR and carries the ID number UMIN000001804.

PMID: 22123160 [PubMed - as supplied by publisher]

Single-Incision Versus Standard Multiport Laparoscopic Colectomy: A Multicenter, Case-Controlled Comparison.

Ann Surg. 2011 Nov 19;

Authors: Champagne BJ, Papaconstantinou HT, Parmar SS, Nagle DA, Young-Fadok TM, Lee EC, Delaney CP

Abstract

OBJECTIVE:: The aim of this study was to compare single-incision laparoscopic colectomy (SILC) to multiport laparoscopic colectomy (MLC) when performed by experienced laparoscopic surgeons. BACKGROUND:: Recent case reports and single institution series have demonstrated the feasibility of SILC. Few comparative studies for MLC and SILC have been reported. METHODS:: Patients from 5 institutions undergoing SILC were entered into an IRB approved database from November 2008 to March 2010. SILC patients were matched with those undergoing MLC for gender, age, disease, surgery, BMI, and surgeon. The primary endpoint was length of stay and secondary endpoints included operative time, conversion, complications and postoperative pain scores. RESULTS:: Three hundred thirty patients (SILC = 165, MLC = 165) were evaluated. Operative time (135 ± 45 min vs. 133 ± 56 min; P = 0.85) and length of stay (4.6 ± 1.6 vs. 4.3 ± 1.4; P = 0.35) were not significantly different. Maximum postoperative day one pain scores were significantly less for SILC (4.9 vs. 5.6; P = 0.005). Eighteen (11%) patients undergoing SILC were converted to multiport laparoscopy. There was no statistical difference between groups for conversions to laparotomy, complications, re-operations, or re-admissions. CONCLUSIONS:: SILC is feasible when performed on select patients by surgeons with extensive laparoscopic experience. Outcomes were similar to MLC, except for a reduction in peak pain score on the first postoperative day. Prospective randomized trials should be performed before incorporation of this technology into routine surgical care.

PMID: 22104563 [PubMed - as supplied by publisher]

Microvascular Blood Flow Changes in the Small Intestinal Wall During Conventional Negative Pressure Wound Therapy and Negative Pressure Wound Therapy Using a Protective Disc Over the Intestines in Laparostomy.

Ann Surg. 2011 Nov 19;

Authors: Lindstedt S, Malmsjö M, Hansson J, Hlebowicz J, Ingemansson R

Abstract

OBJECTIVES:: Blood flow changes in the intestines during conventional negative pressure wound therapy (NPWT), and NPWT using a protective disc over the intestines in laparostomy. BACKGROUND:: Higher closure rates of the open abdomen have been reported with NPWT compared with other kinds of wound management. However, the method has been associated with increased development of fistulae. We have compared the changes in blood flow in the intestinal wall using conventional NPWT and NWPT with a protective disc between the intestines and the vacuum source. METHODS:: Midline incisions were made in 10 pigs and either conventional NPWT or NPWT with a disc over the intestines was applied. The microvascular blood flow was measured in the intestinal wall before and after the application of topical negative pressures of -50, -70, and -120 mmHg, using laser Doppler velocimetry. RESULTS:: The blood flow was significantly decreased (by 24%) after the application of conventional NPWT at -50 mmHg, compared with a slight decrease (2%) after the application of NWPT with a protective disc (P < 0.05). The blood flow was significantly decreased (by 54%) after the application of conventional NPWT at -120 mmHg, compared with a slight decrease (17%) after application of NPWT using a protective disc (P < 0.001). CONCLUSIONS:: Inserting a disc between the intestines and the vacuum source in NPWT protects the intestines from ischemia. The decreased blood flow in the intestinal wall may induce ischemia, which could promote the development of intestinal fistulae.

PMID: 22104565 [PubMed - as supplied by publisher]

Should all papillary thyroid microcarcinomas be aggressively treated? An analysis of 18,445 cases.

Ann Surg. 2011 Oct;254(4):653-60

Authors: Yu XM, Wan Y, Sippel RS, Chen H

Abstract

OBJECTIVE: The purpose of this study was to identify the risk factors that predict papillary thyroid microcarcinoma (PTMC)-related death in a large patient population to determine which patients need aggressive treatment.

BACKGROUND: The management of PTMC is controversial and ranges from observation to total thyroidectomy. The lack of consensus is predominantly due to the general excellent overall prognosis, thereby requiring a large cohort to delineate differences in outcome.

METHODS: All papillary thyroid cancer patients with tumor size of 1 cm or less in the Surveillance, Epidemiology and End Results Cancer Database from 1988 to 2007 were identified. Outcomes, including overall and disease-specific survival, were compared, and different risk groups were evaluated by multivariate analysis.

RESULTS: A total of 18,445 cases of PTMC with surgery were identified. The 10-year and 15-year overall survivals were 94.6% and 90.7%, respectively, while disease-specific survivals were 99.5% and 99.3%. Age greater than 45 years, male sex, African American or minority race, node metastases, extrathyroidal invasion, and distant metastases were stratified to be significant risk factors for overall survival. There were 49 thyroid cancer-related deaths. Forty-five (92%) of the 49 patients had at least 2 risk factors, and 51% of these 49 patients had 3 or more risk factors (vs 5.7% in the rest of the cohort, P < 0.001).

CONCLUSIONS: Although PTMC is generally associated with an excellent prognosis, 0.5% patients may die of PTMC. The presence of 2 or more risk factors is strongly associated with cancer-related mortality and can help to identify patients who should be considered for more aggressive management.

PMID: 21876434 [PubMed - indexed for MEDLINE]

Comment on “A rising ioPTH level immediately after parathyroid resection: are additional hyperfunctioning glands always present? An application of the Wisconsin Criteria”.

Ann Surg. 2011 Oct;254(4):670-1; author reply 671

Authors: Riss P, Bieglmayer C, Niederle B

PMID: 21897198 [PubMed - indexed for MEDLINE]

Laparoscopic Versus Open Intersphincteric Resection and Coloanal Anastomosis for Low Rectal Cancer: Intermediate-Term Oncologic Outcomes.

Ann Surg. 2011 Nov 9;

Authors: Park JS, Choi GS, Jun SH, Hasegawa S, Sakai Y

Abstract

OBJECTIVE:: To compare the surgical outcome and intermediate oncological outcomes for laparoscopic versus open intersphincteric resection (ISR). BACKGROUND:: Intersphincteric resection has been proposed as an alternative to abdominoperineal resection for selected low rectal cancer cases, but the oncological adequacy of laparoscopic ISR has not been established. METHODS:: A total of 210 consecutive patients with low rectal cancer who underwent ISR between 1997 and 2009 in 2 institutions were evaluated retrospectively. Patients were classified into an open surgery (OS, n = 80) group and a laparoscopy (LAP, n = 130) group. The primary endpoint was 3-year disease-free survival. RESULTS:: The major complication rates were similar in the LAP and OS groups (5.4% vs 3.8%, respectively; P = 0.428). However, the LAP group had a shorter hospital stay and time to bowel movement compared with the OS group. In the LAP group, operating time was 16 minutes shorter (P = 0.230) and intraoperative blood loss was less (P = 0.002). Median follow-up was 34 months (interquartile range: 20.0-42.5 months). The local recurrence rates were similar in the 2 groups (LAP, 2.6% vs OS, 7.7%; P = 0.184). The combined 3-year disease-free survival for all stages was 82.1% (95% CI: 73.7-90.2%) in the LAP group and 77.0% (95% CI: 66.9%-86.9%) in the OS group (P = 0.523). CONCLUSIONS:: Laparoscopic ISR can be performed safely and offers a minimally invasive sphincter-sparing alternative. The oncological adequacy of laparoscopic ISR requires long-term follow-up data, but the intermediate-term outcomes seem equivalent to those achieved with OS.

PMID: 22076066 [PubMed - as supplied by publisher]

Comparison of International Consensus Guidelines Versus 18-Fdg PET in Detecting Malignancy of Intraductal Papillary Mucinous Neoplasms of the Pancreas.

Ann Surg. 2011 Nov 9;

Authors: Pedrazzoli S, Sperti C, Pasquali C, Bissoli S, Chierichetti F

Abstract

OBJECTIVE:: To assess the reliability of the International Consensus Guidelines (ICG) and 18-fluorodeoxyglucose positron emission tomography (PET) in distinguishing benign from malignant intraductal papillary mucinous neoplasms (IPMNs) of the pancreas. BACKGROUND:: Since 2006 the ICG have been used to choose immediate surgery or surveillance for IPMN patients, but their low specificity increases the number of benign IPMNs that undergo resective surgery. PET has proved highly sensitive and specific in detecting malignancy in cystic neoplasms of the pancreas, including IPMNs. METHODS:: Patients suspected with IPMNs of the pancreas seen at our Department from January 1989 to July 2010 were identified and classified as cases of main duct, mixed type and branch type IPMN. The indication for resection or surveillance was verified a posteriori for all patients according to the ICG. PET was considered positive for a Standardized Uptake Value ≥2.5. Surveillance included clinical examination, laboratory tests, CA 19-9 serum levels, and computed tomography and/or magnetic resonance and magnetic resonance cholangiopancreatography every 6 months for 2 years and yearly thereafter. Endoscopic ultrasound was rarely performed. PET was repeated in clinically or radiologically suspect cases, or if tumor markers increased. RESULTS:: Sixty-one main duct or mixed type and 101-branch type IPMNs were included in the study. A histological diagnosis was available for 81 of 162 patients, missing for 1 locally advanced IPMN, whereas 62 patients are under surveillance and it proved impossible to contact 18. Conservative surgery was performed in 16 of 68 patients with benign IPMNs. The sensitivity, specificity, positive and negative predictive value, and accuracy of the ICG in detecting malignancy were 93.2, 22.2, 59.4, 72.7, and 61.2, whereas for PET they were 83.3, 100, 100, 84.6, and 91.3. CONCLUSIONS:: PET is more accurate than the ICG in distinguishing benign from malignant (invasive and noninvasive) IPMNs. Prophylactic IPMN resection in young patients fit for surgery should be guided by the ICG, whereas PET should be performed in older patients, cases at increased surgical risk, or when the feasibility of parenchyma-sparing surgery demands a reliable preoperative exclusion of malignancy.

PMID: 22076067 [PubMed - as supplied by publisher]

Does Fundoplication Really Reduce Deoxyribonucleic Acid Methylation of Barrett Esophagus?

Ann Surg. 2011 Nov 9;

Authors: Yuan Y, Chen LQ

PMID: 22076068 [PubMed - as supplied by publisher]

Cognitive Improvement After Parathyroidectomy.

Ann Surg. 2011 Nov 9;

Authors: Burney RE

PMID: 22076069 [PubMed - as supplied by publisher]

Effects of aggressive versus moderate glycemic control on clinical outcomes in diabetic coronary artery bypass graft patients.

Ann Surg. 2011 Sep;254(3):458-63; discussion 463-4

Authors: Lazar HL, McDonnell MM, Chipkin S, Fitzgerald C, Bliss C, Cabral H

Abstract

OBJECTIVE: This study sought to determine whether aggressive glycemic control (90-120 mg/dL) would result in more optimal clinical outcomes and less morbidity than moderate glycemic control (120-180 mg/dL) in diabetic patients undergoing coronary artery bypass graft (CABG) surgery.

SUMMARY OF BACKGROUND DATA: Maintaining serum glucose levels between 120 and 180 mg/dL with continuous insulin infusions decreases morbidity in diabetic patients undergoing CABG surgery. Studies in surgical patients requiring prolonged ventilation suggest that aggressive glycemic control (<120 mg/dL) may improve survival; however, its effect in diabetic CABG patients is unknown.

METHODS: Eighty-two diabetic patients undergoing CABG were prospectively randomized to aggressive glycemic control (90-120 mg/dL) or moderate glycemic control (120-180 mg/dL) using continuous intravenous insulin solutions (100 units regular insulin in 100 mL: normal saline) beginning at the induction of anesthesia and continuing for 18 hours after CABG. Primary end points were the incidence of major adverse events (major adverse events = 30-day mortality, myocardial infarction, neurologic events, deep sternal infections, and atrial fibrillation), the level of serum glucose, and the incidence of hypoglycemic events.

RESULTS: There were no differences in the incidence of major adverse events between the groups (17 moderate vs 15 aggressive; P = 0.91). Patients with aggressive control had a lower mean glucose at the end of 18 hours of insulin infusion (135 ± 12 mg/dL moderate vs 103 ± 17 mg/dL aggressive; P < 0.0001). Patients with aggressive control had a higher incidence of hypoglycemic events (4 vs 30; P < 0.0001).

CONCLUSIONS: In diabetic patients undergoing CABG surgery, aggressive glycemic control increases the incidence of hypoglycemic events and does not result in any significant improvement in clinical outcomes that can be achieved with moderate control. Clinical Trials.gov (ID #NCT00460499).

PMID: 21865944 [PubMed - indexed for MEDLINE]

Simulation-based mastery learning improves patient outcomes in laparoscopic inguinal hernia repair: a randomized controlled trial.

Ann Surg. 2011 Sep;254(3):502-9; discussion 509-11

Authors: Zendejas B, Cook DA, Bingener J, Huebner M, Dunn WF, Sarr MG, Farley DR

Abstract

OBJECTIVE: To evaluate a mastery learning, simulation-based curriculum for laparoscopic, totally extraperitoneal (TEP) inguinal hernia repair.

BACKGROUND: Clinically relevant benefits from improvements in operative performance, time, and errors after simulation-based training are not clearly established.

METHODS: After performing a baseline TEP in the OR, general surgery residents randomized to mastery learning (ML) or standard practice (SP) were reassessed during subsequent TEPs. The ML curriculum involved Web-based modules followed by training on a TEP simulator until expert performance was achieved. Operative time, performance, and patient outcomes adjusted for staff, resident participation, difficulty of repair, PGY-level, and patient comorbidities were compared between groups with mixed effects-ANOVA and generalized linear models.

RESULTS: Fifty residents (PGY1-5) performed 219 TEP repairs on 146 patients. Baseline operative time, performance, and demographics were similar between groups. To achieve mastery, ML-residents (n = 26) required a median of 16 (range 7-27) simulated repairs. After training, TEPs performed by ML-residents were faster than those by SP-residents, with time corrected for participation (mean ± SD, 34 ± 8 minutes vs. 48 ± 14 minutes; difference -13; 95%CI, -18 to -8; P < 0.001). Operative performance scores (GOALS, scale 6-30) were better for ML residents (21.9 ± 2.8 vs. 18.3 ± 3.8; P = 0.001). Intraoperative complications (peritoneal tear, procedure conversion), postoperative complications (urinary retention, seroma), and need for overnight stay were less likely in the ML group (adjusted odds ratios 0.14, 0.04, and 0, respectively; all P < 0.05).

CONCLUSIONS: A simulation-based ML curriculum decreased operative time, improved trainee performance, and decreased intra- and postoperative complications and overnight stays after laparoscopic TEP inguinal hernia repair. ClinicalTrials.gov Identifier: NCT01085500.

PMID: 21865947 [PubMed - indexed for MEDLINE]

Arterial Resection During Pancreatectomy for Pancreatic Cancer: A Systematic Review and Meta-Analysis.

Ann Surg. 2011 Nov 4;

Authors: Mollberg N, Rahbari NN, Koch M, Hartwig W, Hoeger Y, Büchler MW, Weitz J

Abstract

BACKGROUND:: The majority of pancreatic cancers are diagnosed at an advanced stage. As surgical resection remains the only hope for cure, more aggressive surgical approaches have been advocated to increase resection rates. Institutions have begun to release data on their experience with pancreatectomy and simultaneous arterial resection (AR), which has traditionally been considered a general contraindication to resection. The aim of the present meta-analysis was to evaluate the perioperative and long-term outcomes of patients with AR during pancreatectomy for pancreatic cancer. METHODS:: The Medline, Embase, and Cochrane Library and J-East databases were systematically searched to identify studies reporting outcome of patients who underwent pancreatectomy with AR for pancreatic cancer. Studies that reported perioperative and/or long-term results after pancreatectomy with AR were eligible for inclusion. Meta-analyses included comparative studies providing data on patients with and without AR and were performed using a random effects model. RESULTS:: The literature search identified 26 studies including 366 and 2243 patients who underwent pancreatectomy with and without AR. All studies were retrospective cohort studies and the methodological quality was moderate to low. Meta-analyses revealed AR to be associated with a significantly increased risk for perioperative mortality [Odds ratio (OR) = 5.04; 95% confidence interval (CI), 2.69-9.45; P < 0.0001; I = 24%], poor survival at 1 year (OR = 0.49; 95% CI, 0.31-0.78; P = 0.002; I = 35%) and 3 years (OR = 0.39; 95% CI, 0.17-0.86; P = 0.02; I = 49%) compared with patients without AR. The increased perioperative mortality (OR = 8.87; 95% CI, 3.40-23.13; P < 0.0001; I = 5%) and lower survival rate at 1 year (OR = 0.50; 95% CI, 0.31-0.82; P = 0.006; I = 40%) was confirmed in the comparison to patients undergoing venous resection. Despite substantial perioperative mortality, pancreatectomy with AR was associated with more favorable survival compared with patients who did not undergo resection for locally advanced disease. CONCLUSIONS:: AR in patients undergoing pancreatectomy for pancreatic cancer is associated with a poor short and long-term outcome. Pancreatectomy with AR may, however, be justified in highly selected patients owing to the potential survival benefit compared with patients without resection. These patients should be treated within the bounds of clinical trials to assess outcomes after AR in the era of modern pancreatic surgery and multimodal therapy.

PMID: 22064622 [PubMed - as supplied by publisher]

Readmission rates after abdominal surgery: the role of surgeon, primary caregiver, home health, and subacute rehab.

Ann Surg. 2011 Oct;254(4):591-7

Authors: Martin RC, Brown R, Puffer L, Block S, Callender G, Quillo A, Scoggins CR, McMasters KM

Abstract

OBJECTIVE: To prospectively evaluate predictive factors of hospital readmission rates in patients undergoing abdominal surgical procedures.

BACKGROUND: Recommendations from MedPAC that the Centers for Medicare and Medicaid Services (CMS) report upon and determine payments based in part on readmission rates have led to an attendant interest by payers, hospital administrators and far-sighted physicians.

METHODS: Analysis of 266 prospective treated patients undergoing major abdominal surgical procedures from September 2009 to September 2010. All patients were prospectively evaluated for underlying comorbidities, number of preop meds, surgical procedure, incision type, complications, presence or absence of primary and/or secondary caregiver, their education level, discharge number of medications, and discharge location. Univariate and multivariate analyses were performed.

RESULTS: Two hundred twenty-six patients were reviewed with 48 (18%) gastric-esophageal, 39(14%) gastrointestinal, 88 (34%) liver, 58 (22%) pancreas, and 33 (12%) other. Seventy-eight (30%) were readmitted for various diagnoses the most common being dehydration (26%). Certain preoperative and intraoperative factors were not found to be significant for readmission being, comorbidities, diagnosis, number of preoperative medications, patient education level, type of operation, blood loss, and complications. Significant predictive factors for readmission were age (≥69 years), number of discharged (DC) meds (≥9 medications), ≤50% oral intake (52% vs. 23%), and DC home with a home health agency (62% vs. 11%)

CONCLUSION: Readmission rates for surgeons WILL become a quality indicator of performance. Quality parameters among Home Health agencies are nonexistent, but will reflect on surgeon’s performance. Greater awareness regarding predictors of readmission rates is necessary to demonstrate improved surgical quality.

PMID: 22039606 [PubMed - in process]

Cost-effectiveness of the National Surgical Quality Improvement Program.

Ann Surg. 2011 Oct;254(4):619-24

Authors: Hollenbeak CS, Boltz MM, Wang L, Schubart J, Ortenzi G, Zhu J, Dillon PW

Abstract

OBJECTIVE: The purpose of this study was to compare the cost-effectiveness of the National Surgical Quality Improvement Program (NSQIP) at an academic medical center between the first 6 months and through the first and second years of implementation.

BACKGROUND: The NSQIP has been extended to private-sector hospitals since 1999, but little is known about its cost-effectiveness.

METHODS: Data included 2229 general or vascular surgeries, 699 of which were conducted after NSQIP was in place for 6 months. We estimated an incremental cost-effectiveness ratio (ICER) comparing costs and benefits before and after the adoption of NSQIP. Costs were estimated from the perspective of the hospital and included hospital costs for each admission plus the total annual cost of program adoption and maintenance, including administrator salary, training, and information technology costs. Effectiveness was defined as events avoided. Confidence intervals and a cost-effectiveness acceptability curve were computed by using a set of 10,000 bootstrap replicates. The time periods we compared were (1) July 2007 to December 2007 to July 2008 to December 2008 and (2) July 2007 to June 2008 to July 2008 to June 2009.

RESULTS: The incremental costs of the NSQIP program were $832 and $266 for time periods 1 and 2, respectively, yielding ICERs of $25,471 and $7319 per event avoided. The cost-effectiveness acceptability curves suggested a high probability that NSQIP was cost-effective at reasonable levels of willingness to pay.

CONCLUSIONS: In these data, not only did NSQIP appear cost-effective, but also its cost-effectiveness improved with greater duration of participation in the program, resulting in a decline to 28.7% of the initial cost.

PMID: 22039608 [PubMed - in process]

Chemotherapy Before Liver Resection of Colorectal Metastases: Friend or Foe?

Ann Surg. 2011 Oct 28;

Authors: Lehmann K, Rickenbacher A, Weber A, Pestalozzi BC, Clavien PA

Abstract

OBJECTIVE:: We conducted a systematic review of the published literature to critically assess benefits and risks of the use of preoperative chemotherapy in patients presenting with colorectal liver metastases. BACKGROUND:: In many centers, chemotherapy is used before hepatic resection of colorectal metastases, even in the presence of a single lesion. Application of chemotherapy requires clear conceptual distinction between patients presenting with resectable lesions (neoadjuvant) versus patients presenting with unresectable lesions, for which chemotherapy is used to reach a resectable situation (downsizing). METHODS:: The literature (PubMed) was systematically reviewed for publications related to liver surgery and chemotherapy according to the methodology recommended by the Cochrane Collaboration. RESULTS:: For unresectable liver metastases, combination regimens result in enhanced tumor response and resectability rates up to 30%, although the additional benefit from targeted agents such as bevacizumab or cetuximab is marginal. For resectable lesions, studies on neoadjuvant chemotherapy failed to convincingly demonstrate a survival benefit. Most reports described increased postoperative complications in a subset of patients due to parenchymal alterations such as chemotherapy-associated steatohepatitis or sinusoidal obstruction syndrome. CONCLUSION:: Preoperative standard chemotherapy can be recommended for downsizing unresectable liver metastases, but not for resectable lesions, for which adjuvant chemotherapy is preferred.

PMID: 22041509 [PubMed - as supplied by publisher]

Cytology Adds Value to Imaging Studies for Risk Assessment of Malignancy in Pancreatic Mucinous Cysts.

Ann Surg. 2011 Oct 28;

Authors: Genevay M, Mino-Kenudson M, Yaeger K, Konstantinidis IT, Ferrone CR, Thayer S, Fernandez-Del Castillo C, Sahani D, Bounds B, Forcione D, Brugge WR, Pitman MB

Abstract

OBJECTIVE:: Evaluate the value of cytology relative to imaging features in risk assessment for malignancy as defined in the Sendai Guidelines. BACKGROUND:: The Sendai Guidelines list symptoms, cyst size >30 mm, dilated main pancreatic duct (MPD) >6 mm, mural nodule (MN) and “positive” cytology as high risk stigmata for malignancy warranting surgical triage. METHODS:: We reviewed clinical, radiological and cytological data of 112 patients with histologically confirmed mucinous cysts of the pancreas evaluated in a single tertiary medical center. Cytology slides were blindly re-reviewed and epithelial cells grouped as either benign or high-grade atypia (HGA) [≥high-grade dysplasia]. Histologically, neoplasms were grouped as benign (low-grade and moderate dysplasia) and malignant (in situ and invasive carcinoma). Performance characteristics of cytology relative to other risk factors were evaluated. RESULTS:: Dilated MPD, MN, and HGA were independent predictors of malignancy (p < 0.0001), but not symptoms (p = 0.29) or cyst size >30 mm (p = 0.51). HGA was the most sensitive predictor of malignancy in all cysts (72%) and in small (≤30 mm) branch-duct intraductal papillary mucinous neoplasm (BD IPMN; 67%), whereas also being specific (85 and 88%, respectively). MN and dilated MPD were highly specific (>90%), but insensitive (39%-44%). Cytology detected 30% more cancers in small cysts than dilated MPD or MN and half of the cancers without either of these high-risk imaging features. CONCLUSIONS: Cytology adds value to the radiological assessment of predicting malignancy in mucinous cysts, particularly in small BD IPMN.

PMID: 22041510 [PubMed - as supplied by publisher]

Letter to the Editor.

Ann Surg. 2011 Oct 28;

Authors: Kiran RP

PMID: 22041511 [PubMed - as supplied by publisher]

Time for a (Re) Definition of (Recurrent) Sigmoid Diverticulitis?

Ann Surg. 2011 Oct 28;

Authors: Gervaz P, Ambrosetti P

PMID: 22041512 [PubMed - as supplied by publisher]

Reply.

Ann Surg. 2011 Oct 28;

Authors: Roman S

PMID: 22041513 [PubMed - as supplied by publisher]

Risk of Cancer in Meckel’s Diverticulum.

Ann Surg. 2011 Oct 28;

Authors: Lowenfels AB, Maisonneuve P

PMID: 22041514 [PubMed - as supplied by publisher]

Natural Orifice Transluminal Endoscopic Surgery: Where Should We Draw the Line?

Ann Surg. 2011 Oct 28;

Authors: Berney CR

PMID: 22041515 [PubMed - as supplied by publisher]

To be or not to be a general surgeon!

Ann Surg. 2011 Nov;254(5):679-83

Authors: Margreiter R

PMID: 22042465 [PubMed - in process]

A prognostic score to predict major complications after pancreaticoduodenectomy.

Ann Surg. 2011 Nov;254(5):702-8

Authors: Braga M, Capretti G, Pecorelli N, Balzano G, Doglioni C, Ariotti R, Di Carlo V

Abstract

OBJECTIVE: : To develop and validate a simple prognostic score to predict major postoperative complications after pancreaticoduodenectomy (PD).

BACKGROUND: : PD still carries a high rate of severe postoperative complications. No specific score is currently available to stratify the patient’s risk of major morbidity.

METHODS: : Between 2002 and 2010, preoperative, intraoperative, and outcome data from 700 consecutive patients undergoing PD in our institution were prospectively collected in an electronic database. Major complications were defined as levels III to V of Clavien-Dindo classification. On the basis of a multivariate regression model, the score was developed using a random two-thirds of the population (n = 469) and was validated on the remaining 231 patients.

RESULTS: : Major complication rate was 16.7% (117/700). Significant predictors included in the scoring system were: pancreas texture, pancreatic duct diameter, operative blood loss, and ASA score. The mean risk of developing major postoperative complications was 7% in patients with score 0 to 3, 13% in patients with score 4 to 7, 23% in patients with score 8 to 11, and 36% in patients with score 12 to 15. In the validation population, the predicted risk of major complications was 15.2% versus a 16.9% observed risk (C-statistic index = 0.743).

CONCLUSION: : This new score may accurately predict a patient’s postoperative outcome. Early identification of high-risk patients could help the surgeon to adopt intraoperative and postoperative strategies tailored on individual basis.

PMID: 22042466 [PubMed - in process]

Biliary complications after liver transplantation using grafts from donors after cardiac death: results from a matched control study in a single large volume center.

Ann Surg. 2011 Nov;254(5):716-23

Authors: Deoliveira ML, Jassem W, Valente R, Khorsandi SE, Santori G, Prachalias A, Srinivasan P, Rela M, Heaton N

Abstract

OBJECTIVE: : To assess the incidence and impact of biliary complications in recipients transplanted from donors after cardiac death (DCD) at one single large institution.

BACKGROUND: : Shortage of available cadaveric organs is a significant limiting factor in liver transplantation (LT). The use of DCD offers the potential to increase the organ pool. However, early results with DCD liver grafts were associated with a greater incidence of ischemic cholangiopathy (IC), leading to several programs to abandoning this source of organs.

METHODS: : A retrospective analysis of a prospective database from April 2001 to 2010 focused on 167 consecutive DCD-LT. Each DCD transplant was matched with 2 brain death donors (DBD) grafts (n = 333) according to the period of transplantation. Primary outcome measures were biliary complications including the severity of complications, graft survival and patient survival. Minimum follow-up was 3 months.

RESULTS: : Anastomotic stricture was the most common biliary complication (DCD = 30, 19% vs. DBD = 41, 13%). Most were treated endocoscopically (grade IIIa = 72%), whereas hepatico-jejunostomy (grade IIIb) was performed in 22%. Primary IC occurred in 4 (2.5%) recipients from the DCD group and was absent in the DBD group (P = 0.005). However, none of these patients required retransplantation. Patient and graft survival at 1, 3, and 5 years were similar between DCD and DBD groups (P = 0.106, P = 0.138, P = 0.113, respectively).

CONCLUSIONS: : The encouraging results with DCD-LT are probably due to the selection of DCD grafts and clear definition of warm ischemia.

PMID: 22042467 [PubMed - in process]

Are there better guidelines for allocation in liver transplantation?: a novel score targeting justice and utility in the model for end-stage liver disease era.

Ann Surg. 2011 Nov;254(5):745-54

Authors: Dutkowski P, Oberkofler CE, Slankamenac K, Puhan MA, Schadde E, Müllhaupt B, Geier A, Clavien PA

Abstract

OBJECTIVES: : To design a new score on risk assessment for orthotopic liver transplantation (OLT) based on both donor and recipient parameters.

BACKGROUND: : The balance of waiting list mortality and posttransplant outcome remains a difficult task in the era of the model for end-stage liver disease (MELD).

METHODS: : Using the United Network for Organ Sharing database, a risk analysis was performed in adult recipients of OLT in the United States of America between 2002 and 2010 (n = 37,255). Living donor-, partial-, or combined-, and donation after cardiac death liver transplants were excluded. Next, a risk score was calculated (balance of risk score, BAR score) on the basis of logistic regression factors, and validated using our own OLT database (n = 233). Finally, the new score was compared with other prediction systems including donor risk index, survival outcome following liver transplantation, donor-age combined with MELD, and MELD score alone.

RESULTS: : Six strongest predictors of posttransplant survival were identified: recipient MELD score, cold ischemia time, recipient age, donor age, previous OLT, and life support dependence prior to transplant. The new balance of risk score stratified recipients best in terms of patient survival in the United Network for Organ Sharing data, as in our European population.

CONCLUSIONS: : The BAR system provides a new, simple and reliable tool to detect unfavorable combinations of donor and recipient factors, and is readily available before decision making of accepting or not an organ for a specific recipient. This score may offer great potential for better justice and utility, as it revealed to be superior to recent developed other prediction scores.

PMID: 22042468 [PubMed - in process]

Selective targeting of genetically engineered mesenchymal stem cells to tumor stroma microenvironments using tissue-specific suicide gene expression suppresses growth of hepatocellular carcinoma.

Ann Surg. 2011 Nov;254(5):767-75

Authors: Niess H, Bao Q, Conrad C, Zischek C, Notohamiprodjo M, Schwab F, Schwarz B, Huss R, Jauch KW, Nelson PJ, Bruns CJ

Abstract

BACKGROUND: : The use of engineered mesenchymal stem cells (MSCs) as therapeutic vehicles for the treatment of experimental pancreatic and breast cancer has been previously demonstrated. The potential application of MSCs for the treatment of hepatocellular carcinoma (HCC) has been controversial. The general approach uses engineered MSCs to target different aspects of tumor biology, including angiogenesis or the fibroblast-like stromal compartment, through the use of tissue-specific expression of therapeutic transgenes. The aim of the present study was (1) to evaluate the effect of exogenously added MSCs on the growth of HCC and (2) the establishment of an MSC-based suicide gene therapy for experimental HCC.

METHODS: : Mesenchymal stem cells were isolated from bone marrow of C57/Bl6 p53 mice. The cells were injected into mice with HCC xenografts and the effect on tumor proliferation and angiogenesis was evaluated. The cells were then stably transfected with red fluorescent protein (RFP) or Herpes simplex virus thymidine kinase (HSV-Tk) gene under control of the Tie2 promoter/enhancer or the CCL5 promoter. Mesenchymal stem cells were injected intravenously into mice with orthotopically growing xenografts of HCC and treated with ganciclovir (GCV).

RESULTS: : Ex vivo examination of hepatic tumors revealed tumor-specific recruitment, enhanced tumor growth, and increased microvessel density after nontherapeutic MSC injections. After their homing to the hepatic xenografts, engineered MSCs demonstrated activation of the Tie2 or CCL5 promoter as shown by RFP expression. Application of CCL5/HSV-TK transfected MSCs in combination with GCV significantly reduced tumor growth by 56.4% as compared with the control group and by 71.6% as compared with nontherapeutic MSC injections. CCL5/HSV-TK transfected MSCs proved more potent in tumor inhibition as compared with Tie2/HSV-TK MSCs.

CONCLUSION: : Exogenously added MSCs are recruited to growing HCC xenografts with concomitant activation of the CCL5 or Tie2 promoters within the MSCs. Stem cell-mediated introduction of suicide genes into the tumor followed by prodrug administration was effective for treatment of experimental HCC and thus may help fill the existing gap in bridging therapies for patients suffering from advanced HCCs.

PMID: 22042469 [PubMed - in process]

Additional resection of an intraoperative margin-positive proximal bile duct improves survival in patients with hilar cholangiocarcinoma.

Ann Surg. 2011 Nov;254(5):776-83

Authors: Ribero D, Amisano M, Lo Tesoriere R, Rosso S, Ferrero A, Capussotti L

Abstract

OBJECTIVE: : To assess the survival benefit of additional resection of an intraoperative positive proximal bile duct margin (BDMarg) in patients undergoing hepatectomy for hilar cholangiocarcinoma (HCCA).

SUMMARY BACKGROUND DATA: : Intraoperative evidence of invasive cancer at the proximal BDMarg is associated with a dismal survival irrespective of whether a final negative BDMarg is achieved with an additional resection.

METHODS: : Clinicopathologic, operative, and survival data of consecutive patients undergone curative intent hepatectomy with bile duct resection (n = 75) for HCC (1989-2010) were analyzed.

RESULTS: : Frozen-section examination of the proximal BDMarg revealed invasive cancer in 19 of the 67 patients. After additional resection, which was possible in 18 cases, a secondary R0 BDMarg resection was achieved in 15 patients (83.3%), with 2 of these having, at final pathology, positive radial and distal margins. Eventually, 8 patients were classified as R1 and 67 as R0 (54 primary R0 and 13 secondary R0). Median survival of patients who had a secondary R0 resection (30.6 months) was similar to that of primarily R0-resected patients (29.3 months) and significantly better than that of R1 patients (14.9 months) (P = 0.026). Median time to recurrence and site of recurrence were similar in R0 patients independently of the performance of an additional resection. The incidence of biliary fistula was significantly increased (44.4% vs 17.5%; P = 0.02) in patients necessitating a margin re-resection.

CONCLUSIONS: : Additional resection of a positive proximal BDMarg, albeit associated with an increased risk of biliary fistula, offers a significant survival benefit and should be attempted whenever possible.

PMID: 22042470 [PubMed - in process]

Prediction of Prognosis Is Not Improved by the Seventh and Latest Edition of the TNM Classification for Colorectal Cancer in a Single-Center Collective.

Ann Surg. 2011 Nov;254(5):793-801

Authors: Nitsche U, Maak M, Schuster T, Künzli B, Langer R, Slotta-Huspenina J, Janssen KP, Friess H, Rosenberg R

Abstract

OBJECTIVES: : To compare the prognostic value of the sixth and seventh editions of the TNM classification, and of additional prognostic factors, in colorectal cancer.

BACKGROUND: : The seventh TNM edition was released in 2009 with the aim of providing a more precise prediction of prognosis.

METHODS: : Clinical and histopathological data of 2229 patients with colorectal cancer who underwent tumor resection between 1990 and 2006 were analyzed and compared by using the sixth and seventh editions of the TNM classification and a statistically calculated model of prognostic factors.

RESULTS: : With the sixth edition, 5-year survival was 96% for stage I, 90% for IIA, 86% for IIB, 90% for IIIA, 72% for IIIB, 48% for IIIC, and 13% for IV. With the seventh edition, 5-year survival was 96% for stage I, 90% for IIA, 84% for IIB, 87% for IIC, 89% for IIIA, 72% for IIIB, 36% for IIIC, 15% for IVA, and 10% for IVB. The stage shifted for only 155 (7%) patients: from IIB to IIC (2%), from IIIB to IIIC (1%), and from IIIC to IIIA/B (4%). The performance of the seventh edition [concordance index (c-index) 0.83; 95% confidence interval (CI), 0.82-0.85] revealed no relevant improvement compared with the sixth edition (c-index 0.83; 95% CI, 0.82-0.84), or compared to a model based on independent prognostic factors (c-index 0.84; 95% CI, 0.83-0.86).

CONCLUSIONS: : The seventh TNM edition did not provide greater accuracy in predicting colorectal cancer patients’ prognosis but resulted in a more complex classification for daily clinical use.

PMID: 22042471 [PubMed - in process]

Prognostic impact of upper, middle, and lower third mucosal or submucosal infiltration in early esophageal cancer.

Ann Surg. 2011 Nov;254(5):802-8

Authors: Hölscher AH, Bollschweiler E, Schröder W, Metzger R, Gutschow C, Drebber U

Abstract

OBJECTIVE: : To identify differences in survival of patients with pT1 esophageal cancer relating to depth of wall infiltration.

BACKGROUND DATA: : Histologic analysis of mucosal and submucosal infiltration in thirds has shown an increasing rate of lymph node metastases (LNM) according to the depth of wall infiltration in pT1 esophageal cancer.

METHODS: : One hundred seventy-one patients had transthoracic en bloc (n = 161) or transhiatal esophagectomy (n = 10) for pT1 esophageal cancer [121 adenocarcinomas (AC), 50 squamous cell carcinomas (SCC)]. The histologic analysis of the specimen comprised depth of wall penetration of the carcinoma in thirds of pT1a = mucosa (m1, m2, m3) or pT1b = submucosa (sm1, sm2, sm3) and number and infiltration of the resected lymph nodes.

RESULTS: : The rate of LNM was 0% for 70 mucosal carcinomas and 34% for 101 submucosal carcinomas (P = 0.001). For sm1, this rate was 13%, for sm2 19% and for sm3 56%. The 5-year survival rate (5Y-SR) was 82% for pN0 and 45% for pN+ patients (P < 0.001). There was no significant prognostic difference between AC and SCC (5Y-SR: 74% vs 71%). The 5Y-SR of the pT1a group was 87% compared with 66% for pT1b (P = 0.046). The 5-year survival rate for sm1 and sm2 were similar; sm1 + sm2 were together significantly better (80%) than sm3 (46%) (P = 0.008). In multivariate analysis, only sm3 was an independent prognostic factor (P = 0.01).

CONCLUSIONS: : After esophagectomy, the prognosis of patients with sm1/sm2 infiltration is as good as for patients with mucosal carcinoma. Sm3 infiltration is the worst prognostic factor in pT1 esophageal cancer.

PMID: 22042472 [PubMed - in process]

Hedgehog Inhibition With the Orally Bioavailable Smo Antagonist LDE225 Represses Tumor Growth and Prolongs Survival in a Transgenic Mouse Model of Islet Cell Neoplasms.

Ann Surg. 2011 Nov;254(5):818-23

Authors: Fendrich V, Wiese D, Waldmann J, Lauth M, Heverhagen AE, Rehm J, Bartsch DK

Abstract

BACKGROUND: : This study was designed to evaluate the role of the hedgehog pathway in tumor progression of murine islet cell tumors. Blockade of aberrant hedgehog activation has recently been proposed as a therapeutic target, but effects in models of islet cell tumors with a new orally bioavailable Smoothened (Smo) antagonist LDE225 have not been examined.

MATERIAL AND METHODS: : To assess in vivo effects, transgenic Rip1Tag2 mice, which develop islet cell neoplasms, were treated with vehicle or LDE225 (80 mg/kg/d) from week 5 until death. The resected pancreata were evaluated macroscopically and microscopically by iummohistochemsistry. Quantitative real-time polymerase chain reaction was performed for hedgehog target genes with RNA from islet, isolated from treated and untreated Rip1Tag2 mice.

RESULTS: : LDE225 significantly reduced tumor volume by 95% compared with untreated control mice. Hedgehog inhibition with LDE225 significantly prolonged median survival in the used transgenic mouse model (105 vs 116 days; P = 0.02). Quantitative real-time polymerase chain reaction for downstream hedgehog target genes demonstrated significant downregulation in the islet cell tumors of Rip1Tag2 mice treated with LDE225, confirming the ability to achieve effective pharmacologic levels of LDE225 within the desired tissue site, in vivo.

CONCLUSION: : This is the first study to show that the orally bioavailable Smo antagonist LDE225 may provide a new option for therapy of islet cell neoplasms.

PMID: 22042473 [PubMed - in process]

Influence of Surgical Margins on Outcome in Patients With Intrahepatic Cholangiocarcinoma: A Multicenter Study by the AFC-IHCC-2009 Study Group.

Ann Surg. 2011 Nov;254(5):824-830

Authors: Farges O, Fuks D, Boleslawski E, Le Treut YP, Castaing D, Laurent A, Ducerf C, Rivoire M, Bachellier P, Chiche L, Nuzzo G, Regimbeau JM

Abstract

OBJECTIVE:: Define the optimal surgical margin in patients undergoing surgery for intrahepatic cholangiocarcinoma (IHCC). BACKGROUND DATA:: Surgery is the most effective treatment for IHCC. However, the influence of R1 resection on outcome is controversial and that of margin width has not been evaluated. METHODS:: We studied 212 patients undergoing curative resection of mass-forming-type IHCC. The respective influences on survival of resection status (R0 vs R1), surgical margin width, pTNM stage, and the latter’s components were evaluated. RESULTS:: Incidence of R1 resection was 24%. Overall, R1 resection was not an independent predictor of survival [odds ratio (OR) 1.2 (0.7-2.1)] in contrast to the pTNM stage [OR 2.10 (1.2-3.5)]. In the 78 pN+ patients, survival was similar after R0 and R1 resections (median: 18 vs 13 months, respectively, P = 0.1). In the 134 pN0 patients, R1 resection was an independent predictor of poor survival [OR 9.6 (4.5-20.4)], as was the presence of satellite nodules [OR 1.9 (1.1-3.2)]. In the 116 pN0 patients with R0 resections, median survival was correlated with margin width (≤1 mm: 15 months; 2-4 mm: 36 months; 5-9 mm: 57 month; ≥10 mm: 64 month, P < 0.001) and a margin >5 mm was an independent predictor of survival [OR 2.22 (1.59-3.09)]. CONCLUSION:: Patients undergoing surgery for IHCC are at high risk of R1 resections. In pN0 patients, R1 resection is the strongest independent predictor of poor outcome and a margin of at least 5 mm should be created. The survival benefits of resection in pN+ patients and R1 resection in general are very low.

PMID: 22042474 [PubMed - as supplied by publisher]

Novel and simple preoperative score predicting complications after liver resection in noncirrhotic patients.

Ann Surg. 2011 Nov;254(5):832

Authors: Breitenstein S, Deoliveira ML, Clavien PA

PMID: 22042475 [PubMed - in process]

Potential prevention and treatment of intestinal barrier dysfunction using active components of lactobacillus.

Ann Surg. 2011 Nov;254(5):833

Authors: Rijkers GT, Gooszen HG

PMID: 22042476 [PubMed - in process]

Letter to “rate and predictability of graft rupture and open abdominal aortic surgery”.

Ann Surg. 2011 Nov;254(5):834

Authors: Greenhalgh RM, Brown LC, Powell JT, Wyss TR

PMID: 22042477 [PubMed - in process]

Is retrieval of >25 lymph nodes a superior criterion for locally advanced gastric cancer surgery?

Ann Surg. 2011 Nov;254(5):834-5

Authors: Chen XZ, Yang K, Zhang B, Hu JK, Zhou C

PMID: 22042478 [PubMed - in process]

The Impact of Perioperative Chemotherapy on Survival in Patients With Gastric Signet Ring Cell Adenocarcinoma: A Multicenter Comparative Study.

Ann Surg. 2011 Oct 14;

Authors: Messager M, Lefevre JH, Pichot-Delahaye V, Souadka A, Piessen G, Mariette C

Abstract

OBJECTIVE:: The aim of this retrospective study was to evaluate the survival impact of perioperative chemotherapy (PCT) in patients with gastric signet ring cell (SRC) adenocarcinoma. BACKGROUND:: PCT is a standard treatment for advanced resectable gastric adenocarcinoma (GA). SRC has a worse prognosis compared to non-SRC and the chemosensitivity of SRC is uncertain. METHODS:: Among 3010 patients registered in 19 French centers between January 1997 and January 2010, 1050 (34.9%) were diagnosed with SRC. Of those treated with curative intent (n = 924), 171 (18.5%) received PCT with surgery (PCT group), whereas 753 (81.5%) were treated with primary surgery (S group). PCT was based mainly on a fluorouracil-platinum doublet or triplet regimen. RESULTS:: The groups were comparable regarding age, gender, American Society of Anesthesiologists (ASA) score, malnutrition, tumor location and cTNM stage. 60 patients did not undergo resection because of tumor progression (10) or metastases (50) found at operation. The R0 resection rates were 65.9% and 62.3% in the S and PCT groups, respectively (P = 0.308). Fewer patients received adjuvant chemotherapy in the S group than in the PCT group (35.2% vs. 66.5%, P < 0.001). At a median follow-up of 31.5 months, the median survival was shorter in the PCT group (12.8 vs. 14.0 months, P = 0.043). On multivariate analysis, PCT was found to be an independent predictor of poor survival (HR = 1.4, 95% CI 1.1-1.9, P = 0.042). CONCLUSIONS:: PCT provides no survival benefit in patients with gastric SRC. ClinicalTrial.gov record: ADCI001, ClinicalTrial.gov identifier NCT01249859.

PMID: 22005144 [PubMed - as supplied by publisher]

Long-Term Follow-Up After Right Hepatectomy for Adult Living Donation and Attitudes Toward the Procedure.

Ann Surg. 2011 Oct 14;

Authors: Sotiropoulos GC, Radtke A, Molmenti EP, Schroeder T, Baba HA, Frilling A, Broelsch CE, Malagó M

Abstract

OBJECTIVES:: To determine the long-term health status of donors after right hepatectomy for adult live donor liver transplantation (ALDLT). BACKGROUND:: The long-term outcomes for ALDLT donors are unknown. METHODS:: ALDLT donors undergoing right hepatectomy from April 1998 to June 2007 were invited to complete a questionnaire regarding health status, satisfaction (1-10/worst-best scale), self-esteem, willingness to donate again, and suggestions for improvement. In addition, donor files and cholecystectomy specimens were reviewed. Fisher’s exact test, Kaplan-Meier and logistic regression analyses were performed. RESULTS:: Eighty-three donors were contacted (median age: 36 years; median follow-up: 69 months). 39 (47%) were free of symptoms. The remaining 44 (53%) reported: intolerance to fatty meals and diarrhea (31%), gastroesophageal reflux associated with left liver hypertrophy (9%), incisional discomfort requiring pain medications (6%), severe depression requiring hospitalization (4%), rib pain affecting lifestyle (2%), and exacerbation of psoriasis (1%). Median satisfaction score was 8. Self-esteem diminished in 5%. Thirty-nine (47%) recommended improvements particularly more detailed informed donor consent and a centralized living donor liver registry. Seventy-eight (94%) were willing to donate again. There were no differences between donors with and without complaints with respect to: donor age, gender, early complications and follow-up time, young-to-old donation, recipient diagnosis of malignancy and death of the recipient. Noninflamed donor cholecystectomy specimens correlated with intolerance to fatty meals and diarrhea (P = 0.001). CONCLUSIONS:: ALDLT donors are at risk for long-term complaints that are neither reflected nor related to early complications. This information should be included in both the donor evaluation and the ALDLT decision-making process.

PMID: 22005145 [PubMed - as supplied by publisher]

Potential Prevention and Treatment of Intestinal Barrier Dysfunction Using Active Components of Lactobacillus.

Ann Surg. 2011 Oct 14;

Authors: Liu Z, Ma Y, Qin H

PMID: 22005146 [PubMed - as supplied by publisher]

Novel and Simple Preoperative Score Predicting Complications After Liver Resection in Noncirrhotic Patients.

Ann Surg. 2011 Oct 14;

Authors: Otto G, Hoppe-Lotichius M, Blettner M

PMID: 22005147 [PubMed - as supplied by publisher]